I was recently having a chat with my good mate Alzan about opening my own physio practice. Once I finished talking, he asked me a question that very unexpectedly caught me looking for words.
“How do you fix people?”.
I didn’t have a straight and simple answer. I know the science of what I’m doing back to front. I know the assessments to perform to get the answers I need. I have a bank of treatment techniques and movement recommendations to get someone on the path to being pain-free and moving freely. But I couldn’t find the words to answer this simple question. Perhaps I didn’t have a straight forward answer because there isn’t one.
Some quick definitions of pain before I get started (borrowed from painaustralia.org.au):
Acute pain lasts for a short time and occurs following surgery or trauma or other condition. It acts as a warning to the body to seek help. It usually improves as the body heals.
Chronic pain lasts beyond the time expected for healing following surgery, trauma or other condition. It can also exist without a clear reason at all. Although chronic pain can be a symptom of other disease, it can also be a disease in its own right, characterised by changes within the central nervous system.
Note: In my opinion, the word ‘disease’ being used to describe chronic pain is an error. Chronic pain is merely an adaptation to persistent stimulus. An adaptation that is completely reversible. Like the hardening of the soles of the feet in response to walking without shoes; and the de-hardening when shoes are constantly worn.
Adaptation – a characteristic of a plant or animal that makes it able to adjust to the conditions of a particular environment.
If you can adapt into something, you can adapt out of it.
Figure shows the adaptation and de-adaptation of Hominina in response to persistent stimulus.
So, how do you fix people?
Acute pain is basically treated with the RICE acronym (rest, ice, compress, elevate) and followed up with some manual therapy and/or exercises to address any identified structural or muscular deficits to reduce the risk of re-injury. This is also the traditional physiotherapy model – often used on people with both acute and chronic pain due to a poor understanding of chronic pain physiology (ie. how chronic pain comes about).
Chronic pain cannot and should not be treated the same way as acute pain.
Chronic pain is multi-factorial. It often starts with an acute injury; however, this acute injury evolves and adapts to become something entirely separate from the original injury.
Factors that can play a part in the evolution/adaptation of pain are:
- Body structure – e.g. a narrowing of space in the spine that has the potential to cause nerve irritation.
- Functional ability – person’s ability to perform everyday tasks, like, picking up something from the floor.
- Recovery – giving your brain and body time to heal, through: a sensible daily movement practice, adequate sleep, adequate nutrition, healthy socialising, reducing stress.
- Perception – each person perceives things differently based on their understanding of each situation and therefore responds differently.
For example, a disc bulge:
To me, this means that the inner part of an intervertebral disc in my spine has herniated to a degree that may or may not cause nerve irritation, and the herniation will eventually resorb. A normal part of aging. The best way for me to recover is with gentle, pain-free movement and addressing other factors in my recovery as best I can.
To my regular patient – a part of my back has been squashed/crushed and is oozing out and squashing a nerve. I should avoid any and all movements of my back otherwise it will get much worse. I had a friend who had this and they had to: quit their job; lost their job; get surgery; are on a disability pension; etc.
Notice the difference in perception and how one could lead to more of an exacerbated response to pain than the other.
- Psychological – this has been somewhat addressed in the previous points, surrounding stress reduction, recovery and perception. Along with this, movement itself has an emotional aspect – movement feels good, bad, euphoric, crippling, empowering, embarrassing. Our emotions will contribute to our want to move.
- Environment – contributes to all facets of health: strengths, weaknesses, sleep, diet, community, and how much we want to move. A small apartment surrounded by other buildings, with a large couch directed at a large TV does not do much for encouraging movement. A sedentary lifestyle does not do much for encouraging recovery from pain.
This list could go on further still and in much more detail, but I will save that for a future Practice Point. I hope that what I’ve written so far covers the complexity and the multiple factors that lead to the adaptation towards chronic pain.
And now, how the nervous system (brain, spinal cord and nerves) adapts in chronic pain…very briefly.
The brain is capable of continuous learning and adaptation. Our brains can and do reorganise and form new neural connections throughout our life in response to new situations (e.g. learning an instrument). The term often used to describe this ability is neuroplasticity.
Due to the many factors mentioned earlier, your brain can reorganise its ‘pain networks’ so the messages it receives from the body are pain signals when it should be receiving movement signals.
The original injury may have completely healed structurally and inflammatorily weeks to months ago, but now, the body and brain have completely rewired and blurred the signalling. Resulting in pain that feels the same, if not worse, than day one of the injury.
Please do not confuse this with “It’s all in your head” because it is certainly not. It is all in your brain (and nervous system) however. And it is important to understand the difference. It is also important for your healthcare professional to understand this difference.
In your head means – you are thinking or imagining the pain and the pain manifests from your thoughts.
In your brain means – the signals that your brain is receiving from the body are from the nerves that send pain signals. As smart as we are, a pain signal can only be read as pain. There is no choice in the matter. The choice we have is – to educate ourselves on how best to recover, or, to see someone with expertise in the area that can educate us on how best to recover.
This may all sound daunting from a ‘being fixed’ perspective, but as I stated earlier if you can adapt into something, you can adapt out of it.
The best way I (and science) have found to reverse the nervous system’s adaptation towards an increased pain state is through optimising recovery and developing proprioception. Proprioception is the term used to explain our ability to sense our body’s position and movements, often referred to as our sixth sense.
How does this relate to chronic pain?
A typical person with chronic lower back pain can not perform movements of the pelvis and lower back due to an inability to sense the area. Coordination obviously plays a role too, but generally, the person can not sense anything but pain in the area when trying to move.
How does this relate to chronic pain?
Imagine a ‘battle of the nerves’ is occurring when you perform a pain-inducing movement, like bending forward. All different nerve types are sending signals at different strengths to be the overriding signal that the brain receives.
The person with chronic pain’s overriding signal is from the pain-signalling nerves (nociceptors). The person responds by stopping the movement as a threat to health has been detected.
The pain-free person’s overriding signal is from the movement-signalling nerves (proprioceptors). The response is to complete the movement as no threat has been detected.
Another way to think of it is like this – when you’re at a family lunch and all your aunties are talking to you at once. The auntie with the loudest voice will override the others and you will respond to her first…to ease the pain in your ears.
How does this relate to fixing pain?
Through a well-planned movement practice you can improve the signalling capabilities of your proprioceptors, so they become the overriding signal. That’s right, your proprioception can be improved, and this can happen at any stage of life.
Through commitment to rebuilding your proprioception via a movement practice, the negative adaptations that have occurred throughout your nervous system in the development of your chronic pain can be reversed…after all if you can adapt into something, you can adapt out of it.
And now, How I Fix People:
I learn their pain story.
I learn their lifestyle and the factors that may be contributing to their chronic pain.
I teach the physiology of chronic pain.
We plan how to best recover.
We develop a movement practice.
We commit to our recovery and practice.
Let’s get moving…