Explaining Pain

Dr. Erik Pohlman, PT, DPT

Pain is a common problem!

 1 in 6 Americans live with persistent pain 1  Globally, 20% have pain > 3 months 2  Persistent pain costs ~$100 billion/yr 3

Definition of Pain

 Pain is an “unpleasant sensory and emotional experience associated with actual or potential tissue damage.” 4

Old Model

 Painful stimulus→PAIN  Tissue damage = pain

How do we explain…

  Phantom limb pain  even in those born without the limb 5 Painless battle wounds  Papercut hurting so much

Other Examples

  WWII vet – bullet in neck 60 years, he never knew!

6 Surfers – feel a ‘bump,’ no more leg!

These patients had no pain, weakness, or sensation changes!

7

A ge in Years X RAY DJD CT/ MRI HERNIA

Will this hurt?

How about now?

Why?

Threat

  Initially, the body only had to worry about the nail  Nail→Threat→PAIN When you are running from the lion, the nail is the least of your worries   Nail→Lion is bigger threat→Nail doesn’t hurt Explains soldiers in battle

Threat

 It is the perception of the threat that determines the output, not the tissue damage itself or threat to the tissues… 8

Pain = Output

So how does pain really work?

Nociceptors (“Pain sensors”)

  Mechanical, Temperature, and Chemical They tell the brain ‘danger’, NOT ‘pain’  Brain determines if you should feel pain   Body can add or subtract all over the body Replaced as often as every few days  Current levels of sensitivity can and will change!

Sensitization

 Increased sensitivity after injury  Allodynia, hyperalgesia   Normal, but should fade after healing Persists in people with chronic pain

Central Sensitization

2   The spinal cord and brain cells are more sensitive You may notice:   Pain longer than normal tissue healing time Spreading pain     Worsening pain Even small movements hurt Pain is unpredictable (what hurts one day may not hurt the next, or thinking about it can cause pain) You have other significant ‘threats’ in your life

Homuncu-what?

Homunculus

 Map of body in the brain    Phantom limb ‘Smudging’ in chronic pain and phantom pain More chronic -> more smudging 9

Neuroplasticity

 Not to worry!

 The brain and nervous system are constantly changing  1 Braille users 10 and guitarists/violinists/cellists 1

   

Brain Centers

Not just 1 center or one input (like from the tissues) Neurotag – many parts of the brain activating in a unique pattern 2 Sensory, motor, memory, emotion, autonomic nervous system, etc.

All parts light up in phantom pain Danger signal, on its own, is NOT enough to produce pain!

Pain relies on context

 Perception of threat level modifies pain according to the situation  Finger injury in professional violinist vs. dancer 12  Whiplash from car accident

Thought Viruses

 Thoughts are nerve signals too   Ever feel pain when thinking about the painful movement or watching someone else do it?

Anxiety about pain or disability can increase pain

What does this tell us?



Pain comes from the brain, not muscle, tendon, disc, etc and…



HURT ≠ HARM

How can we fix our pain?

Bed rest?

 NO WAY!!!

   Blood flow leads to healing and less pain Re-define that ‘fuzzy’ section in brain Prevent atrophy

Surgery

 Last resort, or when rapidly progressing neuro symptoms     Costly Risky  Infection, nerve damage, Still have a recovery period May still not help  Plenty of people who still have their pain after surgery

Medication

 Pain killers, anti-inflammatories, muscle relaxers, etc.

  May or may not help symptoms Often won’t help the actual cause

You are already well on your way!



Pain education

   Patients can understand pain theories 13 Knowing pain physiology reduces threat level 14  …reducing sympathetic, endocrine, and motor activity.

15,16 Combining pain physiology education and movement therapies improves physical capacity, reduces pain, and improves quality of life!

17  Evidence shows that pain education may even be better at preventing pain than core stabilization 18

Caution!

 Don’t get hung up on anatomy!

 Knowing more about pain leads to better results than knowing more about anatomy (bones, discs, alignment, etc) 14  You have now learned that is one (possible) part in the pain experience

Tone down that nervous system

    Active Relaxation Deep breathing Breathing with diaphragm Heat, ice, TENS, anything else that works for you

Graded exposure

  Gradually increasing exercise, activity, and stimulation (desensitization) Re-teaches body/brain that movements and stimulation are ok  Can also gradually re-expose yourself to driving or the thing you were doing when originally injured

Trick your nervous system

 Same movement, different context  Do the movement in a different way  Change the position or what moves first, do in water, etc.

See your friendly local physical therapist to…

    Rule out more serious issues and refer you to the proper provider if one is found Determine if there is a mechanical cause Provide more pain education Provide treatments like manipulation, dry needling, therapeutic movement/exercise, etc.

Points to remember

       Your pain is REAL Imaging (Xray, MRI) may be misleading Bedrest and waiting for it to improve will likely not help and may make it worse Motion is Lotion Pain is normal and it’s ok to feel some pain with exercise if you have chronic pain already HURT ≠ HARM See your physical therapist!!!

(Strongly) Recommended Reading

Explain Pain, by David Butler

Thank you!

References

                  1. Chronic Pain elective, Regis University 2011, quoted this as coming from the ‘American Chronic Pain Association.’ 2. Butler D, Moseley GL.

Explain Pain

. Adelaide: NOI Group Publishing, 2003.

3. Chronic Pain elective, Regis University 2011, quoted this as coming from the ‘American Alliance of Cancer Pain Initiatives.’ 4. www.iasp-pain.org

5. Saadah ES, Melzack R. Phantom limb experiences in congenital limb deficient adults.

Cortex

. 1994;30(3):479-485.

6. The Times, Feb 17 2003, p 5, London.

7. Boden SD, et al. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects.

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8. Moseley GL. Reconceptualising pain according to modern pain science.

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9. Flor H, et al. Extensive reorganisation of primary somatosensory cortex in chronic back pain patients.

Neurosci Letters

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10. Pascual-Leone A, Torres F. Plasticity of the sensorimotor cortex representation of the reading finger of braille readers.

Brain

. 1993;116:39-52. 11. Elbert TC, et al. Increased cortical representation of the fingers of the left hand in string players. 307.

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1995;270:305 12. Moseley GL. Joining forces- combining cognition-targeted motor control training with group or individual pain physiology education: a successful treatment for chronic low back pain.

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13. Moseley GL. Unravelling the barriers to reconceptualisation of the problem in chronic pain: the actual and perceived ability of patients and health professionals to understand neurophysiology.

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14. Moseley GL, Hodges PW, Nicholas MK. A randomized controlled trial of intensive neurophysiology education in chronic low back pain.

Clin J Pain.

2003;20(5):324-330. 15. Melzack R. Pain and stress: a new perspective in psychosocial factors in pain.

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16. Moseley GL. Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain.

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17. Moseley GL. Physiotherapy is effective for chronic low back pain: a randomised controlled trial.

Aus J Physioth.

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18. George SZ, Wittmer VT, Fillingim RB, Robinson ME. Comparison of graded exercise and graded exposure clinical outcomes for patients with chronic low back pain.

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