As seen in Therapeutic Outlook Magazine | Volume 10, Issue 2: #ChoosePT
Opioid use is spiraling out of control in the United States, and those suffering from pain need an alternative. Some herald physical therapy as a safe and effective alternative to treating pain, without the threat of addiction. The American Physical Therapy Association (APTA) has joined others in the federal, state, local, and private sectors to address the prescription drug abuse and heroin epidemic. They collectively advocate that a multidisciplinary clinical approach—including physical therapists (PT’s) serving on the care team alongside physicians and other healthcare providers—can improve quality of life for patients with acute and chronic pain.
Can you recall the first time you experienced physical pain? Maybe it was when you learned to ride your bike. You fell and scraped your knee, causing it to bleed. It hurt…for a bit. Then mom or dad came over, put a Band-Aid on it, told you everything was ok, and you were back out riding again. Over time your knee healed, left a wicked scar that you told all of your friends about, and things were good again. This story resonates well, because nearly all of us have experienced some level of pain in our lives. Most often, the story goes very much like the bike example. Tissue is injured, we experience pain, tissues heal, and the pain goes away over time. We typically equate our pain to something wrong or injured in the body. But does this really tell the whole story about pain? What about pain that lasts longer than typical healing time? Or pain that occurs in amputated limbs, such as in phantom limb pain? How about stories of people with incredible amounts of tissue injury in the ER that report very little pain? Have you ever had a paper cut that hurt terribly, despite the relatively small size of the injury? These experiences tell us that pain is much more complex than we might think. Let’s shed some light on what pain is, based on the most recent research.
Our society tells us that pain is a direct stimulus-response relationship; meaning we get hurt and we have pain. This model is derived from concepts originally brought forward by philosopher René Descartes 350 years ago. Descartes believed that a damaging stimulus, such as putting your foot in a fire (or scraping your knee), caused particles to travel through a wire to your spinal cord and ultimately to the brain, causing pain and telling us to pull our foot out of the fire. His theory suggested that the spinal cord and brain are simply the receivers of a so-called “pain message” generated by damage to our tissues.
We now know this doesn’t tell us the whole story, and yet it is still the predominate approach taught at many medical institutions. One result is that we are now in a difficult cycle of ever-increasing prescription of pain medications and excessive treatment of all things pain related. We have become addicted not only to medications, but also to diagnoses, imaging results, and complex testing procedures that only tell us one part of the story. Has a medical provider ever sat down and asked you, “why do you think you are in pain?” Simple questions like this probe into the depth of how accustomed we have become to Descartes’ model. Patients often reply with phrases like: “my disc is degenerated”; “I have the worst knee this side of the Mississippi”; or “my tissues are torn/ripped/ruptured/etc.” Common thoughts like this reflect how we have been raised and conditioned to understand pain: tissue damage/breakdown = pain.
Throughout life, our bodies constantly undergo change. This is normal, and 100% human. We scrape our knees, strain our backs, wear silly shoes that deform our feet, run hundreds of miles for “fun,” drive fast moving hunks of metal down a freeway, sit on the couch for 8 hours binge-watching TV shows, and still come out ok.
While our bodies take an incredible amount of use, it is normal for our tissues to develop wrinkles on both the inside and outside. These wrinkles are the telling signs of tissue change and healing, not just from injuries, but from life. Just because our bodies inherently change, it doesn’t mean we can’t adapt to these changes in more appropriate ways. Studies show that degenerative changes in the spine, for example, are actually normal. One such study showed that 60% of people 40 years or older, without lower back symptoms, have signs of disc degeneration, and 50% have bulging discs on MRI scans. Even more stunning, 96% of people over the age of 80 who do not report lower back pain have spinal degeneration, and 84% have bulging discs on an MRI. So what gives? All of these people have classic signs of tissue damage or degeneration, yet they do not have pain. If we believed Descartes, we would expect these individuals to be writhing around in pain. This simple model of pain cannot explain why one person hurts and the next one doesn’t.
So, what is pain and how do we understand it to work in our modern research? Unlike Descartes’ theory, pain is now defined as “a multiple system output activated by the brain based on perceived threat” (Moseley 2003). We now recognize that pain is 100% created by the brain as a protective means to keep us safe from real or potential threats to our health, safety, or well-being. In more simple terms, if we perceive it to be dangerous, our brain and nervous system will do anything possible to keep us out of harm’s way, even if it means producing pain.
Mostly, this works out well for us. We fall off our bike, scrape our knee, and it HURTS!! That remembered pain helps us recognize we shouldn’t be going down the hill as fast as we were, and we slow down to PREVENT falling and sustaining additional injury. This protective system is so smart that we subconsciously correct without even recognizing it. Sometimes this correction manifests with a pain response, sometimes with caution or avoidance, and sometimes with other physiologic factors like swelling/inflammation/weakness/etc.
Our pain system, governed by our brain, acts like a living, breathing alarm system, which can become more or less sensitive depending on a multitude of factors. Think of it like having an adaptive smoke alarm in your house. When a dangerous stimulus is present (fire and smoke), the alarm “knows” to set off a very loud and impossible to ignore signal. However, what about that annoying smoke alarm that goes off every time you cook a grilled cheese in the kitchen? We know that the small amount of smoke produced isn’t dangerous, yet a super-sensitive smoke alarm doesn’t know any different. If there is smoke, there must be fire, or at least there must be fire on the way. The alarm goes off regardless, with the same very loud, impossible to ignore signal. Our pain systems work very similarly, except that unlike the set sensitivity of a smoke alarm, our internal alarm constantly adapts and changes depending on what we perceive we need to survive.
As we go through life, various factors influence how sensitive this system becomes. Things like the environment in which the pain began or occurs in, our belief systems, social context and support, educational level, past experiences or trauma, and even economic factors influence how our bodies experience pain. These factors often help our system take things in stride and handle pain appropriately. Usually we just need to rest, recover, seek help as needed, and go on with life. Unfortunately, it is these same normal protective systems gone haywire that often contribute to long-term, chronic pain issues that currently impact over 20% of the population of the United States. In many cases, people struggling with these issues develop a super-sensitive internal alarm, impacted heavily by the world around them. When these systems go awry, it often leaves patients feeling lost, out of control, and that the medical systems have failed them.
Today, a pain revolution is upon us. We learn more about pain every day and how to help those in pain. We don’t have all the answers, but we know that pain, especially chronic pain, cannot always be helped through imaging studies, medication, or labeling it with multiple diagnoses. Here’s the good news and bad news: Pain is normal, at least in the right context and situations. We all have to deal with it at some point in our life. Usually it’s a good thing that helps us slow down, re-evaluate, and make decisions about how to move forward in life. As we learn more, pain itself becomes more complex than how some like Descartes’ originally labeled it. This is somewhat unfortunate, because it means there is no magic “pain off-switch.” However, as we learn more about pain, we better understand how to truly help those in need, not just by quick fixes, but by truly addressing the person in front of us and the very complex nature of their own individual pain experience.