The Science of Pain Management
It Takes a Village
Reviewed by: Jonathan Geralds, PT, DPT, OCS
Written by: Abbi Havens
The International Association for the Study of Pain (IASP) defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
Let’s break that down.
An unpleasant sensory and emotional experience. Pain hurts. ‘Sensory’ means relating to the physical senses or transmitted or perceived by the senses. But authentic pain is also felt emotionally and can be trauma by injury, depression, anxiety, heartbreak, loneliness and so much more. Associated with actual or potential tissue damage. Pay special attention to the word potential. That’s right. You don’t actually have to experience physical injury to feel pain. If you are at risk of trauma, you may feel pain prior to or in the absence of tissue damage.
According to physical therapist Jonathan Geralds, PT, DPT, OCS, in UT Health Austin’s Musculoskeletal Institute, this definition of pain reflects a shift away from focusing exclusively on the mechanics of pain and towards the experience of pain which is multifaceted.
“The reason for this evolving definition is that we see people who have a huge amount of tissue damage, for example, a missing a limb, and they experience no pain. The converse is also true,” explains Dr. Geralds. “Some people with very little to no tissue damage from what we can see on our most advance scans have completely debilitating pain, so for any person, their pain experience is individual and multifactorial.”
Dr. Geralds and his team have found that for most people, their pain experience and recovery is compounded by chronic sleep disturbances, financial stressors, social stressors that come from abusive relationships, isolation or work stressors, which prevent a person’s nervous system from coping as best as possible. Because that’s what pain is: a warning sign.
Pain is predominantly a threat detection system. A way for our brain to warn us when we’re in danger in the hopes you’ll do something to remove yourself from that danger. Your home security system doesn’t sound the alarm when your TV is stolen. It sounds the alarm when a window is opened that shouldn’t be. An unpleasant sound alerts you to the threat of danger in the hopes that you take some action before real damage occurs (i.e. before the burglar gets away with your new 72” smart TV).
The existence of pain receptors is a common misconception. Dr. Geralds explains that what we think of as pain receptors are actually called nociceptors, a type of high-threshold sensory receptor. They respond to light touch, vibration, stretch or irritation that might result from a non-noxious stimulus (a harmless situation), but they have more amplitude before they fire to let us know that something dangerous might occur. This intricate warning system is ramped up or quieted down based on past experience, perception, a given person’s ability to cope, the overall sensitivity of a person’s nervous system and all of the factors that make up a person’s pain presentation.
But your nervous system doesn’t just turn on and off like the switch on your home security system. It constantly reacts to your environment. Imagine you’re walking down a crowded hallway at work and a coworker’s arm brushes against your arm. Chances are you’re not going to feel any pain, if you even feel anything at all. But if you experience a brush against your arm while you’re alone in bed, all of a sudden, that light touch becomes a much bigger concern.
“If you sprain your ankle as you’re walking across a crosswalk, but there’s a car hurdling towards you at 60 miles per hour, I guarantee your ankle will not start hurting until your life is no longer in danger, because that’s just how our bodies react,” says Dr. Geralds. “Your body makes pain apparent when it’s perceived to be beneficial to your survival, and less so when it’s not. For this reason, we can manage our pain experiences through a host of different techniques. This is not to say you can simply think away your pain, but a big part of managing pain is understanding what drives it.”
At UT Health Austin, behavioral health is an integral component of pain management. In fact, the two biggest predictors of chronic pain are long-standing sleep disturbances and depression, which means while there are often mechanical factors contributing to pain, the mechanical factors aren’t always the key players. Treatment varies greatly from patient to patient, but Dr. Gerald’s process typically consists of three parts. The first is to help the patient understand their pain.
Picture a tattoo artist. What image comes to mind? Probably a person covered head to toe in tattoos. Getting a new tattoo, that person may barely feel a thing. They’ve gone through this exact experience, the sight of the needle, the buzzing sound, the smell of a tattoo parlor, the feeling on the skin, enough times to know that they will come out on the other side, unscathed. If this is your first tattoo, however, this may not be your experience. You’ve likely built up some anxiety around the experience. The sight of the needle is unnerving. The sound unsettling. Your nociceptors are firing off signals that tell your brain, “Hey, this might not be a safe situation. Let’s get out of here.” And chances are, it’s going to hurt, because your threat detection system is doing its job.
“The better someone understands why they’re hurting, the less afraid someone is to move into that pain,” says Dr. Geralds. “If you believe moving is going to cause further tissue damage, you’re not going to exercise. You become deconditioned, more prone to flareups, and stuck in a cycle. My job, along with my team, is to identify those cycles and offer an alternative we can both agree to.”
The second part of Dr. Gerald’s process is to help patients re-engage in meaningful activities.
“The good news is there are an unlimited amount of ways to exercise so if you’re creative, you can find something enjoyable for everybody. If someone can’t tolerate land-based exercises, maybe they can swim. If someone can’t tolerate weight bearing exercise, maybe they can exercise on a mat. It doesn’t matter what you do, whether it’s Zumba, swimming or yoga, it matters that you get the length and intensity needed to reap the benefits,” says Dr. Geralds.
The third piece of Dr. Geralds’ treatment plan is to help the patient get healthier overall. By collaborating with a clinical social worker, the team works together to identify modifiable pain contributors and develop a comprehensive plan to address them.
“Part of being a healthy person is identifying modifiable factors that make life harder and doing something about it,” says Dr. Geralds. “If workplace conditions are causing a problem, a person can seek accommodation or, if possible, a new job. Lack of social interaction has a profound impact on pain. Something as simple as five social interactions a day can improve someone’s pain presentation. And then there are the more complicated aspects of cognitive behavioral therapy that require cognitive restructuring, and that’s where my colleague in social work is critical to helping managing patients’ pain.”
When it comes down to it, it’s the team that sets UT Health Austin apart.
“We are not a multidisciplinary clinic, we’re an interdisciplinary clinic, and that changes everything,” says Dr. Geralds. “In a multidisciplinary clinic, a group of providers cross-refer to each other, so you see a physician, they refer you to a physical therapist, and the collaboration ends there. In an interdisciplinary clinic a physical therapist, clinical social worker, psychiatrist, pharmacist and physicians all work in the same office and constantly communicate about improving patients’ care, so care is so much more comprehensive than sending off a physical therapy report card to your physician every six weeks.”
Patients who seek treatment for comprehensive pain tend to walk in through the medical front door. But along the way, they may find that there’s much more contributing to their pain than meets the eye, and our team is here to find a collaborative solution. If you or a loved one are struggling with chronic pain, call 1-833-UT-CARES to make an appointment.
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