11 Important Things To Know About Pain

As someone who spends his life thinking about how to better understand pain, I have reached the point where I have amassed a great deal of knowledge on the topic.

The problem with knowing a lot about a topic is, it is easy to fall victim to the curse of knowledge.

The curse of knowledge is best explained by this example:

In 1990, a Stanford University graduate student in psychology named Elizabeth Newton illustrated the curse of knowledge by studying a simple game in which she assigned people to one of two roles: “tapper” or “listener.” Each tapper was asked to pick a well-known song, such as “Happy Birthday,” and tap out the rhythm on a table. The listener’s job was to guess the song.

Over the course of Newton’s experiment, 120 songs were tapped out. Listeners guessed only three of the songs correctly: a success ratio of 2.5%. But before they guessed, Newton asked the tappers to predict the probability that listeners would guess correctly. They predicted 50%. The tappers got their message across one time in 40, but they thought they would get it across one time in two. Why?

When a tapper taps, it is impossible for her to avoid hearing the tune playing along to her taps. Meanwhile, all the listener can hear is a kind of bizarre Morse code. Yet the tappers were flabbergasted by how hard the listeners had to work to pick up the tune.

The problem is that once we know something—say, the melody of a song—we find it hard to imagine not knowing it. Our knowledge has “cursed” us. We have difficulty sharing it with others, because we can’t readily re-create their state of mind.

I, like many health professionals (and experts in every area) often struggle to convey our knowledge to our patients. This is a huge problem, as education (transferring knowledge), is one of the key strategies we can use to help people.

We say one thing, and with it we are thinking of many other things implicitly, based on our years of accumulated knowledge and experience. Unfortunately, patients only hear what we say, and not everything else that we are thinking of when we say it. To make matters worse, patients will often hear all of what we say, but truly understand even less.

So what’s the solution? How do I make this information as clear as possible?

Simple:

  • Use concrete, not abstract, language.
  • Use examples that relate to you.
  • Repeat the key concepts, over and over, until they stick.

With this in mind, here are 11 important things to know about pain.

1) Pain does not equal tissue damage

This is the most important thing to understand about pain.

Pain is not a marker of tissue damage.

Yes, it does occur with injuries that involve tissue damage. That is not in dispute. However, there are countless examples of people experiencing tissue damage and not feeling any pain. There are also many examples of people experiencing very minor or no actual tissue damage and a lot of pain.

Think about stubbing your toe. Often there is no discernible tissue damage, yet stubbing your toe hurts, a lot. However, after you look down and examine it, often the pain quickly subsides.

Or what about the examples of people who have been shot and don’t realise this until later!

Additionally, the intensity of pain we experience is not a direct measure of the severity of what is wrong. A paper cut hurts immensely, at least at first, but it is hardly a serious injury. On the other hand, many people with life-threatening cancers feel little no pain, especially in the early stages of the disease.

So if pain is not a measure of tissue damage, what is it?

2) Pain is protective

Pain is a protective “feeling” we experience with our conscious awareness.

Huh?

Well you can’t be unconscious and experience pain, by definition. That’s how anaesthetics work.

I’m going off on a tangent here, back to the point. Pain is protective.

Whether it is protective of an injured body part or protective of a threat to our brain’s concept of self pain is a biological process that is meant to keep us safe.

 

Imagine if, instead of being told that her sore knee is because of wear and tear, a doctor tells her patient that her knee pain is because her NERVOUS SYSTEM is being PROTECTIVE of it. ~ Imagine this doctor then tells her patient that to deal with the pain she needs to become more ADAPTABLE and RESILIENT, and that she can do this by improving her flexibility, strength and endurance with EXERCISE and ACTIVITY. ~ Imagine if this doctor also told her patient that STRESS and FEAR makes her PAIN WORSE, and that she not only needs to become more physically adaptable and resilient, but more MENTALLY as well, and that this is possible because even into older age, the BRAIN and nervous system CAN LEARN and CHANGE for the better! ~ #integrativeosteopathy #osteopathy #osteo #pain #neuroscience #exerciseismedicine #positivevibes

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That sentence is complicated, so read it again, and then I’ll break it down.

Pain can be protective of an injured body part. Most of us would have experienced this, but as I said above, it doesn’t measure damage. Pain can protect a previously injured body part too, often way before it is at any risk of being injured again. This is what happens when people talk about having a bad ____ (insert body part here).

Pain can also be predicatively protective. That is, we feel pain in anticipation of something happening to us. I see this lots with people who have low back pain – before they even move they feel pain, even though nothing has happened except a thought!

Finally, pain can also be protective of our concept of self. Our concept of self is the idea of “I”. It is who we think of when we think in the first person. The concept of self has been discussed anddebated in religious and philosophical circles for millennia.

The self is an individual person as the object of his or her own reflective consciousness – Wikipedia

When you understand this, you can see how pain that comes on for “no reason” can be explained as being protective of the self.

If you experience pain after intense periods of stress, then this is an example of your brain (we’ll get to that) deeming that stress as “threatening”, and along with the corresponding changes in a biochemistry during periods of stress, producing pain to get you to change your behaviours

3) Pain is produced by the brain and localised to the body

You don’t see with your eyes.

Your eyes have cells in them that respond to stimulation by light. Once stimulated, these cells send the information signal, via the optic nerve, to the brain. It is the brain which composes the “image” that we see. Interestingly, our brain doesn’t always produce an objectively accurate image. Unless we are really paying attention, it will often give us a generalised image, that is predictive, based on previous experiences. This is why eye-witness testimony is not considered reliable enough to convict as a stand alone evidence. It is thought this is to save energy.

The same goes for all our sensory experiences. Our brains produce a conscious experience based on input from the sensory nerves.

 

Most people are familiar with taste, touch, smell and hearing, which along with sight make up the “5 senses”. However, our brain is also receiving sensory information from many other nerves throughout the body. This gives us interoception (our sense of our internal body) and proprioception (our sense of our body’s position).

Along with the sensory stimuli mentioned, we also have sensory stimuli we are unaware of.

Nociception.

Nociception is “noise” from the body. Sensory nerves that respond to thermal, mechanical or chemical stimulation are constantly sending signals to the spinal cord. Most of this is blocked, because it is just that – noise. However, when when those nerves are stimulated to a greater degree – think an injury, or contacting a hot surface – then your brain becomes aware of the change to the noise levels.

Think about how you can hear your name spoken at a noisy party.

Your brain, not knowing exactly what is going on, will respond by producing pain, and will decide to protect the area where the increased nociception is coming from.

How does it do that?

With pain of course!

To make matters even more complex, we can have pain in the absence of nociception – think of amputees with phantom limb pain – but the majority of pain people experience is either the result of increased nociception or decreased inhibition of nociception.

More on that later.

4) Chronic pain is different to acute pain

Acute pain is usually a response to either a tissue injury or other immediate threat, it subsides as the injury or threat does.

Chronic pain is the result of changes to the nervous system which make it more sensitive. This means the nervous system and brain become “hyper protective”, generating pain with little or no provoking stimulus.

Whether you or someone you know has chronic back pain, arthritis, headaches or some other chronic pain condition (like fibromyalgia), it is important to know that in cases like this, the problem is pain, and it is the same mechanisms that are involved across the board.

How can this be? How can low back pain be the same as a headache or arthritis?

The changes that take place in the nervous system, predominantly take place in the central nervous system (brain and spinal cord). This is like the central control room for our nervous system. Thus if something is wrong with the central control room, then everything linked to it (which is everything), can be affected.

Of course, there are local (or peripheral) factors involved, which contribute to the pain being localised, but there is often a large central nervous system component to chronic pain.

As a result, chronic pain needs to be addressed as a problem in its own right, and not treated like acute pain.

5) Recurrent pain and multisite pain are both forms of chronic pain

Some people experience recurrent pain. That is pain that “comes and goes”.  They will often think that each episode is a discrete event, that is, it is the same problem happening over and over again. It gets better for a while, then it happens again.

Others experience pain in multiple body regions. They might all be one sided, or they cross midline and are above and below the waist. There may or may not be a pattern (often this pattern is explained in biomechanical terms by well meaning practitioners, but that’s another issue altogether).

This is not the case.

Both recurrent pain and multisite pain are forms of chronic pain, and need to be managed as such.

Often multisite pain starts as a single site, and progresses to multisite, chronic pain. In these cases it can be considered a progression of the same condition. It is important to understand the distinction between these presentations of pain, because chronic pain requires different management to acute pain (see no. 4).

6) Pain is never simple, even when it seems so

It may seem like some pain is simple.

You twist your ankle and it hurts.

Or, you drink lift too much and end up in pain.

We think like this because our brains like linear “cause and effect” relationships.

However, pain is not linear. It is emergent.

A linear process is when one thing progresses to another. In simple terms, it is when A + B = C.

An emergent process is when two or more things combine to form something that doesn’t share the properties of the things that make it up.

Because of this, and all the invisible and unconscious factors that contribute to us experiencing pain, we can never say that pain is simple.

When you twist an ankle, all the associations with twisted ankles you have ever experienced that are buried in your brain are activated. The meaning and context of the ankle twist comes into play (a soccer player who will miss the final will experience different feelings to someone who gets out of duties they didn’t want to do because of the injury). Sometimes the nociception doesn’t represent tissue damage at all, but spikes due to a sudden increase in load.

Why does this even matter?

Because chronic pain starts as acute pain, and in some cases, it was considered “simple”.

7) Pain is not caused by “poor posture”, weak muscles or being “out of alignment”

 


If you have understood everything up until now, this should make sense.

However, many people still think of pain being caused by these things, because we observe these things when people are in pain.

It is the common error of attribution: correlation is not causation.

When you experience pain, you might be weak, or stand/sit differently or even look and feel like you are twisted or bent. There is no disputing this.

But it doesn’t cause pain.

More likely, these things are caused by pain.

They are defensive, or protective behaviours.

8) Osteopaths (and other practitioners) don’t “fix” pain

You might think this is a strange statement to make.

Why else would you pay to see an osteopath then?

Well, there are lots of reasons, but when it comes to pain, the resolution can only come from within your own body and brain.

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A good osteopath will do everything in their power to help remove the barriers to recovery, and facilitate the physiological and psychological processes that need to take place, but no one can change you on the inside from the outside.

Even pain relieving drugs can only work if you are in the right context – morphine doesn’t always help, while sometimes a placebo pill works better than the real thing.

So if you are looking to be “fixed”, it is unlikely to happen as you want. This is probably the hardest thing to accept as both a patient and a practitioner.

9) Everything can “work”

There are claims from therapists, doctors and other kinds of healers about all kinds of treatments for all kinds of pain.

It’s likely all of these people have numerous success stories to confirm that what they do works.

But just as an osteopath can’t fix someone (see no. 8), everything can work for pain.

This is because the brain has the ability to produce pain relieving chemicals, in the right circumstances.

These pain relieving chemicals are extremely powerful, and when the context is right – belief, expectation and ritual all come into play – then the brain, in anticipation of what’s to come and in response to what has happened sends out all these amazing substances to help you deal with pain. This process is called descending modulation (or inhibition).

This is not a bad thing at all. It is actually the goal of many therapies, including osteopathy and exercise rehabilitation.

The problem comes, when interventions are sold in misleading ways, i.e. they are sold as doing something unrealistic or impossible.

In simple terms, if something sounds too good to be true (amazing success rate, top secret, revolutionary) or can only be done by a particular person, it is unlikely that the intervention is really doing what is claimed.

That’s not to say it doesn’t work, only that is doesn’t work because of what is claimed.

10) Inflammation is a good thing

Many people take anti-inflammatory medications for pain without a prescription. They don’t work (at least for low back pain).

Many others use ice after sustaining injuries.

The majority of people doing this don’t know why they are doing it. If you asked them, they might mention something about stopping inflammation.

If you asked them why they want to do this, they might say it helps with pain and recovery.

Now what is more likely?

Our bodies have, over thousands of years, evolved highly effective mechanisms for dealing with injury, part of which is the inflammatory process, or this process is an error of biology and must be stopped?

Inflammation is the body’s way of healing.

Yes, it can be painful, but pain is a protective response. And you know what needs protecting? Injured tissues.

That is not to say you need to completely rest an injured tissue by the way. It is simply saying that suppressing inflammation (particularly with drugs) can impair and delay healing.

Finally, chronic inflammation is not a good thing. However, it is usually the result of other issues, and while suppressing it relieves the inflammation, it doesn’t address the reasons why it is happening. Like chronic pain, chronic inflammation needs a different approach to acute inflammation.

Oh and one more thing,

11) How you live is more important than what you do

 

Most people in pain are looking for a fix.

Be it medication, treatments of various kinds, a specific exercise or even surgery.

The issue here, is that for many pain problems, these interventions all have low effect sizes. That means, they work, but not by very much. Hence the cost and risks often outweigh the benefits.

What is most important, particularly for sufferers of chronic pain, is living well, despite your pain.

Healthy lifestyle habits contribute to healthy bodies and brains.

Healthy bodies and brains experience less pain overall, and when they do experience pain, respond better to interventions.

That is not to say all treatments for pain don’t work.

Nor is it to say how you live can solve all types of pain.

It is simply saying, that your lifestyle plays a large role in your likelihood of developing and recovering from pain.

Think about it. If someone leads an unhealthy, high stress lifestyle, barely sleeping and consuming lots of drugs and alcohol, do you think it matters what kind techniques an osteopath uses, or what type of exercise they do?

Do you think it will make any difference in the grand scheme of things?

Conclusions

I consult with people in pain on a daily basis.

I work with them to try and help them feel and live better.

Sometimes, their pain goes away. Sometimes it doesn’t. Sometimes it gets worse. We are not predictable like a machine.

It is a really hard job, and while many practitioners love to talk about their success rate, I think if you take a big picture view, it is unlikely any single practitioner gets results above and beyond what the statistics say they should for the patient base they work with.

I do believe there are practitioners who would do worse, simply because this information about pain is still not common knowledge, even among health professionals, but to do better is unlikely.

Thus, if someone has a long waiting list, it doesn’t necessarily mean they are the best therapist, it simply means they have a lot of people waiting for their services.

When you choose a therapist to help you, it is less about what kind of therapist they are, and more about how they work, and whether that suits you. A good way to know if they are up to date with the research is to ask them about some of the topics above. They don’t have to agree, but if they have no idea, or dismiss things outright, that might be a hint.

Pain is a mystery, but that doesn’t mean you can’t reduce it, or live well with it. After all, it’s not just about the pain.
Nick Efthimiou Osteopath

 

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

The Curse of Knowledge

Self

 

Management Strategies For Chronic Itch

Scratch

Chronic itch is a frustrating experience. Sufferers of skin conditions like eczema know this all too well.

I know what you’re thinking. Why the hell is an osteopath writing about itch? Shouldn’t they stick to their scope of practice?

There are a few reasons:

  • We treat people manually, usually to exposed skin, so we often come across people with skin conditions who aren’t managing them well, or are suffering from a persistent itch.
  • Itching associated has a lot of parallels to pain. Both pain and itch are outputs of the brain and both can be caused by either peripheral causes (in the skin), central causes (in the nervous system), or a combination of both.
  • Many of the general recommendations surrounding itch are within the scope of practice of an osteopath to recommend.

If you suffer from chronic itch, it is important to consult with your GP, and possibly a dermatologist, in order to get a diagnosis of your condition.

Your itch/skin condition could be the symptom of some underlying pathology that gets worse because you tried to self-treat.

Itch Physiology

We’ve all had an itch that needed scratching at some point in our lives.

Whether it was after being bitten by an insect or due to social contagion – like yawning, we tend to scratch ourselves when we see others doing it – or some other reason.

For some people though, itching is a daily occurrence, and the desire to scratch is often so strong that sufferers of chronic itch cause damage to their skin trying to find relief.

It used to be thought that itching was a sub-group of pain, but it’s now understood to be a separate entity, though they share many similar traits physiologically.

There are different mechanisms of itch, which we can classify as peripheral or central, just like pain.

This is an important concept to grasp, because most medical treatments are only directed at peripheral drivers of chronic itch.

There are 4 classifications of itch:

  • Dermal or pruriceptive itch: refers to an itch that results from activation of itch receptors in the skin. This activation is often caused by histamine (which is also the main driver of hayfever).
  • Neurogenic itch: is an itch that originates in the central nervous system, where itch-mediating pathways are activated. This can occur with the spinal application of opioid medications, or more commonly in skin conditions, inflammation within or affecting the central nervous system.
  • Neuropathic itch: also originates in the central nervous system, but is caused by diseases of the nervous system.
  • Psychogenic itch: is related to illusional states.

When it comes to itch associated with eczema and other similar skin conditions, we want to focus on dermal itch and neurogenic itch, as these are the mechanisms involved.

Why does it feel good to scratch?

Normally, when we are exposed to a scratching stimulus, we withdraw, as we perceive it as either painful or unpleasant.

However, when we are itchy, we welcome the scratching sensation as relieving.

When we scratch an itch, there are multiple brain areas that are active, including areas involved in both pleasure and pain.

Both active (scratching yourself) and passive (having someone else scratch you) forms of scratching have been shown to relieve itch.

Interestingly, scratching nearby to the site of the itch also relieves the itch, suggesting a central inhibitory effect, rather than a local effect from scratching.

Chronic Itch Is More Than Skin Deep

Dermal/pruriceptive itch is mostly mediated by sensory nerves that are embedded in the skin called C-fibres.

There are two kinds of dermal itch:

  1. Histamine mediated.
  2. Non-histamine mediated.

Histamine mediated itching

This typically occurs when we are bitten or scratched, and there is a release of local histamines as part of the immune response.

This also occurs with conditions like hayfever.

With chronic itch related to skin conditions, this is often managed with topical steriods and over the counter anti-histamine tablets (the same ones you would take for hayfever).

Non-histamine mediated itching

This occurs in people with certain diseases (cancer, HIV/AIDS, liver disease) and as a side effect of certain medications.

It is also a big feature of the itch associated with chronic skin conditions, like eczema, though it’s not commonly discussed.

This type of itching is a massive issue – it’s difficult to treat and causes lots of distress for the suffer.

One key feature of this form of itch seems to be neurogenic inflammation. Mentioned above, this is itch that originates in the nervous system.

Setting off positive feedback loops, this inflammation is self perpetuating, as long as the stimulus is in place.

Topical treatments don’t work well for this, which is why many eczema sufferers get short term relief from creams, but in the long term may continue to suffer.

In order to get lasting relief, the root cause of the neurogenic inflammation must be addressed.

This could be down to a number of factors (or combination of), including:

– Dietary
– Gastrointestinal distress
– Psychological stress
– Environment exposures

Considering the systemic nature of most chronic skin conditions, and their relationship to other conditions (such as asthma and hayfever in eczema sufferers), it makes sense that there is an underlying physiological dysfunction that is common to all.

One such proposal is the relationship between cellular energy and inflammation. Cellular energy is needed on a constant basis for our cells to function and reproduce optimally.

It is increasingly apparent that bioenergetic function and inflammation are interdependent processes. (2)

This simply means, when cellular energy is low, due to lifestyle factors or illness, inflammation results.

Without addressing lifestyle factors that could be contributing to chronic inflammation, most sufferers of chronic itch related to skin conditions will not get complete respite from their itch.

How To Treat Itch

The best approach to resolving a chronic itch associated with a condition like eczema would be multi-modal and address all the causative factors.

  • Topicals as directed by a dermatologist, to provide symptomatic relief and manage flare ups.
  • Anti-histamines to address the histamine component of the itch (usually in eczema the two kinds exist in tandem).
  • Dietary modification: detection and elimination of dietary irritants, which can be determined by performing an elimination diet with the assistance of a dietitian other qualified health practitioner.
  • Supplements as directed by a health practitioner based on testing, to address any nutritional deficiencies (commonly Vit D and magnesium when it comes to neurogenic inflammation).
  • Meditation/mindfulness or relaxation to alleviate and manage psychological stress. Alternatively, go for a walk in nature, which has proven stress relieving effects.

Conclusions

Like most chronic conditions, there is no single cure-all for chronic itch, thus a multi-modal approach works best.

Whilst most medical approaches can work well for symptomatic relief, there is yet to be any treatment approach that delivers a change to the underlying pathology.

With this in mind, long term strategies to deal with neurogenic itch related to skin conditions should address factors related to both chronic lifestyle related inflammation as well as local skin irritation.

 

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

(1) McMahon, S.B., et al, Wall and Melzack’s Textbook of Pain, Elsevier Saunders, Philadelphia, 2006

(2) Bioenergetic dysfunction and inflammation in Alzheimer’s disease: a possible connection.