PTSD & Pain

A therapeutic approach to treatment in veterans and the general population. Soft Tissue Therapist Yaad Hassan explains the complex relationship between PTSD and pain, and his first hand experience of treating both the mental and physical challenges.

I enlisted in the IDF (Israeli defence forces), infantry regiment, in 2002 and after medic school, bootcamp and advanced training I was deployed to Gaza strip where I served for 2 years. 

Since this time, I have been a reserve solider serving in several short deployments and one large operation (Operation Protective Edge, 2014). 

After leaving the army, I became a civilian trauma medic (Ambulance- Red David’s Star) in the Tel Aviv district. 

As a company medic I have seen injuries ranging from daily strains, cuts, bruises and broken bones to more serious complex multi-system injuries, and for someone that experienced long combat periods, losing friends in the service and having to treat some seriously injured fellow soldiers I have experienced how complex the invisible” (mental) injuries can be and how they almost always are accompanied by physical pain. 

One of my closest friends in the company suffered from what was later diagnosed as PTSD, he struggled with panic attacks, emotionally distanced himself from his family and loved ones, anger and crying episodes and feeling anxious luckily he didn’t suffer physical pain. 

He was fortunate to be treated by the IDF’s mental health unit (with EMDR) ending up making lemonade from the situation by writing down a one man show that describes his journey from start, operation in 2014, to finish, the treatment and following two years. 

Processing his trauma through writing, performing and the audience, even travelled around the country and abroad to perform.

My personal experience of the therapeutic effectiveness of touch and physical connection with the right therapist highlighted that a great deal of this pain can be alleviated by such a relationship; and if by any chance that therapist is a veteran themselves then the stigma and fear associated with PTSD and other mental health disorders is lessened by a mutual understanding.

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Yaad Hassan, Soft Tissue Therapist

Civilian Vs Army-Combat #

The major difference between army-combat and the civilian environment, in my perspective, is the capacity of the individual to cope with and process the traumatic situation. Injuries tend to be more severe and multiple in combat and there is a risk that the casualty’s condition can deteriorate more rapidly — particularly when the ability to treat them is limited by the ongoing physical threat to the casualty and the medic. 

The uncertainty of combat adds to the already high pressure and stress of both the wounded and the medics, increasing the likelihood of experiencing post-trauma disorder. 

Increased combat exposure, discharging a weapon, witnessing someone being wounded or killed, severe trauma and combat specialists are all more likely to suffer from PTSD’ {1}

Furthermore, the lingering consequences of a psychological trauma are particularly striking. 

The probabilities of an easy re-entry (returning to civilian life) drop from 82% for those who did not experience a traumatic event to 56% for those who did, those who served in a combat zone and those who knew someone who was killed or injured also faced steeper odds of an easy re-entry.’ {2}

Identifying the Signs #

PTSD has many faces and manifestations; it’s important to understand, know and identify them among people that might be high risk. {3} Most common symptoms of PTSD include: 

  • Intense feelings of distress when reminded of a tragic event 
  • Extreme physical reactions to reminders of trauma such as a nausea, sweating or a pounding heart
  • Invasive, upsetting memories of a tragedy 
  • Flashbacks (feeling like the trauma is happening again) 
  • Nightmares of either frightening things or of the event 
  • Loss of interest in life and daily activities 
  • Feeling emotionally numb and detached from other people
  • Sense of a not leading a normal life (not having a positive outlook of your future) 
  • Avoiding certain activities, feelings, thoughts or places that remind you of the tragedy 
  • Difficulty remembering important aspects of a tragic event

The following quotes are from veterans themselves, or their therapists, who have experienced PTSD. These may help you to recognise the signals of PTSD, and the thought processes of those who are going through it. {4,5}

1. Whenever I’m lying in bed at night and my shoulder starts hurting, I start having thoughts of when I was shot.” 

2. When I think about the day our Humvee was hit, I can feel the pain in my back flare up right where I was hurt.” 

3. Pain is like a barnacle on my hull – it keeps reminding me of what I went through.” 

4. I tried my PT exercises, but the pain started increasing and I started thinking about what I saw and heard in Iraq, so I just said the heck with it and called it quits for the day.” 

5. pain was the price” or a penance” he paid for surviving while some friends did not. 

6. Experiencing pain for a reason, so that he would never forget.”

7. Using pain and PTSD symptoms as a distraction- intentionally bring on pain by physically over‐​exerting himself in order to take his mind away from his PTSD

8. Intentionally expose himself to trauma‐​related cues that would elicit anger in order to feel alive and forget his pain.

9. It’s like a million voices in my head telling me that I’m not good enough to be alive,” — he believed depression was a sign of weakness and that it was his selfishness that let his friends die. 


Beliefs and Behaviours #

Over time, negative thoughts and beliefs about pain, and behaviours related to pain can become very difficult to change. I’ve listed some examples below.{6}

Thoughts Behaviours
My body has failed meDecreasing activities that have the potential to increase pain. Taking more medication than prescribed
I’m worthless/​disabledI’m a bad parent, spouse, and provider
This is never going to endStaying in bed all day /​Sleeping all day
My military career is ruinedStaying away from friends/​family etc.

It is clear that PTSD, whether involved an actual injury or not, has massive mental and physical implication, with pain as major player. {7} Research suggests that: 

  • PTSD and Pain co-occur at a high rate and may interact in such a way as to negatively impact the course of either disorder and even increase the symptom severity of either condition. 
  • Pain was the most common physical complaint 
  • One in four showed some type of musculoskeletal or pain problem 
  • There are higher levels of life interference in those who experience PTSD 
  • PTSD pain patients had higher levels of depression and suppressed anger than non-PTSD pain patients 

What Comes First? #

The question is should we treat the physical pain or the cognitive/​emotional pain first? 

As PTSD and pain are intertwined mechanisms it is likely to see fear, avoidance, anxiety, catastrophizing thoughts, insomnia alongside constant muscle tension, impaired range of movement and central/​local sensitization. 

The literature suggests a more comprehensive approach; studies show that several methods combined might provide a wholesome solution to those living with PTSD. Addressing mostly the emotional and cognitive aspects such as stress, fear, anxiety, and avoidance. 

Commonly used techniques on the cognitive-emotional-behavioural spectrum include: 

  • Prolonged Exposure Therapy 
  • Cognitive Processing/​Behaviour Therapy (CBT/CPT)
  • Stress Inoculation Training (SIT)
  • Eye Movement Desensitization and Reprocessing (EMDR)

PTSD had a significant total effect on physical pain severity — the most common physical pain was chronic neck or joint pain 83%, chronic low back pain 63%, and rheumatism/​arthritis 59%. {8}

Although it’s extremely important for a patient’s recovery to treat the mental and cognitive aspects of PTSD, more attention should be given to the physical pain, preventing the chances that this pain type will persist for a longer period of time or become debilitating. 

PTSD in the General Population #

PTSD is not limited to combat veterans, about 7 or 8 out of every 100 people will have PTSD at some point in their lives, compare to 32% (on average) in combat-veterans. {9} Signs and symptoms are almost the same in both veterans and the general population. Other potential contributing factors which can affect the likelihood of someone experiencing PTSD are race, gender and education. 

Below are some common causes of PTSD

  • serious accidents
  • physical or sexual assault 
  • abuse, including childhood or domestic abuse 
  • exposure to traumatic events at work, including remote exposure 
  • serious health problems, such as being admitted to intensive care 
  • childbirth experiences, such as losing a baby

I was mugged and then about a year later I was on the Tube when the police were trying to arrest someone who had a gun. In neither experience was I physically injured – although in the second one I thought I was going to die and that I was going to see lots of other people die.” {10}

I was diagnosed by my GP with PTSD a few weeks after the death of my father who died very suddenly, following a family outing to the local pub for lunch. He collapsed in front of us and we had to administer CPR at the scene while waiting for the ambulance. He died later on the way to hospital.” {10}

Multidisciplinary Approach #

All the above conditions are well treated and have shown positive results in numerous studies, suggesting that a wide, holistic approach to the physical aspect of PTSD and chronic pain might be a good start or a great adjunct to Cognitive- Behaviour Therapy. 

Exercise #

Guided Training has positively affected many of the psychological and physiological symptoms and conditions specifically faced by military veterans with PTSD. Regular exercise is known to have a hypoalgesia effect, that can reduce an individual’s perception of stress, tenderness, and sensitivity and provide an effective coping mechanism, improving overall mental health. {11,12,13}

Soft Tissue Therapy #

Physiological effects are common by-products of soft tissues treatments for chronic pain; increased endorphins, serotonin and dopamine, thereby inducing relaxation. 

Furthermore, because of my background and experience the patient is having a great opportunity to openly talk about their experiences and what they feel with someone that has been in the same situations and lifestyle that comes with a veteran’s life. 

Along with managing physical pain, other benefits such as: helping with muscles tension and stiffness, increasing range of movement (especially those who are injured), reducing blood pressure and improving blood flow, might improve not only the quality of the life but also mitigate the severity of the emotional symptoms. 

Acupuncture for Sleeping and Relaxation #

Acupuncture is well-known for stress reduction, as a sleeping aid and for general relaxation which is a key factor in recovery for those who experience insomnia, nightmares and high levels of stress. 

Acupuncture was significantly better on improving parameters in sleep quality and duration” {14}

Acupuncture is shown to be an effective treatment for veterans with PTSD, reported Healthwatch Norfolk. 

All participants experienced a large improvement in their condition and limited evidence suggested that the benefits of acupuncture may be sustained over a longer period.”{15}

To reinforce this message, Naji Malak, co-founder of Norwich based charity Stand Easy, added: 

Having worked with civilians and military personnel for more than 35 years, I firmly believe in acupuncture as an effective treatment for PTSD and the quick change it can bring out in people can be remarkable(…)encouraging more healthcare professionals to recommend acupuncture as a treatment for PTSD.” {15}

Acupuncture has the potential to reach PTSD patients (veterans) who are not willing to engage in trauma-focused psychotherapy due to avoidance from trauma-related memories and stigma, concludes Michael Hollifield in Acupuncture for PTSD in Combat Veterans. {16}

As a Soft Tissue Therapist who also uses acupuncture for the treatment and management of pain, I can say from experience that I have seen great results — for both emotional and physical pain – from these two forms of treatment. Through the holistic approach which we adopt, and creating bespoke rehabilitation programmes for each individual person, we provide the patient with a personalised recovery plan, which can facilitate both their emotional and physical requirements for recovery. 

I will finish off with the words of Ulrey, a combat veteran, who wrote his message for his fellow soldiers: 

You were strong enough to make it this far, don’t give up! Dig a little deeper and make that final push.” {17}

If you are living with chronic pain and any symptoms of PTSD, I urge you to seek help from your family, friends, fellow soldiers and any experts in the field — psychologists, counsellors and even Soft Tissue Therapists, like myself. 


  • {1} https://​www​.ncbi​.nlm​.nih​.gov/​p​m​c​/​a​r​t​i​c​l​e​s​/​P​M​C​4368749/
  • {2} https://​www​.pew​so​cial​trends​.org/​2011​/​12​/​08​/​t​h​e​-​d​i​f​f​i​c​u​l​t​-​t​r​a​n​s​i​t​i​o​n​-​f​r​o​m​-​m​i​l​i​t​a​r​y​-​t​o​-​c​i​v​i​l​i​a​n​-​l​i​f​e​/​#​f​n​-​10341 – 2 
  • {3} https://​black​bear​rehab​.com/​m​e​n​t​a​l​-​h​e​a​l​t​h​/​p​t​s​d​/​s​i​g​n​s​-​a​n​d​-​s​y​m​p​t​o​m​s​-​o​f​-​ptsd/
  • {4} file:///C:/Users/Pure/Downloads/PCSSO-Webinar-Managing-Chronic-Pain-Coocurring-Postraumatic-Stress-Disorder.pdf
  • {5} https://​then​ation​shealth​.apha​pub​li​ca​tions​.org/​c​o​n​t​e​n​t​/​42​/​3/1.1
  • {6} file:///C:/Users/Pure/Downloads/PCSSO-Webinar-Managing-Chronic-Pain-Coocurring-Postraumatic-Stress-Disorder.pdf {7} https://​www​.rehab​.research​.va​.gov/​j​o​u​r​/​03​/​40​/​5​/​O​t​i​s​.html
  • {8} https://​www​.ncbi​.nlm​.nih​.gov/​p​m​c​/​a​r​t​i​c​l​e​s​/​P​M​C​3609886/
  • {9} https://​www​.ptsd​.va​.gov/​u​n​d​e​r​s​t​a​n​d​/​c​o​m​m​o​n​/​c​o​m​m​o​n​_​a​d​u​l​t​s.asp
  • {10} https://​www​.mind​.org​.uk/​i​n​f​o​r​m​a​t​i​o​n​-​s​u​p​p​o​r​t​/​t​y​p​e​s​-​o​f​-​m​e​n​t​a​l​-​h​e​a​l​t​h​-​p​r​o​b​l​e​m​s​/​p​o​s​t​-​t​r​a​u​m​a​t​i​c​-​s​t​r​e​s​s​-​d​i​s​o​r​d​e​r​-​p​t​s​d​/​c​a​u​s​e​s​-​o​f​-​ptsd/
  • {11} Stults-Kolehmainen M, Sinha R The effects of stress on physical activity and exercise. Sports Med 2014; 44(1): 81 – 121
  • {12} https://​aca​d​e​m​ic​.oup​.com/​m​i​l​m​e​d​/​a​r​t​i​c​l​e​/​181​/​9​/​953​/​4159847
  • {13} van Middelkoop M, Rubinstein SM, Kuijpers T, et al. A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. Eur Spine J 2011; 20(1): 19 – 39
  • {14} https://​www​.ncbi​.nlm​.nih​.gov/​p​m​c​/​a​r​t​i​c​l​e​s​/​P​M​C​3156618/
  • {15},-June%204%2C%202018&text=Healthwatch%20Norfolk%2C%20the%20consumer%20champion,Traumatic%20Stress%20Disorder%20(PTSD).
  • {16} https://​grantome​.com/​g​r​a​n​t​/​N​I​H​/​I​01​-​C​X​001416-04
  • {17} https://​then​ation​shealth​.apha​pub​li​ca​tions​.org/​c​o​n​t​e​n​t​/​42​/​3/1.1