Pain is something we all experience at one time or another. When we’ve stubbed our toes as kids to when we’ve cut a finger or fallen down stairs as adults, breaking many bones. But even though the feeling of pain has been in our lives forever, do you understand what pain really is?
Have you wondered why it can stick around for a long time through the recovery process? Some people find that the pain changes and then never actually goes away following an injury or illness.
This article delves into the latest knowledge and strategies that are most likely to improve how you feel. We’ve set out the things you need to know, including:
- What is pain?
- The ultimate purpose of pain is to act as protector
- Why persistent pain occurs
- Surely a doctor can do a scan and diagnose why I have pain?
- The massive impacts from pain that affect wellbeing (you’ll be shocked)
- So why do people feel pain differently?
- Four must-know strategies to help you manage pain and improve your life
Scientists and doctors have been uncovering a myriad of interesting—and most importantly, useful—things in recent years such as this: Hospitalised patients with less pain can breathe better!
If that’s not enough to convince you that pain is important to understand and manage, these same patients felt less stressed, were able to rest better and their wounds healed more quickly[i].
But while there are many research studies, oodles of drug and drug-free products promoted as relieving pain, all sorts of advice from friends and family, the experience of pain is a very personal thing to each of us.
“The experience of pain is a very personal thing to each of us”
My friend’s experience
A friend of mine recently broke four bones in her foot and has been in a lot of pain. Even though she’s recovered from injuries before, she says this one is different. She’s been in immense pain and felt many new sensations. She talked about burning pain, tingling. Numbness in different parts of her foot. Sharp pains that felt like they were going straight through the bone. It really worried her as she kept thinking “what have I done?” and every time she moved, which caused more pain, she thought “am I making my foot worse?”.
As we delved deeper into what she was going through, and we laughed and sobbed over the impact from injury, she asked a series of questions:
“Why do people feel pain differently? And, is it a bad sign if you don’t feel as much pain or if you feel more than what other people tell you they did or didn’t? In other words, is there such a thing as ‘normal or expected’ pain with an injury? How do you know if a pain is ‘good’ or ‘bad’?”
I know through my own painful experience and talking with hundreds of people about their injuries, that many questions come up during injury recovery. And pain is a major concern.
And that’s one of the reasons I’ve written this article; because I wish someone had written it for me when I was experiencing and wondering about the mystery of pain. The anguish and fear I felt about my injury was heightened because of the pain; and I now know that the anguish and fear made my pain worse.
The leading experts on pain emphatically say that by having a deeper understanding of pain you will experience less of it. So that’s a great place to start!
What is pain?
The feeling of pain is generated after a series of things happen. For example, an injured body part senses changes (like chemical, pressure, temperature) that *could* mean danger. And the tissues send signals (like a coo-ee) to the brain.
If you have no idea what a coo-ee is, listen to this funny Australian song:
The brain then interprets these messages and a whole gamut of factors like emotions, past trauma experiences, cultural values, and conscious and subconscious interpretations of what this situation might mean. (For example, loss of income or loss of independence.)
The brain determines the actual feeling of pain and its intensity. Ummm… So not simple at all! And yes, you read that right; the sensation of pain is not actually generated from the injured body part.
“Pain is made by the brain. 100% of the time. No exceptions. Ever.” David Butler and Lorimer Mosely.
In this podcast interview with Lorimer Moseley (I highly recommend listening to it) he says: “Teaching you how to cope and manage increasing your quality of life but also giving you the knowledge to understand your pain; pain changes its meaning. The wonderful thing about pain is if it changes its meaning it becomes no longer necessary. So, if your pain means your tissue is in danger, you should have pain. But if we can convince you (through a very scientifically grounded, evidence-based process) that your pain means your system is overprotective and doesn’t mean your tissue is in danger… your pain goes away. It sounds easy but it’s not easy.”
Types of pain
I never realised that there were so many different ways to feel pain before my knee injury. It obviously wasn’t the first time I’d experienced pain. But it was definitely the most intense and scary pain I’d ever felt. And, being laid up at home, putting my normal life on-hold, I had a lot of time to reflect on the sensations and pain I was experiencing.
Call me odd (that’s ok); I actually journalled all the different ‘pain personalities’ I met over the first couple of months:
- Diablo: the hot, swelling pain.
- Prickly monster: the tingling and pins and needles pain.
- Nasty Nancy: Sharp, stabbing pains that would occur at odd times.
- Stretch: the feeling that a muscle or tendon (or something) was completely stretched.
- Achey breaky: the ache that just never went away… breaking my heart…
Why were there so many different pain divas getting around in my knee? Well clearly my knee, with all the damage I’d done—including torn ligaments, tendons, muscles, a bone bruise—sent out the pain party invitations and everyone came.
According to health experts, there are three widely-accepted pain types, with a fourth one proposed and no doubt being debated. Injury is of course just one situation leading to pain. Other common causes of pain include osteo- and rheumatoid-arthritis, cancer and spinal problems.
Short-term pain: associated with an injury or surgery, is the most common type of pain. It occurs in the acute phase of something happening. This kind of pain is called nociceptive pain. Nociceptors are sensory endings on nerves that can be excited and signal the potential of or actual tissue damage. Examples of nociceptive pain include dropping something on your toe, spraining your ankle or burning yourself with a flame.
Inflammation pain: After the initial injury, the second type of pain called ‘nociceptive inflammatory pain’may appear. Inflammation is normal and is a well-coordinated physiological response that involves a range of chemicals from the blood, immune system and specialised nerve fibres. These chemicals talk to each other to help coordinate tissue repair. Examples of when nociceptive pain is common are with: a sprained wrist, non-specific low back pain or neck pain, broken bones, or pulled muscles. There may be signs of tissue injury such as swelling, bruising, increased sensitivity to touch and movement. All of these signs are associated with tissues healing.
Nerve pain: The third type of pain is neuropathic pain, which is associated with injury or disease of nerve tissue. Neuropathic pain is often described as burning, shooting, stabbing, prickling, electric shock-like pain, with hypersensitivity to touch, movement, hot and cold and pressure. When you have neuropathic pain, even a very light touch or gentle movement can be very painful. It is the type of pain associated with: shingles, sciatica, trigeminal neuralgia, Complex regional pain syndrome (CRPS) or diabetic neuropathy.
If you have neuropathic pain, it is important to get the right treatment as early as possible to reduce the chance that your pain will become persistent and is also associated with better outcomes (less pain and better function and quality of life).
It is not uncommon to experience a mix of pain types. Check out this great video from New South Wales Government: Understanding pain in less than 5 minutes and what to do about it!
Pain as protector
You may be thinking: Why does our body do this to us? What’s the point of different types of pain that can go on for months? Pain is a protective tool; an internal signal that makes you (consciously and unconsciously) change your behaviour.
Immediately after injury, pain will cause you to stop moving or twisting in the way that exacerbates the pain. Makes sense but it can get weird… If you’re still hurting after a few days the brain will adapt and start looking for alternative ways to move to avoid the feelings of pain and this means that often muscles are switched off when they really shouldn’t be. You’ll continue to move differently. This can then cause more pain as a result of you moving incorrectly.
Tom Dixon, Senior Physiotherapist with Get Active Physiotherapy in Sydney, explains further. He highlights that if you are still in pain a couple of weeks after an injury you are at risk of losing muscle and developing persistent conditions.
“Some muscles can lose strength and start to atrophy (a reduction in the size of the muscle) after one, two or three days of being in pain,” he says.
“So, if you consider most injuries can expect to take roughly six weeks to recover from, that’s a lot of time that the muscles are not functioning optimally. Motor patterns—the way that a group of muscles work together to create and control a specific movement—can then be affected. Without adequate muscle function in the correct muscles, the body will compensate by using other muscles to get the job done. The brain, to create the movement, will always take the path of least resistance.
“This leads to abnormal or dysfunctional motor patterns, which can further aggravate current symptoms and lead to secondary issues as a result of abnormal loads on other structures. For example, walking with abnormal gait pattern due to a knee injury will sometimes cause hip or low back pain.”
Have you ever ignored pain and thought it’ll go away only to realise things have gotten worse? You’re not alone. It’s important to not ignore it. Pain can affect other parts of your body or, depending on the circumstances, develop into ongoing conditions.
Persistent pain and why it’s a problem
Chronic pain—now more being called ‘persistent pain’ by health professionals—is usually defined as pain that has lasted for three months (out of the last six months). Often chronic pain is triggered by the ‘more simple’ pain types, the acute and inflammatory, but not always.
For some reason or another, the (not-so?) smart brain concludes that you are still threatened and need protecting. What can make you feel like you are threatened and need protecting? In our modern world, not usually the tigers or the snakes so much but feelings of stress, worry and being under threat (e.g. from that job you’re not enjoying or those bills you have to pay). These feelings of threat and stress can join in and mix with pain, ultimately creating a recipe for persistent pain disaster!
The statistics on persistent pain are astounding
- At any one time on the planet, around 20% of people have pain that has persisted for more than 3 months[iii].
- Up to one-third of people in the US suffer from some type of chronic pain, which affects more people than diabetes, heart disease and cancer combined, at a total cost of $560-635 billion every year.
- More than 100 million adults suffer persistent pain in the USA according to the landmark report: Relieving Pain in America, A Blueprint for Transforming Prevention, Care, Education and Research[iv].
- According to Painaustralia, one in five Australians lives with persistent pain, including adolescents and children. This prevalence rises to one in three people over the age of 65. Persistent pain in Australia was estimated to have an economic cost of $34 billion each year in 2007[v].
- Pain following trauma persists in many: one in four have moderate to severe pain 12 months following trauma, and up to one in three have significant pain and disability three years later[vi].
- World Health Organization estimates that as many as 1 in 10 adult individuals are newly diagnosed with chronic pain each year[vii].
- 19% of the general adult population of Europe have had moderate or severe persistent pain for a median of 7 years. One in five of those with chronic pain had suffered for other 20 years[viii].
Many health and pain advocacy agencies worldwide are saying that pain should be acknowledged as a disease in itself rather than just a side effect or symptom of other illness.
Painaustralia the agency driving Australia’s National Pain Strategy advocates that people in pain should be seen as a national health priority and should be supported with interdisciplinary care at all levels.
Why can’t a doctor do a scan and diagnose what’s causing the pain?
There is no simple test to diagnose pain. According to Dr Traeger in Choosing wisely – increasing the value of physiotherapy: “Unfortunately we know that those tests don’t tell us very much about where the pain is coming from, and they don’t really inform management—so they can’t lead to more specific treatments that will help people recover better.”
In the case of lower back pain (one of the most common pain ailments in Australia with quarter of the population having it any one time) there can be many causes of pain and many patients are sent for unwarranted scans, resulting in an unnecessary cost to Australia’s medical system as well as unnecessary mental anguish.
“Imaging results can make you worry more because they often detect changes in your spine that are normal for age but might not look that pretty on a scan. We know from large scale research that when people with low back pain have scans they tend to feel worse afterwards, they tend to use more healthcare, and that healthcare doesn’t improve their outcome,” said Dr Traeger.
Massive impacts on wellbeing
Why are so many health agencies so concerned about persistent pain? Because pain affects wellbeing and quality of life. Studies across Europe have found:
- While there have been major advances in the management of acute pain, over half of the patients going through surgery or suffering trauma have severe to intolerable levels of pain.
- Between half and two-thirds of sufferers were less able or unable to exercise, enjoy normal sleep, perform household chores, attend social activities, drive a car, walk or have sexual relations.
- One in four reported that relationships with family and friends were strained or broken.
- One in three were less able or unable to maintain an independent lifestyle.
- One in five had depression because of pain and 17% suffered so badly that some days they wanted to die.
- 39% felt their persistent pain was inadequately managed. In such cases half felt their doctor did not view their pain as a problem[ix].
How is it that so many people around the world suffer from pain and with all the advances in medicine these numbers aren’t going down? I can’t answer that question. The only thing I can say is that pain is common, complex, and arises from a range of different situations. Each person feels is differently and has a different relationship with it.
Why do people feel pain differently?
It’s important to note that how two people feel about pain is never the same. It makes sense that two people with broken arms may have different amounts of tissue damage or inflammation right? But it’s not that simple. David Butler and Lorimer Mosely, say in their book Explain Pain: “The amount of pain you experience does not necessarily relate to the amount of tissue damage you have sustained”.
Amazingly, there are many stories of people suffering severe injuries, such as war veterans during war or surfers being bitten by sharks, not feeling pain. Apart from physical reasons, like poor circulation (this is not a ‘good’ thing) or having a higher tolerance for pain, some people are simply less sensitive to pain. In simplest terms, their brain subconsciously plays down the pain in its interpretation.
This often comes back to the psychological and emotional experience and the mindset that’s employed. For example, if you had a very rough-and-tumble childhood and crashed your bike often but got up and kept riding, you’ll probably have less stress about your injuries and therefore, experience less pain. Your mindset is likely to be something like: ‘I’ll get through this’.
In a paper in the European Spine Journal, ‘Pain assessment’, researchers say there are five key factors that determine the likelihood of experiencing persistent pain:
- coping strategies
- pain acceptance
- pain tolerance
- anxiety of pain
- fear-avoidance behaviour[x].
Measuring the extent of the pain problem
While there is not a ‘gold standard’ for measuring pain and its contributory factors, there are many scientifically-robust tools and approaches available that measure different aspects of pain. These can help patients and their health carers to understand the extent of the pain problem as a first step to treating it. Some examples of widely-used approaches/tools are:
- taking a full history of pain experiences
- the Visual Analogue Scale (VAS) which explores severity/intensity
- the Verbal Rating Scale (VRS), which is used to help doctors understand how pain is affecting ability to do things in life. The VRS involves looking at a list of adjectives and choosing the one that is most appropriate for them.
- the Chronic Pain Acceptance Questionnaire (CPAQ-R), which includes 20 questions
- the Pain Anxiety Symptoms Scale
- the Fear Avoidance Beliefs Questionnaire.
What’s important is to be aware of is that a combination of reputable and applicable tools are available and doctors and health professionals (eg. psychologist, physiotherapist) should be able to explain to you the basis of what they use for their assessments. You can see an example of a combination of tools used in this Sample Pain Assessment. Some of the above tools and questionnaires may be viewed as more or less robust than others and research and validation is ongoing.
So once you know the extent of the problem, how can you change the future?
Four things you can do now to help you manage pain and improve your life
There is no magic pill. The best approach you can take to treat your pain is to learn more about pain and then take action.
If you can learn to cope and manage to limit the impact of pain day-to-day, you will have an improved life. For example, if you can learn the skill of pacing your day so pain is less, this will help. Over time, this can make a big difference to quality of life. Ready to dive in to four key strategies?
1. Mindset: Start with your head (thoughts, mindset and behaviour)
The way you choose to relate to your pain will affect much power it has over you. This is pretty amazing! In an earlier article, I wrote about the many thinking-feeling factors that influence recovery and disability more generally. Our psychology directly affects how we relate to pain. If you’re injured but feel safe and secure or couldn’t care less, your pain will be much less than if you’re freaked out about the situation you’re in.
So what can you do? The first step is to explore how you are coping with your pain. Are you taking an active or passive approach now?
This may seem like an odd question. Multiple studies show that patients who use active coping behaviours are at a lower risk of developing disabling pain than those who are more passive. An example of being passive is giving the responsibility for pain management to others including doctors or family members. Or thinking negative thoughts or feeling like you can’t cope… reducing social activities… telling others it hurts all the time… or praying for it to hurt less[xi].
Watch out for catastrophic thinking
What I call going down the ‘sh&t! This is bad’ spiral could actually be a hint that you are prone to what professionals call “catastrophic thinking”. It is widely acknowledged that this kind of thinking can be a serious problem. Catastrophic thinking—viewing a situation as much worse than it actually is—is assessed in an objective way (for example, by the Pain Anxiety Symptoms Scale and the Fear Avoidance Beliefs Questionnaire) as it can increase the severity of the pain experience[xii]. If you’re prone to this type of thinking, ask yourself how your parents respond to pain. New research shows that the tendency to catastrophise pain might be biologically inherited[xiii]. This doesn’t mean though that the way you respond to pain can’t be changed; you’ll just potentially have to work a little harder at learning to control your reaction to pain.
According to Michael Sullivan, creator of the Pain Catastrophizing Scale[xiv], catastrophic thinking about acute pain can also influence a tendency to develop persistent pain conditions and contribute to ongoing disability.
“It is becoming increasingly clear that catastrophic thinking in relation to pain might be a risk factor for chronicity. In other words, catastrophising not only contributes to heightened levels of pain and emotional distress, but also increases the probability that the pain condition will persist over an extended period of time.”
Active coping mindset and behaviours
So, on the flipside, what are examples of an active coping mindset and behaviours?
- Managing your mindset to try not to feel angry, depressed or anxious.
- Forgetting the pain or distracting yourself from it.
- Keeping busy, working on projects, getting back to work.
- Doing regular exercise.
- Doing things you enjoy and finding pleasure.
As researchers from the Center for Integrative Medicine, University Witten/Herdecke summarise in their paper on adaptive coping strategies for patients with chronic pain: “Apart from effective pain management, a comprehensive approach is needed which enhances the psycho-spiritual well-being, i.e. self-awareness, coping and adjusting effectively with stress, relationships, sense of faith, sense of empowerment and confidence, and living with meaning and hope. Also changing negative illness interpretations and depressive or avoidance coping by means of an intervention and encouraging social support by means of patient support groups may at least improve quality of life.”[xv]
2. Move: Get physical
I’m a huge fan of exercise, physiotherapy and massage as ways to reduce pain, assist in healing and improve strength, stability and flexibility. Due to pain, the brain will often try to protect the area by reducing activity in the area that originally triggered the messages. And then the muscles turn off in that area. These turned off muscles are no longer supporting the joints, which can lead to further joint injury or lead to alternative muscles working to stabilise the area and then they often get strained. It can become a downward spiral.
So this brain-led self-protection strategy is actually a bad plan. But all is not lost; we can retrain the neuromuscular pathway, this brain to muscle communication channel, and get back to normal function.
According to Tom Dixon, Senior physiotherapist with Get Active Physiotherapy in Sydney, Australia, pain can stick around for a long time due to this automatic switching off.
“In the case of back pain, the deep stabilising muscles around the lower part of the spine (lumbar spine) are used less when people are in pain and strength starts to deteriorate after three days of pain. Without the motor control a vicious cycle starts causing abnormal movement patterns to develop, leading to more pain, resulting in further weakening and so on.
“Early intervention is important to reduce symptoms quickly in order to minimise the effect that pain has on muscle function. Even after symptoms have fully resolved you’re not quite out of the woods and it is likely that exercises are still needed to retrain the affected muscles back up to their previous levels of strength, if not better. This will help minimise the chance of re-injury again.
“The body as a whole (joints, muscles, tendons, cartilage) works better when we move. From the outset for the majority of injuries (not all), I get people moving their injured area. It’s important to remember at this point, however, that I do not mean that you should push through pain. (Athletes use the philosophy of “no pain, no gain” to indicate progress; this is not relevant for pain management.) To expand this further, what I mean is that there will be a way that you can move most body parts even with an injury and more often than not I will encourage people to move only in a pain-free range. With this, you get pain modulation through de-sensitisation of the pain centres of the brain. A reduction of pain improves muscle activity and increases the effectiveness of muscle activation/strengthening exercises. Range of movement are therefore a great adjunct to strengthening exercises.”
3. Medication: Be smart about the drugs
Oxycodone, Codeine, Ibuprofen, Indomethacin, Acetaminophen, Diclofenac, Aspirin… You may be prescribed one or a few of these by your doctor. Keeping on top of pain is important, especially in the first few weeks, to maintain quality of life.
Hell! I would have sucked down twice as many drugs as I had to make the pain more bearable in the first couple of months, if I could have.
However, the standard “pop a Panadol” may not be the best call to action for everyone, all of the time. There is increasing evidence showing that drugs are failing to help with long-term pain and indeed, in the short-term, the side effects can be more trouble than they’re worth.
But medicines do have an important place in managing pain. Drugs stimulate certain parts of the brain to interrupt the pain communication in the nocioceptive system. And this can offer a whole lot of relieve to people who are in agony.
For people suffering pain not resulting from an acute injury (for example back pain), rethinking the drugs is actually really important so you can work on other things to get back to pain-free. A recent article, Taking drugs to treat back pain isn’t worth it, highlighted an Australian review of 35 trials involving more than 6,000 patients. It found that non-steroidal anti-inflammatory drugs (NSAIDS) used to treat back pain provide little benefit, but cause side effects.
The researchers and physiotherapists quoted in the article agree that there is no quick fix (AKA that magic pill) for treating back pain. They emphasise the need for education, exercise and changing the way people think about pain. Interestingly they do confirm that topical NSAIDs are effective in providing temporary pain relief (mainly gel formulations of diclofenac, ibuprofen, and ketoprofen, provide the best results)[xvi].
4. Mix it up: Experiment as much as you can with recommended techniques to help manage and reduce pain
Scientists and medical professionals understand a lot about pain but what works to reduce pain for one person may not work for another. Overarching advice for improving your pain (as well as other aspects of your health and wellbeing) is positive lifestyle changes like: diet, exercise, attitude, reducing stress.
Here are some more techniques or approaches that you may like to try:
- Diet: Some people find that certain foods exacerbate their pain (for example, migraine sufferers often find wine and cheese trigger attacks). And certain foods are linked to inflammation, which can be at the root of some types of pain. If you’re struggling to keep pain under control, keep a food diary and track your pain levels for a few weeks at least and then start experimenting by dropping out certain foods for a couple of weeks.
- Distraction is a technique that applies to both adults and children. When you’re doing things like a Sudoku or talking with someone, the areas in your brain that process pain are less active. Read more about some research on this here: Parents’ reactions can lessen or worsen pain for injured kids.
- Acupuncture / dry needling: there is some evidence that this works for some people. It may be because the fine needles increase blood flow or interrupt the nerve signals that are being sent up the line. Or it may be that the idea of being poked with a needle releases natural painkillers. (It helped me. Yes, it made me feel euphoric and I said crazy things… but that’s another story.) It’s worth keeping up with emerging research on this and I recommend the Cochrane reviews, such as this one: Acupuncture and dry needling for low back pain. The authors conclude: “When acupuncture is added to other conventional therapies, it relieves pain and improves function better than the conventional therapies alone. However, effects are only small.”
- Pacing: doing physical activities up to 80% of what you could do on a bad day and then repeating consistently to start getting closer to normal activities again.
- Feldenkrais: a specific type of physical therapy working with neuroplasticity.
- Transcutaneous electrical nerve stimulation (TENS): a therapy that uses low-voltage electrical current or pulses. The current or pulse interrupts the signals from pain nerves and it is very effective for persistent pain management.
- Neuromodulation (also called spinal cord stimulation, or SCS) is a proven therapy to manage persistent pain and improve quality of life.
- Relaxing, meditating and going on retreat: yes please! Bring on the positive feelings!
It is worth noting that while researching this article I came across many posts (blogs, podcasts) worldwide by people talking about how they have healed their pain through self-work to clear their emotional pain.
Often referred to as the psychosomatic model of healing it claims that the cause of persistent pain is deep emotional wounds or unexpressed emotions. Dr Sarno, probably the most well-known spokesperson on this school of thought, believed that pain (and almost all other body symptoms) is the result of an emotional process: tension. He labelled his discovery TMS; Tension Myoneural Syndrome. (Read more in Forbes: articles on Dr Sarno’s approach.) I haven’t read his book or looked into this further.
Last words on taking action on pain
The main thing is don’t get stuck; keep trying to make your pain better so that you can avoid going down a negative spiral.
The evidence is clear that by reducing pain you’ll have a better recovery and you’ll be giving yourself a better chance to get back to thriving not just surviving after your injury.
“It’s all about learning as much as you can to manage the pain as effectively as you possibly can.”
Michael Clarke, one of Australia’s top cricketers. He has lived with chronic pain since he was 17 years old.
Dr Trinca from St Vincent’s Hospital Melbourne says that after an injury people generally fit into three categories: in the first group, people recover completely; in the second, they recover with some ongoing impairments but are well-adjusted to their new circumstances; in the third group, the story is very different…
“What is very distressing for me as a Pain Medicine Physician of many years’ experience is that many sufferers of chronic pain and disability are in the third category and could have been in one of the first two groups if the correct approach had been adopted in the early phases of the injury. Ten years down the track, things are much more difficult to reverse. However, with a lot of effort from the patient assisted by with the right help, some patients learn to adapt much better to their injury and lead much more functional lives often with less pain and less medication.”
If your doctor or health and wellbeing team isn’t listening to you about your pain, find others who are up-to-date with the latest best practice around treating pain. You could also seek a referral to a reputable pain specialist. Download the Understand Your Pain Resource Kit (below) and see what else you can learn through reading books or taking a course like this one for chronic pain from This Way Up.
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[iv] IOM (2011) Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Institute of Medicine, Washington, DC, The National Academies Press, https://www.nap.edu/catalog/13172/relieving-pain-in-america-a-blueprint-for-transforming-prevention-care
[vi] M Hogg (2015) What dictates how much pain you feel after injury?, The Conversation, November 30, 2015, http://theconversation.com/what-dictates-how-much-pain-you-feel-after-injury-48985
[vii] IASP (2004) Unrelieved Pain is a Major Healthcare Problem fact sheet, International Association for the Study of Pain https://www.iasp-pain.org/files/Content/ContentFolders/GlobalYearAgainstPain2/20042005RighttoPainRelief/factsheet.pdf
[viii] IASP, 2004.
[ix] IASP, 2004.
[x] M Haefeli and A Elfering (2006) ‘Pain assessment’, Eur Spine J. 2006 Jan, 15(Suppl 1), S17–S24, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3454549/
[xi] Multiple: AC Mercado, LJ Carroll, JD Cassidy, P Côté (2010) Passive coping is a risk factor for disabling neck or low back pain, Pain, 2005 Sep;117(1-2):51-7, https://www.ncbi.nlm.nih.gov/pubmed/16043291; Snow-Turek A, Norris MP, Tan G (1996) Active and passive coping strategies in chronic pain patients, Pain, Volume 64, Issue 3, March 1996, pp 455-462, http://www.sciencedirect.com/science/article/pii/0304395995001905; GK Brown and PM Nicassio (1987) Development of a questionnaire for the assessment of active and passive coping strategies in chronic pain patients. Pain. 1987 Oct;31(1):53-64, https://www.ncbi.nlm.nih.gov/pubmed/3696743?report=abstract
[xii] A Craig, R Guest, Y Tran, K Nicholson Perry, J Middleton (2017) Pain Catastrophizing and Negative Mood States After Spinal Cord Injury: Transitioning From Inpatient Rehabilitation Into the Community, (Corrected proof), http://doi.org/10.1016/j.jpain.2017.02.431
[xiii] Z Trost, E Strachan, MJL Sullivan, T Vervoort, AR Avery, and N Afari (2015) The heritability of pain catastrophizing: A twin study. Pain, 156, 514–520.
[xiv] MJL Sullivan, SR Bishop, J Pivik (1995) The Pain Catastrophizing Scale: Development and validation. Psychol Assess. 1995, 7, 524–32, PubMed, https://eprovide.mapi-trust.org/instruments/pain-catastrophizing-scale/abs
[xv] A Büssing, T Ostermann, EAM Neugebauer and P Heusser (2010) Adaptive coping strategies in patients with chronic pain conditions and their interpretation of disease, BMC Public Health 2010, 10:507, https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-10-507
[xvi] S Derry, R Moore, H Gaskell, M McIntyre, PJ Wiffen (2015) Topical non-steroidal anti-inflammatory drugs for acute musculoskeletal pain in adults, Cochrane, http://www.cochrane.org/CD007402/SYMPT_topical-non-steroidal-anti-inflammatory-drugs-acute-musculoskeletal-pain-adults
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