Chronic pain can truly be considered a pandemic, affecting a large swath of people all over the world -numbers vary, but 20% of the world population seems to be a conservative estimate (1). Introducing the no-pill remedy. Over the last few decades, as scientific understanding of chronic pain evolved, pure biomedical treatments focusing on drug prescription, and potentially dangerous interventions such as lumbar fusion surgery, gave place to multimodal approaches acknowledging the complex biopsychosocial nature of chronic pain. Based on this knowledge, and a dire need to address an ever-growing public health concern, pain clinics and pain centers proliferated to specifically treat chronic pain syndromes (pain with no demonstrable cause was rarely treated before the 1970s) (2).
Today, we have a strong -but still fragmentary- idea of how lifestyle factors (nutrition, physical activity, occupation, sleep habits, and so on), rather than disease per se, contribute to and can even trigger chronic pain. However, current treatment options do not always address the many lifestyle factors associated with chronic pain, and when they do, advice is often generic and rather vague: “eat well”, “exercise more”, “do not smoke”.
Physical Therapy is an increasingly common point of entry into the healthcare system, especially for people with chronic pain. Therefore, the ability to provide individually tailored, multimodal lifestyle interventions to manage and overcome chronic pain is a great and unique opportunity for physical therapists.
The No-Pill Remedy & Crossing Pathways: Lifestyle ⇄ Chronic Pain
Physical (in)activity: Chronic pain is normally associated with decreased physical activity, especially in the elderly and in those with substantial pain-related disability. However, there is a strong consensus about the importance of physical activity as part of multimodal management approaches to chronic pain.
Physical activity and exercise interventions have shown to attenuate pain severity and improve physical functioning and quality of life (4). Conversely, physical inactivity has been linked to excess mortality in patients with chronic pain (5). Remarkably, however, data from the National Health and Nutrition Examination Survey (NHANES) revealed that people with chronic pain that adhered to the minimum recommended amount of daily physical activity had lower risk of all-cause mortality than people without chronic pain that were physically inactive.
Sedentary behaviour (performing activities while sitting or lying down) might also contribute to chronic pain independently of physical (in)activity. Available research supports plenty of anecdotal evidence linking sedentary occupations and habits with chronic pain. Seating for long periods of time (either at work, or watching TV) was reported to double or triple the odds of developing chronic pain (6, 7, 8). Therefore, engaging in physical activity and exercise is paramount to minimize the chances of developing chronic pain for those with sedentary occupations (or who spent a great deal of leisure time sitting on a couch).
Stress. Stress may have physical, psychosocial, or emotional roots and entails physiological imbalances that may exacerbate pain sensations and negatively condition behavioral responses to their effects (9). Pain and stress are both evolutionarily conserved, protective adaptations, and a tight relationship exists between them. Indeed, chronic pain has been conceptualized as “one type of stress that adds strain on the organism” and determines “wear-and-tear” (i.e. allostatic overload) in the body and brain “from chronic dysregulation (i.e., over-activity or inactivity) of physiological systems that are normally involved in adaptation to environmental challenge” (10). According to this view, chronic back pain (CBP) has been considered “a stress overload resulting in an increased risk for depression, alcohol abuse, or weight gain” (11). A second model linking pain and stress focuses on cases in which wear-and-tear precipitates chronic pain. In this model, an unpredictable and strong stressor (a migraine attack, for example) leads to a vicious circle of “feed-forward” maladaptive physiological responses involving altered nociception in the brain and increased vulnerability to persistence of pain (11).
Sleep. Sleep problems are very common in people suffering from chronic pain. Up to 90% of adults and approximately 50% of children and adolescents with chronic pain report a clinically significant degree of insomnia (12). If left untreated, insomnia can represent a barrier for an effective chronic pain management: sleep problems act as a perpetuating factor of chronic pain, and are correlated with depressive symptoms, functional disability, more frequent healthcare utilization and reduced quality of life (13, 14).
Non-pharmacological treatments of insomnia (often Cognitive Behavioural Therapy) for chronic pain conditions demonstrated rapid, significant improvement in sleep quality, smaller improvements in pain and fatigue, decreased symptoms of depression, and less stress (15).
Unfortunately, current pain treatments rely mostly on prescription of sedative pain/sleep medications to address sleep problems associated with chronic pain.
Nutrition. Although poor nutrition can worsen many chronic pain conditions, eating habits are frequently overlooked in current pain management strategies. Evidence shows that being overweight or obese increases the risk of developing multiple conditions associated with chronic pain, such as diabetes, arthritis, and cardiovascular disease (16). Accordingly, chronic pain is more prevalent -and more severe and debilitating- in overweight and obese people (17). Conversely, chronic pain patients, especially those reporting high-intensity chronic pain, tend to show higher rates of obesity/metabolic syndrome-related pathologies like cardiovascular disease (18). Evidence-based support for the therapeutic effect of nutrients on chronic pain was provided by a recent meta-analysis, which confirmed that nutritional interventions targeting dietary patterns and specific nutrients resulted in significant pain relief (19).
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Implications for Physical Therapy
Considering the multiple factors at play in those experiencing chronic pain, the authors emphasize the importance of a multimodal approach to chronic pain treatment. Such approach should consider patients’ needs, goals, values, and possibilities, in the attempt to modify lifestyle aspects that help maintain chronic pain.
- Individual barriers to physical activity and exercise adherence need to be considered when designing interventions for people with chronic pain. Such barriers include pain cognitions and beliefs (e.g. fear of movement, pain catastrophizing, self-compassion, and acceptance) that promote sedentary or avoidant behavior and hamper recovery efforts.
- Stress management should be incorporated for people having difficulties coping with everyday stressors
- Sleep issues need to be addressed in relation to physical and psychological stressors that prevent optimal sleep (12).
- Nutrition habits need to be evaluated, to assess whether dietary advice or a behavioral weight reduction program need to be set up.
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9- Hannibal, K. E., & Bishop, M. D. (2014). Chronic stress, cortisol dysfunction, and pain: a psychoneuroendocrine rationale for stress management in pain rehabilitation. Physical therapy, 94(12), 1816-1825.
10- McEwen, B. S., & Gianaros, P. J. (2010). Central role of the brain in stress and adaptation: links to socioeconomic status, health, and disease. Annals of the New York Academy of Sciences, 1186, 190–222. doi:10.1111/j.1749-6632.2009.05331.x
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19- Brain, K., Burrows, T. L., Rollo, M. E., Chai, L. K., Clarke, E. D., Hayes, C., … & Collins, C. E. (2019). A systematic review and meta‐analysis of nutrition interventions for chronic noncancer pain. Journal of Human Nutrition and Dietetics, 32(2), 198-225.