Pain Science Changes Everything

To understanding the Checker Shadow Illusion that is the featured photo for this blog is to understand pain science.  This pictured arrived to me via a fascinating talk I found online by Lorimer Moseley, who is a leading research in pain science.  By watching that 90 minute video, you will have a foundational understanding of pain science that is beyond what many doctors understand.  Nearly all of the talking points in this blog come from that presentation.

Let’s return to that photo. When you look at that photo and compare the color of squares A and B, your brain is telling you (and everyone else) that Square A is darker than Square B.  Despite this obvious message, this is actually not true.  Square A is the exact same shade of Square B.  How is this possible?

The human brain is constantly trying to rationalize and interpret any stimulus in a way that makes sense.  The fact that every other square on that board follows a pattern makes your brain create that same pattern at Square B, even though it is the same shade of Square A.  This reality fundamentally frames what pain science is showing us about pain.  Pain is not an interpretation of reality but a summation of experience.  In fact, pain is entirely an output of the brain.  Pain does not exist in the body and we do not (really) have pain receptors. What we do have are pressure sensors, temperature sensors, vibration sensors, chemical sensors, etc.  The summation of this raw data delivered to the brain is used to create pain as a means of behavior modification.  It is meant to guide us and modify our behavior to ensure that we remain alive and able to breed.  What pain science really shows us is that sometimes this process is faulty.

Pain Is Expensive

40 – 50% of income protection insurance claims are because people have pain resulting in soft tissue injuries that are not catastrophic

Talking about pain in terms of dollars is a hard right turn in this reading.  This hard turn is on purpose to highlight the very real and very omnipresent problem that pain creates in the world.  By viewing chronic pain as an economic costs, we can remove our opinion about pain and begin to look at data on pain.  In the US alone, pain costs us between $560 – $635 BILLION.  Back pain, knee pain, shoulder pain, and neck pain are the most costly symptoms for insurance companies to fund. Lorimer Moseley states in his presentation that:

“On the global burden of disease, there is nothing more burdensome on the planet in terms of years of disability and economic cost than low back pain, followed by depression, followed by neck pain . . .”

Diseases like cancer and diabetes rank around 14.  I want you to pause and think about all of the fun runs and marathons dedicated to breast cancer you have come across.  I want you to think about what color the ribbon is for breast cancer awareness.  Its probably very easy for you to know that it is pink.  But what color is the ribbon for chronic pain? Is there even such a ribbon?  This statement is not to diminish the importance of breast cancer research (as it is monumentally important) but to highlight how our globe holds the space for chronic pain.  If most people were to list the their top 3 issues for public health, it is very unlikely pain would be on that lists.  Chronic pain is a very real problem and a very costly one.

Pain Does Not (Always) Equal Injury

Increasingly, pain science as well as imaging data are showing less correlation between pain and severity of injury.  The reality of phantom limb pain challenges are entire notion of pain monitoring mechanical pain. Phantom limb pain is a term given to a person experiencing pain in a limb that is no longer there.  This occurs when a limb has been removed traumatically (injury) or atraumatically (planned surgical removal).  It is impossible for a missing limb to be generating any pain because those nerve endings do not exist.  So how do these people have pain?

In our medicine, we are often dealing with low back pain and often of a chronic nature.  Many of these patients come to us with a variety of imaging findings.  Some show disc herniation or tear, but many show nothing.  Many of our patients that experience real pain have normal MRIs or Xrays.  There is no evidence of any tissue damage or compromise.  Again, how do we explain this.

Pain Does Equal Experience

What pain science is showing us is that pain is a combination of many factors both internal and external to the person experiencing pain.  My most classic example of this is an experiment that was conducted by placing a probe on participants hands.  The probe was always very cold and always the same temperature.  Participants were also shown a blue light or a red light at the same time.  Participants were asked to rate their pain in contact with the probe.  The overwhelming trend is that the same stimulus with a red light created higher pain levels than with a blue light.  The hidden message here is that humans generally associate red light with danger.  Red has regularly been equated with something that is hot and therefore dangerous.  Our experience of stimulus (red is hot) creates an output of behavior and feeling (be careful of things that are red).  We see this pattern and experience every day in our clinics.  Nearly all of our patients with low back pain have a faulty pattern of sitting or bending over that is associated with pain.  When we try to replace that pattern with a more successful one, we continue to see apprehension and worry, despite the pattern being entirely and objectively different.

Chronic Pain Management Requires Motion

There are copious studies relating physical motion to pain modification.  Nearly all studies show that, in the words of Lorimer, “Motion is lotion.”  Physical motion is critical to resolution of chronic pain, but there are limits.  There is a U-shaped curve that can be correlated with back pain and activity.  This suggest that there is a limit to what amount of motion or load that body can handle to create positive effects.  This marries beautifully with a good strength training program.  Any exercise program must account for many variables to control the effect of the program. Getting muscles bigger is very different from getting muscles stronger, and it shows when you look at the programming for each.  A good exercise program, regardless of the goal of the program, controls many factor in a consistent way to create consistent and measurable progress.  I will often say that strength training can be simply summarized:

“Move something pretty heavy, a few times, with lots of rest in between”

Our very first blog post specifically talks about the need for good programming for anyone, regardless if the goal is performance or pain.  In clinic, the above phrase can be accurately translated to a repeatable formula we use with all of our patients in the first phase of care.

4 sets of 4 reps at 80% of maximum with 4 minutes rest between sets.

This is exactly a way to control the amount of motion for a person to experience pain relief versus pain onset and we have seen it work successfully over and over.

Chronic Pain Science in Summary

These last points are taken directly from Lorimer Moseley and are the most important points of intervening with chronic pain.

1. Active gradually suppresses the pain system.

2. Active protects you against other problems.

3. In an overprotective system, movement is safe even when it is painful. Avoiding movement is not.

4. In an overprotective system, the risk of inactivity is much greater than the risk of activity.

There are many times where I personally doubt myself and my thoughts on medicine.  The cost of pushing boundaries is that you are often alone in doing so.  I have found, however, that there are small injections of affirmation.  Other fields and other people are using the same words and thoughts I have, just in entirely different fields.  Chronic pain is one of those fields.  Its seems that we aren’t the only ones trying to deliver Movement Based Medicine.