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.
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
Feeling dizzy? You Could Have a Vestibular Disorder
Do you experience dizziness? Perhaps when rolling into or over in bed, or turning your head to one side?
Dizziness can be more than dehydration, a big night out, or a compulsion to spin in circles on your office chair. It can be a symptom of asymmetry in your body’s sensory systems.
The most common condition that causes dizziness is benign paroxysmal positional vertigo, or BPPV. The brain has three main mechanisms for perceiving how we interact with the environment around us. These are the visual, proprioceptive, and vestibular systems.
The visual system is self-explanatory. The proprioceptive system is a network of nerves in all of your muscles and joints that relay information about the position of those muscles and joints back to the brain. It is how you can close your eyes and still accurately position your arms and legs in different poses.
The vestibular system is located in your inner ear and is used to identify the position and movement of the head in space. This is the system commonly linked to dizziness and vertigo.
The vestibular system is made up of three perpendicular fluid filled canals in each ear, which relate roughly to the planes of movement.
These canals each have sensory nerves at one end that are made up of crystals resting on fine hairs. When you turn your head, the fluid moves through the canals and pushes on the crystals. This causes the hairs to move and stimulates the nerves.
Your response in each ear should be equal and opposite, and work in tandem with your visual and proprioceptive systems. If things are not working in tandem, then dizziness, vertigo (room spinning), or nausea may result.
Have you ever felt nauseated in a car, or on a boat? This is because your vestibular system recognises that your head is moving but according to your eyes, you are still or moving a different way.
Someone may have suggested looking out the window or finding the horizon. This is great advice as fixating on something which the car or boat is moving relative to, provides a visual reference point and reduces or eliminates the disagreement between the visual and vestibular system.
In patients suffering BPPV, a similar disagreement occurs but it is completely internal. It occurs when crystals in one ear canal become dislodged from the hairs and drift down into the canal. This can happen as a result of trauma but is just as frequently unrelated to any incident.
When the head is turned, the nerve stimulation in one ear is different to the other and a combination of dizziness, vertigo, and nausea can result.
Generally, this resolves in seconds, or in more severe cases last up to two minutes. Usually only one canal will be affected at a time so symptoms are commonly worse to one side, and occur most severely in a single plane of movement.
If you are dizzy due to asymmetry, then your physiotherapist can assess and treat it. Assessment of specific movements can isolate which ear and which canal is causing the problem and treatment involves techniques designed to use gravity and inertia to relocate the crystals back to where they belong at the end of the canal.
NOTE: If you are suffering from severe, sudden onset headache, or persistent dizziness, double vision or nausea that seem unrelated to any particular movement then consult a medical doctor immediately.