Back to NEUROPLASTICITY - the ability of our nerves to learn and unlearn. A phrase that patients can relate to is something commonly referred to as “motor memory.” Your muscles themselves do not remember certain actions, but the NERVES that innervate them can. A good example of this is playing musical instruments. Let’s say you learned to play piano very well when you were 8 years old but didn’t necessarily keep up with it. 30 years later you may find yourself in front of a piano playing “Fur Elise” by memory. Your hands just start moving and they find the correct keys to hit in the correct order. Your nerves practiced that over and over and over when you were EIGHT - and they REMEMBERED!
An example of this more related to chronic pain might be if you’ve injured your knee skiing in the past. When you see someone injure their knee skiing - you may feel knee pain! This is another scenario where your nerves have learned that particular movement or injury is a painful action and thus nerve signals are sent to your brain to perceive pain - even if you’re just sitting still watching the injury happen on TV. There’s an underlying and learned nerve pattern that still sends those signals in response to seeing the injury happen. These signals are REAL and so your pain is REAL. The question then becomes, “is it APPROPRIATE?” This brings me to my next important point...
Pain is a signal of danger or tissue damage
We have nerves everywhere in our body that sense pain. Pain signals will be sent when tissue damage occurs. For example, when you sprain your ankle you place an inappropriate stretch or strain to ligaments. Those ligaments have nerve receptors that will send a signal to the brain saying “hey, we stretched beyond our capacity and we are injured,” and so the brain will receive the pain signal and your ankle will start to hurt. In turn, this tells you to rest, ice, seek physical therapy, etc. This is also an INTEGRAL part of where CHRONIC PAIN arises. We learn in school and throughout our careers that nerves are exceptionally FAST at LEARNING, but exceptionally SLOW at UNLEARNING. Back to that example of injuring your knee while skiing… if you watch someone do it on TV 10 years later, it may cause nerves to fire in your body to respond to pain EVEN IF THERE IS NO RISK OF INJURY OR DAMAGE TO TISSUES. Hence, the response in INAPPROPRIATE.
Let’s take a look at an example I learned from a lecture on chronic pain. There was an elevator worker who fell 10 stories inside an elevator and broke his back. He clearly had tremendous injury and also needed surgery. These nerve pathways from injured tissues in his back going up to his brain were used FREQUENTLY and became very well LEARNED. He recovered well from surgery and reported no pain. His physical therapist had him perform visualization exercises to simulate being in an elevator to help him with return to work. He thought they were being silly - he was fine! He went back to work, and sure enough, didn’t have any issues. However, he called his physical therapist 5 YEARS LATER with the following story: “You’ll never guess what happened. I’ve been working on elevators for 5 full years without any pain. But I had to go back to THAT SPECIFIC ELEVATOR that injured me, and I felt a pain in my back. I couldn’t believe it!” This brings us back to the full circle of PAIN BEING A SIGNAL OF TISSUE DAMAGE OR DANGER and whether or not its APPROPRIATE. This elevator worker was able to utilize his CONSCIOUS MIND to help CHANGE NERVE PATHWAYS by using techniques like saying out loud, “I’m just standing here looking at this elevator. I’m in no way putting my back in a dangerous situation.” Ultimately, this elevator worker was able to alter and improve his pain signal by utilizing his CONSCIOUS MIND.
So what does this have to do with Physical Therapy?
That last piece is where physical therapy comes into play. When we have a patient in chronic pain, we try to implement various strategies to help change a nerve’s response to certain stimuli. Contrary to popular belief, we can’t just “exercise the pain away.” There needs to be an intentional approach of retraining our nerves - accessing their unique neuroplastic characteristic mentioned in the beginning of this blog. Now, I know I said early on that pain is perceived in the BRAIN and to throw out the phrase “it’s all in my head.” That still holds true. However, we can use the power of CONSCIOUS thought processes to redirect or change the path of the nerve and where it gets perceived in the brain. Certain parts of the brain respond to pain, light touch, deep pressure, burning, itching, etc. All of these sensations have their own specific place in the brain. Just like the elevator worker, one technique is to use verbal affirmation that you are NOT IN DANGER of tissue damage. A more common technique is to TOUCH the area that is hurting. This is actually just more natural - if someone pinches your arm, you almost reflexively rub it with your hand. The original injury, the pinch, sends pain signals. The secondary action, the rubbing, sends signals almost right next to it to inhibit the pain or decrease it.
This differs in chronic pain as it is most likely that whatever the ORIGINAL PAIN GENERATING injury was that caused ACTUAL TISSUE DAMAGE is no longer present. If you herniated a disc 6 months ago that resulted in sciatica, we know that the disc has likely healed almost completely, but you may still be feeling that sciatic pain! To reiterate, the pain signal is still being sent but is inappropriate! When there is a faulty nerve signal happening that might be causing significant burning in the leg, we often tell people to touch it with their hands A LOT in addition to saying out loud “this is just the light touch of my fingertips and not dangerous to my leg.”
The short answer to the question “Am I Going To Be In Pain Forever?” is NO! The goal of this blog post was to inform you how complicated chronic pain can be but also that it has the ability to change. With guidance from a physical therapist, we can provide appropriate techniques, exercise strategies, visualization routines, and education to best help retrain your nerves and manage your pain. And as a friendly reminder to close out this post… nerves learn very quickly, but unlearn very slowly. It’s a process, but it’s possible!
Lisa Corken, PT, DPT
Bob Cranny, PT