Stories and Metaphors to Help Understand Pain

Giuseppe_Maria_Crespi_-_Buchregal_mit_Musikschriften_1725-30

The first step to taking control of your pain is to understand it.  Once again, let’s thank researchers Lorimer Moseley and David Butler for finding out that understanding pain by using stories and metaphors helps to decrease it by realizing that pain can occur for many reasons, not just because of an injury. We can then treat the various components of pain.

You will relate to some of the examples, but not others. But overall I hope that you find it to be helpful. After reading this section, you are welcome to add your own story or metaphor in the comments section which can give different perspectives regarding your pain process. Which in turn may help someone experiencing something similar.

I would recommend that you take your time while reading this page and re-read it as often as you need in order to fully understand the concepts. Please don’t forget that it is okay if you do not understand it the first time you read it. I have to admit that I didn’t get it in the beginning and it took years for me to understand! So helping people understand their pain process without having to spend as much time as I did is another reason why I created this website.  Like for me, it might take time for the brain to process this information, so please do not worry.

So here we go…… I have given a few examples of various topics of pain and why we can experience it.

1. When we have pain, the injured site can become more sensitive to pain. Imagine yourself hitting your thigh with the hard part of your sofa or with the foot board of your bed. Ouch!! Then a bruise develops. That small bruise can become very sensitive and pain can increase from even very light touch. We know that light touch will not cause further tissue injury but there is an increase of pain. How is this possible?

Nerves have sensors that send messages regarding inflammation, light touch, pressure, temperature, tissue injury, potential injury, and etc to the spinal cord and ultimately to the brain. When a bruise forms, our nerves may create more sensors at the site of injury and even throughout the nerve. This magnifies the response to the environment for protection. So very light touch can activate nerves to trigger protective responses to increase pain.

Nerves can be more sensitive if we keep irritating them and this is one of many components to chronic pain. Therefore one method of treating pain is to provide a positive environment for our nerves. They can become less sensitive with positive feed back through movement and manual therapy. There really isn’t “best way to move and exercise” so find something you enjoy doing and gradually progress it. Just try not to over do it, which may be considered negative feedback to your nerves.  Various types of movements will be discussed in the Movement and Motor Control sections. There is a book titled The Sensitive Nervous System for clinicians interested in more information  about providing a positive neural environment.

2. When we have pain, our central nervous system (brain) can also become more sensitive to pain. Children are very enjoyable to tickle. For fun, we tend to tickle them and tickle them until they need in order stop to breathe. Then when we tell the child “I’m going to tickle you” and wiggle our fingers without even touching them, they start to giggle and protect their underarms while withdrawing their body. The more you tickle a child the more ticklish they get. Pain can function in the same way. When you experience a painful event it is easier for your pain increase with various activities due to changes in our brain. Even expecting pain may increase pain. A sensitized brain can also be associated with chronic pain.

If you expect pain to occur, perform movements  to the degree where you do not expect pain. For example, you may expect or anticipate  pain when you lift your arm overhead.  As an exercise, lift your arm only to the level where you do not anticipate pain. Repeat it a few times per day. This promotes positive changes within in the nervous system including your brain.

3. Pain can be a protective mechanism. Much like the tickling sensation promotes bracing and tightening of the body to protect from further tickling, pain triggers mechanism of the body to protect from harm or potential harm. Pain or potential threatening input to the body may activate  automatic protective mechanisms from the brain leading to more pain and stiffness. This is an automatic process much like the bracing we would do when someone is about to run into us.

A problem can occur if we are in a constant protective state resulting in excessive bracing and stiffness. Many people in the military or police officers for example tend to be on high alert while at work and have a difficult time relaxing when they are not at work. The same thing happens with chronic pain. Our body can produce excessive tension due to its state of alertness even when we are at rest.

Here is one reason why this concept is important to understand:

In the 1980’s a physical therapist and neuroscientist name Paul Hodges published a study that found that muscle activity (the transverse abdominis if you are interested) was delayed in people who experience low back pain. This lead to the establishment of core stability exercises and many people tried to find ways to turn on this muscle group. Therapists, chiropractors, and trainers may have told you to tighten your abdominals excessively when you lift something or do movement exercises in order to activate your core to protect your back. What if excessively tightening of your abdominals while lifting something is like making an excessively tight grip when we swing a racket while playing tennis or excessively gripping a pen while writing. This increase of tension may increase compressive forces, rather than protect your back.

Dr. Hodges has mentioned in current literature that  we should  learn ways to turn on and activate our trunk muscles in a relaxed and automatic way instead of excessively tightening our body. Unfortunately, many people paid attention to his original research, but not many have paid attention to his current publications. So for example, if we swing a bat and hold it in a relaxed way, tension automatically increases as the ball hits the bat. We don’t think about it, it just automatically occurs.  You will learn these types of motor control exercises for your back and rest of the body in the stabilization section.

Here is a fun fact for those interested in neuroscience. Lorimer Moseley studied under Paul Hodges in graduate school for his PhD and they have given lectures together. If you are a clinician, please don’t miss it if you have a chance to attend one of those events.

4. The brain may connect many things such as emotions, movements, thoughts, and feelings including all our senses to pain to create a memory of your painful event. Have you ever listened to a song that instantly reminded you of an ex-boyfriend or girlfriend? Is there a scent that reminds you of a childhood event or your grandmas home? Our senses, experiences, and memories are inter-connected and filed in our brain for easy access. Pain is the same way. The brain connects everything that occurred during your initial injury, whether it’s a song, the time of year, your emotions, the weather, a specific movement, and etc. Pain is the same way and can turn on when any of the associated factors are stimulated. Grading your exposure to movement exercises as well as graded motor imagery may be effective in order to change, block and prevent the expression of your pain memory.

You can read more about the memory of pain in a future section.

Here are some examples of how memories of events occur and can change:

Imagine driving to work the same way every day. For example you would exit on 2nd street from a local highway to go to work. Then on a weekend, you decide to go to a restaurant with your family that is on 3rd street. But you automatically exit 2nd street without thinking. What happened was that your brain automatically brought your to work because the highway triggered the memory of going to work. The automatic memory of driving to work will decrease in your brain if you would drive that highway more often and took various exits.

Movement and pain is the same. Introducing novel and variability to your movements help to dampen pain memories associated with specific movements that trigger pain.

5. Because various parts of the brain are connected to your pain, tissue injury does not have to occur for pain. Have you ever seen someone fall and it triggered discomfort in your legs or back? Do you feel uncomfortable watching someone on TV or at a doctor’s office get a shot in their arm? These are uncomfortable situations that occur even though you are not physically harmed.  You may even feel a little pain because you experienced something similar that resulted in pain. When you see something happening, the automatic processes involving pain are active as if it were actually happening! You can even experience pain when you visualize a movement that is painful without actually physically moving. This may be  due to sensitivity of the brain to trigger protective mechanisms. This is another component of pain that may benefit from graded motor imagery.

6. The nervous system uses a map within the brain to decipher where the pain is located. An example of this would be phantom limb pain. There are people who have amputated legs, but still feel pain in the part of the leg that is no longer there. The body part is missing, but the map, neurological properties,  and memory of the amputated body part is still present and is triggering the pain response. This can also occur with people without amputations. This means that the location of pain may not be the actual origin of pain.

7. We must not ignore pain. Pain is similar to a “check engine” light in a car that gives us information that something is potentially wrong. The car will still drive, but there may be more problems down the road if we ignore it. Sometimes the check engine light goes on even if there are no problems with the car. Pain responses can be similar due to inappropriate functioning of the nervous system. This means that pain messages from the brain may not mean that there is a serious problem. Like a computer, the brain may need to reboot to “reset” the nervous system. This may also be done with movement, manual therapy, graded motor imagery and much more. Read on to re-boot your brain!

8. The amount of pain we experience does not correlate with the amount of injury.  Have you ever cut your arm or leg and didn’t noticed it until someone told you that you were bleeding? Then there was an increase in pain? Have you noticed that paper cuts are so painful for something so small? One reason for this is that the degree of pain is partially related to the context of pain. If our brain considers something to be dangerous then there may be more pain. Dr. Henry Beecher found that soldiers who had severe injuries required much less morphine than civilians with the same type of injury. Dr. Beecher found that civilians who had serious injuries had stress and concerns about the injured body part, impending process of recovery, loss of income, concerns about family, and etc. Soldiers with the same injury were relieved that they were no longer in the battle field were happy that they were going home resulting in less pain.

 . . .

I hope that you understand pain a little more and that you feel a little more at ease about your pain. The more we understand pain, the less stressed, anxious, and worrisome we can be, which ultimately leads to less pain. At this point, my goal is  that you feel hopeful that there is a possibility for you to be in charge of your pain process.

So keep reading on and remember that pain is always real and it is a complicated process involving tissue injury, potential tissue injury, and the coordination of the body and mind. Please do not think you are going crazy and that pain is made up in your mind. Pain is always real.

As you continue to read and practice the exercises, another important concept to understand is that constantly pushing into pain, may actually increase pain due to sensitivity. So the theory of “No Pain No Gain” is no longer valid. The new way it should be stated is “Know Pain, Know Gain”.

These examples mentioned here discusses increased sensitivity to pain that can be reversed by various types of movement exercises. Research studies are showing that there is no best way to move and exercise. This means that you should find something you enjoy doing but not force yourself into discomfort. It is also important to pay attention to your movement and provide variation to your movement exercises to stimulate your brain. This will be discussed in later chapters.

References:

Photo: http://commons.wikimedia.org/wiki/File:Giuseppe_Maria_Crespi_-_Buchregal_mit_Musikschriften_1725-30.jpeg

Articles:

Beecher HK. Measurement of Subjective Responses: Quantitative Effect of Drugs. New York: Oxford University Press; 1959.

Butler DS and Moseley GL. Explain Pain. Adelaide, Australia: NOIgroup Publications; 2003

Cohen SP, Mao J. Neuropathic pain: mechanisms and their clinical implications. BMJ. 2014 Feb 5;348:f7656. doi: 10.1136/bmj.f7656. PubMed PMID: 24500412.

Dubin AE, Patapoutian A. Nociceptors: the sensors of the pain pathway. J Clin Invest. 2010 Nov;120(11):3760-72. doi: 10.1172/JCI42843. Epub 2010 Nov 1. Review. PubMed PMID: 21041958; PubMed Central PMCID: PMC2964977

Grace PM, Hutchinson MR, Maier SF, Watkins LR. Pathological pain and the neuroimmune interface. Nat Rev Immunol. 2014 Apr;14(4):217-31. doi: 10.1038/nri3621. Epub 2014 Feb 28. PubMed PMID: 24577438

Jay GW, Barkin RL. Neuropathic pain: etiology, pathophysiology, mechanisms, and evaluations. Dis Mon. 2014 Jan;60(1):6-47. doi: 10.1016/j.disamonth.2013.12.001. Review. PubMed PMID: 24507705.

Moseley GL, Butler DS, Beames TB, Giles TJ. The Graded Motor Imagery Handbook. Adelaide, Australia: NOIgroup Publications; 2012

Moseley GL. Painful Yarns: Stories and Metaphors to Help Understand the Biology of Pain. Canberra, Australia Dancing Giraffe Press; 2007

Louw A. Diener I., David S. Butler DS, Puentedura EJ. The Effect of Neuroscience Education on Pain, Disability, Anxiety, and Stress in Chronic Musculoskeletal Pain. Arch Phys Med Rehabil. 2011; (92): 2041-2056.

Gallagher L., McAuley J. and Moseley GL. A Randomized-controlled Trial of Using a Book of Metaphors to Reconceptualize Pain and Decrease Catastrophizing in People With Chronic Pain. Clin J Pain 2013;29:20–25

Louw A, Diener I, Landers MR, Puentedura EJ. Preoperative Pain Neuroscience Education for Lumbar Radiculopathy: A Multicenter Randomized Controlled Trial With 1-Year Follow-up. Spine (Phila Pa 1976). 2014 Aug 15;39(18):1449-1457. PubMed PMID: 24875964.

Moseley GL, Hodges PW, and Nicholas MK. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clin J Pain, 2004: (20); 324-340.

Moseley GL. Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. Eur J Pain. 2004 Feb;8(1):39-45. PubMed PMID: 14690673

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