When you get pain, either a new pain or some familiar pain, what’s the first thing you think?
If you’re like most people, you’ll wonder “why”, and start asking questions like:
“What did I do to hurt myself?”
Or “How badly did I really injure myself if I can’t even remember doing anything strenuous?”
Then come other questions like:
“How long will this pain last?”
“Am I safe to do normal things?”
“Can I work with this pain?”
It’s easy to become afraid and worried when you’re not sure why you have pain. Your worry, which is completely normal, can play a part in your pain feeling worse.
Understanding why you hurt, and what you can do about it, is some of the best medicine you can take when you have pain.
Pain and Worry
As a physical therapist, it is important that I listen carefully to your story of your pain, what happened when your pain started, and what other things are going on your life. It’s important that you get answers to your questions that lead to worry.
Reassurance that you are safe and not in danger can kickstart your recovery. Reducing fear and worry can help you get back to living well.
Unconscious, protective things you do when you have pain can lead to increased pain. Things like holding your breath when you move, groaning, and stiffening up when you move all keep you focused on pain and protection, which makes it harder to calm down your nervous system.
Understanding that you can have pain without any tissue damage is one way that you can help yourself to worry less.
Pain and Your Nervous System
One of the especially important jobs of your nervous system (which includes your brain, spinal cord and nerves) is to warn you about threat and danger, which helps keep you safe and alive.
As you can imagine, this is no easy task for your nervous system. There is a lot of information to process and many things to keep track of, so it’s easy for your brain to get something wrong.
This might mean that your brain perceives a threat that isn’t actually there, or maybe exaggerates and amplifies an existing threat well beyond how dangerous it actually is. What does this have to do with pain? It can actually describe why the link between pain intensity and tissue damage or harm to your body isn’t always clear.
Sometimes your brain makes the decision that not feeling pain is best for you, because you need to pay attention to getting help and finding safety.
Alternately, sometimes you might injure yourself in a minor way, where you aren’t in much danger overall, yet still feel quite a bit of pain (think of a paper cut, a splinter, or a sunburn).
This applies to both serious, life-and-death injuries, and the bumps and bruises of everyday life that you don’t even remember getting when you see them in the bathroom mirror.
Imagine twisting your ankle while crossing the street. It’s certainly a very real injury with tissue damage, but if there are cars coming, pain won’t be helpful, because you need to move out of the way!
Pain and Injury (or not?)
I work in an emergency department, where I see many interesting things everyday. People come in with all sorts of injuries and pains, which often are difficult to fully understand or explain.
Imagine a construction worker, who enters the ED crying and screaming with a nail straight through his steel-toed boot. This was the case in a famous article published in the British Medical Journal. The construction worker was clearly experiencing very real pain and was very distressed, but when the boot was removed, the doctors realized that the nail hadn’t actually touched him at all. It had actually passed right between his toes. But to the construction worker, it certainly looked like the nail had done serious damage, so his brain produced pain so he would protect the area and seek help.
A more relatable example might be stepping on a Lego. Certainly painful but not likely to do much damage, if any at all. Still, what if that Lego were actually a pin? Would you have more pain due to tissue damage?
These types of injuries show that pain and damage don’t always go together. You can have serious injuries without any pain (and sometimes pain without any damage to your body). Pain is meant to protect you from danger, and when you’re injured, your system has to make a complex decision about whether pain would actually be protective. Things like context, the environment, and your past experience all influence this decision.
Here’s a 7-minute video of Professor Lorimer Moseley telling a real-life story of a patient he met in the emergency room with a gruesome injury, and no pain at all.
You Can’t Stop the Healing Process
When any of your body tissues get damaged, your body’s wonderful healing systems go to work cleaning up the mess and start the process of fixing your tissues.
If you sprain your ankle, the pain, swelling, redness and heat that you feel are part of the essential process of inflammation getting healing underway.
As your healing and repair processes carry on, your pain decreases well before the injury has fully healed.
So, what if you have pain without an injury?
Your back is strong and is not damaged by the usual stresses of everyday life. However, it’s very easy for your nervous system to become sensitive and turn on protective responses like pain, stiffness and muscle tightness.
There are many ‘alarms’ around your spine – different sensors that detect threats and send that information to your brain. Normal daily activities can be enough to activate those alarms, especially if you’re living with significant stress in your life.
These are common activities that might activate your sensitive alarm system:
- Bending forward to tie up your shoe
- Standing up after sitting for some time
- Waking up in an unusual position
- Picking up your pen from the floor
None of these are strenuous enough to damage or harm tissues in your back, yet it is common for these benign tasks to trigger severe pain.
Pain without Tissue Damage is Common
It’s sensible to assume that if the pain is really bad, there must be a horrible injury. This seems logical, but it isn’t always the case.
Depending on the situation, your nervous system can increase or decrease your experience of pain. You can experience severe pain but have no tissue damage and can have severe tissue damage yet feel no pain, depending on the situation.
Depending on the circumstances of when your pain began, you may have felt, seen, or heard something happen in your body or your environment that was “bad”.
The sensor systems in your body send signals to your brain, telling it that “something just happened, better check it out”. Your sensors are so good that in an instant your nervous system sizes up the situation and concludes whether it seems threatening or not, and whether pain would be helpful to protect you.
This assessment is based on your current situation, as well as all of your past experiences. If threatened, the normal response of your nervous system is to go into protection or “lockdown” mode which includes tightening the back and stomach muscles to keep your back still.
Because the spine is a particularly important region of your body to protect, nerves in your back are extra sensitive. That way they can report on even the smallest of changes in movement and pressure.
When this protective system becomes sensitive, awareness of things like light touch and small movements are magnified and can feel very painful and threatening, even though there may be no damage at all. It’s like a faulty intruder alarm that goes off when it’s only the wind blowing past your front door, not a burglar breaking in.
As you pay more attention to your pain and worry more, your nervous system becomes even more sensitive. It amplifies every sensation, causing you to pay more attention. Your muscles tense more, warning you of danger that isn’t actually there every time you try to move. This feels terrible, and it’s easy to think that the worst-case scenario of a catastrophic injury has occurred.
So, hopefully this article has helped you understand something very important: pain is always real, but it can sometimes misrepresent what’s happening in the body. Here are some ideas for where to go now that you know about how pain and damage don’t always relate.
1. Get a Medical Check
Health professionals are helpful! If this is new pain or different pain to normal, it’s time to book a check up with a medical professional like your physician or a physical therapist (and do the next step before you go to that appointment). Unless your pain was caused by trauma or has some specific symptoms, you might want to reconsider going to the emergency department.
2. Work out your worries with these questions
- Can you explain why this pain may have happened?
- Are there any possible reason for this pain like suddenly doing more exercise, less exercise, a new exercise or activity, stress, poor sleep, travel or unusual movements and positions?
- What do you think is happening in your body that’s causing your pain?
- Are you worried that you have an injury, or worried that you might be injuring yourself more with movement?
- What questions do you need answered so that you can feel safe?
You should also take these questions to your health professionals so they can help make sense of your pain.
3. Practice self-soothing techniques
Learn about the things that calm you and have a soothing effect on your nervous system and harness the power of all your senses.
Different calming strategies work better for different people, but here are some frequently helpful ideas to try:
Skin touch and stimulation is one way that you can soothe yourself. It’s usually even better if you can receive it from someone else around you. Gentle massage can feel nice if you’re not too sensitive, as can little things like sitting in a warmer room or taking a hot shower. Some people find gentle tapping or squeezing their arm, or their leg can also help them feel more comfortable.
Sights and Sounds:
Calming sounds have soothing effects on your nervous system. You might like nature sounds, uplifting music, or even white noise – you’ve got many options for soothing sounds. Similarly, videos of beautiful places, nature, funny cats – whatever YOU like – can help your nervous system to return to a calm state.
Smell is our most primitive sense, and strongly linked to memory and emotion. Sweet smells like vanilla, lavender, cinnamon, or your favorite scent or cologne can have a calming effect and even bring up pleasant memories when you’re worried about pain.
Food or drinks that have pleasant memories or attachments can help you regain a sense of calmness. Emotional eating is not a strategy to rely on, but it’s ok to know it’s a tool that you can use for special circumstances if needed.
4. Try active, not passive, pain treatments
There are many treatments offered for pain – many of them are passive, things that are done to you, rather than things that you can do to help yourself. High-value pain care gives you strategies to drive your own recovery.
Movement reassures the protective alarm system that all is well, and this helps to turn the alarm back down. That’s why you’ll always hear health professionals that know about pain suggesting ways for you to slowly and gently get moving again, safe in the knowledge that you’re not doing damage to your body.
5. Change your routines and build social support
Once you’ve checked that you’re medically safe, the best self-treatment technique you can start with is to do something new. Literally, you can do anything, as long as it’s out of your normal routine.
Getting out for a walk is a good starting point if you’re not doing that already. A new place to walk, walking with a friend, or joining a walking group can help make this a new habit. Get some help and support if you can – things are better with a friend. Even a cup of tea or coffee and a conversation is a place to begin.
Keith is a physical therapist with the University of Utah. He treats patients in the orthopedic clinic and also works in the Emergency Department, where he sees patients with a variety of issues including spinal pain, orthopedic injuries, falls, and vertigo. He is involved in research investigating the impact of adding physical therapy services in Emergency, and is working to improve collaboration and pain literacy within his local medical community.