Pain and Personal Responsibility

The Mind Is Key

When it comes to persistent/chronic pain, taking responsibility for your thoughts, emotions and actions is paramount to achieving any semblance of a normal life.

If you’ve ever experienced any intense or lasting pain, there’s a big chance you’ve said to yourself at least once “I don’t deserve this”.

Unfortunately, the world is not a fair place, and bad things happen to good people, but, viewing yourself as a victim of pain helps no one, least of all yourself.

This post isn’t about blaming your (or anyone for your pain), but rather to encourage you to take responsibility for the things you can control, in order to give yourself the best possible chance of living a fulfilling and meaningful life.

Is It Your Fault You Are In Pain?

The most commonly accepted model of pain is Melzack’s “neuromatrix model” (1). This model says that pain is an output of the brain, based on multiple sensory inputs, including:

  • Cognitive: memories, attention, meaning and anxiety
  • Sensory: inputs from skin, musculoskeletal tissues and the viscera (organs)
  • Emotive: inputs from the limb system

With this in mind, it is fair to say that any time you experience pain, you probably aren’t at fault based on anything you were consciously aware you were doing, because so much of the pain experience is generated unconsciously.

It is also fair to say that you can influence your pain based on what you think and do when you experience it.

So, to answer the question, in general, the answer is no, it’s not your fault you’re in pain.

However, as always, there are a few exceptions:

  • Acute pain is your fault if it stems from an injury that occurred because you did something stupid – think alcohol related injuries or playing a game of pick-up football knowing you haven’t been active in years.
  • Gradual onset pain stemming from overuse type injury (work, exercise etc) is very preventable with appropriate workload management.
  • Acute, non-specific pain is often the result of psycho-emotional components, more so than any tissue trauma, thus if you constantly put yourself in stressful situations and don’t know how to manage your thoughts and emotions, then you are probably playing a big role in your pain.

No One Can “Fix” You

One of the biggest examples of not taking personal responsibility for your pain, is the misguided notion that someone, or something, will fix you.

There is a growing body of research demonstrating that people with the highest expectations about making a recovery from pain do so. (2)

Combined with the large (and growing) body of research that suggests passive approaches to managing chronic pain aren’t very effective, it is obvious to see that there is a big role for you to play in your own recovery.

This doesn’t mean more passive therapies are useless. It just means the appropriate context has to be set.

What we can boil this down to is as follows: if you can find a knowledgeable practitioner that your like and connect with on some level, who inspires confidence in your ability to recover and gets you involved in the process, then you probably will.

Now, before you think that you have found and done all of that and you’re still in pain, it’s important to define “recovery”.

Defining Recovery

Most of the data on chronic pain comes from specialist chronic pain clinics. These are often public funded and run in, or in association with hospitals. They are typically “end of the line” treatments for people who have not responded to any other form of pain management.

The results these clinics achieve are “fair” when taken objectively, often decreasing a persons self-rated pain by a couple of points on a 10 point scale.

But, when we take into account that nothing has worked before, this improvement is quite impressive.

Additionally, when people are asked to rate their quality of life, measuring things like anxiety, depression and fear of the future, things are generally even more positive.

This gives us good insight into what is realistic for chronic pain sufferers.

If “end of the line” sufferers can improve this much, then good management earlier in the timeline can theoretically achieve even better results.

One of the biggest differences between those who succeed in managing their pain and those who don’t, is that they take action despite their pain.

Don’t Wait For Your Pain to Get Better to Start Living Well

In personal finance circles, there is a lot of talk about developing the habit of saving money, no matter your income.

That is, if you are on the minimum wage, and can only afford to save a few dollars each week, it is still important to do so, even though the amount across a year might not be very much, the habit developed carries on with you throughout life, as you (hopefully) increase your income.

A similar approach can be taken when you are in pain.

Instead of thinking “when I feel better, I can finally do x”, try shifting your mindset to “how can I find a way to do x, despite my pain”.

Now this is often easier said than done, but a good practitioner will be able to guide you through the process. Many times the limitations are self imposed, and a graded exposure approach can work wonders.

What Can You Do About Your Pain?

  • Accept your circumstances, rather than looking for someone or something to blame.
  • Seek out an excellent health practitioner to work alongside you and help build a team around you.
    • Don’t be afraid of medications. Used appropriately, they can be life changing. It goes without saying that you should talk to your doctor before starting or stopping any medications for your pain.
    • Consider working with a psychologist who specialises in chronic pain, in Australia there is an excellent Medicare rebate for psychology – discuss it with your doctor.
  • Outline functional based goals, rather than pain based goals. For example, saying “I’d like to walk my dog for 45 minutes” as opposed to saying “I’d like to walk completely pain free”.
  • Focus on processes, rather than outcomes. Processes are the things you do, outcomes happen based on what you do, but they are always variable (because of factors beyond your control).
  • Start small and build up slowly. 
  • Don’t “let pain be your guide”. Chronic pain is an unreliable guide of what to do or not do. Some days or weeks are worse than others. The challenge is to persist through the bad weeks as much as you can, and enjoy the good weeks without being fearful.
  • Stay positive. I know this can sound like throaway type advice, but there is evidence to suggest that if you can get through your pain, your brain returns to normal – the changes associated with pain are not permanent! (3)

Conclusions

It can seem like an impossible journey at times, and a completely isolating one, but you are definitely not alone.

People have gone before you and conquered pain. Others going on to live full lives despite their pain. Both, in no small part, due to their determination to make their lives better.

This doesn’t mean that you can will yourself better, but it does mean that there is hope.

There are dedicate professionals out there who study hard and work even harder to help people in pain live better lives.

Sometimes you have to work to find them. Sometimes you have to travel to reach them.

But you must, you owe it to yourself, because, the right advice, the right words at the right time, the right actions in the right amount, can change your life.

 

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) Melzack and Katz, Pain

(2) Expectation and low back pain recovery

(3) Brain structure during and after pain

 

Does Sitting Cause Low Back Pain?

Sitting And Low Back Pain

Sitting is the new smoking. – everyone

You’ve heard it. You’ve read it. Somewhere in your brain is the meme that sitting is the new smoking.

Yes, sitting for long periods without moving is unhealthy, mostly from a metabolic point of view, but does sitting cause low back pain?

In reality, like all things related to pain, it’s complex, and as a result, the research seems to be mixed, which is a far cry from what you’ll read in most health articles posted online, in newspapers and magazines.

What Does The Popular Media Say?

It’s really common for articles in the popular media, both online and offline, to say that sitting causes low back pain. (1,2)

Most say that the incidence of low back pain has increased because of increased sitting time or via mal-adaptive processes (like muscle shortening) as a consequence of sitting.

You will read about how sitting shortens hip flexors and hamstrings, about how sitting compresses the spine and the discs and about how sitting weakens “the core”.

Because these mechanisms sound plausible, and because they are repeated so often, they are gradually accepted as fact, without much further questioning.

Unfortunately, what makes sense in theory doesn’t always pan out to work in the real world, which is why we use the scientific method to try and determine cause and effect.

This is important for two reasons:

  1. If we determine that sitting causes or doesn’t cause low back pain, then we can act on this information accordingly.
  2. If we determine a causal relationship between sitting and low back pain, we can then look at why this might be happening, in order to better treat it.

What Does The Research Say?

When we look at the research around sitting and low back pain, the results are mixed.

One study (3) took a group in 1993 and followed up at 5 year intervals until 2012. They looked at mental health, metabolic health and musculoskeletal health. They found no association with occupational sitting and low back pain.

Another study (4) I looked at objectively measured sitting time as a risk factor for low back pain. This is important, because most studies rely on self-reported data, which is typically inaccurate. The authors found that total sitting time (most studies just measure occupational sitting time) was associated with low back pain intensity, when other factors were controlled for. This means that the more these people sat, the more intense low back pain they experienced.

The third study (5) I looked at wasn’t a study, it was a review. A review is when researchers look at all the studies on a certain topic that meet certain criteria, and then compile their results.

Aside: a meta-review is when researchers review all the reviews on a topic to get an idea of what “works”. This is regarded as the best form of research evidence, because it is more robust and has more statistical power (is more likely to be correct).

In this review the authors reached the following conclusions:

Although occupational physical activities are suspected of causing LBP, findings from the eight SR reports did not support this hypothesis. This may be related to insufficient or poor quality scientific literature, as well as the difficulty of establishing causation of LBP. These population-level findings do not preclude the possibility that individuals may attribute their LBP to specific occupational physical activities.

So as you can see, from my small sample, one showed a link, another showed no link and the review found no link, but also acknowledged potential issues as to why this is so.

So, Does Sitting Cause Low Back Pain?

As you can see, the results were not conclusive. Even if increased sitting time is associated with low back pain, it doesn’t mean it causes low back pain.

This is because, pain is emergent, not dependent.

An emergent property is a property which a collection or complex system has, but which the individual members do not have. A failure to realize that a property is emergent, or supervenient, leads to the fallacy of division.

What this means, is that pain arises based on many factors, that are unpredictable, so to try and isolate one variable, like sitting, as the cause, is impossible.

No one thing causes pain.

A “More” Plausible Explanation?

If we look at why somebody might experience pain after sitting, we have to ask:

Was it the sitting, or something the sitting did?

Do people who experience low back pain from sitting also experience low back pain from other activities?

What about positions that replicate sitting, but aren’t sitting?

If they do, then what do these activities have in common?

Finally, is there ways they can sit that don’t cause them pain?

Most of the time, we will find that sitting is not the sole cause of low back pain, and when it is apparently so, it’s likely that there are still other factors at play.

One way to explain why we get pain in certain positions, is to understand the sensitivity of peripheral nerves.

When we occupy any position, particularly when pressure on the body is involved (sitting, lying etc), there is a compression of body tissues taking place, including the peripheral nerves.

When we apply pressure to peripheral nerves, they deform.

This deformation causes altered neural blood flow – rabbit models show a reduction of up to 70% of their blood flow when a strain of only 8.8% is applied.(6)

This could feasibly be a driver of nociception (bearing in mind that pain is produced by the brain, there are no “pain signals”) which could result in a pain experience.

So instead of thinking that sitting causes low back pain, it is probably better to look at the function of your body as to why you don’t have the capacity to sit for extended periods, and address those issues.

Conclusions

Just because sitting doesn’t necessarily cause low back pain, doesn’t make it harmless. Sitting has many pronounced negative effects on our metabolic functions, and movement has many pronounced benefits, including reduced incidences of pain (7).

Additionally, if you understand that no one thing causes pain, you will be in a much better position to deal with pain when it happens.

 

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) Heal your lower back pain with these 5 yoga poses

(2) Proper sitting

(3) Occupation sitting and cardiometabolic, mental and musculoskeletal health

(4) Sitting time (measured) and low back pain

(5) Occupational physical activity and low back pain

(6) Structure and biomechanics of nerves

(7) Physical activity and chronic pain (in mice)

How To Manage Pain Flare Ups

Nature Helps Calm Stress

Pain flare ups are a common occurrence with both acute injury or chronic pain. Knowing how to manage them well can be the difference between being able to maintain a high quality of life or not.

Pain flare ups, simply put, are a normal part of being a human in pain. Sometimes, they are related to something you have or haven’t done, but many times, there is no discernable cause for a pain flare up.

Most pain flare ups are short term – be it a few days or weeks – which can, at the time, seem like they will never end, leading you to pursue options for relief that are ineffective, costly and possibly even dangerous.

Instead, with this article, I hope to show you some strategies you can use immediately, or store away for reference in the (unfortunate) event of a pain flare up.

Why do pain flare ups occur?

Biological systems are non-linear, complex systems. Whilst it is easy to think of recovery as a straight line from injury to repair, in reality, things are a lot more up and down. (2)

In fact, I wrote about this in the last newsletter (you can subscribe at the end of this post, so you won’t miss any future issues).

This fact alone means pain flare ups are an expected, yet unpredictable phenomenon, but beyond saying that flare ups are inevitable, there are more issues at play.

Sensitisation

Sensitisation is the increased sensitivity of the nervous system to stimuli, whether it is at a peripheral level (nerve endings throughout the body), a spinal level or in the brain itself (3).

Because of this process, what was once a pain free task can become painful over time.

Biologically this is designed to protect us from further harming an injured area, which works well in acute injuries, but with chronic conditions, where pain and tissue damage become poorly correlated, it’s not so useful.

Lowered tissue tolerance

Whilst similar to sensitisation, lowered tissue tolerance occurs when you do not use/load body tissues appropriately over time and they decondition.

Whereas sensitisation is purely neurological, tissue tolerance is related to structural changes as well as a heightened sensitivity. The two often go hand in hand.

An easy way to understand this is with the example of muscle wasting caused by immobilisation. There is a reduced tolerance for load, and exceeding this can cause pain.

With both acute injuries and chronic pain, often the loading on the affected area is decreased, either consciously or unconciously, which leads to decreased tolerance of the tissues to loading.

Expectation

Often people with pain, whether acute or chronic, expect certain things to hurt them.

I was wearing heels all day yesterday because I had a wedding, so I knew I’d be sore today.

What’s interesting about expectation, is that is a self-fulfilling prophecy.

If you think something will hurt, it probably will, thus confirming your thoughts.

That’s not to downplay the involvement of the activity in question, but there are studies that show simply priming  (3) someone with “old” words and thoughts causes them to walk more slowly, without even realising it.

With this in mind, if you are expecting the worst, then chances are you’ll get it. (4, 5, 6)

What to do about pain flare ups

Every strategy to manage pain needs to be individualised to the individual – no one thing works for everyone, nor does anything work the same from person to person.

Acceptance

Acceptance and Commitment Therapy (ACT) is becoming more and more popular in treating/managing pain, because it is so effective (7).

What is so powerful about ACT, is that accepting flare ups will happen, and that you will be in pain, takes away their biggest weapon – frustration and disappointment.

In ACT, thoughts and feelings are not considered to be “helpful” or “unhelpful”. This is important during pain flare ups, because pain can cause us to think negatively, painting situations into worse than they are within our minds.

In essence, ACT is a form of mindfulness.

This is probably the most challenging thing to master, but when you do, the results are profound, both in the context of pain, but also in the greater context of your life.

Modify your activities

Whilst in the long term, avoidance strategies aren’t very successful, because they simply reduce what you are capable of, in the short term, as a management strategy, modifying or even ceasing activities that hurt is a viable option.

Ideally, you will continue as best you can, with what you want/have to do, but it is completely reasonable to put things off.

This makes intuitive sense: if you have low back pain and it hurts to bend, then you will likely avoid bending when it hurts.

However, as mentioned, simply avoiding bending forever is not a solution, and actually makes things worse.

A better approach is to see if you can modify how you bend, and how much you are bending in the short term, whilst working to restore the ability to bend freely in the long term, using a graded approach.

Use pain relieving techniques that work for you

When in pain, it’s natural to want to get rid of it as soon as possible, no matter the cost.

Unfortunately, there is no one medication/therapy/product that can effectively eliminate pain in everybody, all the time.

So, instead of chasing a magic bullet that drains all your time, money and energy, it makes sense to stick with proven strategies.

Once you have found your “recipe” for relieving pain, you can seek to optimise it, with less conventional methods, if they are safe.

Things you can try, which do have effectiveness to varying degrees are:

Focus on what you can do

It’s really hard to stay positive during pain, the whole point of pain, from a biological perspective, is to over-ride our consciousness to take alternative/evasive action from our current situation.

This means a stress response, and a stress response, physiologically, is designed for action, black/white thinking.

What this can do, is cause you to focus on negative thoughts and emotions, setting of a vicious cycle making things worse over time.

If you focus on what you can do – with both a macro and micro perspective – then you completely shift the way you are living.

After all, if you can’t control whether you experience a pain flare up, wouldn’t you at least want to control your thoughts and activities?

BONUS TIP: Spend time in nature to calm stress

Just as I was editing this, I realised it was hard to find pictures of “pain flare ups”, so instead I went for a calming picture of nature, because spending time in nature is quite beneficial for a multitude of reasons, but simply put, time in nature calms our bodies and our minds, which is a massive key for anyone in pain.

Conclusions

Pain flare ups are a massive challenge for patients and practitioners alike, for many reasons.

As with most things, there is no quick fix, but you can definitely improve your experience of pain flare ups in the short term, whilst in the long term, a tailored pain management strategy can help reduce or even eliminate them.

 

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) Complex systems theory

(2) Neurobiology of pain

(3) Priming

(4) How expectations shape pain

(5) The subjective experience of pain

(6) Expectation of pain enhances response to non-painful stimuli

(7) ACT

How Your Mindset Impacts Your Pain

Mind

Most people think pain is a physical problem, because we feel it in our body.

Whilst this is not wrong, it is not completely right either.

This is because all pain has 3 components:

  1. “Bio” (biological – aka what is going on in the body)
  2. “Psycho” (psychological – what’s going on in the mind)
  3. “Social” (what’s going on in our environment)

You might be thinking, that doesn’t apply to me, “I strained my back shifting the couch, there’s nothing going on in my head or around me”.

That might be so, but, even if we strain out back moving furniture (an obvious physical cause to pain), by the time we experience pain, our brains have done a magnificent job of filtering the sensory information from our body via all our existing biases and preconceptions (“psycho” and “social”).

This simply means, if you’ve heard your grandfather complain about how getting old sucks because his back hurts, and if you’ve heard people talk about “wear and tear” or anything else about back pain, you brain, cool as it is, will consider this when deciding whether to produce pain that you feel “in your back”.

The fancy name to describe this, is a neurotag.

I like to think of it as a filing system in our brains.

When you see, hear, or read something about low back pain for instance, it goes in your “file” titled “low back pain”.

It doesn’t stop there. Neurotags, I mean, the filing cabinet in our brain, also cross reference.

So when your grandfather complains about being old and having low back pain, your brain files “low back pain” into the “old” file, and “old” into the “low back pain file”.

So, when you strain your back, causing the sensory nerves to start firing rapidly and bombard the spinal cord with messages of danger, your brain is pulling up all these files:

  • Danger is coming from the body
  • The danger seems to be around the low back
  • Low back pain
  • Old
  • Wear and tear
  • Can’t move
  • Never be the same

Or whatever else is stored in there. As you can imagine, over time, this could get pretty full.

All this means that even a “simple” low back strain is not so simple.

Some people are at a high risk of developing chronic pain, even from a relatively benign back strain. All because of the psycho-social factors involved. This is why it is important to always address all factors involved in your pain. After all, all chronic pain was acute at some stage. 

When it comes to treating pain, your mindset matters.

In general, there are two types mindsets that we can possess.  One can lead to a better recovery, while the other can actually impair your recovery.

The Two Types of Mindset

When it comes to our mindset, we either have a fixed mindset, or a growth mindset.

This concept was first described by a psychologist, Carol Dweck, who once had a teacher who arranged the seating order of the class by IQ. Whilst Dweck was actually in the number one position, she felt enormous pressure to maintain that position, whilst those lower in the order became resigned to their fate.

This teacher inspired Carol to conduct her own research, which lead her to conclude:

People with fixed mindsets believe that they were born with all the intelligence and talent they will ever have, and that this cannot change.

People with growth mindsets, as you might guess, believe that their abilities can expand and improve over time.

The vast majority of people who have had success in life, especially those who have had to overcome adversity, display characteristics of a growth mindset.

How Your Mindset Affects Pain

If you search for articles on “fixed vs growth mindset”, most of the results will be about personal development and business, but this concept can also apply to pain.

The easiest way to demonstrate this is with an example.

Let’s imagine two completely fictitious people, Danny and Danielle.

Danny

Danny, 30, is a rising star in the corporate world. He works his ass off every day to improve at his job – networking, learning persuasion and sales techniques, studying his field so he is on top of his game. He goes to the gym 5 times per week and ensures he eats well most of the time so he looks and feels good. On top of this, Danny has a daily ritual of visualising his success.

One day Danny starts to experience neck and shoulder pain. The onset wasn’t caused by anything in particular, but he did recall training extra hard that month.

Not wanting the pain to interrupt his life more than necessary, Danny seeks the help of an osteopath named Nick.

His osteopath formulates a treatment plan designed to get him back to full training in 4 weeks. In the mean time, Danny reads some articles Nick sent him and does some extra research on the topic from some trusted health sites he frequents.

At 4 weeks, Danny is not only pain free, but he has learnt about injury management and knows how to improve his gym workouts so that the issue doesn’t recur. In essence, he has come back stronger than ever.

Danielle

Now, let’s have a look at Danielle, 35, who is a public servant. Danielle enjoys her life – she works from Monday to Friday and enjoys exploring galleries and cafes on the weekends with her partner. At work she does what she has to do, but no more, thinking “if I’m not paid to do it, it’s not my responsibility”. Danielle feels like her life is pretty good, but she has one eye on retirement.

One day at work, Danielle starts experiencing neck and shoulder pain, and she recalls her mother having something similar due to her work as a seamstress and thinks to herself that it “must be genetic”. After talking to a colleague whose partner, Danny, had a similar problem and was able to resolve it after consulting an osteopath, she books an appointment with the same osteopath.

When she arrives for her consult, they discuss a treatment plan and get started. After a few days, there has been no change and Danielle loses motivation to do her home based exercises. She continues treatment for a few more weeks, as she enjoys the way manual therapy feels, but she is disengaged. After 6 weeks there is no change, and she is convinced her original thoughts were correct, and that her pain is “genetic” and “there is nothing she can do”.

Your Mindset Affects Your Behaviour

It should be obvious who has the growth mindset, and who has the fixed mindset, and as you can see, your mindset permeates every aspect of your life, including pain.

Having a growth mindset meant that Danny saw his pain as something that could be changed, if he changed what he was doing and improved (his knowledge, his body etc).

Having a fixed mindset limited Danielle’s recovery, as she saw her pain as her destiny (genetic), and thus was not inclined to try and change or help herself.

While pain is never simple, there are so many unseen factors, we can control much of our reaction to pain and what we do in the future. If you have the belief that you can grow and improve throughout your life, that it is likely this will extend to your beliefs around pain.

Can You Change Your Mindset?

This is the trickiest question to answer. People with a growth mindset will believe so, but people with a fixed mindset may not.

The science is unequivocal – our brains are plastic and can continue to change as long as we are alive.

As we change our thoughts and behaviours, our brain structure changes too.

If you want to change your mindset (wanting to change is key), then the best way is via actions.

You see, our brains are funny.

When we sit idle and think, especially about the future, our brains can get very creative. This can be a positive if you start thinking about where you want to be in 5 years and what you have to do to get there, but not so much if all this thinking does is keep you idling in place for another 1/2/5/oh-shit-where-did-my-life-go years.

It’s even worse if you start getting into negative thought spirals.

However, if we take action, any action, then our brains can’t get carried away. And, if we are smart, and start small, then we achieve a little success, we build confidence and momentum. Repeat this process long enough and you become a different person.

This, in essence, is mindfulness, but let’s call it something else – let’s call it momentum. Create momentum by starting small and before you know it, you have changed.

Really, My Back Hurts, How Does This Help Me?

In essence, it all boils down to this: are you resigned to having pain or looking for someone else to solve your problem (fixed mindset), or, are you willing to adapt, change and do what it takes to help yourself?

Some conditions are very easy to recover from, others very hard. What doesn’t change though, is that if you have no doubt in your mind you will improve, no matter what it takes, then you probably will*.

 

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) Wikipedia – Carol Dweck: https://en.wikipedia.org/wiki/Carol_Dweck

(2) Stanford News Service – Fixed versus growth intelligencehttp://news.stanford.edu/pr/2007/pr-dweck-020707.html

(3) NY Times – If You’re Open To Growth, You Tend To Grow: http://www.nytimes.com/2008/07/06/business/06unbox.html

(4) Brain Plasticity and Behaviour – https://www.psychologicalscience.org/journals/cd/12_1/Kolb.cfm

 

*Please don’t take this the wrong way if you suffer from chronic pain. This isn’t meant to belittle your pain or say you are not trying. The recovery rate for chronic pain is quite low, but many people learn to live fulfilling lives and manage their pain quite well. In part this comes from re-shaping their thoughts, emotions and behaviours around pain. Cognitive Behavioural Therapy (CBT) is quite helpful in this regard.

Rethink Pain: Moving Beyond Muscles and Bones

Classical Anatomy

This is the first post in what will be a series about “re-thinking pain”, or rather, re-conceptualising it.

The aim of the series is to help you move from a tissue based understanding of pain to one based in neuroscience, which is more accurate and more correct (although a better term would probably be “less wrong”, as there is still so much to learn).

Why is this necessary?

  • The language we use around pain shapes the way we think about, and experience pain. Using tissue based descriptors of pain reinforces the idea of a “bottoms up” model of pain, which is wrong, and can often make things worse in the long term. Moving towards a neuroscience approach helps move away from this model.
  • Chronic pain is a massive problem in Australia (and around the world), affecting millions, costing billions and growing worse every year. Chronic pain often starts as poorly managed acute pain. One of the most important management strategies of any painful condition is education.

The Problem

To begin to understand how we have ended up with such a problem regarding pain requires tracing back through the centuries of medical and philosophical history.

In short, we used to describe pain as “coming from the tissues” up to our brains, where we felt it.

What is now understood, is that pain is a brain output, with many different “filters”, that are unique to each and every one of us, being applied before we are consciously aware of it.

Despite having this knowledge, we can see that even within the official definition of pain, the problem exists.

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

The definition of pain above has been put together by a group of highly intelligent people (International Association for the Study of Pain), who have spent a large portion of their lives studying pain, it’s effects and how to treat it.

Unfortunately, there is one small problem, and it has nothing to do with the definition itself, but rather, the fact that pain is “described in terms of such damage”.

When we explain all pain in terms of tissue damage we paint a picture in people’s minds. Unfortunately, when it comes to pain, this picture is not only incorrect, but harmful.

One can assume this became part of the definition because of what takes place in the real world:

  • Your back hurts, people say you have strained a ligament/joint.
  • Your knee hurts, people say it must be arthritis.
  • You have a headache, must be wear and tear of the head. No, that last one doesn’t sound quite right.

So how exactly is this harmful?

When pain is described in terms of body tissues alone and combined with the type of language typically used (words like torn, strained, scarred, degenerative) to describe tissue based pain, irreversible damage in the form of nocebo* can be caused.

This can lead you to think that something is wrong with your body that needs to be fixed, when things are in actual fact, completely normal.

Additionally, thinking in terms of body tissues leads to a mechanistic view of the body, one that wears out over time and the association of this “wear” with pain. The body is a biologic organism, one that is always adapting as best it can, it doesn’t “wear out”, but rather fails to adapt. There are lots of reasons for this failed adaptation though, it’s not just the result of “getting older”.

Check out this Facebook post on from September:

"It's probably just WEAR AND TEAR"My oh my, does that saying get tossed about. Usually, it goes something like this:…

Posted by Integrative Osteopathy on Wednesday, 30 September 2015

*Nocebo, is basically the opposite of placebo, ie causing harm when no harm has been done.

The Solution

We need to rethink pain, to conceptualise it as a dynamic process, arising in the nervous system and governed by our brains.

Yes, pain is often a result of tissue damage. However, there are many cases of severe tissue damage with no pain experienced at all and vice versa.

Additionally, the intensity of pain is very poorly correlated with the severity of any tissue damage.

Finally, when tissue damage has occurred, there are three scenarios.

  1. It is quite severe and needs medical intervention at a hospital. Think of compound fractures, 3rd degree burns, deep cuts etc.
  2. It is not severe enough to require medical intervention beyond basic first aid.
  3. It is somewhere in the middle.

In all 3 cases, with time, the body will heal as best it can.

As long as there is adequate rest, nutrition and then re-loading of the tissues in a progressive manner as governed by the condition and individual requirements, you’ll get as full a recovery as possible.

So initially, once the need for medical intervention is ruled out, the important thing to do is treat the pain.

This goes against almost all manual therapy and allied health advertising to “treat the cause of your symptoms”.

Alleviating pain will, in many cases, sort out a lot of associated “findings”, the so called causes of your pain, and then beyond that, allow your body to heal.

If you came to us for treatment, here’s how we might do that:

  • Explain all of this information about pain, in a way that makes sense to you, so that you aren’t as stressed or anxious about it anymore.
  • Have a look at you stand and move and suggest ways that might make standing and moving less painful.
  • Get hands on and apply some really pleasurable manual techniques. There is no need to dig in deep for the sake of it. The goal isn’t to change the tissue, it’s to change the perception and get the brain releasing pain relieving chemicals.
  • Do some breathing techniques to help you relax. You’d be surprised at how poorly most people breathe, even when they are concentrating on doing it properly.

All of these techniques are based on the same principle – once the threat is reduced to an acceptable level, the brain will stop protective behaviours, which include pain and altered movement.

So to summarise a blog post in a sentence:

Pain is all about threat perception, it doesn’t mean damage and body tissues can’t produce pain, only the nervous system can**, so we must focus on the nervous system, including the brain, when describing and treating pain, so as to not cause further complications via nocebo.

 

 

**Yes, the nervous system is a body tissue, but for the sake of the argument we are using simple language.

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

Integrative Osteopathy is an osteopathic practice located in the heart of Fitzroy North, within the reputable Healthy Fit gym. For all inquiries, call 0448 052 754, or to make an appointment online, click here.

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.