Breaking the cycle of chronic pain. What is chronic pain?
Upto one in five Canadian adults suffer from chronic pain. It affects one in five people globally and is the primary reason people seek medical treatment. In most cases, chronic pain starts with an acute injury or illness. Sometimes, what can happen, is that even after you’ve healed from an injury, surgery or other conditions, the pain continues. If the pain lasts longer than 3 months it’s then considered chronic pain.
Chronic pain syndrome can then be considered short term pain, or acute pain, that doesn’t go away and has a physical and psychological impact on a person’s life. Chronic pain syndrome often creates secondary complications such as sleep deprivation, depression, irritability and fatigue, affecting a person’s personal and social relationships.
What is Pain?
Pain functions as a warning signal. The nervous system senses danger and responds to it with actions called guarding responses, designed to protect and defend us from further injury or harm.
Muscle tension, decreased range of motion, anxiety, fear of movement, increased sympathetic responses (raised heart rate, increased blood pressure, change in respiration) and a mechanism called low pain threshold (becoming excessively sensitive to pain and minor impulse or stress to the body region cause pain) are all consequences of the guarding response. This is the way the body protects itself from future painful incidents.
In chronic pain, even after the injury has healed, this mechanism remains and continues to affect the body creating a vicious cycle of real pain.
Your Brain and Pain
When we adopt this instinct to guard ourselves against future pain, it actually does the opposite and keeps feeding your pain cycle and increasing symptoms including pain (scientific research “Pain Processing in the Human Nervous System: A Selective Review of Nociceptive and behavioral Pathways). This guarding mechanism is most likely to occur to those people that view their pain or condition as a threat, rather than something that just is and that in all likelihood can be overcome or at worst worked through towards acceptance and continuing on with life in as normal or your new normal way as possible.
Being extremely apprehensive about your injury and symptoms, avoiding activities believing that that may be harmful, stress and negative emotions are coupled with autonomic, endocrine, and immune responses which may amplify pain through a number of psychophysiological pathways prolonging your “fight or flight” response to the original injury. This will lead to a downward cycle of deconditioning, weakness, muscle spasms and/or tension, increased anxiety and depression.
What can Saanich Physiotherapy and Sports Clinic do to help reverse pain?
Part of our job as physiotherapists and massage therapists is to help you and guide you, our patients, to overcome any fear avoidance behaviour (learned fear), such as fear of movement, by using not only hands-on treatment, dry needling or exercises, to target your injury or pain, but to talk to, explain and assist you in understanding the way that pain and our brain works. We can help you to overcome or negate some of these non-helpful brain responses. By doing this we help you to down-regulate your brains protective response in order to minimise your pain experience.
Working with you in this 1:1 way, taps into your brain and nervous system. Your brain and nervous system is complex. We can work with you to change your neural pathways and learned patterns of thinking and beliefs that in turn produces more of your own natural brain chemicals like endorphins. This resetting and rebalancing, forming positive neural/brain connections, plays a large part in you overcoming your injury or pain experience.
Of course, each individual person is unique and we all come with our own history and life story that also plays a major part in how we experience pain and how we as therapists target your particular treatment. The way we think about our pain and ourselves, how we act and what kind of self-talk we undertake can all play a major role in the way that our Physiotherapists work with you, our patients who suffer from injury, pain, chronic pain, pain sensitivity, learned fear, anxiety, and depression.
What is Dry Needling?
Dry Needling is a specialised form of treatment that we use for reducing your pain and inflammation. Your trigger points are targeted with acupuncture needles to treat your pain, muscle tension, injury, and dysfunction. Dry Needling treatment is highly effective and you will often feel immediate pain relief as your muscles relax.
Common injuries treated with Dry Needling
Headaches & Migraine
Carpal Tunnel Syndrome
Hip & Knee Pain
How does Dry Needling work?
Needles are usually used to target painful trigger points in muscles. The penetration of the needle causes a micro-trauma that increases blood flow and alters the chemical balance in the muscle, assisting with muscle relaxation and healing.
The stimulation of pain receptors also causes the body to release opioids (e.g. endorphins). These are natural pain relievers in your brain. Their release provides further pain relief to you.
Your muscle may respond with a twitch response to the needle stimulation. This is a highly effective form of dry needling treatment and you often feel immediate benefits from this form of release. Your muscle releases tension and lengthens. Substance p, a pain chemical in your body, as well as inflammatory chemicals are eliminated around your trigger point. Flushing out these nasty chemicals can provide a longer lasting pain relief.
How is Dry Needling different to Acupuncture?
Acupuncture generally refers to the traditional Chinese medicine which is based on stimulating the flow of Chi (energy) through the meridians of the body, whereas Dry Needling is based on anatomical and neurophysiological principles. While the dry needles are the same and many of the ideas behind acupuncture are still applicable, the principles behind the use of Needling are very different.
Often people may use the term acupuncture when referring to Dry Needling so if you have had acupuncture in the past it could have been Dry Needles.
Is Dry Needling Physiotherapy safe?
Dry Needling Physio is very safe. There are certain factors that may make you unsuitable for Needling or that require extra care to be taken (e.g. Diabetes) but your Physio will consider these. All dry needles are sterile and used once before being disposed of safely in a sharps container.
Will Dry Needling Hurt?
One of the great advantages of Dry Needles over deep tissue massage for muscle release is that there is generally less pain both during and after treatment.
Most people don’t feel the insertion of the dry needle. When the needle penetrates the trigger point, you may feel an initial twitch or deep ache that quickly settles to become a light dull ache, warmth, heaviness or nothing at all. This is far better than the constant feeling associated with a firm massage that would be required to achieve an equal effect.
After Dry Needling Physio treatment there is often no or little soreness. Sometimes you may feel slightly tight, sore or an ache for a short time (up to 1-2 days). This again is invariably much less that than felt after massage and soft tissues techniques.
By Vanessa Service, Physiotherapist
What does my vestibular system do?
Your vestibular system’s job is to process sensory information that is required to control balance and eye movements. This means that information from the inner ear, the visual system, and from the muscles and joints is analysed by the brain. Integrating this information allows you to1:
– Maintain clear sight while you move your head,
– Figure out the orientation of your head in space in relation to gravity,
– Identify how fast and in which direction your are moving, and
– Make fast and automatic adjustments to your posture so you can maintain balance (stay in your desired position).
In other words, your vestibular system coordinates your movement with your balance, allowing you to navigate through and adapt to the world. It is this process that allows you to walk down the sidewalk, to step off a curb, to sit down and stand up again and to turn your head while walking. Anytime your head moves through space you’re depending on your vestibular system.
What are vestibular disorders and what are the symptoms?
If the vestibular system encounters disease or injury, such as a viral infection or head trauma, the result may be a vestibular disorder. However, aging, some medications, and genetic or environmental factors may also cause vestibular conditions.
Symptoms of damage to the vestibular system may include:
– Vertigo (a sense of the world spinning around you)
– Dizziness (feeling lightheaded or floating/rocking in space)
– Imbalance and special disorientation (stumbling, staggering, drifting to one side while walking)
– Difficulty with changes in walking surfaces
– Tinnitus (ringing or buzzing in the ears)
– Discomfort in busy visual environments (such as the grocery store) or when looking at screens/television
Examples of vestibular disorders include:
- Benign paroxysmal positional vertigo or BPPV (a common condition where loose debris or “crystals” collect in a part of the inner ear)
- Vestibular neuritis or labyrinthitis.
- Migraine associated vertigo
- Endolymphatic hydrops
- Acoustic neuroma
- Meniere’s disease
How can a vestibular physiotherapist help?
The effect of a vestibular condition on a person’s life can be profound. Dizziness and balance problems are often a barrier to activities of daily living, to independence, and to engaging with the community. This negative impact on daily function and socialization may also contribute to anxiety and depression. As such, appropriate management of vestibular conditions is an essential component to improving quality of life for individuals and families affected by vestibular disorders.
A vestibular therapist will interview you about the history of your symptoms and perform a series of vestibular, balance, and visual tests. Treatment will depend on what is found in the assessment. For example, if you are diagnosed with BPPV, your therapist will perform a manoeuvre to reposition the associated crystals. Other vestibular disorders are treated with specific exercises and strategies that your vestibular therapist will teach you and help you progress through to reach your specific goals.
Although for most people a vestibular disorder is permanent, an exercise based plan can be designed to reduce dizziness, vertigo, and balance and gaze stability problems1. This is made possible by your brain’s incredible ability to adapt its other systems in order to effectively compensate for an improperly functioning vestibular system. Vestibular rehabilitation is a non-invasive and drug free intervention that helps to promote and maximize the amount of compensation that occurs. Current research supports the use of vestibular rehabilitation in the management of vestibular conditions2, demonstrating reduced dizziness, balance issues, and increased independence with regard to activities of daily living 3. Additionally, no adverse effects associated with vestibular rehabilitation have been reported2. As such, vestibular rehabilitation can provide a pathway to improved quality of life for those living with a vestibular condition.
1. About Vestibular Disorders (n.d) Retrieved from https://vestibular.org/understanding-vestibular-disorder
2. Hillier SL et al., Vestibular rehabilitation for unilateral peripheral vestibular dysfunction, Cochrane Database of Systematic Reviews 3, 2011.
3. Cohen HS, Kimball KT Increased independence and decreased vertigo after vestibular rehabilitation. Otolaryngol Head Neck Surg 2003 Jan;128(1):60-70
Our spinal columns are made of twenty four vertebrae stacked one above another on the pelvis. They are joined together at the front by discs and at the back by facet joints. When we bend forward, the vertebra above tilts and slides forward, compressing the disc and stretching the facet joints at the back of the vertebrae. When we bend backward, the disc compression is reduced at the front and the facet joints are compressed at the back. In the upper neck and thoracic areas we tend to have more facet joint strains and in the lower cervical spine and lumbar spine areas, disc injuries are more frequent. This is because our upper spine joints allow us to turn our heads to see, hear and smell, so they need mobility but do not support much weight. Our lumbar spine bears around half our body weight and as we move and sit, there are huge, sustained, compressive loads on our discs.
CAUSES OF BACK PAIN
Disc injuries are the most common cause of low back pain and can range in severity from a mild intermittent ache, to a severe pain where people cannot move. Disc injuries occur mainly during sudden loading such as when lifting, or during repetitive or prolonged bending forces such as when slouching, rowing, hockey and while cycling. They are often aggravated by coughing and running. A flexed posture during slouching, bending or lifting is a frequent cause of disc damage because of the huge leverage and compression forces caused by gravity pulling down on the mass of the upper body.
It is important to understand that damage from small disc injuries is cumulative if discs are damaged at a faster rate than they can heal and the damage will eventually increase until it becomes painful. Pain sensing nerves are only on the outside of the disc, so by the time there is even small pain of disc origin, the disc is already significantly damaged internally where there are no nerve endings to feel pain with.
There may be a previous history of pain coming and going as the damaged area has become inflamed, perhaps was rested or treated, settled for a while but as the underlying problem was not fixed, the pain has flared up repeatedly since. This type of disc injury responds very well to Physiotherapy treatment.
A marked disc injury causes the outer disc to bulge, stretching the outer disc nerves. In a more serious injury, the central disc gel known as the nucleus, can break through the outer disc and is known as a disc bulge, prolapse or extrusion.
Spinal muscles are often blamed as the cause of spinal pain but this is rarely the cause of the pain. Muscle pain may develop as the muscles contract to prevent further damage as they protect the primary underlying painful structures. This muscle pain is secondary to the underlying pathology and when the muscles are massaged, given acupuncture etc, there is temporary relief but the pain will often come back, as the muscles resume their protective bracing. Treatment must improve the structure and function in the tissues which the muscles are trying to protect. The most common sources of primary pain are the discs, facet joints and their ligaments.
There are four facet joints at the back of each vertebra, two attaching to the vertebra above and two attaching to the vertebra below. A facet joint strain is much like an ankle sprain and the joints can be strained by excessive stretching or compressive forces. The joint ligaments, joint lining and even the joint surfaces can be damaged and will then produce pain.
Facet joint sprains can occur during excessive bending but typically occur with backward, lifting or twisting movements. Trauma such as during a car accident or during repetitive or prolonged forces such as when slouching or bowling at cricket.
There are many other sources of back pain including arthritis, crush fractures and various disease processes. Your Physiotherapist will examine your back and advise you should further investigation be necessary.
SYMPTOMS OF BACK PAIN
Symptoms of structural back pain are always affected by movement. This is important to understand. Symptoms, usually pain but perhaps tingling and pins and needles, are often intense and may be sudden in onset but also may be mild and of gradual onset. There are other conditions which can produce back pain such as abdominal problems, ovarian cysts and intestinal issues. If you have symptoms in these areas which are not affected by movement, you must consult with your doctor. If you have chest, jaw or upper limb pain which is unaffected by movement, you must attend your doctor or hospital immediately.
Facet joints, discs, muscles and other structures are affected by our positions and movements. More minor problems produce central low back pain. With more damage, the pain may spread to both sides and with nerve irritation, the pain may spread down into the thigh or leg. As a general rule, disc pain is worse with bending, lifting and slouching and facet joint strains are worse twisting and bending backward or sideways. A severe disc problem is often worse with coughing or sneezing and on waking in the morning.
DIAGNOSIS OF BACK PAIN
Diagnosis of back injuries is complex and requires a full understanding of the onset history and a comprehensive physical examination. It is important for your Physiotherapist to establish a specific and accurate diagnosis to direct the choice of treatment. In some cases, the pain may arise from several tissues known as co-existing pathologies and each of these are treated as they are identified. Where the Physiotherapist requires further information or the management may require injections or surgery, the appropriate x-rays, scans and a referral will be arranged.
UPPER BACK AND LOWER BACK PAIN RELIEF
Eighty percent of adults will experience severe spinal pain at some time in their life. Much of this pain is called non-specific low back pain and is treated with generic non-specific treatment. This type of treatment often fails to provide lasting relief. However, Musculoskeletal Physiotherapists have developed specific diagnostic skills and specific treatment techniques, targeted to specific structures. We identify the structure and cause of the pain producing damage and develop specific advice and strategies to prevent further damage and promote healing.
Specific techniques are chosen to correct the structural and mechanical problems. Among many choices, treatment may include joint mobilisation, stretching, ice, strengthening and education. As normal tissue structure and function returns, there is a reduction in the inflammation and the pain will subside.
When normal movement has been achieved, the inflammation has settled and the structures have healed, your new strategies will reduce the possibility of the problem recurring. We use this specific approach to reduce or stop chronic pain.
While we have the choice to manipulate, adjust or click joints, patients with ongoing pain will seldom benefit from repeating these techniques. This is because our tissues are elastic and the benefit of the quick stretch of manipulation is lost, as the elastic tissues tighten and shorten again. Adjustments of this type have little long term benefit and often lead to an unhealthy dependence on the provider. Your Physiotherapist will choose a safer and more appropriate treatment for you.
PROGNOSIS OF BACK PAIN
Physiotherapy for back pain can provide outstanding results but it is a process, not magic. The damage which produces pain in a back takes time to develop and also time to repair and heal. You will understand there are often several interacting factors to deal with and patient compliance is necessary.