Non-pharmacological treatment

Non-pharmacological treatment is an extremely important part of chronic pain management. It is a very broad term that includes many different methods, e.g. patient education, psychological treatment, physiotherapy, breathing and relaxation exercises. massage, acupuncture, transcutaneous electrical nerve stimulation (TENS), heat and cold therapy, and distraction.

Unfortunately, there is a lack of knowledge about non-pharmacological treatment among healthcare professionals. As a result, their patients neither get adequate healthcare, nor the help and support that they need to manage their pain. They also don't get enough information about non-pharmacological treatment methods which can lead to consequences that may affect the entire treatment.

One of these consequences is that, without adequate information, the patients have no idea how non-pharmacological treatment works. I know by my own experience that if you are in severe pain a doctor or a nurse tells you to do breathing exercises, it's difficult not to feel offended, misunderstood, or even plain mad. It is often interpreted as disbelief, or as if they believe that it's all in your head or that you are just making it up. So, if you feel mistrusted and, on top of that, you don't even believe that non-pharmacological treatment can help, you will be unlikely to actually follow your treatment plan or even just try some of the methods and see what happens.

Unlike what most people believe, non-pharmacological treatments actually create physiological changes in your body that help relieve the pain. Below is a very simplified list of some of these ways:

Pain signals can get blocked, which means that they never reach the brain. This, in turn, reduces the pain we feel.
Other nerve impulses (e.g. touch or heat) override the pain signals so that they aren't perceived by the brain. (This is called the gate control theory, and will be explained a little further down on this page.)
Receptors that are involved in the pain pathway may be blocked (e.g. by heat). This makes it more difficult for the pain signals to be transferred from one nerve to the next, and finally all the way up to the brain.
The parasympathetic nervous system is activated (e.g. by breathing or relaxation exercises), which helps us to calm down and reduces the pain.
Release of the hormone oxytocin, e.g. from touch.
Release of endorphins which mimic opioids by binding to their receptors.

Psychological treatment

Psychological treatment is one of the most important parts of chronic pain management. *****

A counselor, psychologist or psychotherapist can help people with chronic pain in two main ways. First of all, they can help you understand how your thoughts/behavior and your pain are related to each other. They can help you identify thoughts and behaviors that have a negative impact on your pain and quality of life, and replace them with more positive ones. They can teach you coping skills that you can use to manage your pain and flares, and help you figure out how to live a life that is as good as possible despite the pain.

A lot of people with chronic pain also develop depression and anxiety, which in turn often increases their pain, thus creating a negative circle. Counselors, psychologists and psychotherapists can help you manage your depression and anxiety and break this cycle. They can talk you through negtive thoughts and feelings and help you see things in a different light. They can also help you accept the situation that you're in and get a sense of self-efficacy.

For more detailed information and exercises, look under "support" in the menu at the top of the page.

Breathing exercises

When we are stressed, anxious or in pain, we instinctively start breathing faster and in a more shallow way than usual. This shallow breathing sets of the sympathetic nervous system - the part of the autonomous nervous system whose job is to prepare our body for danger (a.k.a. the "fight or flight reaction"). This causes even more stress, which makes your breathing even more shallow, and suddenly you're stuck in a negative cycle that only increases your pain and anxiety. Shallow breathing can also cause symptoms that further increase the anxiety. You may experience chest pain or heaviness because you've been tightening your chest muscles. You may feel dizzy or lightheaded, get a more rapid heartbeat, and sometimes numbness or a tingling sensation in your hands, arms, feet or legs.

I know how frustrating it can be when you're in severe pain and someone tells you to just "take a deep breath", but it's actually a good way to cope with the pain. Relaxed (or diaphragmatic/abdominal) breathing reduces the level of stress hormones in our blood, relaxes our muscles, and lowers our blood pressure and heart rate. It increases feelings of calm and wellbeing, and also improves our ability to deal with intense sensations and emotions.

Check under "support" in the menu at the top of the page for breathing exercises!

Relaxation

When we are in pain (or any other kind of stressful or threatening situation), our body automatically responds by becoming tense. This occurs because the pain activates our sympathetic nervous system whose job it is to keep us safe from harm or threat. When the body is tense, the pain gets even worse, and this leads to a negative circle.

Relaxation can be very helpful in relieving muscle tension and decreasing pain. It also reduces stress, helps us feel more in control of the situation, and releases endorphins (our body's "natural painkillers"). As a bonus, it promotes sleep, which is something a lot of people with chronic pain have difficulties with.

Trying to relax when you're in a lot of pain can be very difficult and even feel impossible in the beginning. However, it's a skill just like any other, and it will get easier and easier the more you practice. There are a lot of ways to relax your body and mind and it's important to find the methods that work for you. Some people take warm baths or listen to calming music while others prefer meditation or relaxation exercises such as progressive muscle relaxation.

For more suggestions and relaxation exercises, look under "support" in the menu at the top of the page.

TENS

TENS (transcutaneous electrical nerve stimulation) is a non-pharmacological alternative for pain relief, and consists of a device that is connected to the skin with two or more electrodes. It uses non-painful electric currents to stimulate nerves, which has a pain-relieving effect. As of yet, we are not 100 % sure how it works, but the most common theory used to explain it is the gate control theory.

According to this theory, pain signals travel from the body part where the pain comes from, through nerves "gates" in the spinal cord, and then up to the brain. These gates can open and close, and determine if the pain signals should go through and reach the brain or not.

The theory also explains that there are different types of nerve fibers in the body. A-beta fibers carry non-pain sensations like pressure and touch to the spinal cord. The electrical currents of TENS also travel through the A-beta fibers. Pain signals, however, are carried to the brain by smaller nerve fibers, called A-delta and C fibers. Since these fibers are smaller, the pain signals move a lot slower than the sensations that are carried by the larger A-beta fibers.

When the pain signals are less intense than the non-pain sensations (like the electrical currents of TENS), the non-pain signals override the pain signals, which means that the gate closes and the pain is therefore not perceived by the brain. This is what happens when you use TENS: when the sensations from the electrical currents become more intense than the pain signals, you experience less pain.

The good thing about TENS is that it doesn't have any side-effects, except that your skin might get a little irritated beneath the electrodes. You can use it anywhere and you can combine it with any medical treatments you may have. If you haven't tried it already, I suggest you give it a shot :)

Physiotherapy

Physiotherapists can help people with chronic pain in several ways:

They can assess how the pain affects your ability to move and find ways to get you moving again.
They can teach you breathing and relaxation techniques that can help remove muscle tension and calm your body.
They can identify abnormal postures and movements that your body may have adopted to guard the pain, and help you unlearn them.
They can assess if any special treatments may be useful, e.g. TENS (transcutaneous electrical nerve stimulation), acupuncture or manual therapy.
They can teach you skills that you can use to manage your pain, increase your activity, and improve your quality of life.
They can help you identify exercises or movements that you (often unconsciously) avoid because of the pain.
They can help you prevent the consequences of long-term inactivity.
If you are afraid of exercising because of the pain, they can help you come up with exercises that are good for you, and learn which ones you should avoid and how hard you can push yourself.

Anti-inflammatory diet

Although further research is needed, the so-called anti-inflammatory diet (or endometriosis diet) has become more and more widespread lately, not only among those with endometriosis, but also people who suffer from any chronic inflammatory illness. The concept behind this diet is that some food types increase inflammation, which has a negative impact on the pain. In order to find out what works for you, try to eliminate or decrease your consumption of one of these food types at a time and see if it helps (keeping a journal can be helpful!). However, make sure that you replace these food groups if needed, so that your body to get all the nutrients it needs.

Foods to avoid:

Trans fat (mostly found in fried, processed, and fast food)
Red meat
Gluten
High-FODMAP foods, which are groups of carbohydrates that have a tendency to trigger digestive symptoms like bloating, gas, and stomach pain
Dairy products (especially with lactose)
Added sugars
Caffeine

If you suffer from endometriosis, try to buy organic meat and dairy products, as they contain less hormones than the regular ones, as well as organic fruits and vegetables which have less pesticide residue. Another tip is to avoid eating soy products since they contain phytoestrogens, compounds that are structurally similar to the hormone estrogen. Studies have shown that, when ingested, phytoestrogens seem to mimic the effects of estrogen in our body, although they have a much weaker effect.

Foods that may have a positive effect:

Fibrous foods, e.g. fruits, vegetables, legumes, and whole grains
Foods that are rich in essential fatty acids, e.g. salmon, sardines, herring, trout, avocado, grains, nuts and seeds
Antioxidant-rich foods, e.g. colorful fruits and vegetables like oranges, berries, spinach, beets, and dark chocolate
Cold-pressed vegetable oils (olive oil, canola oil, flaxseed oil, nut-based oils)

Exercise

Exercising with chronic pain can be really difficult, but it is actually a very important part of staying as healthy as possible. In some cases, light exercise such as walking, stretching, or doing yoga can actually relieve the pain, but even if it doesn't, it usually helps long-term.

Regular exercise...

Increases mobility and flexibility
Loosens tight/stiff muscles
Increases joint flexibility
Strengthens your muscles
Releases endorphins and activates your body's own endogenous opioid systems
Improves your emotional wellbeing, decreases depression and anxiety
Improves sleep
Increases your overall energy levels
Decreases the risks associated with inactivity, eg obesity, high blood pressure, heart disease, diabetes, etc.

If you're dealing with chronic pain, it is important to listen to your body. While doing some light exercise even though you're in pain can be beneficial, pushing yourself too far and ignoring your body's warning signals can make things worse. It's always better to start carefully and gradually increasing your exercises if everything feels all right.

There are 3 types of exercise that each have different benefits - if you can, try to mix things up a little instead of always doing the same thing. Here are some examples:

Aerobic/cardiovascular exercise, e.g. walking, cycling or swimming.
Strength, e.g. using free weights, machines, stretchy bands, your own body weight, or even household items to strengthen your muscles.
Flexibility, e.g. stretching, yoga, pilates or tai chi.

Remember to stretch and warm up before doing any type of exercise!

Distraction

Distraction is one of the most commonly used pain-relieving techniques. When you suffer from chronic pain, it's easy to get offended if someone tells you to just "stop focusing on your pain and think of something else". After all, if it were that easy, we'd be doing it all the time. But even though distraction techniques won't help you bring your pain down from an 8 to a 0, studies have shown that mental distraction actually reduces the amount of pain signals from reaching the brain. The reason behind this involves endogenous opioids, which are naturally produced by the brain. In one study, they even used fMRI scans that showed lower activity in the spinal cord when the participants were distracted and therefore perceived less pain.

Here are some ideas that you can try:

Try breathing or relaxation exercises
Meditate
Take a warm bath
Watch your favorite movie or TV-show
Listen to music or a podcast
Play video games
Read or listen to a sound book
Do a crossword puzzle or sudoku
Paint, color (I love mandalas!) or doodle
Call a friend and talk about anything other than the pain
Play a music instrument
Go outside for a walk
If you can, do some light exercise

I know it can feel almost impossible to think about something else when you're in severe pain, but try different things to find what works for you, and keep practicing. Since it can be difficult to come up with distraction techniques during a flare, you may want to include your favorite ones in a flare plan. That way, all you have to do is follow the plan.