Pain Science Part 1
Pain science is a topic that I really wanted to discuss since I started this blog. Much of what I do nowadays refers back to pain. Our job as therapist is to treat patients who are in pain. It is what we do. It is why we get paid. The end product of every patient that walks through that door is to relieve their pain and to improve function. They are dependent on each other. Do you really think that a patient will be happy with the care if there is not a pain reduction? Probably not even if they can function normally. They came to us to help their pain. Then why do most therapists not know what pain is? Where pain comes from? Many therapists, and I did for a long time, feed into pain. We give it life. We make it worst with our words and demeanor. I hope that, at the least, what you can take away from this is to not feed into the pain. To debunk the common myths about pain so that you can communicate that to your patients.
Pain education isn’t only important for chronic pain but also for acute pain. All pain does start at some point. Hopefully, if we can educate our patients early on in the process we can begin to change the onset of chronic pain. Take a patient, who may be at risk for developing chronic pain (many reasons for this), and help to reduce the effect that pain has on their future self. Like most other “interventions” it is not best to memorize the information but rather to learn the concept. You can apply an intervention to a handful of patients but you can apply a concept to every patient. Learn the concepts of what pain is and what pain isn’t. Learn how to properly explain pain to patients. It changed my career path and I hope by at least starting this conversation with you that it will do the same.
There are many avenues to learn more about pain. The first is research of course though it is harder to find in the US versus other countries who push out a lot of research about pain (if looking for research just look at Moseley and all the research that he puts out). The US seems to be focused on this drop step/jump down and rehashing old and abused research material. Honestly, do we need another research article on a step down task or jumping tasks to know that faulty mechanics equal ACL tears/other injuries? What we need is more research on the rehab behind this and proper exercises that will improve this functionally and not the same old 4 way SLR with some planks thrown in for good measure. The second area that I have learned the most from and is where much of this talk comes from is Medbridge course by Adriaan Louw called “teaching people about pain”. If watching this course doesn’t completely change your practice re-watch it and really try to learn the concept. Not the individual parts. Thirdly, are the blogs. In the margin I have a lot of blogs that I follow. All experts and clinicians that I admire. If I become half the therapist that they are my career will be a success. Some of the ones that I like the most for pain:
- Noijam and
- Body in Mind.
- Forward Thinking PT
- Explain Pain
Yet, all of them have some type of pain related education involved in their postings.
So why is pain science important?
Chronic pain has doubled in the last 15 years and continues to be a growing problem in the clinic. Chronic pain itself can be hard to define but for simplicity we can give it a quick definition of pain that the patient is perceiving that has lasted longer than the healing phase for the original acute injury (though ~ 30% of chronic pain doesn’t have a related injury). Treating chronic back pain isn’t always about targeting core musculature or activating the TA or giving heat/stim and “cracking” them. It starts way before any intervention that you want to give. You must treat their fear and beliefs first.
Fear can be defined as a distressing negative sensation induced by a perceived threat. The fear of pain is worse than the fear itself. The circle of fear is something like (from Vlaeyen, Linton 2000)
Injury -> Pain experience -> no fear -> confrontation -> Recovery OR
Injury -> Pain experience -> Fear from lack of knowledge/medical tests/words/internet -> Pain catastrophizing (irrational thoughts) -> pain related fear -> avoidance -> depression/anxiety to move/disability -> feeds back to the pain experience again.
This is where we need to educate them and stop that second loop from starting acutely or move them out of the second loop.
Many patients in pain have impaired beliefs about pain such as:
- Pain is always bad and pain equals injury
- All pain must be gone before engaging in normal activity and movements
- Pain will increase with all activity/any activity
- Passive treatment is the best
- I have to live with pain the rest of my life
We feed into these beliefs by using our words. These words include any medical test findings such as arthritis and bulging discs, something is out of place, your posture is bad therefore you will have pain, you have a weak core or you are “unstable”. I am not saying that some of these don’t happen or that we shouldn’t treat what we see as deficits but rather we need to pick our words better. They are very abrasive words and telling someone who sits all day that there posture is causing their pain then that will only increase the hyperactivity of the entire system every time they sit!
Our educational systems feed into these beliefs as well. It is hard to change something that you learned in school and then practiced when you graduated. It is not easy to start to change your thinking. Believe me, I know! It is a small steps each day to change the way you think about pain and change the way your patients think about pain. It is hard to drop this biomechanical model/patho-anatomy model of pain in lieu of something that you can’t see! Once again, I am not saying to drop the entire system and only think about pain. That is not at all. But question what you have been taught and why things happen. I use the biomechanical model with pain science to explain the reasons why the brain could be perceiving outputs as pain or to explain the original injury. I am very much biomechanical based but adding pain to the whole picture actually clears up so any questions that I have. [Look at “explanatory and diagnostic labels and perceived prognosis in chronic low back pain” by Sloan/Walsh 2010 Spine.]
Definition of pain: “Pain is a multiple system output, activated by the brain based on a perceived threat” (Moseley via Louw)
Lorimer Moseley performed a study on someone with 4.5 years of pain. Pain started as LBP then became widespread in lower extremities. Using an fMRI they measured brain level activity. On evaluation the fMRI showed severe hyperactivity of the brain. Then they educated on spinal stabilization exercises for one week. There were improvements! But mild! There was a small change in hyperactivity of the fMRI. Then they educated patient for 1 session on pain and did nothing else. What happened? Severe decreases in brain activity. Pain education decreased pain much more than any spinal stabilization exercises. I know that it was just a single subject but isn’t that enough to warrant a longer look at it. [Moseley 2005. Widespread brain activity during an abdominal task markedly reduced after pain physiology education]
There are more: A couple of systematic reviews on therapeutic neuroscience education from Clark and Louw that also show marked improvements in chronic pain. Lorimer Moseley/Body in Mind have plenty of articles to keep you busy.
Tissues and pain
- Tissues due to get injured! But they heal!
- And even shown that disc bulges reabsorb in one year.
- Tissue injury does not equal pain
- I have read anywhere between 40- 60 % of people have a disc bulge with no pain
- Arthritis does not equal pain
- Arthritis is one of those bad words. Patients feel doomed by the thought of having arthritis and become afraid to move. How terrible that is. The one thing that will help them they become afraid to do inciting a hyperactivity throughout there CNS.
- Cool study on “neck pain in demolition derby drivers (Simotas, Shen. 2005)”
- Shows only a 2.5% chronic neck pain
- Shoulder after rotator cuff repair. MRI imaging findings in asymptomatic individuals (Speilmann 1999)
- 90% showed abnormal signaling and 16% had partial tears while 20% had complete tears
In my next post I want to go through the pain process. How pain develops and where it comes from. I am going to review the basics from what I have learned. I have many more research articles which I think that I am going to review as a group after the next post.
Like I said above, and I want to reiterate. I know, that in order to treat patients, we need to look everywhere for the possible reasons why someone is in pain. Sometimes it is simply fixing the mechanics to take pressure of an area. Yet, it is also, fix the mechanics to take the pressure off an area and have a neurological input that decreases the hypersensitivity of the nervous system/brain. Think more! Challenge yourselves to go above the standard treatments for people in pain. Remember: we go to work and then leave work but patients come to clinic in pain then go home and there pain continues. For many of our patients the pain never ends. Think about that! Pain that never goes away. Think of a time that you had pain from an activity (as most PTs were athletes at some time we all have them) now think about it being there all the time and every day for years. That is what many of your patients experience.