A Good Hurt vs. Pain: An Introduction to Understanding Pain

Most runners are no stranger to pain.

Though there are a select few who manage to run injury free, the majority of us mere mortals will tend to, on more than one occasion, push our limits of frequency, intensity and/or duration and end up with a running injury. The upside is, if we deal with the injury correctly we can learn a valuable lesson and come out the other end a stronger runner.

The question is, why is it that some injuries hurt more than others?

Is it a case that the more damage done the higher the level of pain? If that were true, how is it that a paper cut can hurt so much, and yet one can quite easily wake up with a relatively more serious bruise and have no idea how it got there?

The role of your brain in pain

The truth is, pain is still a bit of a mystery for scientists – both “acute” pain (recent) and “chronic” pain (has lasted longer than three months).  Recent research suggests that many of us (including health professionals) have preconceived notions of pain that may be hindering injury treatment and prolonging discomfort. Learning how pain works can not only decrease pain but sometimes even prevent it.

The aim of this article is to present you with a simple introduction to modern “pain science”, using concepts developed by esteemed professor of neuroscience Dr Lorimer Moseley together with pain scientist and Director of the Neuro Orthopaedic Institute Dr David Butler. In doing so, I will draw on articles by two of my favourite writers on the subject of pain:

Tony Ingram, Physical Therapist, B-boy dancer (Google it!) has a brilliant “Pain Education” section on his website www.bboyscience.com.

Paul Ingraham, science writer and retired Registered Massage Therapist, has written an excellent piece “Pain Is Weird,” which I also heavily recommend you have a look at.

The overall message is that pain is not a signal from damaged tissue informing us we have been injured.

Tissue damage can occur without the sensation of pain, just as pain can occur without the existence of any tissue damage. The two may well exist together but they are not inter-dependent.

As Ingram puts it “You can have a lot of pain with little to no damage, or you could have a lot of damage with little to no pain.” The reason for this is simple… pain is an opinion formed by the brain.

Now, before we go on, it is vital that you do not think anybody is suggesting pain is “all in the head”. It is, as far the fact that your brain is in your head, but no one is saying your pain it is not real or significant.If you are clearly injured, whether in pain or not, seeing a health professional is always recommended. Probably a good time now to put in a disclaimer!

Disclaimer
You should not rely on the information in this article as an alternative to medical advice from your doctor or other professional healthcare provider. If you have any specific questions about any medical matter you should consult your doctor or other professional healthcare provider. If you think you may be suffering from any medical condition you should seek immediate medical attention. You should never delay seeking medical advice, disregard medical advice, or discontinue medical treatment because of information in this article.

So, that made clear, what scientific research is achieving by recognizing the brain as the source of pain is the beginnings of far more effective methods to treat pain.

Much of the research to date has involved chronic lower back pain, long thought to have been the product of herniated discs, degenerative disc disease, scoliosis, osteoarthritis, pinched nerves, etc.

However,  x-rays, CT scans, and MRI’s clearly show that the aforementioned “problems” are often seen in people who are not experiencing pain.

As a result, more attention is being given in treatment to the connection between emotion and pain. Understanding that pain does not necessarily mean there is significant damage or degeneration occurring in your body, has helped bring relief to many sufferers of pain. Pain is real, very real, but in some cases (not all!) understanding it can actually lower it.

Understanding pain: a five-minute video

The video below was produced by Hunter Integrated Pain Service (HIPS), a multidisciplinary pain management team based in the public hospital system in Newcastle, New South Wales, Australia (where I happened to be living near in 1989 when it suffered an earthquake of Richter magnitude 5.6, one of Australia’s most serious natural disasters).

Both Tony Ingram and Paul Ingraham link this video on their websites, and both are quick to point out that in its mission to deliver a clear message in just five minutes, the video could be charged with over simplification, particularly in the advice given at the end.

Paul Ingraham makes the extremely valid point that stress is often the product of major life challenges and social problems that quite simply an individual may not be able to solve. Advising such individuals to “reduce their stress” could border on being plain insulting if it is not accompanied by sufficient support structure.

Tony Ingram adds that he does not like how the video gives the impression that only “chronic” pain involves changes in the brain. He suggests it happens right away, and that context and fear are important factors even for acute pain.

That said, for the purpose of this general article, the video does encapsulate the subject matter nicely:

VIDEO: GP Access & Hunter Integrated Pain Service, New South Wales

So, to summarize, these are the most important points to take away from the video:

Pain is in your brain (as opposed to in the tissue) – This is not suggesting pain isn’t real, as in “it’s all in your head.” Pain IS real. But it is a perception and treatment methods used need to take this into account.

Pain and tissue damage are not always related – You can have tissue damage with no pain, just as you can have pain with no tissue damage.

Chronic pain persists after tissue damage has healed – Most tissues in the body are healed as well as they can be by 3-6 months

Many factors contribute to perception of pain – Biological, psychological, social and cultural.  Ongoing pain produced by the brain may well be less about structural changes in the body and more about the sensitivity of the nervous system.

Rehabilitation: Recovery vs. Healing

“Why does my muscle still feel weak if the injury was a year ago?”

“Why am I still in pain? Why won’t it heal?”

If you have ever found yourself asking one of the questions above, you are in good company. As a rehabilitator of runners, I probably hear these two questions more than any other when first meeting a new patient.

The answer lies within clarification that a successful return to running requires recovery.  This is not the same as healing. Ingram distinguishes the two particularly well:

“Healing” is the body’s natural process of repairing damage. It is complete when the damaged tissue has been repaired. Though not a lot can be done to speed up healing of acute injuries, following the correct protocol can definitely help in avoiding a  slowing down of the healing process (P.O.L.I.C.E. – Protect – Optimal Loading – Ice – Compression – Elevation).

“Recovery” refers to the ability to return to your level of activity pre-injury, in our case running. It is a product of function and emotion, in other words being able to not only run again but to do so without fear.

It is important to recognize that full recovery can be achieved without complete healing, as long as a suitable, progressive period of rehabilitation is followed, addressing both physical and emotional needs.

For example, a ligament may remain loose for years (or even forever) following an ankle sprain but if you manage to improve strength, coordination and running form such that the stress originally placed on the ankle is no longer an issue, and at the same time eliminate the fear of it happening again, you can be just as strong a runner as you were pre-injury, potentially even stronger.

Even more important though is the fact that complete healing can be achieved without full recovery, and this is all too often the recipe for disaster.For example, muscle tissue following a strain may heal perfectly but it still feels weak and even hurts when you move it a certain way.

Pain following an injury is often the result of poor, rushed or non-existent rehab, including the failure to eliminate fear of movement. In not restoring full recovery, the likelihood of re-injury is greatly increased.

As a runner, understanding pain can help enormously in seeing where you are in your road to full recovery. During rehabilitation, I encourage runners to use pain as an aid, a friend, not something to be feared or used as a measure of damage.

As Ingram notes: “pain is your brain’s best guess at whether or not something is dangerous, for the purpose of protecting you from actual or potential damage. Pain is like an alarm, and it wouldn’t be very useful if it only happened when damage was already occurring!”

Pain management and rehabilitation are about addressing the nervous system, encouraging runners to remember what it’s like to move in a safe environment.  Fear and anxiety need to be gradually eliminated to ensure full recovery. Otherwise, chances are in a year’s time you will find yourself asking that same question: “Why does it still feel weak if the injury was a year ago?”

I hope you have enjoyed this introduction to modern pain science. It is obviously far more complex than I have presented it, but hopefully you will walk away realizing that (and there are exceptions) we often have more to gain by seeing pain as something that can help us, as opposed to something that should be feared.

Happy running!
Matt Phillips is a Running Injury Specialist & Video Gait Analyst at StrideUK & Studio57clinic. Follow Matt on Twitter: @sportinjurymatt

DISCLAIMER
The material presented in this article is intended for informational purposes only. The information represents the opinion of the author, and does not constitute medical advice. This article is not intended to replace medical advice, nor to diagnose, prescribe or treat any illness, disease, or injury. The author expressly disclaims liability for any adverse effects that may result from the use, application or interpretation of the material in this article.