Which comes first, anxiety or pain? We could all agree that persistent pain (i.e., pain greater than 3 months) and anxiety often go hand in hand, typically sharing physical and emotional components. The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage” (Merskey and Bogduk, 1994). According to the American Psychological Association, anxiety is “an emotion characterized by feelings of tension, worried thoughts and physical changes like increased blood pressure.”
In mapping out a mechanism in the brain’s anterior cingulated cortex, Dr. Min Zhuo and his team at the University of Toronto have discovered a link between anxiety and pain. Essentially, the brain’s ability to physically change in response to bad experiences (or even good ones) can trigger the interaction between persistent pain and anxiety. So what?
The relationship answers a common question from my patients – why I, as a physiotherapist, ask about anxiety. Pain can be either, or both, the cause and consequence of anxiety. To some extent, each sways the other. Accordingly, treating persistent pain goes beyond treating the “broken bit”. Clinicians and patients, therefore, must help each other in peeling away the many layers of the onion to understand what is driving the brain to cause pain.
In doing so, it is important to understand that anxiety and pain both serve the purpose of helping us attend to a potential threat or prepare for danger. It, however, can be detrimental when both persist once the “danger” is gone. Pelvic health physiotherapists do extensive external and internal (both vaginal and rectal) assessments to find adverse neuromuscular weakness or tension that may be driving the brain to produce pain. Once tissue issues are addressed, pain ought to improve. However, when pain persists, patients can lose hope and trust, and often fall into the vicious realm of negative thoughts, beliefs and ongoing physical symptoms. We need to think outside of the box.
Given the evidence that anxiety and pain can influence each other, it would be sensible for a health care provider treating persistent pain to assess whether anxiety issues need to be addressed. This can typically be accomplished through validated outcome measures. If issues are detected, or even suspected, it would be prudent to use other practitioners to help assess and address the interaction.
Ultimately, for some, the best treatment for anxiety is to understand the unknown pain. This can be done with confidence. Mostly, treatment requires patients to re-conceptualize their pain. In his recent TED talk (https://www.youtube.com/watch?v=gwd-wLdIHjs), Professor Lorimer Moseley, a clinical scientist who investigates pain in humans, highlights how pain is always produced in the brain and how attitudes, thoughts, beliefs and experiences can influence pain perception.
The challenge to everyone treating patients with persistent pain is to look beyond the “broken bit”. Patients should be taught on how to move well, enjoy what has been “robbed” from them (i.e., intercourse, urination, etc.), and to love both their mind and body. Physiotherapists should not focus only on muscles, bones and joints, but also give attention to the connection between body and mind.
Canadian Association for Neuroscience. “Better understanding of links between pain, anxiety reveals treatment opportunities.” ScienceDaily. ScienceDaily, 27 May 2015. <www.sciencedaily.com/releases/2015/05/150527191649.htm>.
Anxiety and Pain: two sides of the same synapse?| U of T News
Written by Jessica Nargi