Pain is an opportunity. An opportunity to listen to your body as you determine which challenges are worthwhile ventures. Pain forces you to live in the present. You can wait for it to disappear, much like a shipwreck survivor awaits rescue. Or you can begin the long, arduous process of shaping this opportunity into success. Building your own raft requires the right tools and determination. The problem is that most people simply don’t have the necessary tools to escape persistent pain. It’s not a lack of intelligence or willingness. Instead, it’s the painful mystery caused by misleading information and outright lies limiting the potential for healing of neuromusculoskeletal conditions. Discovering the most effective methods for healing painful conditions of the neuromusculoskeletal system requires a desire for change and the right information. Change which truly matters, information which can change the course of your life.
Neuromusculoskeletal conditions are caused by tissue injury or disuse. These tissues involve nerves, muscles, and/or joints. Hence, the term neuromusculoskeletal (NMSK) is unique from other types of pain which may involve some type of pathology or illness. We have all experienced NMSK pain at some time in our life. Perhaps, it involved a sprained ankle or banged up knee. Most adults deal with spinal pain (back or neck) on a regular basis. Let’s also consider the reality that we have all experienced healing. Healing is an-ongoing daily process. However, our nervous system is faced with new challenges each day requiring it to triage and determine which challenge is the primary threat. Often times, tissue healing is not the same as fixed. Injured tissue does not regain it’s original form or condition. With healing comes residual stiffness and weakness, but the pain is resolved so the nervous system moves on to the next challenge. Even if the pain is not fully resolved, healing may be interrupted due to the tissue bluff.
The tissue bluff is like trying to raise the card stakes when you’re holding a pair. Always bet like your holding a royal flush, is my motto. Back to the point, the nervous system is processing enormous amounts of information from the body and it is directing different systems to operate in an efficient manner. It’s quite easy for the nervous system to mistake stiffness for strength. For instance, a stiff hip can result in reduced drive to the hip muscles causing them to become weak. Remember, the nervous system is geared towards homeostasis (balance) and efficiency. It’s got the mind of a teenager, never do more than is necessary. So if a joint is stiff and it’s interpreted as strength then the gluteal muscles will receive less neural drive. A similar response occurs with weakness. For instance, a residual weakness of the peroneal muscles after an ankle sprain will lead to ankle stiffness. Again, the nervous system becomes aware that the supporting muscle is weak so stiffness must be employed otherwise instability will likely occur with regular use. The tissue bluff is one of the ways our body recovers from pain but acquires deficits which began to change our movement patterns and potentially set the stage for injury or tissue disuse in nearby regions.
Once NMSK pain becomes chronic, the pain level experienced is no longer directly related to the original injury or condition. Instead, the primary problem is the compensation caused by the neuromuscular system adaptations to the painful condition. In most cases, the nervous system is struggling to compensate for the limits caused by the painful region by relying upon adjacent or supportive tissue which may not be at an optimal level of function. So the reality is that chronic pain does not occur in isolation. I’ve never encountered a client with a shoulder problem who didn’t have a hip or back problem. About the only assumption I will make is that there’s never just one problem in the human body. By the time we experience pain, the nervous system has tried a multitude of corrective measures. Unfortunately, it will often adopt the most efficient and effective method for getting us through the day. This is not always the best method for ensuring pain relief and healing, but must I remind you that our nervous system is task oriented and geared towards efficiency. It simply gets the job done, day in and day out. So chronic pain of the NMSK variety is more related to compensatory behaviors of tissue disuse, whether it’s overuse, improper use, or a lack of use. Some of the most prevalent NMSK pain conditions include; low back pain, neck pain, shoulder impingement, joint sprain, muscle spasm, fibromyalgia. This is just a short list of the many conditions which have the potential to cause long-lasting pain.
Every living cell in the body is designed to heal. Just like every organism on this earth has the will to survive. Living tissue is designed to heal due to our immense capacity for adaptation and tissue recovery. The problem with healing is that tissue deficits (weakness, imbalance, stiffness) build up over time. Every person on this planet has some WIS. Some of us have more than others. WIS is a good reason for maintaining a routine level of activity and fitness. Think of it as putting money in the bank to pay your debts. The human body is designed to heal but it’s a struggle, not a procedure or a pill.
I’m getting old so it’s no wonder my body is falling apart. This statement actually holds some merit but it’s not entirely true. Most degenerative conditions, like arthritis are more common as we age. Older joints become stiffer and muscles tend to weaken without use. However, the human body is still designed to heal. As long as there is breath in your lungs and a beat in your heart, healing is possible. Acceptance of a painful condition can be healthy if you are willing to struggle for change. Change in habits and behavior, change in tissue nutrition and change in mindset. Over time our bodies accumulate plenty of wear and tear. So we must be prepared to mend our ways with a regular routine of good body health and fitness. Otherwise, the accumulated wear and tear can have devastating effects.
There is overwhelming evidence showing the benefits of simply being active as we age. It doesn’t require an aggressive gym routine or competitive spirit. A recent study determined the age old adage is true, Use it or lose it. ‘During the aging process, a dynamic lifestyle, including regular physical activity, is a crucial factor to improve quality of life and physical fitness in aging people.’ (Battaglia 2016) Less pain as we age, requires adopting an active lifestyle. The daily threshold for physical activity in a dynamic lifestyle is 20-25min of aerobic conditioning. The particular activity is less important than the duration and consistency. Set a goal for daily activity, you won’t regret it.
Imaging of your spine shows… so it looks like you will need surgery to resolve your pain. There are many valid indications for surgery. We have some of the best surgeons in the world using the most advanced methods to restore function and save lives. The primary debate is whether surgery is a good remedy for pain. As we will discuss later, pain is a very complex matter especially in the case of NMSK conditions. Plus, we have to consider the fact that the pain can be coming from other tissues or nearby regions since the nervous system is already trying to adapt. So the problem with surgery for pain solely based upon imaging, is that the problem in the image may not be the problem causing the pain. Not to ignore the fact that imaging findings of spine degeneration are present to some degree in most adults over the age of 35. (Brinjikji 2015). Still the rates of spinal surgery continue to grow exponentially. I cringe every time I meet a client who explains that a neurosurgeon claims they need surgery to fix their herniated discs. This my friend is a bold face lie.
Consider the evidence that just came out this year in the publication of Pain Physician. (Zhong 2017) It states ‘the phenomenon of lumbar disc herniation reabsorption is well recognized’. In this longitudinal study, the authors reviewed cases of LDH and discovered that disc reabsorption occurs in 66% of cases. The authors went further to claim that ‘conservative treatment may become the first choice of treatment for LDH’. Yet, the US is on track to continue tripling the rates for lumbar surgery. (Rajaee 2012) If there’s such well recognized evidence that most cases of LBP will heal why are so many cases rushed to surgery?
You need to take narcotic drugs or opiates to manage your pain. Let’s not deny the fact that pharmaceuticals have advanced significantly in the past couple decades. Many people are reliant upon medications for quality and longevity of life. Yet, when it comes to pain management even the Centers for Disease Control (CDC) recommend a drastic change in narcotic prescriptions. A quote from their recent guideline on the use of opiates ‘Across specialties, physicians believe that opioid pain medication can be effective in controlling pain, that addiction is a common consequence of prolonged use, and that long-term opioid therapy often is overprescribed for patients with chronic noncancer pain.’ Yet, we continue to see the common case of NMSK conditions prescribed opiates. Here’s a little game of did you know. Did you know that the US consumes nearly 90% of the global supply of opiates? Did you know that 6 out of 10 heroin addicts started on prescription opiates? Did you know that pain medications actually weaken the pain threshold? So if you think you have a high pain tolerance and you take opiates, then the reality is that you are a pain wimp. Ouch!!
My prediction is that it will take a couple of decades before we fully understand how our nation has been swindled by the pharmaceutical lie. It’s easy to look back 4 or 5 decades ago and see how naive the population was about tobacco use. There were actually some fools who believed the ad campaign claiming cigarettes were healthy and cool. Good thing we’re not so easily fooled about pain meds. Not even close… Let’s consider a snapshot from the CDC guidelines published in 2016:
- No evidence shows a long-term benefit of opioids in pain and function
- Extensive evidence shows the possible harms of opioids
- Extensive evidence suggests some benefits of nonpharmacologic treatments compared with long-term opioid therapy, with less harm.
With such profound statements by the most respected pillar of medical science, how can it be possible for pain meds to retain their title. Perhaps a better term would be to call them by their real name, poison. Remember we are talking about NMSK pain which is different from cancer or other pathology related pain. So with this in mind, does it really make any sense to take poison to relieve pain? It must make sense to some because Americans are still the number 1 users of opioids in the world.
The Real Science of Pain
Pain is such a complex edifice that it cannot be isolated or reduced to having one cause; therefore, rendering a reductionist approach unfeasible in explaining persistent pain. (Brodal 2017) Wow, that’s like hearing Einstein explain the theory of relativity. Basically, the interpretation of pain is not processed in a standard or uniform fashion nor is pain processing the same for each individual. In order to better understand why pain occurs in one person, but not in another, you must take a “bird’s eye view” approach, looking at multiple contributing factors to include nervous system processing, memory, body image/ownership, and what pain means to the individual.
Pain receptors exist throughout the tissue, weaving their way into nearly every crevice which has blood supply. These nociceptors are not “pain”-specific receptors, but rather tissue antennas which interpret and send messages to the nervous system regarding mechanical and thermal input, which in some contexts are interpreted as pain. Though nociceptors evaluate all sensory signals – those interpreted as pain and those that are not is dependent upon a complex mix of input and processes. Brodal states that the term “homeoceptors” would be a more appropriate term since the nociceptors only send information to the nervous system regarding homeostatic threats.
The brain interprets and processes pain in many areas of the cortex. One finding consistent among many studies is the decrease in cortical grey matter with persistent pain. Pain is a learned experience that results in neural plasticity changes leading to fear avoidance behaviors. The pain process varies based on how the entire situation is perceived to include: sensory inputs, social context, past experiences, expectations, mindset, and what this means to the individual. Bottom line, the pain experience is variable and it is crucial to put the individual’s pain experience in the proper context. The body protection system involves motor, autonomic, psychological, endocrine and immune systems, and pain emerges from the activation of a specific neurological network, matrix or signature. (Jones 2014) The authors have presented the Pain and Movement Reasoning Model to capture the complexity of the human pain experience. The triangular structure of the Model demonstrates the integration of pain information within the three categories located at the apices of the triangle; central modulation, regional influences and local stimulation.
The pain experience involves local pain which is specific to a particular tissue or it may spread regionally affecting other unrelated areas. It’s not uncommon for a painful joint to cause referred pain in a more distal area of the body. For instance, a chronic shoulder condition can refer pain to the elbow. Muscle pain is very likely to cause referred symptoms often mimicking pain typically diagnosed as Fibromyalgia or Irritable Bowel syndrome. Some pain is mediated and perpetuated by the processor (Central Nervous System). The reality is that all pain fits somewhere within this triangle while masking the potential for a shift across the scale.
Don’t get the wrong impression. You can’t think your way out of pain. Pain travels the course from process toward product and to the individual experience. It can be affected or modified anywhere along this path. The preferred route would be prevention but this is not always feasible since most NMSK conditions occur gradually and the nervous system has already adopted compensatory patterns by the time pain is experienced. The best way to understand pain is to first appreciate its complexity. Pain is a no fault experience which you will survive. Now, you have to begin the slow and steady path towards modifying the process, product or experience.
Change the process by restoring health to the tissues. Get quality treatment directed at improving tissue nutrition and resolving WIS. Tissue nutrition requires specific intervention to the injured tissue to restore blood flow and promote healing. This intervention could be manual therapy, dry needling or movement based therapies. The main goal is to get the dysfunctional tissue moving so blood flow can be restored. WIS is the next issue to be addressed. Strength and balance can not be restored without modifying the compensatory patterns which have been developed over time by the nervous system. Motor learning is the preferred method for modifying movement patterns and triggering the activation of normal movement patterns. The key to retraining normal movement patterns is feedback, whether self-detection of errors or skill-based training. Not all exercise involves motor learning so banging out some reps at the local gym is not always the answer. You will simply reinforce the impaired movement strategies and cause more tissue disuse. If you are determined to heal rather than seek a fix for pain, then you will need some skilled intervention to change the process which has contributed to pain.
Change the product by improving mental health. Some train the body, others train the mind. Why not try to combine them, kind of like salt and pepper. Healing requires more than healthy tissue, it demands a healthy mind. Be mindful of how you perceive your body and its potential to heal. If you think of your condition as being a burden to others or you worry about missing out on life due to pain then you are setting the stage for the pain product to be long-lasting and relentless. Instead, if you refuse to allow pain to wear you down mentally then you are well on your way to recovery. If you have trouble accepting the reality of your healing potential then try some routine exercise. Sometimes, doing something for yourself is the best way to restore a little faith. Plus, aerobic exercise will help address both the process and product.
Change the experience by living life to its fullest. Follow your dreams, live with purpose. Be the person your dog thinks you are. Whatever it takes, make your experience matter. Start writing that book, begin planning your next hike, volunteer at a local charity, spend time with family and friends. Make it count and do it regularly. Crowd your life with good and relevant experiences leaving little to no time for the pain experience. Keep in mind that your experience has a past. If you allow history to dictate your future, than the outlook can be quite bleak. Even if you have forgotten the previous pain experience, your nervous system easily recalls it. In fact, it is prepared to recognize pain with each potential mishap or activity which previously resulted in pain. So experience takes a bit of retraining similar to emotional lessons which must be learned in order to risk disappointment for the sake of gaining a meaningful relationship.
These simple tips are the directions for changing the painful state. I’m sorry this guide does not include any fancy procedure or pretty colored binder. That’s because this is healing, it’s not surgery or drugs. The beauty is that you won’t face any new danger with healing and if it fails you always get another chance. I can’t say the same for surgery or drugs.
Dr. Keith Poorbaugh has completed specialty certifications, internships and a residency fellowship to develop mastery of manual therapy skills and clinical expertise. Throughout 20 years of clinical experience, he has discovered that clients consistently heal faster when the provider is both compassionate and skilled.
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