What is Pain and What is Happening When We feel It?

What is pain? It might seem like an easy question. The answer, however, depends on who you ask.

Pain doesn’t originate at the site as most think, it’s created by the brain so we protect the area that’s in danger.

Some say pain is a warning signal that something is damaged, but what about pain-free major trauma? Some say pain is the body’s way of telling you something is wrong, but what about phantom limb pain, where the painful body part is not even there?

Pain scientists are reasonably agreed that pain is an unpleasant feeling in our body that makes us want to stop and change our behaviour. We no longer think of pain as a measure of tissue damage – it doesn’t actually work that way even in highly controlled experiments. We now think of pain as a complex and highly sophisticated protective mechanism.

How does pain work?

Our body contains specialised nerves that detect potentially dangerous changes in temperature, chemical balance or pressure. These “danger detectors” (or “nociceptors”) send alerts to the brain, but they cannot send pain to the brain because all pain is made by the brain.

When you’re injured, the brain makes an educated guess which part of the body is in danger and produces the pain there.

Pain is not actually coming from the wrist you broke, or the ankle you sprained. Pain is the result of the brain evaluating information, including danger data from the danger detection system, cognitive data such as expectations, previous exposure, cultural and social norms and beliefs, and other sensory data such as what you see, hear and otherwise sense.

The brain produces pain. Where in the body the brain produces the pain is a “best guess scenario”, based on all the incoming data and stored information. Usually the brain gets it right, but sometimes it doesn’t. An example is referred pain in your leg when it is your back that might need the protecting.

It is pain that tells us not to do things – for example, not to lift with an injured hand, or not to walk with an injured foot. It is pain, too, that tells us to do things – see a physio, visit a GP, sit still and rest.

We now know that pain can be “turned on” or “turned up” by anything that provides the brain with credible evidence that the body is in danger and needs protecting.

All in your head?

So is pain all about the brain and not at all about the body? No, these “danger detectors” are distributed across almost all of our body tissues and act as the eyes of the brain.

When there is a sudden change in tissue environment – for example, it heats up, gets acidic (cyclists, imagine the lactic acid burn at the end of a sprint), is squashed, squeezed, pulled or pinched – these danger detectors are our first line of defence.

They alert the brain and mobilise inflammatory mechanisms that increase blood flow and cause the release of healing molecules from nearby tissue, thus triggering the repair process.

Local anaesthetic renders these danger detectors useless, so danger messages are not triggered. As such, we can be pain-free despite major tissue trauma, such as being cut into for an operation.

Just because pain comes from the brain, it doesn’t mean it’s all in your head. 

Inflammation, on the other hand, renders these danger detectors more sensitive, so they respond to situations that are not actually dangerous. For example, when you move an inflamed joint, it hurts a long way before the tissues of the joint are actually stressed.

Danger messages travel to the brain and are highly processed along the way, with the brain itself taking part in the processing. The danger transmission neurones that run up the spinal cord to the brain are under real-time control from the brain, increasing and decreasing their sensitivity according to what the brain suggests would be helpful.

So, if the brain’s evaluation of all available information leads it to conclude that things are truly dangerous, then the danger transmission system becomes more sensitive (called descending facilitation). If the brain concludes things are not truly dangerous, then the danger transmission system becomes less sensitive (called descending inhibition).

Danger evaluation in the brain is mindbogglingly complex. Many brain regions are involved, some more commonly that others, but the exact mix of brain regions varies between individuals and, in fact, between moments within individuals.

To understand how pain emerges into consciousness requires us to understand how consciousness itself emerges, and that is proving to be very tricky.

To understand how pain works in real-life people with real-life pain, we can apply a reasonably easy principle: any credible evidence that the body is in danger and protective behaviour would be helpful will increase the likelihood and intensity of pain. Any credible evidence that the body is safe will decrease the likelihood and intensity of pain. It is as simple and as difficult as that.

Implications

To reduce pain, we need to reduce credible evidence of danger and increase credible evidence of safety. Danger detectors can be turned off by local anaesthetic, and we can also stimulate the body’s own danger-reduction pathways and mechanisms. This can be done by anything that is associated with safety – most obviously accurate understanding of how pain really works, exercise, active coping strategies, safe people and places.

A very effective way to reduce pain is to make something else seem more important to the brain – this is called distraction. Only being unconscious or dead provide greater pain relief than distraction.

In chronic pain the sensitivity of the hardware (the biological structures) increases so the relationship between pain and the true need for protection becomes distorted: we become over-protected by pain.

This is one significant reason there is no quick fix for nearly all persistent pains. Recovery requires a journey of patience, persistence, courage and good coaching. The best interventions focus on slowly training our body and brain to be less protective.

This article was originally posted on https://theconversation.com/explainer-what-is-pain-and-what-is-happening-when-we-feel-it-49040

For more information and audio recordings discussing pain, follow this link.

Basic Self-Massage Tips for Myofascial Trigger Points

Learn how to massage your own trigger points (muscle knots)

Massaging yourself might seem as useless as trying to tickle yourself. But if there is a good reason for rubbing your own muscles, it’s probably muscle “knots” or trigger points: small patches of clenched muscle fibres that are sensitive and cause aching and stiffness. They may be a major factor in many common pain problems like low back pain and neck pain. Most minor trigger points are probably self-treatable.

You can often get more relief from this kind of discomfort with self-massage than you can get from a massage therapist. Professional help can be nice — and sometimes essential — but it can also be cost-effective to learn to save yourself from trigger points. It is a safe, cheap, and reasonable approach to self-help for many common pain problems.1

It’s also a controversial one: there is plenty of scientific uncertainty about trigger points. It’s undeniable that mammals suffer from sensitive spots in our soft tissues … but their nature remains unclear, and the popular idea that they are a kind of mini-spasm could be wrong.2

This article just introduces the basic principles of treating trigger points with self-massage. If you’d like to dive deeper into the subject, see my huge trigger points & myofascial pain tutorial.

Why are minor trigger points so easy to deal with?

A lot of trigger point pain can be relieved with a surprisingly small amount of simple self-massage with your own thumbs or cheap tools like a tennis ball. Although trigger points can be amazingly nasty, most are fairly easy to find and get rid of with a just little rubbing.

Dr. Janet Travell3 wrote that “almost any intervention” can relieve a trigger point, and self-massage is usually the simplest, cheapest, safest, and most effective. Which sounds to good to be true, so we should probably be suspicious of it. How can such a trivial treatment work?

The pain may be more of a sensory phantom than something wrong with the tissue.4 It may be relatively easy to change with massage because there’s not much to “fix” — just a sensation to change.

A little self-massage is often the most effective treatment for minor muscle knots. But how can such a trivial treatment work?

Or maybe the rubbing actually helps muscle tissue directly in some way, like stirring a sauce until it’s free of lumps. Maybe massage works because it’s literally pushing and flushing waste metabolites out of a trigger point5 — which, in theory, interrupts a vicious cycle and prevents the trigger point from coming back. But, so far, no one has actually been able to demonstrate how a muscle “knot” can be untied by massage.

Isolated trigger points are probably much easier to manage — neurologically simpler.6 If the problem is limited to one body part, there’s a better chance of dealing with it.

Basic self-massage instructions for trigger points

Just a few moments of gentle rubbing can be enough for an easy case.7 For moderate cases, several larger doses — a minute or two — of rubbing over a couple days will usually do the trick. The toughest self-treatable cases might need an investment of about a half dozen 5–minute treatments per day for a week. But none of this is science-based, and treatment can definitely fail.8

Here are a bunch more basic tips …

Rub with what? Rub the trigger point with your fingertips, thumbs, fist, elbow … whatever feels easiest and most comfortable to you. Simple tools are handy for spots that are harder to reach — various balls and other handy objects. Tennis ball massage is surprisingly good stuff! You can use a foam roller, of course, but the contact area is just too wide for many jobs.

A tool like Pressure Positive’s Backnobber can be great. But for quick and easy self-massage, there’s usually something around the house that works pretty well — like a tennis ball!

Rub in what way? For simplicity, either simply press on the trigger point directly and hold for a while (10–100 seconds), or apply small kneading strokes, either circular or back and forth, and don’t worry about the direction of the muscle fibres. Really, anything goes. But, if you happen to know the direction of the muscle fibres — sometimes it’s obvious — then stroke parallel to the fibres as though you are trying to elongate them, because that might be more effective.

Rub how hard? This matters more! Because massage is mostly about having a conversation with your nervous system, you want it to have the right tone: Friendly and helpful! Not shouty and rude. The intensity of the treatment should be Goldilocks just-right: strong enough to satisfy, but easy to live with. On a scale of 10 — where 1 is painless and 10 is intolerable — please aim for the 4–7 range, and err on the side of gentle at first. Beginners are often much too aggressive. (And the pros too!)

What should it feel like? Pressure on a muscle knot should generally be clear and strong and satisfying; it should have a relieving, welcome quality. This is “good pain.” Massage is a conversation with your nervous system. So you want it to have the right tone. Friendly and helpful! Not shouty and rude.If you are wincing or gritting your teeth, you probably need to be more gentle. You need to be able to relax. See the next section for more information about how trigger point massage should feel.

What if it backfires? It probably won’t, especially if the pressure is reasonable. But if you experience any negative reaction in the hours after treatment, just ease up. In basic therapy, you can count on tissue adapting to stronger pressures over the course of a few days of regular treatment. If they don’t, either the problem isn’t really trigger points, or they are (much) worse trigger points than you thought.

Rub where? For basic self-treatment, you can trust your instincts: rub where it hurts! Do explore for sensitive spots, but you can limit your exploration to a fairly small area of muscle tissue around the “epicentre” of your symptoms. So, for instance, if the top of your shoulder aches, search for trigger points mainly in the top of your shoulder. (You will notnecessarily be able to feel a bump or “knot” in your muscle, so don’t worry too much about that.)

What if the trigger point is not where the pain is? Trigger points may generate symptoms that aren’t where the trigger point is. What’s a beginner to do? Don’t worry about it too much — this is basic trigger point treatment. Bear in mind the possibility of confusing referred pain, but don’t worry about it unless basic therapy is failing.

Rub how much? Massage each suspected trigger point for about 30 seconds, give or take depending on how helpful it feels. This is actually enough for many trigger points — especially if you think that you have several that all need attention! Five minutes is roughly the maximum that any trigger point will need at one time, but there is not really any limit — if rubbing the trigger point continues to feel good, feel free to keep going.

Rub how often? As long as you aren’t experiencing any negative reactions, you should massage any trigger point that seems to need it at least twice per day, and as much as a half dozen times per day. More is probably too tedious and involves too great a risk of just pissing it off.

How do you know it’s working? Getting a trigger point to “release”

The goal of self-massage for trigger points is to achieve a “release.” What is trigger point “release” and what does it feel like? How do you measure success? It mostly refers to an easing of sensitivity of the trigger point, and/or a softening of the tissue texture — the melting of the knot.

But release is a vague term with no specific scientific definition. It’s a label for the unknown, for whatever is going on when the trigger point seems to goes away. Maybe it refers to the literal relaxation (or even the violent disruption!) of the tightly clenched muscle fibres. Or maybe it’s “just” a sensory adaptation, which might be a kind of healing (it just stops hurting), or trivial and temporary (like scratching a mosquito bite).

A release may not be obvious. In fact, things could even feel worse before they feel better: tissue might remain “polluted” with waste metabolites even after a successful release. Release might even require some damage to the tissue of the muscle knots — that is one theory. If so, the area would probably still be quite sensitive even if you’ve succeeded.

In my experience — both treating and being treated — it’s a weird mixture of these possibilities: initially there’s a satisfying but profound sense of scratching an itch, but the tissue is actually more sensitive afterwards, not less.

For beginners, don’t worry about the details: just stimulate the trigger point, and trust that you probably achieved a release, or a partial release, and then wait for the trigger point to calm down. If you were successful, you will notice a reduction in symptoms within several hours, often the next morning.

If you were successful, you will notice a reduction in symptoms within several hours, often the next morning.

Good pain? With easy trigger points, successful release is typically associated with “good pain” — that clear, strong, and satisfying sensation that is somehow both painful and relieving. It is positive in the same sense that barfing is positive: it’s not pleasant, and yet your body “knows” that it needs and wants that much pressure. Usually, if you feel “good pain,” a trigger point release is more likely.

On the other hand, if you are wincing or gritting your teeth, you probably need to be more gentle. Comfort is an important component of successful treatment for most people! If you can’t massage the trigger point without wincing, you’re being too brutal on yourself, especially in the early stages. Sometimes a trigger point will feel nasty and hot and burning and still release anyway. But often such a rotten trigger point will need more persistent or advanced treatment. The “pressure question” — how much is too much? — is surprisingly complicated.

This is the tip of the trigger point iceberg

There are many reasons why basic self-massage might fail. The skeptics could be right: maybe there’s really nothing there but an abnormal sensation, nothing in the flesh to fix. Or it could fail for quite technical reasons — due to the neurological phenomenon of “referred pain,” the trigger point may not actually be located in the same place as the pain. This sends people on wild goose chases, rubbing the wrong things, and the only solution is education and experimentation.

this article originally appeared on painscience.com and was written by  Paul Ingraham.

A Must Read For People in Pain: 'Explain Pain'

If I could make only one recommendation to individuals living with chronic pain, it would be to read the book Explain Pain by David Butler and Lorimer Moseley.

Directed at both clinicians who work with chronic pain patients and patients who live with chronic pain, Explain Pain shows how the discoveries of modern pain science can be put to practical use. Written in understandable language with a touch of lighthearted humor, Butler and Moseley take a complex subject and make it possible for the average person to understand and use. One client remarked that she thought it would be hard to read and was delighted that she did not find it difficult at all. 

Pain education can help

Research has demonstrated that pain education can help to reduce chronic pain. For instance, a recent study by the army followed 4,325 soldiers over a two year period and found that one session of pain education could help lower the incidence of low back pain. Understanding how pain works is not a magic bullet that will make pain go away immediately, but it can help to take some of the fear and anxiety out of the experience which can then begin to help alter the experience. With time, thinking a little differently about pain can lead to more successful strategies for reducing, limiting, and eliminating pain.  

Pain is useful and should not be ignored. Pain is a protective mechanism generated by the brain in response to perceived threat. However, when pain is chronic and there is no direct or immediate threat to the body, understanding how the body can get "stuck" in pain can suggest ways to help it get "unstuck." 

Butler and Moseley provide some amazing stories to illustrate the surprising discovery that pain is not directly related to tissue damage. While this concept may, at first, seem odd and difficult to grasp, they produce convincing evidence to support this idea. Consider this: a paper cut produces very little tissue damage, yet can cause a lot of pain. A soldier can get shot in battle, yet not realize he is injured until he is off the battlefield. Amputees may experience phantom limb pain in tissue that no longer exists. How does that happen? The part of the brain that corresponded to the amputated limb can still generate the sensation of pain, even after the limb is gone.

Pain can be influenced by context. If everyone around us seems to be in pain, we may also expect to be in pain. Athletes involved in vigorous sports ignore impacts that would upset most of us because to them it's all part of the game. In that context, it is expected and not a threat. 

Butler and Moseley describe how pain is generated by the nervous system. Understanding that pain is generated by the brain, rather than by damaged tissues, does not mean that pain is "all in your head" and should be ignored or dismissed as imaginary. In fact, understanding that pain is the body's alarm system highlights the importance of treating pain so that the alarm system does not become oversensitive. 

The book describes what happens in different systems of the body and how they may be affected by pain. Normal responses to painful stimuli are contrasted with what happens when the responses become altered. The influence of our thoughts and beliefs is examined for the role it can play in chronic pain.

Practical suggestions

The last few chapters of Explain Pain suggest practical tools that can be used to manage chronic pain. Using "the virtual body" is explained, as is the use of graded exposure to break the association between particular movements and pain and to cultivate successful movement without pain. 

Pain education should be part of every client or patient's rehabilitation.Explain Pain provides an excellent model for pain education.

One of my clients suffered for many years with a painful chronic condition and found this book immensely helpful. Although she had seen many doctors and therapists, she had never been given any pain education. After reading this book, she asked, "Why didn't anyone tell me this?" My response was, "They didn't know." Although Explain Pain was first published in 2003, pain science is still only slowly finding its way to practitioners. 

Since I've begun studying pain science, I've incorporated information the information presented in Explain Pain into my practice. It has been a useful tool for helping clients get out of pain and feel in control of their lives once again.

Additional resources

I've posted a fifteen minute TED Talk by Lorimer Moseley on Why Pain Hurts in a previous post. There is also, in the same article, a forty-five minute lecture to a professional audience for those geeky folks who want to understand details about the biology of pain. Recently, I've found a twenty-five minute video by Moseleywhich has become a favorite because he addresses how we think about conditions like herniated discs and how our thinking can feed and perpetuate fear, anxiety, and pain. If you watch only one of these videos, this is the one I recommend. These videos are educational and entertaining. Moseley, who is both researcher and clinician, has a charming Australian accent and a great sense of humor. Imagine Crocodile Dundee giving an introduction to pain science and you'll get the picture.

For more information about understanding pain, I also suggest the following: 

Painful Yarns by Lorimer Moseley (stories to help understand the biology of pain)

Also, check out this article about understanding how pain works by Paul Ingraham of SaveYourself.ca. 

Cory Blickenstaff, PT, has put together some useful videos of "novel movements." Here are links to the ones on the low back, neck, and hand, wrist, forearm, and elbow. 

This article originally appeared massage-stloius.com and was written by 'Ask the Massage Therapist'.