“Throughout time, perspectives on the experience of pain have substantially evolved.  As we continue to explore, the more we realize how much power we actually have over our pain.  This new understanding is quite consequential considering nearly half of the US population reports experiencing either daily chronic pain and/or notable pain experienced over the last 3-month period.  This equates to a total healthcare cost exceeding $600 billion annually in pain management & therapies.

Punishment = Pain

During the Middle Ages pain was predominately attributed to spiritual & religious factors such as celestial punishment for wrongdoings & ‘opportunities’ for spiritual growth.

Tissue Damage = Biological Signaling = Pain

After the Scientific Revolution of the Renaissance Period, pain was explained primarily as a neurobiological model describing receptors in the body identifying nociceptive stimuli (a type of sensory input that signals potential tissue damage).  This naturally led to pharmacological advances in medicine aimed at reducing those sensations.  Not until the 1990s did we refocus our understanding of pain using newly developed functional brain scans leading to the biomedical explanation of pain.  Although an impressive breakthrough, this allowed us only to understand pain within a very restrictive construct.

One astute attempt to address this issue is termed the Gate Control Theory of Pain.  This theory describes a phenomenon in which a ‘threatening’ pain signal gets interrupted by an alternative stimulus.  This includes exciting receptors for pressure and/or vibration (i.e. kinesiotape, compression sleeves, massage, electric stimulation unit, etc.) to reduce painful stimuli.  Although quite effective in some cases, this does not tell the whole story.

Expectation & Beliefs = Pain

It was not until very recently that the psychophysiological mechanisms of pain were explored.  These factors involve the expectations & beliefs about pain leading to Fear Avoidance & Pain Catastrophization.

Fear Avoidance Behavior Patterns are the acts of avoiding movement patterns & activities that one perceives will reproduce expected pain.  This is often coupled with Pain Catastrophization which is the negative mental state that produces an exaggerated response to pain.  This occurs due to an exaggerated threat of pain, perseveration on pain, inability to cope with pain, and/or believing pain is inevitable.  The evolutionary purpose of pain is to alert the body to nociceptive stimuli that may, and often does, cause damage to biological tissue.  This promotes protective behaviors, increased arousal, prioritization of attention to sources of pain, autonomic withdrawal from stimuli, changes in affect & future avoidance of similar stimuli.  These are all appropriate self-preservation techniques.  However, this can eventually lead to inappropriate behavior patterns that can bring about maladaptive learning, emotional anticipatory responses, anxiety & false expectations.

Chronic Pain & Fear Avoidance

Chronic pain (pain lasting longer than 3 months) occurs when pain related fear & avoidance persists despite the traumatized tissue already being physically repaired.  This can also occur when we expect non-noxious stimuli to be noxious due to our erroneous, fear-based expectations & historically negative experiences.  Consequently, quality of life is naturally impaired due to self-restricting movements patterns, as well as the avoidance of purposeful activities & hobbies altogether, to avoid a perceived threat of pain that is often not warranted in the first place.

Physical Therapy & Pain

One essential aspect of physical therapy is to educate, treat & guide a patient through their journey while judiciously confronting these fears to allow for physical tissue adaptation & psychological inhibition of a patient’s learned fear & avoidance.  This is achieved when one gradually develops the ability to confront apprehensive movement patterns & begins feeling empowered, through exposure, to live a more fulfilled life without pain.¹

The marriage of the biomedical & psychophysiological approach birthed a more nuanced & accurate understanding of the functional, structural & cognitive changes in the brain that occur in individuals suffering from chronic pain.  We now coin this the ‘biopsychosocial model‘.²

Chronic Pain & Your Brain

There is a large collection of scientific articles published on the importance of the biopsychosocial model.  Before continuing, it is important to understand to concept of Pain Neuroscience Education (PNE).  Well-articulated in Physiopedia:  ‘Chronic pain is not viewed as a result of unhealthy or dysfunctional tissues.  Rather, it is due to brain plasticity leading to hyper-excitability of the central nervous system, known as central sensitization.  The ultimate goal for PNE is to increase pain tolerance with movement (e.g., be able to perform exercise with mild discomfort), reduce any fear associated with movement, & reduce central nervous system hypersensitivity.  In practice, this often includes the use of educational pain analogies, re-education of patient misconceptions regarding disease pathogenesis, & guidance about lifestyle & movements modifications that can be introduced.’³

One of the more historically challenging examples of chronic pain occurs in individuals suffering from fibromyalgia.  A fascinating study by Serrat et al⁴ describes the promising effects of combining pain neuroscience education, therapeutic exercise, cognitive behavioral therapy & mindfulness in patients with fibromyalgia.  It has been well established in further studies that a multidisciplinary approach to challenging chronic pain conditions can be well managed, and in many cases resolved, with a more comprehensive treatment program involving physical therapy interventions & variations of psychotherapy.⁴

Another encouraging study by Galan-Martin et al⁵ explores the effects of physical therapeutic exercise combined with pain neuroscience education as a first-line treatment on patients with chronic spinal pain.  This experiment cleverly combined physiotherapy that involved playful, dual-tasking & socialization-promoting activities with pain neuroscience education.  They compared these individuals with a control group that underwent a more ‘traditional’ physiotherapy protocol.  The experimental group showed statistically significant improvements in quality of life, pain catastrophization, kinesiophobia, central centralization, disability, pain intensity & pain pressure thresholds.  Most importantly, these results were maintained at a 6-month follow up.⁵

Pain, particularly chronic pain, can be difficult to navigate.  As previously described, it is often a complex intersection of physical tissue injury, psychological expectations & past experiences.  However, the further we understand the links between these factors, the more hopeful and efficacious we can be in managing, and in many cases resolving, the symptoms we experience.”

Sources:

1. Vlaeyen JWS, Crombez G, Linton SJ. The fear-avoidance model of pain. Pain. 2016 Aug;157(8):1588-1589. doi: 10.1097/j.pain.0000000000000574. PMID: 27428892.
2. Louw A, Puentedura EJ, Zimney K, Schmidt S. Know Pain, Know Gain? A Perspective on Pain Neuroscience Education in Physical Therapy. J Orthop Sports Phys Ther. 2016 Mar;46(3):131-4. doi: 10.2519/jospt.2016.0602. PMID: 26928735.
3. https://www.physio-pedia.com/Pain_Neuroscience_Education_(PNE)
4. Mayte Serrat, Juan P Sanabria-Mazo, Míriam Almirall, Marta Musté, Albert Feliu-Soler, Jorge L Méndez-Ulrich, Antoni Sanz, Juan V Luciano, Effectiveness of a Multicomponent Treatment Based on Pain Neuroscience Education, Therapeutic Exercise, Cognitive Behavioral Therapy, and Mindfulness in Patients with Fibromyalgia (FIBROWALK Study): A Randomized Controlled Trial, Physical Therapy, Volume 101, Issue 12, December 2021, pzab200, https://doi.org/10.1093/ptj/pzab200
5. Galan-Martin MA, Montero-Cuadrado F, Lluch-Girbes E, Coca-López MC, Mayo-Iscar A, Cuesta-Vargas A. Pain Neuroscience Education and Physical Therapeutic Exercise for Patients with Chronic Spinal Pain in Spanish Physiotherapy Primary Care: A Pragmatic Randomized Controlled Trial. J Clin Med. 2020 Apr 22;9(4):1201. doi: 10.3390/jcm9041201. PMID: 32331323; PMCID: PMC7230486.

If you’d like to learn more about the pain you feel and/or chat with Jerrod about potential treatment options, feel free to email or call (208) 375-5511.

Here’s a list of past articles written by Jerrod Ackerman:

• Bring on the Cold-Water Plunge
• Everything You Need to Know About Spinal Manipulation
• What the Heck is Functional Dry Needling?