Pain: factors at play
In a previous article we introduced the idea that persistent pain is often more about sensitivity of the “alarm system” rather than damage of the body. You and your nervous system can become sensitized by a variety of factors. This article will cover different factors that may be at play.
Here is a common scenario: you went to the doctor and you have been told that your pain is because there is something wrong with the body part that hurts (“wear and tear”, arthritis, disc bulging, cartilage problems etc), and maybe you even saw it on an X-ray.
What if I told you that pain is not all about the physical damage and that sometimes the physical damage is not relevant in the pain picture?
Yes, you can have damage in the joint and it could be a factor, but not necessarily. You may have had that damage for long before your body started to hurt. Many degenerative changes happen very gradually with age, just like we start getting wrinkles on our skin.
Considering that you may have had this damage for a while without knowing, it means that you can get out of pain with no changes to your structure (i.e. surgery).
Also it can be helpful to remember that lots of people have the same changes and are not experiencing any pain. On top of that, a lot of people have pain without any damage.
How could this be? Pain is often the result of the interaction between physical factors and other things in your life that you may have control over.
There are many factors that influence pain and contribute to the sensitization. Some factors may be relevant in your circumstances, some may be of marginal importance.
Tissue damage or pathology: Arthritis of the joint, muscle strains, inflammation, degeneration of the discs, spinal stenosis and many more.
Lifestyle: Regular physical activity or sedentary behavior, sleep habit, diet, smoking, drinking, work-life balance, stress.
General health: Examples like metabolic disorders and obesity have an impact on recovery and pain perception.
Beliefs: About your pain and how you cope based on your beliefs. The reason why you believe you are in pain matters. Many unhelpful beliefs about pain can continue to sensitize your nervous system. For example, if you believe that moving and putting your body to work are bad and will cause injury, then you will be likely to avoid activities even though those activities are good for you. In short, your beliefs might be hindering recovery.
Psychological factors: Emotions such as frustration and fear of movement, negative outlook and expectations, catastrophizing, stress, negative memories and emotions about the pain experience, perceived threat, a low sense of control on your condition, the loss of meaningful activities like hobbies. These factors can all contribute to your sensitivity.
Social factors: Social withdrawal, work life and job satisfaction, recreational activities.
Speaking with a physical therapist can help you understand what factors may be relevant in your situation that could be worth addressing.
Here is the story of one of my patients, Sandra.
Sandra has had knee pain for 3 years. It started during the summer when she hiked longer than usual. After this painful hike she decided to stop hiking for a while and stop going to her usual Zumba classes at the gym because they were setting off the pain. The pain got progressively worse and the x-rays her doctor ordered showed degeneration of the joint. The doctor said its arthritis and all the wear and tear is only going to get worse with age. Sandra was 49 at the time and she wasn’t told that those changes were common in people her age and often they don’t give any trouble. Moreover, she probably had those changes for years and knee osteoarthritis progresses very slowly. She also wasn’t told that exercise is very beneficial for joint health, so scared to avoid injuring her knee any further she stopped hard workouts and preferred go on easy walks. She started to feel that her knee was less and less reliable. She couldn’t count on it like she used to do. She had been told that her hamstrings were tight, so now she is spending every morning stretching her hamstrings. She was also told that her knee was caving in when doing stairs, so until her gluteus medius keeps her knee from caving in, she should take elevators and escalators!
The problem with that is that Sandra is now miles away from doing what she wants to do (hiking, Zumba and move around NYC without relying on MTA fixing elevators and escalators). Also, let’s keep in mind that things like weakness, tightness, stability are poorly related to pain. She might have tight hamstrings and a “weak” gluteus medius but they aren’t very relevant to her pain. So those hamstrings stretches and clamshells with yellow band are likely to not make an impact on her ability to get back to use the knee for things that matter to her. Hiking and getting back to her active lifestyle is what will help Sandra. It is important to her, movement is good for her knee and exercise does not create further damage.
The challenge to get back to these activities is to find a tolerable entry point and then proceed in a gradual and progressive manner. Sandra should be aware that flare-ups may occur along the way, but these are likely due to "doing too much too soon" rather than indicating worsening and permanent damage to the knee.
References:
Butler DS Moseley GL. Explain Pain. Adelaide: Noigroup Publications; 2003.
Can Biomechanics Research Lead to More Effective Treatment of Low Back Pain? A Point-Counterpoint Debate. Jacek Cholewicki, Alan Breen, John M. Popovich, Jr., N. Peter Reeves, Shirley A. Sahrmann, Linda R. van Dillen, Andry Vleeming, and Paul W. Hodges. Journal of Orthopaedic & Sports Physical Therapy 2019 49:6, 425-436
