Let a Physio Tell you All About Pain

All of us have experienced pain at some stage in our lives.

Whether it’s hitting our knee on the corner of a table or dropping something on our toe, we can all relate to the sensation that tells you that something is wrong.

But for many of us, pain can be more than just a transient bump or a localised ouch and instead can be highly acute, severe and restrictive.

Pain may also endure for a long period of time and may be chronic.

According to the Australian Institute of Health and Welfare, 70-90% of people will experience back pain in their lives and the MOVE muscle, bone and joint health & PWC report of 2017 estimates that musculoskeletal pain costs Australia $9.2 billion in direct costs with additional costs in loss of productivity.

Unsurprisingly Musculoskeletal Australia have recommended further investments be made in order to address the mismatch between the burden of disease and the programs that reduce it.

If you are living with pain, these large-scale statistics may seem of little significance, understandably so, as pain limits your movements and therefore restricts how you live. For example, a pub meal with friends, once a frequent occurrence, has become something you actively avoid. The hard stools at the bar or even sitting down as you commute leaves a memory on your body for days.

So as a physiotherapist, whose primary job is to treat, educate and counsel about pain, I thought I’d share my wisdom and hopefully, there’s a little pearl in there that might help you unthread your condition.

We can’t really trust the nature of our own pain.

Sounds odd, doesn’t it?

However, we may see blood before we feel pain, or be diagnosed with life-threatening cancers that aren’t painful.

The same can be said for musculoskeletal pain, what we see or think we experience may not always be obvious. For example nerve pain, something we see often is usually treated naturally by our instinct to stay still, however, nerve pain can tolerate and is often healed by movement in that area.

This is where an accurate diagnosis is paramount to understanding your pain. At my clinic to locate the area of concern you may undergo a movement-based assessment. This helps us distinguish if your pain is caused by a muscle, nerve, bone, joint, or another bodily structure.

It might also involve scans such as X-rays and MRIs for which we have guidelines on the where, when and why for referring. In fact, getting the diagnosis is a big part of what we call the Relieve Phase of treatment.

The length of time you’ve experienced pain is important.

Why so?

Well here comes the rather interesting discipline of pain science.

Traditionally, there was a very cause-and-effect relationship when understanding the significance of pain. We believed severe pain equaled a severe problem, and low-grade pain equaled a low-grade problem. An issue that I hope I’ve already debunked in the paragraph above. We also expect that the ongoing presence of pain means that the tissue is still damaged, but in fact, this is not always the case. Let me give you an example:
 

• Person has a sitting based job for many years => Back becomes tight
• Tightness in the back leads to irritation on disc => Disc becomes bulged
• Bulged disc presses on the nerve => Nerve creates pain
• Bulged disc releases chemicals and acids => Disc and surrounding tissue becomes sore
• Extreme pain triggers the body’s protective response => Back muscles spasm
• Back spasm requires bed rest => Muscles become weak
• Person reduces their movement => surrounding tissues such as skin, ligaments and joints become sore
• Soreness leads to less activity => Back becomes tight

What we know is that our bodies are wonderful healers of acute injuries such as disc bulges.

Our body goes into inflammation fixing mode using cells such as macrophages and neutrophils which are effectively like the dust busters of the body. We know that this process takes about 6 weeks.

But why can back pain from an injured disc last longer than that?

Firstly you can see in the scenario above that pain can come from more structures than just the injured disc: tight muscles, spasm, irritated nerves, sensitised skin, ligaments and joints all cause discomfort. But you can also see the vicious cycle that presents itself- as the back becomes more generally tight the pain persists for a longer period (and potentially allowing the cycle to repeat itself).

Does it get any more complicated?

In fact yes, it does.

For us to notice pain, we don’t just need an irritated structure, we also need something to tell us it hurts. Enter the nerves and brain. The relationship our brain has with our pain is important, as it tells us when to be cautious and careful. But the longer the nerves and brain are required to do this, the less accurate this messaging becomes. For example, if the sciatic nerve creates pain, that pain has a synapse at the spinal cord with a structure called the dorsal root ganglion. Because the brain knows sciatica is something that needs attention, it is on the lookout for any information the nerve chooses to give which means we experience ‘hyperalgesia’. If that pain persists, surrounding nerve endings also become sensitised which results in a condition called ‘allodynia’. Increased sensitivity is a really common in chronic pain. The pain itself is normal, but the processes behind it are altered meaning that the body doesn’t definitively know which structure is actually causing the pain.

Our brains also help by being on high alert (to protect us), and dedicating a greater proportion of our brainpower to the injured structure. We refer to this process as “central sensitisation” and amazingly the body feels a similar pain regardless of which area it’s coming from – the original disc injury, the nerve or the brain. I often refer to this brain process to help describe why being in pain can be so exhausting – if you’re expected to still think, respond and act like everyone else while your brain is effectively executing another process it gets really tiring!

So what can be done about it?

The wonderful thing is that all those structures can be changed. Including and especially the brain. Do you know Norman Doige’s book, The Brain that Changes Itself? It gives us an awesome insight into just how changeable (we call it plastic!) the brain really is. I have a copy at home if you’d ever like me to lend it to you.

So coming back to physio……

So most commonly we think of physio being massage, mobilisation, manipulation and stretching. This is all really helpful for the tissues and if techniques are chosen strategically (on the back of an informed assessment) they should provide you with some relief. There are other things that can provide relief such as heat and ice, topical creams such as voltaren, dry needling, botox, magnesium and medication. We are great supporters of things that provide relief and help to “break the cycle”.

But as experienced physios, we see the relief of pain as only one-third of our work. To adequately address long-term pain we need to help restore normal movement, by helping the stiffness that your body creates in response to pain we can help get your supporting muscles working again. We call this phase the “Restore Phase” and it’s really the foundation on which we build your recovery.

One of the biggest skills you’ll get out of the restore phase is the understanding of which pains are helpful and which are less so. Pushing into some pains may be the foundation upon which you regain your movement, this helps you to understand what you’re feeling and why. From there we can teach you about what to expect as you’re moving through the pain (we really love this part of our job!).
 

What about the role of other professions such as a GP or Pain Specialist Doctor?

These can be really important people in your network, particularly if you have long-term pain. Doctors who have a special interest in pain can work alongside your physio to help you with medications, scans and advice to help the healing process. And taking medication is not only just about ‘pain relief’ as we think about in standard terms. The medication your doctor provides may help to allow your body to move more without pain being a barrier, and therefore create the first step towards healing, or help to get you sleeping better so your body can rest and recover from day to day. GP’s can be a wonderful source of advice when it comes to referral to more specialised doctors such as a radiologist who can help with a steroid injection, or a sports doctor who can give advice on loading a healing injury. You may come at physio on recommendation from your doctor, or you may arrive at a pain specialist on recommendation from your physio. We can help you navigate this process to choose the best doctor to help.
 

Is there a way of future-proofing my body?

Well, I can’t promise the Holy Grail or a round of cosmetic botox, but there are a few little key things that I can share with you that have been both proven by research and demonstrated to me many times over the years I’ve treated pain.
 
1. Get Strong
Our bodies are made to move, and our muscles support our bodies. We can improve our body’s ability to withstand postural and gravitational forces by developing our muscle strength. Getting strong is important for our bodies to withstand our regular activities and most importantly gives ourselves a little buffer on top. By doing what we call at Viva the “Perform Phase” we are more likely to feel good.
 
2. Don’t underestimate the power of your lifestyle.
The word ‘wellness’ is used a lot in today’s world, but really take it seriously. The better we sleep, the more we drink water, the more we understand the way that cortisol (or what your body releases when it’s stressed) affects our physiology, the better equipped we are to ward off pain and injury. And I’d take this a step further. Look for ways to let exercise assist in your wellness by making it a key foundation to your work, play and life. This may be finding a moment to relieve stress through yoga or to help tire your body to sleep better by running regularly.

You are never alone in your pain and as a physio I have been alongside, supporting and guiding many people through relieving pain, getting stronger and ultimately feeling good and in fact, it’s the best part of my job. Whatever stage of your journey we are here to support and guide you, so get moving!

Sources:

“Back Problems” 30th August, 2019. https://www.aihw.gov.au/

Pre-Budget Submission 2020-21, Musculoskeletal Australia. https://treasury.gov.au

Explain Pain, Butler and Mosely, Second Edition, Noi Group 2019. Section 1 & 4.