We all get it. Most of us have had an injury that has settled at some point, but for some pain hangs around longer than we would expect. Why does this occur? And when it does, what can be done? In this article, Musculoskeletal Physiotherapist Mike Callan will talk about pain; how it works, factors that can affect how much pain we feel, and strategies for those who suffer with persisting pain.
Pain is well, a pain. But what is it exactly? An emotion? Physical damage in the body? In reality it is much more. Pain is a complex psychological experience that is different for each person. The experience of pain occurs when your body’s alarm system alerts the brain to actual or potential tissue damage. There is no such thing as pain nerves in our bodies. We have millions of detectors in our body known as nociceptors, which are located in skin, muscle, bone, joint, ligament, blood vessel, disc, and nerve. When stimulated, these detectors can send signals through our nerves to our spinal cord, then on to the brain. But these are not inherently painful. The messages sent from the receptors and nerves are just a ‘danger’ signals; the brain then decides whether or not we experiencing pain, and how strongly we feel it based on how threatening the signal is.
The second category of pain is when we have actual tissue damage. Think of your favourite footballer who tries to kick a goal and tears a hamstring. The muscle bruises and swelling is present, which is the body initiating the repair process. There may be resting ‘danger signal’ from the presence of inflammatory chemicals, and when the player tries to contract the hamstring, they experience pain to stop them from further injuring it. The smoke alarm has gone off because there is actually a small fire in the kitchen.
Finally, pain can be present when there is not tissue damage, or when tissues have previously healed. In this case, the brain, spinal cord and nervous system can all be firing so the person experiences pain without structural damage. A prime example is phantom limb pain, when there is no actual limb, yet the individual feels pain. In this example, the smoke alarm is going off, but nothing is actually happening in the kitchen. This category can mistakenly be labelled as ‘psychological’, when physiological processes are happening in the brain and nervous system.
Making matters more complex, the brain and nervous system can get better at detecting danger and feeling pain the longer pain persists. Just like we learn a new skill like piano and get better the more we practise, the brain can get better at feeling pain, and can get better at detecting danger by making more neurotransmitters and receptors in the nervous system. This is how the pain system becomes more sensitive and easier to trigger. But hope is not lost! The same processes that allow us to feel pain more easily over time can also work in the reverse process. The brain and nervous system can be de-sensitised over time with a number of strategies that will be discussed below.
As there are two sides to a coin, there are two sides to the pain system in the body. There is a detection system and a pain-dulling system. This complicated pain-dulling system is strengthened when we exercise, get a good night’s sleep, are in a better mood, and when we have manual therapy.
The body’s pain system is constantly changing. The amount of pain we feel at any given time is much like the volume on our TV. If the pain system is very sensitive, the volume is on high. Every conversation is like shouting, and that action scene is almost deafening. Vice versa, when the volume is turned down, we might not hear conversations at all and the action scene might not make that much noise. Factors that can alter our perception of pain (changing the volume) include: sleep, mood, stress, exercise, previous pain experience, upbringing and beliefs around pain, anxiety, depression, fear of pain or injury, and hypervigilance (paying too much attention to pain). Additionally, genetics can play a role in how much pain we feel. Research has shown that individuals with fibromyalgia, irritable bowel syndrome (IBS), chronic jaw pain (TMJ), and chronic tension headache may be genetically pre-disposed to having a more sensitive pain system. Individuals with these co-existing conditions should be made aware of this to allow more appropriate pain management.
For those who have persistent pain, there are currently evidence-based strategies to help manage pain.
- ‘Know pain, know gain’. Knowledge is power. Understand that pain does not always equal harm or tissue damage.
- Pacing. Slow and steady wins the race. In those with persistent pain or a more sensitive pain system, pain often flares-up following a large increase in activity or a new, unaccustomed activity. Small amounts of regular activity with a gradual, consistent increase is the key. Evidence suggests a 10% increase in activity per week as a guideline to avoid booming and busting.
- Avoiding painful activities is not helpful. The body will gradually increase its tolerance to painful activities the same way your fitness gets better the more you run. Avoidance doesn’t allow the body to adapt. Use pacing, but gradually do more aggravating things, even if they cause a bit of pain.
- Strengthen the pain inhibiting system. This involves appropriate daily exercise, activities that elevate mood, and sleeping well.
- Focus on functional gains, not pain levels. Those who focus on returning to normal day to day function and daily activity do better in the long run than those who focus just on pain.
- Sleep well and prepare your body for sleep. Sleep is critical for sensitivity of the pain system and tissue healing.
- Pain management is important, especially in the early stages of increasing exercise and returning to function. But some pain medications do not have evidence for long term use, and in fact can turn up your pain volume. Speak to a health care professional to ensure your pain management is appropriate.
- Passive (relying on others) strategies can have a short term benefit, whereas active strategies have longer term benefits! Our Physiotherapists can help you take control of your body rather than rely on someone else.
- Make sure you are addressing the factors that are specific to you! If factors like stress or poor sleep are contributing to your disorder, ensure you are taking steps to managing them. Person-specific management will always work better than generic management!
At Central Bassendean Physiotherapy we understand pain and provide individualised management strategies to help you get back to doing activities that are important to you.
Butler, David S. and Moseley, G. Lorimer Explain Pain
First edition 2003. Published by Noigroup Publications for NOI Australasia, Pty Ltd.
Senior Musculoskeletal Physiotherapist
Throughout his career, Mike has taken every opportunity to learn and upgrade his skills, completing courses in shoulder treatment, neck and back pain, hip and groin pain, gym rehabilitation, dry needling, and chronic pain management. Mike also has experience with sporting injuries as Physiotherapist for various rugby, football and tennis clubs around Perth, as well as being part of medical teams for various tri-sport events in WA.
Low Back Pain (LBP) and Cognitive Functional Therapy (CFT)
WHAT IS COGNITIVE FUNCTIONAL THERAPY (CFT)?
CFT provides a patient centered targeted approach to management of LBP based on a thorough examination. This classification based management approach for LBP considers many domains including: lower back movement and postures, psychological factors, social factors, workplace factors, comorbidities (e.g. diabetes, obesity), pain processing mechanisms: influenced by genetics and life experiences, sleep and lifestyle factors and their relative contributions to an individual’s LBP. CFT challenges thoughts and behaviours in a functionally specific and graduated manner.
It differs from Cognitive Behavioural Therapy (CBT) as changes in beliefs, thoughts and emotions can be realized by the patient when they experience an improvement in symptoms as they move which may challenge previous beliefs, experiences and knowledge about their condition. In a recent study CFT when compared with a manual therapy and exercise group showed clinically and statistically significant large effect sizes across multiple dimensions. The group receiving CFT was 3x less likely to take time off work in the 12 months following treatment1.
As physiotherapists, in a practical sense, it means we are considering both mechanical and non-mechanical aspects of a person’s disorder. By managing patients in this way we are helping them better understand their pain and to move and function in a way that does not perpetuate their pain. By involving the patients in the problem solving and goal setting the longer term prognosis is improved. Essentially this puts patients back in the “driving seat” for directing the course of their rehabilitation and Sarah and I are both excited about the results we are seeing implementing our improved skills so far….
Low back pain (LBP) is very common and is currently the leading cause of disability worldwide3. Only a very small proportion of people with LBP have serious pathology, such as vertebral fracture, cancer, infection or underlying inflammatory disorder, causing their pain2. Unfortunately using a scan to help diagnose LBP is not reliable because MRI abnormalities are as common in those with LBP as in those without. A common recommendation across all high quality LBP guidelines is routine imaging is discouraged unless serious pathology or specific disease is suspected e.g. if surgery is being considered or there has been a limited response to conservative care. There is no evidence that routine imaging improves LBP outcomes. Over time there has been a significant increase in LBP expenditure without any change in associated levels of disability.
Key positive messages supported by current best evidence regarding LBP include:
- The causes of LBP are rarely serious
- LBP has a good prognosis
- Stay active and resume normal activity as soon as reasonable
- Bed rest is specifically not advised
- The back is a strong structure
- Pain does not equal harm
Key management principles for LBP include:
- Diagnosing LBP via thorough questioning and physical examination
- Limited use of imaging
- Advice about what’s contributing to LBP and an understanding of what’s contributing to the pain experience
- Strategies to self-manage pain including physical activity
- Treatment and exercise specific to the problem
- Medication when required but not as the primary management
The key message here is the clear majority of people with LBP, including leg pain (sciatica), will have a good outcome with evidence based, non-surgical care. Cognitive Functional Therapy is an emerging approach to deliver high quality care considering the complexity of factors that can be relevant to a patient’s lower back condition. At Central Bassendean Physiotherapy we pride ourselves on our accurate diagnosis and evidence based, contemporary management of LBP. We are happy to have a further discussion on the material presented here.
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- Vibe Fersum, K, O’Sullivan P, Skouen J, et al. Efficacy of classification based cognitive functional therapy in patients with non-specific chronic low back pain- A randomised control trial. Eur J Pain 2013;17;916-28
- Almeda M, Saragiotto B, Richards B, et al. Primary care management of non-specific low back pain: key messages from recent clinical guidelines. Med J Aust 2018;208(6):272-275.
- Clark S, Horton R. Low back pain: a major global challenge. The Lancet 2018;391(10137):2302.