Exercise Pain

Anxious About Persistent Pain

Persistent pain can be a frightening experience because there are so many unknowns. As the pain persists, the worry that something bad is driving the pain increases which can increase anxiety and fear. This article will discuss the relationship between anxiety and persistent pain.

Origin of fear and anxiety

The two areas of the brain that are involved with fear and anxiety are the amygdala and the prefrontal cortex.

The amygdala is located in the central portion of the brain and is involved in the evaluation, detection, and anticipation of threatening events. The amygdala is also connected to the thalamus and other cortical regions of the brain. These connections allow the brain to associate information with pain or a threatening event (for example, if you were in a car accident, your body may react the next time you are at the same intersection because your brain remembers the last time you were there).

The prefrontal cortex is located in the front portion of the brain and is involved in similar functions as the amygdala. However, it also functions to control the way the body reacts to a learned stimulus. This means that the prefrontal cortex can influence the body’s response to an event, whether it is pain, anxiety, fear, happiness, etc… For example, the prefrontal cortex can modify how painful or euphoric a given situation is.

Biological effects of anxiety and fear

When the body is in distress, it secretes a host of hormones in response to the stressful situation. The body’s response is meant to get you to safety in the short term, but chronic elevation can have longer term consequences. Some of the hormones involved in this response are glucocorticoids, DHEA, epinephrine, norepinephrine, and cytokines. While these hormones may be considered to be “bad,” they are actually essential for survival.

Chronic elevation of these hormones effect a variety of systems in the body, including the nervous system, cardiovascular system, and the immune system. Chronic elevation of glucocorticoids can impair wound healing and cause a decreased immune response in the immune system. Atherosclerosis, increased homocysteine levels, and increased glycosylated hemoglobin occurs in the cardiovascular system. In the nervous system, atrophy of the brain, cognitive impairment, and central sensitization are some of the consequences to elevated stress hormones.

Reducing anxiety with persistent pain

The presence of pain, especially persistent pain, can create a cycle of anxiety and fear. As the pain lingers, the thought that something must be broken or seriously wrong increases leading to more anxiety. There are multiple options to reduce anxiety and fear associated with persistent pain, which can also reduce pain.

Educating the patient on pain is one approach to decreasing the fear and anxiety of pain. Many patients (and practitioners for that matter) associate pain with tissue damage, which causes a fear of movement because it will worsen the problem. Pain can definitely mean that there is tissue damage, however, the correlation between tissue damage and pain decreases over time. When pain persists after an injury, pain acts as a protective mechanism to keep you and your tissues safe. By providing assurance that there are no structural issues or sinister pathologies present, can go a long way in reducing the anxiety of the patient with pain.

Graded exposure to movement is another approach to reducing fear and anxiety associated with pain. Graded exposure can occur in many different forms depending on the level of safety the brain needs for movement. One form of graded exposure is to use manual manipulation to guide a body part through a range of motion. This is the most dependent type of graded exposure as it relies on the assistance of someone else to reduce the threat of danger. Another form would be through the use of exercise bands to increase activation of various muscles through a movement. This type of exposure to movement is preferred as it doesn’t require assistance from anyone. The movements can then become more self-reliant starting from the least threatening position (typically supine or prone on the ground) and gradually progressing the movement to standing.

For example, graded exposure for a patient with flexion-intolerant low back pain could begin with manual guidance of the hips and low back through flexion. The assistance provided by the provider could decrease the danger of flexion, allowing the patient dissociate movement with pain. A banded toe touch could also be used to allow the patient to move through low back flexion, increasing confidence with movement since the patient is doing the movement without the assistance of the provider. Both of these examples reduce the fear and anxiety of pain since the patient can see that the pain is modifiable. The movements can then become progressively more challenging with the final progression adding load to the movements.

In conclusion

Pain that lasts longer than expected can be worrisome, leading to anxiety and fear as to what is causing the pain. Fear and anxiety are generated in the amygdala and prefrontal cortex in the brain and are responsible for releasing many hormones in response to a stressful situation. While these hormones are vital in an acute situation, prolonged elevation of these hormones can be detrimental. Educating the patient on pain and gradually exposing the patient to movement can reduce the mysteriousness of pain and thus the anxiety and fear that are associated with it.


Butler, David Sheridan, and G. Lorimer. Moseley. Explain Pain. Adelaide: Noigroup Publications, 2015. Print.
Schulkin, Jay. Allostasis, Homeostasis and the Costs of Physiological Adaptation. Cambridge: Cambridge U, 2012. Print.

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