Managing Persistent Pain, Anxiety and Stress During Covid-19
The world we find ourselves in today is different from our normal, is constantly changing and has so much uncertainty. For many people this can lead to increased levels of stress and anxiety. This period of self-isolation due to Covid-19 is an extremely challenging time for everyone but for a variety of different reasons. But no matter what you’re going through or why, we’re almost all dealing with increased levels of stress and uncertainty.
Now, what is the link between stress, uncertainty, and physiotherapy? Pain. Pain is the primary reason why people come to see physiotherapists, and it is very closely connected to stress and anxiety. As clinicians we have a duty to educate our patients about their pain, and all of the factors contributing to it.
How can stress cause pain?
Pain is very complex. Many people think that pain = damage and although this can be true to an extent, we can also have pain with no real damage and often the amount of pain we experience is not directly proportional to the amount of damage an injury has caused. It depends on many factors making pain a very individual experience – no two individuals are going to feel the exact same amount of pain and it will last differing amounts of time for each person despite arising from the same injury. Many people experience physical pain long past the known time for tissue healing (have you ever had a sprained ankle that gave you trouble 12+ weeks later…once those tissues have healed?). We can have pain even when you would think that it wouldn’t be physically possible – like how individuals with an amputated limb can feel pain in part of their limb that doesn’t exist anymore – this phenomenon is known as phantom limb pain.
How Does Pain Work?
Pain is an electro-chemical response of our nervous system which consists of our central nervous system (our brain and spinal cord) and our peripheral nervous system (the nerves that supply our senses of our skin, muscles and ligaments). Because our pain system involves our brain – our thoughts, beliefs, fears, past experiences and our emotional states (such as stress and anxiety) are intricately connected and affect our experience of pain.
Credit: Gifford (1998)
In a very basic sense what happens in the signalling of a pain (the production of, or a decrease/increase of a pain experience) depends on a chemical balance. Research has shown that a perceived threat (even if it never actually occurs or isn’t a true threat) can be enough to activate a stress response, change the chemical balance and change a person’s pain experience (research). Perceived threats in the brain such as stress, anger, anxiety, fear or painful memories cause an increase in the chemicals that excite the spinal cord (such as glutamate and substance P) and if the spinal cord gets excited enough it increases the transfer of the pain signal to the brain. If the brain does not perceive a threat (you are thinking of happy thoughts or doing something that releases these happy chemicals such as exercise) it decreases the excitement of the spinal cord via chemicals such as endorphins and serotonin and that helps to dampen the pain messages and to decrease pain.
This short animated clip is one of my favorites to explain the pain process, and I hope this helps you understand what is a really complex phenomenon
You are not alone!
When the COVID-19 shutdown started and I began reaching out to my patients through phone calls and virtual sessions to check in , I became acutely aware of just how much stress people are under and how some individuals are noticing an increase in symptoms because of this. It is an extremely tough time for everyone but especially those in pain so I wanted to provide some hope and strategies to help cope in this unique environment.
What Can I Do To Ease My Stress Related Pain?
First off, know that this will not last forever and you are not alone. The world is different right now and we are all adjusting. For example, just because you can’t go into your Physiotherapy clinic doesn’t mean you are alone dealing with your pain. Most medical professionals are doing some sort of telehealth or virtual care for patients. If you haven’t heard from your care provider and need help then reach out to them or find someone who can support you at this time. Don’t downplay the importance and effectiveness of this. In a recent publication it was found that the information we gain from listening to you about your pain and the education we provide to help you understand your pain are two of the most effective ways to help patients improve pain, mobility and function.
Sometimes education is the key to helping you manage your symptoms. For example – one of my virtual assessments resolved their pain completely by just following two of my suggestions: During a virtual call, I suggested she upgrade her worn down running shoes, and add a bit of variety to her workouts. We didn’t need to see each other face-to-face in a clinic to improve her pain, she just needed someone to listen, and provide some guidance.
Research has shown that pain education alone can help improve pain. Prominent pain researcher Lorimer Mosely showed that after receiving pain education, patients’ pain thresholds were increased when performing a physical task and the outcome of other therapeutic interventions such as exercise also improved. Click here for the article.
For those of you who had already begun working with a physiotherapist before this self- isolation you should be armed with at least some home exercises to help you manage independently. If you need a refresher or need to change your program we are here to help! Exercises and education are some of the most important things we provide to our patients and this is easily done over a virtual consult. Home exercise is always an integral part of our treatment whether in clinic or virtual. These exercises are what will help you improve quickly – they are specific to your needs and can be done everyday to speed up your recovery.
My patients who are diligent with their home exercises improve much faster than those who aren’t. We can provide you with the tools to make yourself better by consistently working toward your goals. Virtual care is a great option and will be here to stay even when clinics do re-open. Don’t wait to take control of your pain!
What can I do to help manage my stress and pain during this time?
1) Take it one day at a time.
On any road to recovery it is a roller coaster ride – although the trajectory is overall trending up it is not typically a straight line right up with no “bumps” in the road. There are going to be good days and bad days. When you are feeling like you’re improving and then have a bad day/pain day it is hard not to get frustrated or sometimes to feel like you are taking steps backwards but know this is normal – just because one day has more pain, it doesn’t mean that it will stay like this.
2) Take control of your pain in the ways you can.
Many patients have expressed fears of regressing during this time. This is a normal response to the loss of treatment that was helping you. But know that you will not slip back to where you were before. Do the parts of your recovery plan you can (home exercises etc) – many of you will actually have more time to get these done with your usual commute eliminated. Reach out to your care provider for help. If you’re having a rough day and experiencing a lot of pain – remember it won’t last forever, and focus on what you CAN do to manage. Something as simple as intentionally using positive imagery can help to decrease your pain. Creating different emotions in times of pain or stress can help (i.e. watch a sitcom, listen to a stand-up act or podcast, listen to some upbeat music or look through a photo album that brings back happy memories).
3) Stay positive!
Focus on the good things that have come from this…more time connecting with family and time for things that typically are difficult to fit in : home workouts, read a book, paint/draw – enjoy the slower pace of life many of us crave when we are busy, rather than focusing on the parts that are hard or frustrating.
4) Keep yourself stimulated with activities you enjoy.
This could be anything: puzzles, arts and crafts, reading a book, cooking/baking, exercising, watching a TV show, gardening or board games.
As humans we naturally want to contribute and feel like we are doing something that has a purpose. Losing this sense of productivity can be really hard. However, we also derive feelings of happiness and purpose from helping others. There are so many ways we can do little things to brighten someone’s day – there are many elderly people who are truly isolated right now – can you write letters or give a quick call to those in your community to reach out and chat with them? Can you order food online for your elderly neighbours or family members? Use your special skills to help in ways others might not be able to (i.e. making masks if you have sewing skills).
6) Stick to a routine
Although it is so appealing to wake up and stay in your PJs all day, try and stick to your typical routines as much as possible (i.e. wake up, have a shower, get into some clothes – even if they are just track pants…make a change out of those PJ’s). If you are lucky enough to still be working, then carve out a dedicated place to do your work that is not your bed. If you aren’t working, come up with some things you want to accomplish each day (write a letter, call a grandparent or clean out a storage space). It doesn’t have to be a lot – just making a call to help brighten someone else’s day can bring a sense of happiness and accomplishment.
7) Take some time for yourself.
Having family around is a blessing but none of us are used to being around our spouses and kids 24-7! This alone can be stress inducing! It’s important to carve out time in the day just for you, and make sure not too much of the day is spent multitasking. Take time to go for a walk, take a bath, meditate, or listen to music – do something each day that is just for you!!
Fresh air, a change of scenery and exercise can really help to improve your mood, stress, anxiety and pain. This was described in a recent publication from McMaster University about the importance of staying active during COVID. Just ensure you are doing so with proper social distancing. If you’re not able to leave the house there are many other ways to keep active in this time as well: online/virtual classes, group zoom workouts with your friends/family,even taking the stairs up and down in your condo!
I hope this helps you understand your symptoms a little bit more, gives you some strategies to manage them and remember: if you need help, we are here for you! If you want to dive deeper into this topic, I highly recommend the book Explain Pain by Lorimer Moseley.