By Ari Witkin, DPT

This is Part Two of a two-part series. Click here to read Part One.

In recent years, mindfulness and meditation have crept into the mainstream. Not too long ago, we thought of this practice as religious or mystic. It was either inaccessible or too scary for most of us. With the inclusion of meditation in society at large comes a great deal of scientific research into its effects on various aspects of life. One of those is how mindfulness affects pain.

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By Ari Witkin, DPT

This article is Part One of a two-part series. Click here to read Part Two.

As children, we would sometimes fall and scrape our knee. Maybe it was bleeding; certainly it was painful. We thought the pain was caused by something at the site of the injury and it was sending a signal to our brain, saying, “THIS HURTS!” Our parents would give us a kiss, put a bandaid over our injury to soothe our pain. Again, we thought if we could cover the wound and heal the tissue we’d be in less pain. As it turns out, this entire concept of the pain experience was not wrong, but incomplete.

There are a number of myths about how we experience pain and why getting rid of it is often more complicated than simply healing our tissues. We will discuss three important myths and offer a more complete truth about the pain experience.

Myth #1 – Pain signals in your body send messages to your brain telling you when to hurt.

Truth #1 – The brain interprets messages from your body and decides how much pain, if any, you will experience. Thus, ALL pain originates in the brain.

A person wakes in the morning with excruciating pain in his right foot. Except, he doesn’t have a right foot; it was amputated 6 months ago. The pain is real. So, how is this possible?

Throughout our body, we have signal receptors called nociceptors, which have, in the past been deemed “pain receptors.” More accurately, they are “danger receptors.” When something happens at the tissue level – sprain, strain, bruise, break, puncture, pinch – these nociceptors initiate a signal to our central nervous system comprised of the spinal cord and brain. It is then up to our central nervous system to interpret that signal. That interpretation has many factors (more on this later). If the signal is deemed sufficiently dangerous, the brain will create a pain response. 

That response is sent to a genetically predetermined map in our brain that creates pain in our body. Sometimes, this pain signal is sharp and localized, other times it can be diffuse and dull. 

This map exists in your brain no matter what happens in your body. This is why someone with an amputation can feel pain in a body part they no longer have – their brain is creating a pain sensation, even without input from the body. It’s also why some signs of a heart attack are pain in the jaw and down the arm. And why sometimes back pain can feel sharp and localized and other times like your whole back is on fire. 

Myth #2 – Pain is dependent only on the amount of tissue injured.

Truth #2 – Many factors play a role in your pain experience including your environment and stress levels.

Imagine two women in their mid 30’s sitting next to each other at the PT clinic. They’re both generally healthy and active. Both have been experiencing neck pain for 3 weeks. MRI and x-ray imaging look identical. Anatomically speaking their injuries are the same, but one woman is experiencing significantly more pain than the other.

In order to find out why there’s a discrepancy with seemingly the same injury, we have to delve deeper. Pain is multifactorial and does not depend solely on the state of the tissues.

What if you knew that one of the women, the one in more pain, was going through a divorce? Or maybe she’s a swimmer and is nervous she may not be able to get in the water again. Perhaps she’s been fighting this injury for 3 years and hasn’t yet found a physical therapist she’s connected with.

What would change if that woman had a terrific social support system of close friends and family? Perhaps her pain would be different if her physical therapist listened to her whole story, understood what swimming meant to her, and made it their objective for the patient to achieve her goal. 

Injury at the tissue obviously plays a major role in the pain experience. However, it does not tell the whole story. Stress, anxiety, fear of future pain, social support system, happiness with career, nutrition, and numerous other factors play unique roles. The brain will interpret all of these factors and either up or down regulate the severity of pain. 

Myth #3 – There must be an injury in order for there to be pain.

Truth #3 – Pain is a signal of potential danger, rather than past injury.

This may be the most crucial aspect to understanding how pain works. Pain is not a result of tissue injury; it is a conscious alarm your brain sounds to beware of potential future danger. 

Lorimer Moseley, a pain scientist credited with much of the research in this field, shared a story in what is now a famous TED talk (https://ed.ted.com/on/Li50Ci7S). Moseley was walking in the desert and gets bitten by a snake. Thinking his leg was simply scraped by a tree branch, he keeps going, feeling no pain. He returns to town, ends up in the hospital and barely survives. Sometime later, he goes back on the same walk. This time, his leg does get scraped by a tree branch. Thinking it’s another snake bite, he is in agonizing pain.

Why the dichotomy? The pain experience Moseley describes in the latter case, shows that the brain remembered the life threatening experience of the snake bite and interpreted a skin scraping as a more dangerous and therefore, more painful.

Evolutionarily, the pain experience is no different than other biological protective mechanisms. Like the turtle’s shell or the rose’s thorn, pain helps protect us from threats. This process translates past experience into current pain in order to protect us from future danger. 

In more specific terms, when your brain interprets signals as a credible threat, it will increase pain levels. On the other hand, if it determines that you are in a safe and protected environment, it will reduce pain. 

The pain you’re experiencing is very much real. Our understanding of how it comes about has shifted in recent years. Knowing that the cause of pain is more multifactorial allows the treatment to be more holistic, giving physical therapists and patients endless options to assist in its relief. 

Resources

Louw, A., Diener, I., Butler, D. and Puentedura, E. (2011). The Effect of Neuroscience Education on Pain, Disability, Anxiety, and Stress in Chronic Musculoskeletal Pain. Archives of Physical Medicine and Rehabilitation, 92(12), pp.2041-2056.

Louw, A., Farrell, K., Landers, M., Barclay, M., Goodman, E., Gillund, J., McCaffrey, S. and Timmerman, L. (2016). The effect of manual therapy and neuroplasticity education on chronic low back pain: a randomized clinical trial. Journal of Manual & Manipulative Therapy, 25(5), pp.227-234.

Moseley, G. (2007). Reconceptualising pain according to modern pain science. Physical Therapy Reviews, 12(3), pp.169-178.


About the Author

Ari WitkinAri is originally from Austin, TX. He received an undergraduate degree in Economics and Political Science from UC Santa Cruz, and a Master’s degree in Public Policy from University of Texas. After years of working in the public policy sector in Washington, DC and Austin, TX, Ari decided to make a professional change, return to school and received his Doctorate of Physical Therapy from Texas State University.

Ari believes that movement is a fundamental human right and derives great joy from guiding clients towards achieving their goals. From getting on the ground to play with your grandchildren to preparing for your next marathon and everything in between, Ari wants to help you get there with a smile on your face.

Read more about Ari.

May is National Arthritis Month and Rose City Physical Therapy would like to spread the word about joint health, prevention, and treatment. Arthritis is one of the most widespread health conditions in the United States affecting one in four adults – over 54 million men and women. We’ve selected a few articles that highlight the important relationship between arthritis and your diet – including which diets can reduce arthritis inflammation and what foods to avoid.

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Rose City Physical Therapy specializes in orthopedic and sports injury physical therapy. Please visit our staff page to learn more about our Board-Certified Orthopedic Specialists. Our highly-trained physical therapists have decades of experience in orthopedic physical therapy and will work with you to design individualized treatment programs to help reduce your pain, regain normal movement, and get back to your regular activities. Contact us to schedule an appointment today!


Article Featured on MoveFowardPT, Reviewed by Karl Kolbeck, PT

As many as 40% of people will experience sciatica during their lifetime, according to Harvard Medical School, and the condition becomes more frequent as one ages. Although sciatica is among the more common causes of pain, it is also often incorrectly categorized and misunderstood.

What is sciatica? What are its common triggers? What are the signs and symptoms? How is it diagnosed? Can it be prevented? How is it best addressed and treated?

Lumbar radiculopathy (also known as sciatica or radiculitis) is a condition that occurs when a nerve in your low back is injured, pinched, or compressed, causing pain or other symptoms that can extend from the low back to the hip, leg, or foot. Sciatica can be caused by sudden trauma or by long-term stress affecting structures in the back. It most often affects people aged 30 to 50 years.

How Does it Feel?

Sciatica can cause pain, muscle tightness and weakness, or other symptoms. The pain usually starts in your lower back, and can travel to your hip, leg, or foot. The location of the pain can vary depending on which nerve in your back is affected and how much it is irritated. Greater irritation causes the pain to spread farther. Spreading pain usually affects one leg, but may affect both legs. Pain and other symptoms can be constant or come and go, and your pain may vary in intensity.

If a nerve or nerve root (the nerve branches deep in your back at the spine level) is severely pinched or compressed it can cause severe pain, muscle weakness, or extreme movement problems. Surgery may be recommended in more severe cases. On rare occasions, nerve compression can cause bladder control or bowel function problems, in which case immediate surgery is recommended.

Rose City Physical Therapy can determine the details of your condition and discuss what a successful treatment plan consist of, and whether consultation with a surgeon is necessary. Our physical therapists will work with your physician or surgeon to determine your best treatment.

Signs and Symptoms

Sciatica can cause a variety of symptoms and signs. The type and location of your symptoms will depend on the amount of pressure being placed on the affected nerve(s). Symptoms and signs may include:

  • Pain and/or pressure in the back, hip, leg, and/or foot/feet
  • Pain that can be throbbing, aching, shooting, sharp, dull, or burning
  • Limitation in or inability to bend or rotate the back
  • Numbness or tingling in the back, hip, leg, or feet
  • Leg weakness
  • Increased pain when coughing, sneezing, reaching, or sitting
  • Inability to stand up straight; being “stuck” in a position such as stooped forward
  • Pain with sitting and difficulty getting up from a chair
  • Inability to remain in one position for a long period of time, such as sitting or standing, due to pain
  • Pain that is worse in the morning
  • Limping when walking

The pain or other symptoms can occur in one or both limbs. Your pain may present in different locations at different times, and can change depending on your activity or body positioning. For example, pain can lessen or worsen when walking versus sitting, or lying down versus standing up.

How Is It Diagnosed?

Rose City Physical Therapy will conduct a thorough evaluation including a review of your health history. Your therapist will ask you detailed questions about your injury, such as:

  • Do you have loss of control of your bladder or bowel? CAUTION: Contact a medical professional immediately if you experience this condition.
  • How and when did the pain start?
  • At what time of day is it worse?
  • What type of discomfort do you feel, and where do you feel it?
  • What are you unable to do right now in your daily life due to the pain?

Your physical therapist will perform a variety of tests to identify potential complications and assess the severity of your symptoms. These tests are designed to check for symptoms and clinical signs including:

  • Difficulty moving
  • Muscle weakness or tightness
  • Changes in skin sensation (numbness)
  • Changes in reflexes
  • Joint stiffness
  • Changes in posture
  • Difficulty walking or balancing

If your physical therapist finds any of the above problems, physical therapy treatment may begin right away. Our goal at Rose City Physical Therapy is to help get you on the road to recovery and back to your normal activities as quickly and safely as possible.

If testing indicates any concerns, your physical therapist will consult your physician or surgeon regarding the need for special diagnostic testing, such as magnetic resonance imaging (MRI).

Our board-certified physical therapists at Rose City Physical Therapy will work closely with your physicians and other health care providers to ensure you receive an accurate diagnosis, treatment, and the care you need.

How Can a Physical Therapist Help?

In all but the most extreme cases of sciatica, conservative care (such as physical therapy) often produces better, faster, and more cost effective results than surgery or pain medication (such as opioid medication).

Your physical therapist will work with you to design a specific treatment program that will speed up your recovery, including exercises and treatments that you can do at home. Physical therapy will help you return to your normal lifestyle and activities. The time it takes to heal your condition may vary, but improvement can be achieved in 4 to 8 weeks when a proper posture, pain reduction, stretching, and strengthening program is implemented.

During the first 24 to 48 hours following your diagnosis of sciatica, your physical therapist may advise you to:

  • Protect the area by avoiding activity that causes worsening symptoms, such as heavy lifting, sitting, bending and twisting, or standing.
  • Avoid too much bed rest.
  • Stay active around the house, and go on short walks several times per day. Movement will decrease your pain and stiffness, and help you feel better.
  • Apply ice packs to the affected area for 15 to 20 minutes every 2 hours.
  • Sit in supportive, firm chairs. Prolonged resting in soft couches or easy chairs may make your pain worse.
  • Consult with a physician for further services, such as medication or diagnostic tests.

Your physical therapist will educate you about specific exercises designed for patients with sciatica. For example, water exercises can be a great way to stay physically active when other forms of exercise are painful. It’s important to note that some traditional exercises, such as those that involve twisting, bending, or weight lifting may aggravate your sciatica if not conducted with the proper form. We will design an individualized exercise program to reduce your leg pain and meet your specific needs.

Rose City Physical Therapy will work with you to:

Reduce pain and other symptoms. We will help you understand how to avoid or modify the activities that caused the injury, so healing can begin. Your therapist may use different types of treatments and technologies to control and reduce your symptoms. Your treatment, based on your condition, may include specific motion exercises, mechanical
traction, and electrotherapy such as Interferential Current or Transcutaneous Electrical Nerve Stimulation (TENS).

Improve motion. We will choose specific activities and treatments to help restore normal movement. These might begin with “passive” motions that your physical therapist performs for you to move your spine, and progress to active exercises and stretches that you do yourself. You can perform these motions at home and in your workplace to help hasten healing and pain relief.

Improve flexibility. We will determine if any of the involved muscles are tight, start helping you to stretch them, and teach you how to stretch them at home.

Improve strength. If your physical therapist finds any weak or injured muscles, they will teach you the correct exercises to steadily restore your strength and agility. “Core strengthening” exercises are commonly used to restore the strength and coordination of muscles around your back, hips, abdomen, and pelvis.

Improve endurance. Restoring muscular endurance is important after an injury. Your physical therapist with work with you to will develop a program of activities to help regain the endurance you had before the injury, and improve it.

Improve posture. Your physical therapist will teach you how to improve your posture so that pressure is reduced in the injured area, and healing can begin and progress as rapidly as possible.

Learn a home program. Your physical therapist will teach you strengthening, stretching, and pain reduction exercises to perform at home. These exercises will be specific for your needs; if you do them as prescribed by your physical therapist, you can speed your recovery.

Return to activities. We will discuss your activity levels with you and use them to set your work, sport, and home-life recovery goals. Your treatment program will help you reach your goals in the safest, fastest, and most effective way possible. For spine and leg pain from sciatica, your physical therapist may teach you correct ways to lift objects (called “body mechanics”) that will help protect your spine from aggravating symptoms.

Once your pain is under control or gone, it will be important for you to continue your new posture and movement habits to keep your back healthy and pain free.

To learn more about how physical therapists treat sciatica, listen to this informative episode of Move Forward Radio. In this episode, physical therapist and researcher Mark Bishop discusses the basics of sciatica. An expert on the condition, he also addresses how physical therapists treat the condition.

Surgery

In some cases, surgery is necessary to prevent further damage. If you undergo surgery for your sciatica, your physical therapist will work closely with you and your surgeon to help you regain motion and strength more quickly than you could on your own, and help you get back to your normal lifestyle as quickly as possible.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat people who have low back and leg pain as a result of sciatica. You want to consider:

  • A physical therapist who is experienced in treating people with orthopedic, or musculoskeletal, problems.
  • A physical therapist who is a board-certified clinical specialist or who completed a residency or fellowship in orthopedic physical therapy. This therapist has advanced knowledge, experience, and skills that may apply to your condition.

Unless you do not have access to TV, internet and social media, you have heard the recent concerns about opioid use and the national epidemic.  Recently I’m getting more and more questions from patients with reservations about taking prescribed opioids.  As a physical therapist it’s not within the scope of our practice to prescribe medications; however, we do witness the benefit they can provide patients, and at times the adverse effects.  For acute pain associated with injuries and post-operative procedures, opioids are important for pain management to allow patients recuperative rest as well as to complete necessary physical therapy treatment and the home exercise program.  Patients with intractable pain associated with certain end of life diseases or cancer often need medication to provide comfort; which out-weigh negative aspects of prolonged opioid use.  Drawbacks include the common complaint of constipation, increased risk of depression, withdrawal symptoms and the serious issue of addiction.

The CDC reports that every day more than 40 people die from overdose of prescription opioids.  Thomas Friedman, CDC Director, stated in USA Today, “We know of no other medication routinely used for a nonfatal condition that kills patients so frequently.  We hope to see fewer deaths from opiates.  That’s the bottom line.”  A survey over a period of one month in 2014 revealed 4.3 million Americans had engaged in non-medical use of prescribed opioids.  Science Daily reported study findings that 4 out of 5 heroin users ages 16-25 had used opioids prior, often prescribed for dental procedures or sports injuries.  In addition to young people, the CDC states one of the fastest growing heroin use groups is higher income individuals who have used a prescribed opioid.

New 2016 CDC guidelines recommend using physical therapy and exercise to manage pain.  The guideline reports, “There is high-quality evidence that exercise therapy (a prominent modality in physical therapy) for hip or knee osteoarthritis reduces pain and improves function immediately after treatment and that the improvements are sustained for at least 2-6 months.  Previous guidelines have strongly recommended aerobic, aquatic, and/or resistance exercises for patients with osteoarthritis of the knee or hip.  Exercise therapy also can help reduce pain and improve function in low back pain.”

Physical therapy involves a comprehensive evaluation of movement, mechanics, range of motion and strength while assessing for dysfunction.  An individualized plan of care is developed based on the findings.  Treatment may include soft tissue and joint mobilization or manipulation, therapeutic exercise, modalities (ice, heat, electrical stimulation), and education to improve posture, body mechanics, movement, decrease repetitive stress and strain, and pain management strategies.