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Pain is incredibly complex, making the treatment and management of chronic or persistent pain a unique challenge. After reading this article, the hope is that you have a better understanding of the complexities of pain and how treatment must be directed if one is truly to overcome chronic pain.
Pain has a nasty habit of getting in the way of activities that we not only enjoy, but also the mundane tasks of everyday living. It becomes of paramount importance that treatment not only decreases pain, but also that the individual is able to resume activities that are important to them with improved function and mechanics.
To begin with, let's start with an understanding of pain and the reality behind why we perceive pain.
1) Pain is in the Brain
Pain is a message from our brain that is meant to protect us. Even though pain is meant to protect us, pain is not a reliable source of indicating the extent of an injury or even where the injury is located. The classic example here is phantom limb pain. Amputees regularly will experience this phenomenon. One may experience left leg pain, yet they do not have a left leg. If pain is purely related to damage or injury, how would one experience pain in a limb that doesn’t exist?
The reality of pain perception can be a difficult education point as this is typically a new concept for the majority of patients and one they may need some time to understand. But it’s critical as their beliefs about pain can complicate the recovery process. It’s extremely beneficial for patients to learn about pain and address fear-avoidance behaviors and other factors that will interfere with reactivation into normal movement and activities of daily living.
2) Hurt Doesn't Equal Harm
Another key component of the education process is that “hurt doesn’t equal harm”. Just because a movement or activity may “hurt” this doesn’t mean that you are doing harm to the body or damaging tissues. In fact, there is a growing body of research supporting poor correlation between pain and structural changes seen on advanced medical imaging. Just because one has degenerative joint disease, a disc bulge, or rotator cuff tear doesn’t mean they will have pain as these imaging findings are routinely found in asymptomatic individuals.
It’s important patients understand this concept because when it comes to exposure to movement through exercise, you don’t want the fear of structural damage to interfere with the ability to become more active. While not all movement will be pain free, movement isn’t causing harm. And that’s extremely powerful for patients to understand.
3) Movement is Medicine
Movement has the ability to be healing by reducing the pain response in our brain. Thus this is why movement is like medicine and why movement eventually has to take center stage in the management of chronic pain. Similar to manual therapy, graded exposure to movement through exercise will essentially teach your nervous system to “wind down” and not be as sensitive to pain. In doing so, you become more confident and reassured that you can do more without pain or the fear of a relapse in your condition.
4) The Work is Just Beginning
Unfortunately, the pain fix isn’t an overnight solution. For chronic pain patients, often times the rehabilitation process can take months of consistent work and repeated inputs to the nervous system to make a substantial change on pain and function. Repeated inputs come in the form of manual therapy and home exercise/self management strategies. Thus patient’s must understand the importance of compliance within their home exercise program as this makes a significant difference in their outcomes.
It’s important they understand the nervous system is easily tricked. It's easy to yield immediate change, but these changes should not be confused with lasting results. This concept is illustrated with any number of assessments commonly used in chiropractic and physical therapy offices – from leg length analysis to functional screens - as well as therapeutic interventions – from manual therapy to manipulation. By performing pre and post checks, it's possible to see immediate changes within one treatment. It can be easy to impact pain and create changes in range of motion or body function that have patients leaving your office feeling great.
But no single input can create lasting change. It requires multiple inputs over a period a time to create lasting change within the nervous system. This is why exercise and training is so important. If patients are not provided with the right exercises to compliment therapy, this is why they have pain relapses. Patients must exercise and must train to make a lasting change within their body. Otherwise they will get frustrated with chronic recurrences of leaving a provider's office feeling great only to experience a return of pain symptoms. And this becomes the pain cycle many become stuck in unless a change is made.
Break the Pain Cycle
If you are dealing with chronic or persistent pain or stuck in the pain cycle, the hope is that this article gets you thinking differently about how pain should be managed for successful outcomes. It’s why the management of painful conditions, especially chronic pain, must focus on pain education, the appropriate use of manual therapy (ex: joint mobilizations/manipulation, relaxation techniques such as PIR, soft-tissue and neurodynamic mobilizations) and graded movement exposure through exercise.
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