“Pain” is one of the most common complaints patients bring to a physiotherapist. With those experiencing pain always wanting it reduced or eliminated. It is important to understand that pain is a real and complex personal experience. The more knowledge and less fear an individual has regarding their own personal pain. The better equipped they will be to achieve their pain reduction goals.

Here are a few truths about pain that are critical to “getting well” – in this case reducing pain and maximizing function………

1. Pain is all in your head!

The brain is the final processing center that decides if something is painful or not. Here’s how it happens. We have sensors in our tissues (muscle, ligaments, and bone) which can sense mechanical, temperature and chemical changes. When the stimulus is sufficient, a signal (or impulse) is sent through our nerves to the spinal cord through the peripheral system1,3.

If the signals reaching the spinal chord are strong enough. The information travels from the spinal cord to the brain (or cortex) through the central mechanism (The central mechanism includes the spinal chord, medulla, midbrain, thalamus, hypothalamus, and limbic system1,3.) Different parts of the central mechanism have different roles to play in how signals are received and processed, and how pain is recognized and measured. For example, the thalamus is the first area for pain recognition and the hypothalamus is important for maintaining homeostasis and is rich in endorphin and opioid receptors1,3. While we have dramatically simplified what is in fact a very complex process, the simple truth is that ultimately it is the brain that decides when you are in pain, and how bad it is. (See Diagram 1)

2. The amount of pain you experience does not relate to tissue damage1,3.

The common expression “Hurt does not equal harm” can be very true when relating pain to tissue damage. Good examples of this can be found by contrasting accident victims who experience little if any pain in spite of massive tissue damage and others who experience debilitating pain with no evidence of bone or tissue damage. There can be many reasons for this, but one is how, in the peripheral system, painful threats can be amplified by our own body chemistry (neuropeptides), causing more receptors to activate and send stronger signals to the central mechanism, leaving us to perceive more pain1,3!

3. Pain involves the context of your experiences, memories, reasoning, beliefs, and emotions.

We now know pain is recognized by the brain, however how an individual perceives a situation can influence the degree to which the central mechanism is excited, and consequently how much pain is experienced. So, negative thoughts, attitudes, anger, stress and depression can all contribute to the perception of pain symptoms1,2,3.

4. “Chronic pain” is not a purposeful or “helpful” pain.

Chronic pain can be defined as persistent pain lasting more than 6 months1,3,4. However, it may be better to define chronic pain as an individual experience1. Acute pain warns your body of injury or harm but chronic pain is a result of a sensitive or up-regulated peripheral and central mechanism. There are also many other physiological factors that affect chronic pain including the endocrine system (hypothalamus, adrenal glands), sympathetic/parasympathetic system, and immune system1. For example, when the brain receives threatening information the hypothalamus releases hormones (ACTH) which leads to the release of cortisol from the adrenal glands. Cortisol is a stress hormone which protects us when we are challenged1. (However, persistent cortisol can result in memory loss, depression, slower healing and reduced physical abilities.)

For these reasons, the treatment of pain requires a multi-dimensional approach. Overall, if the perceived threat of pain to the brain is reduced, we can get much closer to achieving normal function. Your physiotherapist is a valuable resource in this area. Physiotherapy can address the very important areas of exercise and education. Not only does exercise improve the health of the muscles and joints; it also establishes and re-establishes good connections between your body and your brain.

Education is a regular part of your interaction with your physiotherapist. Through education about pain mechanisms physiotherapists can place a measure of situational control back in the hands of patients. A review of personal pacing, coping, relaxation strategies and a plan for coping with potential flare-ups are all essential elements of a pain management program. Manual therapy, or hands on skills also help reduce painful signals and improve inputs into the peripheral and central mechanisms. And finally, a powerful strategy, don’t forget to laugh! This simple pleasure boosts endorphins and brightens your day!

The Pain Mechanism.

Footnotes:

1. Butler,D.,Mosely,L. (2003). Explain Pain.Adelaide,: Noigroup Publications.
2. Kachur, S.,Carleton, R.,Asmundson, G. (March/April2007). “Fear-anxiety-avoidance model of chronic pain:A brief Review. Orthopedic Division Review, 28-31.
3. Patterson,D. (2004)Chronic Pain, Part One,Workbook.
4. Steinfeld,S. (Nov/Dec 2005)”Therapeutic education and the chronic pain patient ” Orthopedic Division Review, 41-42.