Treatment Table Talk – Pain

Today we’re hopping on the yoga mat to talk about Pain. A lot of patients come to me because they’re in pain. I think it’s important for patients to understand almost as much about pain as I do. Pain is a very unique thing. I tell a lot of patients right off the bat (and many think this is super weird!) that I don’t treat pain. I treat how you move and because I improve how you move we can reduce your pain, but that’s not my ultimate goal. My ultimate goal is to make your movement efficient.

I like my patients to understand that I treat movement because it separates movement from pain, a lot of people get those two very intertwined. Along with intertwining movement and pain people also have started to correlate pain and tissue damage. Sometimes we think that because we have pain, we must have tissue damage. That’s also not true and it is very interesting to look at. You can have a whole lot of pain with no tissue damage, or tissue damage without pain. These metaphors aren’t my own, they come from pain neuroscience education coursework from Adriaan Louw & Lorimer Moseley – if you’re interested in learning more about pain it’s worth looking them up on YouTube!

The thing to know about pain is that you can have tissue damage without pain. Have you ever noticed that you have a big bruise on your leg and you have no idea when or where it happened? You clearly had tissue damage. So much tissue damage in fact, that you had bleeding under your skin but you had no pain. This is because you probably didn’t even know it happened. You likely bumped into something and it didn’t cause what really causes pain – threat. Pain is our ability to understand and represent a threat that something poses to us. So if I am going about my day, I bump my leg on something, it’s not threatening to me it might not hurt and I might not have any pain despite the fact that I have tissue damage. On the other extreme, I’ve seen patients where they have no tissue damage but they have an incredible amount of pain.

Now a lot of people will think, ”Oh, that pain is all in their head!” and we should talk about that too. All pain is all in your head. That is where pain happens. Pain is not at the level of the tissues, it’s processed in your brain. I never think with a patient that their pain is made up. That is so demeaning to a patient and unhelpful for treatment. Your pain is real, even if it is all in your head.

An extreme example of this is patients that I’ve worked with who have phantom limb pain. They may have had an amputation of their arm, yet they still feel pain in the hand that isn’t there. And the reason they’re feeling pain is because the pain is being created and processed by the brain just like all other pain. So we work with that patient to help reduce pain in a limb that isn’t even there. That tissue cannot be damaged because it healed years ago at the level of their residual limb and they don’t have the rest of the limb that is actually in pain. So that pain isn’t related to tissue damage, but again, I don’t want to ever minimize patient symptoms because that pain is very real. The good thing is we can treat both things – we can tissue dysfunction with no pain, and we can treat pain with no tissues even left! That’s the beautiful thing about physical therapy, we treat movement!

Part 2

In part 1 I said that pain is created in the brain. I didn’t mean that pain is made up, but all pain is created in the brain. Pain is an output of the brain. We think of it in the classic Descartesian model – René Descartes originally discussed pain as being a signal. So say you feel a pinch, that then sends a signal to the brain which causes pain. But we’re finding now that this theory isn’t right at all.

There’s something to be said about a nerve being stimulated in your body and sending a signal to your brain and causing pain. We call that nociception. So when I pinch myself it sends a signal to my brain (that’s nociception) but my brain chooses how to process that information to see if it is threatening or not.

An experiment for that is if you pinch yourself it hurts a lot less than if someone else pinches you with the same amount of force. That’s because you trust yourself more, you know exactly how much pressure you’re going to use. But when someone else pinches you, you don’t always know how hard it will be, it might be more threatening. So the input here is nociception, the brain processes and then it puts an output of pain. Nociception isn’t the only thing that can cause pain our brain can associate pain with different things. All of a sudden those things that have pain associated with them like movement (a common one for me!). So then movement instead of nociception triggers the brain to process and outputs pain just the same way.

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