Considerations of the pain + stress interaction

*Note that this post, while not specific to physical therapist, is written with that career-bias in mind.  Other professionals in the movement arts as well as patients or clients with chronic pain might find this information useful*


Considerations of pain + stress interaction for physical therapy professionals


Pain is a significant cause of disability and often is the driving force of patients and clients seeking physical therapy.1  Pain is a subjective perception.  Rather than being just localized, specific nervous system information (nociception, or the detection of a painful stimulus), pain is a complex interaction of an individual’s physiology (nociceptive nervous system input, immune system, autonomic nervous system, movement system, endocrine system), thoughts, emotions, and social environment.  In fact, pain can be present even without tissue damage but through the perception of tissue damage. The bodily systems are so interconnected, that the transition from acute pain (occurring at the time of injury) to chronic pain (long-lasting) is precipitated by psychological factors.2   Because pain is subjective, pain is experienced differently across people and even over time within the same individual.  The complexity of pain therefore fits a biopsychosocial model, rather than physiological model.


Besides being so complex and multifaceted, what is noteworthy is pain’s relationship to stress (here, distress, rather than beneficial stress known as eustress).  An injury can result in a stress response (ie, pain causes stress).1  The stress response can benefit an individual by promoting survival, or by intensifying the pain, the stress response can be maladaptive.1Exaggerated, prolonged, or recurrent activation of sensitized stress response to pain or non-pain-related stressors may initiate or exacerbate pain and disability.”1   Prolonged stress can perpetuate pain via cortisol dysfunction, and cortisol dysfunction is linked to chronic pain disorders, such as fibromyalgia and low back pain.1   Variability between the stress and pain relationship exist because of individual and environmental differences.1


Mindfulness-based interventions are recommended as possible stress and pain management tools.   For more information on mindfulness interventions for stress as well as links for specific studies, see the National Center for Complimentary and Integrative Health’s page:  as well as my own write up about meditation here: .  Research suggests that mindfulness is an effective modality in pain management, including for patients/clients with low back pain, fibromyalgia, injured athletes, and irritable bowel syndrome 3,4, though the success of mindfulness varies with the type practiced.4  Some physical therapists utilize mindfulness-based modalities and stress-reduction techniques in their practice, including diaphragmatic breathing, guided relaxation, and physical activity to modulate stress.5  Registered Yoga Teachers (RYTs, via the Yoga Alliance) are another commonly available resource of mindfulness modality utilization, and yoga can aid in pain management.6


Because of the impact of stress and mental health on patients and clients, some in the physical therapy profession have called for “Psychologically informed” practice therapists.7,8,9.   Indeed, a global health strategy is underway to recognize mental health as a non-communicable disease (NCD) because of the bidirectional linkages between mental illness and our primary source of mortality in the western world – NCDs.10,11  The importance of mental health is recognized within physical therapy education curriculum, within the medical models we are moving toward (biopsychosocial), as well as the International Classification of Functioning, Disability, and Health (ICF) by acknowledging the person beyond the medical dysfunction.  Bezner5 articulates how physical therapy professionals can incorporate stress management into their professional health promotion and wellness practice, though her recommendations are not specific to pain, but improved general practice.  Additionally, by assessing psychological and psychosocial barriers to recovery, we can help patients and clients optimize function.9  Several outcome measures utilized in research and the clinic to assess stress and mental health in general include Psychological Stress Measure (PSM-9), Mindful Attention Awareness Scale (MAAS), Depression Anxiety and Stress Scale (DASS), Profile of Mood States (POMS), Perceived Stress Scale, Pain Catastrophizing Scale, Fear-Avoidance Beliefs Questionnaire, Impact of Events Scale, the Daily Stress Inventory, and State-Trait Anxiety Inventory.ex.1,3,12,13  Though the preceding list is not exhaustive, the outcome measures are an initial starting point for healthcare professionals interested in becoming “psychologically informed” as a screening for stress and the need for education or referral of their patients and clients.


Ultimately, the early identification of stress and the incorporation of stress management education into pain rehabilitation may facilitate effective pain management, prevent the transition to chronic and depressive symptoms, minimize disability, and improve the quality of life1


If you are a physical therapy professional, have you noticed an interaction between stress and pain in your clients?  How have you assessed and addressed their unique needs?


Written by Dr. Allison Mitch, PT (DPT)

RYT 500, reiki master

Contact me at

All writing is copyright protected.  Photo is from Pexels. 


Citations and recommended reading:



-          Psychological Aspects of Chronic Musculoskeletal Pain:

-          An overview of systematic reviews of mindfulness:

-          NIH, Information on meditation and low back pain:

-          Zeidan F. has several articles examining mindfulness and pain, including:,