Explaining PainExplaining PainDr. Erik Pohlman, PT, DPTDr. Erik Pohlman, PT, DPT

Pain is a common problem!Pain is a common problem!

1 in 6 Americans live with persistent 1 in 6 Americans live with persistent painpain11

Globally, 20% have pain > 3 monthsGlobally, 20% have pain > 3 months22

Persistent pain costs ~$100 Persistent pain costs ~$100 billion/yrbillion/yr33

Definition of PainDefinition of Pain Pain is an “unpleasant Pain is an “unpleasant

sensory and emotional sensory and emotional experienceexperience associated associated with actual with actual or potentialor potential tissue damage.”tissue damage.”44

Old ModelOld Model

Painful stimulus→PAINPainful stimulus→PAIN

Tissue damage = painTissue damage = pain

How do we explain…How do we explain…

Phantom limb painPhantom limb pain even in those born without the limbeven in those born without the limb55

Painless battle woundsPainless battle wounds

Papercut hurting so muchPapercut hurting so much

Other ExamplesOther Examples

WWII vet – bullet in neck 60 years, he WWII vet – bullet in neck 60 years, he never knew!never knew!66

Surfers – feel a ‘bump,’ no more leg!Surfers – feel a ‘bump,’ no more leg!

These patients had no pain, weakness, or sensation changes!7

Find your age on the Find your age on the AAge in Yearsge in Years line then look up the chance line then look up the chance of a findings being present before your symptoms begin.of a findings being present before your symptoms begin.

AABBNNOORRMMAALL

DISC FINDINGS IN NORMAL SUBJECTSDISC FINDINGS IN NORMAL SUBJECTS

DISK CRACKSDISK CRACKS

DISCOGRAMDISCOGRAM

XX--RAY DJDRAY DJD

CT/ MRICT/ MRI--HERNIAHERNIA

OIL MYELOGRAPHYOIL MYELOGRAPHY

AGE 70AGE 70

AGE 42AGE 42

AGE 28AGE 28

AGE 23AGE 23AGE 35AGE 35 AGE 60AGE 60

AGE 51AGE 51AGE 30AGE 30

AGE 15AGE 15

AGE IN YEARSAGE IN YEARS00 10 2010 20 3030 4040 5050 6060 7070

100%100%90%90%80%80%70%70%60%60%50% 50% 40%40%30%30%20%20%10% 10%

0%0%

2525

7575

1515

6060

3434

100100 100100

4040

3030

Will this hurt?Will this hurt?

How about now?How about now?

Why?

ThreatThreat

Initially, the body only had to worry Initially, the body only had to worry about the nailabout the nail Nail→Threat→PAINNail→Threat→PAIN

When you are running from the lion, When you are running from the lion, the nail is the least of your worriesthe nail is the least of your worries Nail→Lion is bigger threat→Nail doesn’t Nail→Lion is bigger threat→Nail doesn’t

hurthurt Explains soldiers in battleExplains soldiers in battle

ThreatThreat

It is the It is the perception of the threatperception of the threat that that determines the output, not the tissue determines the output, not the tissue

damage itself or threat to the damage itself or threat to the tissues…tissues…88

Pain = Pain = OutputOutput

So how does pain really work?

Nociceptors (“Pain sensors”)Nociceptors (“Pain sensors”)

Mechanical, Temperature, and ChemicalMechanical, Temperature, and Chemical They tell the brain ‘danger’, They tell the brain ‘danger’, NOTNOT ‘pain’ ‘pain’

Brain determines if you should feel painBrain determines if you should feel pain

Body can add or subtract all over the bodyBody can add or subtract all over the body Replaced as often as every few daysReplaced as often as every few days

Current levels of sensitivity can and will Current levels of sensitivity can and will change!change!

SensitizationSensitization

Increased sensitivity Increased sensitivity after injuryafter injury Allodynia, Allodynia,

hyperalgesiahyperalgesia

Normal, but should Normal, but should fade after healingfade after healing

Persists in people Persists in people with chronic painwith chronic pain

Central SensitizationCentral Sensitization22

The spinal cord and brain cells are more The spinal cord and brain cells are more sensitivesensitive

You may notice:You may notice: Pain longer than normal tissue healing timePain longer than normal tissue healing time Spreading painSpreading pain Worsening painWorsening pain Even small movements hurtEven small movements hurt Pain is unpredictable (what hurts one day may Pain is unpredictable (what hurts one day may

not hurt the next, or thinking about it can cause not hurt the next, or thinking about it can cause pain)pain)

You have other significant ‘threats’ in your lifeYou have other significant ‘threats’ in your life

Homuncu-what?Homuncu-what?

HomunculusHomunculus

Map of body in the Map of body in the brainbrain

Phantom limbPhantom limb ‘‘Smudging’ in Smudging’ in

chronic pain and chronic pain and phantom painphantom pain

More chronic -> More chronic -> more smudgingmore smudging99

NeuroplasticityNeuroplasticity

Not to worry!Not to worry!

The brain and nervous The brain and nervous system are constantly system are constantly changingchanging Braille usersBraille users1010 and and

guitarists/violinists/celliguitarists/violinists/cellistssts1111

Brain CentersBrain Centers Not just 1 center or one Not just 1 center or one

input (like from the tissues)input (like from the tissues) Neurotag – many parts of Neurotag – many parts of

the brain activating in a the brain activating in a unique patternunique pattern22

Sensory, motor, memory, Sensory, motor, memory, emotion, autonomic emotion, autonomic nervous system, etc.nervous system, etc.

All parts light up in All parts light up in phantom painphantom pain

Danger signal, on its own, is NOT enough to produce pain!

Pain relies on contextPain relies on context

Perception of threat levelPerception of threat level modifies modifies pain according to the situationpain according to the situation

Finger injury in professional violinist Finger injury in professional violinist vs. dancervs. dancer1212

Whiplash from car accidentWhiplash from car accident

Thought VirusesThought Viruses

Thoughts are nerve signals tooThoughts are nerve signals too

Ever feel pain when thinking about Ever feel pain when thinking about the painful movement or watching the painful movement or watching someone else do it?someone else do it?

Anxiety about pain or disability can Anxiety about pain or disability can increase painincrease pain

What does this tell us?What does this tell us?

Pain comes from the Pain comes from the brain, brain, notnot muscle, muscle, tendon, disc, etctendon, disc, etc

and…and…HURT ≠ HARMHURT ≠ HARM

How can we fix our pain?How can we fix our pain?

Bed rest?Bed rest?

NO WAY!!!NO WAY!!!

Blood flow leads to healing and less Blood flow leads to healing and less painpain

Re-define that ‘fuzzy’ section in brainRe-define that ‘fuzzy’ section in brain Prevent atrophyPrevent atrophy

SurgerySurgery

Last resort, or when rapidly Last resort, or when rapidly progressing neuro symptomsprogressing neuro symptoms

CostlyCostly RiskyRisky

Infection, nerve damage, Infection, nerve damage, Still have a recovery periodStill have a recovery period May still not helpMay still not help

Plenty of people who still have Plenty of people who still have their pain after surgerytheir pain after surgery

MedicationMedication

Pain killers, anti-inflammatories, Pain killers, anti-inflammatories, muscle relaxers, etc.muscle relaxers, etc.

May or may not help symptomsMay or may not help symptoms Often won’t help the actual causeOften won’t help the actual cause

You are already well on your You are already well on your way!way!

Pain educationPain education Patients Patients cancan understand pain theories understand pain theories1313

Knowing pain physiology reduces threat levelKnowing pain physiology reduces threat level1414

……reducing sympathetic, endocrine, and motor reducing sympathetic, endocrine, and motor activity.activity.15,1615,16

Combining pain physiology education and movement Combining pain physiology education and movement therapies improves physical capacity, reduces pain, and therapies improves physical capacity, reduces pain, and improves quality of life!improves quality of life!1717

Evidence shows that pain education may even be better at Evidence shows that pain education may even be better at preventing pain than core stabilizationpreventing pain than core stabilization1818

Caution!Caution!

Don’t get hung up on anatomy!Don’t get hung up on anatomy!

Knowing more about pain leads Knowing more about pain leads to better results than knowing to better results than knowing more about anatomy (bones, more about anatomy (bones, discs, alignment, etc)discs, alignment, etc)1414

You have now learned that is You have now learned that is one (possible) part in the pain one (possible) part in the pain experienceexperience

Tone down that nervous Tone down that nervous systemsystem

Active RelaxationActive Relaxation Deep breathingDeep breathing Breathing with Breathing with

diaphragmdiaphragm Heat, ice, TENS, Heat, ice, TENS,

anything else that anything else that works for works for youyou

Graded exposureGraded exposure

Gradually increasing exercise, activity, Gradually increasing exercise, activity, and stimulation (desensitization)and stimulation (desensitization)

Re-teaches body/brain that Re-teaches body/brain that movements and stimulation are okmovements and stimulation are ok

Can also gradually re-expose yourself Can also gradually re-expose yourself to driving or the thing you were doing to driving or the thing you were doing when originally injuredwhen originally injured

Trick your nervous systemTrick your nervous system

Same movement, different contextSame movement, different context

Do the movement in a different wayDo the movement in a different way Change the position or what moves first, Change the position or what moves first,

do in water, etc.do in water, etc.

See your friendly local physical See your friendly local physical therapist to…therapist to…

Rule out more serious issues and refer Rule out more serious issues and refer you to the proper provider if one is you to the proper provider if one is foundfound

Determine if there is a mechanical causeDetermine if there is a mechanical cause Provide more pain educationProvide more pain education Provide treatments like manipulation, Provide treatments like manipulation,

dry needling, therapeutic dry needling, therapeutic movement/exercise, etc.movement/exercise, etc.

Points to rememberPoints to remember

Your pain is REALYour pain is REAL Imaging (Xray, MRI) may be misleadingImaging (Xray, MRI) may be misleading Bedrest and waiting for it to improve will Bedrest and waiting for it to improve will

likely not help and may make it worselikely not help and may make it worse Motion is LotionMotion is Lotion Pain is normal and it’s ok to feel some pain Pain is normal and it’s ok to feel some pain

with exercise if you have chronic pain with exercise if you have chronic pain alreadyalready

HURT ≠ HARMHURT ≠ HARM See your physical therapist!!!See your physical therapist!!!

(Strongly) Recommended (Strongly) Recommended ReadingReading

Explain Pain, by David Butler

Thank you!Thank you!

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