Pain – just reading??the word probably evoked a response in you! We can all recall a time that we have had it,??and generally speaking, it is not a nice experience. Although most episodes resolve,??we??estimate that 28,000,000 adults across the globe have chronic pain. It??is a fascinatingly complex subject which the medical world, including physiotherapy, is learning more about. Here are some simple concepts about pain:
1) Pain is not directly proportionate to the amount of damage
Some really interesting developments on pain knowledge have??taken place??in the last decade or so. We now know that the amount of pain somebody feels is not directly proportionate to the level of damage. As practitioners who regularly manage patients whose primary complaint is nearly always pain, this has been a revelation! There have always been stories that support this ??? war veterans who lost limbs in battle but kept on fighting, the shark attack victim who could swim to safety despite major injury and the individual who bent over to tie shoelaces and??found themselves in agony. These situations do not make sense if pain was purely down to amount of damage sustained.
2) Pain is an output of the brain and not an input of the body tissues
This is??an idea that takes some getting used to but it is now known that when the brain receives information from the sensory nervous system, it is then placed into context e.g. is this a threat to me? This decision is made at lightening speed whilst taking into account factors such as context, previous experiences and visual feedback. Based on the multitude of information, if deemed harmful, the brain will then send pain as an output. This is encouraging in chronic pain as it means that consciously, the way we react to a stimulus can effect our experience.
3) The Central Nervous System (CNS) and pain response can be hyped up or dampened down
Imagine the CNS as an old radio with a dial. When the body sustains an injury, the volume (sensitivity level) increases. This can be helpful in the initial stages of an injury as it helps us manage that ‘just sprained’ ankle appropriately. The volume would then slowly turn down as the body repairs and recovers and we get back to normal. However, due to a mix of??psychological, social, lifestyle and lifestyle reasons, sometimes the volume stays turned up. In a day-to-day sense, this means that pain can come on??both quicker and at lower stimulus than it would normally take. This process can then become the ‘norm’, and is often found in people with chronic problems.
4) Beliefs feed behaviours
Beliefs about pain drive behaviours and responses e.g. if you believe that you have damage, then your body will behave as if you have damage. This cycle can then be fed by factors such as high emotional stress, how much symptoms bother a person and physical manifestations such as guarding, limping etc. We also know that emotional stress or responses can make physical inflammatory changes within the body, which subsequently can feed the cycle.
Some of the language used around pain is also now thought to be an important factor in people’s experience of it. Imagine that somebody tells you something likes this:
- ???your bones are crumbling???
- ???your disc is squashing a nerve???
- you have the spine of a 90 year old???
- ???your joints are rubbing and wearing away???
This has the potential to frighten anybody that hears it! Imagery both in the media and in your practitioner’s therapy room can also be both unhelpful and inaccurate. Here are some choice examples:
This sort of thing can??play into people’s fear and beliefs about their body and promote unhelpful behavioural responses. As the below diagram shows, fear can be the deciding factor on whether an individual recovers or enters activity avoidance and chronic symptoms:
5) Back pain is more than just bad posture, bad lifting or a weak core
It has been widely accepted that chronic back pain is down to poor posture, poor lifting techniques and/or having a weak core. One of the leading physiotherapists in the field of chronic pain is Professor Peter O’Sullivan who discusses many of the flaws in the ‘weak core’ reasoning in this video: (https://www.youtube.com/watch?v=YezBG_NdLgs).
Todd Hargrove (a former chronic pain sufferer who was able to become pain free through education, movement and changes to lifestyle) has also blogged about the lack of evidence surrounding core stability and posture in improving symptoms.
The manual handling/ergonomics industry recommend specific approaches to lifting including ‘keeping a straight back’ to avoid loading through your spine. EMG (Electromyography) scans have shown that muscles have to work harder in a straight back position and are far less efficient. In terms of these widely-accepted techniques preventing pain and injury, it has also been shown in the research that manual handling training does not reduce musculoskeletal disorders.
It is now too simplistic to solely attribute pain to posture, ‘bad lifting’ or weak cores ??? the evidence base simply does not support this. If you are still unsure about this, ask yourself whether it is likely that the workers below underwent ergonomics training to ensure they bend their knees rather than their back? Or is it likely that they perform several plank exercises a day to build up their core strength? How likely is it that they all have back pain?
Chronic pain is now being tackled differently
With the information that we have on pain, it has become easier to assist people with chronic pain. Interventions such as CBT, mindfulness, physiotherapy, aerobic exercises, goal setting and pain education have been shown to be useful. Within physiotherapy, a biopsychosocial model is now advocated for use which as the name suggests involves breaking down all factors exacerbating pain: biological, psychological and social. It is also helpful to tackle physical activity avoidance and unhelpful behaviours in order to break the pain cycle that people can find themselves in. These treatment approaches in time, should hopefully ease some of the global burden of symptoms??and unnecessary procedures that are performed in the pursuit of pain reduction.
Some physiotherapists that are leading the way with these principles are Mike Stewart who can be found on Twitter @knowpainmike and Professor Peter O’Sullivan.??The latest research is coming from these sources and they are well worth following if this is an area that??interests you.
In conclusion, long-standing pain is multi-factorial in its nature and the way we approach this as healthcare professionals has dramatically changed over time. Long-standing pain does not always equal damage and pain can be moderated by adjusting the inputs that the brain receives. Now, off you go and strengthen your core… 😉
A guest post by Jess King, Chartered Physiotherapist