Opening the can of worms
The human body is an amazing structure, made up of many different cellular mechanisms that help it to grow, repair, change, move, adapt and function. It is no wonder that when it comes to understanding how everything works, there is still a multitude of information still yet to discover. This is particularly true in the case of chronic- or what has now been dubbed “Persistent” Pain.
Persistent pain is pain that has been present for greater than three months, following an episode of acute or insidious onset injury and one in five Australians suffer from Persistent Pain. What we know about this is that often, the inflammatory period has resolved but for some reason, the pain has not. So what happens when we injure ourselves? How does the body tissue heal itself? What happens when the pain doesn’t go away? Why is this problem something that we see on a daily basis in our Pilates clinic? “Pain is the unpleasant sensory and emotional experience we associated with actual or potential tissue damage…”
After an initial injury that has resulted in tissue damage, the body kick starts the inflammatory process. For example, when you sprain your ankle you will see swelling and heat around the joint, pain while moving it and you will naturally protect the injured body part by limping or non-weight bearing. The inflammatory process is an important part of the healing of the damaged tissue, these days health professionals are moving away from prescribing anti-inflammatories in the case of an acute injury. The acute inflammatory process should only last a few days to two weeks at most. Depending on the extent of the tissue damage and where it is located, the tissue healing timeframe can vary. For example, a minor ankle sprain will heal much faster than an open, comminuted fracture of the femur or a dislocated shoulder. As a general rule, tissue healing should be well under way by the three-month mark. During this healing phase, pain can still be felt if the damaged tissues are over-strained or if the activity level is too advanced for the current stage of healing. Pain lasting longer than three months has been given the term “Persistent Pain”, and in this situation, tissue damage is NOT the cause of the pain.
This blog will further explain where persistent pain may stem from, to help you understand a bit more about why it is so hard to get on top of. When we injure ourselves, pain is an important signal our body sends to the brain to help prevent further tissue damage. When we move the affected body part including the damaged tissue, we feel pain. This allows our body to both understand that we are injured, and to avoid further damage by preventing further movement. For example, if you bend over and hurt your back, your body will produce localized spasm to somewhat “splint” the injured area, which will in effect stop it moving and allow for healing. When we have a sore back, we change the way we bend, lift and move in order to avoid the pain. These altered movement patterns are important in the initial phase of injury healing, but if we allow these altered movement patterns to continue, they can actually be detrimental! Using altered movement patterns once the tissue damage has healed, leads the body into a very vulnerable position because it is not moving in the most efficient manner and therefore, puts a strain on other areas.
When our body has been signalling pain along the nerve fibres, up the spinal cord to the brain for an extended period of time, neuroscientists have discovered that the nerves actually change their activity levels, they open up more neurotransmitter channels and allow the pain message to get through to the brain much more easily. In short, the nerves facilitate the pain message so they eventually start reacting to not only “tissue damage” but also what would normally be sensed as a non-painful stimulus, for example, movement, stretch or tightness is signalled as “pain”. This is known as hyperalgesia. Studies have also shown that people with persistent pain, also have a lowered pressure pain and hot/cold threshold, which in laymen’s terms, means they are more sensitive to external stimulus. So it isn’t necessarily the case that the pain you feel after an injury is healed is in your head, there are physical and neurological changes that occur that are causing the brain to sense the pain.
To help understand the multi-faceted nature of persistent pain, I will break it down into subsections to help you understand what healthcare professionals term, the biopsychosocial model of pain to help you understand why pain is all about the brain and not always, all about the tissue.
Bio{logical} Physical Health
- Is the body also trying to cope with comorbidities eg high blood pressure, diabetes, or celiac disease
- What is your general fitness and strength?
- Lifestyle factors such as lack of sleep, sedentary lifestyle, and stress can sensitize the neural system and increase the sensation of pain
- Genetic Vulnerability | Some people are genetically predisposed to more lax ligaments due to their collagen/ elastin integrity, or the genetic shape of their joints
- Physiological dysfunction | Is the body having problems processing nutrients?
- Is there an hypo-functioning system within the body, eg the thyroid?
- Neurological Dysfunction |Have the nerves changed the way they are sensing pain?
- Are the nerves sensitive or do they have neural tension or “tightness”?
- Drug Side effects | Smoking and alcohol and other drugs can interfere with the natural progression of tissue healing and cause a heightened nerve response to pain
- Immune Function | If the immune system is constantly under strain, the body’s energy will be spent on trying to support the immune system instead of healing an injury
- Stress Reactivity | The circulating level of cortisol in the body will envoke the fight or flight response, which will cause a cascade of events that will eventuate in poor tissue healing and increased neural sensitivity to pain.
Psycho{logical} Stress
- When you are experiencing emotional stress, you will not only physically heal slower but you will emotionally be less equipped to cope with injuries and pain compared to if you aren’t stressed o Think back to when the pain first appeared, was it a stressful period of your life? What was going on
- Pain Beliefs | Your beliefs about how to cope with an injury can affect how long the pain lasts and what you choose to do about the pain
- Too much focus on pain on a daily basis can amplify the sensation of the pain- is it all you think about?
- What sort of mental imagery do you associate with the pain?
- Do you use words such as “flared up, stabbing, inflammatory, severe, debilitating etc” to describe your pain? The way we choose to label our pain can actually affect the sensation of the pain, catastrophizing can lead to worse symptoms and poorer healing.
- Memory | Has this happened before and how did it feel then?
- The limbic system in the brain is responsible for emotional memory, so chances are, if this is not the first time you’ve felt similar pain, your body will behave in the exact same way as if it were the exact same injury when there may actually be no tissue damage this time.
- Personality | Are you generally impatient? Are you a pessimist? Consider how you react to bad news or a bad situation, could this be affecting your recovery from an acute injury?
- Emotions | Someone who has stressed, angry, fearful or experiencing other negative emotions, will deal less well with an injury and tend to become overwhelmed when the injury takes longer to heal.
- Fear of re-injury can affect the way you move and in turn, put more strain on other sensitive structures within the body.
- Coping strategies | Are you dealing with the emotional effects of being functionally limited? Is this something that you might need some help with?
- Try some relaxation techniques, for example, diaphragm breathing, massage, exercise or meditation when you are experiencing your pain, see if this actually helps to lessen the symptoms.
- Past trauma | Due to memory, our body will remember how the pain felt last time it was injured, and respond accordingly.
Social Social and economic status
- This can affect a person’s beliefs of whether they have the means to help their situation
- Social Supports | Someone who is struggling with their societal and family roles due to the acute injury is more likely to be worse affected by an initial injury and take longer to recover
- Are you asking for the right amount of help from friends, family, work in trying to overcome your injury?
- Family Background | Is the injury affecting the way they can fulfil their family role?
- Education | Have you received the right information regarding your injury?
- Have the healthcare professionals given you all the up-to-date information they know to equip you to cope with your persistent pain? (if any of this blog info is new to you, I suggest that you don’t know everything about persistent pain ? ).
Some of you may be asking, “But I have a disc bulge shown on my scans, of course, my pain is coming from tissue damage that isn’t healing!” What we know from research is that pathology identified on MRI is very common in the non-painful population too. In terms of low back pain, 91% of the pain-free population will show up with “Degeneration”, 56% will have “disc bulges”, 32% “disc protrusions” and 38% will show “Annular tears”. So why do people without pain show up with tissue damage, why aren’t they also painful? If we look at the above “biopsychosocial” model of pain, it is important to consider all the possible contributing factors that makeup someone’s pain experience, to understand why some people feel it and other people don’t. Is it that the person with persistent pain has a stressful job, where they sit all day, but feel a sense of responsibility to the family to maintain the status quo, knowing that last time their back was sore it took them at least 6 months to recover? Is it possible that a person not in pain, but with radiological tissue damage, could have better posture, exercise more, maintain a healthy lifestyle and have good coping strategies? In our next blog, the focus will be on what to do about persistent pain. Until next week, watch these two videos on persistent pain to help better understand what we have written in this blog. Understanding Pain- Hunter Medicare Local http://www.youtube.com/watch?v=4b8oB757DKc Prof Laurimer Moseley- TEDx Talk “Why things hurt” https://www.youtube.com/watch?v=gwd-wLdIHjs
References: http://www.bodylogicphysiotherapy.com.au/common-problems/back-pain.html Rattaporn et al (2014). A prospective, cluster-randomized controlled trial of exercise program to prevent low back pain in office workers. European Spine Journal. 786-793 George et al (2011). Brief psychosocial education, not core stabilization, reduced incidence of low back pain: results from the Prevention of Low Back Pain in the Military (POLM) cluster randomized trial. BMC Medicine. P128. http://www.lower-back-pain-toolkit.com/pain-1.html