Pain is just stuff that hurts right? Well yes, it’s also so much more than that. It’s actually a much more philosophical question than we might initially think. Years ago we just assumed that pain was there because there was something wrong with the bit that hurt. If I bang my knee my knee hurts right? Which can of course be entirely true. If I’ve just broken my leg that hurts because it’s broken!
But pain, especially long standing pain, is much more complex than that. The kind of pain that didn’t really have a start point. Or the kind of pain that after a specific injury, like a broken leg, or car crash or surgery that just won’t go away.
In the last 20 years there has been massive leaps in understanding in pain and neuro science with the advent of video MRI scanning which can look at live brain activity. Giving us greater insight into what happens in the brain when we feel pain. This gives people in pain better ways to understand pain. With greater understanding an opportunity free ourselves from pain.
How do We Define Pain?
Thousands of books have been written all about pain and just what it is and what it means. You’ll be relieved this article is not going to regurgitate volumes of neuro science text books! An easier to digest start point would be to start with some of our favourite definitions of pain.
Let’s start with the International Association of the Study of Pain and their definition:
“An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”
So this covers the ouch I’ve just hurt myself broken leg, banged my knee, sprained ankle type pain. But it also introduces the emotional aspect of pain and ‘potential’ part of what pain is. Which is why at Brighton Physiotherapy & Sports Therapy we like to connect Mind and Body when treating pain.
The theme of actual or potential damage is repeated by Professor Lorimer Moseley, renowned pain expert, in his definition of pain:
“Pain is an unpleasant conscious experience that emerges from the brain when the sum of all the available information suggests that you need to protect a particular part of your body”
So it would seem from these definitions that what is going on in the local area where you feel pain is only one part of the whole pain experience. There are other contributing factors to your overall pain experience, not least of which is your brain.
This concept has been illustrated with some fantastic research which made use of video MRI technology. Lots of people with knee pain were scanned for brain activity whilst being touched on their painful and pain free knees.
On the non-symptomatic side a part of the brain lit up which was the knees representation in the brain. When the same stimulus was used on the painful knee an equivalent area many times the size lit up in the brain. In other words, the brain had a larger than normal representation of the injured side. It’s paying more attention to what is going on. In real terms meaning the knee is more sensitive to pain, or just feels more pain.
Another way of looking at pain is based on the work of Louis Gifford and is called the Mature Organisms model. To grossly simplify my interpretation from this in depth work is that simply pain is there to tell us that something needs to change. If we’re standing on a pin we need to move our foot. If we have chronic pain that has come out of the blue due to stressful situations we need to move ourselves through those stressful situations.
How Do We Change Pain?
For mechanical pain we just need time to allow things to heal. The pin in the foot, the broken leg, the swollen ankle will get better with time. Physiological healing time for tissues such as ligaments, muscles and bones is all 6 weeks. That’s not to say things don’t still hurt after 6 weeks. They often do.
Of course severity of the original damage is a factor in how long things take to properly heal. But more relevant, we think, is the altered movement patterns that the original injury creates. Avoiding the pain for fear of making things worse is a common mindset we help with.
In terms of changing pain we of course look to change things physically with exercises and stretches as you’d expect. Although we try to keep those to minimum where possible. We also consider the overall sensitisation. When we’re more wound up, whether we know we are or not, we simply feel more pain. The best way to do that for each person we see is unique. But we’ve put together our favourite ideas to help this process in this wellbeing article.
Changing beliefs is a huge part of what we do. In my experience it’s the most effective thing we can do for lasting change. It’s the brain that ultimately determines what our own unique experience of pain feels like.
Let’s consider an example to give all this theory some context. Someone might come to us with knee pain that they’re had for many years. They may fear it’s arthritis or may have been told it’s arthritis by another therapist or medical practitioner. We like to explain the latest research that wear and tear on a joint isn’t an accurate predictor of pain. That wear and tear on cartilage is a normal part of ageing and doesn’t necessarily have to hurt.
For some people the pep talk is enough and they literally run with it. For others, including myself, I like to see evidence. This is where the hands on techniques we use are invaluable. If we can use our hands on techniques to release something and it makes the pain reduce it gives evidence that what we feared was the problem isn’t. If we can change unhelpful beliefs that’s a massive step to full recovery.
How Should We Describe Pain?
The importance of what the brain ‘feels’ is reflected in our choice of words. If we use harsh sounding, scary words to describe our conditions this will make them worse. If we use nicer less threatening words then our pain will be reduced.
Sounds crazy but just think of the word chronic. People often use it in the wrong context to mean it’s terrible. Referring to a knee as chronic just sounds bad. By physiotherapy definition it simply means the pain has been there for more than 6 weeks.
A big part of what we do for some people can be to translate the medical jargon into less threatening terms to help make everything sound less scary. This is particularly the case with x-ray and MRI reports.
Is Your Injury Mechanical Or Psychological?
Traditional medicine looks to explain pain by known entities. Looking for certainty. To be able to say your back pain is caused by a disc bulge. Or your knee pain is caused by wear and tear on the cartilage. Pain doesn’t work like that.
How can we can be sure? Well we’ve seen people with these conditions make a full recovery. Do they still have a bulge in a disk or wear and tear in their knee, yes. But they don’t have pain. On a day to day basis is your pain the same every day? Probably not. There is variation in it. Based on how much you’ve used it perhaps. But in our view more relevant is your mood and current stress levels.
Of course we do have to rule out anything bad or serious. There are conditions that do have a large mechanical component to them. These will be the ones of course with a particular painful start point. But whilst there are some degenerative conditions we need to be mindful of, these are very rare indeed. And most cases can be completely alleviated with the right whole body approach.
There’s some fascinating work by an American doctor by the name of John Sarno. He was a pioneer of moving away from the mechanical view of pain. He was a strong and successful advocate of treating the mind to treat the sensations in the body. His work can be accessed via his excellent book The Mindbody Prescription.
My favourite piece of research he quotes in the book was done around the time when MRI scan use became prevalent. The study involved two groups of around two thousand people. The first group had significant back pain. The second group had no symptoms at all. Both groups were x-rayed and MRI scanned and the findings compared. There were NO differences.
Wow. What an excellent way to show pain is way more complex than trying to find the bit inside that is causing all the pain.
That said it’s important not to overlook the physical. In my view the mind and body and one completely entwinned circle. The mind will hold a movement pattern based on its beliefs, changing that movement pattern can change the feeling and so the beliefs.
At the clinic we consider a theoretical scale describing how much of our pain is mechanical and how much of our pain is down to sensitisation of the local area or the body as a whole. We can have a condition that is entirely mechanical, for example a broken leg. Almost all of our pain will be mechanical. Things are quite literally broken and there’s lots of chemical reactions going on to tell us as much.
A similar but opposing condition would be someone who broke their leg a few years ago. The bone has long since healed (in the 6 weeks we would normally expect) yet they are still in significant pain. Possibly from fear of damaging the area again. Maybe from sub consciously guarding the area. In a case like this we say for arguments sake that the pain is 20% physical still and 80% sensitisation.
Such categorisation is only for illustration and these numbers are entirely made up and could never be measured. Where it’s useful to consider is guiding our treatment to find the best solution for each individual. If we find that our calming of the nervous system type treatments help reduce the pain then this suggests the best approach may be more wellbeing focused. Where as if we release a muscle, or improve it’s function and this improves the symptoms this would suggest a more exercise based rehabilitation plan could be the best way forward.
In reality most people’s plans are a combination of both. Most importantly people need to be bought into why and be enthusiastic about doing what is asked of them. It they’re not interested or able to implement wellbeing changes then we keep the advice physical. If they’re not interested in specific exercises but enjoy the wellbeing aspect more then we focus on this.
Basically it’s a whatever works approach to reducing pain!
Pain Is Not Damage
One of our favourite one liners to start to alleviate fear and start reducing pain is that pain is not damage. We of course do this after we’ve screened for anything very mechanical in nature.
Here’s a practical anecdote that hopefully you can relate to demonstrating that pain is not necessarily damage. Picture yourself walking down the road. Maybe you step on something or miss the kerb and you ‘go over’ on your ankle.
You immediately get a shot of pain that’s quite unpleasant. But then something miraculous happens. You tentatively put your foot down and it seems ok. You get increasingly confident and after a few tentative limps you realise nothing is wrong and you carry on regardless.
Pain was simply the warning shot before any damage was actually done. Now I do appreciate if you had continued to put more weight through the ankle in an unnatural position then you would most likely have done damage. But it illustrates the point nicely that we get pain before we do any damage. Pain is there to help us. It has performed it’s role and told us that something needs to change to avoid doing any real damage to the ankle.
This is a very physical, mechanical example. But I think chronic pain that comes from nowhere is also a sign that something needs to change. It just may not be that as obvious as to what needs to change. Our job is to help guide people to finding just what needs to change. What was going on in life around the time it started to come on? Was there anything especially stressful going on at work or in your personal life? The answer to these questions by the majority of people that we see is yes.
If you can’t think of anything stressful around the time the pain became apparent consider these two further questions. Have you increase the amount of physical load on your body? Of course that can be a factor in sports, DIY, gardening or even increasing the amount of computer work we do. We need to allow the body time to adapt.
Another deeper idea could be to look back further. Especially for those who’ve had a life time of pain. How was your childhood? Is there any history of trauma in your life to this point?
In our treatment we don’t need to do a full life regression, that’s what psychologists are for. But if we acknowledge that things from our past can influence the pain that we feel in the present it gives the pain less power. We can start to remove the fear of the mechanical which in itself can be enough to rid us of our pain.
How Do We Feel Pain?
I have reduced this section on molecular biology into a snooker table analogy. Go with me on this one! We’ll do the science bit first then simplify with the snooker table…
We have pain receptors (nociceptors) which pick up on pain chemicals. Each pain receptor has holes on them which allow the pain chemicals through into the receptor molecule. This in turn sends a ‘pain message’ upwards towards the brain. The more pain chemicals that get into the pain receptors the more ‘pain messages’ will be delivered to the brain. We feel more pain.
To simplify consider pain receptors as a snooker table. The more balls in the pockets of the snooker table the more pain messages are sent to the brain. So increasing our experience of pain. If we’re stressed, or put another way, in a state of heightened alert there are more snooker balls on the table and the pockets are bigger. We simply feel more pain.
There’s a very entertaining video about all of this just here by Lorimer Moseley who’s definition of pain we introduced above. His own near death incident involving a snake he talks about in the video is the perfect example of all that we have discussed so far.
Our Painful Conclusion?
Thankfully all these aspects of pain can be changed and this what our clinic is about. Firstly we identify what your pain is and what you think the problem is to find out what your beliefs are.
We then chat to you to gauge how sensitised your nervous system and check some nervous system markers to see if your body is agreeing with what you’re saying. General muscle tone is a good clue, as is how we’re breathing. The severity of the pain in relation to the amount of actual tissue damage is the biggest clue of all.
Many of us are very adept at hiding stress, myself included. But this stress will always be represented physically somewhere in the body. Some areas within the body more likely to hold stress than others. Like our abdominal area for example.
With treatment we look to change your symptoms. If we can show you with some treatment that for your back pain can ease perhaps we can start to change that belief that you will always have a bad back. This will allow you to move more freely which in turn means you don’t hold your muscles so tense. We’ve broken the vicious circle.
We also look to reduce your stress with simple, practical lifestyle advice. We’re not Psychologists. This all take the form of some realistic and relatively easy to implement ideas the sum of which is greater than the part.
Hopefully this article has given you food for thought and opened your eyes to the incredibly complex nature of pain. If you’d like to have a chat about your pain and how we might be able to help please fill out the form here and leave your details and we’ll be happy to give you a call to discuss.