All About Managing Pain

By mc schraefel

Most of us have had the experience of having a paper cut feel like it’s a “center of our universe” pain, while we may have broken a limb or cut ourselves severely in another circumstance and not noticed until later on.

How can something as trivial as a paper cut be so huge, when something as damaging as a break could happen without our awareness?

What these simple differences tell us is that pain is a rich, complex experience. Pain involves not just the physical experience of some injury (or threat of some injury), but, according to research over the past 30+ years, pain involves processing stimuli from various inputs, including social, psychological and physiological experiences.

Pain is interpretation

Research in pain indicates that the electro-chemical signals from an injury do not of themselves always say “pain” to the brain. The same signals triggered in the body that say “pain” today may just be translated as “frustration” tomorrow.

In other words, pain is cognitive: it’s an interpreted event in which the brain takes in multiple signals – including physical, social, psychological input – and then decides whether the combined output says “pain.”

At its most fundamental level, we can say that:

1. Pain is not the same thing as injury.

2. Pain takes place not at the site of injury but in the brain.

Research also tells us that the brain interprets a particular input as pain when it perceives something jeopardizing the body’s balance (homeostasis).

Likewise, the role of pain seems to be an action signal: a signal that, if perceived, means something needs to be changed to restore the body’s homeostasis. This gives us a third point:

3. Pain is a signal to change.

One of the challenges for physical culture and rehab is that the site of pain is not always the source of pain. While pain is a brain signal, it does not necessarily tell us what is wrong. All we know is that our brain thinks something threatens our homeostasis.

Acute & chronic pain

Generally speaking, pain breaks down into two categories (though the International Association on Pain Studies has about 30 categories of pain).

Acute pain

According to the International Association for the Study of Pain (IASP), acute pain would be a sudden back twinge during deadlifts, or banging your shin into the barbell.

Acute pain is generally associated with an injury (or anticipated injury) and is site specific. With acute pain, the sufferer can usually show exactly where the pain is, and what triggers it. The pain is sharp and clearly defined. If there has been tissue damage, there can be swelling or later scarring.

Chronic pain

Chronic pain is more like the nonspecific shoulder or backache that’s been around for a year. Chronic pain is ongoing and tends to be more diffuse.

Chronic pain can be particularly challenging, because its intensity can come and go. It can often be unpredictable, and not always associated with specific events. For instance, sufferers might just wake up sore some days.

Sufferers of chronic pain often reduce their movement (to reduce pain), and fear the types of movements that seem to stimulate the pain, although it may not be a specific movement that induces the pain. Although chronic pain may be accompanied by inflammation, there may be no physical signs that there is any particular tissue repair work going on.

In both acute and chronic pain cases, however, pain-free movement can be a way to accelerate healing and break chronic pain cycles.

Managing pain with movement

Thus:

Pain is an action signal.
Pain a signal to change, but not a prescription for rehab.
Pain is indicative rather than diagnostic.
Pain is the brain telling us that something is threatening our homeostasis; it doesn’t tell us specifically what is wrong or what to do about it.

Pain is often described as acute or chronic. And for those of us who work out or play physically, acute or chronic pain seems to be par for the course.

Unfortunately, the two most common sports responses to pain – work through it or stop moving until it goes away – are both largely wrong. Turns out, we need to keep moving, but, unless it’s life and death, never move into pain.

Movement we know is a key part of health. Because of how we’re wired, movement — though again, not into pain — actually plays an important role in pain management.

Silencing pain signals

In the gym or on the field, if we experience a twinge, we often ignore it until it becomes a scream. The best response to an immediate pain, however, as soon as it happens is:

Stop what we’re doing – whether it’s a muscle cramp or just a twinge.
Reduce speed – recheck.
If there’s still pain, reduce load – recheck.
If there’s still pain, reduce range of motion.
If there’s still pain, do some other movement that incurs no pain.

In each of these tests, the advice is not to stop moving our body but where possible to keep moving the affected body part without pain. Find a pain-free way to move.

The importance of movement

Movement is a key signal to our bodies about how well we’re doing. We are designed as “use it or lose it” systems, constantly adapting to what we do (see Woolf’s Law for bone formation and Davis’ Law for tissue; also see Lederman reference below for reducing scar tissue formation).

Our bodies adapt to the demands — or lack of them — they experience. If we don’t move something for a while, our bodies begin to adapt to support that lack of movement. Unused bone disappears. Unused muscles atrophy.

Our bodies compensate in other ways too, to make up for the lack of mobility. We often get new pain as a result of those compensations. For instance, our joints may swell, or muscles may complain when asked to do work for which they were not designed.

For instance, let’s say you have pain in your right hip. You start favouring your left leg to compensate. While this makes your right hip feel better (sort of), you eventually get pain in your left leg and hip, because you’re suddenly doing much more unbalanced work on the left hand side. Then, maybe your right shoulder starts to hurt, or your neck, because you’re walking around lopsided like a boat with one oar, and it’s pulling on your spine.

Here’s another common example. Your back hurts. So you go to bed. After a few days of lying around, you feel worse. Now your shoulders and neck hurt too. Your hips hurt from the pressure of lying down. Not a great solution!

Thus, immobilizing oneself can create a vicious cycle. Compensating for one painful movement induces other restricted movements.

By staying as mobile as possible, at every joint, without pain, we signal two things.

First, movement says we are still using this part of our body and thus this body part needs resources for healing and growth.

Second, the movement signals themselves can overwhelm a pain signal to say there’s more right than wrong going on in the area: there are more nerves that tell the body how we’re moving than nerves that say there’s something wrong.

Movement nerves (mechanoreceptors) are also easier to turn on than nerves that trip in the presence of noxious stimuli. This receptor ratio is used to great effect when we drop a weight on our thumb and then shake and rub the area and find the pain is reduced, as per the Oh Canada section in All About Dynamic Joint Mobility.

Managing pain: a complex system response

Beyond reducing the intensity of an immediate pain experience by reducing load, speed and range of motion, we can help protect ourselves from pain by considering our somatosensory system in our skills practice.

Prevention: movement, balance and vision practice

The somatosensory system includes a hierarchy of three interdependent systems:

the visual system (what we see);
the vestibular (our sense of balance and orientation relative to gravity); and
the proprioceptive system (our sense of movement and position in space).

If our nervous system perceives a threat to any of these systems, it can trigger compensations and eventual pain responses.

For instance, if someone has an esophoria – a condition where an eye may tend to pull in (example here) — that condition makes objects appear closer than they are. Imagine always reaching for something thinking it’s closer than it is, and having to readjust constantly.

This micro miscue and constant readjustment results in a low-grade ongoing stress that may affect muscular posture and eventually contribute to what becomes a chronic strain. Just rehabbing muscles of the body won’t eliminate the problem – we need to address the eye muscles too.

We can address this in the same way that we train: using movement work. Here, sports vision training can help address the phoria and enhance visual performance, often improving proprioceptive and vestibular performance too, also often ultimately addressing the pain signal’s request for change.

Remember, the site of pain is not always the source of pain. In this case, the source of pain is the eyes’ muscular coordination. The site of pain may, in fact, be posture — or any number of other underlying problems.

It’s important to note that there are a variety of ways to address pain via better movement, balance and vision skills. This is not to say that glasses or orthotics or drugs are wrong; just that work with the somatosensory system is a powerful, if often overlooked, way to work with the body to improve performance and reduce pain.

A movement program can be used as a cornerstone of such a mixed practice to reduce the incidence of injury in physical practice and to help manage or even eliminate chronic pain. See All About Dynamic Joint Mobility for program suggestions.

Response: movement assessment

If we’ve experienced fresh or ongoing pain, it may help to seek out a movement assessment. This means being assessed in motion.

This guidance may seem obvious, but it’s not in practice. Many of us have seen specialists that will look at how a painful limb moves, or test our range of motion while lying on a table or standing still, but may not consider how we carry ourselves as we walk down a hallway.

Likewise, some approaches may deal only with musculo-skeletal issues. If that works, great, but if it does not, that may be a sign that some other part of the somatosensory system – like the phoria example above – is at play, affecting performance.

Pain is a signal to change. Until the underlying issue is identified and addressed, the signal to change may keep coming.

Moving forward, pain free

Pain takes place in the brain. It is an outcome of the cognitive interpretation of multiple signals, from social to physical to neural.
Pain is a response to actual or perceived threat to the body’s homeostasis. The same action may be interpreted differently under different circumstances, depending on whether the body thinks it’s a threat.
The site of pain does not equal the source of pain.
Pain is individual. Our experience of pain can change, depending on who we are, what we’re doing, and the context in which we experience it.
Pain is a signal to change; it is not a prescription of what to do or where to go.
Pain often directly affects quality of movement. However, one of the worst things we can do in response to pain is either ignore it and keep going (the tough it out, “no pain no gain” response) or respond to it by shutting down movement (the chronic pain vicious circle).
Movement that does not cause pain is often an effective path to better function. It both reduces the duration of acute pain and helps to address the intensity or frequency of chronic pain.
A movement assessment – especially one that considers somatosensory responses from the integrated visual, vestibular, and proprioceptive systems — can provide insight about movement strategies to help address a particular pain and improve performance.