When the primary complaint is pain, treatment of pain should be primary. – Barrett Dorko, P.T.
At Integrative Osteopathy, one of my core practices is to empower people through education, so they feel better both in the short term, and the long term as a result of resilience and independence.
A hugely important part of this process is pain and neuroscience education.
Whilst this may sound daunting and perhaps even irrelevant to you, research shows that neuroscience (including pain science) education has a positive effect on pain, disability, physical performance as well as anxiety and stress.
In addition, not learning about pain early on can lead to the rise of chronic pain conditions later, by not alleviating the fear that is often associated with pain (consciously or unconsciously)
Considering how effective this intervention is, and the fact that pain is the number one reason people consult an osteopath in Australia, it’s a no brainer to ensure a thorough teaching about pain precedes any other treatment.
What is pain?
Any teaching about pain must start with exactly what pain is, and currently, the definition put forward by the International Association for the Study of Pain (IASP) is:
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
Now that seems straight forward enough, but let’s look at it a little deeper.
What exactly does this mean though?
Pain is more than just a physical phenomenon
Most people associate pain with injury and damage, and whilst this is often a component of pain, pain is much more than damage.
This is why the word potential is used, it implies something else is at play – we don’t need tissue damage to occur in order to feel pain.
Pain is an alarm, not a damage meter. This can be one of the hardest things to grasp when first learning about pain, and will be explored in more depth later in this post.
Pain is an emotional experience
If you have ever experienced pain, you will likely recall not being yourself, you may have been “short” with people, or become more introverted, or demonstrated any number of changes to your normal demeanour.
That’s the emotional part.
Every person’s pain is unique
We commonly use words like sharp, dull, throbbing, aching, burning, stabbing and shooting to describe pain.
This helps communicate each pain experience in a more “universal” manner, allowing clinicians and patients alike to identify certain attributes of pain, potentially helping with diagnosis or coping.
However, what this doesn’t allow for is the uniqueness of pain.
The use of the word experience in the above definition, suggests the individual nature of pain.
We all feel differently and what we feel depends on many factors – our genetics, our current situation in life and our cultural upbringing are just a few of the contributing factors to how we experience pain.
Pain is an output of the brain
Understanding the broadness of pain and the fact that pain is not reflective of tissue damage, the next step is to grasp the concept that pain is an output of the brain, rather than an input to the brain.
To understand what this means, let’s use a simple analogy.
On a computer, we can use a mouse or keyboard to provide an input. This input is then processed, and then, depending on the program in operation, and output is displayed.
Currently, I’m typing in a word processor, which means when I hit the “w” key, w appears on the screen. However, if I were playing a game, that “w” key might move my character in a certain direction.
Same input, different output.
When it comes to pain, we experience it when our brain decides, unconsciously, that the sum of information it is processing is “dangerous” and we realise this danger consciously – the feeling of pain.
Regarding the inputs to the brain, there are 3 main sources (in no particular order):
- Cognitive (thoughts)
- Affective (emotions)
- Physical (messages from the nerves)
What’s interesting, is that only one of the three inputs is regarding the status of the body.
If the sum of all this information is perceived as “dangerous”, then we experience pain, changes to movement and posture, a heightened stress response etc.
So really, pain is a broader part of the nervous’s systems operations to keep us safe. Though sometimes it goes wrong, for the most part, it’s a pretty good system. If it wasn’t, we wouldn’t be here today.
Nociception and pain
We are really diving deep into this pain stuff now, but this is quite an important part of the pain experience.
Nociception is simply the reporting from the peripheral nerves to the central nervous system (brain and spinal cord) on the status of the tissues.
There are 3 main kinds of nociceptors:
- Thermal (reporting on heat/cold)
- Chemical (reporting on chemical irritation, like inflammation)
- Mechanical (reporting on tension and compression)
There is always some nociception occuring, that is so our brain knows what’s happening with our body. However, this doesn’t necessarily turn into pain.
When nociception reaches a certain threshold, then the nerves fire faster, which can alert the brain to something happening. It doesn’t mean there is damage – but only that there is more stimulation of those nociceptors.
This only becomes pain, if, when combined with the other inputs mentioned above, your brain decides the information means “danger”.
Acute versus chronic pain
Acute pain is a completely normal response to dangerous stimuli. It usually follows some form of tissue irritation, which may or may not include damage to the tissues.
This is the pain we experience when we bump into something, strain a muscle or cut ourselves. It serves a protective purpose – alerting us to the incident and getting us to change our behaviour accordingly, so we do no further harm. It usually subsides when healing has taken place – often before (think of a cut, it doesn’t hurt all the time, only in the beginning).
For some people, pain does not resolve after the acute phase, and it becomes chronic pain, which is a problem in and of itself.
Chronic pain occurs due to changes in the nervous system, which make it more sensitive.
Whilst too deep a topic to cover in a short section, the most important thing to grasp about chronic pain is that the longer it has been present, the less correlation there is with tissue damage, and the more sensitive the nervous system has become.
Chronic pain is manageable, but it needs a very different approach to acute pain.
Conclusions
Pain can be thought of as an alarm bell. A highly sensitive alarm bell that often rings for no reason and sometimes keeps ringing despite people cutting of its power supply.
Understanding the complexity underpinning the pain experience is an important step to resolving or managing pain, and one that pays long term dividends.
This post can only touch on the basics of pain, but it is enough to give you an overview of the main components.
This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.
This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.
References
Burke, S.R., et al, A profile of osteopathic practice in Australia 2010-11: a cross sectional survey, BMC Musculoskeletal Disorders 2013, 14:227 [http://www.biomedcentral.com/1471-2474/14/227]
Louw, A., et al, The effect of neuroscience education on pain, disability, anxiety and stress in chronic musculoskeletal pain, Arch Physical Med Rehabilil, 2011 Dec;92(12):2041-56 [http://www.ncbi.nlm.nih.gov/pubmed/22133255]
Melzack, R. and Katz, J. (2013), Pain. WIREs Cogn Sci, 4: 1–15. doi: 10.1002/wcs.1201