Pain and the Brain part 1

Pain is in the brain 100% of the time. Let me say that again with several dramatic pauses. Pain, is in the brain, 100% of the time. This statement isn’t meant to offend or call anyone “crazy.” Well, given the level of self-inflected torture that most of us put ourselves through we are likely a little off somewhere. But that is a different conversation for a different day. This statement comes from Lorimer Moseley one of the leading researchers in a field of study that is commonly referred to as neuroscience. Dr. Moseley and David Butler have spent the vast majority of their careers trying to understand the complexity of pain and how it has such a wide variance amongst people. Pain is a very normal experience that often occurs as a protective response to some type of stimulus to our bodies. Sprains, strains, broken bones and sore muscles can all signal a cascade of events in our bodies that create the pain experience that is ultimately registered in our brains. This highly complex, primitive process, is designed to alert us to what the brain perceives as a threat and to get us to take action to protect itself. The concept of pain and pain management is a widely studied area of medicine and can get very dense very quickly. I will do my best to keep the “nerdiness” to a minimum but provide you with a solid idea of how we generate pain, how that impacts performance and what you can do about.


The types and stages of pain

Cuts to the hand, muscle tears and low back injuries all share one thing in common, they hurt! Although they are all described by the term pain, the way in which the body has generated the pain signal is significantly different. To better understand pain and how this relates to us as athletes we need to define several key components. Pain is a very general term. Everything from a sprained ankle to a paper cut is often referred to as being “painful.” But the process to generate a pain response is unique based upon the type of stimulus and structures that are involved. Nociceptive pain, neuropathic pain and visceral pain are all terms used to describe the types of pain we experience. Acute and chronic reference the amount of time pain has been present.

Nociceptive Pain is generated by stimulating specialized nerve endings called nociceptors. There are two subgroups of nociceptive pain, somatic and visceral. Somatic pain is a type of nociceptive pain response that is common with injuries such as a sprained ankle or a muscle strain. Visceral pain is brought on by stimulation of nociceptors in organs and can be described by aching and squeezing.

Neuropathic Pain is often the result of nerve damage or irritation. Symptoms are often described as burning, tingling, electrical and stabbing. A true case of sciatica, irritation to the sciatic nerve, is an example neuropathic pain.

Acute, subacute and chronic pain is defined in terms of duration. While some authors will vary on their definitions, it is mostly accepted that acute pain is 0-3 months in duration and anything greater than 3 months is considered chronic. Subacute pain will sometimes be referenced as a subset of acute pain and is defined as anything greater then 6 weeks but less then 3 months.

The Pain Process

Our bodies are equipped with a vast neural network that serves very unique roles and functions. Chemical, thermal and mechanical stimuli can trigger the millions of tiny sensors that line a nerve. In order for a nerve to be stimulated a specific threshold needs to be exceeded. That means that the nerve needs to receive a sufficient amount of a particular stimulus in order to be trigger. To see this in action, picture a ten-pound kettle bell resting on your foot. Uncomfortable yes, but not enough mechanical stimuli to generate a pain response. Now, same kettlebell dropped onto your foot from only a few inches up. What happens? The weight of the kettle bell stimulates a ton of these mechanical sensors that activate the nerve that will produce a signal that travels to the spine and then up to the brain. Now here is where it gets really “groovy” as Dr. Mosely likes to put it.


The stimulus from your foot alone is not enough to generate a pain response. Once the signal has reached our brain, it will go through an incredibly detailed process to determine an appropriate response. Within milliseconds your brain will take in information about the situation from your eyes, nose and ears. It will recall past experiences that may be similar in nature. Even our current mood, state of stress and perception of the situation is factored into the equation.  There is no “pain center” in the brain so this process requires rapid communication amongst various parts of the brain. Ultimately your brain will need to come to a decision about the situation and if the experience warrants a pain response or not. If the answer is yes, a painful response is produced and action is taken. In this case it will likely be a quick jerk of the foot followed by the not so graceful “walking it off” limp. If the brain doesn’t feel the situation requires any significant type of response then there is no pain and the kettle bell rolls to the floor.

Sounds simple enough right. I drop something on my foot, foot hurts, I move foot and curse wildly. Well not exactly. Did you catch the part about perception, mood and stress influencing the pain experience? The amount of pain you experience doesn’t always reflect the amount of tissue trauma. A key element to what we feel is dependent on how we perceive the situation. We have all heard of stories of military personal returning back to base after taking enemy fire only to then realize they had been wounded. But how is that possible? Didn’t those mechanical and chemical nociceptors produce a pain signal that went to the brain? They sure did and lots of it. But the brain, in its infinite wisdom, recognized that there were more pressing issues at hand (an understatement) and produced a response that diminished the pain response to allow the soldier to attend to what was necessary at that moment in time.

Another way to think about this concept is with the idea of hurt vs. harm. During any given day we will find a variety of things that we would say hurt. Work activities can hurt, stretching can hurt, even therapeutic exercises can hurt. That doesn’t mean any tissue trauma has occurred though. Harm is when we see trauma occurring to a region of our body and this is what we want to avoid. That is why it is vital as an athlete for us to have a good sense of what is going on with our bodies and seek quality information about any injury or physical issue. A well trained physical therapist, coach, chiropractor or athletic trainer can not only help you better understand what is going on but can also limit your Google searches which can lead to misinformation or inappropriate treatment.


Happy Joints

Body weight, movement and the quest for happy joints

The human body is an incredibly complex, efficient and resilient machine that is built for one thing, movement. Yes, I understand that movement is a very general term but when you look at everything that we do it relates to some element of movement. Whether it is a fine motor task like sewing or typing or a large complex movement like swinging a golf club or swimming, our bodies thrive and strive to move. In recent TED talk Daniel Welpert discussed the idea that the sole purpose of our brain is to create “adaptable and complex movements.” Food for thought, but some of the most basic elements of the human body, digestion, circulation, respiration and joint health all rely on movement. I’m not suggesting that these processes are simplistic by any means, but they are basic systems of our body that require movement as a component of how well they function. As a physical therapist and a movement specialist, one of the things that I commonly address in my practice is how to keep someone moving. Most of my patients seek my advise to help deal with some element of pain and dysfunction that always relates back to movement and the impact it has on their day-to-day life. The pain in their shoulder limits their ability to raise their arm and now they are having difficulty washing their hair. Or the catch in their knee doesn’t allow them to bend it as much as they need to and now they can’t go up stairs without pain. By having a better understanding of how joints work, factors that negatively impact a joint and ways to maintain good joint health, it will become clear that proper movement under optimal loads can help us reduce some of the factors associated with joint pain.

hip joint

Joints, an overview

There are various joints in the human body that are named based upon their shape, function and contents. Comprised of synovial fluid, articular cartilage, articular capsule, synovial membrane, ligaments, blood vessels and nerves, synovial joints represent the majority of the joints of the upper and lower extremities. These joints rely substantially on joint loading as a way to stay healthy. The cartilage of synovial joints can be thought of like a dense sponge that is absorbing the fluid in the joint to maintain optimal health while slowly releasing naturally occurring waste products for our bodies to remove. When we stand we load the knee joint and this compresses the cartilage, squeezing out additional waste. As the load is released the cartilage has the ability to absorb additional nutrient rich fluid. This process is carried out constantly as we load and unload our joints throughout the day and is necessary for our joints to function optimally.

Joint pain risk factors

Proper joint health requires a certain amount of compression and movement, but what happens when the load is excessive or beyond the body’s ability to control? Elevated BMI, muscle weakness and decreased joint stability have all been linked to pain and dysfunction in joints. In recent study it was noted that women with an elevated BMI, >30, had a risk of 24% for developing knee OA compared to those with a BMI 5 points lower had reduced their risk to 16%. Inadequate dynamic stability, the ability to control joints during movement, can increase the likelihood of shear and compressive forces on joint surfaces. Overtime this has the ability to cause pain, dysfunction and may contribute to early osteoarthritis. These undesired movement patterns can be related to muscle weakness but external variables such as shoes can also impact the forces that our joint experience, particularly the foot/ankle complex, knee, hip and spine.

Keep’em moving, keep’em happy

Movement is a necessary component to keep a joint well hydrated, lubricated and the tissue in and round the joint mobile, allowing for pain free movement. Given that we know of the various types of factors that can negatively impact our joints here are several key elements to proper joint health.

  • Mobility of muscles, the nervous system and joint structures is vital for proper movement of the human body. You need to have proper mobility before you can even think about loading the body with more force or weight. Poor mobility, leads to poor form, which can leave you susceptible to preventable pain and injury.
  • Move and move often but find a suitable form of exercise that your body can adequately perform without pain.
  • Be aware of how much activity you are doing in a given workout or during a given week to avoid over training. You can exercise daily but by varying your intensity you can give your body necessary “active rest” to allow for proper physical recovery and healing time.
  • Shoe type will vary depending on your foot and body structure. Not everyone needs to or should be in a minimalist shoe. But not everyone needs an arch support either. Proper fitting by a knowledgeable health professional or shoe specialist is key. And if high heels are in your closet, pack them up and ship them out! Too many reasons to list here but your feet, ankles, knees, hips and spine will thank me.
  • Strength training is necessary but functional training is key. You can have a strong quadriceps muscle but if you don’t have proper lower extremity mobility, stability and functional strength you can run the risk of injury
  • Maintaining a proper body weight can reduce the forces applied to joints


TRX: A New Technique

In 2005, former Navy SEAL commander Randy Hetrick introduced a new training method called TRX to the fitness world. After serving his country for 14 years, Hetrick discovered that a simple set of sturdy straps – upgraded with cushy handles and new hardware that optimizes home training – could greatly increase mobility, flexibility and core strength in its users.

That was then, but this is now: TRX is one of the most popular, up-and-coming, efficient ways to re-program your body’s core muscles and movements without hitting the gym. In fact, many of these isometric exercises accomplish what gym workouts sometimes never address.

Jason Villareal, Therapydia Portland’s clinic director, employs TRX in his physical therapy techniques. So for those of you who are curious about the methods and equipment, this short video from TRX helps illustrate how it works and its possible impacts.

Why Physical Therapy?

This video from the American Physical Therapy Association helps illustrate just how physical therapy works and why it can benefit a range of physiological issues — from joint pain and sore muscles to sports injuries and even “preventive” measure to avoid surgery. With physical therapy, you don’t have to end up on the operating table.

One of the key differences between physical therapy and, say, visiting the chiropractor, is that physical therapy tends to be less intense. We tend to use less invasive methods to increase your range of motion and flexibility. We’re also a cheerleader for progress that’s with you every step of the way.

Understanding Pain

What is pain, where does it come from, and how do I conquer it? These basic questions are essential to your recovery, and this clever video literally “illustrates” the finer points of preventing persistent pain.

There are many things to consider. As you will see, it’s not as simple as popping a pill or hopping on an operating table. One must really look at the issue holistically, as if it were part of a larger picture, and use the latest evidence-based techniques to solve it. That’s what we do at Therapydia Portland.

We’re new to the Portland physical therapy scene, but we’re not rookies. Clinic Director Joshua Zavertnik uses multiple techniques to guide your body to its ultimate goal of healing itself.  But this process is a partnership, and it helps when the patient understands exactly what his or her body is trying to tell them.