An Orthopedic Manual Physical Therapist Explains How Pain Works

Updated: Jun 4, 2019



What is Pain?

As featured on http://www.pt-helper.com/blog.html

What is Pain? Pain is an unpleasant sensory experience generated by an individual’s unique pain neural signature that may be activated either spontaneously or when a stimulus is perceived as a threat.

Why Learn About Pain?

Erroneous ideas about pain abound among patients and health care providers alike. If you are seeking relief from pain, understanding pain is a very important step on your way to recovery. If you are an orthopedic manual physical therapist or other health care provider who treats patients in pain, you owe it to your patients to 1) have a correct understanding of pain and 2) be able to explain it accurately in plain language to your patients.

Misconceptions About Pain

Many understand pain to work like this: “Pain fibers throughout the body send pain messages from an injured body part up to the brain so that a person will do something to eliminate the pain.” While it may sound logical, this outdated model has fallen short on many fronts.

Let’s break it down into 6 common myths about pain:

Myth #1: “Pain receptors in my body convey the pain message to my brain.”

If this myth were true, phantom limb pain wouldn’t exist. However, 90-98% of individuals report experiencing phantom sensations in a limb following its amputation – the majority of them reporting distinct pain. [1],[2],[3] Therefore, pain may be experienced even in the absence of any tissue in that area at all.

Myth #2: “Pain means tissue damage. Therefore, when I have severe pain, it means I have severe tissue damage.”

This may sound reasonable, but it has been disproven in scientific studies several times over.[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15] Many people have injured tissue such as bulging discs, arthritis, labral tears, tendinopathy, degenerative changes, muscle tears or ruptures, etc without any pain at all. Others have incapacitating pain without any tissue damage at all. Pain is not simply “an issue of the tissue.” Tissue injury can occur without pain, and pain can occur without injury. (You're also invited to consider the inability of X-ray, MRI, and CT Scan findings to explain the patients' pain.)

Additionally, this myth cannot explain why surgeries that successfully remove injured structures don’t always eliminate – or even improve – pain afterward.[16],[17] Conversely, it cannot explain why sham orthopedic surgeries were just as effective as actual surgery in reducing pain and disability.[18]

Myth #3: “I’m always in pain, but I’m not aware of it at present because I’m just used to it.”

Pain is an unpleasant sensory experience. Therefore, you cannot be in pain without being aware of it. For instance, no pain is experienced during surgery despite the extensive bombardment of sensory information because anesthesia removes the conscious component of the experience.

Myth #4: “Chronic or persistent pain means that my injury hasn’t healed properly.”

Injuries heal in predictable stages, and even slow-healing tissues, such as herniated discs, have been shown to heal over time.[19] Most tissues heal within weeks; however, some pain experiences last for months or even years. Further, many individuals have chronic pain with no history of injury. Typically the longer the pain lasts, the less important tissues are and the more important a sensitive nervous system is. For more information, you're invited to read my blog "Subclassification of Chronic Pain".

Myth #5: “Pain is all in your head.”

It is true that pain is an experience produced by the brain - with or without contribution from the body. However, the phrase "pain is all in your head" inaccurately and insensitively implies that your pain is imaginary. Additionally, chronic pain may be due to a series of physical changes that happen over time called "central sensitization". While learning about the scientific explanation may not be for everyone, simply understanding that your pain is not “all in your head” can be very liberating. For those intrigued by the physiological explanation of chronic pain, this is for you:

It appears that the chronic bombardment of C-fiber activity into the dorsal horn results in permanent changes over time, killing off the interneuron with high levels of amino acids, and allowing more information to be passed onto the spinal cord and brain. As C-fibers pull back and A-fibers grow into the dorsal horn, light touch fires more easily into the spinal cord and leads to increased sensitization and decreased endogenous mechanisms, leading to allodynia or hyperalgesia. Chronic retrograde firing may result in inflammation, swelling, and immune responses.

Myth #6: “I feel your pain! I know how that feels!”

Despite good intentions, none of us can truthfully make that claim. That is because each pain experience is dependent on a unique combination of each person’s experiences, beliefs, knowledge, logic, social behavior, anticipated consequences, mental state, emotional state, financial concerns, sensory cues, anticipated outcomes, fears, environment, and more. A typical pain neural signature commonly involves a map of these 9 areas of the brain:

  • Amygdala – responsible for processing and memory of emotional reactions, fear, fear conditioning, addiction.

  • Primary Somatosensory Cortex – involved with somatic sensation, visual stimuli, movement planning.

  • Hippocampus – performs consolidation of info from short-term to long-term memory, spatial navigation, memory, fear conditioning.

  • Anterior Cingulate Cortex – regulates blood pressure and heart rate, assists with reward anticipation, decision-making, empathy, emotion, and concentration.

  • Primary Motor Cortex – assists with planning and executing movements

  • Hypothalamus – regulates body temperature, hunger and thirst, fatigue and sleep.

  • Thalamus – plays a role in consciousness, sleep, alertness

  • Prefrontal Cortex – moderates personality expression, decision-making, social behavior, memory.

  • Cerebellum – facilitates movement, balance, proprioception, coordination, cognition, and fear.

Therefore, it’s impossible for two persons to experience the same pain.

So… What Is Pain?

As we have discussed, misconceptions about pain are prevalent. But, they have fallen short of accurately explaining the true pain experience. Arguably the most concerning fact is that an outdated and inaccurate theory of pain can lead to an increase in both pain and disability for individuals who persist in avoiding activity or certain movements out of fear of pain[20], and some well-intentioned health care providers unwittingly contribute to this increase by advising their patients to avoid certain activities altogether.

Therefore, we need to better understand pain.

Pain is an unpleasant sensory experience generated by an individual’s unique pain neural signature that may be activated either spontaneously or when a stimulus is perceived as a threat.

The truth is that there simply are no “pain fibers”; there are only “nociceptors”. These terms are not synonymous. Nociceptors are nerve cells that transmit sensory information – not pain – to the brain via the spinal cord for processing. Nociceptors do not perceive, produce, or transmit pain. Pain is experienced only after the sensory input is sent to the brain, processed by the pain neuromatrix, and is determined to be a threat.[21]

The amazingly complex neural signature located in your brain ultimately determines when you experience pain, and the body may or may not be involved in the process. For a sensation to become painful, you must perceive it as a threat.

You are likely to experience pain when spraining your ankle while playing a recreational sport; you are highly unlikely to experience pain when spraining your ankle while running from a tiger. In the latter scenario, you likely wouldn’t be tremendously concerned about your ankle that just got tweaked, as you’d have a bigger threat to deal with in the 600-lb combination of speed, power, and teeth right behind you. If you are fortunate enough to survive that encounter, you may eventually experience ankle pain once you’re able to calm down and compose yourself. Ultimately, the level of perceived threat assigned to a given sensation determines whether or not you experience pain with it.

Further, the nervous system is a dynamic and living organism driven by thought and emotion, and it is very closely linked to the immune and endocrine systems. Therefore, cognitions such as fear, anxiety, and catastrophization are strongly correlated to the pain experience as they are to overall health and wellbeing.[22],[23],[24]

If you are an orthopedic manual physical therapist or other health care provider who treats individuals in pain, you owe it to your patients to have an accurate understanding of pain and to promote a healthy approach to it without unwittingly contributing to increased pain and disability. If you are a patient seeking relief from pain, it’s critical that you choose a health care practitioner who has an accurate and up-to-date understanding of pain and knows how to best treat it. You're also invited to consider how an orthopedic manual physical therapist treats pain or how orthopedic manual physical therapy works.

Dr. Damon Bescia is a fellowship-trained Doctor of Physical Therapy, board certified in orthopedics and sports physical therapy, who specializes in Orthopedic Manual Physical Therapy and serves Naperville and its surrounding communities by way of his Concierge Practice, providing private one-to-one orthopedic manual physical therapy for his clients. For more information, please visit https://www.napervillemanualphysicaltherapy.com.

[1] Melzack R. Phantom limbs and the concept of a neuromatrix. Trends in neurosciences. 1990 Mar 31;13(3):88-92.

[2] Melzack R. Pain and the neuromatrix in the brain. Journal of dental education. 2001 Dec 1;65(12):1378-82.

[3] Ramachandran VS, Hirstein W. The perception of phantom limbs. The DO Hebb lecture. Brain. 1998 Sep 1;121(9):1603-30.

[4] Twomey L, Taylor J. Age changes in the lumbar spinal and intervertebral canals. Spinal Cord. 1988 Aug 1;26(4):238-49.

[5] Alyas F, Turner M, Connell D. MRI findings in the lumbar spines of asymptomatic, adolescent, elite tennis players. British journal of sports medicine. 2007 Nov 1;41(11):836-41.

[6] Videman T, Battié MC, Gibbons LE, Maravilla K, Manninen H, Kaprio J. Associations between back pain history and lumbar MRI findings. Spine. 2003 Mar 15;28(6):582-8.

[7] Taylor JR, Twomey LT. Age Changes in Lumbar Zygapophyseal Joints: Observations on Structure and Function. Spine. 1986 Sep 1;11(7):739-45.

[8] Kjaer P, Leboeuf-Yde C, Sorensen JS, Bendix T. An epidemiologic study of MRI and low back pain in 13-year-old children. Spine. 2005 Apr 1;30(7):798-806.

[9] Spielmann AL, Forster BB, Kokan P, Hawkins RH, Janzen DL. Shoulder after Rotator Cuff Repair: MR Imaging Findings in Asymptomatic Individuals—Initial Experience 1. Radiology. 1999 Dec;213(3):705-8.

[10] Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am. 1995 Jan 1;77(1):10-5.

[11] Reilly P, Macleod I, Macfarlane R, Windley J, Emery RJ. Dead men and radiologists don't lie: a review of cadaveric and radiological studies of rotator cuff tear prevalence. The Annals of The Royal College of Surgeons of England. 2006 Mar;88(2):116-21.

[12] Milgrom C, Schaffler M, Gilbert S, Van Holsbeeck M. Rotator-cuff changes in asymptomatic adults. The effect of age, hand dominance and gender. Bone & Joint Journal. 1995 Mar 1;77(2):296-8.

[13] Munk B, Lundorf E, Jensen J. Long-term outcome of meniscal degeneration in the knee Poor association between MRI and symptoms in 45 patients followed more than 4 years. Acta Orthopaedica Scandinavica. 2004 Jan 1;75(1):89-92.

[14] Bedson J, Croft PR. The discordance between clinical and radiographic knee osteoarthritis: a systematic search and summary of the literature. BMC musculoskeletal disorders. 2008 Sep 2;9(1):116.

[15] Major NM, Helms CA. MR imaging of the knee: findings in asymptomatic collegiate basketball players. American Journal of Roentgenology. 2002 Sep;179(3):641-4.

[16] Ostelo RW, Costa LO, Maher CG, de Vet HC, van Tulder MW. Rehabilitation after lumbar disc surgery: an update Cochrane review. Spine. 2009 Aug 1;34(17):1839-48.

[17] Deyo RA, Mirza SK. The case for restraint in spinal surgery: does quality management have a role to play?. European Spine Journal. 2009 Aug 1;18(3):331-7.

[18] Louw A, Diener I, Fernández-de-las-Peñas C, Puentedura EJ. Sham Surgery in Orthopedics: A Systematic Review of the Literature. Pain Medicine. 2016 Jul 11:pnw164.

[19] Autio RA, Karppinen J, Niinimäki J, Ojala R, Kurunlahti M, Haapea M, Vanharanta H, Tervonen O. Determinants of spontaneous resorption of intervertebral disc herniations. Spine. 2006 May 15;31(11):1247-52.

[20] Vlaeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000 Apr 1;85(3):317-32.

[21] Louw A, Puentedura E. Therapeutic Neuroscience Education: Teaching Patients about Pain: a Guide for Clinicians. International Spine and Pain Institute; 2013.

[22] Meeus M, Nijs J, Van Oosterwijck J, Van Alsenoy V, Truijen S. Pain physiology education improves pain beliefs in patients with chronic fatigue syndrome compared with pacing and self-management education: a double-blind randomized controlled trial. Archives of physical medicine and rehabilitation. 2010 Aug 31;91(8):1153-9.

[23] Moseley GL. Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. European Journal of Pain. 2004 Feb 1;8(1):39-45.

[24] Vlaeyen JW, Kole-Snijders AM, Rotteveel AM, Ruesink R, Heuts PH. The role of fear of movement/(re) injury in pain disability. Journal of occupational rehabilitation. 1995 Dec 1;5(4):235-52.

#Pain #PainScience #PhysicalTherapy #PhysicalTherapist #PainTreatment #PainReliefTherapy #BackPainTreatment #NeckPainTreatment #OrthopedicManualPhysicalTherapy

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Contact

Dr. Damon Bescia DPT

Naperville Manual Physical Therapy

2140 Skylane Dr

Naperville, IL 60564

P (630) 408-9703

F (630) 868-9020

 

Open Monday-Friday, 9am-5pm

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Dr. Damon Bescia DPT, board certified in orthopedic physical therapy

Board Certified in Orthopedic Physical Therapy

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Dr. Damon Bescia DPT, board certified in sports physical therapy

Board Certified in Sports Physical Therapy

Legal Disclaimer:  No content in this website is to be construed as medical advice of any kind, as any guarantee of treatment success however defined, or as any guarantee that treatment success however defined will be achieved in any specific number of visits. Every client's presentation is unique, and treatment results will therefore vary accordingly. Additionally, no content in this website is to be construed as any guarantee of reimbursement by individual insurance companies; all clients are directed to contact their insurance provider personally to inquire of reimbursement for Physical Therapy should they desire to submit for it. Dr. Damon Bescia is a licensed Doctor of Physical Therapy, Board Certified in Orthopedics, Board Certified in Sports Physical Therapy, a Fellow of the American Academy of Orthopaedic Manual Physical Therapists, a Strength and Conditioning Specialist, and a Certified Personal Trainer.