Chronic Pain – A Three-Tiered Approach

Chronic Pain – A Three-Tiered Approach

Pain serves a purpose; it exists to alert us to potential or existing damage to the body. It can arise from injury or disease. After the brain has received and processed the pain message and coordinated a suitable response, pain has served its function. Endorphins, the body’s natural pain killer, are meant to derail further pain messages from the same source. However, these natural pain killers may not dampen a continuing pain message sufficiently. Certain conditions lead to chronic pain which does not resolve. The time limit used in definitions of chronic pain ranges from three to six months but most use a flexible definition which considers pain chronic when it endures beyond a normal period of healing. Unfortunately, many people with autoimmune conditions are all too familiar with chronic pain. Much has been done in the field of pain management to assist these patients. It has become clear that the best approach is often one that incorporates a multidisciplinary approach, with the greatest relief being achieved using a combination of treatment options. In this three-part series we examine a multitude of options for pain relief and ways to ameliorate chronic pain symptoms. These options can be classified into three broad categories: noninvasive/non-drug pain management, noninvasive pharmacologic pain management and invasive pain management. Over the next three months we will address each in turn and evaluate the different options for pain management.

Part 1: Noninvasive, Non-drug Pain Management

Given the circumstances created by the COVID-19 pandemic, pain management techniques that can be undertaken at home are increasingly important. Many of the options outlined below are easy, affordable and don’t require much beyond what can be found in our own homes and cupboards. So, read on for techniques that can be used during social distancing and beyond.

Superficial heating and cooling

A very simple, yet tried and true pain reduction technique is altering between the use of cold and hot packs. Heat works to soothe stiff joints and relax muscles. Cold can be effective to numb sharp pain and reduce inflammation. Temperature therapy is a simple and affordable option than can be used to complement other pain management techniques. One key point to remember when using this technique is to not overdo it. It is perfectly normal for your skin to look pinker after applying a hot or cold pack. Before repeating, allow your skin time to return to its normal color to avoid skin damage. Ensure you wrap the pack in a towel to avoid using overly extreme temperatures. Along with traditional hot or cold packs there are other ways to employ this technique such as taking a warm bath or exercising in a heated swimming pool. Low level heat wraps (that can be purchased from most drug store)s can provide extended periods of warmth for up to eight hours and heating your clothing up on a radiator can give relief until morning stiffness has eased with movement.


Physical activity plays a significant part in interrupting the vicious cycle of pain and reduced mobility in conditions like arthritis and fibromyalgia. For patients with chronic conditions, this can be a balancing act as pain and fatigue can lead to exercise avoidance. Research has shown that regular exercise diminishes pain in the long term through improved muscle tone, strength and flexibility which help to stabilize and support affected joints. In the short-term, exercise helps to curb pain by increasing the levels of our own body’s natural painkiller – endorphins. It may be tempting to avoid exercise altogether on “bad days.” Try instead switching to a gentle routine with lower impact like yoga or swimming.

While at home you may not be able to attend a yoga class or go to the gym but don’t simply skip your workout sessions. Technology has ensured that there are a multitude of options for working out at home from instructional online videos to live instructional classes, many of which are geared towards those with limited mobility. If you have regular workout partners perhaps arranging a video call so that you can still workout “together”.

Physical and Occupational Therapy

These two specialties can be among your strongest allies in your fight against chronic pain. Physical therapists can assist through targeted massage and gentle movements to stretch and strengthen muscles. Some physical therapists will offer the use acupuncture or dry needling.  It is thought that these methods decrease pain by increasing the release of endorphins. Numerous acu-points are near nerves, when stimulated, these nerves cause a dull ache or feeling of fullness in the muscle. The stimulated muscle sends a message to the central nervous system (the brain and spinal cord), resulting in the release of endorphins thus blocking the message of pain from being delivered to the brain. Transcutaneous electrical nerve stimulation therapy, more commonly referred to as TENS could also be an option given by your physio. This technique uses electrical stimulation to diminish pain. The procedure involves a low-voltage electrical current delivered through electrodes that are placed on the skin near the source of pain. The electricity from the electrodes stimulates the nerves in an affected area and sends signals to the brain that “scramble” normal pain signals.

Occupational therapists can teach you new ways to carry out daily tasks so as to avoid aggravating your pain. Together these two specialties help you to work out an effective exercise routine giving different options for days when your pain is worse.

In the current circumstances, contact your physical or occupational therapist for advice on how best to continue therapy at home. They may be able to assist you through video chatting, give you instructional documents or may even instruct your family in simple techniques they can perform to assist you.

Therapeutic Massage

Massage is so much more than an indulgence. For those with chronic pain this can be an effective tool to reduce muscular tension as well as anxiety and stress. An additional benefit can be that the pleasant sensations caused by massage can compete with pain signals, thus overriding the pain signals offering a great deal of relief and helping again to break the pain cycle, therefore giving short- and longer-term relief. So, consider this as part of your pain management strategy and not merely an occasional treat.

A massage doesn’t have to be done by a professional to have an effect. If you stay with friends or family chances are, they’ll be happy to help out. Ensure they approach the task gently with an emphasis on any areas or joints that are particularly sensitive or tender and be vocal if something hurts so as to avoid damage.

Mind-Body Techniques

These techniques include but are not limited to meditation, mindfulness, biofeedback and breathing exercises. These techniques can help you to gain a sense of control over your body through the mind’s ability to affect functions and symptoms within the body. They can help to turn down the “fight or flight” response which can amplify chronic muscle tension and pain.

Visualization may be another useful technique to help with pain control. There are a number of different guided visualizations available for free online. An exercise to get you started can be as simple as closing your eyes, calling up a visual image of the pain you are experience – picture the shape, color and size of the pain. Once you have a clear visual try to slowly alter the image, focus on creating a more pleasing visual – a color you associate with calm, a smaller size and a pleasing shape. Repeat this as often as necessary. Breathing techniques can be incorporated such as making changes to the image as you exhale slowly.

Biofeedback as a technique involves learning relaxation and breathing exercises with the aid of a biofeedback machine. A biofeedback machine turns data on physiological functions (such as heart rate and blood pressure) into visual cues such as a graph, a blinking light, or even an animation. Watching and changing the visualizations gives you a degree of control over your body’s response to pain and gives valuable feedback on what is or isn’t working for you.

Record Keeping

A pain diary can be extremely useful. It can help you to track your pain and identify triggers that make your pain worse or those that lead to improvement. A diary can help you to identify contributing factors that you may not have realized were having an impact. Keep track of your daily activities, rate your pain on a scale and whether your reaction reduces it. Review your diary regularly to explore avenues of possible change. This record can also be helpful to your physician to better accurately identify the source of the pain, identify side effects from new drug therapies and alter their treatment protocol appropriately. This can help you to also see pain as just a part of your life not all of it. There are a number of online templates available to get you started. 

Given that usually in our daily lives time is limited we may not have prioritized keeping a record of our pain. Use the time saved from travelling and not being able to socialize while you shelter at home to start your pain diary. Once daily life resumes and an element of normality has returned, chances are you’ll already have picked up on a few things that impact your pain positively or negatively. Knowing the value of keeping a pain diary will make it easier to do in the future.  


Support can take many forms but no matter the form it can be an effective way to mentally cope with chronic pain. A support group can offer you a number of benefits. People who have been living with chronic pain for extended periods can be a wealth of wisdom regarding ways to reduce and handle your own pain. Establishing relationships with others in a similar situation can help to reduce the isolation that can accompany chronic pain.

Consider seeking professional help from a mental health professional. Depression is a common side effect of chronic pain which in turn can make the pain worse. It’s important to acknowledge when you need assistance, a therapist can give you effective coping techniques and provide a safe space to discuss your feelings regarding your condition. Developing a healthy attitude to your situation can contribute to avoiding negative thoughts which can make the pain worse. Asking for help is a sign of strength not one of weakness.

Many health professionals and support groups have made themselves available for telephonic or video counselling during this difficult time. The emotions many of us are feeling in these unique circumstances can make it all the more important to reach out where possible.

Healthy Habits

This is something we should all practice but for those with a chronic condition this can be of even greater importance. Avoid smoking which can cause pain due to poor circulation and increased inflammation. Smoking triggers a response which has been shown to result in increased levels of inflammatory markers, such as C-reactive protein and white blood cell count. Nicotine activates certain white blood cells, called neutrophils, which in turn release molecules that lead to increased inflammation. Although stopping smoking can be difficult due to the physiological and psychological addiction, smoking could be genuinely contributing greatly to your chronic pain. Speak to your physician about medication that can assist with quitting and whether it is something you would be able to use. Or speak to your mental health professional about techniques you can use to overcome the initial cravings.

A well-balanced diet can not only help to maintain a healthy weight which reduces pressure on painful joints, it can in fact be a tool by which you reduce inflammation. The grocery store can be a key tool to combat inflammation and reduce the associated pain. Certain fruits and vegetables including blueberries, apples, and leafy greens that are high in natural antioxidants and polyphenols (protective compounds found in plants) are the mainstay of an anti-inflammatory diet. Studies have also linked nuts with reduced markers of inflammation and a lower risk of cardiovascular disease and diabetes. Coffee, which contains polyphenols and other anti-inflammatory compounds, may protect against inflammation, as well. Unsurprisingly, the same foods that are generally considered bad for our health are those that are associated with increased inflammation, including sodas and refined carbohydrates, and red meat and processed meats. Many food plans targeted at reducing inflammation are available.  There is no need to deprive yourself to the point of misery, but consider that some pro-inflammatory foods should be taken in limited moderation.

Sheltering at home may be an impediment to healthy eating for many people. Food can be used for emotional comfort or consumed in higher quantities during periods of boredom. On the other hand, current sheltering orders could work in favor of developing new eating habits that can help keep pain at bay. As its not simply a case of popping to the shops at the moment, if you limit the “wrong” food in your rare shopping trips, you won’t have a choice but to practice moderation. Additional time at home may also be an opportunity to become more comfortable in the kitchen. Consider trying a new anti-inflammatory recipe every day. You may be surprised by the yummy and physically beneficial results.

A Multi-Tiered Approach

If you suffer from chronic pain, consider the benefits of incorporating some or all of these recommended techniques to your daily routine. Pain can affect different people differently, so go at your own pace in putting these ideas into practice and find the combination that works best for you. Of course, the medication and surgery free approach may only be part of the overall plan to get your pain into check. Stay tuned to upcoming editions of the ANRF Chronicle for in depth looks at non-invasive and invasive medical options for pain management as we continue our three part series.


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Article Author
Arthritis National Research Foundation

The Arthritis National Research Foundation's mission is to provide initial research funding to brilliant, investigative scientists with new ideas to cure arthritis and related autoimmune diseases. Writing articles about the patients affected and the science being done to find a cure shows why we need to come together to #CureArthritis!

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