Pain - where the Body meets the Brain - hacks to help us through these episodes
As a physio, there is not a day that goes by when pain is not part of the narrative, whether it's centred around interventions to reduce pain, discussing expected timeframes or discussing a patient’s beliefs around the pain.
When it comes to the management of pain we have been inadvertently juggling with our eyes closed for decades. I’ve watched the pendulum swing from one in-vogue treatment to the next, some to be demonised and then re-embraced in the blink of an eye. The truth is some of these treatments can have benefits, at the right time and as part of a wider treatment strategy. For some, it’s the dated rationale and narrative given by the practitioner that lets them down. However, one thing is clear, our thoughts and feelings play a major role in shaping our experience with pain. The path to better management and treatment of pain, is to embrace the subjectivity of the experience.
Our response to pain is complex, more complex than senses like smell and hearing which comprise a direct neural connection between the nose / ear and respective regions of the brain. With pain we know that emotions can manifest in physical symptoms, this relationship is complex, but we must understand that there are overlapping brain mechanisms at play.
To help us consider this further, it helps to understand the three broad categories we use to in contemporary clinical practice:
Nocioceptive Pain, the classic response above to touching something hot, or to an injury or acute inflammation. This is common in the world of a physio working in sport and no doubt in the everyday lives of you and I.
Neuropathic Pain, caused by damage to, or inflammation around, sensory nerves, a classic example being the burning pain and paraesthesia associated with true ‘sciatic’ pain. Again, this is a common presentation in the general population.
With these two categories, it is worth noting that the vast majority of minor tissue damage sustained by your body, through low grain strains and sprains, heal within 2-3 weeks, higher level damage such as tears and breaks (unless there are complications) will heal from damage within three months.
In some healthcare instances, once the pain is reviewed and cleared as structural or neuromuscular, it can take 12 weeks before anyone looks at it. The problem with this, is the profound changes it can induce on the way someone moves (or often, doesn’t move) around their pain in that time, and importantly the way they view their pain. This can lead to neuromuscular pain lasting longer than three months, after the damage has been repaired, this is termed ‘chronic pain’. This is where things can get complicated and where the third type of pain is important;
Nocioplastic pain, where the brain's pain centre becomes hyper-vigilant, it has rejigged and learned to send disproportionate pain signals. This is known as central centralisation - an over-sensitisation of pain pathways that may require therapies that differ from acute pain management. We know that chronic pain is much more than a physical sensation - it’s a complex emotional experience too and it should be treated accordingly.
In the modern world we are often over-stimulated, dealing with a volume of information and pressure, that it could be argued, our brains are unable to effectively process on a day to day basis. This may lead to a hyper-sensitised nervous system. If an appropriate multi-faceted approach isn’t considered when considering pain in a hyper-sensitised system, the brain centre can respond disproportionately to minor injury or inflammation, perceiving them as a major threat and resulting in high levels of pain. In some cases with central sensitisation, there is no ‘physical pain stimulus (nocioceptive stimulus)’ or ‘tissue damage’ at all, but the brain still perceives high level pain signals.
It’s important to note that negative mental states, such as tiredness, anxiety and detrimental or catastrophic beliefs fuelled by misinformation can create this perfect storm and lead to a vicious cycle of pain. This heightened sensitivity to potential threats, can make an individual more receptive to pain signals and heighten the urge to withdraw themselves, potentially leading to a lack of drive to pursue challenging and meaningful things in life and result in being more sensitive to negative experiences - characteristics that are synonymous with depression. The relationship with challenge or fear has become over sensitive. Some studies suggest 75% of people with chronic pain have anxiety and depression - yet we continue to focus ‘pain related’ treatment on the physical symptoms alone.
There is no immunity here. We must recognise this can affect us all at different stages. A few poor nights of sleep, a few life stressors and a caffeine low can easily leave us walking a tight-rope. I’ve sat with Professional Rugby Players and Special Forces Operatives alike, who are considered resilient in every respect and witnessed this perfect storm. In these instances, mis-information and catastrophic beliefs (stuff they have heard in the locker room!) have led to an additional ‘Nocioplastic’ driver to their pain perception. Unless this is addressed, by considering the mis-information / beliefs and implementing good education, you could be setting the pain pathway in action and grossly detracting from their rehabilitation path. At times Health Professionals can be guilty of using big words, or off the cuff statements that can unintentionally drive fear and fuel anxiety, having a detrimental effect.
So, what can we do about it? Pain requires a multifaceted approach. There is no magic bullet. Many treatments only have partial or short-term efficacy when used in isolation and only work for some patients. As I physio – I structure my rehab programs on three main principles;
Education – to deliver a clear understanding, expected timeframes and address the patient’s beliefs around their pain – the aim here is to address the emotional issues that can arise and put the individual firmly in the driving seat. In this frenetic world, it is clear that we need to equip people with strategies to calm their nervous systems, an active process, not a passive one. There are promising pain education therapies and mindfulness programs that have emerged in the past decade, such as Cognitive Behavioural Therapy, My Surgical Success, Empowered Relief and Pain Reprocessing Therapy have all been shown to have positive effects on the top-down self-management of pain.
Pain Modulation – we need to get a few things straight here. There are a huge variety of ‘hands-on’ therapies that claim to address pain, often shrouded with tribalism. Let’s be clear. The vast majority of these techniques are doing the same thing, they have a short-term effect that reduces your brain's perception of the painful stimulus. This can create a cycle of dependence, luring people back for a quick fix. However, if used sparingly at the front end of a program, with an appropriate narrative, this can allow an individual in pain to move a little more and engage with their rehab – and that's the important bit. Ideally, this is best made an active process – so that there is no reliance, little self-administered hacks that can be done little and often. That way the individual is in control. In the physio world the pendulum has swung against manual therapy, but perhaps a little too far, I believe it can have a place for a person in pain to enable a person to build confidence with their movement in the short-term and to engage with life and rehab effectively. The key being it part of a wider treatment approach and that the goal is to get them incontrol, moving and loading their system.
Movement and Loading – this is the key! The regression and progression of movement, loading and rehab exercises are key to appropriately stimulate injured or inflamed tissue, to address the structural damage and create change at a tissue level. This is well accepted and more often than not well executed. However, we should also understand that often, this is also providing ‘graded exposure’ to movement, i.e. building an individuals confidence as we slowly increase range, and load and therefore address any nocioplastic elements of an individual's pain presentation.
Consideration of these three principles during a period of injury and pain rehabilitation can be helpful to help ensure a comprehensive treatment strategy. In my experience, those who are proactive and armed with appropriate education and active interventions to help themselves do well. In addition to this, spending time in the day calming the nervous systems and understanding how to self-modulate pain, helps to avoid the unnecessary use of pharmaceuticals, or passive short-term fixes on the couch of a one-trick pony.
We know our relationships with pain are complex and truly take shape in the early stages of development, hence there is so much variation in our experiences. To make the best of a painful episode, addressing our inner narrative through and ensuring good information is key, wherever possible ensuring the locus of control is with us and that we are empowered by self-administered pain management strategies, lastly building our movement and loading tolerance progressively will lead to increased capacity, resilience and ultimately a faster recovery!