The Crucial Role of Stress in Chronic Pain Management

The Crucial Role of Stress in Chronic Pain Management

I’m writing this for those of us who are living with chronic pain and want to be more successful with not only managing our pain, but ending our suffering as well. I believe that freedom from suffering is our right – but it’s also our responsibility.

It’s so important that we learn as much as possible about our pain and what constitutes effective chronic pain management. Since stress management is one of the most fundamental interventions for effective chronic pain management, it’s vital that we learn what the stressors are in our lives and how to effectively address them.

Stress Management

First of all, stress isn’t all bad. It’s important to realize that human beings need some level of stress to motivate us and deal with life on life’s terms. Stress can also provide energy and fuels the fight, flight, or freeze phenomenon. The stress response is a combination of biological, psychological, social and behavioral factors. However, when we live with a chronic pain condition, stress can also intensify the experience of pain.

In today’s busy world, it’s very important for everyone to incorporate effective stress management tools into daily living, but it’s especially for those of us living with chronic pain. You hear it all the time, phrases such as “I’m stressed out” or “this stress is killing me.”  This is all too true for medical conditions like heart disease or diabetes, as well as for those of us living with chronic pain. Remember, increased stress can lead to increased pain.

In response to stress, our body mobilizes an extensive array of physiological and behavioral changes in a process of continual adaptation. This is an important part of our body’s defenses, with the goal of maintaining homeostasis and coping with stress.

Our body reacts to stress by secreting two types of chemical messengers: hormones in the blood and neurotransmitters in the brain. That is why stress management needs to be an integral part of an effective chronic pain management program.

Remember: Managing Your Stress Helps You Manage Your Pain

It is important to understand the connection between stress levels and pain symptoms, as well as recognizing how managing stress can decrease the perception of pain. Physically, chronic pain raises stress levels and drains physical energy, while psychologically, it affects our ability to think clearly, logically and rationally, as well as how effectively we manage our feelings. Not only that, it can also impact memory. Again, in most cases, when someone learns how to lower their stress levels, they will also experience a decrease in their perception of pain.

Of course, before we learn how to manage stress, we need to know how to describe our level of stress at any given time. What is important to remember is that when we reach the upper moderate to severe levels of stress (6-10 range or what I call the “stress reaction”) our thinking, emotions and behaviors are affected. The goal is always to keep our level of stress at six or below as much as possible.

Self-Assessment Information

Since self-assessing your levels of stress is so important and then learning how to implement simple but effective stress management tools, we need something to help you do that. I use the Gorski-CENAPS® Stress Thermometer below to help my patients accurately articulate their level of stress. I would like to take you through this in the same way I do with my patients. Developing a personalized stress thermometer starts with the premise that there are ten levels of stress.

As I continue to describe this tool, you can create and personalize your own stress thermometer using the one above as a model. If you do make up your own, it will help you to internalize this process and enable you to be more successful at using it.

Levels 1, 2 and 3

I am going to describe the stress thermometer by starting at the bottom with the first zone, which has Levels 1, 2 and 3.

  • Level 1: This first zone is titled “Relaxation.” The description I use on the right for Level 1 is “Relaxed-Nearly Asleep.” This level is when you first wake up in the morning, your eyes aren’t even open yet, but you’re no longer asleep. At this level, you aren’t functioning at all. Describe what a Level 1 might mean to you.
  • Level 2: “Relaxed-But not Focused.” At this level, you might start functioning, but it’s like being on auto pilot; fixing coffee, brushing your teeth, combing your hair, etc. You aren’t really focused yet and at a low level of functioning. What does Level 2 look like for you?
  • Level 3: This level is titled “Relaxed-And Starting to Focus.” I call this “vacation” level. Yes, I’m focused, but my focus is on relaxing. This is the last level of the relaxation zone. If different, describe what Level 3 means to you.

Levels 4, 5 and 6

The next zone is titled “Functional Stress” and it contains Levels 4, 5 and 6.

  • Level 4: This level is called “Focused and Active.” At this level, I have energy and am starting to get things done.
  • Level 5: This is where you want to be most of the time if you want the best level of functioning and the most effective pain management. Level 5 is “Focused with No Effort.” This is the optimal level for getting things done. Write your own description for each of these levels.
  • Level 6: This level is called “Focused with Effort” and is the beginning of what I call the “danger area.” Let me explain what I mean by that. Have you ever had one of those days that even though you’re getting things done, it seems to take much more effort or push to make it happen? I know when I get to that point I’d better stop, rest and get centered or else I am setting myself up for trouble. What would a Level 6 look like for you?

Levels 7, 8, 9 and 10

The next zone is titled the “Stress Reaction” zone and it has numbers 7, 8 and 9. When you are in this zone, you start to lose some of your frontal lobe functioning and begin transitioning into survival mode – fight, flight, freeze or the amygdale limbic system of the brain. This isn’t necessarily a bad thing. Sometimes in emergency or crisis situations, an active amygdale becomes a healthy survival tool. But for someone living with chronic pain, it can also raise their pain levels or at least the perception of pain.

  • Level 7: This “Stress Reaction” zone is “Loss of Focus or Spacing Out.” At this level, you aren’t really present to learn anything new and not emotionally present with others. Many people go in and out between levels 6 and 7. Often at Level 7, long-term memories are not being recorded. Can you think of a time when you were in a class and noticed you couldn’t remember what was just covered? Describe what Level 7 means to you.
  • Level 8: If you don’t intervene at Level 7, you are at risk for moving on to level 8 – “Getting Driven and Defensive.” When I’m at this level, I tend to feel irritated or agitated and sometimes can’t sit still. What happens for you at a Level 8?
  • Level 9: Not addressing Level 8 stress puts you at high risk for a Level 9 called “Over-React.” When I get to this level, I experience foot in mouth reaction – I say or do something that I know I’m going to regret, but just can’t stop myself. Have you ever been at that point? What would a Level 9 mean for you?
  • Level 10: The final zone is titled “Trauma Reaction.” Level 10 is “loss of control.” At this point, people reach the shut down stage. Some will go to bed and pull the covers up, while others are at high risk of using inappropriate pain medications that could include alcohol or other drugs in order to escape. This is loss of control, can’t function, shut down or escape. Describe a Level 10 stress reaction for you.

Seven Tips for Effective Stress Management

Once you understand the stress thermometer, you need to learn how to better manage your stress. Following are seven simple tips for managing stress that could also significantly improve how you manage your chronic pain:

  • Understanding Stress:


    It’s important to learn about stress and understand the stress scale, as well as to recognize that stress can either be a positive influence or make your life overly difficult. When looking at stress on a 1 to 10 scale, with 1 meaning you are very relaxed and 10 meaning you can’t function or you shut down, the danger zone begins at levels 6 and 7 – stress overload! From levels 7 to 10, you will experience disruptive symptoms. It depends on how you interpret this distress whether you face the situation with confidence or helplessness. At this point, you could shift into survival mode – fight, flight or freeze. Any of those three modes will amplify your pain levels. The fight mode leads to anger and attacking others; the flight mode leads to fear and hiding; and the freeze mode leads to depression and immobilization.


  • Stress Reducing Self-Talk and Positive Affirmations:


    The premise here is if you change the way you think, you will start to change the way you feel. For example, if you’re under high stress the thought might be “I can’t stand this… I need to escape.” This in turn could lead to, fear, anger, anxiety, or even cravings to use self-defeating behaviors or even inappropriate pain medication for stress relief. You really can talk yourself into feeling better, no matter what’s happening around you or to you – you can tell yourself things like “I can handle this!” “This too shall pass!” “Breath; Relax!” etc.

  • Emotional Management:


    If you are undergoing chronic pain management, you may be experiencing many types of uncomfortable emotions such as fear, anger, shame, frustration etc. Emotional management starts with learning to identify which emotions you are feeling and rating them on a 0 to 10 intensity scale. The next step is to develop early awareness of what you are feeling and when, then take immediate action to cope with any uncomfortable feelings before they lead to self-defeating urges. Developing healthy feeling management skills is very important. Learning to share with trustworthy people is one way to deal with uncomfortable emotions. If the feelings are too intense or overwhelming, counseling or therapy may be necessary.

  • Autogenic Breathing or Breath Self-Regulation:


    This is a systematic daily practice of breathing sessions that last between seven to ten minutes, usually in the morning, at lunch time, and in the evening. One simple exercise is to breathe in deeply to the count of five, hold for seven counts, and slowly exhale starting from nine to zero. You might consider adding this breath exercise to the next stress tip and practice both three times a day.

  • Progressive Muscle Relaxation:


    One way to do this is by taking slow deep breaths and then holding them while tensing up one muscle group at a time. When you exhale, let the muscle group relax. You then move to the next group and keep going until you have tensed and released all the muscle groups in your body. Both the breathing self-regulation and the progressive muscle relaxation exercises can help you evoke what’s called the “relaxation response” in your body.

  • Meditation:


    There are literally hundreds, if not thousands, of styles of meditation. The easiest way to start is selecting a consistent time and a quiet place, either early morning and/or evening. Wear loose, comfortable-fitting clothing and find a comfortable position that you can stay in for at least 30 minutes. Do deep breathing for a minute or two to help relax the body. Close your eyes and then focus on the point between your eyebrows to help increase your concentration. If your mind wanders, be gentle with yourself and refocus back on your breathing. In the beginning, sit for at least 5-7 minutes, and then slowly increase your time.

  • Exercise and Nutrition:


    A very effective stress management strategy is exercise. In addition to lowering stress levels, regular exercise can also be an important part of a pain management program. Some people with chronic pain find exercising difficult to do, but because it helps reduce overall pain, its benefits will be worth any temporary discomfort. All individuals, particularly someone undergoing chronic pain management, should check with their doctors before beginning an exercise regimen.



    Nutrition and diet can influence chronic pain symptoms. Many people find it extremely difficult, but reducing or even eliminating nicotine, caffeine, and sugar will go a long way toward developing healthy eating plan that can impact pain symptoms. According to the National Fibromyalgia Association, certain foods aggravate some musculoskeletal conditions. These include dairy products, gluten (found in wheat, oats, barley, and rye), corn, sugar, and members of the nightshade family (potatoes, tomatoes, eggplant, peppers, and tobacco). Seeking out an experienced nutritionist can be very beneficial for both stress and chronic pain management.

Stress Management Toolkit

Review this checklist for healthy options to manage your stress. Pick four or five from the previous tips list and/or this toolkit that you are willing to practice consistently on a daily basis:

  • Eliminate the use of alcohol and other drugs (other than appropriate prescriptions)
  • Reduce or eliminate the use of nicotine, caffeine, and sugar
  • Exercise or engage in some form of physical activity, such as walking, every day
  • Eat a proper, well-balanced diet – also, use a good multivitamin daily
  • Obtain an adequate amount of sleep – if sleep is a problem discuss this with your doctor/therapist
  • Focus on positive aspects of your life and start making a daily gratitude list
  • Pace yourself, modify your schedule and set realistic goals
  • Eliminate or reduce unnecessary tasks so that your schedule is more manageable
  • Consult with a physician if you are experiencing any medical problems
  • Reducing negative self-talk by developing and practicing positive affirmations
  • Practice Deep Diaphragm Breathing for five to seven minutes 2-3 times per day
  • Practice Progressive Muscle Relaxation for five to seven minutes 2-3 times per day
  • Meditation: There are hundreds of styles of meditation – learn and practice one daily

This is Just the Beginning

Start with the seven tips and/or the toolkit. I encourage you to learn as many other stress management tools as you can. As you become increasingly aware of your stress levels, you will feel more empowered to take action to reduce the stress in your life, which in turn will lead to a decrease in your pain symptoms – your perception of pain.

My call to action for you is to implement a proactive and strategic stress management plan. Doing so will improve your health, quality of life and most importantly reduce the severity of your pain symptoms.

It’s Time to Develop Your Personal Stress Management Plan

Take a few minutes here to pause and reflect. Think about what we’ve covered so far in this article on stress identification and management and complete the next three steps.

  • What is the most important thing you learned about yourself and your current pain management plan as a result of what was covered in this article?
  • Make a list of four or five things you can start practicing on a daily basis that will help you better identify and manage your stress. Feel free to use the information we just covered in this section as a starting point. But it’s not enough to just write these down—in order to get the most out of this call to action you have to also make a commitment to practice these action steps at least two to three times per day while you’re in a good place and your stress levels are below a Level 6-7. This way they’ll be programmed in and you’ll be able to activate them even when your stress levels are high.
  • Finally, what might get in your way of being successful with activating this new stress management plan and how will you overcome any roadblocks to implementing it?

Your Tools in Action

Remember, effective chronic pain management and freedom from suffering is your right – but it’s also your responsibility. In fact, you are the only one who can truly make a difference and create lasting changes to improve your health and your ability to manage your pain more effectively.

Now that you have some new tools, find an accountability partner.  This should be someone you trust, can share insights about what you have learned, and someone who will be helpful with implementing an authentic plan of action to implement the insights and tools you have learned in this article.

Remember: If you manage your stress you will better manage your life.

 

Image Courtesy of iStock