I have a 23-month-old daughter that seems to constantly get herself in an “ouchy” situation. Just the other day, she was so excited about coloring that when she gathered her crayons and wanted to show me some drawings, she missed a step and fell. Additionally, we are also dealing with her teething. So, pain is a topic, inevitably, on my mind.

Pain is a complex subject because it’s both a physiological and emotional response. It can be subjective, meaning my pain tolerance and yours may differ due to our prior experiences, general health, and state of mind. For example, I can sometime distract my daughter from her teething pain when Peppa is on the television.  

Pain is the body’s way of interpreting events surrounding us & providing information to keep us safe.  

Let’s begin with a brief overview about the pathway of pain. I’ll try to keep it succinct:

What Are the Types of Pain That the Body Recognizes?

1. Thermal: this type of pain relates to heat and cold temperatures
2. Mechanical/physical: for example, a pinprick to your fingertip or your stomach lining stretching
3. Chemical: these can be noxious substances released by the body, such as prostaglandins (PG)

The area of the brain responsible for processing pain is called the somatosensory cortex. In it, there is a map of sensory neurons correlating to each part of the body, called the somatosensory homunculus.  When you google a picture of the somatosensory homunculus you will notice areas with exaggerated body parts, such as the lips, eyes, hands, and feet. Areas of the body with larger representation will be more sensitive, meaning there is more brain area dedicated to it, or in other words, more density of receptors (and also more sensitive to pain).  Information from your finger has a specific place where it will synapse on the brain in the sensory strip on this homunculus.

When you experience an injury to, let’s say, the hand, inflammatory mediators or immune cells, like cytokines & prostaglandins  (PG),  are released as a response to inflammation. These stimulate nociceptors.  When nociceptor fibers detect a painful stimulus, they send an electrical signal to an area of the brain called the dorsal root of the spinal cord via neurotransmitters (basically, these are chemical messengers). The two main neurotransmitters that specialize in pain messaging are glutamate and substance P (SP).

An area of the spinal cord called the dorsal horn sends these signals up two tracts, the spinothalamic and spinorecticular tracts. The spinothalamic tract provides information about where pain is located, while the spinorecticular tract is associated with the emotional part of pain.

Just as there is a pathway for pain, there is another pathway within the body that modulate it, this one is called the descending pathway and consists of the periaqueductal gray (PAG) (located in the midbrain) and the nucleas raphe magnus (the medulla). The raphe nuclei are clusters of serotonins and the PAG is rich with opiate and endogenous receptors. They play an important role in inhibiting pain and is how pain medication works. When you take a pain-relieving drug, the chemical binds to an opioid receptor and blocks pain from reaching your brain.  Similarly, electro-acupuncture (EA) utilizes this endogenous opioid mechanism, as well.

Aside form acute and chronic pain that usually presents at our clinic, we also see a fare number of the following:

Referred Pain:

Have you ever noticed that when you have pain on one particular part of the body, but when you apply pressure to it, you feel it at another body part? Sometimes when a person is having a heart attack, symptoms will appear at the jaw and teeth. This phenomenon is known as referred pain. One theory that may explain this has to do with sensory signals or information from different parts of the body converging on the same order neurons. When this occurs, the brain is unable to distinguish the exact location of pain.

Neuropathic Pain:

This arises when there is damage to the nervous system, which includes the brain, peripheral nerves, and spinal cord. Once damaged, incorrect signals are sent to the brain. Often it is seen in diabetics, painful radiculopathy, as well as, shingles. This type of pain is usually described as burning, shooting, and/or electric shock.

Practical Ways to Manage Pain:

(Please note, before adopting any protocol, we would advise you to consult with your physician or therapist as they know your condition best).

How can we apply what we know about the body’s approach to pain and use it to our advantage?  Let’s start with acute pain, like a sprained ankle. In the past, we’ve always been told to use ice, but more research is pointing to heat. Contrary to popular belief, heat in an acute phase works best to improve the tissues’ viscosity and clearing debris out of the injured area by ways of macrophages. Some will even say that the ice protocol is actually a placebo-effect or top-down modulation. Ice, as argued by Dr. Kelly Starrett, an exercise physiologist, can cause more damage to the tissues and nerves by restricting the natural flow of oxygen. 

When it comes both acute and chronic management of tissue injury, think: PEACE AND LOVE.  Published in the British Journal of Sports Medicine in 2020, this was coined by Dubois & Esculier to describe the protocol for not only the management of pain at its onset but also how to rehab the injured tissue as it goes through its stages from subacute to chronic.

Next time, when you have a tissue injury, consider the following in PEACE AND LOVE :

P – Protection. Avoid activities that increase pain for 1-3 days post injury.

E- Elevation. Have the injured limb higher than the heart as much as possible.

A – Avoid anti-inflammatories as they reduce tissue healing. Avoid icing.

C- Compression. Reduce swelling of tissue with elastic bandage.

E- Education.

&

L – Load. Gradually return to activities. Let you body guide you when it’s ready to handle more load.

O- Optimism. Have a positive mindset.

V- Vascularisation. When ready, include cardio exercises, ie) Zone 2 cardio to increase blood flow for repairment of tissues.

E – Exercise. Keep mobile and proceed with active approach to recovery.

Remember when we said that pain is part emotional?  We can utilize this information to further mitigate pain. In addition to PEACE & LOVE, we also like to include the following tools in detail:  breath work and visualization.

First, let’s start with breathing. Breath work is an instant way to slow down your heart rate and allows you to be calm in a situation when the body feels tense, which can exacerbate pain. For this, you want to inhale deeply through the nose and then take a longer exhale. Let your exhale be longer than your inhale. When you exhale, your diaphragm relaxes and moves upward, as your lungs squeezes the air out. When you do this, a signal is sent to the brain to slow down your heart rate. Another type of breath work we like is diaphragmatic breathing. To do this, place one hand on the chest and another on your abdomen, inhale and feel your belly pushing out, exhale and feel your belly sinking towards your spine. This can be performed while seated or lying down on the floor.

Second, visualization. Changing mindset or perception of pain can actually decrease its intensity. An anecdotal example that I can provide relating to my own experience was during my tattoo sessions. I had a large artwork that I was getting done on my thigh. It was not a pleasant experience, but I noticed that when I kept picturing my dog, Suki, the pain intensity was not as high. I kept doing this for the subsequent two sessions and it drastically helped me to ..not really enjoy the pain, but to not really mind it either.  This shows how our brain has the ability to adapt. It does this through neuroplasticity. It describes the brain’s ability to make new connections and change in response to experience.

If you suffer from chronic pain, try visualization. Start with picturing your pain as a medium size ball and with each breath work, imagine that ball of pain is getting smaller and smaller and smaller and smaller.

Pain is an exhaustive topic but the main premise is to understand that it is a natural process in which the body and brain communicate about the external and internal environment. It is a set up of various alarms in our body to ensure self-preservation. Our body is also set up through various mechanisms to help us navigate pain when it arises.  So, when my toddler tells me she has an “ouchy,” after jumping off the couch, I know that by kissing her “boo boo” away, her nervous system is doing what it does best, which is, applying its top-down approach and signaling to her growing brain that the pain is “all gone.”

Written by Dr. Lam

Harvest Pointe Chiropractic & Integrative Health Centre

Reference:

https://www.physio-pedia.com/Pain_Descending_Pathways

https://www.sciencedirect.com/topics/medicine-and-dentistry/electroacupuncture

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3947586/

https://www.scielo.br/j/jaos/a/MqcyVvkmJV4BGCPBygg7BMk/?format=pdf&lang=en

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5371025/

“Stop Icing!” An Interview with Dr. Kelly Starrett and Gary Reinl

https://bjsm.bmj.com/content/bjsports/54/2/72.full.pdf