Did you know that at least 50% of people over the age of 50 with no back pain have evidence of disc bulges? Or that the severity of a rotator cuff tear shown on imaging does not correlate well with the amount of pain a patient experiences? Same goes for those with knee osteoarthritis. We’re beginning to realize that structural damage is not the only factor involved in pain, which is contrary to the often assumed damage=pain theory. This is incredibly important to know both as a doctor and a patient, and I’ll get into some of the information you should know below when it comes to managing your pain.
Defining pain
Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential damage. It is multi-dimensional and reflects central (brain and spinal cord) processes at many different levels.
Essentially, pain is a complex experience in which the body draws upon many different sources in order to determine whether or not it needs protection. These include your previous experiences, fears, thoughts, emotions, damage to that body part in the past, etc. Your brain takes all of this into account in determining how it needs to respond. For instance, the brain may activate pain signals in someone who’s had repetitive ankle sprains (who no longer has any structural damage) when they go past a certain range of motion. The brain does this because it feels like the ankle needs protection due to a fear of re-injury from past experiences. On the opposite end of the spectrum, it is relatively common for some people to realize they have a bruise without knowing how they got it. The brain did not feel like it needed to activate pain signals in order to protect itself in this case. This further drives home the point that even though tissue damage has occurred, pain does not necessarily go along with it.
Defining nociception
This is a process involving the direct stimulation of a specific type of nerve (nociceptors) which are stimulated in response to, for instance, touching a hot stove or being pricked by a sharp needle. These nerves send signals to the brain in response to something that may be harmful to the body, which leads to a pain response. This is important in protecting the body but as discussed above, pain can occur in the absence of stimulation of nociceptors. Interestingly, nociceptors can also become activated without being perceived by the patient, which could be reducing their ability to function optimally.
What this means for you as a patient
Understanding pain is experienced for many different reasons is a great start. Although knowing this may not help change how you’re experiencing pain right away, it can help spark a discussion with your healthcare provider in order to engage in a more accurate and effective treatment plan.
What this means for healthcare providers
Our wording with patients when it comes to describing their findings on imaging is important. Saying to a patient “you have a slipped disc” or “there’s evidence of degenerative disc disease” puts literal pictures of damage in their head which can influence how their system is responding (i.e. increased pain signals being sent to the area as a protective mechanism). When an MRI is done, as an example, it is fantastic at picking up anything that differs from the “norm”, but our job as practitioners is to understand that those differences aren’t always significant, and convey that message to the patient.
How I can help with your pain
The main way to modulate pain signals is to interact with the patient’s nervous system. I can accomplish this through various soft tissue techniques, as well as acupuncture with electrostimulation. This combination allows for stimulation of our peripheral nerves, and when the correct frequency stimulation is applied, non-painful muscle contractions occur. This non-painful contraction is sent as a message to the Central Nervous System (the brain and spinal cord) in order to have it understand that the nerve can and should be operating in a pain free way. The messages the brain sends back out to the body change (i.e. decreased pain response), allowing for more optimal functioning.
Below is a video demonstrating just that, with the stimulation of the superior and inferior gluteal nerves, which can be involved in back pain, glute pain, hip pain, etc. My goals for this particular treatment were much more than just pain reduction, but this gives you a sense of what a treatment might look like. Again, it is designed to be pain free in order to be effective.
Pain is a complex issue that is difficult to understand. As healthcare professionals we’re still keeping our eyes open for emerging studies to better understand the pain response. If you have further questions or would like a consult to discuss in more detail how I can help address your specific pain concerns, contact me to book an appointment.
References
1. Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015; 36(4):811-6.
2. McMahon PJ, Prasad A, Francis KA. What is the prevalence of senior-athlete rotator cuff injuries and are they associated with pain and dysfunction? Clin Orthop Relat Res. 2014; 472(8):2427-32.
3. Dunn WR, Kuhn JE, Sanders R, An Q, et al. Symptoms of pain do not correlate with rotator cuff tear severity: a cross-sectional study of 393 patients with a symptomatic atraumatic full-thickness rotator cuff tear. J Bone Joint Surg Am. 2014; 96(10):793-800.
4. Kuni B, Wang H, Rickert M, Ewerbeck V, et al. Pain threshold correlates with functional scores in osteoarthritis patients. Acta Orthop. 2015; 86(2): 215–219.
5. Glover TL, Horgas AL, Fillingim RB, Goodin BR. Vitamin D status and pain sensitization in knee osteoarthritis: a critical review of the literature. Pain Manag. 2015; 5(6):447-53.
