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28 November, 2023

Pain Management: The Journey Begins with Understanding

Lets go through a step by step approach in understanding what you can do to manage your pain.

1. Understanding what pain is.

2. What you can do about the pain.

3. How we can help you with the pain.

We at Therapia Sports and Spine, Adelaide, have found from our experience, the literature available on best management of pain and feedback from our clients that, the first step in managing pain is to understand the multiple factors that can contribute to pain.

Let’s begin the journey together in the following series of articles which will follow.

In this article, we’ll focus on step 1 i.e. understanding the nature and complexity [of course we’ll make it simple ;)] of pain.

As a physiotherapist who helps people with pain, I find it interesting to start by answering this by considering the following scenarios:

Keep a pen and paper or any other writing material ready to write down your answers to the questions below.

Scenario 1:

A tiger is chasing you.

You roll your ankle very badly. But still, keep on running. It’s not until you reach your home safely, that you see the hugely swollen ankle, all purple and round and not normal-looking and then a sudden wave of pain hits you.

Why you feel the pain only after reaching home and not while running with a tiger on your tail?

Scenario 2:

You feel your headache intensely when sitting in a lecture regarding the mathematical formulae for predicting the weather

and not while having a fun video game party with friends. What could be a cause of this? can environment have an influence?

Scenario 3:

I might borrow Lorimer Moseley’s famous example here¹. All credit to him:

1^st visit to a jungle – you are wandering through a jungle and something brushes your outside of the foot. You keep on walking thinking it is a twig and the next thing you remember, you wake up in a hospital! You were bitten by a highly venomous snake and it’s a miracle you are alive!

2^nd visit to the jungle – you go to the jungle and this time you feel something brush the outside of your foot and you leap screaming in agony due to the tremendous amount of pain! Only to find it was only a twig! Why did you feel pain when it was only a twig?

HOLD UP!!! Lets build up the suspense!

Without scrolling below, try to answer the questions above by writing down your answers on a sheet of paper and then see how close you are to the actual answers! (No fail grade here!). The explanations will be revealed later in this article.

Is pain multifactorial^2,3?:

For this section, I would like to credit the YouTube video below by Generation Care titled ‘Understanding the Complexity of Pain’. The creators have provided a simplified visual representation in understanding the multifactorial nature of pain. Have a look at this video and then come back to this page to look at examples which will add to your understanding.

This is the link to the above mentioned YouTube video

https://www.youtube.com/watch?v=Zv6RPoVZx9M

So now, how does our brain produce the experience of pain?

The brain samples information from various sources. For simplification, let’s group these into 3 sources.

1. Information from the body:

a. Body structures such as muscles, ligaments, tendons, nerves, viscera, skin, blood vessels, etc. The information regarding these tissues (e.g. if there’s injury ) is picked up by special receptors (think of them like sensors) which is relayed to the brain via nerves. Point to note – even if there is no injury, there is continuous pickup of information by the sensors resulting in a continuous feedback loop.

b. Body physiology. This includes information such as change in body temperature, change in blood pressure, etc. This again is picked up by special sensors relayed to the brain via the nerves. In addition to this, alterations in body chemistry (secretion of certain chemicals or hormones) is also picked up by the special sensors (chemoreceptors) and then relayed to the brain.

Examples:

you might have some tingling down the legs which can be contributed due to mechanical compression of the nerve along some point picked up by the sensors and relayed to the brain.
You might have a ankle sprain and the resulting inflammation picked up by chemical receptors which is then relayed to the brain

2. Information from the surrounding:

a. Physical environment. This includes where you are (home, office, school, etc.) The brains also analyzes this information while determining the response to any situation.

E.g. You might feel more comfortable and/or stressed at home and may have less physical pain as compared to when you are at work or at school.

b. Social interactions. This involves information regarding your personal and work-related relationships and stress factors. Brain takes into account all the factors related to your social life while making decisions regarding a response.

E.g. When your boss asks you to do overtime and adds like a million files to your desk! The brain may respond by giving an output in the form of physical pain, just so you try to get out of the situation. Doesn’t this make you question how smart all of our brains are!

3. Information regarding mood, emotions and sleep:

Whether you are happy, sad, frustrated, anxious, depressed, have you had a good night’s sleep or have you slept only for an hour; all contribute to our experience of pain.

E.g., Feeling flat resulting in physical aches, working overtime can trigger headaches or body aches, inefficient sleep results in aches and pains, etc.

4. Past experiences and memories and knowledge:

This is a very important piece of the puzzle. Along with the information from the body and the environment, the brain analyzes and recalls information from previous experiences and memories regarding similar situations and takes that into the context of the present situation. So, this is brain scrutinizing itself!

Now, considering all this information and analyzing it efficiently within a fraction of a second, gives the body advice on what is to be done. Let’s consider that as an output. This could be in the form of pain (telling you to stay away from something e.g., when you scratch your knee, the pain resulting from it results in you avoiding the movement of that body part, in a way to protect it until it heals. However, sometimes pain can be overprotective as in cases of chronic pain – we’ll get into it some other time!). The output can also be movement alterations or gait variations (variation in the walking pattern) e.g., not bearing weight on an ankle to avoid triggering the receptors and the nerves when you have ankle pain. The output can also be changes in body physiology (increase or decrease in blood pressure, etc.) or a change in body chemistry (secretion of adrenaline in cases where survival needs to be prioritized)

Now, to think of it, all these outputs have the potential to become inputs (pain can lead to the release of stress hormones, disturbed sleep, etc. muscle stiffness can lead to ischemia and trigger chemical changes which can lead to pain) and trigger the whole chain of events again resulting in a vicious cycle.

IASP (International Association for the Study of Pain) defines pain as an unpleasant sensory or emotional experience associated with actual or potential tissue damage or described in terms of such damage⁴.

Here, are important points to note:

Pain is an experience i.e. it is something that is a product of the brain (after analyzing every input source) and it is 100% real (pain is not in the head!).
Pain can result from structures in the body conveyed to the brain via the nerves but emotions also have a role to play in the experience of pain.
It is associated with actual or potential tissue damage. It results from damage to any structure conveyed to the brain via the nerves but also, it is associated with potential tissue damage i.e., it is protective in nature and helps avoid any potential damage to the body tissues. For, when you accidentally touch an iron that is plugged in and immediately feel pain and withdraw the hand only to find that the power source isn’t on and the iron isn’t hot. This is pain being protective.