More people in America experience pain than heart disease, cancer, and diabetes combined.(1) One out of every five people currently experience chronic pain, while one out of every ten people are newly diagnosed with chronic pain each year. (2) These statistics are shocking and have led many researchers to try and better understand pain and how it works. As you probably have experienced, pain affects many areas of life. The underlying cause of many of these problems is fear of pain with movement. Fear of movement often leads to disuse and disability while increasing the chance of noncommunicable disease. As coaches and clinicians the goal is to keep people moving and healthy. As an athlete the goal is to continue training without pain or injury. Throughout the past decade, there has been an increase in the amount of information on pain and how to use this information to better train and treat our athletes and patients. However, there still seems to be a disconnect between relaying this information properly from coach to athlete and clinician to patient. This disconnect has left our athletes and patients with misconceptions about pain that evoke fear and hinder recovery and performance. Although there are many misconceptions that need to be addressed, I believe that there are three misconceptions that need to be addressed first.
1) Pain is not normal.
First off, it is important to understand that experiencing pain is normal, and the ability to experience pain is a good thing. Some people are born with the inability to experience pain. These people are at extreme risk for injury. Our body’s nervous system serves as an alarm system to tell us that our body is in danger. Therefore, experiencing pain is a much-needed protective mechanism. Pain is experienced due to a sequence of events. Receptors are spread throughout the body that detect danger. Once a receptor is stimulated enough, it causes the neuron to fire. The neuron then travels to the spinal cord where it interacts with more receptors. Once these receptors reach a certain level of excitement, then its neurons will send danger messages up to the brain. In the brain, there is a large network of neurons that work together to decide if the danger message is indeed a threat. If so, pain will be experienced. It is important to note that pain is experienced in the brain. Pain signals are not sent from the site of injury. Instead, only danger signals are sent from the site of injury. Pain is an output that occurs due to the perception that the body is threatened. This should give relief to those who believe the pain experienced directly correlates with the severity of their injury. Although the ability to experience pain is normal and much needed, its processes can be skewed. This leads us to the next misconception.
2) Pain is directly proportional to tissue damage.
When we think of “normal” pain, we often think that the pain experienced is somewhat proportional to the tissue damage done. An acute, sudden type of pain is usually when we would expect our pain system to be working properly. However, when those pain signals are sent over and over again to the spinal cord, our body can adapt negatively. Receptors in the spinal cord become extra sensitive and begin to increase the number of danger signals sent to the brain. This leads to a disproportional amount of danger messages being transmitted from what is actually happening at the site of injury. We call this central sensitization. These receptors and nerves can become so sensitive that danger signals can be sent in the absence of a stimulus. Pain can become the disease and not just a symptom.
There have been many great studies that support the fact that pain is not directly proportional to tissue damage.
- Ultrasound of 411 individuals with no pain, 23% of people had a rotator cuff tear. (4)
- CT scan or MRI of 3110 individuals with no pain, 30% of 20 year-olds and 84% of 80
year-olds had a disc bulge while 29% of 20 year-olds and 43% of 80 year-olds had a
disk protrusion. (5)
- Fake surgeries were found to be just as effective as actual surgeries in decreasing
These studies show that changes occur to our bodies as we age and they do not have to correlate with a pain experience.
The recent research findings about pain have also caused a shift in understanding pain from a biomedical approach (looking at the anatomy and damaged tissue) to a biopsychosocial approach. We now know that pain is more complex than just the tissue damage done. Biologically, we know that some people are more prone to experiencing pain. We also know that biological changes can occur that can increase or decrease pain. Psychologically, we know that our thoughts, beliefs, and past experiences all play a role in the amount of pain experienced. Even our social environment plays a role in a pain experience. Although biomechanics are an important part of our pain experience, we cannot assume that all the pain is caused from a cut, break, or tear. We have to look at the person as a whole in order to really determine why someone is experiencing pain.
3) Pain means quit moving.
People often live on the extremes. When it comes to pain and the decision to move or be sedentary, it is no different. Either people will say “no pain, no gain” and push through the pain or they are fearful of pain and quit moving altogether. Neither of these approaches are what we want. With acute pain, we usually assume the pain to be more accurate and protective in nature. An appropriate response would be to scale the movement to where the pain is lessened or no longer experienced. This will prevent repetitive danger signals being sent to the spinal cord so that the chances of chronic pain will decrease. Whereas with chronic pain, we know that the pain experienced is not necessarily proportional to the damage done. This changes the whole view of how to approach exercise. Pain experienced during exercise is then okay within certain parameters because we know that the structure being damaged is probably not what is causing the full pain experience. The research shows that understanding how pain works and slowly returning back to sport (graded exposure) is one of the best solutions for those experiencing chronic pain.
How to Apply Your New Understanding of Pain
For the Athlete
Pain changes the way we move. Pain can totally shut down some muscles from working and can also cause muscles to compensate for others, leading to muscle imbalances. It is important to understand how pain works in order to know when to scale back an exercise, know when a little bit of pain is okay, and know how to manage your body and take control of your own health. It is also important to know your own limitations and when it is time to consult a medical professional you trust.
For the Coach
Understanding pain should change the way we coach. Many coaches tell their athletes to push through the pain. Although sometimes this can go without consequences, the risk outweighs the reward. It is important to understand that pushing people through pain on a continual basis can lead to chronic pain problems down the road. It is also important for the coach to understand pain so that they can appropriately reassure athletes who are out of sport due to pain and refer out to an appropriate medical professional when necessary.
For the Clinician
The large majority of the patients we see are experiencing pain. The research has shown that simply educating people on how pain works can lead to decreases in pain. For the longest time, medical professionals neglected the brain. The whole focus of treatment was on treating the painful tissue. As we once treated just the tissue, we also do not need to just treat the brain through education. The best solution is to treat the brain and treat the tissue while keeping the patient active and moving!
As you can see, pain is highly prevalent and highly complex. Researchers are continuing to find more information on pain and how it works. As of now, we only know what has been published. We know that the ability to experience pain is a good thing in itself because it helps to protect us from harm. We know the processes behind pain can be altered and lead to a false representation of the damage done, and we know that pain affects how people move and how often they move. Due to the high prevalence of pain, it is important for all coaches and clinicians to be educated on what pain actually is. Understanding pain helps clinicians and coaches safely treat/coach their patients/athletes, decrease the fear associated with the perception of pain, and empower them to keep moving. Education and movement is the best medicine!
- American Academy of Pain Medicine. AAPM Facts and Figures on Pain. http://www.painmed.org/PatientCenter/Facts_on_Pain.aspx#refer
- Goldberg DS, Mcgee SJ. Pain as a global public health priority. BMC Public Health.
- International Association for the Study of Pain. IASP Taxonomy. http://www.iasp-pain.org/Taxonomy. Last updated May 22, 2012.
- Tempelhof S, Rupp S, Seil R. Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg. 1999;8(4):296-9.
- Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-6.
- Louw A, Diener I, Fernández-de-las-peñas C, Puentedura EJ. Sham Surgery in Orthopedics: A Systematic Review of the Literature. Pain Med. 2016.
- Butler DS, Moseley GL. Explain Pain. Noigroup Publications; 2003.