Most of the education you have ever received about pain has fallen into two categories. Category one is the “Anatomy Lecture” and category two is the “Mechanic Analogy.” What gets overlooked is category three, ‘The Almighty Software.” A big misconception is that our body creates pain. Wait, say what? Our body is just a servant to the almighty software; our brain. That thing that keeps our heart pumping, lungs circulating oxygen, stomach digesting, liver filtering and our muscles flexing on the beach. This leads us to one of the most costly myths related to pain. The myth that you are in pain because a previous site of injury has not healed. This concept makes life simpler, but does not make you feel any better. It also does not allow your to accomplish any of the wildly important goals you set for the new year.The truth will set you free! Stick with me.
Myth: “I am in pain because _________ still hasn’t healed.”
We are going back in time! You are all suited up on the basketball court for your high school’s championship basketball game. You are mid air in your new Air Jordan’s (maybe converse) about to dunk the ball! Ok let’s be realistic, it is more like a finger roll lay up. Out of nowhere you get absolutely stuffed by the shortest player on the opposing team! That is the end of the story, thank you for reading. Just kidding. You are lying on the ground with your hands up like a well-trained FIFA soccer player. Asking for a foul, all the while knowing it was all ball.
As the other team is high fiving, and your parents and friends are wincing in embarrassment you realize that you are having excruciating pain at your back that travels down your leg. It is a sad day in sports. One your friends will never let you live down.
Fast forward a couple of months. You are still going to physical therapy for your back. The radiating pain down your leg is beginning to subside. You are still hesitant to give it a 100% on the basketball court because of your back pain, but are getting more comfortable running and lifting weights. After your injury an orthopedic surgeon pointed out a herniated disc at your lower lumbar spine. She assured you to give it some time to heal and stick with physical therapy for now.
Fast forward a couple years. You didn’t quite make the NBA, not that you ever had the chance. Your friends also never miss an opportunity to remind you about that time you got stuffed in front of the entire school. You still have some pain at your back every now and then. You blame it on your desk bound job and that damn herniated disc that occurred during the unmentionable basketball game.
Skkkrrtttt, pump the breaks!
Photo by Nikita Kachanovsky on Unsplash
It is important to remember that the HARDWARE (bones, joints, muscles, ligaments, nerves) communicate with the SOFTWARE (your brain). However, at the end of the day the software creates any sensation that you actually feel. Our hardware is often blamed when it is the faulty software that we should be focusing on. Knowing what we know now, we need to consider the three categories that contribute to pain. No longer can we blame pain on tissue healing alone.
“Pain is an output and ultimately a conscious decision by the brain, based on the sum of all the information it receives from the tissues and surrounding environment” (Moseley, 2003a).
The Anatomy Lecture
We have all received this lecture at some point in time. As we uncomfortably sit on one of those really high tables in a doctor’s office out comes a model or picture of a jacked up spine or a knee with loads of arthritis. Maybe even your own MRI. It is like a horror movie! Clearly this is why you are still in pain, right? If it were only that simple. It is actually frightening that a large portion of the orthopedic surgeries performed today are purely based on anatomy, or what we see on MRI. “We will just clean this up over here, attach that and maybe even just fuse those things together. You should be good to go after.”
If pain was purely based on tissue healing most of us should feel better within six months. (Stroncek, 2008)
Healing is relatively predictable. The severity of your muscle strain, ligament sprain or disc injury gives us a timetable for the healing of that tissue. Low grade sprains, strains and fractures should be close to full strength within a couple months, sometimes weeks. Studies have also shown that herniated discs will spontaneously improve, sometimes as early as two months, but most within a year. Larger disc herniations actually tend to resolve even quicker (Komori, 1996; Henmi, 2002; and Autio 2006).Often times without even knowing it we have some ugly tissues on MRI and X-Ray. Ignorance is bliss.
If pain were purely based on tissue quality we would be in a world of hurt. Luckily, it is not.
- 2/3 people over the age of 70 have pain-free rotator cuff tears (Milgrom, Schaffler et al., 1995)
- 50% of people with knee arthritis have no reported pain (Bedson and Croft, 2008)
- 35% of collegiate basketball players without reported knee pain have notable abnormalities on MRI (Major and Helms, 2002)
- 30% of those 20 year olds show disc bulges without complaints of pain (Brinjikji et al., 2015)
- 84% of those 80 years of age have disc bulges without complaints of pain. (Brinjikji et al., 2015)
The Mechanic Analogy
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Most physical therapists and fitness professionals rely heavily on mechanics, or biomechanics. This is the concept that your pain is a result of two categories. One would be your CAPACITY for a particular activity. Two would be your SKILL with a particular activity. Kind of like bringing your car into the shop for a nice tune up. We will just realign the tires and change the oil. After that your ride should be much smoother! This isn’t necessarily wrong. It is just wrong to assume that this alone will work for everyone.
1. Capacity: Strength, endurance & flexibility.
2. Skill: Your form with movement (i.e. lifting mechanics, running mechanics, golf swing mechanics, etc.)
You and your physical therapist need to consider which activities cause you pain, and how your current capacity and skill with those activities may be contributing to your pain. It is important that we ensure you actually have the flexibility, strength and endurance to perform the task being asked of you, with good skill (aka technique) of course. We have all seen someone on a Sunday morning run that makes your cringe a little. You may think to yourself, “man that guy needs a little boost is his form!” Most of us look good for the first mile or so, but how does our form look around mile 5, 10, or 26.2. Being able to maintain skill over a longer period of time may be necessary for improving your performance, but also reducing pain.
The Almighty Software [aka Brain]
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Software is messy. It is not for the faint of heart, but it drives everything.
We underestimate the impact of our brain when it comes to any and all sensations that we feel. The brain has one primary goal… SURVIVAL. Our brain was primed to help us elude lions and survive the cold. In the United States today, our brain has to elude chocolate chip cookies and binge watching Netflix. Sometimes just as challenging.
For some, pain has always been a normal part of life. Take for instance, children that grew up playing contact sports or maybe someone that grew up in a third world country with less than optimal living conditions (Raudenbush, 2012). For others, physical pain may not have been a normal part of life. Sometimes it even resulted in a reward, such as love or compassion from our parents when it did surface. If you have ever seen a grown adult rolling on the ground when upset you know what I mean. Our interests, culture, upbringing, etc. will alter the intensity of pain and how we respond to it. This is why the question, “how would you rate your pain today from 0-10?” is a terrible question. That is like saying how much do you love your wife today? Be careful with that one. What you need to understand is that what we feel is a combination of both inputs and outputs.
A pain mechanism model. From Gifford (1998).
Tissue (muscle, tendon, fascia, ligaments bone): Following an injury, local inflammation will alert the brain that we may have a problem, or potential threat. Remember that the brain ultimately decides if that injury is worthy of pain, not the tissue. Consider a bruise that showed up on your arm without any recollection as to when it happened. The brain did not think it was meaningful enough at the time. For whatever reason, potentially your focus on something more important; yard work, work deadline, the chance to win gold in the olympics. If you recall the “Anatomy Lecture” we discussed above, we listed examples of less than perfect tissue quality that does not result in pain.
Environment: We need to consider the environment that the injury occurred in. Whiplash is a mechanism of neck injury that is common with car accidents. The recovery time tends to take a little longer than general neck pain. Interestingly, demolition derby drivers sustain whiplash regularly with only 1/40 drivers reporting any chronic neck pain (Simotas et al, 2005). The emotional impact of an injury can way heavily on the recovery time. We need to consider the role that emotional pain or stress is having on your physical pain. Emotional and physical pain is not distinct from on another.
Visual: Numerous studies have shown that visual input can impact pain. This is another prime example of the role that our software can have on what we feel. We can induce pain by making people think that we are turning up the dial on a sham muscle stimulator or the temperature gauge on a rod that is placed on the skin, even if we aren’t or even if the machine is not actually plugged in (Bayer, 1991; Moseley and Arntz, 2007).
Knowledge: Our knowledge of pain plays a significant role in what we feel. Our KNOWLEDGE shapes our BELIEFS, which shape our FEARS. If all this man knew of back pain before his own injury is that his uncle had a similar pain that resulted in a multilevel fusion this could understandably create a lot of fear. This fear leads people to often catastrophize a situation. He may automatically assume that he will also need surgery. This could lead to feelings of depression, imagining all of the wonderful things he will no longer be able to do. This depression and fear can lead to disuse. He may experience pain when exercising or lifting heavy objects. Now he assumes that no longer doing those things is the answer. Which leads to more depression, more fear and further physical decline (Louw et al., 2013).
(Vlaeyen and Linton, 2000)
Outputs are psychological and physiological changes that our software (brain) creates in response to the inputs. Remember that the brain’s number one mission is… SURVIVAL.
If for any reason it thinks it needs to protect you, it will.
Alarm System: Following your back injury at the unmentionable basketball game five years ago your brain beefed up the alarm system. It went from a low grade ADT alarm system to one of those things you see in a James Bond movie. With the software being all hot and bothered, we also see a change in many other systems in our body. We enter a “fight or flight” state, or a more sympathetic state. This can be helpful in the short term if escaping lions or getting through the last three miles of a marathon. However, in the long term constantly being in a “fight or flight” state can be costly to your body (Yanagida, 1995).
Cortisol Release: Adrenaline release during the acute phase of an injury (“fight or flight” state) will eventually shift to increased production of cortisol. Cortisol is a stress chemical that can increase local inflammation and swelling by stimulating our inflammatory system. Similar to achiness with the flu, you may feel discomfort at the original site of injury or in surrounding areas (Sapolsky, 1998).
Protective Mechanisms: As long as our software is under the impression that there is a threat, true or potential, it will ramp up protective mechanisms, like pain, limping and muscle stiffness to keep you “safe.” Or at least it thinks it is keeping you safe. Similar to your mom putting three coats on you before going out in the cold. With increased nerve sensitivity you see pain thresholds go down and even un-painful responses become uncomfortable. It seems illogical, but our brain wants to know what is going on. We truly become more sensitive to detect any potential threat (Moseley, 2003).
Brain Map: We now know that pain is not solely dependent on tissue. It also isn’t reserved to only one region of the brain. When we look at the brain under MRI while a person is experiencing pain, many areas will light up like a Christmas tree. Regions responsible for balance, coordination, sensation, memory, focus, mood, and so on. Everyone’s pain map is unique, which is why everyone’s experience with pain can be a little different.
Similar to practicing your lay up time and time again, the longer you are in pain the more you engrain this map in your brain. Any false information you have about pain can stimulate that pain map, strengthening it as if you are repeatedly practicing lay ups. Repeated fear and avoidance behaviors related to pain can strengthen the map even more (Moseley, 2003). Making it easier to experience pain. If pain used to set in after one hour of walking it may only take 20 minutes now. Worsening of pain does not mean that your injury has worsened or is not healing. Medical providers also tend to strengthen these maps. Inconsistencies in what you are hearing from provider to provider can cause confusion. The mission of this post, and website, is to provide you with accurate information. With the goal of minimizing the fear and uncertainty that can delay your progress.
This is why it is crucial that you understand how pain actually works. Enhancing your knowledge will lead to healthier beliefs, reduced fear, less disuse, less depression, and ultimately less pain.
Pain is messy. I truly believe that your understanding of pain, regardless of your hobbies, interests and athletic abilities can have a dramatic impact on your quality of life and your wallet. Remember that pain is a three part system.
- “The Anatomy”
- “The Mechanics”
- “The Software”
This understanding will allow you to face any injury that comes your way. We go into way more depth on this topic in a recent course that we created called “Understanding Pain: Debunking Pain Myths and Optimizing Your Health” that can be found here.
Other inputs that we will not touch on today, but are super helpful are returning to exercise, optimizing your sleep and diet, working on relaxation techniques to get you out of that “fight or flight” state and understanding good pacing strategies to get back to the lifestyle you want. All of this helps downgrade that sensitive alarm system. If you are interested in learning more about these inputs check out a free sample of our E-Course.
-Dr. Michael Infantino, DPT
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