Understanding Pain - Physiotherapy and Pain Management and the Role of the Physiotherapist in Treatment and Rehabilitation
Pain
Pain is the most common reason behind why people seek health care advice. But have you ever stopped to consider its purpose?
Pain is a complex event constructed by your nervous system in response to a threat to well-being or survival. This threat may be real, stepping on a pin or touching a hot iron for example, or perceived. Consider the sensations experienced when watching someone experience something you know to be painful!
Pain is essential for the survival and long-term health of the person experiencing it. People born without the ability to detect painful stimuli, a condition known as congenital insensitivity to pain, tend to die young from complications related to their injuries. Commonly from infections related to continued movement on broken bones.
Acute pain
Pain is often the first indicator that something is wrong with the body. It can come on rapidly, as in the case of a cut or a burn, or slowly, up to two weeks following a whiplash type injury. Its purpose is to take you away from the harmful stimulus, a hot iron for example; form unpleasant associations beneficial for the future, touching that iron was unpleasant - I won't do it again!; and promote healing behaviors, i.e. go and seek help from someone you trust, or limp to protect an injured part.
Even at this early stage it is unlikely that the pain will be well localized. Apart from the skin, which is your first barrier of defence and needs to localize 'breeches' (cuts, mosquito bights etc), most injured structures will give you a vague awareness of the area of injury or may create pains at some distance from the source. More important is that the appropriate action is taken, be it escaping danger, protecting an injury, or seeking an external source of help.
Chronic pain
Chronic pain is pain which continues after healing should be complete, or persists in the absence of any reason for it being there.
When does a pain become chronic? This all depends on the structure injured initially. For example, muscles are known to repair quite quickly and so it would be unusual for people to suffer pain from muscular injuries for longer than a few weeks. A slower healing structure, a disc for example, might be justified in causing pain and stiffness for many months. Bear in mind that even after many weeks, feelings of pain and stiffness might be helpful in promoting behaviours that will ultimately lead to the best possible healing. Think back to the dangers highlighted by those people born without the benefit of the pain warning system!
Some pain persists in the absence of any identifiable source, i.e. medical tests fail to identify a cause of the pain. Research is now looking at the similarities between memory formation and pain processing. It appears that some pains, if they are particularly severe or last long enough, can become 'learnt'. That is effectively people form a memory of the pain which persists after healing is complete. This makes sense if you consider the attention that some pains get, and that the same chemicals are involved in pain processing and learning! Pain has been likened to an annoying song that keeps repeating over and over in your head, and trying to 'un-learn' pain is a very difficult task indeed.
Physiotherapy and Pain
Physiotherapists are ideally placed to help in the management of both acute and chronic pain. In the acute stage the key is effective pain management in combination with detailed advice and explanation on what is to be expected with the injury and the rehabilitation period. Chronic pain presents much more of a challenge for both client and practitioner but again the key is to enable a thorough understanding of the situation in conjunction with advice on pain management and a graded programme of enjoyable exercise. In both instances, if the pain is understood and controlled, some of its threat value is lost, less attention needs to be placed on it and people can return to health either without developing unhelpful pain 'memories' or by beginning the process of un-learning.