explaining pain
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Explaining Pain. Dr. Erik Pohlman, PT, DPT. Pain is a common problem!. 1 in 6 Americans live with persistent pain 1 Globally, 20% have pain > 3 months 2 Persistent pain costs ~$100 billion/yr 3. Definition of Pain. - PowerPoint PPT PresentationTRANSCRIPT
Explaining PainExplaining PainDr. Erik Pohlman, PT, DPTDr. Erik Pohlman, PT, DPT
Pain is a common problem!Pain is a common problem!
1 in 6 Americans live with persistent 1 in 6 Americans live with persistent painpain11
Globally, 20% have pain > 3 monthsGlobally, 20% have pain > 3 months22
Persistent pain costs ~$100 Persistent pain costs ~$100 billion/yrbillion/yr33
Definition of PainDefinition of Pain Pain is an “unpleasant Pain is an “unpleasant
sensory and emotional sensory and emotional experienceexperience associated associated with actual with actual or potentialor potential tissue damage.”tissue damage.”44
Old ModelOld Model
Painful stimulus→PAINPainful stimulus→PAIN
Tissue damage = painTissue damage = pain
How do we explain…How do we explain…
Phantom limb painPhantom limb pain even in those born without the limbeven in those born without the limb55
Painless battle woundsPainless battle wounds
Papercut hurting so muchPapercut hurting so much
Other ExamplesOther Examples
WWII vet – bullet in neck 60 years, he WWII vet – bullet in neck 60 years, he never knew!never knew!66
Surfers – feel a ‘bump,’ no more leg!Surfers – feel a ‘bump,’ no more leg!
These patients had no pain, weakness, or sensation changes!7
Find your age on the Find your age on the AAge in Yearsge in Years line then look up the chance line then look up the chance of a findings being present before your symptoms begin.of a findings being present before your symptoms begin.
AABBNNOORRMMAALL
DISC FINDINGS IN NORMAL SUBJECTSDISC FINDINGS IN NORMAL SUBJECTS
DISK CRACKSDISK CRACKS
DISCOGRAMDISCOGRAM
XX--RAY DJDRAY DJD
CT/ MRICT/ MRI--HERNIAHERNIA
OIL MYELOGRAPHYOIL MYELOGRAPHY
AGE 70AGE 70
AGE 42AGE 42
AGE 28AGE 28
AGE 23AGE 23AGE 35AGE 35 AGE 60AGE 60
AGE 51AGE 51AGE 30AGE 30
AGE 15AGE 15
AGE IN YEARSAGE IN YEARS00 10 2010 20 3030 4040 5050 6060 7070
100%100%90%90%80%80%70%70%60%60%50% 50% 40%40%30%30%20%20%10% 10%
0%0%
2525
7575
1515
6060
3434
100100 100100
4040
3030
Will this hurt?Will this hurt?
How about now?How about now?
Why?
ThreatThreat
Initially, the body only had to worry Initially, the body only had to worry about the nailabout the nail Nail→Threat→PAINNail→Threat→PAIN
When you are running from the lion, When you are running from the lion, the nail is the least of your worriesthe nail is the least of your worries Nail→Lion is bigger threat→Nail doesn’t Nail→Lion is bigger threat→Nail doesn’t
hurthurt Explains soldiers in battleExplains soldiers in battle
ThreatThreat
It is the It is the perception of the threatperception of the threat that that determines the output, not the tissue determines the output, not the tissue
damage itself or threat to the damage itself or threat to the tissues…tissues…88
Pain = Pain = OutputOutput
So how does pain really work?
Nociceptors (“Pain sensors”)Nociceptors (“Pain sensors”)
Mechanical, Temperature, and ChemicalMechanical, Temperature, and Chemical They tell the brain ‘danger’, They tell the brain ‘danger’, NOTNOT ‘pain’ ‘pain’
Brain determines if you should feel painBrain determines if you should feel pain
Body can add or subtract all over the bodyBody can add or subtract all over the body Replaced as often as every few daysReplaced as often as every few days
Current levels of sensitivity can and will Current levels of sensitivity can and will change!change!
SensitizationSensitization
Increased sensitivity Increased sensitivity after injuryafter injury Allodynia, Allodynia,
hyperalgesiahyperalgesia
Normal, but should Normal, but should fade after healingfade after healing
Persists in people Persists in people with chronic painwith chronic pain
Central SensitizationCentral Sensitization22
The spinal cord and brain cells are more The spinal cord and brain cells are more sensitivesensitive
You may notice:You may notice: Pain longer than normal tissue healing timePain longer than normal tissue healing time Spreading painSpreading pain Worsening painWorsening pain Even small movements hurtEven small movements hurt Pain is unpredictable (what hurts one day may Pain is unpredictable (what hurts one day may
not hurt the next, or thinking about it can cause not hurt the next, or thinking about it can cause pain)pain)
You have other significant ‘threats’ in your lifeYou have other significant ‘threats’ in your life
Homuncu-what?Homuncu-what?
HomunculusHomunculus
Map of body in the Map of body in the brainbrain
Phantom limbPhantom limb ‘‘Smudging’ in Smudging’ in
chronic pain and chronic pain and phantom painphantom pain
More chronic -> More chronic -> more smudgingmore smudging99
NeuroplasticityNeuroplasticity
Not to worry!Not to worry!
The brain and nervous The brain and nervous system are constantly system are constantly changingchanging Braille usersBraille users1010 and and
guitarists/violinists/celliguitarists/violinists/cellistssts1111
Brain CentersBrain Centers Not just 1 center or one Not just 1 center or one
input (like from the tissues)input (like from the tissues) Neurotag – many parts of Neurotag – many parts of
the brain activating in a the brain activating in a unique patternunique pattern22
Sensory, motor, memory, Sensory, motor, memory, emotion, autonomic emotion, autonomic nervous system, etc.nervous system, etc.
All parts light up in All parts light up in phantom painphantom pain
Danger signal, on its own, is NOT enough to produce pain!
Pain relies on contextPain relies on context
Perception of threat levelPerception of threat level modifies modifies pain according to the situationpain according to the situation
Finger injury in professional violinist Finger injury in professional violinist vs. dancervs. dancer1212
Whiplash from car accidentWhiplash from car accident
Thought VirusesThought Viruses
Thoughts are nerve signals tooThoughts are nerve signals too
Ever feel pain when thinking about Ever feel pain when thinking about the painful movement or watching the painful movement or watching someone else do it?someone else do it?
Anxiety about pain or disability can Anxiety about pain or disability can increase painincrease pain
What does this tell us?What does this tell us?
Pain comes from the Pain comes from the brain, brain, notnot muscle, muscle, tendon, disc, etctendon, disc, etc
and…and…HURT ≠ HARMHURT ≠ HARM
How can we fix our pain?How can we fix our pain?
Bed rest?Bed rest?
NO WAY!!!NO WAY!!!
Blood flow leads to healing and less Blood flow leads to healing and less painpain
Re-define that ‘fuzzy’ section in brainRe-define that ‘fuzzy’ section in brain Prevent atrophyPrevent atrophy
SurgerySurgery
Last resort, or when rapidly Last resort, or when rapidly progressing neuro symptomsprogressing neuro symptoms
CostlyCostly RiskyRisky
Infection, nerve damage, Infection, nerve damage, Still have a recovery periodStill have a recovery period May still not helpMay still not help
Plenty of people who still have Plenty of people who still have their pain after surgerytheir pain after surgery
MedicationMedication
Pain killers, anti-inflammatories, Pain killers, anti-inflammatories, muscle relaxers, etc.muscle relaxers, etc.
May or may not help symptomsMay or may not help symptoms Often won’t help the actual causeOften won’t help the actual cause
You are already well on your You are already well on your way!way!
Pain educationPain education Patients Patients cancan understand pain theories understand pain theories1313
Knowing pain physiology reduces threat levelKnowing pain physiology reduces threat level1414
……reducing sympathetic, endocrine, and motor reducing sympathetic, endocrine, and motor activity.activity.15,1615,16
Combining pain physiology education and movement Combining pain physiology education and movement therapies improves physical capacity, reduces pain, and therapies improves physical capacity, reduces pain, and improves quality of life!improves quality of life!1717
Evidence shows that pain education may even be better at Evidence shows that pain education may even be better at preventing pain than core stabilizationpreventing pain than core stabilization1818
Caution!Caution!
Don’t get hung up on anatomy!Don’t get hung up on anatomy!
Knowing more about pain leads Knowing more about pain leads to better results than knowing to better results than knowing more about anatomy (bones, more about anatomy (bones, discs, alignment, etc)discs, alignment, etc)1414
You have now learned that is You have now learned that is one (possible) part in the pain one (possible) part in the pain experienceexperience
Tone down that nervous Tone down that nervous systemsystem
Active RelaxationActive Relaxation Deep breathingDeep breathing Breathing with Breathing with
diaphragmdiaphragm Heat, ice, TENS, Heat, ice, TENS,
anything else that anything else that works for works for youyou
Graded exposureGraded exposure
Gradually increasing exercise, activity, Gradually increasing exercise, activity, and stimulation (desensitization)and stimulation (desensitization)
Re-teaches body/brain that Re-teaches body/brain that movements and stimulation are okmovements and stimulation are ok
Can also gradually re-expose yourself Can also gradually re-expose yourself to driving or the thing you were doing to driving or the thing you were doing when originally injuredwhen originally injured
Trick your nervous systemTrick your nervous system
Same movement, different contextSame movement, different context
Do the movement in a different wayDo the movement in a different way Change the position or what moves first, Change the position or what moves first,
do in water, etc.do in water, etc.
See your friendly local physical See your friendly local physical therapist to…therapist to…
Rule out more serious issues and refer Rule out more serious issues and refer you to the proper provider if one is you to the proper provider if one is foundfound
Determine if there is a mechanical causeDetermine if there is a mechanical cause Provide more pain educationProvide more pain education Provide treatments like manipulation, Provide treatments like manipulation,
dry needling, therapeutic dry needling, therapeutic movement/exercise, etc.movement/exercise, etc.
Points to rememberPoints to remember
Your pain is REALYour pain is REAL Imaging (Xray, MRI) may be misleadingImaging (Xray, MRI) may be misleading Bedrest and waiting for it to improve will Bedrest and waiting for it to improve will
likely not help and may make it worselikely not help and may make it worse Motion is LotionMotion is Lotion Pain is normal and it’s ok to feel some pain Pain is normal and it’s ok to feel some pain
with exercise if you have chronic pain with exercise if you have chronic pain alreadyalready
HURT ≠ HARMHURT ≠ HARM See your physical therapist!!!See your physical therapist!!!
(Strongly) Recommended (Strongly) Recommended ReadingReading
Explain Pain, by David Butler
Thank you!Thank you!
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