Strategies to Reduce Chronic Pain, Part Two

Warning sign.
No gain?

In a previous post I discussed some basic strategies to reduce chronic pain, based on what we know about pain science.  As discussed here, chronic pain is sometimes not so much a problem with actual ongoing physical damage to the body, but instead due to overactivity in the pain alarm system itself.  Here are some more strategies to prevent the alarm system from getting out of control.

Don’t Ignore Pain – Take Corrective Action

Pain is above all a survival mechanism designed to encourage you to take action to correct what the brain perceives to be a threat to the physical tissues.  Ignoring the signal can lead to problems.  When a window appears on your computer screen saying there is a virus, you don’t solve the problem by minimizing the window.  Similarly, you don’t solve pain problems by ignoring the signal.  Instead, listen to the signal and try to take corrective action.

To understand what is meant by “corrective action”, consider thirst, which is a signal that you are dehydrated and need to drink.  The thirst will go away as soon as your brain concludes that you have drank an appropriate amount of water, and before the dehydrated tissues have actually received any water.  The thirst ends when the brain concludes that corrective action has been taken, it doesn’t wait until the problem is actually solved. Pain is similar, because the brain will often stop pain suddenly even though no tissue healing could have possibly occurred.  Ever notice that you got better as soon as you walked into the a doctor’s office and then you were frustrated because you had nothing to complain about?  Perhaps this occurs because the brain concludes that you have taken appropriate action to solve the perceived problem, and that pain is no longer necessary to encourage action.

It is an unhappy fact that pain often arrives for no good reason.  On the other hand, it is a happy fact that that it can go away for no good reason as well.  So, even if you don’t know the right thing to do about your pain (most people don’t), any reasonable corrective action you take has some chance of working, even if it does nothing to remedy the actual tissue damage (assuming there was any in the first place.)  What your brain considers corrective is anybody’s guess, but some good guesses might be rest, massage, a hot tub, some empathetic nurturing from a caregiver, magic herbs or other placebos, or a trip to a guy in a white coat who claims to be an expert about something.   Sham acupuncture works just as well as real acupuncture in curing pain.  Sham surgeries work as well.  You can call these placebos, and that is the right word, but what is really happening is that the brain is concluding that corrective action has been taken and that pain is no longer necessary.  Placebos work sometimes, so try one.  (It probably doesn’t matter much if you know it’s a placebo.)   By contrast, don’t try to tough it out, or take drugs or do other stuff to ignore the pain signal.  This will only make things worse.

Don’t Turn Temporary Pain into Chronic Pain

In a previous post I discussed the unfortunate fact that the longer pain goes on, the easier it becomes to feel.  This is a consequence of many complicated physiological factors, as well as a very basic process by which the neural pathways responsible for generating pain become more easily activated the more times they are used.  It’s like blazing a trail in the jungle or forest – the more times you walk on the trail, the clearer the path becomes, and the more likely you will be to take that path again.

In some cases you can use this knowledge to prevent a temporary pain from becoming a more persistent and permanent pain.  Let’s say you tweak your foot and have a minor pain that you suspect will go away in a few days, if you stop running.  But you go ahead and run anyway because the pain is very minor and you don’t want to lose training days.  The running doesn’t seem to be making the pain worse, but it does prevent the pain from going away.  Six months later, the pain is still there, and now it won’t go away even when you do take a few days off.   After a few more months, the pain can be activated at lower and lower thresholds of activity, including walking.  And now it is really starting to interfere with your running and you need pain pills to continue.   A tiny problem has now magnified into a major problem, because …. pain breeds pain.  Maybe you or some expert will erroneously conclude that you have tendonitis or some other mystery overuse syndrome, when the only real problem is a hyped up pain system.

I had a client once who knew many ex-professional basketball and football players.  Many of these guys were living in extreme pain and were unable to do simple things like walk up and down stairs.  I think one of the major reasons was not the physical wear and tear on their bodies, but the reprogramming of their pain systems that occurred over time.  When you are a pro, you can’t take time off until the pain stops, you play through it, sometimes for years.  This is a perfect recipe for reprogramming your nervous system to cause pain.  Bill Walton recently admitted that chronic back pain was literally making him suicidal.  His pain started in college when he injured his back in one game and then played another (in a brace) three days later.  Twenty five years later, Walton said the pain was so bad that being dipped in boiling acid wouldn’t even begin to describe it.  Perhaps some exaggeration there, but a chilling cautionary tale nonetheless.   Playing through pain is often necessary to reach the highest levels of sport, but it is a great way to develop some long lasting and nasty pain problems.  Remember that pain breeds pain, so don’t turn small problems into big ones by playing through pain.

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13 Responses to Strategies to Reduce Chronic Pain, Part Two

  1. Hi Todd,

    I think you could have talked about nourishing the nerves with oxygen rich blood with movement (neurodynamics). that is one way movement affects the CNS and thus pain.

  2. hi Todd, i’m an italian PT and I follow your blog with a lot of interest. It’s very useful to me for helping my patients to try to learn pain’s mechanisms. I totally agree with your approach (it’ essentially mine too) but I’m not only sure about not ignoring of little pains because I think they can even make worse just because we don’t ignore them…Maybe they could have a greater area in body map in the brain and I tihnk it’s not a good thing.
    it’s hard to me to explain these issues in English but i have tried. :-)
    Thank you for your comprehension and thank you again for your excellent work on the blog.
    Have a nice year

    • Antonello,

      Thanks for the comment and glad you like the blog. I’m not exactly sure what you are saying but I’m guessing that your point is that we shouldn’t make too big of a deal about small pains because this could lead to fear and more problems? If so, I can see you point. Awareness of small problems can be a double edged sword – it can help prevent problems by allowing rest but it might also cause fear of movement, which is a bad thing.

  3. Hi Todd,

    I read a few of your posts with a lot of interest and they led me to very interesting sites, books and lectures, particularly Lorimer Moseley’s TED talk. I found him very helpful. Now reading this post you mention not to take painkillers. I have herniated discs and it’s a long story, but had severe pain starting at the back of my knees three months ago and then a whole amount of other symptoms appeared. First I was told by a PT that I had a hamstring problem, then he said it was my lower back giving me sciatica. Then I went to another PT and he said it was a nerve pinched by something as the ct scan showed that the discs were not worse, but better than a couple of years ago. This last PT also told me I probably need a brace, that my hips were too mobile and that I needed further diagnostic. One week later I was in agony, came back and he said he was concerned and thought my back has worsen or something because the nerve pinched by muscle could not cause that much pain. Had two epidurals after that, last one a couple of weeks ago. Went to a new doctor last week and sent me to do an MRI that showed a herniation in L4 that ct didn’t show, now, because I got an MRI in my home country ten years ago, in there it showed a small herniation, but this guy didn’t know it and told me that this one is new and likely to be causing the symptoms. As you can imagine, I am skeptical of everything by now! But one thing he told and I refused to do initially was to take panadol Osteo as well as Ibuprofen and Endep, Endep is used to block the nerve signals and he said it is important to stop feeling pain. Although I was reluctant, I also read that once pain becomes chronic it is hard to get rid of, I didn’t understand why, now I do. But pain, partly because of Moseley’s and surprisingly Sarno’s ideas (not all) I feel better. If pain has become chronic and painkillers can get rid of it, then why not take them? If nerves become sensitive, isn’t it advisable to get rid of that sensation? Anyway possible? I look forward to your thoughts.

    • Hi Andrea,

      Sorry to hear about the pain. I didn’t mean to recommend against pain killers, they have their purpose. All drugs have their effects good and bad, including painkillers. I am not a doc and cannot weigh the good and bad in the context of a particular case or give medical advice about them. My only point is that you shouldn’t chronically use them to avoid taking other corrective action. Best of luck!

      • Thanks for the clarification Todd. Pain is a very complex and emotionally charged experience. I am sure you’re aware of Allan Basbaum and his research. I saw a lecture of his last night and it was very instructive. Cheers.

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