Dr. Nathan Kadlecek, PT
Is a physical therapist committed to providing high quality health information, largely focused on lower back pain and the gross overuse of diagnostic imaging, medication, surgery, low quality treatment methods, and the over-diagnosis of pain conditions. He's also a powerlifter, pain nerd, macro-scale thinker, and wants to help you think differently about pain, healthcare, and life.
What is Pain?
This question likely needs an encyclopedia series to do it justice. There are tons of great books out there, Why Do I Hurt, The Sensitive Nervous System, Explain Pain: Supercharged, Sticks and Stones to name a few, which get into the specifics and strategies of how to help you or someone you know with managing pain. There are also tons of great blogs written by Jarod Hall, Barbell Medicine, Greg Lehman, Bronnie Lennox Thompson, and many others who cover these topics. I hope to further add to this abundance of info about pain, focused on the person who is dealing with pain in an effort to help you better understand what is going on and, I hope, to help reduce the fear that is so commonly accompanied with pain.
Many of us fear pain. We view it as an enemy, and say things like, “this shouldn’t be happening to me.” Our fear is driven by the unknown. What will happen to us if it doesn’t go away? Is it something more insidious and dangerous that needs further medical workup?
Chronic or persistent pain costs an estimated $635 billion, with a 'B,' per year in the United States. That is more than that of cancer ($309 billion), heart disease ($243 billion), and diabetes ($188 billion). Many factors contribute to this statistic including an overmedicalization of patients, and an overreliance on unidimensional pain measures. Overmedicalization, in a nutshell, is: 1. Unnecessary surgeries, 2. Excessive pharmacological (drugs) intervention, 3. Use of diagnostic imaging when not necessary and 4. Language from healthcare providers that is unhelpful and creates high amounts of fear and distress. There are more types of overmedicalization however the four cited above are most prevalent. Additionally, these are likely made possible due to poor health literacy among the general population.
According to one study completed in 2016, 50 million people in the United States deal with chronic pain and 10 million deal with high-impact chronic pain. High-impact chronic pain is defined as chronic pain that limited life or work activities on most days or every day during the past 6 months. This is a major public health issue and one that needs to be addressed at not only a grass roots level but at a public policy level.
In this article I will be delving into what pain is, strategies we can use to live well with pain, and strategies we might use to reduce the risk of developing chronic pain in ourselves, and others.
Let’s jump in!
What to expect:
Word count: ~4500
Read time: ~18-22 minutes
Glossary and important definitions:
What is the purpose of pain?
This is a loaded question as it assumes we can scientifically measure a “why?” behind something. It assumes that there is some sort of justification for sensations we experience. While we can’t necessarily measure this objectively, we can take an educated guess as to why we experience pain. At its most basic biological level, pain is a great asset. It is one of the components of our biology that has helped the human race survive as long as it has. Pain alerts us to danger which then provokes us to act and is an incredibly important evolutionary tool.
Pain alters our actions. If it’s a broken leg, pain prevents us from putting more pressure through the leg and potentially injuring it more. It acts as a protection mechanism. If it’s emotional pain such as a break-up or a friend being unkind to you, then this pain typically results in avoidance, anger, sadness, and ultimately caution when presented with the same situation as we are trying to avoid feeling this way in the future. Pain provides an experience of which we can decide whether we will alter our decisions in the moment or in the future.
Perusing the internet, you’ll find tons of marketing tactics, mainly clickbait, that want to help you “fix your pain,” “rid you of your pain,” “become 100% pain free,” “how to fix low back pain instantly,” and many more. I view these clickbait titles as incredibly unhelpful for a few reasons:
Focusing on point three, above; this is a societal issue. Healthcare providers, the media, and government agencies that perpetuate false and harmful beliefs about pain are likely causing more harm than good. We are collectively perpetuating nocebo’s which is creating more fearful people and more people who now are dealing with chronic/persistent pain.
Nocebo: Adverse events produced by expectations.
Colloca L, Miller FG. The nocebo effect and its relevance for clinical practice. Psychosom Med. 2011;73(7):598-603.
I despise the word “fix” when it comes to pain. It implies pain can be "fixed," when what really need first is to understand our pain. Imagine having an alarm sounding, and not knowing what it meant! It’s an ‘alarming’ experience. Instead of fix, we need to learn how to manage pain when we have it, not fix it. And, more importantly, we must alter our perception of what pain is. Managing pain does not mean that it will never go away, however, in many cases we cannot control how fast or slow our body decides to reduce pain. As is the case with many cases of chronic pain, it may never go away completely, however, it is possible to live well with pain. To learn more about coping and managing, please read some of Dr. Bronnie Lennox Thompsons work. https://healthskills.wordpress.com/coping-skills/
It seems that we view pain as some sort of defect in how we function, that it has no value in our lives, and should it be completely eradicated we would live blissful lives without a care in the world. If we hold this viewpoint, pain becomes the adversary, versus an impartial entity, or an ally. What if instead we viewed pain as an important feature of our biology?
Is it possible that we can view pain as neither good nor bad but rather something that just IS? It’s a challenging thought as this likely goes against our primary belief that pain is always bad.
Pain is an important part of our biology. Without it, we would not live nearly as long as we do. It protects us from touching scalding hot objects, from staying in ice cold water too long, from stepping on nails and other sharp objects, and protecting a joint that might be injured. As we talked about above, it also changes our actions. Instead of touching the hot pan without an oven mitt, next time you remember to use it. Instead walking barefoot in an area that you’re aware has some sharp objects, you make sure to wear shoes. These are all GOOD adjustments that pain provokes us to do.
So… Why Do I Have Pain?
While pain does have a good side it can also have a downside, particularly when it lasts longer than we expect it to even after an injury has healed. Let’s take lower back pain as an example. Typically the course of low back pain with or without sciatica improves dramatically within six weeks of onset. There are, however, a subset of people who don’t improve in six weeks and do end up having persistent pain for months, or even years after they initially started experiencing pain. Assuming all red flags have been ruled out (cancer, fracture, inflammatory autoimmune disease) then we can safely say that one’s back is safe and not in danger of deteriorating or having a disease that leads to complications. But, the question remains, why do people have pain if there is not something more dangerous going on?
Greg Lehman puts it well when he describes over-amplification of the nervous system. Similar to other sensations in our body, pain tends to become over amplified and this is incredibly common in people with persistent pain. Let’s take hunger for example. Humans can go > 20 days without any food and survive, however the sensation of hunger after not eating for 3-4 hours may manifest as intense hunger pain causing us to eat more regularly. Similarly, allergies pose the same response. We may only be exposed to the slightest amount of pollen yet the allergic response that follows is INSANE. I know this as my eyes get incredibly itchy and my nose begins to run uncontrollably in the spring and early summer.
When comparing pain to allergies we can see that these same physiological principles apply. There is some stressor introduced, our body overcorrects or overamplifies and then depending on dozens of factors we either return to baseline or stay in an overamplified or hypersensitive state. Some people will stay in this hypersensitive state for quite a long time while others will recover rather quickly. Chronic and persistent pain is a chronically heightened state of the nervous system.
If you’re wanting to read a bit about the more in depth nervous system response to pain modulation, read through this next bit, if not, skip past it as it gets a bit into the weeds and continue reading at “Enter BPS Model.”
Overamplification and hypersensitive; what do these words actually mean? To understand these two words we need to talk about another term, nociception, and contrast it with pain.
An example of nociception would be your hand accidentally touching a hot stove. The sensory fibers in your fingertips that are stimulated, due to the extreme heat, have free nerve endings which are then depolarized and send an action potential along the nerve, to the spinal cord, and up to the brain stem. Notice I don’t use the word pain in that sentence. The pain only occurs once the signal has traveled up to our brain stem and the stimulus has become large enough to warrant a response and thus our attention. The response in this scenario is that we pull our hand off of the handle.
As you can see, nociception is a good thing. It protects us from potential tissue damage by causing us to change or alter our movement.
When Does Nociception Become Unhelpful?
Nociception becomes unhelpful when there is no inflammation, no tissue injury, yet you are still experiencing pain. What we see in this instance is that although there is no significant dangerous incident, the threshold with which the neuron requires to be activated will be significantly lowered, and, descending inhibition from the brain is also blunted. In layman’s terms; the fire gets kindled (lots of nociception) much easier and there is not enough water (from the brain) to put it out. This is where things get a lot more complicated regarding what actually causes this to happen. In a 2010 paper by Wolff, he describes chronic pain as a disease of the nervous system where the peripheral nerves are intact, there is no neuronal lesion, no inflammation, yet someone is still experiencing pain.
In this regard it is worth discussing all of the different aspects that could potentially lead to a chronically or persistently lowered nociceptive threshold and decreased descending cortical inhibition.
Enter Bio-Psycho-Social (BPS) Model of Pain
Dr. Nathan Kadlecek, PT, DPT
Nathan is a physical therapist, powerlifter, pain nerd, and is rather obsessed with how to think in better in different ways. He graduated from Harding University with a degree in exercise science and his doctorate of physical therapy from Columbia University in New York City. He is passionate about reducing the prevalence of chronic pain, improving the efficiency of the healthcare system, and teaching people how to lift.
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