Stress and Pain -- The Link Between Is Very Real

Many of my patient appointments start with the usual — BP, temperature check, current medication list, pain scale rating, etc. — and the question, “How would you rate your stress level?” Many patients are caught off-guard by the question and ask me why I always want to know the level of their stress.

Just the other day, a patient with CRPS asked me this exact question on her telemed appointment. However, this question is not reserved for my patients with what is considered the severest forms of chronic pain. The patient could have just as well had chronic low back or neck pain, chronic migraines, fibromyalgia, neuropathy, or any other chronic pain condition. I ask this questions of almost every patient because it is that closely linked to the increase in pain, especially chronic pain.

Many of my appointments go a bit like this, ‘Hi, Dr. Rock. I need to talk about my pain and what you can do to help me. Why are you asking me so many things that are unrelated to my pain — if I worry, if that worry keeps me awake at night, what’s going on at home, whether my family believe me that I hurt as much as I do. I’m here to talk about my pain but you seem to want to talk about everything but my pain. Why?’

And it’s true, while I do always evaluate a patient’s pain, I need to assess any stressful problems that my patient is experiencing. To the list above concerns shared by my patient above, I might even add other stress questions like are you depressed, do you feel anxious, is there a past trauma you have experience, do you have persistent problems with concentration or short-term memory issues, or are you worried about finances or the loss of your occupation, family, or relationship, and this list could go on. All these problems cause stress, which is why we call them stressors. So, why is it important to deal with these stressors when you have chronic pain? And why must I look at and address the stressors themselves?

Understandably, my chronic pain patients want to focus on how to reduce their pain. And, this focus is helpful, to some extent. But, there are a number of lifestyle changes that could be helpful for these patients — mild exercise and regular relaxation practice can reduce pain over time. Also there are some medications — tricyclic antidepressants and antiepileptics — that can be prescribed by a specialist, that have been shown to reduce pain, as they act to reduce stress. These treatments are only so effective though. Unfortunately, we don’t have treatments that are really effective in treating chronic pain, particularly a singular treatment. There are procedures — injection therapies, spine surgeries, SCS implant — which can be effective in targeting one aspect of a patient’s chronic pain, but there are other factors that impact this pain that also need to be managed.

At the end of the day, chronic pain is called “chronic” for a reason. It is ultimately not fixable. I do what I can to help alleviate the pain, manage symptoms and mitigate side-effects of medications, procedures, etc. as well as outside stressors. And, if you can’t completely fix pain that is chronic, focusing on other problems that occur as a result of this chronic pain is helpful.

It IS possible to have chronic pain and not have it disrupt your life.

It IS possible to have chronic pain and not be depressed or anxious about it.

It IS possible to have chronic pain and sleep at night.

It IS possible to have chronic pain and work.

AND it IS possible to have chronic pain and have fulfilling relationships.

Many patients do need to learn how. But, if they are open to learning, they can work to self-manage their pain well enough to overcome some of these secondary problems. This can take time and practice. It also takes a certain amount of devotion to maintain the lifestyle changes necessary. But, it IS possible. Patients learn chronic pain stress management, using cognitive behavioral therapies.

When you overcome depression, even if chronic pain remains, it’s still a win for you. When you come to sleep well at night, after a period of chronic insomnia, life gets better, even if you continue to have chronic pain. When the strain in your relationships subside, your family life and relationships with your friends can deepen, making life more meaningful and fulfilling, despite having chronic pain.

Overcoming the stressors in life, even when they occur as a result of chronic pain, is a way to get better, even when there is no true path to a cure for the chronic pain itself. Patients with chronic pain might initially wonder why I want to focus on the stressors in their lives, but it is to figure out a way for them to possibly to get better. I want to help my patients focus on overcoming some of these stressful consequences of living with their pain. To make their living even a little easier and better.

Additionally, by overcoming pain stressors, things get easier to deal with – pain included. It begins to become more tolerable. When you sleep reasonably well on most nights, you deal with everything better, including pain. The same can be true for the stressful problems that go along with living with chronic pain. When you work to overcome the stress, you are better able to cope with the pain itself, to go from what was once intolerable to now tolerable. This is also a form of chronic pain management and is as important, if not more, than directly addressing the pain. A true pain management specialist should focus on both the pain and the patient’s environment.

Whether it is from depression, insomnia, relationship issues or financial problems, stress affects patients by the effect it has on the nervous system. A persistently stressed nervous system leads to chronic muscle tension, which becomes painful in and of itself, on top of any chronic pain conditions. And, when looking at the role of stress from this perspective, most every chronic pain patient readily understands it, because they live it. They see and experience daily how stress affects their levels of pain.

Stress and its effect on the nervous system can exacerbate pain through more direct routes too. It's not just the effect that stress has on muscle tension. It’s harder to see from your own personal experience, however, and so you'll have to rely on a more textbook-like explanation. Stress, particularly the persistent stress of problems that occur as a result of chronic pain, causes changes to the nervous system itself. These changes occur in the spinal cord and brain, resulting in changes in how sensory information is processed. An example of sensory information is pain signals that travel from nerves in the body, through the spinal cord, and up to the brain; the brain subsequently processes this information and the experience of pain results. As a result of persistent stress to this system, the brain comes to process such information with greater and greater sensitivity and, as a result, less and less sensory information is required to experience pain.

It’s generally accepted that by overcoming the persistently stressful problems that occur as a result of living with chronic pain, you can make some headway in reversing these changes in stimuli processing. You might not be able to change them entirely, but enough to reduce the pain itself. Indeed, most doctors concur that to adequately manage chronic pain, stressors must be addressed.

So, the next time your doctor asks you “What is your stress?” you know it is to help you manage your pain.