To read the other articles on understanding chronic
pain/fibromyalgia click back
Over 90% of people with chronic musculoskeletal
pain have fibromyalgia syndrome, although many other names are used
to describe this condition. We use fibromyalgia as the name to describe
a wide range of long lasting pain conditions.
Who gets it?
- 1 to 2 % of the population has this
condition at any one time.
- It is more common in women than men
in a ratio of 6:1.
- The highest incidence
is in people aged 20 to 40.
- Low pain threshold
- Poor quality sleep
- Stiffness particularly
in the morning
- Emotional distress
- Pins and needles or
tingling in the hands
- Irritable bowel symptoms
- Swelling in the hands
- Irritable bladder symptoms
- Changes in the circulation,
e.g. easy blueness of the fingers
In fibromyalgia the pain nerves are too
sensitive and we say that their pain threshold is lowered. Pressure
and movement, previously not painful, become painful. Movement
nerves start to initiate pain messages.
Physical Signs of Fibromyalgia
- Overly sensitive tender points
- The skin is
abnormally sensitive to stroking, quickly producing a red
- Pinching a fold
of skin produces considerable pain. (allodynia)
- Grip strength
can be diminished.
Concern about pain, fatigue, stiffness and other symptoms may drive
people to see many doctors searching for a diagnosis and cure.
doctors find no abnormalities and when fibromyalgia is diagnosed
it can be a great relief. Pain sensitization,
not tissue damage is responsible for the pain, but it
can take time to understand what this means and how it should
When you have the diagnosis, remember:
- Your pain is real.
- Your pain is due to
- You do not need to
keep searching for another diagnosis.
- You can learn to manage
Causes of Fibromyalgia
Fibromyalgia can develop after:
- An accident or injury
- A virus or infection
- Stress or trauma
- No specific illness
Fibromyalgia is not due to any abnormality in
the muscles or joints; nor is it due to a psychiatric illness. There
is a gross disorder of the pain system in fibromyalgia. It becomes
sensitized with an elevation of substance P and a reduction in Serotonin.
Stress appears to make the pain system more sensitive. You can read
more about the development of fibromyalgia in the article
does chronic pain develop?
Understanding your reaction to pain
Pain evolved as a signal to warn us of threat
or damage. If we touch something hot, a reflex response of withdrawal
occurs to protect us from further damage. Pain also alerts us to
disease or pathology in the body. However, sometimes pain becomes
chronic: it persists long after an injury should have healed and
when no tissue damage or pathology can be identified. Sometimes
a disease or degenerative changes has been identified, but the pain
is greater than expected for the severity of the disease or degenerative
changes. In both cases, our instinctive reaction to pain creates
a real problem. If we react to chronic pain with the alarm nature
intended for acute pain, unfortunately, we can amplify the pain
signal. We say that the pain system is sensitized and pain is experienced
at a higher level than expected for the injury or condition. The
diagram below shows how pain sensitization is produced when pain
is perceived as a threat.
A threat, whether real or imagined,
elicits the stress response which prepares us to defend ourselves
or flee from the threat. This primitive response worked well
when the threat came in the form of a wild animal or angry
neighbouring tribe. Once action was taken the body could then
return to its normal level of activity. This response can
still protect us in accidents and other life-threatening situations.
However, if you keep responding to chronic pain as a threat,
the pain sensitization will persist. To break out of this
cycle you need to remove the threat by understanding your
condition and knowing how to change the stress response.
Pain Causes Panic
A common reaction to pain is
to panic. It is difficult to think straight and you may run
for help, swallows pills, or stop everything (freeze). This
is survival mode and underlying these reactions is fear. There
are many things to fear because pain signals danger. You may
be asking yourself these questions:
Have I got a serious illness?
Are they hiding something from me?
Can I handle it?
How long will it last?
Will I be able to work again?
When there is a threat, an obvious
reaction is to defend yourself and this involves fighting or
resisting. Are you fighting your employer, insurance company,
doctors, family or friends? The object/s of your anger and frustration
can be many and varied. Perhaps you have resisted some treatments
or explanations. While you feel threatened you may continue
to fight or do the opposite and flee the situation. Perhaps
you have withdrawn from life or particular activities and people.
Some people escape by taking large amounts of medication or
drinking alcohol. Not surprisingly, these strategies dont
Pain Causes Chronic Stress
The pain itself causes stress but so to
do all the consequences of having chronic pain such as conflict,
uncertainty and physical limitations. Chronic stress affects many
systems in the body including the muscular, gastro-intestinal and
nervous systems. Many people wonder why they cant concentrate
and notice that their memory is poor. This can make it difficult
to learn new coping strategies and to hear explanations for your
chronic pain. Dont underestimate
the effects of stress.
Facing The Threat Without Defending Yourself
The solution is to learn a new
way of dealing with the threat. Instead of reacting to the threat
by fighting, fleeing, or freezing, you can learn to flow. This
takes you out of the cycle of pain sensitisation. The Path
out of Pain poster illustrates how you can change your
relationship to the pain and become a self-manager instead of
a victim. Click here
to view the poster and read about a path out of pain.
Top of page
These myths tend to keep you stuck: dispelling
them can be an important part of your recovery. Your treating
practitioners may also believe some of these myths and be advising
you inappropriately. Read on to discover the myths that you believe
and the consequences of believing them. The Self-Management program
will help you realize the way that the myths limit your recovery
and what you can do instead.
MYTH 1 You Have To Learn To Live
The first myth implies that recovery or progress is not possible
and invariably leads to a sense of helplessness and hopelessness.
Getting on with life is an important part of recovery and in
this sense the statement is useful. However, you can do a great
to improve the situation: you can find a path out of pain.
MYTH 2 Rest Cures Chronic Pain
Secondly, rest does not cure chronic pain
and can be a recipe for disaster. Learning to balance rest and
activity is fundamental to good management.
Lack of fitness, stiffness, loss of function and more pain.
MYTH 3 Let Pain Be Your Guide
The third myth can also result in a steady
decline in your functioning and fitness. Fear of the pain leads
to protective responses such as stopping when it hurts. Pushing
through the pain is not appropriate either. In fact, there is
no satisfactory rule as you may need to push yourself sometimes
and be gentle at other times.
Fear of damaging yourself and loss of function and fitness.
MYTH 4 Hurt Is Harm
The fourth myth probably drives the third
myth. It implies that pain is signalling damage and therefore
pain should guide activities. When we realise that pain is a complex
phenomenon involving physical and psychological factors we cannot
assume that pain signals damage.
Fear, inactivity and more pain.
MYTH 5 Real Pain Is Organic
Many practitioners believe that real pain
has an organic origin (tissue damage or pathology) and if this
organic origin cannot be established the pain is psychogenic ('in
the mind'). It is most important to reassure you that your pain
is real and results from a complex of interacting physical and
need to prove that your pain is real.
MYTH 6 Search Long Enough And
You Will Find The Cause And The Cure
The sixth myth prevents people in pain from getting on with helping
and healing themselves. The search rarely, if ever, leads to
a single cause and simple cure.
A desperate search and continual disappointment.
MYTH 7 Abnormal CT Scans Validate
And Explain The Pain
Abnormal CT Scans do not necessarily explain the pain. Interestingly,
studies have shown that up to 50% of asymptomatic people over
40 have abnormalities on their CT scans. Therefore, there is
a high probability that an abnormal CT scan is not the explanation
for the pain. Unfortunately failed surgery testifies to this.
A focus on findings from CT scans can also misdirect management.
management, fear and more pain.
Top of page
When you are injured in the workplace
or in an accident on the way to work, you enter a system. The
employer and insurance company send you to doctors and other
practitioners. Frequently you return to work on light or modified
duties but you are not asked to take any responsibility for
your recovery. The pie chart below illustrates how the responsibility
is taken by the employer, insurance company and health care
practitioners. The injured worker
is not encouraged to take responsibility and becomes a victim
of the system.
Restricted duties certification
Referrals to specialists
Referrals for treatment
A Shared Responsibility Model
To recover from
soft-tissue injuries you must
take responsibility for your own healing. Your employer,
insurance company and treating practitioners can support
you and provide suitable working conditions: the rest is
up to you. The pie chart shows how the responsibility can
be shared. The Path out of Pain course teaches
you about self-management which involves you accepting responsibility
for getting well. This can mean hard work and a willingness
Pain and disability are rewarded
As you recover and move
along this line from the left to the right, your benefits reduce.
Unfortunately, this means that you have to take a risk to get
well because there is no certainty of full recovery.
Our beliefs are powerful: they
determine how we feel and what we do. Some beliefs about pain
create lots of suffering and make recovery from chronic pain
very difficult. Other beliefs can relieve the suffering and
help the process of recovery. Many people believe that they
are at the mercy of their thoughts, that they can do nothing
to control their minds. However, there are many ways to learn
to control the mind. Ancient meditation techniques were developed
to help people train their minds and create more peaceful and
fulfilling lives. More modern psychological techniques such
as cognitive-behaviour therapy can also help you change what
you are thinking to change how you are feeling. The 2 tables
below shows how changing self-defeating thoughts, to healing
thoughts, can help you find your path out of pain.
- I can’t do what I used to do.
- I will never get rid of the pain.
- I am useless.
- It’s all their fault.
- I must know what is causing the pain.
- I must be damaging myself when it hurts.
- I need someone to cure me.
- I have no control over my life.
- I notice what I can do.
- I am learning how to heal myself.
- Although there are things I can’t
do, I am learning to acknowledge and appreciate who
I am and what I can do.
- There are many factors causing my
pain not just my job.
- I accept the explanation I have
- I know that hurt is not harm with
- I am learning to take responsibility
for my recovery.
- I am discovering ways to take charge
of my life again.
Top of page
Sometimes people with chronic pain are
reluctant to acknowledge that stress may be playing a part in
their pain. They say that they are not stressed and that the
pain is all physical, not psychological. Earlier in this section
on understanding pain, we talked about a bio-psycho-social explanation
for chronic pain. As you develop your understanding about fibromyalgia
and chronic pain you will see the connection between these factors
and pain sensitisation. Stress plays a big part in sensitising
the pain system. When pain sensitisation is present, pressure
and movement which previously did not cause pain, cause pain.
In other words it can take very little to set off the pain nerves.
Most importantly both physical and psychological stressors can
set off the pain nerves.
Many people with chronic pain were living with high levels of
stress before their injury or the development of the pain syndrome,
but once chronic pain has developed, there are many more stressors.
Check the list below and see how many of these apply to you.
- The pain itself
(tiring, relentless, unpleasant)
- Repeated failures
- Uncertainty about
the future (finances, health, relationship)
- Marital / Family
- Disbelief from
employers, co-workers, friends, family
- Judgement by assessing
- Litigation / conciliation
- Loss of quality of life
- Loss of control
Top of page
Top of page
It is common for people to react to
pain by trying to get rid of it or avoid it. They try different
treatments, take painkillers, and stop moving because it hurts
to move. This may provide some short-term pain relief, but,
the diagram below shows how each reaction to the pain can lead
to a trap.
Do you rely on treatment to keep you going? This is the treatment
trap. Many people keep going to the physiotherapist, chiropractor
or masseur hoping to be cured but they find that they become
dependent on the treatment. Sometimes people keep going for
treatment even when it hurts, or makes their pain worse. The
treatment trap is a dead end because it doesnt help you
find a path out of pain. To get out of the treatment trap you
will need to reduce your dependence on treatment and develop
your self-management skills.
Do you rush for painkillers when your pain increases? This is
the medication trap. Unfortunately, your tolerance for painkillers
increases the longer you take them and you will need more and
more to get any effect. It is also common for many people to
take painkillers even when they dont help very much.
Do you retire to bed when the pain gets bad? Have you stopped
most of your activities? This is the rest trap. Perhaps you
get some temporary relief from avoiding activity but there are
better ways to get relief which will also assist your recovery
from chronic pain.
Diagnostic Trekking Trap
How many doctors and other practitioners have you seen? You
could be in the diagnostic trekking trap, or well on the way.
If you accept the explanation in this section, you could stop
diagnostic trekking and begin to learn self-management instead
People caught in these traps often get worse, instead of getting
better, and become dependent on their treating practitioners.
Because they are able to do less and less, they begin to feel
increasingly helpless and hopeless.
As each approach fails to provide the answer, the person in
pain becomes more depressed. While they keep searching for the
cause they remain alert and their anxiety level is high. Chronic
depression and chronic anxiety result.
Reactions to pain amplify the pain