Why Do We Hurt?

Chronic pain is any pain that lasts for more than three months. At that point in time, any tissue that might have been damaged at the onset of injury will have healed and therefore, should no longer be painful. So why do we hurt?

Pain is an output of the brain. The possibility of pain starts when nerve fibers that transmit pain signals (nociception) send information to the brain. Then the brain decides if it is important or not, and what to do about it. To make this decision the brain incorporates all the information you have about pain and all the context around you (your environment). That context could include your beliefs and thoughts about your back (you think it’s weak, unstable, degenerative, etc), your history of injuries, memories of others who have had back injuries, the smell in the room, or the amount of lighting. Any credible evidence of danger to your body will modulate pain (a dark room will upregulate a pain response). If the brain determines there are more “danger cues” than there are “safe cues”, then the brain will say “yeah, we’re gonna make that hurt”.

After pain has been present for an extended time a couple things happen: 1. There is increased sensitivity to that area. In effect, your brain becomes better at creating pain, and 2.) There is decreased precision in deciphering the location of the pain whereby the pain starts to spread, move around, or changes in how it feels (achy, stabbing, etc.). These changes represent real and significant changes in the circuitry of your brain. It may be difficult for people with chronic pain to believe because their pain is 100% real but it no longer accurately signals damage to the tissues.

There is significant evidence that when people in pain are taught about the pain mechanisms of the body and brain, their pain will decrease. There is significant evidence that the brain can regain precision in the areas of chronic pain. The brain is plastic and does change and even the circuitry of pain can be retrained. “Movement is king” with retraining the brain to reduce pain. I often use a “stop light” analogy to guide patients. If there is no pain when doing an activity you have the “green light”. If you have some awareness or pain while doing an activity but there is no residual pain after doing the activity, you have the “yellow light” and can proceed with caution. If you have pain while doing an activity and residual pain after the activity, that is a “red light” and you should avoid that activity until a later time.

If you have questions or want to learn more feel free to contact Pro-Motion Chiropractic. Or, here are some links you may find helpful.

https://www.tamethebeast.org/

TedX talk with Lorimer Moseley

The Lost Art Of Bending Over

One of my favorite clinical terms is “lumbopelvic dissociation”. What this basically describes is when an individual is unable to move their hips without moving their lumbar spine. For instance, bending forward (flexing) at the hips while maintaining a neutral lower back. That movement is called is a “hip-hinge” and I teach it often when rehabilitating lower back pain.

There was recently a story on NPR titled “Lost Art Of Bending Over: How Other Cultures Spare Their Spines” (February 26, Morning Edition) which talked about how (in general) western cultures bend over versus how those in other parts of the world tend to bend over. More specifically, how these differences can lead to, or avoid, lower back pain. What the observer found when traveling to other countries was that people working in rice fields or working in their gardens bent over in a way that made their back like a table, i.e. their backs were flat and their hips were bent. More often than not, an American performing the same task would round their back to create a “C” with their hips and lumbar spine. This is one of the mechanisms that can lead to lower back pain.

In the story, Dr. Stuart McGill, PhD, likens the mechanism to woven cloth which is repeatedly pulled and stretched in one direction. Eventually the fibers start to loosen and unravel. Similarly, the outer layers of an intervertebral disc, when continually pulled in a certain direction, start to “delaminate”, or pull apart, making disc bulges and herniations more likely. By learning the correct mechanics of a hip hinge many people can avoid an episode of low back pain or recurrent episodes of low back pain and people who spend their days working in gardens can do so without suffering from lower back pain.

The hip hinge is a necessary skill for everyone from weight lifters to pregnant mothers. If you are having trouble with lower back pain, sciatica or back and hip strength, please call Pro-Motion Chiropractic and Rehabilitation or seek treatment from a knowledgeable doctor, clinician or therapist.

https://www.npr.org/sections/health-shots/2018/02/26/587735283/lost-art-of-bending-over-how-other-cultures-spare-their-spines

Central Sensitisation

I often have people come into my office who have been dealing with pain for a long time. These people suffering from chronic pain are often frustrated, depressed and anxious. Anything they do may set off their pain, they’ve tried “everything” and sometimes they feel there is no hope and that they just have to “live with it”. In the article “Where pain lives” the author discusses how science is learning that chronic pain isn’t just “acute pain that goes on and on”.

There are several possible mechanisms of how chronic pain starts, propagates and persists, but they all take into account that pain doesn’t equal tissue damage. Meaning that patients with chronic pain no longer have injured or damaged tissue (muscles, ligaments, discs, nerves) that might’ve have long ago been a mechanism for pain, but suffer from the brain creating “circuits” that constant re-live the pain or becoming hypersensitive to any form of stimuli, known as “central sensitisation”.

It is important for people living with chronic pain to understand what they are going through and the specific brain changes that have allowed their pain to continue and then take steps to rehab and strengthen their body knowing that “hurt does not typically mean harm”. There are no pharmaceutical means to treat this type of pain yet but there has been a lot of success using “Cognitive Behavioral Therapy” and graded “non-pain contingent” exercises. I have always said that my “ideal” practice includes a pain psychologist for this reason.

This article contains a lot more detailed information and deserves a read. I hope you will take the time and learn something from it and if you have more questions please feel free to contact me at Pro-Motion Chiropractic.

https://aeon.co/essays/to-treat-back-pain-look-to-the-brain-not-the-spine

Whiplash

Now that the snow is starting to fall, soon the roads will become a bit more dangerous. There’s nothing like the helpless feeling of sliding towards the car in front of you as your anti-lock brakes shutter and try to gain a grip on the ice beneath you. Whiplash is the most common injury following a car accident and can occur even at very low speeds. Here are some interesting statistics about whiplash that may surprise you.

Whiplash Statistics

  • Most injuries occur when traveling less than 12 mph
  • A read-end collision generally causes more damage to the cervical spine than side or frontal collisions do
  • Whiplash injuries are more severe in women and children because their necks are smaller
  • Whiplash injuries occur 5 times more often in women than men
  • Symptoms of whiplash can often appear weeks or months after an accident
  • In 75% of patients, symptoms of whiplash can last 6 months or longer
  • Victims of whiplash lose approximately 8 weeks of work
  • Whiplash injuries occur more often in people 30 to 50 years of age
  • A whiplash injury can increase your chances of chronic shoulder and neck pain
  • People suffering from chronic pain due to whiplash injuries often have abnormal psychological profiles
  • More than 60% of people who have whiplash injuries require long-term medical follow-up
  • More than 50% of those who have whiplash injuries will still have chronic pain 20 years after the injury
  • Pre-existing health conditions such as arthritis will lead to greater severity of injury and greater pain

Signs of a Whiplash Injury

After an accident, you are likely to feel some pain and limited ranges of motion. Even if the pain is minimal, it could worsen hours after the crash. Some signs of whiplash can include:

  • Pain when moving your head side to side
  • Tenderness
  • Headaches at the base of the skull
  • Fatigue
  • Dizziness
  • Difficulty sleeping
  • Memory problems
  • Tingling or numbness in the arms

Signs and symptoms of whiplash usually develop within 24 hours of the accident, which is why it is crucial to seek medical treatment immediately. If you’ve had an accident please let a professional make sure you are ok. You don’t want to be one of the 50% who has chronic pain 20 years after the injury.

Breathing and Low Back Pain

So often I have patients come in with neck pain, headaches, or lower back pain who exhibit something I call “paradoxical breathing”. Paradoxical breathing is characterized by inward motion of the abdomen with expansion of the chest and rib cage. This type of breathing utilizes “accessory muscles of respiration”, including intercostal muscles (those in between the ribs) and muscle of the neck, while excluding the diaphragm. There is a significant correlation between low back pain and dysfunctional breathing patterns.

The reasoning for this is that the diaphragm plays an important role in trunk stability and postural control. When someone exhibits paradoxical breathing, the diaphragm doesn’t descend (contract) like it should and instead rib expansion and lifting is used for inspiration. By constantly using accessory muscles for inspiration, those muscles start to have increased resting tone which can be perceived as neck pain and tension. In contrast, the diaphragm becomes weak and inactive.

There is a significant “co-contraction” between the diaphragm, the transversus abdominus, the lumbar multifidi, and the muscles of the pelvic floor which stabilizes the spine during movement (1). It has also been found that this co-contraction significantly reduces stresses on the spine by as much as 50% (50% in the upper lumbar spine and 30% in the lower lumbar spine) and reduces the loads experienced by the muscles of the low back by as much as 50% (2). When one of these muscles is injured or weak the co-contraction fails to reduce stress to the lumbar spine and musculature and can lead to injury and pain.

The good news is that the diaphragm can be trained and by practice and training the function can be restored and trunk stability increased. Breathing mechanics should always be assessed when treating patients with lower back pain and included with a specific core stability treatment plan when appropriate.

1. Nele Beeckmans et al., “The presence of respiratory disorders in individuals with low back pain: A systematic review”, Manual Therapy, 2016, Vol 26, page 77–86.

2. The Effects of Deep Abdominal Muscle Strengthening Exercises on Respiratory Function and Lumbar Stability. Eunyoung Kim, PhD, PT1 and Hanyong Lee, PhD2

The "Big 3", with Stuart McGill

 I just read a great q & a about the "Big 3" core stability exercises according to Stuart McGill. I have studied his books and followed his research for years and am excited to hear more and more about him in the media. It's a good read and you'll learn about some causes of lower back pain and how the "Big 3" help to alleviate it. Have a good one!

https://www.lifetimedaily.com/leading-back-pain-expert-reveals-fix-back-pain/

The Brain and Pain

I found a couple studies that I wanted to share with you. I often discuss the brains role in pain processing and changes that occur in the brain as a result of pain. The psychological effect pain has on us is immense and is just starting to be recognized and understood. Here are the studies that, I think, help shed some light on how we, as health care providers and manual therapists, can help our patients.

  • Bunzli, S., Smith, A., Schutze, R., Lind, I., & O’Sullivan, P. (2017). Making sense of low back pain and pain related fear. Journal of Orthopaedic & Sports Physical Therapy.

This narrative (not a study per se) is especially interesting to me because I deal with it all the time. The authors conclude that the Common Sense Model (CSM) can be used to cope with “fear-avoidance behaviors”. In the “Fear Avoidance Model”, patients foresee extremely negative outcomes of their pain and so they avoid any and all activity that might exacerbate the pain, which leads to disuse atrophy, depression and chronic pain. By using the CSM patients can 1.) identify the pain, 2.) know what causes the pain, 3.) understand the consequences of the pain, 4.) learn how to control it, and 5.) know how long it will last. With this knowledge the patient is able to better cope with and treat their pain.

  • Kregel, J., Coppieters, I., De Pauw, R., Malfliet, A., Danneels, L., Nijs, J. & Meeus, M. (2017) Does Conservative Treatment Change the Brain in Patients with Chronic Musculoskeletal Pain? ASystematic Review. Pain Physician, 20(3), 139-154

This study reviewed 9 different studies which used MRI to determine if functional and/or structural changes occurred in the brain of patients suffering with chronic musculoskeletal pain after a course of conservative care. They found that conservative care seemed to produce both functional and structural changes in the brain and also that these changes were associated with positive clinical outcomes (decreased pain, increased function).