How Stress is Implicated in Chronic Pain
By the WITHIN Team
Since 1992 in the UK, April has been stress-awareness month and here at the Sleep & Pain Lab we have been reflecting on the role that stress plays in all of our lives: What are the common sources of stress? Can stress affect our pain experiences? Can stress management really improve long-term wellbeing? In this month’s blog, we explore the general relationship between pain and stress, as well as looking at some of the ways we can better manage stress for improved health and wellbeing in the context of pain.
Stress is a state of emotional and mental tension, and everyone experiences it - so it is fair to say that it is a normal part of life! Even though it is not uncommon to say we are stressed in times of unease, we sometimes forget that stress is personal and affects us all differently. What’s more, is that experiencing lots of little stressors can be just as damaging as experiencing one major stressful event. They add up! Both the amount and impact of each stressor can have an influence on our health and wellbeing, and when you throw chronic pain into the mix things can get even more complex…
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The relationship between pain and stress
Living with chronic pain can cause an individual a great deal of stress – in some cases, stress can induce or even exacerbate pain sensation. For example, individuals with inflammatory bowel disease (IBD), may experience “flare-ups” due to heightened stress and it is widely recognised as a stress-related illness. In this way, stress can impact pain conditions by increasing the intensity, duration and even onset of painful symptoms. This is supported by research measuring cortisol (a stress biomarker in humans) - researchers have found that cortisol levels in chronic pain patients were significantly greater than cortisol levels in pain-free adults (Van Uum et al., 2008), suggesting that people who experience chronic pain may also experience greater stress.
However, its not just about stress worsening pain, persistent painful experiences can themselves be a source of stress for individuals. In one interesting study, researchers spoke to people living with chronic neuropathic pain (CNP), following spinal cord injuries about their experiences (original study can be found as a PDF: Henwood & Ellis (2004).Twenty-four adults, aged 31-60 participated in a focus-group and many reported that pain had an impact on family stress and interpersonal relationships. Some of participants expressed a concern that they were potentially “burdening” their significant other(s). The findings from this focus group discussion demonstrated some so-called ‘invisible stressors’ people with chronic pain may experience in particular.
It is clear that the relationship between stress and chronic pain is a complex phenomenon that has wider impact on lived experiences, and can even exacerbate pain sensation. Stress-related illness is becoming a more common occurrence (both in relation to chronic pain specifically and outside this area) and it is widely recognised that too much or too intense stress is not good for us. It is important to remember this is very much on a case-by-case basis and individual differences play a huge role in determining outcomes, but nevertheless there are some things that could be helpful in reducing how much stress impacts you
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Stress Management – What Can You Do?
Simple stress management techniques take on many forms, and the effectiveness of different strategies vary individually, person-to-person. We have compiled a few different ideas, alongside some research, to help you explore different strategies that might work for you. Please also remember to be kind to yourself as you try and work through your stressors - one size certainly does not fit all!
Guided imagery and relaxation:
Guided imagery, which generally involves visualising positive images, may also be a method to help alleviate stress. Lewandowski et al.’s (2005) research found that people experienced enhanced feelings of being in-control as well as lower pain intensity after using guided imagery techniques. In this study, individuals were encouraged to visualize personal sensory images associated with their pain. One participant’s report of this process stated “This morning when I did the tape, it was just really relaxing. When I blow the pain out, I crinkle it up, and then I throw it away, and it flows out.” (Lewandowksi et al., 2005, p. 65).
Yoga or Tai Chi:
Yoga and Tai Chi are forms of movement, stretches and posture sequences combined with relaxing breathing techniques that are commonly used to help reduce stress and pain. There are many adaptations to individual moves or whole classes (e.g. seated yoga) that are widely available online. We previously wrote a blog about somatic practice in chronic pain which further explores how movement can help alleviate some pain sensation as well as other longstanding benefits, check it out by clicking the link above.
It is important to note that the research outlined above should be interpreted with caution. Often, to see long-term positive effects in stress reduction, regular practice is needed over time. Such stress-management techniques are not always ‘quick and easy fixes’ in times of intense stress and as such might not be what you’re looking for.
Managing stress looks different for everyone, so here are a few other things to try that might help:
- Going for a walk – (even just a short walk) can have a real positive impact on mood and reduce feelings of being overwhelmed.
- Dance therapy/rhythmic moving – whether you take a formal class hosted by a professional or you move around your living room to your favourite song on the radio, the power of movement can be very helpful in reducing feelings of stress and improving pain.
- Being around nature or gardening – the benefits to being outside and surrounded by wildlife, plants, nature etc. are widely recognised. This year for Mental Health Awareness Week in May the theme is connecting with nature and the Mental Health Foundation have put together a handy resource with some top tips to bring you closer to nature.
- Simple breathing exercises – try the “square breathing” technique to take a few minutes to yourself and relax your body.
- Creativity – if you’re someone who likes small repetitive tasks to keep your attention focused on something, give activities like painting by numbers, knitting, crochet or Macramé a go! There are many helpful instruction videos or free patterns available online.
- Music or audiobooks – music is a great tool to help mood, with lots of different genres to choose from depending on your preference. There are playlists on lots of different music platforms dedicated to relaxing, or stress-relief. There are even some based-on nature, like recordings of beach waves or rustling trees in the wind. Also, audiobooks are a great way to get lost in a story and transport yourself elsewhere!
- Speaking to a friend/loved one – a problem shared can sometimes be a problem halved! It is encouraged that people talk to one another, sometimes different perspectives can help or sometimes you just need to say what’s wrong out loud to someone you love.
- Sleep – although not always easy to achieve, sleep can help reduce feeling stressed and is the body’s way to relax and rejuvenate. Try not to force yourself if you can’t sleep, listen to your body. The focus is on prioritising and protecting time to be able to sleep when you need it.
People with chronic pain often experience daily stressors that can impact their wellbeing, social relationships, and the pain itself. In this blog we have tried to give an overview of how stress and pain are related as well as a variety of stress-reducing activities.
As we have mentioned, stress management is by no means a ‘one-size-fits-all' approach and there are sometimes no quick fixes; try a few different techniques and see what works for you, remember to be kind to yourself and please talk to your GP or primary healthcare provider if you have any concerns.
For some more ideas of ways to manage stress, check out the NHS recommended ‘stress busters’ and additional independent resources at the end of this blog!
Written by: The WITHIN Team (Jenna Gillett, Paige Karadag, Michelle Pun, Emily Ashton & Dr Nicole Tang)
NHS recommended ‘stress busters’: https://www.nhs.uk/mental-health/self-help/guides-tools-and-activities/tips-to-reduce-stress/
Edinburg Health and Social Care partnership – Stress and Chronic pain webinar handout: https://services.nhslothian.scot/painmanagement/Documents/Webinar%203%20Handout%20Stress.pdf
West Suffolk NHS Chronic pain self-management – Relaxation techniques: https://www.wsh.nhs.uk/CMS-Documents/Patient-leaflets/PainService/6290-1e-Chronic-pain-self-management-relaxation.pdf
Cortisol – the body’s “stress hormone” which is secreted by the adrenal glands as part of the body’s “fight or flight” response.
Biomarker - a naturally occurring molecule, gene, or characteristic in the body that is then used to identify a particular pathological or physiological process or condition.
Stressor – a term given to describe something that causes stress to an individual. It could be an event or a build up of emotions.
Ashkinazi, I. Ya., & Vershinina, E. A. (1999). Pain sensitivity in chronic psychoemotional stress in humans. Neuroscience and Behavioral Physiology, 29(3), 333–337. https://doi.org/10.1007/bf02465346
Henwood, P., & Ellis, J. A. (2004). Chronic neuropathic pain in spinal cord injury: The patient's perspective. Pain Research & Management, 9(1), 39–45. https://doi.org/10.1155/2004/863062
Lewandowski, W., Good, M., & Draucker, C. B. (2005). Changes in the meaning of pain with the use of guided imagery. Pain management nursing : official journal of the American Society of Pain Management Nurses, 6(2), 58–67. https://doi.org/10.1016/j.pmn.2005.01.002
Rosenzweig, S., Greeson, J. M., Reibel, D. K., Green, J. S., Jasser, S. A., & Beasley, D. (2010). Mindfulness-based stress reduction for chronic pain conditions: Variation in treatment outcomes and role of home meditation practice. Journal of Psychosomatic Research, 68(1), 29–36. https://doi.org/10.1016/j.jpsychores.2009.03.010
Tul, Y., Unruh, A., & Dick, B. D. (2011). Yoga for chronic pain management: a qualitative exploration. Scandinavian journal of caring sciences, 25(3), 435–443. https://doi.org/10.1111/j.1471-6712.2010.00842.x
Van Uum, H. M., Sauvé, B., Fraser, L. A., Morley-Forster, P., Paul T. L., & Koren, G. (2008) Elevated content of cortisol in hair of patients with severe chronic pain: A novel biomarker for stress, Stress, 11(6), 483 488, DOI: 10.1080/10253890801887388