There are two things that connect all health care professionals.
First, they are in their respective professions to help improve patients’ quality of life through the alleviation and mitigation of pain. The second is that the skin is the entry point for doing so; this is how the story comes together.
Pain is a billion-dollar market, and it’s snowballing into an even bigger problem. A quick Google search of the word “pain” yields over 900 million results. Click on Merriam- Webster’s definition of pain and you will see words like “suffering,” “punishment” and “disorder.” Reflect on how we ask people about pain: Does it burn, sting, ache, shoot, or stab? Is it sharp, spreading, or constant?
Pain can most definitely be a scary thing, not only for patients but for health care professionals alike. You know through pain science and from leading researchers in the field that not only may you be able to alter the perception of pain—you can also be successful at treating it differently as well.
The value of pain
Most people classify pain into two categories: acute and chronic. Acute pain is good. It serves to protect the body and change a behavior; it’s important for survival. There is usually an issue in the tissue, and if you wish to alleviate it, you must act accordingly.
However, what is the value of chronic pain? Is there any at all? We know that active healing is no longer occurring in most such cases—there is nothing to avoid per se, so why are patients spending millions of dollars to treat chronic symptoms with oftentimes less-than-average results?
Most practitioners in the physical therapy world do not have a proper understanding of pain, nor can they effectively communicate this to their patients. This typically results in a fear-based model, stressing avoidance tactics, and oftentimes encouraging patients to seek alternative medicines, second opinions, and in some cases surgery, injections or pills. Therefore, instead of thinking of chronic pain as something that is happening in the tissue, we should be looking at the central nervous system—the changes in the brain and sensitization of peripheral nerves.
A persisting problem
What we know about pain is that it is an output, not an input. Pain does not correlate with tissue damage. A patient doesn’t require nociception to experience it, and cannot simply think it away, despite it being a conscious subjective experience. Chronic pain is usually the result of sensitized nociceptors. These nerve endings become easily excitable thus contributing to the persistence of pain that patients feel.
Old-fashioned explanations for chronic pain, through lifestyle, demographics and co-morbidities have not established a correlation to a pathway. As new research looks to changes in the brain, we can see distinct adaptations compared to healthy controls—mainly in the cortico-limbic and somatosensory cortex regions, which result in increased emotional processing to stimuli.
Research has established that pain travels via two pathways: A-fibers and C-fibers. A-fibers are rapid, discriminatory receptors that allow for reflexive responses and the body to localize incoming (threatening) stimuli. C-fibers are slower and typically result in the longer, unpleasant ache felt after an initial stimulus produces an affective signal. In other words, A-fibers let you know you’ve stepped on a pin, and C-fibers enable the achy, steady reminder that stepping on a pin is bad.
Remapping the response
Because typical modes of treatment are often unsuccessful in alleviating chronic pain, where is the practitioner to go? New evidence shows that if you use the power of affective touch, educate patients on pain, and gradually expose them to fearful stimuli, you may be able to “remap” their brains and empower them to once again enjoy a pain-free life.
Pain education allows patients to understand that pain is normal and better sense when it’s better to “push” versus “rest.” Complementing this information with coping strategies such as breathing, meditation and visualization equips a patient with initial steps to “rewire” their brains.
What’s more, fMRI imaging has shown that the brain demonstrates similar activity among subjects who moved, and subjects who thought about moving. So if patients are fearful of bending, lifting or running, just having them imagine themselves undertaking those tasks may be a good entry point to movement retraining to de-threaten their central nervous systems and prime them for more advanced motor control drills.
Light touch by way of instrument assisted soft tissue mobilization to stimulate C-fibers, or kinesiology taping to provide non-noxious stimuli and neurosensory cueing can create windows of opportunity to help patients move farther and with higher levels of perceived safety.
We no longer need to think about “releasing” tissue, or “breaking” scar tissue; we should be focusing on peripheral nerves and the sympathetic and parasympathetic nervous systems. Coupling these treatments with graded exposure training has proven to be quite effective in the rehabilitative process.
Chronic pain can be bothersome, but it need not be debilitating if a proper approach and understanding exists between the practitioner and patient.
Joe Lavacca, PT, DPT, OCS, is an experienced outpatient orthopedic clinician. He has obtained certification in movement screens for both the FMS and SFMA, Functional Strength Coaching, as well as Fascial Movement Taping and Performance Movement Techniques through RockTape. He stays current in the most up-to-date evidence-based research, which allows him to give individualized care to each of his patients.
