It’s just stuff that hurts right? Simple but yet so much more complex than you would think. It’s actually a much more philosophical question than most of us realise. Including many people in the physiotherapy industry. 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?
Pain, it turns out, is way more complex than that. In the last 20 years there has been massive leaps in our understanding of pain with the advent of video MRI scanning which can look at live brain activity to give huge insight into what happens in the brain when we are in pain. More importantly this gives us therapists and you, people in pain, better ways to change and manage pain.
How do We Define Pain?
We could just say it’s the hurty bit – as many of our clients with children tend to. But we need something a little more useful for this discussion. One definition that is very much in vogue is from the guru of pain:
“Pain is a multiple system output constructed whenever the brain concludes that body tissues are in danger and action is required.” – Lorimer Moseley
In English: 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 which we shall discuss shortly. Not least of which is your brain.
This concept has been proved with some fantastic research making use of video MRI technology. Lots of people with knee pain were ‘shoved’ in an MRI unit to look at their brain activity. They then stimulated the non injured knee with something that wasn’t painful. Effectively just touching it.
On the non-symptomatic side a part of the brain lit up which was the knees representation in the brain. They then did the same stimulus on the painful knee and an equivalent area many times the size lit up in the brain. So the brain had a larger than normal representation of the injured side.
Simply put the brain was more sensitive to stimulus on the affected side. Therefore more likely to feel pain from not that much happening. Was this due to anything mechanical in the knee. No. It was due to the brains feeling about that body part.
Now consider the fact that your entire brain will be replaced in two months. That is every single cell in your brain that is there currently will not be there in 2 months time as shown in this article here. In real life terms that means that if we can change our beliefs, emotions or understanding about a body part then we will change your pain experience. Preferably to something more positive. This could be without even the need for treatment. Just by talking.
I have managed to do this quite often in the clinic. As you can imagine many people come to us in large amounts of pain. We have tested their response to certain movement before and after we have simply explained their pain and their condition to them. Seeing a positive response in the matter of minutes.
Are we that clever? No. But we have reduced the threat of the condition in the brain and in so doing the overall pain experience. Here’s another more accessible version of the pain definition written in plain English:
“All pain experiences are normal and are an excellent though unpleasant response to what your body judges to be a threatening situation. We believe that even if problems do exist in your joints, muscles, ligaments, nerves, immune system it won’t hurt if your brain thinks you are not in danger.” – NOI Group
Food for thought eh?
The Words We Use
All of this research shows how important the words we use are. 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. ‘How’s your knee Maude?’ ‘Oh it’s chronic.’ It just sounds bad. By physiotherapy definition it simply means the pain has been there for more than 6 weeks.
6 weeks is significant as this is how long genuine tissue healing takes. Obviously anything unnatural like recovering from surgery can take a bit longer but generally 6 weeks is the magic amount of time for your normal injury. Anything after that length of time and we have to ask why?
The sound of the word chronic and what it’s become associated with suggests that something is really bad. Rather than something that has simply been there for longer than 6 weeks. The tone and the way in which you say it makes such a difference to how the brain feels about the word and as result affects the amount of pain you feel.
Is Your Injury Mechanical Or Psychological?
Hopefully you’re coming to terms with the idea that pain is not simply representative of what is going on with the tissues where you feel it. In the clinic we have come up with a nice way to explain this.
We simply use a sliding scale of the cause of people’s pain. You can have a condition that is entirely mechanical as in you have just fallen over and broken your leg. Almost all of your pain will be mechanical in origin. Thinks are quite literally broken and there’s lots of chemical reactions going on to tell you 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% psychological.
Of course such categorisation is only for illustration. But it does help guide us when trying the help people with long lasting symptoms. It also helps to explain why some days pain is worse than others. Usually when we’re having a bad day in the office or there are concerns about people you care about.
Pain Is Not Damage
So we have seen that fear is a massive part of the amount of pain we feel. So if we believe the merest pain to be actual damage we will be walking around in a perpetual state of fear. Which of course will make us feel even more sensitive and more pain. This can become self limiting and this is something we help a lot of our clients with. Breaking the cycle of fear.
They have got themselves into such a viscous cycle of pain and believing every time they feel it they will be making it worse. This is where our definition of pain comes in very handy. If we can demonstrate that you feel pain before any damage is done this will reduce their pain experience.
My favourite way to demonstrate this is to use a practical example we’re all done. Picture yourself walking down the road. Maybe you step on something or miss the kerb and you ‘go over’ on our ankle. We step on the outside of our foot and our ankle goes into an unnatural position.
We immediately get a shot of pain that’s quite unpleasant and if we were a footballer we’d roll around on the floor a lot screaming. But then something miraculous happens. We tentatively put our foot down and it seems ok. We get increasingly confident and after a few tentative limps we realise nothing is wrong and we carry on with the rest of our day.
Pain was simply the warning shot before any damage was actually done. Now I do appreciated if you had continued to put more weight through the ankle in an unnatural position than would most likely have done yourself a mischief. But it illustrates the point nicely that we get pain before we do any damage.
How Do We Feel Pain?
You will be relieved to hear that I have reduced this section on molecular biology into a snooker table analogy! It really does work, trust me. We’ll do the difficult bit first and 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.
There’s a very entertaining video about all of this just here by Lorimer Moseley who’s definition of pain we introduced above. He talks how his own near death incident involving a snake is the perfect example of all that we have discussed here.
How Can We Change Our Pain?
Thankfully all these aspects of pain can be changed and this what we do at our clinics. Firstly we identify what your pain is and what you think the problem is to find out what your beliefs are. We also assess stress levels to understand how sensitive you are as a person. This may be more than you think. Many of us are very adept at hiding stress, myself included. But this stress will always be represented physically somewhere in the body.
With treatment we look to change your symptoms. If we can show you with treatment that for example your back pain can eased in a matter of moments. Perhaps we will be able to change your belief that you will always have a bad back. This will allow you to move more freely which in turns means you don’t hold your muscles so tense. You feel and we’ve broken the vicious circle.
We also look to reduce your stress by helping with lifestyle advice. It’s not rocket science the advice we give. We are after all Sports Therapists and Physiotherapists not Psychologists. But a reminder at the appropriate time to look after yourself in the ways we all know we should – especially when we understand it will help with the pain we are feeling – can go a long way.
Which brings me nicely onto our next post… Why Stress Causes More Pain.
This article first appeared on our Brighton site.