9 THINGS YOU SHOULD KNOW ABOUT PAIN

1. Pain is output from the brain.While we used to believe that pain originated within the tissues of our body, we now understand that pain does not exist until the brain determines it does. The brain uses a virtual “road map” to direct an output of pain to tissues that it suspects may be in danger. This process acts as a means of communication between the brain and the tissues of the body, to serve as a defense against possible injury or disease.

2. The degree of injury does not always equal the degree of pain.Research has demonstrated that we all experience pain in individual ways. While some of us experience major injuries with little pain, others experience minor injuries with a lot of pain (think of a paper cut).

3. Despite what diagnostic imaging (MRIs, x-rays, CT scans) shows us, the finding may not be the cause of your pain. A study performed on individuals 60 years or older who had no symptoms of low back pain found that 36% had a herniated disc, 21% had spinal stenosis, and more than 90% had a degenerated or bulging disc, upon diagnostic imaging.

4. Psychological factors, such as depression and anxiety, can make your pain worse. Pain can be influenced by many different factors, such as psychological conditions. A recent study in the Journal of Pain showed that psychological variables that existed prior to a total knee replacement were related to a patient's experience of long-term pain following the operation.

5. Your social environment may influence your perception of pain. Many patients state their pain increases when they are at work or in a stressful situation. Pain messages can be generated when an individual is in an environment or situation that the brain interprets as unsafe. It is a fundamental form of self-protection.

6. Understanding pain through education may reduce your need for care.A large study conducted with military personnel demonstrated that those who were given a 45-minute educational session about pain sought care for low back pain less than their counterparts.

7. Our brains can be tricked into developing pain in prosthetic limbs. Studies have shown that our brains can be tricked into developing a "referred" sensation in a limb that has been amputated, causing a feeling of pain that seems to come from the prosthetic limb – or from the "phantom" limb. The sensation is generated by the association of the brain's perception of what the body is from birth (whole and complete) and what it currently is (post-amputation).

8. The ability to determine left from right may be altered when you experience pain. Networks within the brain that assist you in determining left from right can be affected when you experience severe pain. If you have been experiencing pain, and have noticed your sense of direction is a bit off, it may be because a "roadmap" within the brain that details a path to each part of the body may be a bit "smudged." (This is a term we use to describe a part of the brain's virtual roadmap that isn’t clear. Imagine spilling ink onto part of a roadmap and then trying to use that map to get to your destination.)

9. There is no way of knowing whether you have a high tolerance for pain or not. Science has yet to determine whether we all experience pain in the same way. While some people claim to have a "high tolerance" for pain, there is no accurate way to measure or compare pain tolerance among individuals. While some tools exist to measure how much force you can resist before experiencing pain, it can’t be determined what your pain "feels like."

EXPECTATIONS DRIVE DOCTORS TO ORDER UNNECESSARY IMAGING

Despite knowing (and agreeing with) recommendations to not use imaging for low back pain without “red flag” indicators, doctors are still ordering unnecessary CTs and MRIs for patients. Most do so out of fear of upsetting the patient, and because there is not enough time to discuss the risks and benefits of the images with the patients, according to an October 17, 2016 study of Veteran’s Affairs health care professionals.

The study surveyed 579 VA clinicians, and included a hypothetical scenario in which a patient had requested imaging for nonspecific low back pain (without red flag symptoms). Only 3% of the responses thought that the patient would benefit from a CT scan or MRI. Almost 75% of the clinicians worried the patient would not be able to be referred to a specialist without an image, and more than half worried the patient would be upset to not receive the image.

The study confirms a concern highlighted by the American Board of Internal Medicine Foundation’s Choosing Wisely campaign, that the use of unnecessary imaging, such as CTs, MRIs, and X-rays, can lead to other unnecessary tests or procedures, drive up patient costs, and expose the patient to unnecessary radiation.

“Our study showed that almost all clinicians were aware that an imaging test was not indicated for a patient with low back pain without danger signals of severe spinal problems, and agreed with the Choosing Wisely recommendations to not do testing,” said study coauthor Erika D. Sears, MD, MS, of the Veteran’s Affairs Center for Clinical Management Research, in Reuters Health News (“Doctors still order imaging for low back pain, against recommendations” – October 17, 2016).

Patient education is key to avoiding unnecessary and expensive medical interventions and tests. There is a growing body of evidence that demonstrates early physical therapy for low back pain lowers costs. 

“Patients should first have a thorough history and physical exam to rule out the presence of “red flag” symptoms, and are often first referred to physical therapy in the initial treatment period,” Sears said. “Because low back pain tends to come back, staying active through activities such as walking, yoga, and supervised training, on top of physical therapy, is key to warding off recurrence.”