Know Your Pain by Brian Kitzerow, DPT, OCS, CMPT

Pain is a multifaceted and deeply personal experience that can be very difficult to describe and communicate.  Pain itself is a very functional experience that warns us to be careful when we might be injuring ourselves.  We can see how important pain is in the rare occurrences in which a person is born without the capacity to experience it.  This condition is known as congenital analgesia and these individuals have a very high mortality rate as they struggle with repeated broken bones and poor healing rates due to tissue re-injury when they can’t feel that they are hurting themselves.  

It is important to consciously acknowledge that pain is a functional sensation and that when properly manifested and interpreted can be very beneficial to our health and self-care.  Especially when we know what the pain signals we experience mean.  When it becomes too prolific, though, it can be impossible to negotiate recovery on your own.  

Most people are very good at pushing through their symptoms so that they can be functional throughout the day.  Unfortunately, they commonly do this by categorizing unpleasant pain impulses into a single amorphous uniculture they relate to as “my pain”.  Everything from a skinned elbow to headache to stomach cramping gets thrown into the same classification schema with little thought about what each individual signal might mean.  

Though this can be very useful in the short-term, this strategy tends to inhibit long-term recovery because they get re-injured over and over.  Just like in the congenital analgesia population, utilizing this strategy to ignore pain tends to worsen symptoms and pain levels over time because it doesn’t allow healing.  

Unaddressed injuries start to pile up on top of each other and it gets very hard to determine what the pain you are feeling means.  This is similar to driving your car with a flat tire; you will make it a little further and might even make it home, but you will have destroyed your wheel, axel and engine by the time you do.  If you don’t address the underlying problem (your tire is flat) you can’t take care of the other problems (your speed has slowed down, the ride is bumpy and there is a horrible smell from your car starting to burn).  

The original centrally driven model of pain is usually attributed to Descartes and was a simple circuit-like reaction where pain was stimulated at the site of injury and went directly to the brain with no control for grading or interpretation.  We now know that this is inaccurate.  Pain is an experience that our brains create.  This was detailed in the neuromatrix theory described by Ronald Melzack in the 1960s and expanded upon by many highly insightful researchers like Lorimer Mosely and David Butler.  

Our brains absorb all the thousands of input signals coming in to them at one time; the sensation of that needle poking our arm, the comforting smells of cookies baking, the angry, stern looks of our employer speaking to us, the full, satiated feeling in our stomach, the sound of breaking glass.  After that the brain filters these inputs through our previous learned experiences (the last time I saw a heavy hammer falling it landed on my foot or I was brutally spanked after I heard that crashing sound as a child and I broke the dishes).   It then decides what it should bring from the unconscious experience into our conscious awareness.  If the brain decides that the input isn’t relevant to our survival it won’t tell us about the pain stimuli.  We commonly see this in imaging studies where 60-70% of the healthy population have a hip or spine injury that they are not impacted by or aware of it in the slightest.

Sometimes the brain and sensory neurons become over-responsive at interpreting inputs as pain.  What was previously benign and safe (like light touch or a gentle walk) can become very painful.  Even when there isn’t any tissue damage.  This is termed a Central Pain Processing Dysfunction and recovery requires treatment to desensitize the central nervous system and remind it of what good and bad stimuli should feel like when determining whether you should hurt or not.  

There has been a swing in pain medicine to treating centrally driven pain with a technique that some psychologists utilize to treat fear and anxiety known as Acceptance and Commitment Theory (ACT).  This approach emphasizes focusing on goals and accepting that pain is an inevitable consequence to reaching them.  For instance, I know that walking two miles is going to make my back hurt worse afterwards, but I enjoy walking and need to get to the store. So I am going to accept that I will be pushing myself beyond what my body is telling me it is capable of and commit to walking anyway (or you could have been more insightful to what your body was saying and walked one mile, rested and then finished with no increase in pain and a progressively stronger body).

 This approach however ignores that at the root of central pain processing dysfunctions, are usually initial and subsequent injuries that stimulated the brain to become hypervigilant in the first place.  This is particularly true in the Ehlers-Danlos Syndrome (EDS) population who always have underlying musculoskeletal dysfunction contributing if there is a central pain processing dysfunction.   ACT based treatments for addressing pain are similar to driving home with that flat tire.  Sure, you can accept that your tire is flat and that you are damaging your car driving it home instead of addressing the flat tire, but your car isn’t going to benefit from it.  In the same way your body won’t benefit from ignoring your pain instead of analyzing what the pain means.  

Cognitive Behavior Theory (CBT) is a psychological technique that works very well with pain medicine and particularly well with the EDS population.  This theory suggests that you cognitively assess and investigate what you are feeling. You then decide on an action based on the logical conclusions you make from what the pain is trying to communicate to you.  

 Very often when we cognitively assess our pain we can tell that this is a very short term and temporary complaint that probably won’t be there tomorrow, such as a sharp, brief stab in the shoulder or a sore thigh muscle.  These are things that we can consciously let go of as they are not serious and are unlikely to affect us long-term.  In effect, we are performing on a conscious level the duties that our unconscious pain processing centers should be performing unconsciously.  This has very strong benefits to reducing stress and anxiety because we know these pain experiences will be temporary and are not threatening to our wellbeing.  

Other times, when we utilize CBT, we recognize that a pain is either more severe, or has been a consistent problem that might indicate damage to our tissue in some way. In this case we are in a position to cognitively assess what kind of pain we are feeling and what that might indicate.  Is this a tendon pain that indicates we aren’t stabilizing our shoulder with our scapular muscles and our rotator cuff is irritated?  Do we see less pain (and by default less tissue damage) when we lift a little less? Or engage our low traps before lifting the arm?  When our rotator cuff is more active and strong, is this pain consistently less?  Or instead of the shoulder is this a burning, nervy pain around our skin and fascia that indicates small fiber neuropathy (as seen in fibromyalgia and very strongly in the recent EDS research)?  

In that case we could benefit from talking to our doctors about a neurogenic pain medication and lowering our baseline inflammation levels.  Is this the headache that starts at the back of our skull and rolls over the skull to sit behind our eyes?  In that case we are probably scrunching the circulation of our greater occipital nerve and need to relax our neck muscles and change our posture, or strengthen our core and shoulder muscles to improve our ergonomics.

CBT-based approaches gives back to you the control to manage your symptoms instead of being placed in the position of a passive victim.  There will be some pains that are unresponsive or have so much complicated noise going on that you will need a good PT, MD or body worker to help with them, but commonly you can have a lot of control over your daily experiences.  It is just important to know what the different “flavors” of pain signals suggest.  Be cognitively aware and assess your symptoms as they come up.  Some will be transitory and unimportant.  Others will be more important to listen to and adjust the intensity of how you’re moving and working at in order to allow your body to heal.  Your physical therapist can help you negotiate what different pains mean and how to manage them successfully. ​

Brian Kitzerow is a Doctor of Physical Therapy at Good Health Physical Therapy with offices in both SW and NE Portland. Interested in learning more about your own pain? Consider seeing Brian at Good Health or coming in for Acupuncture at All Ways Well today!

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