1. Explaining Pain
Dr. Erik Pohlman, PT, DPT

2. Pain is a common problem!
1 in 6 Americans live with persistent pain1
Globally, 20% have pain > 3 months2
Persistent pain costs ~$100 billion/yr3

3. Definition of Pain
Pain is an “unpleasant sensory and emotional experience associated with actual or potential tissue damage.”4
International Association for the Study of Pain (IASP)
Pic found at

4. Old Model Painful stimulus→PAIN Tissue damage = pain
Descartes proposed a direct wiring mechanism of pain in 1644

5. How do we explain… Phantom limb pain Painless battle wounds
even in those born without the limb5
Painless battle wounds
Papercut hurting so much

6. Other Examples WWII vet – bullet in neck 60 years, he never knew!6
Surfers – feel a ‘bump,’ no more leg!

7. These patients had no pain, weakness, or sensation changes!7

8. Also have evidence of people with “bone on bone” OA with no pain.
These examples illustrate the fact that the experience of pain is not perfectly linked with actual bodily harm or damage. 8

9. Will this hurt?
Of course… Pain is normal and is there to protect us from injury.

10. How about now?
Why?

11. Threat Initially, the body only had to worry about the nail
Nail→Threat→PAIN
When you are running from the lion, the nail is the least of your worries
Nail→Lion is bigger threat→Nail doesn’t hurt
Explains soldiers in battle
More on this later…

12. Threat
It is the perception of the threat that determines the output, not the tissue damage itself or threat to the tissues…8 Pain = Output

13. So how does pain really work?
It is a complex system with many contributors.

14. Nociceptors (“Pain sensors”)
Mechanical, Temperature, and Chemical
They tell the brain ‘danger’, NOT ‘pain’
Brain determines if you should feel pain
Body can add or subtract all over the body
Replaced as often as every few days
Current levels of sensitivity can and will change!
Remember that we don’t have to have damage to have pain, but it is important to know a little about the sensors that can send such signals to the brain.

15. Sensitization Increased sensitivity after injury
Allodynia, hyperalgesia
Normal, but should fade after healing
Persists in people with chronic pain

16. Central Sensitization2
The spinal cord and brain cells are more sensitive
You may notice:
Pain longer than normal tissue healing time
Spreading pain
Worsening pain
Even small movements hurt
Pain is unpredictable (what hurts one day may not hurt the next, or thinking about it can cause pain)
You have other significant ‘threats’ in your life

17. Homuncu-what?

18. Homunculus Map of body in the brain Phantom limb
‘Smudging’ in chronic pain and phantom pain
More chronic -> more smudging9
So fixing a mechanical issue, like a disc, doesn’t always fix the real problem.

19. Neuroplasticity Not to worry!
The brain and nervous system are constantly changing
Braille users10 and guitarists/violinists/cellists11

20. Brain Centers Not just 1 center or one input (like from the tissues)
Neurotag – many parts of the brain activating in a unique pattern2
Sensory, motor, memory, emotion, autonomic nervous system, etc.
All parts light up in phantom pain
But there isn’t just 1 center in the brain responsible for pain. Each pain experience is unique and consists of a unique pattern of activation ALL OVER THE BRAIN.
Danger signal, on its own, is NOT enough to produce pain!

21. Pain relies on context
Perception of threat level modifies pain according to the situation
Finger injury in professional violinist vs. dancer12
Whiplash from car accident
An important part of these networks is the brain’s memory of previous situations and its thoughts on what the injury means to the individual.
Explain car accident in depth, looking up and R was how we got hurt, brain says, so don’t do that.

22. Thought Viruses Thoughts are nerve signals too
Ever feel pain when thinking about the painful movement or watching someone else do it?
Anxiety about pain or disability can increase pain
We have proven through multiple studies that pain education, relaxation, etc can reduce pain experiences, sometimes more than drugs, core stabilization, and other treatments.

23. HURT ≠ HARM What does this tell us?
Pain comes from the brain, not muscle, tendon, disc, etc
and…
HURT ≠ HARM

24. How can we fix our pain?

25. Bed rest? NO WAY!!! Blood flow leads to healing and less pain
Re-define that ‘fuzzy’ section in brain
Prevent atrophy

26. Surgery Last resort, or when rapidly progressing neuro symptoms Costly
Risky
Infection, nerve damage,
Still have a recovery period
May still not help
Plenty of people who still have their pain after surgery

27. Medication Pain killers, anti-inflammatories, muscle relaxers, etc.
May or may not help symptoms
Often won’t help the actual cause

28. You are already well on your way!
Pain education
Patients can understand pain theories13
Knowing pain physiology reduces threat level14
…reducing sympathetic, endocrine, and motor activity.15,16
Combining pain physiology education and movement therapies improves physical capacity, reduces pain, and improves quality of life!17
Evidence shows that pain education may even be better at preventing pain than core stabilization18

29. Caution! Don’t get hung up on anatomy!
Knowing more about pain leads to better results than knowing more about anatomy (bones, discs, alignment, etc)14
You have now learned that is one (possible) part in the pain experience

30. Tone down that nervous system
Active Relaxation
Deep breathing
Breathing with diaphragm
Heat, ice, TENS, anything else that works for you

31. Graded exposure
Gradually increasing exercise, activity, and stimulation (desensitization)
Re-teaches body/brain that movements and stimulation are ok
Can also gradually re-expose yourself to driving or the thing you were doing when originally injured

32. Trick your nervous system
Same movement, different context
Do the movement in a different way
Change the position or what moves first, do in water, etc.

33. See your friendly local physical therapist to…
Rule out more serious issues and refer you to the proper provider if one is found
Determine if there is a mechanical cause
Provide more pain education
Provide treatments like manipulation, dry needling, therapeutic movement/exercise, etc.

34. Points to remember Your pain is REAL
Imaging (Xray, MRI) may be misleading
Bedrest and waiting for it to improve will likely not help and may make it worse
Motion is Lotion
Pain is normal and it’s ok to feel some pain with exercise if you have chronic pain already
HURT ≠ HARM
See your physical therapist!!!

35. (Strongly) Recommended Reading
Explain Pain, by David Butler

36. Thank you!

37. References
1. Chronic Pain elective, Regis University 2011, quoted this as coming from the ‘American Chronic Pain Association.’
2. Butler D, Moseley GL. Explain Pain. Adelaide: NOI Group Publishing, 2003.
3. Chronic Pain elective, Regis University 2011, quoted this as coming from the ‘American Alliance of Cancer Pain Initiatives.’ 4.
5. Saadah ES, Melzack R. Phantom limb experiences in congenital limb deficient adults. Cortex. 1994;30(3):
6. The Times, Feb , p 5, London.
7. Boden SD, et al. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. J Bone Joint Surg Am. 1990;72a(3):
8. Moseley GL. Reconceptualising pain according to modern pain science. Phys Ther Reviews. 2007;12:
9. Flor H, et al. Extensive reorganisation of primary somatosensory cortex in chronic back pain patients. Neurosci Letters. 1997;244:5-8.
10. Pascual-Leone A, Torres F. Plasticity of the sensorimotor cortex representation of the reading finger of braille readers. Brain. 1993;116:39-52.
11. Elbert TC, et al. Increased cortical representation of the fingers of the left hand in string players. Science. 1995;270:
12. Moseley GL. Joining forces- combining cognition-targeted motor control training with group or individual pain physiology education: a successful treatment for chronic low back pain. J Man Manip Ther. 2003;11:88-94.
13. Moseley GL. Unravelling the barriers to reconceptualisation of the problem in chronic pain: the actual and perceived ability of patients and health professionals to understand neurophysiology. J Pain. 2003;4:
14. Moseley GL, Hodges PW, Nicholas MK. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clin J Pain. 2003;20(5):
15. Melzack R. Pain and stress: a new perspective in psychosocial factors in pain. RJ Gatchel and DC Turk. 1999, Guildford Press: New York.
16. Moseley GL. Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. Euro J Pain. 2004;8:39-45.
17. Moseley GL. Physiotherapy is effective for chronic low back pain: a randomised controlled trial. Aus J Physioth. 2002;48:
18. George SZ, Wittmer VT, Fillingim RB, Robinson ME. Comparison of graded exercise and graded exposure clinical outcomes for patients with chronic low back pain. JOSPT. 2010;40(11).