Everyone has experienced pain’s unwelcome intrusion into their lives at one time or another. Pain has a way of capturing our attention like few other experiences. Most people go to great lengths and expense in an attempt to avoid pain. In fact the annual expenditure for direct healthcare costs related to low back pain alone exceeds $85 billion (1). Before we can talk about what rehab professionals can do to treat pain, we need to understand more about a subject with a bad reputation.

What is Pain?

Pain is a very complex process involving information from the environment, your senses, past experiences and perception of threat (2). Stress and fear can significantly impact the amount of pain an individual experiences (2). This can be seen in the differing pain responses between individuals to relatively the same trauma. For example, persistent pain following a single whiplash injury can occur as often as one in three people in the general population, but is very low in professional demolition derby drivers who can sustain an average of 1,632 collisions in a career (3).

A common misconception is that there are nerves that carry pain to the brain and that damaged tissue will always hurt (4). However, we can all probably remember a time when we had damage of some sort in our body without experiencing pain. That’s because nerves contain sensation receptors not pain receptors, just as eyes contain light receptors not vision receptors. All of our senses (sight, hearing, taste, smell, touch) are the interpretations by our brain of the input from our receptor systems. As a result, pain is an output of the brain, not an input from the body, and it can be influenced by numerous factors. Understanding this can go a long way in helping individuals begin to move again after an injury, in ways that promote healing, even if it hurts (2).

Why Pain is Beneficial

Pain is not the enemy. Without pain, we may not change actions that are damaging to us or be aware that an injury has occurred. Pain is simply an alarm system in our brain that turns on when the brain perceives a threat (2). Without pain, would we pull our hand out of the fire or take the nail out of our foot? You probably experienced a twinge of pain just thinking about these examples. Our pain response is designed for one purpose – to motivate us to take action.

Treating Pain

First, education can have an impact on the amount of pain an individual experiences. The old adage “knowledge is power” is very relevant. For example, education about low back pain through a media campaign reduced the number of back claims through workers compensation both initially and at three-year follow-up (5). Pain is a whole brain experience involving more areas of the brain than are needed to move. Understanding why pain is occurring can take the fear of movement away and reset the normal brain activation associated with the movement (6).

Secondly, “hurt does not always mean harm.” According to Adriaan Louw, PT, people typically respond to pain, especially chronic pain, and physical limitations with one of three cycles: “boom/bust,” “descent into chronicity,” or “pacing of activity” (2). The first two responses are detrimental and lead to a greater reduction in physical activity. The third option is the one that physical therapists attempt to guide patients to perform.

The “boom/bust” cycle is where an individual does more than they know they are capable of, “boom,” resulting in a re-injury “bust.” “Descent into chronicity” is the opposite of “boom/bust.” Individuals still know where their physical limits are, but they limit their activity to well below the amount that would be required to produce pain. Both of these two cycles result in decreased physical capacity (2). With “pacing of activity,” the goal is to go just a little bit beyond one’s limit. This results in expected soreness the following day, but does not limit normal activities.

Weight lifting can be used to illustrate these three cycles. Lifting too much weight can result in injury while too little weight does not adequately challenge the system. The goal is to challenge the body’s capacity by consistently lifting a little more each time. Over time, the body responds positively to the challenge by increasing capacity, resulting in more reserve during normal tasks so that injury is less likely to occur.

In summary, understanding pain does not eliminate pain, but decreases fear of injury. To manage pain, we need to take appropriate steps if an injury has occurred, while challenging our physical capacity daily in a healthy way. A rehab professional can be a valuable partner in this process.

References:

¹Martin BI, Deyo RA, Mirza SK, et al. Expenditures and health status among adults with back and neck problems. JAMA. 2008;299:656–64.
²Neuro Orthopaedic Institute. “Explain Pain” continuing professional education course. Web site. http://www.noigroup.com/en/Courses. Accessed May 20, 2013.
³Simotas AC, Shen T. Neck pain in demolition derby drivers. Arch Phys Med Rehabil. 2005;86:693-696.
⁴Butler D. Explain Pain. 1^st ed. Minneapolis, MN: Orthopedic Physical Therapy Products; 2003.
⁵Buchbinder R, Jolley D. Effects of a media campaign on back beliefs is sustained 3 years after its cessation. Spine. 2005;30:1323-1330.
⁶Moseley GL. Widespread brain activity during an abdominal task markedly reduced after pain physiology education: fMRI evaluation of a single patient with chronic low back pain. Australian Journal of Physiotherapy. 2004;51:49-52.