Part III: The Stress-Pain Cycle

Managing Stress & Pain

It is clear that the body and brain connection is extremely complex and multifaceted. There are genetic, psychological, physical, personality, and environmental factors that can all affect how we perceive pain and how that pain manifests. Self-regulation of pain describes the capability of one to adapt to the pain condition by maintaining control, guiding, or changing one’s reactions and behaviors. This can allow for successful management of pain.

Medication Management vs. Physical Therapy

Oftentimes, patients are prescribed analgesics and antidepressants to treat pain. However, when a contributing source of the pain is affected by or coming from the brain, these medications have been proven to have limited efficacy with only short-term effects.

In physical therapy, our focus is primarily on the physical contributors to pain, versus the non-pain related stressors in the pain experience. However, it is important for us as PTs to identify our patients who may be struggling with stress management. Then, we can further educate and empower our patients to address potential issues beyond just their physical ailments. Of course, this may entail a multidisciplinary approach, with potential referrals to psychotherapists and other mental health professionals. What other factors might also be vital for a physical therapist and patient to consider when treating the stress/pain cycle?

Developing Sleep Hygiene

We all know sleep is absolutely critical to survival, but stress can cause sleep problems. Researchers have found that sleep deprivation can directly increase pain sensitivity. One study found that just one night of total sleep deprivation in healthy humans impaired descending neural pathways, causing increased excitability of spinal receptors, thus elevating sensory sensitivities. Now think of how chronic sleep deprivation could have an effect on a person over time, especially one that is already dealing with a painful condition. Another study found that even reduced sleep duration of less than 6 hours led to decreased pain thresholds immediately the following day. Promoting healthy sleep habits and developing better “sleep hygiene” can help to break this stress/pain cycle. One study found that a sleep hygiene treatment had profound positive effects on patients with fibromyalgia as an alternative treatment option.

The Role of Exercise

Exercise is another factor that must be considered that is hugely beneficial to us physiologically. A meta-analysis found that aerobic exercise can lead to decreased pain perception as well as an acute improvement in mood. In fact, there is a correlation between exercise and less damaging effects of stress both physically and mentally; as well as evidence that exercise can increase one’s resilience to stress. Of course, as physical therapists, we promote home exercise programs to directly “fix” the problem(s) our patients come to us with. However, addressing a patient’s regular exercise routine, especially one that is aerobic in nature, can have additional benefits in relieving their pain and stress.

Relaxation Techniques

Lastly, relaxation techniques can also have positive influences on reducing the pain and stress cycle for a variety of individuals. These techniques help to elicit the body’s “relaxation response”, which is the opposite of the stress response. As we relax, our blood pressure, breathing rate, and heart rate all decrease. Such relaxation techniques include breathing exercises (diaphragmatic breathing, breath classes); guided imagery or visualization (picturing scenes, objects, ideas that help you feel calm); biofeedback-assisted relaxation (using an electronic device to help you monitor your heart and breath rate, blood pressure, stress levels) ; progressive muscular relaxation (consciously tensing muscles and then relaxing them); and autogenic training (using mental exercises to focus on relaxing). Studies have found this to be effective in treating post-surgical pain, low back pain, headache pain. The effect however is low, and would be worth further research. However, being aware of these relaxation techniques can still be helpful for anyone dealing with stress.

Hopefully this three-part series on how the stress/pain cycle works can empower all of us- as patients, practitioners, and humans- to be aware of how our mental health may be affecting our physical condition. Let’s not forget to work on sleeping better, exercising more consistently, and making conscientious efforts to relax. Certainly, all of us have been under duress for a while and having more tools in our toolbox to keep our bodies healthy and our minds happy will serve us well into this new year!

Crofford LJ. Chronic Pain: where the body meets the brain. Transactions of the American Clinical and Climatological Association. 2015. 126: 167-179.

Hannibal KE, Bishop MD. Chronic stress, cortisol dysfunction, and pain: A psychoneuroendocrine rationale for stress management in pain rehabilitation. Physical Therapy. 2014. 94: 1816-1825.

Staffe AT, Bech MW, Clemmensen SLK, Nielsen HT, Larsen DB, Petersen KK (2019) Total sleep deprivation increases pain sensitivity, impairs conditioned pain modulation and facilitates temporal summation of pain in healthy participants. PLoS ONE 14(12): e0225849.

Hoffman MD, Hoffman DR. Does aerobic exercise improve pain perception and mood? A review of the evidence related to healthy and chronic pain subjects. Current Pain and Headaches Report. 2007. 93-97.

Chou R, Deyo R, Friedly J, et al. Nonpharmacologic therapies for low back pain: a systemic review for an American College of Physicians clinical practice guideline. Annals of Internal Medicine. 2017;166(7):493-505

NIH: National Center for Complementary and Integrative Health. Relaxation techniques: what you need to know. June 2021.