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.
Headaches are experienced by most of the population at some point in their lives. For most they are minor and fleeting, and for others they pose an ongoing problem, having complex underlying causes. Types of headaches vary greatly and determining their root cause can be difficult. Having a greater understanding of how these types of head pain are categorised, can at least provide a starting point for minimising the impact headaches have on daily life.
One thing that is certain for all headaches, is that the pain is not felt from the brain. The brain receives pain signals from the nervous system, yet it is one organ of the body that does not have pain receptors. Rather it is the interactions between blood vessels and surrounding nerves in the structures in the head, neck or elsewhere, that send pain signals to the brain, which make a headache felt.
These pain sensations come in a variety of styles, so classifying types of headache is important in determining the appropriate treatment. There are two main categories of headaches, those being primary and secondary. The most common headaches are primary where the headache is the cause of the pain, as opposed to a secondary headache where there is an underlying medical condition.
Infection such as meningitis or a brain bleed due to trauma are examples life threatening secondary headaches. They can also derive from less severe conditions, for example medication overuse and issues relating to the structures of the head, such as the sinus region. Conditions of the head, neck, and even the the stomach or intestines, that are inflammation, trauma, illness or disease related, may also cause headaches.
As one of the most common ailments we experience, the symptoms and pain experienced will vary greatly. Although types of headaches are classified into groups, this is only a rough guide. There is much crossover regarding symptoms between one category and another, which makes headaches difficult to diagnose. This is where some deductive reasoning comes into play in differentiating one type of headache from another, especially considering there are over two hundred documented types of headaches.
Main types of headache
Tension, migraine or cluster are the main types of primary headaches. Migranes can be very debilitating, and often are accompanied by other symptoms such as nausea, vomiting and are often only felt on one side of the head. They can also be accompanied by an aura, which is a visual disturbance such as seeing sparkles or dots. There may also be feelings of anxiety, sensitivity to light or sensations that effect the limbs or stomach.
Unlike a migraine where these sensations can forewarn the onset of a headache, the cluster comes on suddenly, yet departs as quickly as it arrived. As they are one of the most painful headaches, it is fortunate that they are not as common. The name for this type of headache derives from them appearing as a cluster of short but intense pain, that occur in cycles over a period of a few weeks or months.
These characteristics help differentiate between a migraine, cluster and the most common of all headaches, which relates to tension. A tension headache is less severe and often caused by muscle contraction in the head and neck region. It presents as a tightness or pressure across the forehead, like a tight strap, with pain described as a dull ache. A sensitivity to loud noises, muscles aches on the side or back of the head, or even tenderness when touching the scalp, neck or shoulders, can be other indicators of this type of headache.
Developing tension headaches can be due to stress, anxiety or strain on the muscles over a long period of time, such as staring at a computer screen, especially one that has not been ergonomically positioned. Sitting for extended periods, lack of sleep, poor eating habits or chronic stress can all contribute to tension headaches.
So neck strain is one of many sources of a primary type tension headache. Yet the neck can also be the source of referred pain from a type of secondary headache, known as cervicogenic headaches, with ‘cervicogenic’ meaning originating from the neck. This upper most section of the spinal cord, known medically as the cervical spine, also involves the connected muscle, tendon and nerve structures that surround the neck and head region.
As cervicogenic headaches can refer pain to the head rather than being felt in the neck, it can sometimes times be hard to differentiate them from other types of secondary headaches. The names of these secondary headaches are prolific, but often have descriptors preceding the word ‘headache’ that indicate the root cause, for example ‘caffeine’, ‘pregnancy’ or ‘medication overuse’. For other types of secondary headaches, determining less obvious causes is something that can be assisted with the help of both the patient, and the health professionals involved.
Head pain and deductive reasoning
Sometimes the headaches we experience can be explained by a simple cause and effect. Overindulging in wine, staring at a screen for too long or lacking hydration are all self apparent causes for a basic headache. Then in hindsight, avoiding these triggers can then be the best prevention.
Some causes though will require a little more detective work, and a diary can be very helpful for when the headache is evaluated in a consultation. This record should contain a history of the headaches, with a date, a start and finish time, along with any other symptoms that accompany the pain, such as a fever, an upset stomach or the location of muscular aches. A description of the type of pain, such as ‘throbbing’ or ‘sharp’ can be added, as well as the pain severity on a scale of one to ten, ten being to the point of being incapacitated.
Further detail can be added to the diary such as foods or liquids consumed, including medication or supplements being taken. Quality of sleep, physical or emotional stressors at home or work, daily activities and conversely time spent at a desk inactive, are also important in pinpointing any potential triggers.
Even with these records, primary headaches are more difficult to tackle compared to secondary headaches, as determining the root cause of migraines and cluster headaches is often unclear. However when a headache is due to tension or referred pain from bone or soft tissue of the neck, physiotherapy treatment can offer some assistance.
Headaches relating to physiotherapy
Determining whether a headache is originating from the neck region, may or may not be obvious as symptoms for each type of headache overlap. For example a tension headache and a cervicogenic headache can both be accompanied by pain in the scalp, neck and shoulders.
How a headache differs may help in its diagnosis as to which type of headache is being experienced. For example a cervicogenic headache may be felt at the back of the head, the top of the skull, forehead, temple or behind the eye, as opposed to a tension headache where a band like pressure is felt across the forehead, back or sides of the head.
Unlike a tension headache a direct connection with the neck may not be experienced with a cervicogenic headache, instead there may be feelings of dizziness, nausea or poor concentration. Either of these headaches could start or be increased in severity by head movement or a prolonged posture, and a reduced range of motion of the neck may also be an indicator.
The underlying cause of a cervicogenic headache can either be a problem with the vertebrae immediately below the skull or the soft tissues of the neck. It could also be due to a strain or injury, and even long term conditions such as degenerative disc disease of the neck’s vertebrae.
To make matters more complex, what appears to be a cervicogenic headache, may in fact be occipital neuralgia. This is when the nerves that run from the top of the spinal cord and up through the scalp, become inflamed or damaged. Regardless of the type of headache, a physical examination provides a starting point from which further investigation may involve X-rays, scans and imaging to provide a clearer view of the neck’s structures. If nerve pain is experienced as part of the headache, a nerve block injection may be organised where appropriate, to help diagnose the cause and treat the condition.
Treatment of neck related headaches
Any neck treatment is a delicate matter because of the complexity of its structure. The vertebrae of spine at this point are smaller than those lower down the back, and so support of the head relies on a complex layering of muscles. Muscles closest to the spine are shorter, typically connecting one bone of the spine to another, while further away from the spine, muscles are generally broader and longer, spanning more joints and connecting more parts of the body. As such any of these can be injured as can the connective tissues, such as ligaments and tendons. Further to this the cartilage that assists in the smooth action of the neck can degenerate, as can the joints through arthritis which can lead to headaches and neck pain.
The complex interaction of nerves and bone joints at the junction of the upper spine and skull provides multiple points of potential injury as well. Nerve compression can cause inflammation and pain, whilst the upper spinal vertebrae are susceptible to compression and movement injuries such as bone spurs or a bulged disc, that can in turn impinge nerves. Thankfully nerve pain from the spine can be mapped, as general areas of the skin are mostly supplied by a specific nerve, that can be traced back to its root in a spinal segment. For example the second and third vertebrae of the cervical spine cover the areas or ‘dermatomes’ on the back half of the head. So head pain felt in these areas may provide an indicator to damage within the second or third vertebrae.
With physiotherapy, an assessment can help differentiate which type of headache is being experienced, and where appropriate, treatment can be very effective in managing headaches of a neck related origin. A physiotherapist can assess the joints of your neck, associated muscle and nerve structures, to identify any abnormalities. Along with the diary, any previous trauma to the neck region, such as whiplash, can also be taken into consideration.
Depending on the specific presentation and symptoms of neck related headaches, physiotherapy management may include joint or soft tissue mobilisation and exercise. Joint mobilisation can be used to help unlock or loosen stiff vertebrae, whilst dry needling, massage and the prescription of strengthening exercises can address tight or weak muscles, and restore stability to the neck area. A physiotherapist can also look at posture and general ergonomic improvements, as these can have a significant impact on headache development and its recurrence.
Ongoing management can involve postural advice and correction, which could include an ergonomic assessment or general advice regarding the setup of your work place. To compliment the hands on therapy and exercise prescription provided by a physiotherapist, stress and tension management may also include assistance in seeking out relaxation techniques or taking up classes such as yoga, that incorporate meditation.
Short term Flare ups
For short term flare ups a hot or cold pack can be used until your next appointment. The use of over the counter pain medication should be in moderation, for example less than three days a week, and preferably after advice from your physiotherapist or doctor. Too much medication can cause what is known as a ‘rebound headache’. This is where medication is taken to cope with the head pain, that reappears after an analgesic or painkiller used for a headache, wears off. So paradoxically the headache is the result of withdrawal from the very drug, that is supposed to stop the head pain.
Ultimately treatment for a headache should lead to self management through understanding of the stressors that initiate a headache. Broader lifestyle changes such as a balanced diet, regular sleep and exercise can also have a positive influence of the recurrence, duration and intensity of a headache, be that neck related or otherwise.
Back Pain solutions with Saanich Physio
Back Pain Victoria – Back pain or back injury is a very common condition that we treat on a daily basis. Saanich Physio has a particular interest in treating your back pain by providing quality, effective hands-on Physio & exercise solutions for your back pain.
Back Pain Physio
Once we have your acute back pain under control with hands-on treatments we work with you to rehabilitate and restore the function of your back muscles and spine. All our Physiotherapists will work with you on exercises for your back pain, as we believe self -management strategies are key to the prevention of recurrent back pain episodes.
At Saanich Physio our approach to your back pain is holistic and your back pain physiotherapist will work with you on improving areas such as posture, sleep, lifestyle, work ergonomics, stress reduction, hobbies or your current sports or exercise regimes. We may also discuss the impact of additional factors like heavy schoolbags, lack of exercise or a sedentary lifestyle.
Back Pain – What causes it?
80% of the Canadian population will suffer from back pain at some point during their lives. It is the third most common reason people take time off work after colds and flu. Lower back pain can originate from many causes. Your back pain can originate from your lumbar spine discs, spinal facet joints, arthritis, back muscle strain, back ligament strain, muscle spasm, bony spurs or growths, pinched nerves, irritated nerves, osteoporosis, sciatica and stress just to name a few.
Back Pain – why do I have it?
Some of the most common reasons for back pain are incorrect lifting techniques, repetitive bending, poor posture, prolonged sitting as well as weakness in your core stabilising muscles
Back Pain Victoria – Signs and Symptoms
Back Pain can affect the lower, thoracic or middle back or upper back neck.
Back Pain is often described as one or more of the following:
- Local sharp pain, dull ache or burning pain
- Pain that radiates into your hip, groin or buttocks
- Pain that is aggravated by sitting, standing, bending forward or backwards, twisting or walking
- Pain that travels down your leg to your thigh, calf, ankle or foot
- Pins and needles or numbness travelling into your legs and /or feet
- Weakness of your leg muscles
- Pain associated with loss of bladder or bowel control
Back Pain Victoria – Will Physio help me?
Hands-on Physio treatment for back pain will vary according to the cause of your back pain. In addition to soft tissue techniques and joint mobilisations, we may use dry needling for back pain, taping or bracing to support your spinal muscles, heat or ice therapy and suggestions for medications for reducing your pain and inflammation. Your back pain Physio may refer you for appointments for x-ray, CT scans or MRI to assist in diagnosing your back pain if required. We can liaise directly with the radiologist for scans and or steroid injections.
Non-Specific Back Pain
Degenerative Disc Disease
Stiff Lumbar Joints
Discogenic Back Pain including-
Bulging Disc, Prolapsed Disc & Herniated Disc
Spinal Canal Stenosis
Thoracic-Upper Back Pain
Sacroiliac Joint Pain
Back Sprains and Strains
Pregnancy-related Back Pain
Physiotherapy to prevent relapses and worsening of symptoms
Make a booking today to get your back pain under control. Click our Book Now Button for an appointment today.
A blog by Amy Mathews Amos- See below
My symptoms started in January 2008, with deep pain in my bladder and the sense that I had to urinate constantly. I was given a diagnosis of interstitial cystitis, a chronic bladder condition with no known cure. But in the following months, pain spread to my thighs, knees, hips, buttocks, abdomen and back. By the time my condition was properly diagnosed three years later, I had seen two urogynecologists, three orthopedists, six physical therapists, two manual therapists, a rheumatologist, a neurologist, a chiropractor and a homeopath.
What was wrong? Something completely unexpected, given my symptoms: myofascial pain syndrome, a condition caused by muscle fibers that contract but don’t release. That constant contraction creates knots of taut muscle, or trigger points, that send pain throughout the body, even to parts that are perfectly healthy. Most doctors have never heard of myofascial pain syndrome and few know how to treat it.
In my case, trigger points in my pelvic floor — the bowl of muscle on the bottom of the pelvis — referred pain to my bladder. Points along my thighs pulled on my knee joints, creating sharp pain when I walked. Points in my hips, buttocks and abdomen threw my pelvis and lower spine out of alignment, pushing even more pain up my back. The pain was so severe at times that I could sit for only brief periods.
“Why didn’t anybody know this?” I asked my doctor, Timothy Taylor, soon after he correctly diagnosed the reason for my pain. “Because doctors don’t specialize in muscles,” he said. “It’s the forgotten organ.”
‘There’s no wire’
Most medical schools and physical therapy programs lack instruction in myofascial pain, in part because it involves referred pain, according to Robert Gerwin, an associate professor of neurology at Johns Hopkins University. Gerwin, who is also president of Pain and Rehabilitation Medicine in Bethesda, says that medicine has only recently come to understand this type of pain.
“I remember a long conversation with a neurosurgeon saying that [referred] pain is impossible because there’s no connection, there’s no wire, no string, no blood vessel, there’s no nerve, there’s no nothing connecting these two places,” Gerwin said. Of course, the surgeon was “not realizing that the mechanism of spread is through the spinal cord.”
Pain signals from taut muscle fibers travel to specific locations on the spinal cord that also receive signals from other parts of the body. Referred pain occurs when pain signals from muscles register in the nervous system as if they came from elsewhere.
Although physicians increasingly recognize referred pain today, diagnosis and treatment of myofascial pain often takes more time than most physicians can provide, according to Taylor. Practitioners need specific training to recognize trigger points. And they must examine and palpate patients carefully to identify and locate these taut bands of muscle fiber.
In a 2000 survey, more than 88 percent of pain specialists agreed that myofascial pain syndrome was a legitimate diagnosis, but they differed over the criteria for diagnosing it.
Norman Harden, the medical director of the Center for Pain Studies at the Rehabilitation Institute of Chicago, conducted that survey. He believes that practitioners need clear, validated criteria for diagnosing myofascial pain and identifying effective treatments. He recently conducted another survey to determine if the level of recognition among pain specialists has changed. Preliminary results suggest it has not.
According to Gerwin, myofascial trigger points often cause or contribute to problems such as chronic back pain, headaches and pelvic pain. Trigger points can form anywhere in the body after an injury or if muscles brace against pain or trauma for a long period. They also can result from chronic overuse of muscles due to stress or to poor posture that puts constant pressure on muscles not designed to withstand it.
Taylor understands this as both a physician and a patient. His myofascial pain started in 2003 during his daily run. “I felt a sharp pain in my rear that felt just like when my brothers used to shoot me with our BB gun,” he recalled. He checked himself for signs of injury but found none, then limped home, assuming it was a strained muscle that would heal after a few days. It didn’t.
He sought treatment first from his general practitioner. He then went to a battery of specialists: neurologists, rheumatologists, orthopedic surgeons, osteopathic physicians, physical medicine and rehabilitation specialists, and physical therapists.
Found it on the Internet
After three years, a physical medicine and rehabilitation specialist told him the source of his pain was his piriformis muscle, a pear-shaped muscle that runs diagonally across the buttocks. The doctor prescribed stretching and strengthening exercises to resolve it, but they only made things worse. Eventually, the pain reached down to Taylor’s knees, up to his head and out to his fingers on both sides of his body.
But he finally had a useful piece of information. He did an Internet search for “piriformis muscle” — a common spot for trigger points — and “myofascial pain syndrome” popped up. “I had been to the bone doctor and the joint doctor and the nerve doctor and the rehab doctor, and none of them had really examined my muscles in great detail,” he said. And none of them identified trigger points. Taylor has since changed his focus from radiology to working toward understanding, diagnosing and treating the condition. When I met him in 2011 he had established a practice that specializes in pain syndromes.
A popular treatment is dry needling, which sounds like exactly what it is: Tiny needles are inserted into the skin to stimulate a twitch response in the heart of a trigger point, releasing it. Although similar to acupuncture, dry needling focuses directly on trigger points rather than on the meridians, or energy fields, recognized by Chinese medicine. Usually, each trigger point requires several treatments before it relaxes substantially. Between sessions, patients treat themselves each day by pressing the points against a hard surface with simple tools such as tennis balls and holding for a minute or two. Treatment also addresses posture-related strains on muscles and metabolic factors such as vitamin and mineral deficiencies, low thyroid and hormonal imbalances that can contribute to trigger points.
Though a few studies have been done, they have not adequately demonstrated the effectiveness of treatments for trigger points, according to a 2009 review published in the European Journal of Pain. Researchers at the Universities of Exeter and Plymouth and the British Medical Acupuncture Society reported that only one of the seven studies they reviewed found dry needling to be effective in reducing pain. Four other studies found no difference between dry needling and placebo treatment, and the two remaining studies had contradictory results.
The American Academy of Orthopaedic Manual Physical Therapists recognizes dry needling as a legitimate treatment. The group maintains that research shows that dry needling reduces pain and muscle tension and helps muscles with trigger points return to normal. Other studies are underway. Jay Shah of the National Institutes of Health and Lynn Gerber and Siddartha Sikdar of George Mason University are using ultrasound imaging to examine how dry needling changes the physiology of trigger points after treatment.
Gerwin says that proper training in finding the trigger points can lead to consistency in diagnosing them. He and physical therapist Jan Dommerholt of Bethesda Physiocare run Myopain Seminars, which help physicians and physical therapists learn how to diagnose and treat trigger points.
According to Harden at the Rehabilitation Institute of Chicago, without clearer diagnostic criteria accessible to general practitioners, experiences like mine will continue. “As awareness grows and doctors feel empowered to understand and make this diagnosis, then that endless and frustrating round of trying to find what I’ve got and what the answer is will stop,” he said.
Gerwin agrees that more research will help, but already he sees greater acceptance of trigger points in the medical community.
“I think the bottom line is simply that the
underlying pain physiology is understood now to explain why referred pain occurs, to understand why tenderness occurs,” he said. “And that explains a lot of what muscle pain is all about.”
In my case, through a combination of therapies, including dry needling, compression, stretching, postural changes and relaxation techniques, I feel much better. I no longer need dry needling, but I do need to practice the other techniques myself, regularly, to prevent trigger points from reforming or to release them myself when they do form.
Amy Mathews Amos, a science writer in Shepherdstown, W.V., blogs at amymathewsamos.com.