Fiona McMahon, DPT, PT
Pain is a common part of our lives. We experience it in both large and small doses, from stubbing your toe on a table leg to the pain of childbirth or a broken bone. As clinicians, we see pain on a daily basis and patients with some kind of pain make up the lion’s share of the cases we see at Beyond Basics Physical Therapy.
Up until 20 years ago, pain was seen as a unidimensional phenomenon, simply a stimulus sent to the brain to inform the individual of tissue damage. As our understanding of pain has broadened over the past few years, we recognize that our perception of pain is also comprised of factors like emotion, situational context, experience, and memories, as well as our beliefs and expectations. This new way of looking at pain has expanded our knowledge and has opened up new options for treating pain beyond just facilitating tissue repair. Understanding your own pain can also help you regain control over your pain. If you have pain, I sincerely hope you read on.
Pain, especially acute pain serves a very important function. Pain is the the signal to the brain that warns of tissue damage. It compels you to take action. It is the force that causes you to rapidly remove your hand from a hot surface before severe damage occurs. It keeps you from using an injured limb, which is in the process of healing. It is the protector of your body and is an integral part of staying healthy.
The problem with pain is when there is a mismatch between the actual tissue damage and the amount of discomfort it causes. Chronic pain is a pain that persists 3 months or more after an injury and does not resolve with resolution of the injury. This type of pain is much harder to treat as the causal mechanism is not easily identifiable like a cut or a broken bone would be. According to the American Academy of Pain Medicine, chronic pain affects 100 million Americans, which is more than those suffering with heart disease, diabetes, and cancer combined. Chronic pain accounts for 630 billion dollars of US health care costs.
What makes acute pain chronic?
Pain is very much affected by the circumstances in which it arises. Stress and anxiety are both two huge mediators of pain. We often look at stress as bad. I know I do. But in cases of acute stress and imminent danger, it is stress that causes a release of endogenous opioids (body-produced pain-killers, which actually function to lower your threshold for pain). An example is a man who manages to escape a burning building, who realizes he is severely injured only when he makes it to safety. Stress is not the same as anxiety; it is a reaction to dangerous or harmful events already set in motion.
However, stress, as we know, is not a pure good. We all have read warnings about the long term effects of stress. The hormone most closely associated with stress is cortisol. Cortisol gets a bad rap, but it has its place. In a situation that requires it, cortisol is a veritable godsend. It causes the body to mobilize glucose and calcium to give one energy to escape, fight, or rescue. The only problem with cortisol occurs is when it is released over long periods of time. Cortisol is released with stress, both emotional and physical. Cortisol draws glucose from the muscle tissue and calcium from the bone. Over time, long term stress can cause muscle pain, weak bones, weakness, and beget a further cycle of pain. It has been proposed that the dysregulation of cortisol can be linked to chronic pain syndromes like fibromyalgia.
Anxiety is usually associated with stress and often times go hand in hand. Anxiety has an important distinction from stress. Anxiety is related to the fear of negative events happening before they have actually happened. It has the opposite effect of stress in the body and actually lowers your pain threshold, making unpleasant physical stimuli more painful. This illustrates the effect of perception on pain. Anxiety and stress that occurs from worrying that the pain will go on forever, or prevent you from functioning fully, actually perpetuate pain and may be in fact, a self fulfilling prophecy.
Further evidence that pain is not solely a response to noxious physical stimuli, is provided by the phenomenon of phantom limb syndrome. Phantom limb phenomenon occurs when an individual perceives pain in a limb that no longer is part of his or her body. Phantom limb pain sparked Ronald Melzack’s investigation into pain and his subsequent proposal of the neuromatrix of pain.
Melzack argues that because the pain associated with phantom limb feels so real, there must be an underlying neural circuit, responsible for that limb, and all limbs, that are responsible for the body’s sense or schema of that limb. Melzack goes on to explain that the circuit can be modified by incoming stimuli, such as heat, pain, vibration, et cetera, but the circuit can also exist and work entirely on its own as in the case with phantom limb phenomenon. He argues that these circuits are “built-in” but modified by experience and do not necessarily need external stimuli to activate a given circuit.
All of this goes to say, that pain is much more than the response to a physical stimulus, and cannot be treated simply by removing that stimulus. Effective treatment of pain requires both a top-down and bottom-up approach.
So what is to be done about chronic pain? It appears clear that the first step is to remove the stimuli causing the pain. In physical therapy, an individual’s trigger points may be treated, his or her posture corrected, and muscles strengthened as well as many other techniques and strategies. All of these treatments are a step in the right direction. But in many cases of chronic pain, this is usually not enough. Physical therapists must recognize how their patient’s pain experience is modified by the context the patient is in . A therapist may encourage deep breathing and progressive relaxation to help calm the central nervous system and lessen an individual’s stress burden. He or she must also be vigilant to recognize when counselling, neurodynamic training, or cognitive behavioral therapy is necessary to break the stress, pain, and anxiety cycle.
At Beyond Basics, we realize your pain may not be unidimensional. We practice a holistic therapy designed to put our patients at ease and guide them through their recovery journey. In addition to teaching our patients stress management techniques, we also host bi-monthly meditation sessions with Ryanne Glasper ( see her current schedule in resources). We are also experts at recognizing when a patient might need a little extra help in his or her recovery. We work closely with many tri-state area therapists, psychiatrists, and psychologists and can refer when necessary to help augment our patients’ results.
Pain is an extraordinarily difficult part of the human experience. If you are in pain, today’s the day to seek help and get your life back. We invite you to start your journey with us, Beyond Basics Physical Therapy in New York City.
For Further Reading about Chronic Pain:
Heal Pelvic Pain
By: Amy Stein DPT
By: David Butler
Meditation at Beyond Basics
110 East 42nd Street, Suite 1504
New York, NY 10017
- October 13th, 2016 at 7pm : Pelvic Pain, meditation workshop with Ryanne Glasper, DPT & Restorative Yoga
- Register at: pelvichealth-101.eventbrite.com
- Keep your eye on our website/blog for more upcoming classes!
Allen R, Zahn M. Understanding Pain. DermoNeuroModulating.
American Academy of Pain Management. AAPM facts and figures on pain management. http://www.painmed.org/patientcenter/facts_on_pain.aspx . Accessed July, 2016
Melzack R. Pain and the neuromatrix in the brain. J Dent Educ. 2001. Dec; 65(120: 1378-82