How do we explain pain that comes and goes?

We have known for decades now that pain is a very complex thing. Pain can emerge with or without corresponding tissue damage. When there is tissue damage, pain is usually not very well correlated with the extent of the damage. Two people with the same tissue damage can experience quite different levels of pain. And consider how much a paper cut or wasp sting can hurt even though the actual tissue damage is minimal.

Nevertheless, many people assume that if they are having pain there must be some new or ongoing injury to explain it. I will use spine pain as an example because it is so familiar and yet so perplexing to most people. You may have been told your back pain is coming from a bulging disc. We’ll ignore the fact that is a pretty uncertain statement (e.g. many pain-free people have bulging discs, it is extremely difficult to pinpoint the source of back pain with any certainty, blah, blah, blah) and assume it’s true for the sake of argument. That disc bulge should be pretty well healed after 8-12 weeks. If it continues to hurt after that time, what explains it?

If you “throw your back out” again 6 months later, is that you reinjuring your disc? Anything is possible, but if you fully recovered in 14 days and not 8-12 weeks then you should question whether it was really injured. So what caused the pain?

Rather than think of pain as having a one-to-one connection with injury, we need to adopt a better understanding of what causes our symptoms. We recognize that there are many variables that can go into having painful symptoms, or other types of protective sensations like stiffness. A good way to understand and visualize how these variables interact to create symptoms is a “vector model”. Physical therapist Matthew Low did a good job of explaining this idea here, but I will attempt to give it to you in brief.

Let me take you back to physics class (briefly, I promise). A vector is an arrow that represents some force that has a direction. The longer the arrow the higher the force it represents. Importantly, vectors representing several different forces can be added together to give you the resultant force and the direction it goes. Thus you can see how several forces can interact to create the one force you see.

We can use the same concept to visualize how many variables in your life and body can interact and result in pain.

We’ll return to our back pain example. Some things are factors that increase the risk of back pain. Let’s say being very sedentary, past injury, fear avoidance (not doing a particular movement because you think it will hurt or injure), depression or anxiety, hypervigilance (often leading to excessive, unnecessary muscle contraction), job stress, poor sleep, and poor muscle fitness. These will be represented by arrows that tend towards back pain.

Some things may decrease the tendency towards back pain like positive beliefs about getting better, an enjoyable exercise program or physical activity, and good social support. These will be represented by arrows that tend away from back pain.

Every person will have their own such factors. The amount that they contribute to or detract from the back pain will be different, so the arrows will be different lengths.

Now we have a chart that looks like this. The arrow at the bottom is the result of adding the lengths of all the arrows up. The more and longer the negative arrows, the more likely one is to pass the threshold and feel symptoms. The more and longer the positive arrows, the more protected one might be from experiencing symptoms.

Looking at this, perhaps you can start to understand why some days you feel no symptoms and other days you do. If one or several variables increases quite a bit—say you have a bad day at work and a poor night’s sleep—you may experience back pain, even if you didn’t increase the stress on your back at all.

This can really help us understand the ebb and flow of conditions like back pain. Increase a few of the negative variables and suddenly you get that pain “out of the blue”. Once we might have attributed that to a new injury, but most likely you just crossed that threshold. A few days later, some of those variables can get smaller, the resultant arrow passes back over the threshold and your pain goes away.

Hopefully viewing painful conditions in this way makes you recognize that you have some control. You can make some of those negative variables smaller through activity modification and lifestyle changes, and you can choose which are the easiest or the most convenient to change. You might also decide to tackle the largest arrow first. Additionally, and no less important, you can increase the size of the positive arrows to counteract the negative factors. Now you have options for how you can treat yourself and control your condition. It doesn’t always have to be what the physical therapist tells you to do. If you despise exercise, you may still be able to reduce your pain by addressing other factors (but I still think exercise has huge bang for the buck.)

There are other helpful suggestions about treatment that you can glean from this model. If the resultant arrow passes the threshold line by quite a bit, you can make two important deductions. One, is that changing just one thing may not be enough to reduce your symptoms. For example, if you have untreated or poorly-controlled depression but choose to ignore it and instead focus on increasing your core endurance you may not notice any positive effect. You will probably want to address the biggest contributing factors, and you may need to address more than one. The second deduction to be made is that your rehabilitation will likely take a fair amount of time and require you to be persistent with the changes you deploy.

Viewing the model will help you identify not only those things that you can change, but also those things that you cannot or will not. If you had a previous back injury, you can’t change that. If you have pain at work and you’re a construction worker but can’t change your job or don’t want to, then that variable will always be there.

The model also lets you see when you may need help from more than one specialty. As a physical therapist, I must recognize that my realm is mostly related to activity modification and exercise. If you have a mood disorder, or a serious sleep disorder, or you’re stressed because you’re struggling to make ends meet at home, those are things that must be addressed by the appropriate professional. Ideally, all of us professionals would coordinate to help you.

Lastly, this model can be applied to any and all pains and injuries, not just back pain, and not just pains that come on without an obvious injury. It could be knee arthritis. It could be shoulder surgery. It is important to recognize that increases in any of the variables can bring pain on again and your battle to remain pain-free may require lifelong vigilance in some cases. But viewing your pain in this way should give you confidence that you can manage your condition in a variety of ways. With the proper guidance, you can be put back in control.

‘Use it or lose it’ could be a key for persistent pain

Everyone is familiar with the phrase ‘use it or lose it’. Despite it being cliché it actually does apply well to lots of facets of our lives. If you don’t use your vacation days in a calendar year, they may go away. In some places, if you don’t vote for several years, you can be stricken from the voter rolls. And, of course, if you don’t use your muscles your body—greedy little energy saver that it is—will cause them to get smaller. But it’s not just your muscles that are negatively affected if you don’t move much. It is also your brain.

Neuroplasticity is the idea—now well-established—that your brain’s physical and chemical characteristics are changeable and are, in fact, constantly changing. The impetus for this constant adaptation is the signals transmitted to and within your brain throughout the day.

We know that repetitive use of a body part improves its representation in the brain. That knowledge forms the basis of stroke rehabilitation, for instance, where therapist and patient practice hundreds and thousands of repetitions of various arm movements to improve the representation of that arm in the brain. The result is that the patient gets better control of that arm, not just through muscular strength but also through brain-muscle connection.

Our brains have specific areas dedicated to motor control and sensation. Within each of those areas there are actually discrete sections for every part of our bodies and the size of each area is directly proportional to how well we can sense and how finely we can control that body part. For example, the area for the thumb is much larger than the area for the thigh. Even though your thigh is bigger than your thumb, your thumb is much more sensitive and dexterous than your thigh, so your brain has much more neurons dedicated to your thumb’s control and sensation.

The motor and sensory areas of the brain have specific regions that represent every part of your body.

Moreover, the finger representation in a violinist’s brain is likely larger than that of a truck driver’s since the violinist is constantly using her fingers in nimble and delicate ways. More practice makes the brain area larger. The brain is able to detect what is going on better and able to send signals to control it better.

The opposite is also true, and this may have big implications for persistent pain. If you don’t use/move a particular body part much, that part will lose representation in the brain. The brain will be less able to detect what is going on with that body part and it will have less ability to finely control what that part does. This is the essence of the “garbage in, garbage out” phrase.

How does that lead to pain? Pain is a sensation created by your brain (just like vision or hearing) when it perceives a threat based on information it gleans about the body. If the brain thinks a part needs protecting, you will probably feel pain in that area. If the brain isn’t getting good information about a body part because its representation is so small it may make mistakes and conclude that the area is in danger and needs protecting. This connection between persistent pain and body part representation in the brain has been studied and confirmed with back pain, neck pain, and complex regional pain syndrome.

So, if you rarely move your back except to bend forwards and spend the rest of your time with it still or resting on a chair or bed, the area of representation in your brain can start to get smaller. That can lead to subpar or garbled information about your back reaching your brain and increase the likelihood that your brain will perceive normal sensations as threatening. Voila! Back pain. (I use back pain as an example because it is so common, but this goes for pain in any body part.)

The more pain you have, the less likely you are to move, the smaller the back’s representation in the brain, pain increases in the back, you move less, etc. Breaking that cycle involves movement. Movement is the stimulus that helps redefine and enlarge the body part’s representation in the brain. That is why I advocate moving your back in all directions, not just bending forward. It is why I encourage the pelvis tilting exercise, because it makes you concentrate on movements of individual vertebrae rather than the whole back as a block. (Some people find pelvis tilting as difficult as wiggling their ears, evidence that their brain is not well connected to their back.) It is why movement therapies like tai chi and Feldenkrais that force you to move precisely and thoughtfully can help decrease pain and are often encouraged for people with persistent pain.

Todd Hargrove writes eloquently about this idea in his two books A Guide to Better Movement and Playing with Movement, but the crux of it is: we need to move often. It’s even better if we take some time to move certain body parts in novel ways. Try moving sideways or rotating, bending and twisting, moving fast or very slow. All of it will stimulate your brain and maintain or improve your virtual body’s representation within your brain, which will allow you to perceive it better and have better control over your body. And who doesn’t want that?

So, when it comes to your body and your brain, use it or lose it. The consequences may not just be that you get weaker or can’t play the violin as well as you used to. You may also be setting yourself up for pain in the future, or ensuring that it sticks around.

Safety Precautions for Our Patients During the Coronavirus Pandemic

From the outset, physical therapy clinics have been considered essential businesses during the pandemic. However, when New York City was first struggling with the coronavirus we determined that it was unwise and unsafe to remain open and perhaps risk adding to the burden on the healthcare system. Instead, we made good use of telehealth for those that still needed physical therapy.

With the number of new cases declining and the hospital system in a better place we have decided to begin a limited reopening of our in-clinic services. The safety of our patients and our employees is paramount, so we wanted to detail how we plan to keep you safe should you decide to come to our clinic.

We created this plan by consulting several expert public health guidelines including those of the CDC, the NYC Department of Health, the American Physical Therapy Association, and the New York Physical Therapy Association.

How will we identify possibly sick patients before they enter our clinic?

  • We will send patients automatic appointment reminders with a list of symptoms. By confirming your appointment you will be confirming that you do not exhibit the symptoms listed and aren’t sick before each appointment.
  • We will meet you in the building lobby and ask a series of screening questions to determine if you might be sick.
  • We will check your temperature with a non-contact infrared thermometer. Temperature must be below 100.4 degrees Fahrenheit or 38 degrees Celsius.
  • We will cancel your appointment if you show signs of being sick. We can always do an online visit instead.
  • We will waive your cancellation fee if either you or we cancel your appointment because you feel sick or might be sick.
  • All of our employees will complete the same screening before starting each day to ensure they aren’t sick.

How will we keep you safe when you’re in our clinic?

  • We will have plenty of hand sanitizer and facial tissues available.
  • We will continue to wash our hands between every patient encounter.
  • We will insist that you wash your hands immediately upon entering our clinic.
  • We will continue to sanitize the treatment tables with virucidal cleaner between each patient.
  • We will wear masks and gloves, and change gloves between every patient.
  • All patients will be required to bring and wear their own mask. We cannot allow you to enter if you don’t have a mask. Unfortunately, because of supply shortages we cannot provide masks for our patients.
  • Appointments will still be 45 minutes long, but we’ve added 15 minutes between each appointment to allow time for cleaning.
  • We will clean all of the treatment surfaces, the waiting area, the dressing area, and any items and equipment that were used. Our pillows have plastic coverings that will be cleaned each time and they will be covered with a clean towel or pillow case.
  • We ask that patients try to change and leave within 10 minutes of the end of their appointment so the next patient may enter 5 minutes early. Similarly, patients will not be allowed to enter more than 5 minutes before their appointment time to allow the previous patient time to change and leave. It’s recommended that patients arrive already wearing their workout clothes.
  • We will stagger our appointment start times by 30 minutes so that patients will not be in the waiting room or dressing area at the same time as another person.
  • We will only have two physical therapists working at a time. One will work in the front treatment room, and the other will work in the gym area to ensure the most separation between patients.
  • We will not re-use elastic exercise bands. We will give each patient their own and encourage them to bring it with them for each appointment.
  • All paperwork can be done online so you avoid touching high-contact objects like pens and clipboards.
  • We will encourage the use of contactless pay methods like Apple Pay, but we will also sanitize our payment tablet between each use.

We look forward to seeing you again in our clinic! We will also continue to provide online physical therapy visits to those who want them.

Is Back Pain Avoidable?

After people with back pain finish their course of care with us and are feeling a lot better, their next, logical question is, “How do I keep this from coming back?”

If you’ve never had back pain, you may wonder, “Is back pain avoidable?”

Ah, those are tough questions, indeed.