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Stress Management To Manage Pain

Updated: Feb 7, 2021

As a physiotherapist I see people on a daily basis who are struggling with the management of pain, in particular those with osteoarthritis, which is an area of particular interest for me. In fact, pain is the leading cause of disability and main factor that causes people to seek physiotherapy intervention [6].

Management of patients with chronic or persistent pain has changed quite considerably over the past couple of decades with a strong focus on a more biopsychosocial (BPS) approach in Western society [12], rather than the purely biomedical approach which previously dominated, although this is slow to be adopted in some other societies [3]. This has been a huge leap forwards in the world of pain management and takes on board factors affecting the person as a whole, and not just on the specific area of pain which they have come to see you for.

As Moseley and Butler [10] clearly demonstrate, the BPS model takes in to account the things we think, feel, say, predict and believe including values and knowledge, as well as social factors and the person’s role in their social world, whether it be at home, work, leisure time or in the community. These things are key and should be considered as part of a holistic management approach. Also, as part of this model the focus should be increasing on what the person in pain can do for themselves rather that what we can do for/to them, which often results in greater empowerment and feeling of control for the person.

Chronic pain is deemed as pain that has been present in excess of 3-6 months [5], where the normal healing time of tissues would be expected to have been completed. The BPS approach is of particular relevance in chronic pain because these cohort of patients often have a lot more going on than purely tissue healing. They are also more likely to have features of central sensitisation, [1,5,11].

Merskey & Bogduk [9] state that chronic pain is: ‘A persistent pain that is not amenable, as a rule, to treatments based upon specific remedies, or to the routine methods of pain control such as non-narcotic analgesics.’ It is not just biomedical or biomechanical.

One of the factors that can play a significant part in the development and persistence of chronic pain is stress [1,2,4,6,8,11], but more specifically chronic stress, lack of habituation to repeated stress or prolonged physiological response to a stressor [8], and is particularly relevant to increased muscle tension [2,8]. Although we may not be able to remove particular stressors (e.g. work deadlines, tax bill notice, an embarrassing social situation etc), the way in which someone perceives a stressor and how they respond to it is something that is modifiable [6]. One may be able to implement certain practices in to their lives that help reduce the excitability of their nervous system (particularly the sympathetic nervous system) and reduce the fight-or-flight response, e.g. relaxation exercises, breathing exercises, and mindfulness, to name a few. There is no one-size fits all approach, however different areas can be explored through a thorough stress management programme.

Initially, it is pertinent to ascertain if someone is struggling with non-pain-related stress in order to aid the decision-making process and in order to prevent chronic disability and improve quality of life [6]. In a primary health environment, it may be useful to use screening tools such as the Pain Catastrophizing Scale and the Fear-Avoidance Beliefs Questionnaire, or subjective measures of self-reported stress such as the Perceived Stress Scale, the Impact of Events Scale, the Daily Stress Inventory and the State-Trait Anxiety Inventory. As part of the enrolment of an individual to a stress management training programme where the decision has been made between the clinician and the client that this would be beneficial, it can be useful to assess their stress using the Stress Assessment Questionnaire, which can aid a more in-depth understanding of the specifics of one's problem and how certain lifestyle factors may be playing a role (e.g. smoking, drinking, medications, physical health etc).

In addition to this, the Holmes and Rahe Scale and/or the Cooper’s Life Stress Inventory can be useful in assessing one's stress risk, and stress related illness risk. It is worth also bearing in mind that questionnaires such as these are not just about the score or number at the end. If you look at each component of these forms, it can give you great insight in to someone's situation, a better understanding of them as a person and help to highlight useful talking points. Having an understanding of the person as a whole is key. Through the use of reliable questionnaires and screening tools as mentioned above, if someone demonstrates poor coping strategies, low resilience, and/or high stress risk then it is highly likely that this is having an impact on their pain. A constant activation of the fight-or-flight response due to ongoing stress, which then results in an increase in pain, may also enhance one’s fear of stress, increasing avoidance behaviours, and feeding in to a perpetual pain cycle.

So, how does stress feed in to the pain experience exactly? There is no one defined pathway through which stress directly affects pain because there are multiple underlying factors at play and overall the processes appear multidirectional and cyclical in nature [6]. The key thing to remember here is that one person may perceive something as stressful, whereas another person may not.

When a person is under perceived stress it can trigger the fight-or-flight response due to activation of the sympathetic nervous system, resulting in the release of noradrenaline (norepinephrine) and adrenaline (epinephrine). This is effectively the body being put in to a state of alert, and getting ready to respond to the threat. This can cause various physiological responses e.g. increases in heart rate, blood pressure and respiration, dilated pupils, and sweating. After this initial pro-inflammatory stage of the stress response, the Amygdala activates the HPA (Hypothalamic-Pituitary-Adrenal) axis, resulting in the release of cortisol. In this normal response, cortisol has an anti-inflammatory function. This is the normal stress cycle, and over the next few hours following this initial hormonal response, levels of cortisol should reduce back to baseline through activation of the parasympathetic nervous system. This is also known as the ‘rest and digest’ response and restores homeostasis within the body.

Unfortunately, in people with chronic stress, e.g. those who tend to catastrophize, ruminate/worry or feel helpless, this response can be reactivated over and over again causing ongoing cortisol release and eventually, depletion of cortisol, or cortisol dysfunction [6]. Conversely to cortisol’s normal anti-inflammatory role, this continued release resulting in cortisol depletion may actually result in pro-inflammatory effects (due to increased affinity to mineralocorticoid receptor) or lack of modulation of the inflammatory response, and this stress-induced inflammation has been implicated in many chronic pain presentations [6]. Cortisol can then fail to inhibit CRH (Corticotropin Releasing Hormone) release, which would usually be a normal function of cortisol when CRH reached an appropriate level. Also, activation of CRH receptors has been shown to trigger pain in the absence of tissue damage [7,13].

Worryingly, besides pain, the side effects of cortisol dysfunction caused by chronic stress can include things such as muscle and bone breakdown (it also has links with osteoporosis), fatigue, depression, memory impairments and low blood pressure related to postural change (orthostatic hypotension which is associated with increased falls risk). Evidently the list is a lot longer than this, but these are a few key effects I have picked out of the literature. Of note, stress has been found to be a very powerful exacerbator of pain in women with fibromyalgia [4], which is another common condition which we are seeing more and more of.

As referenced to earlier, people with chronic pain often have signs of central sensitisation. This is described by Nijs et al. (2019) as a ‘physiological phenomenon characterised by widespread hypersensitivity resulting from an augmented response of the central neurons to receptor activity’. In those people with osteoarthritis (OA) in particular, the presence of central sensitisation often results in more severe and unpredictable pain, reduced quality of life and functional disability [1]. This is of particular interest to me as I work with people with OA on a daily basis.

Akinci et al. [1] published a review looking at factors involved in chronic pain in OA where there was a central sensitisation component. Within the review they specifically reference stress management as a non-pharmacological technique which may aid in the reduction of central sensitisation and target the cognitive-emotional component of central sensitisation. There were other factors also highlighted that may have an impact that were also discussed in the Stress Management Trainer diploma that I undertook including CBT (cognitive behavioural therapy) in order to ‘increase cognitive and affective responses to pain in order to deactivate brain-related pain facilitatory pathways’ [1], as well as assertiveness training.

Positive therapeutic alliance can play a significant role in people with chronic pain, particularly in situations where stress is a key component and otherwise, they are not ‘offloading’ their thoughts and fears [12]. As a physiotherapist and health coach, I realise the importance of the client-clinician relationship, and being able to incorporate a stress-management programme in to the holistic management of people with pain is highly likely to be a key component of their success in pain management and increasing function. I also feel that good pain education can form part of the stress management package, as negative pain beliefs, fear and pain-related anxiety can have a significant effect on chronic pain and stress due to pain.

Reconceptualising pain can help to reduce descending nociceptive facilitation, and it’s also been flagged as important to provide reading material and homework at a minimum [1]. This is also an important component of a stress management programme, as clients have activities to undertake between sessions, therefore pain education can be delivered as part of the stress management package. Also, if people understand the role of non-pain-related stressors in the perpetuation of pain, it may allow them to be more open to addressing these. Again, this demonstrates the benefit of additional stress management training for health professionals as an adjunct to their current practice, or as a stand-alone intervention with appropriate insurance. It is important to address multiple factors in pain management and be thorough so that the likelihood of a person having positive outcomes will be enhanced, as multiple failures of interventions can be counter-productive and lead to worsening of stress and reduced resilience [5].

In conclusion, it is evident that a thorough and progressive stress management programme is likely to be very important in helping people with chronic pain, which may involve smoking cessation (see my article related specifically to smoking, stress and pain). This is a key consideration in a person’s pain management journey, especially if we are truly adopting a biopsychosocial approach, and not just relying on a biomedical model using a biomechanical narrative and trying to treat pain with medications alone.

It seems pertinent to me that stress management is aimed at managing a person’s perception of, and response to, possible stressors in order to prevent the constant activation of the fight-or-flight response, and therefore reduce the likelihood of increased pain and to help prevent the development of central sensitisation.

The ability to manage stress, increase resilience, create positive habits, a positive mindset and learn to physically and mentally relax can support human health in a multitude of ways, and is something that should be incorporated into pain management programmes and the management of other long-term conditions.


  1. Akinci A., Shaker M., Chang M., Cheung C., Danilov A., Dueñas H., Kim Y., Guillen R., Tassanawipas W., Treuer T., & Wang Y. (2016). Predictive factors and clinical biomarkers for treatment in patients with chronic pain caused by osteoarthritis with a central sensitisation component. The International Journal of Clinical Practice, 70(1): 31-44.

  2. Alfven G., Grillner S., & Andersson E. (2019). Review of childhood pain highlights the role of negative stress. Acta Paediatrica, 108: 2148-2156.

  3. Ayob S., Ryan C., & Martin D. (2013). The role of pain related anxiety in the functioning of patients with knee osteoarthritis in Malasia. Journal of the Physiotherapy Pain Association, 34: 25-29

  4. Fischer S., Doerr J., Strahler J., Mewes R., Thieme K., & Nater U. (2016). Stress exacerbates pain in the everyday lives of women with fibromyalgia syndrome – The role of cortisol and alpha-amylase. Psychoneuroendocrinology, 63: 68-77.

  5. Griensven H., Strong J. & Unruh A. 2014. Pain. A textbook for health professionals. 2nd Ed. Churchill Livingstone: Elsevier. Great Britain.

  6. Hannibal K. & Bishop M. (2014). Chronic stress, cortisol dysfunction, and pain: A psychoneuroendocrine rationale for stress management in pain rehabilitation. Physical Therapy, 94(12): 1816-1825.

  7. Ji G., Fu Y., Adwanikar H., & Neugebauer V. (2013). Non-pain-related CRF1 activation in the amygdala facilitates synaptic transmission and pain responses. Molecular Pain, 9(2).

  8. Leistad R., Sand T., Westgaard R., Nilsen K., & Stovner L. (2005). Stress-induced pain and muscle activity in patients with migraine and tension-type headache. Cephalalgia, 26: 64-73.

  9. Merskey H. & Bogduk N. 1994. Classification of chronic pain. Definitions of chronic pain syndromes and definition of pain terms. 2nd Ed. International Association for the Study of Pain. Seattle, USA.

  10. Moseley L. & Butler D. 2017. Explain Pain Supercharged. The clinician’s handbook. Noigroup Publications. Adelaide, South Australia.

  11. Nijs J., Polli A., Willaert W., Malfliet A., Huysmana E. & Coppieters I. 2019. Central sensitisation: another label or useful diagnosis? Drug and Therapeutics Bulletin, 57(4): 60-63.

  12. Oldfield G. (2018). Chronic Pain: Improving outcomes by addressing the hidden causes. Journal of the Physiotherapy Pain Association, 45: 7-14.

  13. Shekhar A., Truitt W., Rainnie D. & Sajdyk T. (2005). Role of stress, corticotrophin releasing factor (CRF) and amygdala plasticity in chronic anxiety. Stress, 8: 209-219.

  14. Thacker M. (2015). Is Pain in the Brain? Journal of the Physiotherapy Pain Association, 39: p3.

Please note: This article is intended to be for educational purposes only, and does not constitute medical advice or replace professional assessment or personalised advice.

I do not hold responsibility for the information on any links to external websites within this article and information within these links/websites may change at any time or no longer be accessible. Any website pages/links added are also for education purposes only.


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