Do you suffer “Chronic Pain”?
Do you feel misunderstood and frustrated?
Here at Saanich Physio we want you to remember, the concept developed by Mosely and Butler (2017): All pain is normal, all pain is a personal experience and all pain is real.
The International Association for the Study of Pain (IASP) has classified chronic pain as “pain that persists or recurs for more than three months” (which is longer than the expected healing time of soft tissue), with the exception of pain experienced after some surgeries and some types of traumatic injuries (International Association for the Study of Pain, 2016).
To understand chronic pain, we have to understand why we can have such intense, debilitating pain, when health professionals classify our tissues “normal”.
First we will explain a little bit about inflammation and the nervous system.
Inflammation is the body’s amazing, natural, healing process whereby blood flow to a site of injury is increased and chemicals are released into the area to start healing. Symptoms of inflammation include pain, redness, swelling and heat in the area.
The Nervous System
Nerves originate in our brain and spinal cord. There are two types of nerves.
Sensory nerves: Detectors which help us to understand what is going on around us and keep sending messages, or inputs, to the brain and spinal cord, to make us aware of our environment and inform us whether it is safe or potentially dangerous. Sensory neurons have input in to the brain and spinal cord.
Motor nerves: Action causers, which cause us to move, by activating appropriate muscles or glands to release appropriate hormones. They also cause the spark of thoughts, behaviours and beliefs. Motor nerves are responsible for causing our actions based upon the brain and spinal cords calculations and are outputs.
It is hard to believe that pain is actually generated in the brain and is an OUTPUT released when harm is detected.
Basicially, when danger is detected, the brain and/or spinal cord send pain to that area, so in turn we protect the threatened tissue by changing our behaviours or positions, for example by limping to reduce weight bearing on a potentially broken foot (Littlewood et al. 2013), or moving our hand away from a flame.
It highlights that danger detected by sensory nerves from both our environment and our tissue, are sent up the spinal cord to the brain. The brain and spinal cord assess the incoming signals and produce an appropriate output to adapt to remain as safe as possible.
The brain then interprets this information, and determines whether our tissues are in danger or not. If it suspects we are in danger, it produces an output depending on whether we need to protect ourselves or not e.g. movement away from danger, or feel pain in those tissues so that we stop using them.
There are three biological mechanisms that can cause an output of pain to be produced:
Nociception (the detection of danger): the exposure of tissues to harmful stimuli occurs. These stimuli can be: chemical, mechanical (overstretch or compression of tissue leading to damage) or thermal (tissue that is too hot or cold) (Smart 2012b).
Central sensitization: a dysfunction within the brain and spinal cord is occuring, so that safe, incoming signals are interpreted as harmful (Smart & Keith 2012)
Peripheral neuropathy: there is damage to the peripheral nerves themselves (all nerves outside of the brain and spinal cord) (Smart 2012a)
It is also important to understand that high stress has also been indicated to increase pain, delays recovery and increases risk of chronic pain development (Lentz et al. 2016).
The next fact is something commonly mistaken.
The amount of pain we feel rarely reflects how much tissue damage there really is (Moseley and Butler 2017).
Think about a paper cut, and how painful this can be. Compare this to cases where people have had their entire leg bitten off by a shark, and have not felt a thing. This is all due to the analysis by the brain and spinal cord of the situation and their believed best response to produce outputs that are most likely to protect the person and give them the best chance of surviving at that given time of detected danger.
Now we will discuss two different types of injury that can occur, both which cause significant pain, yet both which have very different mechanisms of reasons why pain is caused.
Pain reported by a person with a recently broken bone, usually relates well to the extent of the tissue damage and the dominant mechanism responsible for the pain output is nociceptive pain (danger detection through chemical and mechanical changes in the tissue).
MECHANISM – FRACTURE (NOCICEPTIVE PAIN)
Bone tissue breaks due to an inability to withstand the intensity, speed and direction of an applied force. It can be caused by trauma, stress, bone weakness or disease (Westerman & Scammell 2011). Trauma causes sensory nerves to detect a harmful change in shape of tissue, which sends danger signals to the brain and spinal cord. It also causes the release of chemicals that cause inflammation to occur – to kick-start the healing process (Birklein & Schmelz 2008). This sends further danger detector signals to the brain and spinal cord. The brain and spinal cord process the input, identifies threat and outputs pain.
On the other hand, the degree of pain reported in chronic tendinopathy, does not always relate well to the extent of peripheral tissue damage or pathology, and the dominant biological mechanism responsible for the pain output can be central sensitisation (safe, incoming signals becoming interpreted as harmful by the brain and spinal cord).
MECHANISM – CHRONIC TENDINOPATHY (CENTRAL SENSITISATION PAIN)
Chronic tendinopathy, is an umbrella term for a number of conditions, and refers to a combination of pain and impaired performance of a tendon, which have lasted longer than 3 months (Seitz et al. 2011).
Non-chronic (acute) tendinopathy occurs when there are mechanical changes to the tendon. They are caused by external or internal factors, or a combination of both. Externally, tendon compression occurs, while internally, degeneration occurs (Seitz et al. 2011), both result in inflammation. Therefore both mechanisms produce the detection of harm at the environment and tissues due to chemical and mechanical changes and send this input to the spinal cord and brain, which then outputs pain to the area.
Amazingly, evidence suggests people experiencing chronic tendinopathy can have minimal or no inflammatory cells in the painful tendons. This suggests there is another reason for their brain to produce an output of pain: an altered processing of input within the brain and spinal cord, so that a threat is still detected despite little tissue damage (Littlewood et al. 2013), this can be caused by a range of things, including previous experiences with pain.
For example, if you once had a back injury, and it was painful every time you bent forward, the central nervous system may now associate bending as dangerous and therefore outputs pain to that same area in your back to feel pain before any tissue damage can occur, as a prevention and protection strategy.
Due to the differences in nature of the pain experienced with both conditions, the management strategies for both of these conditions differs substantially.
If you found any of this information useful or intriguing and would like to learn more about your pain and you would like to make an appointment with one of our physiotherapists, contact us.
How Can I Prevent Back Pain?
The latest research tells us that often people have never had a physical trauma to cause back pain like a car accident, falling, or lifting something heavy. There are usually a combination of factors that cause back pain which could include overuse, poor posture or other stressors.
Keeping in mind everyone is different, here are some expert tips:
Exercise! you can’t escape it, exercise is important for so many reasons, but a big one is preventing back pain. Muscles are meant to move. If you aren’t in good shape, you’re more likely to hurt your back and feel pain when you do even simple movements, such as getting out of the car. Exercise helps keep your joints fluid and your muscles strong.
Core & glute strength a regular strength-training routine that focuses on training your muscles to work together can help support your spine. Core muscles include your pelvis, lower back, hips and abdomen. Strong, activated glute muscles help protect your back from activities such as lifting a heavy object.
Eat well healthy eating habits can keep your weight down. Being overweight can put added strain on all of your joints, especially your spine.
Posture awareness be aware of how often you slouch over your laptop and iphone when texting. Take the time to take a break from long periods in front of the computer with a simple walk around the block or some hip-flexor stretches.
Reduce stress stress can impact your level of pain. Stress causes you to tense your muscles and constant tension can cause back pain. Take up a hobby or regular activity that helps you relax.
Sleep style for most, sleeping on your back can put pressure on your spine, pop a pillow under your knees to reduce this. If you’re a tummy sleeper, put a pillow under your pelvis. Side sleeping is generally the best way to go (but everyone is different!)
Lower back pain can be debilitating and can have a major effect on your daily life and work activities. Don’t let that happen to you, put in place some positive things today.
Physiotherapists are experts in the assessment of musculoskeletal injuries, especially spinal related pain, that’s why we can help you. We can help you with a strengthening home/gym-program for whole-body awareness, strength and posture improvements.
Does running accelerate the development of osteoarthritis?
There are so many misconceptions about running and how bad it can be for your joints. You may have heard many friends and family members comment on this and they may have even tried to convince you to stop running and go swimming instead. Here is what the scientific research tells us so far:
Osteoarthritis (OA) is a musculoskeletal condition that involves degeneration of the joints and impact during weightbearing exercise such as running and may contribute to joint loads. There is very little evidence however, that running causes OA in the knees or hips. One study reported in 1985 by Sohn and Micheli compared incidence of hip and knee pain and surgery over 25 years in 504 former cross-country runners. Only 0.8% of the runners needed surgery for OA in this time and the researchers concluded that moderate running (25.4 miles/week on average) was not associated with increased incidence of OA.
In another smaller study of 35 older runners and 38 controls with a mean age of 63 years, researchers looked at progression of OA over 5 years in the hands, lumbar spine and knees (Lane et al. 1993) . They used questionnaires and x-rays as measurement tools. In a span of 5 years, both groups had some participants who developed OA- but found that running did not increase the rate of OA in the knees. They reported that the 12% risk of developing knee OA in their group could be attributed to aging and not to running. In 2008, a group of researchers reported results from a longitudinal study in which 45 long distance runners and 53 non-runners were followed for 21 years. Assessment of their knee X-Rays, revealed that runners did not have a higher risk of developing OA than the non-running control group. They did note however, that the subjects with worse OA on x-ray also had higher BMI (Body Mass Index) and some early arthritic change in their knees at the outset of the study.
Is it better to walk than to run?
It is a common belief that it must be better to walk than to run to protect your joints. In a recent study comparing the effects of running and walking on the development of OA and hip replacement risk, the incidence of hip OA was 2.6% in the running group, compared with 4.7% in the walking group (Williams et al 2013). The percentage of walkers who eventually required a hip replacement was 0.7%, while in the running group, it was lower at 0.3%. Although the incidence is small, the authors suggest the chance of runners developing OA of the hip is less than walkers.
In the same study, Williams and colleagues reinforced that running actually helped keep middle-age weight gain down. As excess weight may correlate with increased risk of developing OA, running may reduce the risks of OA. The relationship between bodyweight and knee OA has been well-established in scientific studies, so running for fitness and keeping your weight under control is much less likely to wear out your knees than being inactive and carrying excess weight.
Is there a limit?
Recent studies have shown that we should be doing 30 minutes of moderate exercise daily to prevent cardiovascular disease and diabetes. But with running, researchers still have not established the exact dosage of runners that has optimal health effects. Hansen and colleagues’ review of the evidence to date reported that the current literature is inconclusive about the possible relationship about running volume and development of OA but suggested that physiotherapists can help runners by correcting gait abnormalities, treating injuries appropriately and encouraging them to keep the BMI down.
We still do not know how much is “too much” for our joints. However, we do know that with age, we expect degenerative changes to occur in the joints whether we run or not. Osteoarthritis is just as common as getting grey hair. The important thing is that we keep the joints as happy and healthy as possible.
How do you start running?
If you are not a runner and would like to start running, walking would be a good way to start and then work your way up to short running intervals and then longer intervals as you improve your fitness and allow time for your body to adapt. Therefore, running in general is not bad for the joints. It does not seem to increase our risk of developing OA in the hips and knees. But the way you run, the way you train and how fast you change your running frequency and distance may play a role in future injuries of the joints.
Physiotherapy For Back Pain
Back problems are the third most common reasons for taking time off work behind the common headaches and colds and are also the second most common reason people go and see their GP. It is believed that approximately 8 in 10 people in western countries suffer from some form of back pain at least occasionally.
Back pain or back ache is a symptom that can arise from many causes including arthritis, muscle and ligament strains, disc lesions, osteoporosis, sciatica and stress. Many cases of upper and low back pain and sore backs in general are caused by stresses on the muscles and ligaments that support the spine. Back pain affects patients of in the neck (cervical spine), mid back (thoracic spine) and lower back (lumbar spine).
At Saanich Physio we deal with a high volume of cases of back pain/injuries and have a proven track record to providing good relief! Our staff here are specially trained in dealing with back related issues whereby digital spinal analysis, X-rays and a comprehensive physical exam are utilized to determine the exact cause of the back pain. We know that everyone is different and therefore we tailor a management program that best suits you! A ‘generic’ treatment formula simply won’t work if you want to stop your pain from coming back.
Here at Saanich Physio we also take a research based ‘holistic’ approach to one’s back problems; as such we also consider and give advice on lifestyle factors that can contribute to back pain. Majority of cases of back pain are aggravated by lifestyle factors, including lack of exercise, schoolbags, being overweight/obese, sedentary lifestyles, poor posture, stress and bad work practices. In relation to obesity – we can also provide superior quality weight loss supplements to assist in this area. We address all of the contributing factors to prevent the pain in your back from coming back for good. Many back pain ailments can be addressed easily and quickly but those with serious and chronic back pain often benefit from an ongoing maintenance program.
Physiotherapy to prevent relapses and worsening of symptoms
Simply, our Back Program is a tailored treatment program to address the exact cause of your problems and to get you back to your favourite activities fast! So if your back is holding you back from sport, occupation and other activities or you just simply have pain whilst sitting or getting in/out of your car then our Better Back Program may be the answer for you!
Our Back Program involves an initial assessment with one of our highly skilled physiotherapists. You will also receive a detailed report at the beginning and conclusion of your back therapy to show your progress and your family doctor and relevant specialists will receive a copy also so that everyone in your medical team helps you move towards being fit and painfree.