Anu Kulkarni has been happily married for more than 30 years, has a beautiful daughter, a dog, and loves throwing parties.
But, like 2.2 million Australians, she has osteoarthritis, where her knee and foot joints are painfully inflamed.
“I’m in pain every single day,” Anu says, having spent the better part of three decades dealing with chronic pain.
“Medication is what keeps me going. If I wasn’t to take the painkillers, I might be struggling to walk.”
Anu also has depression and anxiety, and for a two-year period, was unable to leave her house.
“I didn’t want to see anyone. The two years of my life, I didn’t drive, I didn’t step out of the house.”
Anu, along with her husband Narendra, wants to enjoy the years to come with the best health possible.
So, they signed up for an eight-week Catalyst experiment to make some changes to their lifestyle with the help of GP Preeya Alexander and a team of experts.
Dr Preeya Alexander was keen to teach Anu some very practical tools for managing her anxiety.(
Navigating chronic pain is complex, and there are a number of factors to consider, Dr Alexander says.
“Things like chronic pain, stress and anxiety are tricky to manage,” she says.
“Over the years I’ve found that not all prescriptions come in the form of a pill.
“Of course, if you need a medicine, I’ll write you a prescription.
“But I also prescribe treatments from another growing speciality: lifestyle medicine.
“Things like exercise, meditation, or even diet changes.”
So, what is chronic pain?
Chronic pain is typically defined by how long pain has lasted — anything over three months is usually considered chronic.
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A number of conditions can fit under chronic pain, from back pain to endometriosis to headaches.
It’s “incredibly complex” — and that’s a good thing, according to neuroscientist Tasha Stanton.
Dr Stanton believes if we can change how we understand pain and what contributes to it, we can reduce our experience of it.
“We’re feeling pain because our brain is determining whether or not we need to be protected,” Dr Stanton says.
“What we often see in people with chronic pain, is that the pain system itself is over-protective — it’s doing too good of a job.”
Neuroscientist Tasha Stanton says a person’s brain can be “tricked” out of chronic pain.(
For someone with osteoarthritis, pain is “a whole-body process”.
“It’s systemic, which means body-wide, low levels of inflammation, that actually change the way that many of the systems of the body are working,” Dr Stanton says.
Dr Stanton says changes to systems such as the brain and the gut “can influence inflammation and how sensitive our pain systems are”.
“There are numerous different contributors to chronic pain, but that means there are numerous different targets — things that we can actually try to treat.”
Can lifestyle interventions really help manage pain?
Lifestyle interventions are “surprisingly more effective than most people think,” Dr Stanton says.
“I guess what we understand from the available evidence is that the things that really help are the things that are ultimately lifestyle changes,” she says.
“So they’re things like making an effort every day to move more, making an effort to get enough sleep, [and] really thinking about diet, because diet can play a huge role in how much inflammation we have within our body.
“All of those things they might not seem like much, but when you add them all together and when you individualise them to that person, that can be an enormous contribution.”
While medication is one way of treating chronic pain, there are a few lifestyle interventions that can help too.(
Dr Stanton says making gradual changes over time slowly helps the body to adapt.
“And I think the best news is that [the ability for the body to adapt] still exists in people with chronic pain,” Dr Stanton says.
“It’s sometimes tempting to think that, because I’ve had pain for a really long time, this is just how it is. Nothing is going to change. And there is nothing farther from the truth.”
Looking at how we can shift the brain’s way of dealing with pain is a big part of making that change.
“We have all these other things that contribute to ultimately that experience of osteoarthritic pain, and our thoughts and our beliefs are a really critical one,” Dr Stanton says.
That’s why she’s keen to address Anu’s anxiety.
Understanding pain and anxiety
Depression and anxiety can have a significant impact on how a person experiences chronic pain.
“There are a lot of people who will say, ‘I notice when I’m feeling really stressed, when I’m feeling really anxious, when my mood is really, really low, that my pain is worse’,” Dr Stanton says.
“That pain is 100 per cent real.”
Mindfulness has a proven effect on anxiety, stress and pain management.(
When a person with chronic pain like Anu experiences anxiety, “it blocks our natural drug cabinet in the brain”.
“So the natural ways that our brain would respond and we would feel less pain, they’re not working properly,” Dr Stanton says.
“So when … you might feel depressed or anxious or fearful, it is not that you are overreacting to something.
“Being depressed changes the biology of your experience of your body and the world around you, and that influences your pain.”
But the good news is because chronic pain management is multifaceted, this type of pain can be managed — the brain is not fixed, but can be retrained to reduce a person’s experience of pain.
“The more that we understand how the pain system responds to different things, the more that we also don’t have to be fearful of different things,” Dr Stanton says.
“If we do take concerted action — and it might be things like gradually increasing activity over time, or learning more about our arthritis and about how to manage pain, or even getting strategies for things like anxiety — all of those different things are little pushes to our system [to change].
“I think there’s a lot of different areas that we can work with Anu and in terms of her knowledge about osteoarthritis, her knowledge about her pain, but also to get into place a nice set plan … so that she’s starting to gradually increase her general levels of activity over time.”
First stop: the kitchen
Anu says the two years she spent “on the couch” were up there with the most pain she’s ever experienced.
“The pain was worse and I wasn’t even exercising then,” Anu says, adding that she also put on weight during this time and has struggled with this ever since.
A good, balanced diet is a key contributor to health in any circumstance, but especially for people with osteoarthritis.
While we often think of weight gain putting pressure on our joints, Dr Stanton says we are starting to learn more about its contribution to inflammation.
“It actually makes more sense why sometimes you can have pain in a joint that we don’t weight bear in, when we have these increased levels of inflammation or increased levels of anxiety or stress,” she says.
Nutritionist Simran Grover explains why a banana is better to eat that a protein ball.(
In an effort to control her weight, Anu is in a damaging pattern of skipping meals and eating protein balls or bars when she feels hungry — sometimes as many as two a day.
“Narendra makes protein powder balls for me. I have been eating this because they say banana is fattening,” Anu says.
Dr Alexander brings in nutritionist Simran Grover to challenge this assumption.
“This actual protein bar or similar would have probably the same amount of calories or energy as a burger … [or] three bananas,” Ms Grover says.
Ms Grover suggests some simple changes, such as swapping the protein balls for a piece of fruit; watching portion sizes; and cutting back on fatty takeaways.
She also wants Anu to increase her veggie intake, and suggests simple switches like using cauliflower instead of potato, or popping cucumber in water.
“We’re in a lucky country, we have so many vegetables. So try to include them in any way you like — it could be as a salad, could be in a curry, could be in a stew. Could be barbecued, microwaved, air-fried, whatever. Whatever you like, but more vegetables,” Ms Grover says, adding that frozen vegetables are a great option, too.
“It’s not about being on a diet. It’s a lifestyle modification — still based on the foods that you love, the flavour, the curries — that’s easy to follow.”
Exercise and managing pain
Exercise is not just good for your physical health, but it’s also a great way to help manage anxiety and chronic pain.
But Dr Stanton says fear is often a huge barrier to exercise for people with chronic pain, because their pain system is over-protective.
“So what that means is that when you’re starting to do a little bit of activity and you do feel pain, you’re nowhere near the level that it would take to damage tissue or to further injure yourself,” she says.
“You’re doing activity at a level that actually you can be sore but you’re safe, and that understanding is really important because when we have increases in activity over time, there are positive adaptations in our pain system.”
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The key to exercising well for someone with chronic pain is to start gradually and increase over time.
“We don’t want someone to start by going for a one-hour walk when they haven’t done anything,” Dr Stanton says.
Swimming is a great exercise for people like Anu with arthritis.
Anu’s anxiety not only saw her house-bound for that two-year period, but also prevented her from swimming — something Dr Alexander wants to change.
“Swimming is a great option and something she once loved, but anxiety has robbed her of that pleasure,” Dr Alexander says.
So Dr Alexander suggests Anu try some exercises that can give both her body and mind a gentle workout.
Mindfulness and tai chi help with anxiety
“One easy thing we can all do, is to take time out of our busy lives to be quiet and calm,” Dr Alexander says.
There is evidence mindfulness can help combat stress and anxiety, and it is even being taught as part of university degrees.
“People who suffer with anxiety show increased activity in the amygdala — a part of the brain that regulates the fear response,” Dr Alexander says.
“Practicing mindfulness meditation can dampen that activity and increase a person’s ability to regulate their emotions.
“If Anu can start introducing a daily mindfulness practice, I think it could help get her swimming again.”
Anu tests out Tai Chi to help her manage her anxiety.(
She also introduces Anu to the ancient Chinese martial arts practice, tai chi.
“There is strong evidence that tai chi improves mental wellbeing and reduces symptoms of depression and decreases anxiety,” Dr Alexander explains.
“The breathing, coordinated with slow body movement and eye-hand coordination, promotes calmness.”
But the real test for all these changes comes a few weeks later, when Anu and Dr Alexander meet at the pool.
Into the water again
As they meet poolside, Dr Alexander takes Anu through some mindfulness meditation practices.
“It’s calm and peaceful here. That’s what I felt most. Because I love water,” Anu says.
They slowly enter the water together, concentrating on their breathing.
Before long Anu begins to float, holding a pool noodle — and the grin on her face says it all.
“I love, I love it!” she cries. “Oh God, I am so happy.”
Joyfully, Dr Alexander was able to get Anu swimming again.(
Eventually, Anu swims a lap, husband Narendra cheering her on.
“It’s freedom for me,” she says.
“Being able to swim again, it’s freedom. I’m free from the whatever was happening inside. The anxiety. It’s an amazing feeling.”
Anu wants to enjoy an uninhibited life with her husband Narendra and their dog Loki.(
While Anu is still on medication for her pain at the end of the experiment, she continues to practice mindfulness and has cut down her protein ball consumption to two a week.
“I mean, it’s small steps … but we knew from the beginning, because I’m suffering from chronic pain, it’s not just going to go away like that,” she says.
“It felt really good, being able to swim … it was a very big achievement.”
To see more of Anu and Narendra’s story, watch Catalyst at 8:30pm on ABC TV, or catch up later on iview.
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