Understanding Pain

What is Pain?

Understanding of the mechanisms by which pain can occur has evolved over recent years. While originally pain was understood solely as an alarm system to indicate the amount of tissue damage, contemporary knowledge defines pain more broadly as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” (as defined by the International Society for the Study of Pain – IASP).

Strong evidence supporting this definition indicates the nature of pain is multi factorial and may include interactions between:

  • patho-anatomical
  • physical (training load, lifestyle, bio mechanics, movement patterns, physical conditioning)
  • non-physical (beliefs, emotions, lifestyle, social stressors, culture) factors.

The complex interplay of these factors in some cases, can lead to a negative cycle that perpetuates pain and disability.

Beliefs about pain

Beliefs about pain can have a strong impact on an individual’s response to pain. They are influenced by a person’s past experiences, contextual factors, culture, and information provided by treating therapists. Lower Back Pain (LBP) is commonly seen as “easy to harm and hard to heal”.

Negative beliefs have been associated with increased pain sensitivity and together with fear of movement are highly predictive of disability. The painful back automatically throws up images of paralysis and disability and irreparable damage into the mind of the individual which very quickly causes apprehension and an unnecessary fear of movement.

Factors affecting pain

Lifestyle factors can affect spinal tissue sensitivity such as:

  • sleep deficits
  • abdominal obesity
  • alcohol consumption

 Social factors can influence stress load, pain coping and vulnerability such as:

  • demands of the sport
  • expectations from coaches
  • team mates and fans
  • family stresses
  • cultural factors

Emotional factors have been described as predictors of injury in athletes. These can be:

  • high levels of stress
  • low mood
  • anxiety
  • disability
  • distress

Take for example Tiger Woods:

Lower Back Pain is one of the most common injury for professional golfers. The difference this time around with Tiger is that it was exacerbated by what was happening in his private life. He seemed to be making a recovery on the surface but he had other pressures.  These were money, sponsors, loss of a long standing title, a possible divorce and the media investigating his personal life. These extra pressures can exaggerate the underlying condition and cause a cascade of stress hormones to be released.  The pain suddenly changes from being in the background and manageable, to being in the forefront of his thoughts and everything is focused around how and when he will get better.

Tiger Woods Timeline

  • He was the top-ranked golfer in the world from August 1999 to September 2004 (264 weeks) and again from June 2005 to October 2010 (281 weeks).
  • November 2009 newspaper reports suggest infidelity and he leaves the marital home.
  • December 2009, EA Sports, Gillette, AT&T, TAG Huere, Gatorade, General Motors and Golfer’s Digest all pull their sponsorship
  • In May 2010, Woods withdrew from a tournament almost halfway through the final round due to a tingling sensation down his right side. It was suspected that he had a herniated disc, but that was never confirmed.
  • August 2010, Woods and his wife Erin divorced
  • December 2011 He ended a career-high winless streak of 107 weeks when he triumphed in the Chevron World Challenge A
  • March 25, 2013, he ascended to the No.1 ranking once again, holding the top spot until May 2014
  • August 2013, Woods complained of a stiff neck and only played nine holes (out of eighteen) in a tournament. Woods blamed the pain on a too-soft hotel mattress.
  • March 2014, Woods dropped out of the Honda Classic tournament with back pain. It was clear from Tiger’s stance, stretching, and movements that he was suffering from back pain during his last round. He aggravated his back while taking a shot on the sixth hole and said, “Well, it’s tough. I mean, it was just one thing that set it off.”
  • April 2014, Woods confirmed that he underwent a micro-discectomy to deal with a “pinched nerve” that had been troubling him in recent years. This meant Woods would not be participating in The Masters, and instead will be in recovery from surgery. His goal is to start playing again in summer 2014.
  • By March 29, 2015, Woods had fallen to #104, outside of the top 100 for the first time since 1996.[12]
  • In May 2016, Woods dropped out of the world top 500 for the first time in his professional career.
  •  May 29, 2017, Woods was arrested near Jupiter, Florida for driving under the influence of alcohol or drugs. Just days before Woods’s arrest, he had published a blog which offered a positive prognosis on his health. The 41-year-old has undergone multiple back surgeries but insisted: “I haven’t felt this good in years.”
  • In July 2017, the Official World Golf Ranking placed Woods at number 1,005, the worst of his career and only time he has ever been out of the top 1,000. He had ranked number one for a total of 683 weeks, more than any other player in history

(Wikipedia 2017)

Woods’ scenario is not very different to many millions of the people who have persistent lower back pain in the UK every day. He just has a lot more money than most people which is not always a good thing when it comes to pain.

It is estimated over 2.5 million people state they have LBP (lower back pain) in the UK every day

Like everyone in his position, he sought physical medical explanations for the pain.  His wealth and perceived urgency allows radiology to become involved early, and suddenly structures like Facet Joints, Discs and Pinched Nerves show some “changes”. Surgeons will always give surgical advice if requested, that’s their job, but it may not be the only option. However most people believe that there must be a structural reason for the pain which is hindering their normal daily life.

Because the patient does not have time for conservative treatment or may have previous bad experiences with physiotherapy or Chiropracters or Osteopaths, the patient opts for surgical intervention but it does not improve their pain to the levels they were expecting, and round and round the cycle goes.  The longer the cycle goes around, the thicker the circumference gets and the harder it is to break in to.

How to get relief from pain

The key to relief from pain, especially back pain is get help early.

The longer the pain goes on the harder it is to treat.  An early assessment is essential to rule out any life-threatening injury.  Following that a combination of rest (time for structures to heel themselves), good quality pain relief (to allow pain free movement and decrease apprehension) and exercises aimed to maintain normal activities of daily living and return to pain free movement.

If pain is allowed to progress, the body starts to become very sensitive towards movements and sensations which may exacerbate the pain.  It can get to a stage where even the thought of the pain can bring on an exacerbation of pain.  This is all due to your body’s defense mechanism going into over drive (SNS).  The SNS controls your Fight or Flight response.

In the presence of pain/stress the SNS fires.

  • Adrenaline is released
  • Blood pressure increases
  • Heart rate increases
  • Respiratory rate increases

This is a normal response to a stimulus or scenario which the brain perceives as a threat.  The unconscious brain is trying to protect the body.

When the stimulus is removed, the body returns to normal when the PNS fires.  The brain perceives any threat the same way, it does not discriminate.  The stress may be emotional, mental or physical.  In each case when the brain perceives this threat it will still send adrenaline around the body thus having the physical effects mentioned earlier.  If someone is already having a stress response to an emotional situation and then injures themselves, the overall stress response may be greater and the pain may be more exaggerated than normal.  This also works the other way around.  If someone is recovering from a physical injury and suddenly another stress is applied to the body or brain Eg, a death, a divorce, increased work, money issues, sick child etc, the body will be much more sensitive to stimulus as it is in a heightened state of readiness due to the adrenaline release from the stress response.  If one or more of the stresses on the body is not removed, the SNS continues to fire and the PNS switches off completely.  Thus the pain cycle continues to build momentum and the more difficult it becomes to find a way in to break the cycle.

North Yorkshire Physiotherapy, stokesley, Senior Physiotherapist

This article was written by Alan Frawley, a Senior Physiotherapist at North Yorkshire Physiotherapy. If you would like help to get relief from your pain please contact us on 01642 205975 to book an appointment or visit our website.

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