If ever there was one thing that we can ALL say we have experienced, it’s pain.

Throughout history and across race, gender, and partisan lines, there’s one statement we’ve always been able to agree on: stuff hurts sometimes. Everyone has experienced pain at some point in their life, so you might assume that it’s one of those things about the body that scientists have pretty much figured out by now. Wrong. We’ve hit that “the more you know, the more you realize how little you actually know” point in our understanding of pain, and there is a great deal of new and exciting evidence that is helping us to better understand how to help people dealing with complex, painful conditions.

What is pain?

Pain is an unpleasant sensory and emotional experience associated with actual or potential damage, or described in terms of such damage. (International Association for the Study of Pain, 1979)

Rene Decartes was one of the first to describe a “pain pathway” in his 1664 Treatise of Man using examples of a hammer or fire as stimuli creating pain in the hand, which then travels along a series of tubes or threads and rings a bell in the brain. The general population’s understanding has evolved to include things like nerves, the spinal cord, etc, and this crude model still makes sense intuitively. The problem is that this in not just an outdated and oversimplified way of thinking about pain; it’s a way of thinking about your symptoms that can lead to more harm than good.

Waht we pecviree is not aywlas atrccuae.

If our ability to read was like our sense of touch, that sentence would be impossible to interpret. Our eyes transmit the image of the jumbled letters on the screen to a networks in the brain that combine an understanding of the English language with previous exposure to these general combinations of letters and, without much (if any) conscious problem solving, another part of the brain provides the output. In this case, the output is the what we assume to be the intended meaning of the sentence- What we perceive is not always accurate.

There are still many unanswered questions about the complex system of networks responsible what we eventually perceive as pain, but developments in research over the last decade or so are clear: pain is like vision, not like touch. Our brains receive input from a body part regarding sensations of light touch, deep pressure, hot, cold, etc. This information is combined with things such as previous experiences involving this sensation, awareness of the current environment, the person’s mental/emotional state, etc. The person experiences pain when their brain determines, based on the available information, that there is some sort of threat to their body that they should be consciously aware of in order to react accordingly. Lorimer Mosely, a leading researcher in this area (and entertaining speaker with a funny accent), has several videos where he gives fantastic examples describing this process in more detail. He also describes several experiments that are more like magic tricks than a boring lab study. I highly recommend this TED talk: https://www.youtube.com/watch?v=gwd-wLdIHjs

So What?

Because pain is an output that an individual experiences based on their history of exposure to this stimulus, beliefs about an injury, how this pain may or may not negatively affect their life in the short or long-term, etc… it’s vastly different for everyone. The kicker is that these variables have SUCH a large on impact on what we feel as pain that, especially in many cases of chronic conditions where the tissues have had sufficient time to fully heal after injury, the pain a person is experiencing is no longer an accurate reflection of what’s actually going on at the site of injury. At this point, pain is no longer that beneficial protective mechanism alerting us of potential harm.

Where to start with acute pain?

There is really no easy answer for whether or not experiencing pain from a recent injury warrants medical attention. For serious traumatic injuries, such as those sustained in a motor vehicle accident or at work, it is always best to err on the side of caution and contact an MD or get to the ER. For injuries that don’t require emergency attention such as…

• a knee or ankle that got “rolled,” “twisted,” “jammed”
• falls where you’re still able get up and walk (though painful)
• “throwing out” your back after going to pick up your son/daughter

or annoying pain you’ve had for a while and keeps coming back such as…

• aching in your wrists or elbow from repetitive motions
• “tightness,” “stiffness,” or a “kink” in your back, neck, or shoulders after a long day of work that is starting to limit your ability do things without pain throughout the day

… seeing your Doctor of Physical Therapy is a safe and cost-effective first step. As experts of the musculoskeletal system trained to thoroughly screen for potential red flags that would benefit from or require further medical attention such as imaging, we promptly refer to the appropriate provider, such as your family physician or specialists in areas such as neurosurgery, orthopedics, or internal medicine.

In the examples mentioned above and after a full physical assessment, one would expect to see significant improvements within the first few sessions using a combination of:

• educating you about what’s going on
• hands-on techniques
• teaching you strategies to manage your symptoms at home and a few specific exercises to continue progressing between sessions

The Role of Physical Therapy in Treating Chronic Pain

If you are dealing with chronic (loosely defined as >3 months) pain that has shown minimal improvement since the initial onset or is getting worse, there are many options to consider. One of the more troubling things I’ve witnessed in my professional career is when someone who has been dealing with pain, has had a bunch of fancy medical names thrown at them to explain why they hurt, and may or may not have undergone surgeries, injections, PT, meds, etc, makes it clear that they believe they’ll be in pain for the rest of their life. I’ll admit that there’s not always a happy ending and that there’s no magic pill, but pain is such a multifaceted physiological process that I’m not convinced the most magic of all magic pills would do it, if such a pill existed.

Treatment for chronic pain in the past has centered around what seemed to be the easiest and straightforward solution- interrupt the pathway somewhere to dull or mask the sensation with a drug, injection, or nerve block. Modern medicine provides us with many great tools like these to provide short-term relief and help people tolerate painful situations as the tissues heal, but there are risks involved with long-term pharmaceutical interventions that can eventually outweigh the benefit. The underlying causes or components of the pain experience must also addressed, and I have yet to hear of a surgical technique that immediately corrects every factor relating to the pain, allowing you to hop off the table as a new person.

In complex cases of chronic pain, the best outcomes often come from using an integrative approach where multiple providers collaborate to help you address the problem from all angles. This care may include medical pain management, physical therapy, cognitive-behavioral therapy or counseling, massage therapy, yoga, or others.

We now know that especially in cases where the tissues have had time to heal after injury, and symptoms persist at levels much higher than would normally be expected, it is necessary to “retrain” the ultimate source of every painful experience, the brain. Physical therapy plays an important part in this process, and several proven strategies are outlined below.

Education: Restructuring Pain Beliefs

Many people suffer from chronic pain that stems from anxiety and fear of further damage- that something might cause them relive that initial painful injury. Sometimes referred to as ‘catastrophising’ or ‘hypervigilence,’ the basic idea is that our bodies become (consciously or otherwise) constantly on guard and expecting the worst. Often restructuring pain beliefs can be as simple as having a conversation about your injury and getting the reassurance that… A) What you’re experiencing is real, and there’s a valid explanation for it. and B) the tissues are healing or have healed, and bending over, for example, will not physically cause damage to the tissues at this point. I don’t mean the kind of “You’re fine, it’s all in your head” speech some may have received in the past. I’m talking about helping you to understand the anatomy and neurophysiology of pain. With this knowledge, a harsh accusation that you’re somehow to blame for this becomes the validating acceptance that pain is, quite literally, always in your head, regardless of the injury.

Desensitization

This can consist of treatments as simple as rubbing both the affected and unaffected limb simultaneously. Because intensity of pain correlates with how serious of a threat the brain considers the signals to be, the goal of these types of interventions is to tell the brain “Look! Something applying pressure to your left foot the same way isn’t causing any problems. Chill out on the conclusions you’re coming to when the same pressure is applied on the right side.”

Graded Exercise and Graded Exposure

These progressive therapeutic strategies work by gradually introducing more exercises and meeting the safe quota at each session or increasing exposure to a movement or situation that a person may have been avoiding for fear of reinjury. Your Physical Therapist will be able to analyze your movement faults and develop an alternate postural strategy to guide you away from the habits that may have caused your chronic pain to start in the first place. A series of graded exercises and drills prescribed to you will then help you strengthen your ability to move away from the offending posture.

By Dr. Nicholas Chamley, Doctor of Physical Therapy

 

Filed under: blog by Alice Holland
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