Pain is much more than an unpleasant sensation. It can disrupt one’s livelihood, cause anxiety, high stress levels and be debilitating depending on cause, injury, and length of time experienced.
Pain is a phenomenon that unfortunately is largely misunderstood and understandably so. It is a complex subject that even clinicians can find hard to explain to their patients.
We must consider a biopsychosocial framework when it comes to managing pain in our daily lives and our training/exercise/rehabilitation programmes. This means a dynamic, reciprocal and complex interaction of biological, social and psychological domains.
How Does Pain Work Within Us?
Pain is an adaptive, attention-demanding brain output of high priority. Its existence is to alert, teach, protect and stimulate a change in bodily behaviour to shield from further threat and allow optimal healing conditions. However, there are no pain pathways or pain endings and so the body can’t send ‘pain messages’ to the brain.
In essence our peripheral nerves enable us to sense the environment – the heat of a flame, pressure of a punch, or change in pH from lactic acid build-up – and this sends nociceptive (‘danger’) impulses to the central nervous system (CNS). Secondary neurones in the spinal cord then carry this impulse for processing in numerous areas within the CNS.
Should all this information be interpreted as dangerous to the body, a defensive response, very often pain, may be constructed by the brain. This is why pain can be labelled as an output rather than an input.
The Brain’s Response
The brain will weigh up all this information in light of – past experiences, it’s predictions and expectations of the future (what will happen if these messages are ignored etc.), societal and familial factors (among many other variables) – and then, if the brain concludes that the body is in danger, it coordinates an complex output of which pain is a component.
Other responses may include, swelling, limping, alteration in muscle tone, sympathetic, endocrine, emotional and cognitive responses (Hunter, The Explain Pain Handbook: Protectometer by G.L. Moseley and D.S. Butler, 2016). There is potential for error as the brain weighs up all this information.
Significant danger doesn’t always result in significant pain, equally nor does a lot of pain always indicate significant tissue damage. This is because the amount of pain we construct is a reflection of the amount of threat our brain ‘believes’ we are under. This is why pain is very often a poor correlate of tissue damage. Despite this a lot of people still think that pain and tissue damage are directly related.
Microglia and astrocytes are essentially danger surveillance cells. They may remain ‘experienced’ and on alert for many months after an injury; even years. An individual overly concerned and vigilant about a body part, enhanced by unfortunate evocative language (‘slipped disc’, ‘collapsed arch’, ‘degenerative’, ‘weak’ etc) may well keep the brain territory representing the body part on enhanced alert. If not managed appropriately this can reinforce chronic alertness making the neurosignature even harder to shift.
To be truly effective, our management of pain needs to be as sophisticated as the pain construct itself.
How to Better Manage Physical Pain
All pain experiences are personal. What someone experiences as a 10 out of 10 pain is true for them. One person’s view as a threat, could be another person is fairly nonchalant about.
This makes using a pain measurement tool challenging as an attempt to determining the extent of bodily damage. It would also be inappropriate to compare one person’s pain to another. We can, however, compare different episodes of pain experienced by the same person at different times. For example, someone who’s experienced a significant ankle fracture presents with exaggerated pain response to a simple ankle sprain a few years later. We must seek to understand the context of the injury and be aware of the notion of immune surveillance.
When we have sustained an injury, our brain places more attention on the harmed area. Sort of like increasing the number of CCTV cameras on an area of known criminal activity. The brain wants to know everything that’s going on around there. It’s ‘looking after us’ because it perceives the threat of further injury or re-injury is high. Unfortunately, these ‘CCTV’ cameras do not disappear overnight or even as the physiological process of healing is complete. As a result, rehabilitation is only complete once.
- The physiological process of healing is complete.
- Physical performance is reinstituted; and
- The brain is satisfied that threat levels have reduced and so has ‘turned off its CCTV cameras’.
How PGPT Help
When we at PGPT are working with a client in pain, the key aim’s with injury management are to foster adaptive behaviours in the acute setting and to intervene to limit maladaptive behaviours. Rreducing the threat by dampening nociceptive mechanisms, education and graduated exposure can help to restore normal movement and function without enhancing the sensitivity of the brain.
Remember, ‘hurts don’t always equal harm’, and similarly ‘you can be sore but safe’. This is not suggesting that ‘it is all in your head’ in a derogatory way. All pain states will include some ‘issues in the tissues’ as well as changes in the representation of tissues and the injury in the brain. In many chronic pain states, tissues may remain unhealthy, unfit and sensitive long past expected healing times but we always need to consider the changes in the CNS so effective evidence-based therapy and rehabilitation can occur.
We focus on aspects of exercise and training that you can achieve during an injury and periods of pain, providing a calming and restorative environment for the CNS. This allows threat levels to reduce and as a result the output that is pain.
Yours in managing your pain