Category Pain

Rethink Pain: Moving Beyond Muscles and Bones

Nick 2 Comments

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.

 

Pain Is A Verb, Not A Noun

Nick 3 Comments

Brain
When you seek treatment for pain, part of that process should be a thorough education about pain.

This education should cover the basics:

So that you understand the physiological process, at least at a basic level.

Many people think pain is only a marker of tissue damage. It’s not. It is a multi-factorial sensory and emotional experience.

To help people change their understanding of pain, I like to describe pain as a verb, not a noun.

For those of you who can’t remember primary school English (or never learnt it in the first place):

  • Verb = doing word
  • Noun = thing

Thinking about pain as something you experience, instead of something you have is empowering.

It gives you an active role in your pain experience. This means you can influence your experience, for better and worse

How? With your thoughts, feelings and actions.

Pain Is A Body and Brain Experience

All pain has three major components:

  1. Physical
  2. Cognitive (thoughts)
  3. Emotional

The relative contribution of each component varies.

Often we can determine which factor is likely to be the primary driver of each pain experience, but we can’t measure by how much.

Even though were aren’t always aware of each component, they are always there.

If the primary driver of your pain is physical, then physical treatment approaches tend to work best.

This is the same for psycho-emotional pain, which response best to psycho-emotional treatments.

Kind of obvious yeah?

Where it gets tricky, is that even physical approaches have cognitive and emotional aspects.

There is no separation.

Get Involved In Your Treatment

The best outcomes in pain treatment occur when you and your practitioner are working together.

This maximises the effects of treatment.

The more effective your treatment, the faster your resolution of pain. Again, kind of obvious yeah?

You are probably more involved in your treatment than you think.

First, you chose your practitioner (hopefully). The act of choosing is both psychological and emotional. You want to choose someone who is good at what they do, and who you like.

Second, you are probably already doing things to help your recovery. They may or may not be the best things, but you’re already changing your behaviour.

A good practitioner will point you in the right direction of what change is best, but you’ve made a start.

How To Change Your Pain Experience

Our mental and emotional state influences our perception.

Think about watching a movie. If you are on a first date, it’s a very different experience to watching the same movie with your long term partner after you’ve had a fight.

Same stimulus, different psycho-emotional status and thus different perception/response.

This principle can be applied to factors affecting pain:

  • Take control of your emotions. First, identify your thoughts and emotions around pain. Commonly these include fear, anxiety, overwhelm and frustration, among others. Then you can change them. A good practitioner will help you with this.
  • Improving your stress management. Stress is dictated by the way we frame an experience. Any event has the potential to be stressful. By learning to change your framing of stressful scenarios, you can minimise your stress load.
  • Change your environment. Our environments shape us, for better and worse. Sometimes, as hard as it is, the best thing you can do for your pain is change or leave aggravating environments.

Conclusions

It might be strange to consider pain as a verb, not a noun. But as I outlined, it can make a massive difference to both your pain and suffering.

Taking a different view on things is the first step to changing your outcomes.

And while different views can be quite confronting, it is the only way to grow.

Hopefully, this growth means improving or eliminating your 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.

 


 

 

Osteopathy For Low Back Pain

Nick 2 Comments

Low Back Pain

Low back pain is extremely prevalent across society (1,2), and one of the most common reasons people consult with an osteopath in Australia.

Unfortunately, whilst there are many published suggestions that low back pain is self-limiting, often this is just a repeated cycle of aggravation and remission (3), and thus professional management is required.

The good news is, that with appropriate management, there is a good prognosis for both the short and long term.

Most manual therapists like to say they “treat the cause and not the symptoms” of low back pain. Unfortunately, we know low back seldom has a singular cause.

My way around this is to use a modifiable system, in order to address the main factors involved with low back pain.

  1. Assess – basically, we want to work out what you can and can’t do.
  2. Educate and empower – I want you to know what’s going on, and what we can do about it
  3. Alleviate pain and discomfort – this goes without saying
  4. Restore function – absence of pain is not function
  5. Build resilience – mentally and physically, so it doesn’t happen again

This approach to treatment is further tailored to each individual based on their risk profile, personality and individual preferences.

This means, that you get the benefits of a systematic approach, ensuring your outcomes are more predictable and that nothing is missed along the way, combined with the individualisation of care, making your treatment, your treatment.

Types of Low Back Pain

Simply put, we can group low back pain into 4 main types:

  1. Acute low back pain with no lower extremity symptoms
  2. Acute low back pain with lower extremity symptoms
  3. Chronic low back pain with no lower extremity symptoms
  4. Chronic low back pain with lower extremity symptoms

 

No matter what the tissue diagnosis is, these 4 groups of low back pain typically behave and respond in similar ways.

So, instead of getting caught up in whether you have a disc injury, a muscle strain or joint sprain, focus on which group you are in, and what stage of recovery you are at.

A process based approach to recovery, Eyal Lederman, PhD.

A process based approach to recovery, Eyal Lederman, PhD.

Then, you can focus your treatment on enhancing that stage of recovery.

We can do this, because we know that each aspect of low back pain has generalised features that occur as part of the pain response.

General Features of Low Back Pain

The general features of low back pain are, more accurately, general features of pain, as to an extent, they occcur with the majority of different musculoskeletal pain.

Stress Response

Pain is part of a threat response system.

Our nervous system is highly evolved, albeit sensitive, and pain is designed to alert us to possible danger.

When we experience pain, we also experience an increase in sympathetic nervous system (fight/flight) activity.

Some of the effects are elevation of stress hormones, an increase in heart rate, decreased visceral blood flow and “narrowed” thinking.

This stress response is important in the short term, as it allows us to “get to safety”. In the long term, it is an impediment to healing.

Osteopathy, in the form of a generalised whole body treatment can stimulate the parasympathetic nervous system (rest and recover), alleviating the stress response and accelerating recovery. (4)

Changes To Local Muscle Tone

As part of the threat response, our brains increase the tone of certain muscles, as a protective measure.

The increased tone of our muscles is the way our brains “brace” the area.

Unfortunately, beyond the very early stages of the pain response, this increased tone will often inhibit movement, which is actually helpful to the recovery process.

Osteopathic treatment can change this tone by affecting neural receptors in the skin, muscles, tendons and joints.

Impaired Motor Control, aka, You Can’t Move Normally

Nociception is the transmission of “danger” signals from peripheral nerves, called nociceptors.

Fast acting or slow conducting nociceptors transmit to the spinal cord. This is the primary driver of pain in the majority of cases.

Nociception affects motor control. Have you ever stepped on something sharp? I bet that your normal walk was altered, for at least a few steps.

Additionally, pain affects our accessory joint motion. This is the movement which is necessary for normal range of motion, but is not under voluntary control – for example: joint rolling and sliding. It allows us to move smoothly, and when it is lost, we lose that ability.

Osteopathy can inhibit nociception, thus allowing better freedom of movement. (5)

Impaired Fluid Dynamics

Deoxygenated blood and lymph (waste product fluid) moves passively, driven by muscular contraction and movement.

For reasons mentioned above, when we are in pain, we cannot move or contract/relax our muscles efficiently, which leads to fluid stasis. Coupled with blood vessel constriction resulting from an increased stress response (6), and we have a situation where there is poor clearance of metabolic and inflammatory waste products.

There are many osteopathic techniques designed to stimulate the lymphatic system and facilitate the circulatory system – enhancing the clearance of these waste products.

Specific Features of Low Back Pain

Mechanical Strain

Mechanical strain occurs when nerves in the low back are tensioned beyond their tolerance.

Mechanical low back pain is often described in terms of joints, ligaments and muscles, and whilst these tissues can be strained, it is the deformation of nerve tissue that is responsible for pain – muscles and joints don’t sense, nerves do!

Nerve tissue is highly sensitive, and it’s role is protective, so often we will experience pain without any major strain to other tissues, which is very typical of low back pain.

This type of pain is characterised by an aggravation, or relief with certain movements and positions. As a result, using manual techniques designed to facilitate movement and resolve the strain pattern, most mechanical low back pain responds well to osteopathic treatment.

Generally it is advised to continue moving as normally as possible during the recovery process.

Treatment of mechanical low back pain should also include a graded movement approach, to restore function, so that you can return to doing the activities that make up your life. You should also increase the loading of the tissues, to build resilience, so it doesn’t happen again.

Inflammatory Low Back Pain

Inflammation is a normal immune response, involved in the process tissue repair.

When we experience trauma to body tissues, there is a local inflammatory response. The trauma can be overt – fall, lifting, contact injury or repetitive – work related, sport related.

When inflammation affects the dorsal root ganglion, a collection of sensory nerve bodies near the spinal cord, then we experience pain.

Inflammatory low back pain is characterised by presence in a wide variety of positions. There is often an overlap between mechanical and inflammatory low back pain, the issue is finding the dominant factor and addressing that primarily.

The common recommendation for inflammatory low back pain is to use NSAIDs (anti-inflammatory medication). This can help in the short term, but there are side effects, which include the inhibition of certain factors required for the remodeling of the tissues. NSAID use should be determined on an individual basis by your healthcare practitioner, with a full discussion of the risks and benefits.

Rest, or more accurately, avoiding aggravating activities can help with short term relief.

Osteopathy can help with inflammatory low back pain in a few ways. Addressing the strain patterns that caused the initial tissue trauma and thus inflammation, enhancing immune response and affecting local circulation. (7)

Effectiveness

So far we have outlined the general and specific features of low back pain and how osteopathy can help. However, the question still remains, does osteopathy work for low back pain?

To be perfectly honest, this is one of the hardest questions to answer.

Research Says Maybe

In research, individual studies are performed, and then studies that investigate similar things are reviewed to see if there is a consistent outcome.

There have been 3 notable reviews of osteopathic management of low back pain.

The results show low to moderate effects. (8,9,10) This is generally positive, but not unequivocal.

However, there isn’t any treatment for low back pain that is (unequivocal).

What does this mean to you?

Well really, low back pain is quite individual, studies and reviews take averages, thus discarding the individual differences in response to a certain effect.

For example, if you took a room full of 10 men and 10 women, the average number of ovaries per person is 1.

Research can be like this, a few people can respond really well, and a few really poorly, and thus the average effect is unremarkable, though for the people whom it worked really well, this is not reflective of their experience.

Is It Safe?

Whilst there are risks involved with osteopathy, there is a sparcity of evidence directly studying osteopathy, so we must draw on broader manual therapies, which show mild side effects (short term soreness) are pretty common (40-50% of people experience this) and serious adverse effects (disc herniation, cauda equina syndrome) range from 1:~38,000 to 1:3.7-100,000,000 respectively. (11)

Conclusions

Those who do not seek appropriate management for their low back pain initially tend to experience more frequent bouts, for longer.

Osteopathy is relatively low risk, and there is supporting evidence for the treatment of low back pain using manual therapy and exercise/rehabilitation.

Usually you should see improvement within the first 2-4 visits, however, osteopathy, like anything worthwhile, takes time.

One of the biggest issues I see is people who don’t complete a course of treatment.

Thus, they improve, but they do not completely resolve – some of the protective behaviours are still present.

In order to prevent this, the use of outcome measures (functional tasks, movement assessments and psychological screening) enable us to detect change beyond “it doesn’t hurt anymore”.

In most circumstances, a pain free period of at least 3 consecutive months, in addition to positive changes on outcome measures would be deemed a resolution.

 

 

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) Incidence of adult LBP

2) Incidence of adolscent LBP

3) Prognosis of LBP

4) Osteopathy and ANS

5) Cutaneous regulation of motor control

6) Neuronal control of circulation

7) Neuronal control of skin function

8) Review of osteopathy and low back pain 1

9) Review of osteopathy and low back pain 2

10) Review of osteopathy and low back pain 3

11) Adverse events in manual therapy

Scary Unkown

Pain Science Made Simple

Nick 8 Comments

Scary Unkown

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):

  1. Cognitive (thoughts)
  2. Affective (emotions)
  3. 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:

  1. Thermal (reporting on heat/cold)
  2. Chemical (reporting on chemical irritation, like inflammation)
  3. 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