Can stress make my pain worse?
Stress!! AAAAAARRRRGGGGHHH! We all feel stress to one degree or another and we all cope with it in different ways, but did you know that stress can affect your pain levels? This article is intended to explain what stress is, how it can affect the pain we feel, and what can be done to help reduce pain associated with stress.
Stress is ‘a physical, mental, or emotional stimulus that causes bodily or mental tension’ (1). The body’s reaction to stress is one that is intended to help the body deal with the situation presented to it, this response can range from a mild and temporary change in your biochemistry to profound changes to how our body and mind function (2). Exposure to either high levels of stress or prolonged exposure over time is known to negatively affect a person’s memory and learning ability, the immune system, their cardiovascular health and digestive function (2), as well as being linked to major depressive disorders and other psychiatric conditions (3).
Stress can also affect how a person perceives pain, the effect is not always in one direction either, depending on the nature, intensity and duration of a stressor the effect can be to either increase or decrease pain (4, 5). The duration of the perceived stressor is important, if the exposure to stress is prolonged the body will change its response over time, this is known as ‘general adaptation syndrome’ (6).
In the early stage of general adaptation (alarm stage) stress results in a reduction in pain, this is known as stress-induced analgesia, the pain reduction effect is usually seen in a situation where the stressor is intense but short-lived, such as the threat of violence or attack, provoking a ‘fight or flight’ response (5). I
n this early stage, the body reacts releasing cortisol and adrenaline which increases the activation of a part of the nervous system known as the sympathetic nervous system. This will result in an increase in blood pressure and heart rate, to help supply the brain and muscles with the necessary fuel to ward off the threat, the activation of the sympathetic nervous system will also stimulate the production of opioids that act to inhibit the perception of pain in order to perform better against the threat. This response to stress serves as a valuable tool to ensure the survival of a species or an individual, be it used to fight off a sabre-toothed tiger or jump out of the way of an oncoming car (5, 7). Once the stressor is removed, the body returns to its a normal state by activation of the parasympathetic nervous system (the balancer to the sympathetic nervous system), it reduces the cortisol in the body which results in a lowering of blood pressure, heart rate, and a reduction in the opioids that inhibit pain.
But what happens if stress is prolonged beyond this short-term response, what if the sabre tooth tiger doesn’t go away? This prolonged exposure to stress will mean the body enters the second stage of general adaptation (resistance) where the body will continue to be on high alert with all the chemical and physical reactions described above. Eventually the body’s capability to produce the necessary reaction will be depleted leading to the third phase, exhaustion (6). It is in this phase where the effects of chronic stress such as memory, mood disorders and digestive problems begin to be seen (2, 3).
One of the effects of chronic stress is that no matter what the original cause of your pain is, stress makes it worse (8). One of the reasons for this is that even in the exhaustion phase of the stress response the body will still try to reactivate the initial alarm phase resulting in an increase in muscle tone, which will eventually lead to chronic tension and pain in the overly contracted muscles (eg jaw clenching). The prolonged exposure to stress also causes changes to the nervous system resulting in how we perceive pain being altered. The more the body is exposed to stress the more the brain and spinal cord become sensitized to sensory input, meaning the amount of input needed to produce a pain response is less than before, and painful input worse than it otherwise would have been (9). This is known as stress-induced hyperalgesia.
Stress-induced hyperalgesia can play a part in patients who attend our clinic with chronic pain patterns. Chronic pain is described as any pain that persists beyond three months, this is seen as the time that nearly all tissues should be healed after injury (10). Chronic pain affects up to 20% of the population at any one time and we see a lot of people who would fall into this category. Often the stress associated with a very acute episode of pain, or the anxiety and worry of prolonged pain and it’s effect on a person’s quality of life will become a part of the problem. We often treat people who’s pain seems to be much more than would be expected of the initial injury, often it appears like the body has ‘turned up the volume’ on their pain levels resulting in a situation where the pain limits their ability to lead a normal life which in turn creates more stress and negative coping strategies (exercise avoidance being the most common) that will maintain or contribute further to the person’s pain levels. 
If you think that stress is contributing to your pain, what can be done about it? Often addressing the source of the stress through psychological intervention can be helpful, there is some evidence that cognitive behavioural therapy can have a positive impact on how a person behaves when they are feeling stress, resulting in more positive coping strategies (11). Even just providing information and perspective on the reasons for someone’s pain can help them reduce the stress associated with it, and in turn, reduce the pain (12). Exercise can also help as it not only been shown to have a positive effect on people’s mood (13), but also has an analgesic effect (14).
Often it is not clear whether a person’s stress is contributing to their pain, or their pain is causing the stress, in our experience the most effective way to treat people who have chronic pain that may be linked to stress is to try to address all the elements of a person’s situation that might be contributing to the pain. If we take the example of someone who has long term low back pain that is mostly felt sitting at a desk, we would;
- Perform a full assessment to see what physical causes there are for the pain, it could be that they have chronic muscle strains on joint problems from the prolonged sitting
- Investigate how they sit at the desk, it may be that they are working at a poorly designed desk, or have a chair that is not suitable for them (or commonly they may be working hunched over a laptop) which can contribute to the pain.
- Consider if they have had a change in work habits or job role, this may mean they have to spend longer at the desk making the pain worse.
- Try to understand if their job causing them stress? If so they may overwork, resulting in them sitting for prolonged periods, stop them taking regular breaks, and stop exercising due to the time pressure they feel they are under. If stress is a factor then they will be susceptible to the chemical and neural changes explained above.
Once we have fully investigated the causes of the person’s pain we can then recommend the most appropriate treatment to help relieve their symptoms. Often it will be a mix of manual therapy, exercise recommendations, and advice on reducing the causes of the pain being generated. In the case of someone who we suspect stress being a large part of their pain we would recommend they try to address the causes of the stress either through self-management of the stressor, or referral to someone who specializes in stress management.
If you enjoyed this article, why not have a look at our other articles on pain such as How We Measure Pain, and Could My Weight Be Causing My Pain?
If you feel you need help dealing with stress, depression, or other feelings that are worrying you we would encourage you to speak to someone about it. You can find a list of mental health helplines here.
Do you want to know what is causing your pain and if we can help? Why not take advantage of our new patient assessment introductory offer to get you started towards a tailor made recovery plan for only £19.
Are you in a lot of pain and want to get better as soon as possible? If so then why not book in for a new patient consultation, with treatment on the day, for £72.
References
1 – Shiel, W. (2020). Medical definition of stress. Available at; https://www.medicinenet.com/script/main/art.asp?articlekey=20104, accessed March 2020.
2 – Yaribeygi, H., Panahi, Y., Sahraei, H., Johnston, T. P., & Sahebkar, A. (2017). The impact of stress on body function: A review. EXCLI journal, 16, 1057–1072. https://doi.org/10.17179/excli2017-480
3 – Cattaneo, A., Riva, M. (2016). Stress-induced mechanisms in mental illness: A role for glucocorticoid signaling. The Journal of Steroid Biochemistry and Molecular Biology, Volume 160, June 2016, pp169-174.
4 – Ahmad AH, Zakaria R. Pain in Times of Stress (2015). Malays J Med Sci, Dec;22(Spec Issue):52-61.
5 – Mehnaz F, Finn D (2018). Chapter 4 – Stress-induced modulation of pain: Role of the endogenous opioid system, Progress in Brain Research. Volume 239, 2018, Pages 121-177
6 – Hans Selye, “The General Adaptation Syndrome and the Diseases of Adaptation” (two parts), Journal of Allergy [later and Clinical Immunology] 17/4 (July 1946): 231–247; and 17/6 (Nov. 1946): 358-98. Available online at https://doi.org/10.1016/0021-8707(46)90148-7
7 – Olpin, Michael. “The Science of Stress”. Weber State University. Archived from the original on 2017-11-20. Retrieved 2013-04-25, accessed through; https://en.wikipedia.org/wiki/Fight-or-flight_response#cite_note-The_Science_of_Stress_-_Olpin-16
8 – Alexander, J. K., DeVries, A. C., Kigerl, K. A., Dahlman, J. M., & Popovich, P. G. (2009). Stress exacerbates neuropathic pain via glucorticoid and NMDA receptor activation. Brain, Behavior, and Immunity, 23(6), 851-860. doi: 10.1016/j.bbi.2009.04.001.
9 – Rivat, C., Becker, C., Blugeot, A., Zeau, B., Mauborgne, A., Pohl, M., & Benoliel, J. (2010). Chronic stress induces transient spinal neuroinflammation, triggering sensory hypersensitivity and long-lasting anxiety-induced hyperalgesia. Pain, 150, 358-368.
10 – Treede, R. D., et al (2015). A classification of chronic pain for ICD-11. Pain, 156(6), 1003–1007. https://doi.org/10.1097/j.pain.0000000000000160
11 – Heapy A. A., Higgins D. M., LaChappelle K. M., Kirlin J., Goulet J. L., Czlapinski R. A., Kerns R. D. (2016). Cooperative pain education and self-management (COPES): Study design and protocol of a randomized non-inferiority trial of an interactive voice response-based self-management intervention for chronic low back pain. BMC Musculoskeletal Disorders, 17(1), 85. doi:10.1186/s12891-016-0924-z
12 – Hakim, A., Keer, R., Grahame, R., (2010). Hypermobility, Fibromyalgia and Chronic Pain. Churchill Livingstone, Edinburgh.
13 – Schuch FB, Vancampfort D, Rosenbaum S, Richards J, Ward PB, Stubbs B (2016). “Exercise improves physical and psychological quality of life in people with depression: A meta-analysis including the evaluation of control group response”. Psychiatry Res. 241: 47–54. doi:10.1016/j.psychres.2016.04.054. PMID 27155287.
14 – Harber VJ, Sutton JR (1984). “Endorphins and exercise”. Sports Medicine. 1 (2): 154–71. doi:10.2165/00007256-198401020-00004. PMID 6091217.