Talking Back to Chronic Pain

The Vicious Cycle of Chronic Pain

Has your chronic pain led you into a vicious cycle of worsening health? Here’s how that has happened for many people, according to a 2020 study of older adults (average age 65) with knee osteoarthritis, led by Dr. Ruixue Zhaoyang of Penn. The research is stated and summarized here.

Chronic pain is a widespread problem, the study authors report: "Chronic or persistent pain affects approximately 60% to 75% of adults older than 65 years of age in the United States. Musculoskeletal disorders such as knee osteoarthritis (OA) are the primary cause of chronic pain in older adults."

Staying physically active can ease knee osteoarthritis. However, researchers uncovered a vicious cycle in which pain sufferers stopped physical activities because of pain. Avoiding movement further increased their pain. Because of the increased pain, sufferers moved around even less, thus further adding to their pain problems, and completing the vicious cycle. In addition, adopting a sedentary lifestyle created other problems, such as a higher risk of depression and a decline in general health.

A group of 143 pain sufferers (all of whom had knee osteoarthritis) participated in the study. Some tended to talk to themselves like this in the morning:

• “The pain is terrible and is not going to get any better.”
• “I can’t stand the pain anymore.”

In other words, they “catastrophized,” imagining the worst possible outcome. Such catastrophizing self-talk turned out to be independent of their actual experience of pain, according to a daily log of pain intensity kept by each participant for 22 days. Not only did this self-talk cause mental anguish, but catastrophizers were less likely to exercise both on the day they engaged in negative self-talk and also the next day as well.

This research suggests that chronic pain sufferers might be able to lessen their pain experience by altering their self-talk. But how to do this? Previous research offers a strong case that techniques from cognitive behavioral therapy (CBT), alone or combined with other interventions, could help.

While more research is being done on such interventions, you could experiment with one or more of the self-talk ideas below to find out if these simple mental strategies can alleviate your pain. Although the research above looked at only one type of chronic pain—osteoarthritis of the knee—it is possible that sufferers from other types of chronic pain could benefit also. (Important cautions appear at the end of the blog.) Here are six ways to talk back to chronic pain:

1. Reframe Your Pain as a Cue to Move

Begin by interpreting stiffness, aches and pains, and lethargy as cues to move around, not as signals to sit and rest. This helpful idea comes from Carol and Mitchell Krucoff, authors of Healing Moves. As they write in their insightful blog, "...when we get stiff, achy and sluggish, we generally don't recognize these signals as cues that our body craves movement. Instead, we misinterpret them as a need for rest, which makes us stiffer, achier and even more sluggish." So when you feel knee pain, for example, tell yourself, "This could be a signal that I need to move around."

2. Catch It, Challenge It, Change It

"Catch it, challenge it, change it" is shorthand for a classic cognitive behavioral therapy (CBT) technique. The technique involves a three-part process, each part of which is helpful in itself:

1. Catch it. When you find yourself thinking catastrophically, notice it. When you succeed in "catching" your thinking, congratulate yourself. It's hard to capture a thought.

Then label that thought: “Hmm, I’m catastrophizing again." Amazingly enough, just putting your feelings into words will ease your worry and help activate the problem-solving part of your brain. (Details here.)

2. Challenge it. Find a counter-thought to your current thinking pattern. For example, if you have told yourself, "The pain will never get better," you might oppose that thought with a better one, such as: "That's not true. The pain comes and goes There are good days and bad days."

3. Change it. To modify your thinking, you might choose one of these examples of healthier self-talk:

• “Even a little exercise might lower my pain level.”
• “Avoiding physical activity may feel good in the short run but isn’t good for me in the long run.”
• "I'll try a short walk and see if I feel better."

3. Turn a Problem Into a Challenge

Instead of telling yourself, "I have a problem with pain," tell yourself, "I have a challenge with pain." This is another helpful and quick way to reframe your pain. Like the labeling above, the word "challenge" sets the problem-solving part of your brain into motion.

4. Try an Attitude Adjustment

Taking a different perspective on your problem can often lead to a helpful attitude adjustment. A friend says to herself, "Five years from now I might look back fondly on the days when this was the worst thing I had to worry about." I like to tell myself, "My worst day could be someone else's best day."

5. Mindfulness Self-Talk

The suggestions below can be found in How to Be Sick: A Pocket Companion by PT blogger Toni Bernhard, a chronic pain sufferer herself.

1. Replace “The pain is unbearable” with the simple statement, “I’m in pain” or “Pain is present.” By eliminating emotionally charged adjectives like “terrible” and “unbearable,” you acknowledge your pain but refrain from adding “an emotional charge,” according to Bernard. Like the old saying says, pain is inevitable, suffering is optional.
2. Remind yourself that everything changes. Your pain will not only fluctuate from day to day, but from moment to moment.
3. Practice self-compassion. Odd though it may sound, you might even talk to the hurting part of you in a kind way: “Knee, I’m sorry you are hurting.” This tactic separates “you” from the body part that is feeling pain, making it clear that the pain is not overtaking who you are.

6. Distraction Solutions

Any task that requires concentration on something other than your painful thoughts seems to be surprisingly effective. While not strictly self-talk solutions, you can use self-talk to remind yourself of the following tactics:

1. “Count down.” A recent study, though tiny, (involving just 20 participants) found that subjects who concentrated on counting down from 1000 by 7s reduced their perceived intensity of pain by 50%. While my brain might refuse to attempt this, I admit that’s a huge amount of pain reduction. It's worth a try. Other tactics used in this study that worked to some extent were focusing on something pleasant or beautiful or persuading oneself that the pain was bearable.

2. Deliberately refocus your attention from the pain symptoms to the world around you. Spending time in nature might be a particularly effective way to lower stress and therefore to lower any anxiety that may accompany your chronic pain.

3. Music or any other enjoyable distraction can lessen your perception of pain. A cup of coffee or tea can provide warmth and sustenance. So can spending time with supportive others.

4. Getting lost in an interesting work project can often make you forget about pain or worry.

Other Solutions

In addition to self-talk and distraction solutions, there are behavior solutions that work well for many people. Briefly, these solutions could include techniques such as acupuncture, massage, physical therapy, an ice or heating pad, and the various complementary/integrative therapies. Oh, and just to remind you, exercise itself is a behavior solution!

Medication is a must-have solution for many pain situations. As a longtime sufferer from migraine headaches, I can attest that only medication will stop my migraines in their tracks.

(Consult your medical professionals to learn the best ways to guide the management of your chronic pain.)

Caution: Avoid Judgment

Toni Bernhard cautions us to avoid the trap of believing that "perfect health is within your power if you'd just eat right, exercise, etc." I hope the suggestions above provide tools for your toolbox, not fuel for self-blame or other-blame.

It is also important to realize that not all chronic conditions respond to exercise the way knee osteoarthritis does. Your chronic pain may respond better to rest, medication, or meditation. Because everyone is different, different people will respond better to some techniques than others. As Carl Jung said, “The shoe that fits one person pinches another; there is no recipe for living that suits all cases.”

© Meg Selig, 2020. All rights reserved.

Special thanks to Dr. Ruixue Zhaoyang, the first author of the study described above and cited below, for sending me a preview copy of this fascinating research paper.

Note: This blog is a revised, expanded, and updated version of an essay from my brand-new book, Silver Sparks: Thoughts on Growing Older, Wiser, and Happier.