The Purpose of Pain

Part two, "Understanding the Purpose of Pain." One of the things that we come across quite frequently, both as physical therapists and as I talk with my colleagues that are surgeons, is pain. And how do we deal with pain? How do we minimize pain? I wanna talk a little bit about how do we understand the purpose of pain? I think a lot of times we expect to be pain free or that it's a human right to be pain-free.

And I think that that would be a misconception people who are pain-free die very young because pain is a messenger that tells us things that are potentially harmful for us. So I wanna go over, what is the purpose of pain? Where does pain reside? What influences pain? How does medication control pain?

What is the latest management that's out there for the philosophies of pain? I was talking to you a little bit earlier in module one, about opioids and hopefully more and more surgeons and pain medicine doctors are finding other ways to control pain than using opioids especially the really strong ones. Not just for the patient but we find that the leading cause of suicide and overdose these days typically are tied to these opioid drugs on the street. So again, keeping them philosophically off the street is really important. And then finishing up with what's best for you is just totally going through this process.

Understanding what is it that you need to understand about medication and pharmacology as you take on something major like a total hip replacement or a total knee replacement. So, the purpose of pain, Lorimer Moseley he's a leader in the physical therapy world out of Australia has written books and worked with David Butler and Adrian Lowe and some other great names, that are really trying to understand pain. And how do we educate our clients about pain? And not just chronic pain, but even acute pain that we have day to day. Lorimer Moseley made the statement "The pain system is not very good "at being a physical damage meter." And I always find that very interesting that its job really is about giving us information to take action on things that potentially could be harmful to us.

I think this is really, he tells us a great story of walking out, back and as he's walking, he feels something in his leg and it sorta clip or like a scratch and he just ignores it, and he keeps walking and falls down and passes out. And so he describes what was happening, his nervous system, he said something bumped up against the side of his leg, the nerves came up to the brain to the thalamus, and they said to the thalamus there's something happening on the outside of your right leg, and thalamus then sends a message to the historical part of the brain and says, "Do I need to be worried about this scratch "on the outside of the leg?" And the historical part of the brain said, "No, no, no, he walks through the Bush all the time "it's probably just a scratch." And so the message gets cut and there's no pain but it turns out that he had been bitten by a very poisonous snake out back in the bush in Australia. And he said, he tells the story much better than I can but he gets medevaced, voila he survives and he lives. He says a couple of years later, he's back out in the bush and he's walking along in the Bush and all of a sudden, boom, once again, he gets hit and he feels something in his leg, same neurological pathway. Something comes up to the thalamus, says, "Hey something just brushed you "on the outside of your leg." And then that goes to the historical part.

And historical part of the brain goes, "Heck yes you were bitten by a poisonous snake "a couple of years ago, you almost died. "You got medevaced to the hospital." So then it relayed a message to the conscious part of the brain, the front of the cortex. And he had the most excruciating pain. The funny thing was is that when they lifted his pant leg up and he thought he was dying, they saw that he had just been scratched by a bush. And so we see this type of dichotomy all the time in pain literature.

That if we perceive that there is a high risk or danger, the pain will be magnified greatly irrelevant of the tissue damage. If we feel safe, and we believe that it's gonna be okay, those symptoms go away. This is really evident when you've been dealing with a back pain for a while, and you finally got your doctor's appointment or therapy appointment, and you've been hurting all this time, you finally show up to the doctor's appointment, and on that day that you show up, that morning you don't have any pain. And you're like, "I've been having severe pain "for the last four weeks. "I don't know why no pain today." Well, research shows that when you have the anticipation, that you're gonna have a solution to your problem, then pain no longer has to motivate you to take action.

Especially if you believe you're gonna get better, this was called the placebo effect. And so one of the things we like to discuss is if we understand the surgery, if we understand the procedure, if we understand what the medications do, then we're in a better place to avoid the fear and anxiety, that often makes pain much, much worse. Most people deal with pain on a daily basis, and are able to see, feel, and interpret it, and come to a conclusion that it made them aware of something they had to change, or something they had to do. So, what influences pain? On this slide, you notice I put five key elements that influence pain.

The first one is inflammation. It really does cause pain. So when we have an inflammation response, there are certain chemicals released that are irritating, these free nerve endings called nociceptors, and the nociceptors come up into the central nervous system, and are interpreted. It's there in the interpretation, that the brain decides whether or not you need to take action or not, or if it's something severe. So we also have other messages that come up into our brain like proprioception, or touch, or sharpness, or temperature.

And those messages also get interpreted in similar centers of the brain. So, if the brain is hypersensitive and angry, we could say, and the history has been bad, then any message coming up from that area, is going to signal a pain response based on the psychology and the history of the brain. So the first point I wanna make is that pain can only be felt in a conscious state, and it can only be interpreted in the brain. So, we don't feel pain in our leg, our brain tells us something's wrong with our leg and gives us pain, right? The interpretation, we would often say, a child would say, "I have pain in my ankle or my knee.

"I have pain in my hip." The pain is an interpretation. There are people who show up to the emergency room with the craziest injuries, knives sticking through their back, that have zero pain, and people that have hanged nails, that are screaming bloody murder. So, this goes to the next point is perception, and fear of pain. So perception and fear of pain really is a biggie. When people are experiencing anxiety, we often refer to these as triggers that cause painful episodes, or lower the pain threshold.

So I happen to know in my personal life, I have two triggers. One trigger is finances. If I find out in my company or my home, that we're struggling financially, I notice that my pain threshold goes down, and my experience of pain goes up. Even though there's been no change, no tissue damage, no accidents, just merely the fact that my financial situation changed, I notice that my pain gets worse. I also noticed that my pain gets worse with relationship issues.

In particular, if I have to let an employee go or fire somebody, for weeks I dread this horrible act of having to let somebody go. I'm much better at it today by the way. But I dreaded it. And what I noticed is that for weeks, before knowing that I had to let somebody go, that I would have this increased sensitivity to pain. And so I started realizing and learning a great book is Adrian Lowe's book called "Fibromyalgia." And inside that book, it's a book for patients.

It's not really just for fibromyalgia, but anybody that's dealing with pain, and understanding what is the lion within you, that makes emotionally, makes your pain worse or better. And I think this is a very important thing to understand before going into a major surgery, it could be a spine surgery, a hip surgery, a knee surgery. It could be a cancer surgery, whatever the surgery is, having a sound understanding of what manipulates our pain, is crucial to us. And so that's why I wanted to talk about this because not everybody's experience, is gonna be as good as the one that I had. I had zero pain with this surgery procedure.

I had far more pain, prior to the surgery, than I had any symptoms after the surgery. So, sort of a cool side note there. So, what else influences pain? We know that emotions can influence pain. So, when I am sad, when I'm depressed, if I am angry, that it can fluctuate pain.

For example, when we're angry, pain often goes down when we're angry. But when we're sad or self-reflecting pain will often go up. So, sometimes the anger is the adrenaline in our body. It's the sympathetic system that is the fight or flight mode, and so we're surviving. And you know this that, you know if you had to save somebody, or there was an accident, or something in you're home with a child, whatever pain you had is gone while you have to do that and take care of that emergency.

On the other hand, if you're just reflecting on yourself and your pain and feeling sorry for yourself, poor me, then those emotions will actually create a greater sense of pain. One of the things I do with my pain patients that come in, is I ask them, or they ask me if I'll treat them, and I'll say I have two conditions to be treated for chronic pain in my clinic. Number one, is I need you to not participate in a pain support group, right? You might ask why? Well, because if you've ever been to a pain support group it becomes a competition, whose pain is worse than somebody else's pain, not a good setting if you want to get rid of pain.

As long as we're preserving on it, and we keep elaborating our pain and making our pain bigger, and badder, and worse than the person next to us, we will continue to get worse. The other one condition I have is that they go and do two hours of service a week to a population, people that have greater trauma or pathologies. Go to a cancer ward, go to a food kitchen, go work with the homeless, go work in a church that has need of assistance. And what I find as soon as people get out of self-focus, quit focusing on themselves, that they actually have a decrease in their pain. The fourth one on here is crucial and this is knowledge.

And this was the one that I think helped me the most. And that's why I want to cover this. Is that the more knowledge you have of your surgery and of the pharmaceuticals that you're gonna be using, the easier it is to process information and to suppress the fear and the anxiety associated with a major surgery. This is crucial. I can't think of anything more important and it's interesting that I'm doing this for Pilates any time, but I've had surgeons asking me now to be able to teach this same content.

So we're just gonna refer them to PilatesAnytime, to be able to take this workshop. And the idea is that when you have knowledge, you now have a perception. We all have perception, but the perception that is more accurate. And if you can understand that the pain you're feeling, might be the inflammation, and the doctors are gonna do all they can to control the inflammation, with certain pharmaceuticals and some ice, and different things that they have in their protocol. And with knowledge, the knowledge is, that I no longer have a pathology in my hip.

What was causing my hip pain is gone. So now all that's left is a little bit of this sutures that bring the muscles that were not cut, but the capsule and the muscles back together again, and sew up my skin. So I might have a little bit of pain in the bone ending where the stem was put. I could imagine having a little bit of pain where the fascia was cut to be able to get down to the capsule, and I could imagine having pain in my skin where things were stitched back up or stapled back up following the surgery. Matter of fact, my surgeon used glue.

So I barely have a scar on my hip that they just used glue. And when the glue fell off, the wound was healed, right? I could go into the shower. So, knowledge becomes crucial. Sometimes the fear of like is that new prosthesis gonna pop out, right?

Is the femur gonna fracture? You hear these horror stories. 99% satisfaction or 98% satisfaction now with total hip replacements, both anterior and posterior, they have perfected the science of this. And that's also why in the previous module, I said, if your limitation is over 50%, you should consider having a total hip. If you meet the other criteria.

Because you can have such a great quality of life. And you also decrease the risk of injuring things like your back chronically, or your ankle or your knee. The last one I wanna talk to you about is the pharmaceuticals that are being used. And I have on this next slide, the idea of understanding what medications control what? I have a patient right now, who is on a number of very heavy medications that don't really make sense, but they're different doctors, and they're all referring different things.

And he himself does not have an understanding of what the medications do. And what their side effects are, and what happens when you mix them. It's very hard for a lay person to know. In each of our situations, I go back to the term, we are the consumer, and consumers should know what they're taking. I always find it a shame that pharmaceutical companies can advertise in the United States on TV.

I think that's a very dangerous thing. And you hear it dangerous when they paint this beautiful picture, of how happy you're gonna be taking this medication, where the slight side effect is death, where the slight side effect is suicide, where the homicidal tendencies, where the slight side effect of kidney failure, whether it's slight side effect of respiratory failure. You know, these are things that physicians and pharmacists need to really think through and not make it something that the patient comes in and says, "Hey I saw this great commercial "that shows really happy people. "I'm not happy, can you prescribe the medication for me?" It's a big marketing ploy. If we understand the medications, if we get counseling, like even going, your local pharmacist are amazing.

I love going to pharmacist and saying, what's the contraindication between this medication and this medication? And they know, a lot of times your physicians won't know. The pharmaceutical rep comes in gives them a bunch of free samples, and that's what they're gonna use. In the case of total hip replacement, they are making it a science of the pharmacological treatment, pre and post-surgery, one, to get away from the opioids and two to minimize the pain. So here's a list of some common pain medications that are used.

And I wanna go through just briefly and tell you what they do. The non-steroidal anti-inflammatories. This would be like our ibuprofen Advil, Aleve, Naprosyn, diclofen, Voltaren. There's a lot of different things out there but they're considered a non-steroidal anti-inflammatory. There are long lasting that you sort of get in your system and they're less harsh on the stomach.

They're short, like the Advil or Aleve, or ibuprofen, that have a much more immediate relief but could be much more dangerous to your digestive or gastrointestinal system. There are topical application. So Voltaren you can buy across the counter in the United States, you've always been able to do that internationally by the way. And you just rub the gel on top of the area that's hurting, and it's an anti-inflammatory that gets absorbed into the bloodstream. It still has its consequences.

We still need to use them as they're prescribed, but that's a nonsteroidal anti-inflammatory. Aspirin also has a analgesic, meaning that it controls pain, and it also has an anti-inflammatory, and it also has one other really important contributing factor, which is blood thinning. So a lot of times the surgeons now are not using heparin, or other types of blood thinners following these big surgeries, they used to, because the risk of blood clots and embolisms, was a real risk following these big surgeries, right? And now taking the aspirin seems to be just enough, to be able to prevent the blood clotting and then after a couple months or a month, you're off of the aspirin and you don't need to take it anymore. The acetaminophen is Tylenol, and Tylenol is an analgesic.

The good thing is it's not as hard on your stomach, but it could be hard on your liver. So having a mixture between the nonsteroidals and the Tylenol, might be what your physician prescribes for you. There also is some papers that show that nonsteroidal anti-inflammatories could actually slow down some of the collagen mending during the healing time. So some surgeons don't want you to use any anti-inflammatories during that healing phase. So again, listen to your doctor.

Steroids are also an anti-inflammatory. You might've heard of things like prednisone, and cortisone, and corticosteroids, and epidurals. Those are all steroidal, and they're longer lasting, and they are anti-inflammatory. So, you'll often hear them using a epidural block, for total hip replacements now. And there's a very good reason for it.

Remember what I said about the free nerve endings, the nociceptive fibers in our body, that transfer messages of pain up to the thalamus? Well, an epidural block will block those messages from getting to the brain during the surgery. And what they're finding is that that block decreases the trauma that the brain has during the surgery, right? The violence of a surgery. That said, you are on a general anesthesia, or you're on a sort of Coma kind of drug where you don't really care about it, propanol or something like that.

And your consciousness is not there so you're not having pain consciously during the surgery. However, if you block the pain messages from even getting to the brain, the brain never experiences that trauma. So, that's a really powerful tool that they're using now that by the time they use the steroids and some of the long lasting marcaines and painkillers in the surgery, you might have 24 to 48 hours, of zero to little discomfort or pain going into the central nervous system to be interpreted. If you have the knowledge and you understand that that's what happens and now you're never going to experience that bad pain. You don't have pathology in the hip anymore, and as you start moving around and doing your therapy and going home that same day or the next day, you're not going to have that horrific experience that people used to have with more primitive procedures, and more primitive pharmaceuticals.

So, very important to understand the doctors now are using special cocktails and mixtures of these. Another one is a neurogenic drug. This would be like Lyrica or Neurontin, some of these different drugs. And they're playing with it just a little bit to be able to ease the neurological pain, right? So you hear people that have fibromyalgia and chronic pain, often will use gabapentin, will use Lyrica, Neurotin those kinds of things to be able to control the pain.

I, for example, had a little bit of Lyrica in my pre-surgery cocktail, which I think when the doctor said they're just trying it to be able to see if they can minimize the need for the opioids, right? And that's their whole objectives like how do we avoid this addictive drug? That's dangerous in the community, and really is not the best pain inhibitor or pain medication out on the market? And speaking of opioids, these are things like morphine, Dilaudid, Percocet, the list goes on Oxycodine and Oxycodentin are less and less popular now, especially the Oxycodine you hear that's very hot on the street market and really responsible for a lot of overdoses and suicides from that particular drug, and that's a synthetic opioid. And so it has a slow release.

And the problem with it, is that you might only get the effect of the high for four hours, but it's long lasting on the pain for eight hours. So, it also has long lasting for your respiratory and heart center. So, if you take a lot of, you get a high for four kids on the street, they take another one at four hours, Now their half-life on that drug has really, really, it has decreased. And so what happens is the respiratory center and the heart center are slowed down for a longer period of time and they ended up overdosing. And so that's why that drug is such a bad drug on the street, I can't emphasize it enough.

And I just am one that I don't wanna bring it into my house. I don't wanna have it... I don't wanna have the risk of the addiction to it either. And then the benefit of low to no opioid post-surgery I think this is really where we need to be thinking in our healthcare system. And I would go into the surgery thinking that I'm not gonna have opioids.

And if things are so bad that they need to give you an injection of Dilaudid or you need to come home with a low level one like Percocet, that you're gonna get off of that as quickly as possible. There are things like Tramadol and Flexeril and muscle relaxers that are also used in harmony with these drugs to help out. My biggest pitch here, and the reason why I go through this as important is because a lot of times you're not gonna get this explanation. And if you have this, you can write these things down and you can go to your doctor and ask him, what do you use pre-surgery? What do you use before you go into surgery?

Are you gonna do an injection? Are you gonna do something into my hip? Do you flush it out with marcaine afterwards? Do you put a steroid in it? Asking them what they do and let them explain why they do what they do.

And express your interests that you do not want to use opioids afterwards, unless absolutely necessary. And with the new procedures, the new surgeons, the epidural, the Hana table, all of these things out there right now, there just is minimal trauma, minimal invasiveness. And with the prolong lasting marcaines and pain blockers, I think we can really, the majority of us can avoid having to use any of these opioids. So, what is the latest management that we're seeing in some of these surgeries? As I mentioned, the pre-surgery on this slide that I had a cocktail is what they referred to it as, and it had a steroid, it had Lyrica, I think it had an anti-inflammatory as well in it a couple of things.

And that was just sort of to prepare my body, for an inflammation storm that would be happening from the surgery. Anytime you cut through your body, or you cut through bone, you're gonna create inflammation. The second thing before surgery is I had an epidural. So that's where they put a steroid and anesthesia in the spine. And it basically causes a block.

So I didn't feel anything below my pelvis. And so that also meant that there was not gonna be, as I mentioned earlier, the pain signals coming up into my brain. And then post-surgery, I had minimal to no opioid, the day of the surgery afterwards. I think I took like a Tramadol or something like that. And then I went home with aspirin, Tylenol, and an NSAID, and I did have a few Tramadol just to go to sleep at night or if I started getting anxious about something to be able to manage that.

And this leads to the next question which is your personal experience. And this slide asks, what's best for you? What is your past medical experience with pharmaceuticals? Have you had any addictive behaviors? Do you have an addiction with alcohol?

Do you have an addiction to pain medications in the past? You'll notice people that have gone through rehabilitation from addiction to opioids, are just adamant that they will suffer any pain that they have to, to avoid the opioid. One of the biggest side effects of the opioid is that it decreases your pain threshold, and creates anxiety that you need the drug, to be able to control or disconnect from the pain. And it's not even really reducing your pain. It's just reducing the anxiety of that.

And that's where that addictive behavior comes from. You know, do you have a high versus low pain tolerance typically? If you've been dealing like I did with severe hip pain for 20 years, I was so tickled coming off my bed immediately after surgery with a therapist, and be able to stand up and not have joint pain. Yeah, I felt the tenderness over the incision barely, but I didn't have joint pain. And it was such a relief to me, and I was so happy.

I knew the surgery had been successful and the surgeon told me it went really well, that I immediately put a framework in my mind that I'm okay. There's nothing I need to be afraid of right now. I dealt with some of the wooziness of the anesthesia, and they had to wait for me to get clear on that. And then I was able to go home and I was able to manage it with minimal hardcore drugs to be able to get back to normal. So, it was like, I've been through multiple surgeries.

I had a cervical fusion 10 years ago, and that was a major ordeal. And it took a little bit longer and I've had ankle surgery from a fracture, and a shoulder surgery when I was 16 there was open surgery, horrible experiences with opioids. So, the idea is like learning about yourself. What is your tolerance? If you think that you're low tolerance to pain, maybe now's the time to start toughening up before you go into the surgery, and getting mentally prepared maybe working with a counselor or with somebody that could prepare you for the surgery to be stronger in that sense, because again, pain is not a measure of tissue damage.

It is a central nervous system response, to whether or not you need to take action. And if you know the surgery was successful, there's no other action you need to take. And so you can allow that pain to go away. The last one that's really important is allergies. Some people are very allergic to different medications.

One that I'm allergic to is morphine, not in a severe way, but whenever I've had morphine, I end up breaking out in a rash, right? So then they do a Benadryl push, after they do a morphine push. And I basically said, no morphine, no opioids, that way. So, you might have an allergy to the anti-inflammatories an allergy to Tylenol or an allergy to the antibiotics that you usually will go on after a total hip replacement, to be able to prevent infection in the prosthesis. These are all things that are very individual, they should be discussed with you, with your doctor, there's not a right or wrong way, there's just an educated way.

And that's what I wanna encourage you to do is to be that educated consumer.