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When pain just doesn’t go away

Most people come to us because they are in pain. Pain has that function, to move us to do something about whatever it is that might be damaging to our body. And most times we can help and things get back to normal again.

What we also know about pain, is that it is not that easy. If the cause of pain is a door that is squeezing your fingers or a nail that you happen to step on, normally, yes. The pain is quite straight forward; potential or actual damage – I get out of the situation – I, the body itself or some health professional help heal it – pain disappears.

But what about the man that came into the clinic in Australia with excruciating pain in his foot where the nail he had stepped on came out from under his boot and through the top of his foot. He was desperate and had unbearable pain as he came into the emergency room. As they cut the boot open, they saw that the nail had gone through between two of his toes and not done any tissue damage whatsoever!

Then what is pain? Real enough, for sure! For this man, he was in a terrible state of pain, that was real and not imagined.

A common definition of pain says:

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (1).

This definition covers the understanding that it is a sensory and emotional experience (like for the man seeing the nail though the top of his foot, imagine that fear!), and it is associated with an actual or POTENTIAL tissue damage (seeing that nail though his boot as a very potential damage, and the pain signals firing at full alarm in his body).

Understanding pain is a complex thing. That´s why we have investigated and done research and work on it for decades and decades, and that despite of all pain clinics worldwide we have not been able to find The Solution to get people completely out of pain.

So, as in every situation, the question is, what do we know, and what can we do something about in the complex problem of persisting pain?

One thing do we now know; Understanding the mechanisms of pain can help reduce it!

(2)

PAIN IS AN ALARM

Whenever there is an unpleasant stimulus to the body (like the nail through the foot or a hand too close to a candle), we call these signals noxious, and they are picked up by sensors called nociceptors. The nociceptors are programmed to pick up signals of physical, chemical or temperature stressors. These sensors then send the signals through the nerves to the spinal cord.

Remember, these signals will come if you are on the verge of getting your hand burnt just as well as if you have an actual burn. Potential damage sends the same signals as actual damage. Which is useful, because that gives you the opportunity to consider whether keeping your hand over that candle or doing something about it.

Now, the spinal cord is an exciting place when it comes to the mechanism of pain.

THE CONFUSED SECRETARY IN THE SPINAL CORD

Dr. Greg Lehman is a kinesiologist, chiropractor, physiotherapist and a researcher in the field of pain and biomechanics for more than 20 years, and he gives the example of the spinal cord as the secretary of the boss (the brain).

She gets a call in (pain/nociceptive signal) and can choose on previous experience whether to pass the “call” up to the boss, or to turn it down. The boss can have told the secretary that certain calls are not important (also based on past experience as well as other considerations), and the signal does not reach the brain, it stays in the spinal cord.

Which means we will not feel the pain, we can only feel it when it reaches the brain. Hereby the expression: The pain is in the brain.

Now, what can happen is that the assistant gets a little excited, or perhaps stressed, and she can make some mistakes.

If the boss has given the instruction that all calls are equally important, she might confuse the different signals. “Calls” from the line that informs about touch can be confused with those of pain (like the man with the nail, he probably felt the touch of the nail between his toes), just as well as those that tell about movement of a joint or of pressure. So now instead of just feeling touch or pressure, we feel pain, because that is the information that the brain gets!

THE NOT-SO-GOOD ALARM

Alarms are meant to make us do something. And that is ultimately why we have pain. It’s a way the body moves us to take action.

When your hand gets near a fire you will feel pain and will move your hand away from the fire. The alarm comes on and tries to protect you.

If you sprain your ankle you will feel pain when you move it. Initially, the alarm is pretty good and it tells us to minimize walking or heavy loading on the ankle while it starts to heal.

The long term pain alarm is not a very good alarm.  Meaning it is disconnected from the initial problem.  Alarms don’t tell us how much smoke there is nor do they tell us if there is even a fire.  A smoke alarm can even go off when there is no smoke. 

Our pain alarm can work the same way.  The fire can have been put out but the alarm is still going off.

And when we have pain for a long time we can even increase the sensitivity of the alarm. So movement, pressure or temperature change can reach the brain in the form of pain (like our secretary confusing the “calls” she receives from different senses or signals and passes them all up to the boss as dangerous/important pain signals to act upon).

THE DECISION-MAKING BRAIN

The brain makes the decision on what to do with the alarm (nociception/pain signals). It will do that – mostly subconsciously – based on previous experience and on knowledge, but also on expectations (“I always get neck pain when we drive over speed bumps”), beliefs (“My disc will slip out if I don’t hold my spine stiff”) and attitudes (“All things pass, I´ll get through this one as well”).

Based on the total decision, the brain will send inhibiting, calming instruction to the body (the muscles relax, less stress hormones are produced, back-to-normal body functions) or exciting, alarming instruction to stay alert and on guard (tensing muscles, increasing heart beats, more adrenaline, less energy to everyday body functions like digestion and more).

The same nociception, pain signal, can therefore have a completely different outcome on how much we actually feel that pain.

This does not mean that when we feel pain, we are just exaggerating, or we just imagine it. The alarm is going off, the nociceptive signals are firing – it IS painful! The question is if there is anything we can do when it seems clear that there is no mechanical reason for this persisting pain (after having been examined sufficiently to discard that).

The great answer is yes, we are multidimentional, so is pain, and therefore we can use various ways to calm down these signals when they have started to fire away on their own.

 
 

TODAY´S KEY MESSAGE

Pain is an alarm that might have been disconnected from its inicial source of damage but is still firing off.

How we understand pain can influence how strong it will be.

 

 

 

In my next article I will discuss more about what happens with a body that is in persistent pain and different ways to deal with pain that is disconnected from actual damage.

Key sources:

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