Master your pain… by the doctor who learned to fix herself: Pain specialist Dr HELENA MIRANDA reveals the simple techniques that could transform your life
- Chronic pain is thought to affect around 28 million adults in the United Kingdom
- It persists for more than three months, often in more than one part of the body
- On average, learning a new pain management method takes a couple of months
Chronic pain is thought to affect around 28 million adults in the UK
As a medical doctor and a researcher, I’ve studied pain for more than 20 years.
I’ve also lived with pain for most of my adult life, suffering from weekly migraines, constant sciatic pain, occasional knee and hip pain, and early osteoarthritis in the small joints of my hands.
I know how it feels when you can’t sleep on either side for more than five minutes without pain.
I’ve woken in the early hours with awful migraine, knowing I have an important meeting in the morning.
Chronic pain — pain that persists for more than three months, often in more than one part of the body — is thought to affect around 28 million adults in the UK.
In Europe, around 100 million live with it; globally, it’s about 1.5 billion.
You aren’t alone.
Tips for talking to your doctor
It’s not easy to be understood as a pain patient, as I know from my own experience. Here are some tips on how to get the most out of appointments…
- If you only have a 15-minute slot, focus on your most important concern. Think in advance about what you want to ask and what you hope the doctor will do — and write it down.
- If you have several concerns or a more difficult problem — and chronic pain is always difficult — ask for a double appointment.
- Take notes, or take someone who can take notes for you — it’s easy to forget much of what the doctor says.
- Beforehand, list the medicines you’re taking, the doses and how long you’ve been taking them, with a summary of previous illnesses, tests and ops. Hand this list to any new doctor right away.
- Be honest. You’ll get the best help if you’re open. Speak about emotions your symptoms cause. Practise bringing up sensitive issues out loud in front of a mirror or to your partner.
In my work, I help people trying to get on with life despite their pain. I can say with confidence that you can learn to live well with chronic pain, whatever the cause.
I say this based on my own experience, both as a specialist and a sufferer, as well as the latest research data.
Something I encourage my patients to think about is putting together a ‘toolbox’ for good pain management.
It should contain many different tools for different situations — and I have personally tested all of the tools that I recommend here.
Most of them don’t involve medication and aren’t quick fixes, but are instead lifestyle-related aids, from prioritising sleep to visualisation techniques.
Learning a new pain management method takes, on average, a couple of months —treating chronic pain is not like many other conditions, and expecting a speedy solution only leads to despair and frustration.
So be patient and take your time with new approaches.
Don’t give up, even if it initially seems there are no results.
Follow these steps to change your life…
THE REASON YOU’RE ALWAYS IN PAIN
Pain is a perfectly normal part of life. It exists to serve as a warning signal, protect us and teach us to recognise our limits so that we can avoid injury.
However, sometimes the pain pathways of the central nervous system (the network of nerves in the brain and spinal cord that allow the brain to coordinate your body’s various functions) become sensitised, and pain signals remain switched on in the brain, even once the original trauma or injury has healed.
Typical conditions associated with this phenomenon are back pain, headache, osteoarthritis and rheumatoid arthritis, irritable bowel syndrome and fibromyalgia (which causes fatigue and pain all over the body).
This sort of pain is hardly ever a sign of danger, unlike acute pain from an immediate injury.
Chronic pain, therefore, shouldn’t necessarily be taken as a sign to stop moving or hide away under the duvet.
This doesn’t mean that your pain is imagined.
Pain is always real, and genuinely felt.
This has been revealed by new research using brain imaging techniques that can measure pain reactions objectively.
At the same time, pain is always in our heads.
What I mean is, pain is experienced in the brain, mainly within the cerebral cortex — the outermost part, made up of what we sometimes call ‘grey matter’.
For example, if you scratch your foot with a nail, the sensation is conveyed as an electric signal from the skin through receptors and nerve fibres to the cerebral cortex.
Why not give acupuncture a shot?
I’m repeatedly surprised at how often chronic pain patients seem to have tried everything but acupuncture.
In skilled hands it is safe, and four to eight treatments are usually enough. According to a review in the journal Pain in 2017, discomfort is relieved for up to a year.
Although often still considered an ‘alternative’ remedy, acupuncture has been in use for so long that a good deal of research has now accumulated to support it.
One analysis in the Journal Of Pain in 2018 included 20,827 patients from 39 trials. It concluded that acupuncture is an effective treatment for chronic musculoskeletal pain, headaches and osteoarthritis, and that the effects persist over time.
Traditional Chinese medicine says it works by unblocking the energy flow through ‘meridians’ or trigger points.
Scientifically, several studies using magnetic resonance imaging (MRI) scans have demonstrated acupuncture modifies brain regions involved in handling pain (even though the needles are inserted into the back or neck, not the brain).
I’ve treated patients who shuddered at the thought of it, but found the needles — which are nearly as thin as human hair — didn’t bother them.
This part of the brain then processes the signal and quickly gives it importance.
The trouble is, our brain can play tricks on us.
How we ‘file’ the pain signals can be influenced by our memories, our past experiences of pain, the people around us and their experiences of pain, as well as our thoughts and feelings at any given moment.
Chronic pain also sends the brain into overdrive, reacting to other harmless stimuli as well as painful stimuli.
A person with chronic pain can gradually become sensitised to many things: draughts, noise, bright lights, poor indoor air quality.
This can create a vicious circle of pain and overstimulation of the nervous system.
I can’t promise that your pain will stop.
It may be difficult to accept, but the only way to improve your situation is to let go of the wish to get back to your previous, pain-free life.
Pain itself doesn’t make life unbearable.
What makes life unbearable is the suffering that results from our pain-related thoughts and feelings.
The losses associated with pain and the limitations it causes hurt people more than the pain itself.
When we face our feelings and change our way of thinking, we move towards achieving better health and quality of life.
SLEEP: IT’S YOUR SECRET WEAPON
Getting enough restorative sleep is one of the most effective pain management tools.
Unfortunately, many people think poor sleep is an unavoidable part of living with pain.
You do not have to accept this. In fact, it may not be possible to alleviate pain unless sleep quality is dealt with at the same time.
And even though the pain may not be eliminated, better sleep will have a decisive impact on how you cope with it.
Sleep supports health in many different ways.
It allows your immune system to tackle inflammation, and help wounds and other tissue damage heal better.
It also makes your metabolism more efficient and hormones work steadily.
It keeps stress hormones in check, in particular, as well as hormones that make us hungry and less able to resist sugary treats.
(As dull as it sounds, sticking at a healthy weight is helpful for managing pain — and not just because a sore joint benefits from a lighter load.
The ‘super’ nutrients… and what to avoid
MAGNESIUM
Studies have shown many chronic pain sufferers have little magnesium (vital for coordination of nerves and muscles) in the body, but it’s not known if this is a cause or a result of pain.
One study found taking magnesium for six weeks helped those with chronic back pain. Magnesium-rich foods include cashews, almonds, sunflower and pumpkin seeds, pine nuts, whole grains, fish, avocado, banana and dark chocolate.
OMEGA-3
Omega-3 fatty acids, found in fish oils and some plant oils (such as linseed), have anti-inflammatory effects. In many studies, omega-3 fatty acids have also alleviated pain in osteoarthritis, irritable bowel syndrome and menstruation.
The richest sources are fatty fish such as salmon, mackerel and herring and some nuts, especially walnuts.
The recommended daily dose is 2g to 3g — you get around 2.5g in 100g of mackerel; 1.8g in a typical salmon fillet.
TURMERIC
Research suggests that turmeric can bring significant relief in chronic pain. It may also ease depression, a common problem among pain sufferers.
A minor issue with turmeric is that, in the form we add to food, it is not potent enough. For this reason, it is now sold in capsules — and even then, quite a few capsules need to be taken per day to get the benefits.
VITAMIN D
People in chronic pain often have a reduced level of vitamin D. In one study, patients whose level of vitamin D was too low took double the amount of strong painkillers compared with those who had adequate vitamin D levels.
However, these studies don’t indicate which is the chicken and which is the egg — the pain or the vitamin D deficiency.
The usual source is sunlight, so during winter we need to get it from our diet (via eggs and oily fish). In the UK, the advice is to take 10mcg daily in winter.
DON’T OVERDO… CAFFEINE
A review of 20 studies involving more than 7,000 people concluded that taking painkillers with a cup of coffee (or caffeine) gave better relief than the drugs alone. But be careful if you have sleep problems. A good night’s sleep is much more important for pain relief than the boost of caffeine.
…OR ALCOHOL
Alcohol brings temporary pain relief, but after an evening of drinking, the entire body is sensitised to pain. It also disturbs sleep.
Moreover, painkillers and alcohol are not compatible. Intestinal bleeding and liver damage often set in unnoticed.
Opioid painkillers and spirits together induce respiratory depression — where breathing becomes dangerously shallow — and each year it sends many people to an early grave.
The risk is particularly high in older people, says a 2017 study in the journal Anesthesiology.
Weight gain can damage self-esteem, and the more in control and confident we feel, the more successful pain management is likely to be.)
For a chronic pain sufferer, just one bad night’s sleep increases sensitivity to pain the next day.
But which came first, insomnia or pain? Bad sleep and pain can be a vicious cycle.
The traditional thinking has long been that when a person is in pain and sleeps badly, the pain should be taken care of properly so that sleep quality can improve.
However, many recent studies suggest that it’s far more common for poor sleep to be the trigger of pain problems, or at least exacerbate them.
That’s why the pain sufferer really needs to solve their sleep problem first.
The first step is to tell your doctor about any sleep troubles. In reality, the intensive treatment of pain with strong painkilling drugs called opioids, such as tramadol, buprenorphine, fentanyl and oxycodone, can further aggravate sleep problems.
Opioids break the structure of sleep, reduce the amount of deep, restorative sleep we get, and increase the risk of a sleep disorder called sleep apnoea (where the soft tissues of the throat collapse during the night, reducing oxygen levels and causing you to wake momentarily but repeatedly).
One in four people who take opioids regularly suffers from sleep apnoea, often unknowingly.
I know this is a sensitive point, and many say that they wouldn’t be able to do without opioids, but it is worth discussing alternatives with your doctor.
I have, at times, taken a two to three-week course of the sleep-promoting hormone melatonin, which improved my sleep quality. It’s available in the UK for short-term use.
Other drugs sometimes prescribed for chronic pain, such as the antidepressants amitriptyline or mirtazapine (in small doses), can safely maintain the structure and quality of sleep.
At home, create a peaceful space. If your spouse snores, ask them to move to another room, or try earplugs.
Don’t nap for more than half an hour in the day — any longer may make it harder to fall asleep at night.
If you have trouble falling asleep, don’t go online after the evening news — even a small dose of blue light from electronic devices can be overly stimulating.
Similarly, don’t check the time on your smartphone during the night.
My own wellbeing has been boosted considerably by getting a new bed.
Although I tell my patients about the importance of a good bed — and research has suggested that a softer mattress, rather than a very firm one, can be better for chronic back or neck pain — my mattress was more than ten years old.
I had spent nearly 25,000 hours in the same bed.
A shallow area had developed and the whole bed shook when I tossed and turned.
I don’t know of any other object that I would stubbornly continue to use for seven to eight hours a day even though it should have been taken to the dump a long time ago.
I am now the grateful owner of a viscoelastic mattress (sometimes called memory foam).
When I flopped onto it in the shop, I felt as if I was in heaven.
I lay on my side — a position I’d had to give up, as it was too painful to lie like this for more than five minutes — but my ever-temperamental sciatic nerve made no complaint.
Now, I wake less at night.
The morning brain fog is only an occasional guest, and the need for painkillers, especially in the middle of the night, has decreased.
Depression is a common companion of pain, and can manifest as pain symptoms.
Of course, not everyone suffering chronic pain will feel depressed, and not all of those who are depressed suffer from pain. However, more than half of the patients at pain clinics — in some studies as many as 80 per cent — can be diagnosed as having depression.
Yet it can also go unnoticed, because most pain sufferers seek help only for their physical complaint. Pain and depression together — especially if accompanied by poor sleep —prolong sick leave, make people more vulnerable to permanent disability and ruin their quality of life.
That’s why both need to be treated, regardless of which is the cause.
If you think you might be depressed or are concerned about becoming depressed, tell a loved one as well as a healthcare professional.
WHAT TO EAT
Many people with chronic pain also live with fatigue, anxiety, mood swings, mobility problems, the side-effects of medications, impaired ability to work, and often financial hardship.
This can mean healthy eating isn’t always the first thing that comes to mind.
But much can be achieved by eating sensibly.
You can’t go far wrong if you adopt a diet rich in berries, vegetables, other fruits, wholegrain fibre, nuts, fish, and plenty of fresh water.
Make sure you get enough protein — chicken, legumes and curd cheese (akin to cottage cheese) are excellent.
Many of my patients report that omitting all added sugar and white flour from their diet has helped, too.
A study in the journal Neuroscience showed short-term and long-term memory deteriorates, and new learning becomes more difficult, if a person consumes large amounts of sugar and fat.
Eating foods rich in trans fats (found in shop-bought biscuits, cakes and pastries) also increases anxiety and depression symptoms, and excessive consumption of sweet food and drink seems to reduce cognitive flexibility.
Flexible thinking is vital for maintaining a positive attitude, which in turn is key to managing pain.
I must admit that my sweet tooth screams for pick’n’mix sweets.
I also love high-fat cheeses.
However, I feel better when I curb my intake. I’m calmer, my concentration improves, and I can cope better.
One area in which I think we are on the brink of a major scientific revolution is the importance of the gut to health, including pain.
More than 90 per cent of neurotransmitters, the chemical messengers used in our brains, are produced in the intestinal tract.
These strengthen, block or modify electronic messages between neurons (specialised nerve cells) and other cells in the body.
We all have a unique ecosystem of bacteria in our guts. Probiotics, or ‘good bacteria’, help to reduce intestinal inflammation.
They reduce the effects of stress, and may even improve chronic pain.
In the future, probiotics such as lactobacilli and bifidobacteria will probably be used to manage pain.
For now, try including foods that contain lactobacillus acidophilus in your diet, such as sauerkraut and miso.
It’s also added into many yoghurts, especially those that say ‘live’ on the label.
It also pays to avoid unnecessary antibiotics, as just one course can upset intestinal bacteria for up to two years.
So should you be taking painkillers?
Should you be taking painkillers?
Finding the right medication for chronic pain can take months, or even years.
I manage my own pain mainly with non-pharmacological methods, and cope quite well.
If necessary, I take ibuprofen or paracetamol.
A migraine — which I get about once a week — requires a powerful drug called a triptan. If my sciatic pain is bad, I have resorted to codeine. But I try to avoid it since it brings with it an unpleasant tipsiness, as well as brain fog the morning after.
My sciatic pain started five years ago.
I had surgery to treat it, but the operation was only partly effective.
I now have permanent nerve damage and walk with a slight limp, and the pain is almost constant.
Unfortunately, this is relatively common.
Chronic pain rarely improves with surgery alone.
As for medication, according to recent studies, half of all chronic pain patients don’t benefit.
Medication provides a 30 to 50 per cent reduction in pain for only about one in three people.
For fibromyalgia and chronic lower back pain, a pharmacological treatment’s effectiveness can be even more modest.
One good indication of whether or not a medication is worth it is the 30-30 rule: if on the worst days your pain is 30 per cent less with medication than without it, and if there are 30 per cent fewer bad days when taking it than without it, then you should continue to use the drugs.
Talk to your doctor if you feel your medication is not having an effect this significant, as there may be other options.
Understandably, pain patients often hope for a scan that will provide answers. But such investigations can cause more problems than they solve.
For example, an MRI scan of the back will reveal some sort of ‘finding’ in almost anyone over the age of 50, regardless of whether or not the person experiences back pain.
Just as skin wrinkles, the spine shows signs of normal ageing. Scans can indicate changes in the back even among people in their 20s. By no means do all of them experience pain.
The same is true of scans of the shoulder and knees in middle-aged people — they’re rarely ‘clean’.
It’s problematic when misinterpretation of such findings causes someone to start behaving as though they have a knee injury or back disorder.
They may become cautious and restrict movement (which may be much worse for pain in the long run).
An MRI scan is justified if symptoms such as weakness, numbness or other problems with your legs are getting worse, or if there is a major back injury in the background, fever, bladder problems or a history of cancer.
And, if surgery is planned, MRI is both useful and necessary.
Here are the five mind games that work like magic to tackle pain
Five mind games that work like magic to tackle pain
Maybe it sounds ‘out there’, but pain can be alleviated by using visualisation exercises.
We know this from brain scans that show how the brain’s functioning can be altered by the imagination.
Visualisation exercises work by tricking the brain.
For example, in mirror therapy for chronic limb pain, the patient watches the reflection of their healthy limb in place of their painful limb hidden behind the mirror.
This teaches their brain to reduce its experience of pain.
Even though we know what we see isn’t real, the brain processes the observation as though it was.
An experienced physiotherapist may be able to help you. Alternatively, there are CDs and downloads that can guide you through visualisation techniques (have a look at painsupport.co.uk).
Here are five exercises to try — use one when you’re going for a procedure, or at home when you feel your pain worsening.
I try to do a visualisation exercise while I do my weekly 30 to 45-minute aqua-jogging session in the pool.
With my patients, I’ve also found that acupuncture is more effective when combined with visualisation.
The power of the mind is verifiably awesome!
1. TURN DOWN THE LIGHT
Imagine your chronic pain has some other form. It might be a loud sound or an annoyingly bright lamp. In your mind, dim the light or make the sound quieter with the control knob.
You can also imagine that your brain has begun to pump large amounts of morphine into your bloodstream, and this eases the pain.
2. THE SOUL’S LANDSCAPE
I call one exercise I often do, ‘visualising the soul’s landscape’.
Sit or lie still, close your eyes, and concentrate on your favourite place — a place where your body and soul are at rest.
In the soul’s landscape, you’re safe and protected from pain.
In 2014, Danish researchers found that people who performed this exercise before a medical procedure experienced less pain and therefore required less painkilling medication.
The patients, undergoing a cardiac ablation (where a thin tube is guided to the heart via a vein in the leg, under a local anaesthetic), were asked to sense the scents and sounds of their favourite place and focus on its tranquil ambience — the wonderful warmth of the sand on a beach, the gentle touch of a soft breeze, the fresh smell of a forest.
Patients are often asked to sense the scents and sounds of their favourite place and focus on its tranquil ambience
3. HOLD IT AWAY
When you feel that bubble of anxiety as pain starts to intensify, focus your thoughts on some other part of your body that isn’t painful. Imagine that place starts to feel comfortingly warm. Or, in your mind, slowly transfer your pain to a place it feels easier to manage — say, transferring back pain to your hand.
4. QUIZ YOUR PAIN
This exercise is recommended by PainSupport (an information and support site for people with chronic pain).
The idea is to question your pain, ‘listen’ to the answers, and then try to subtly shift how the pain feels based on those answers.
Sit somewhere quiet, then take your mind to the area that hurts.
Ask yourself what the pain is like. Is it a colour? How big is it? What shape is it? Is it hot or cold? Are there any memories associated with it? Is it trying to tell you something?
Use the first images that come to your mind, no matter how fleeting they are. Now change the images.
Make the new ones positive, strong and clear. Change heat into cool; red into a calming blue. If it seems like a tight band, loosen it.
If it’s like iron bars, soften them so they melt. Imagine healing light soothing the hurt. Visualise the images changing until you are more comfortable.
5. THE NEW YOU
Imagine yourself as you would like to be: fit, healthy, strong. See yourself doing all you would like to be doing.
Say to yourself as you go about your imagined activities, ‘comfortable body, strong legs’, or similar words that best apply to what you would like to achieve.
When you go about your day, repeat this affirmation to yourself, over and over. You will see results, even if it takes time.
Don’t stop doing what you love
A chronic pain sufferer may have to relearn how to feel pleasure.
Emotions affect pain, and pain affects emotions, too.
In normal circumstances, stubbing a toe on the edge of a dresser is likely to make us curse and shout (incidentally, it has been proved that profanity helps us withstand pain better).
However, when you’re in a truly good mood, you might not even notice the pain.
A chronic pain sufferer may have to relearn how to feel pleasure. Emotions affect pain, and pain affects emotions, too
Thoughts and feelings are nerve impulses in the brain.
Meanwhile, the experience of pain is a series of nerve impulses processed by our thoughts and feelings — that is, by other nerve impulses.
The good news is this means happiness can actually relieve pain.
Try to do something that brings you joy every day.
Even if you can’t get out of bed, you can still listen to good music, watch amusing videos, or phone a friend.
Sew, tinker, decorate, arrange photos, tend the garden — do whatever inspires you. Do too little rather than too much. Stop before you get sore, or, if you are in constant pain, before it gets worse.
Take going to a flea market. You know roughly how long you can manage to walk before pain arrives or gets worse.
It could, for instance, be half an hour. When you get to the flea market, wander for 20 minutes and then sit down to rest.
In other words, sit down before you feel pain.
After a rest, continue for another ten to 15 minutes and then sit down again.
Get a pet – and go swimming!
A few years ago, my family became the proud owner of a Tibetan spaniel named Oliver.
He is, without a doubt, one of the pillars supporting my work and ability to function.
Because of him, it’s essential to take a walk every day.
Life suddenly has new meaning, a new kind of responsibility, and a more regular rhythm — together with a lot of selfless love and affection.
Just stroking an animal increases your production of oxytocin, a hormone that acts as a natural painkiller.
A pet also helps us make friends, and it’s well known that social relationships promote health.
Loneliness, in contrast, increases our experience of pain.
In one U.S. study, 235 patients were given the opportunity to stroke a therapy dog while waiting for the doctor.
Patients did a questionnaire before and after, which showed that those who spent time with the dog reported less pain than those who did not, regardless of their diagnosis.
Fibromyalgia patients reacted exceptionally well — their pain was alleviated by a third.
Try out having a pet by taking care of a friend’s, or use a pet-sharing website such as borrowmydoggy.com.
Meanwhile, water has been used to treat pain for millennia, and research indicates hydrotherapy (physical therapy in warm water) and balneotherapy (treatments in mineral-rich waters and mud baths) can relieve chronic pain — and the effects can last months.
Warm water relaxes the muscles, while the pressure of water on the skin activates nerves that prevent the transmission of pain signals to the brain.
Both therapies stimulate the release of endorphins, another natural painkiller.
Hydrotherapy is available on the NHS. Ask your GP to refer you, via a physiotherapist.
Leave when you’ve made your way through half of the market.
Come back again the next week. Then extend the time you’re walking by a few minutes. Remember to stop and rest before your pain gets worse.
This is how you boost your resilience and unlearn negative thinking patterns — ‘I’ll do this until it hurts and then I’ll stop’ — that reinforce pain through expectation.
The goal is to teach your brain that doing what you enjoy is neither painful nor harmful.
Go at your own pace and don’t worry what others think.
While in the past you may have been able to weed your garden in a couple of hours, let your new goal be staying out in the garden long enough to get just a few weeds pulled up.
A brief time outside being active is much better than doing nothing due to fear of pain.
On days when you’re unable to do anything much more than lie about, playing games is a brilliant, research-backed way of distracting yourself from pain.
If I could get an image of your cerebral cortex (the part of your brain that processes pain signals) while you play cards or attempt a Sudoku puzzle, I would be able to show you how beautifully the electric scramble in areas that sense pain calms down.
Your attention is focused away from pain, and so pain is relieved.
Music is also a brilliant pain management tool.
Listening to your favourite music on a daily basis has been shown to reduce chronic pain by as much as 20 to 25 per cent, a good result in view of the fact that painkilling drugs, on average, reduce pain by around 30 per cent.
Music seems to intensify the functioning of descending nerve pathways that block pain signals.
Our body constantly sends messages about sensations to the central nervous system.
But not all messages reach the brain: more than 70 per cent of them stop at the spinal cord.
The brain, after all, has much more to do than observe messages of discomfort.
These signals are deflected by descending nerve pathways in the spinal cord, and by chemical messengers that weaken the progression of pain signals.
Natural ‘painkillers’ produced by the brain, such as endorphins, also prevent the signal from reaching consciousness.
Listening to music activates the brain’s reward system, too, and so the production of these good hormones is accelerated.
If you have missed any of the expert guides on how to beat pain, find them all at dailymailplus.co.uk/beatpain
Source: Read Full Article