What Is Pain and How Does it Relate to Tissue Damage?

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Welcome to the Back Pain Solutions Podcast – What Is Pain?

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Introducing ‘What Is Pain’?

For most people the first signs of any issue with their back health will be a result of the back pain they experience. But what exactly is pain? What is happening in the body to cause the discomfort you experience? Is pain actually helpful, and how can it be managed effectively?

In this episode we introduce the concept of pain. How does tissue injury create a chain reaction that is ultimately interpreted by the brain as discomfort? We discuss how pain can be helpful to us and is important in preventing the progression of an injury. We also discuss what we must do to alleviate back pain and help the body to recover whilst discussing how some of the different pain medications work to prevent pain.

The Mechanism of pain

Pain is a physiological response to tissue damage and is an unpleasant sensory and emotional experience. However, pain is important because it makes us aware that there is a problem. Without this communication tool we would be at risk of developing serious tissue damage, and even death. Imagine for example that you put your hand on a hot stove. If you didn’t become aware of that as a result of the pain it would cause, then the potential damage could be catastrophic to your hand! We need pain to keep us alive so when you become aware of it, even if that pain is relatively minor, take action!

All of the various tissues in the body (muscles, ligaments, bone, intervertebral discs) have nociceptors which are pain sensing cells. These cells respond to a noxious stimuli, to chemicals, that are released by damaged tissue. So if you experience a disc herniation the intervertebral disc will release chemicals that aggravate the nociceptors at a local level. The nociceptors will then relay the pain signals through the nervous system to the brain.

There are nerves entering, and exiting, the spine between each vertebra. Each nerve has an anterior, and a posterior, nerve root. The anterior nerve root carries motor fibres that create movement whilst the posterior nerve roots carry sensory fibres that relays pain signals, as well as other sensory information. As information from the nociceptors is carried through a posterior nerve root it enters the dorsal horn which is part of the grey matter of the spinal cord where many cell bodies are located.

In the dorsal horn the first order neurone (nerve fibre) ends, and a second order neurone begins. Information is relayed between the 2 neurones by neurotransmitters, in this case a chemical called substance p. At this point the second order neurone crosses the spinal cord (decussates) and then passes up the spinal cord in the spinothalamic tract. So, interestingly, the result of this decussation is that pain in the right side of the body is ultimately interpreted by the left side of the brain, and vice versa.

The second order neurone continues up the spinal cord, in the spinothalamic tract until it reaches the thalamus in the brain. Here, the second order neurone ends, and a third order neurone begins. ALL sensory nerve signals have this same 3 neurone system. Once again the pain signal is carried between the 2 neurones by neurotransmitters. From here the third order neurone relays the information to a specific area of the brain, and we experience discomfort.

In addition to the ascending pathways we also have descending pathways. In this instance it is a descending pathway that helps us manage pain. The descending pathway releases chemicals called serotonin, and noradrenaline, between the first and second, order neurones. The result is that they inhibit the action of substance p and help ‘dampen’ down pain. They also influence an interneurone which releases a chemical called enkephalin which further inhibits pain signals. Enkephalin is also known as opioid and it is copies of this substance that have been created as ‘pain killing’ drugs.

Show Highlights What Is Pain

Should we be taking painkillers if the pain pathways are designed to help us? Ultimately it’s not about avoiding painkillers just so long as we’re not avoiding an underlying problem. Without acknowledging there is an underlying problem then we’re at risk of simply masking that issue, and allowing the damage to develop. As always, you have to take some responsibility for the pain you’re experiencing in order to resolve it.

Interview Transcription for What Is Pain

Ben James 0:00
When we’re young, we move with freedom and confidence with a great resilience to injury. Somewhere along the line, we’ve developed poor habits and become more vulnerable to back pain, smart, strong features, evidence based and practical advice to help you take back control of your health and get back to the activities you love. This is your guide to better health. So join us as we demystify some of the commonly held beliefs about back pain. build your confidence, a stronger band, the smart Welcome back to the smart strong podcast Everybody with me, Ben James and my co host, as always, Jacob say morning Jacob.

Jacob Steyn 0:35
Morning Ben.

Ben James 0:36
So today we’re talking about pain and introducing the subject of pain, talking about some of the pathways and interpretation of pain. Why because often, the first time we’re aware of any back problems or back issues, or any injury, in fact, is when We start to feel discomfort or we start to feel pain sometimes that can be acute and a really serious discomfort. And sometimes that’s more low grade pain that gradually builds over time. So we wanted to introduce the subject of pain, talk a little bit about how your brain interprets that pain, just to put it into context. And as always, we’ll share some good videos in the show notes that will put this visually in video content context, and, and help to bring it to life a little bit because there are some complex and difficult parts of this podcast. And there’s some words there that may be quite foreign to a lot of people. So as always, there’ll be a video there to help support what we’re discussing today. And then we’re going to talk a little bit about opioids and some pain management and bring that back to what we’re doing and what it’s important that we do in terms of movement. And in terms of awareness, when we get back pain and back issues, particularly, because as always, what about the movement, we’re about the functional movement and how we can use that strategically and beneficially, to manage our back pain. So, Jacob, we’re going to kick off and talk a little bit about anatomy, physiology of pain. So feel free to jump in to contribute. And stop me at any point where you think that there’s a bit of a value to add or a bit of information that you feel is missing or could be explained a little bit better. And then we’ll go on to discuss a little bit about the, the opioids how they work, and then bring that back. circle back around to how we manage it with exercise movement.

Jacob Steyn 2:56
Sure, yeah, just go ahead, Ben. I’ll fill in when I can.

Ben James 3:00
So pain imagine we’ve got a disc herniation. For example, we’ve talked a lot about disc herniation. And today, as well as other back injuries and back back issues. So let’s imagine that we’ve got a patient who’s got a disc herniation and they’re experiencing discomfort and pain in the lower back. So how does that work? How is it that they get that discomfort? Well, peripherally, or distally, if we like all of our joints, muscles, and other soft tissues have what we call nociceptors. So we’re talking pain sensing cells. So imagine that the neurology the nerves, the spinal cord, the brain is all our electrical wiring system, if you like within the body. So this Lee it starts or paints and he starts with nociceptors. And as a Pain sensing nerve cells. So what they’re going to do is they’re going to respond to a noxious stimulus and they’re going to respond to some irritation. So the disc herniation, for example, results in chemicals being released. And those chemicals are going to irritate these nociceptors these pain sensing cells, okay, so that’s the first part. There’s a localized discomfort that is acknowledged dystiny and then those nociceptors relay or what we call propagate that information through the nervous system into the back of the spinal cord. So as we’ve discussed before, you have spinal nerves all the way up and down the spinal cord entering the spinal cord at different levels. So if you’ve got lower back discomfort, it’s going to be lower down the spinal cord and our sensory system. Our system that interprets pain, touch, etc, always enters posteriorly, the posterior nerve root of a spinal nerve and all of our motor system our movement passes out anteriorly. So, the nociceptive becomes stimulated by chemicals and then that is relayed through a nerve through the nerve root posterity into the spinal cord. And it’s important so at this point we have alpha fast myelinated and five nerves there five is and we also have C fibers which are unmyelinated. And those are more poorly localized though throbbing kind of burning sensations and that’s important to just be aware of further down the line when we next discuss chronic pain and we talk a little bit about chronic pain because that’s one of the reasons we want to get a bit of a foundation going to talk about chronic pain later on and how we prevent ourselves moving into that into that status. So once those nociceptors of related and inflammation, it goes into the dorsal horn, and that’s in the spinal cord. So if having you see a cross section of a spinal cord, you might visualize it as a bit of a capital H. figure in the middle, but the grave. And imagine that one of those is the dorsal horn, got doors will open each side, and an anterior hananiah on the front on either side. So, at the dorsal horn, there’s going to be neuro transmitters released, what we call substance P. And that’s going to then help to transmit that impulse that that nerve information If you like to what we call a second order neuron, and that’s going to cross or decorate the spinal cord, and pass up the spinal cord in what we call the spinal tract. And this is interesting because if you imagine the right side of your body receives information and it crosses over the spinal cord to then extend up the spinothalamic tract. What actually happens therefore, is that the left side of the brain interprets right side of the body. So pain on the right side, your body is interpreted by the left side of the brain, which interesting fact for the day. So once that information is transmitted up the spine over lemic tract in this second order neuron is going to reach the relay station, which is the thalamus and the thalamus is in the brain. And from there, there’s going to be a third order in Europe. And that third order neuron relays the information to a specific area in the brain This specific area in the brain is we’ve got what we call a monkey laughs which again, when you look at the video, you’ll see and that’s where the, the different areas of the body that are represented within the brain. So the low back is going to have a specific area. So that neuron if we’re talking about pain is going to go up to that part of the brain brain interprets, we’ve got low back pain. Okay. So in addition to that, we’ve got a descending system. And we won’t go into too much detail here, but it is interesting because this is how we understand how some of the painkillers work. So if you imagine the ascending pathway is the acknowledgement of pain, and it’s telling our body we’re in pain, the body reacts to send a descending kind of inhibitory system to help was management So what it does is it helps in a number of ways. So there’s a descending pathway that inhibits that first order neuron. So where we said that that first bit of information enters the posterior part of the spinal cord at the dorsal horn. So the first order and second order neuron signups where those where those that chemical is released and that information is interpreted to relate the spinal cord with our bodies will release serotonin and noradrenaline that inhibits this substance P. So where we said that nosey scepter is activated information passes into the dorsal horn, and when it reaches that side that releases a chemical called substance p, which transmits to the second order neuron and so the descending pathways inhibiting that release of substance p by releasing serotonin noradrenaline and if you imagine, you’ve probably all heard of adrenaline and the fight or flight we reduce re release adrenaline. So this is another example of how that adrenaline can work within the body.

Another element of this pain inhibiting pathway is the release of serotonin and noradrenaline also stimulates the inter neuron. So there’s an inter neuron that releases and caffeine or opioid. So if we then imagine opioid analgesics, Painkiller, some of those common painkillers that we’re often aware of, we often take those painkillers to reduce pain. So the way they work is between that inter neuron, so they’re helping to manage that ascending pain pathway. So they’re telling our bodies or the helping with the physiology within this pain pathway to dump it. or prevent this discomfort or certainly reduce it. And again, that inhibits the release of substance P. So it’s also inhibiting action at the post signups where that second order neuron is passing up information up to the brain. So that’s a basic overview of the anatomy physiology of how pain works and how our brains interpret it. And a little bit of an introductory bit of information about how painkillers can help manage it. And I think, as part of this series will touch a little bit more on some of the pain medications and that we see being used and we see that patients are taking as part of their pain management, whether that’s been given by the doctor, whether it’s something they’ve read, or whether that’s just a habit they’ve got into if they have access to some of these painkillers because it’s quite a complex subject, the A lot of medications out there and used in different ways. But for us, it’s it’s important to recognize how these medications can work, how they can help within this pain pathway. But the big question at this point is, should we be taking painkillers to influence his pain pathway? Because it’s there for a reason? Or should we not be taking painkillers? And should we just be focusing on what’s the underlying problem? And clearly, as you will be aware, our big concern and our big focus is on what’s the underlying problem. And what are we doing to take away that initial irritation, because that irritation is there to make us aware of the problem. So once we’re around the problem, what are we going to do about it? to Jacob, on that note, painkillers. We talked a little bit Just before we started this show about painkillers, and we’re not saying as some people might often think of alternative medicine and alternative medical practitioners, we’re not saying that all pain medications are bad and it’s a bad idea what we’re saying we’ve got to use them in the right way.

Jacob Steyn 13:21
Yeah, we’re definitely not saying it’s all about idea but we are definitely saying this. To explain we should consider how we go about this topic and especially when we’re in pain, what we what we do to alleviate I think the trap for people is that they, they often end up taking, they have a busy schedule and they want to carry on with a busy schedule, they have children there, they have duties they have things to do. And in order to do so, they they do not consider what we just discussed. They go for an easy solution. Which is actually just popping a painkiller and carrying on with what they should be doing. And, you know, quite often the pain will go away. But there’s also a good chance it will come back. And depending on how busy they are, it will not only come back, it might even get worse. And what we’re saying is we’re saying, you know, maybe take a moment stand still look at what’s causing the pain. If there’s a recurring problem, usually at the same site, then you’re more likely to actually experience a real problem in the future. We know that if we don’t fix that problem, it’s gonna most likely build up to something that becomes a real problem later.

Ben James 14:44
Yeah, and I think, is, as always the case or I say always the case you often see patients that will come in and they’ll already be taken some pain medications, and if you delve into the history there and ask them a few questions that They’ve been there a while and they’ve been taking painkillers a while. And often the story is, they’re no longer working. And the problem therefore is, it’s too easy sometimes like you say busy schedule or some of the worst culprits are those that are doing exercise because they just want to pop a pill to continue their exercise. They’re not looking at the underlying movements that are causing the problem. They’re just trying to mask the issue. And I think that for me is the key point is painkillers can be very, very useful in managing that pain in that issue initially, if Clearly, we want to get you out of discomfort. But what we don’t want to do is mask a problem only for that problem to get worse, and then those painkillers not to work and then you subsequently will potentially take some stronger painkillers, take some stronger painkillers, and then over time, and more regularly because of the potential side effects that they can have, which is obviously another show itself, but mainly because we want to look at that underlying problem. So what we’re saying is, by all means, take advantage in the short term at the early stages of a problem, but probably more. So if it’s acute. If we’re starting to notice a little twinge and discomfort, generally, we’re not going to need pain medications for that low grade discomfort. That’s the point where we want to be searching for a solution to the underlying problem. Don’t wait.

Jacob Steyn 16:33
Yes, yes, that’s it. Yeah, I think it comes back to the responsibility. You know, you want to take responsibility. And by taking a painkiller, you’re just you’re just avoiding that responsibility. Yeah. Yeah. And then we haven’t even started talking about what, what we’re actually missing out on when we take this painkiller, especially if we take a non sterile anti inflammatory drug an inset. We were actually interfering with the ability of the body to heal the problem. And what we quite often see is we see people taking or having been been recommended to take a high dose, say the maximum dose of ibuprofen or instead today for two weeks consecutive every day. And then you have a massive interference in the actual inflammatory process which we so desperately need for that the three phase process to actually heal the problem. And, Yeah, what’s your opinion on that?

Ben James 17:39
Yeah, I think you know, like, like you said, We, the pain pathway is there for a reason to help identify the problem. But we want to work to manage that pain, but we also want to respect that the body has an amazing capacity. To heal, and I think it’s back to education and it’s back to understanding. And it’s back to where we go for our advice as well. Because, you know, it’s it’s all too easy. And I say too easy sometimes i think it’s it’s all people know to do is I’m in discomfort, all of a sudden, that’s not normal. I’m going to take some pain medication, so people aren’t doing it always for the wrong reasons. But the actions of a cultural thing. Yeah, and I often have this conversation with friends with patients that we’ve grown up with a medical system that’s been fantastic in terms of solving bacterial viral infections, you know, the antibiotics and the invention. The antibiotics was a huge leap forward for us. You know, from a health point of view, you know, in terms of longevity and saving lives, but sometimes have we applied the same logic to wall problems, you know, and therefore, a medication or a pharmaceutical is the first line of defense over a problem. Now, clearly if, you know if you’ve got a serious bacterial infection, that makes sense, you know, and certainly this is the case for other injuries and other health problems. But is it the right thing to do with low back pain for example, straight away, if you’ve got a serious and sudden onset of low back pain, then clearly the first thing you need to do is try and get out of that discomfort and you’re going to take some pain medications completely understand that. But if it’s a low grade discomfort that you started with, and then you started to take nonsense anti inflammatories is an example just because that’s what I feel I should do, or that’s kind of the the medical way as it were, then we’re probably doing ourselves a disservice. So, again, I think it’s around about kind of convoluted answer to the question there. But I think it’s back to the education and it’s back to take a moment to stop and think, what is the underlying issue here? And do I want to try and educate myself and understand what that problem is and try and adopt some strategies, movement wise, particularly as always, with a focus here on the low back before I just start taking pain medications, because how much of the discomfort is that masking? You know, what point during the day Am I feeling that discomfort and I’m I was aware of it because I’m taking some pain medications. So I think if you’re My response to people is if that pain is really debilitating, then first and foremost, we’ve got to roll out those red flags. Because if it’s so serious that you’re feeling the an absolute need for painkillers, then that suggests to me that there’s there could be a serious problem. Or you’re one of the unlucky ones that’s maybe had a disc, a sudden onset of, you know, disc herniation irritation, and that’s going to be really uncomfortable. And there are some of the other situations clearly that are going to warrant it and people are going to need it. But I think the advice from my point of view is that there’s a underlying discomfort and irritation there. Do I really need those painkillers at that point? And what can I do right now to help my low back rather than try and master problem because when you started to look at, for example, a pain Hurry. And if you’re speaking to a practitioner and they’re saying, okay, so when you notice that discomfort, what point of the day is it? And its worst? What relieves it? How can you answer those questions? Clearly, if you’re taking pain medications that might be masking the problem a little bit, you know, so it is a fine balance again, because what’s the takeaway for a listener? Or should I or should I not take a painkiller, if I’ve suddenly got back pain because of course, it is very subjective. You know, if some people that say, yeah, that pains, not too bad, so I’m not going to take a painkiller. And then you’re going to have someone that says, I’m in serious pain, I need a painkiller. And actually, the pain experienced, you know, might be far more in the person that’s not taking them, but they’ve just got a better tolerance. So it’s subjective. So my advice and the take home message for me is this. If it’s seriously uncomfortable to the point, that movement Difficult, then clearly you’re going to pick up some, some painkillers in the first instance to allow you to get somewhere for some advice. And, and, and move there with a element of comfort. If it’s not causing you a problem in movement, and it’s not so severe that you can’t get out and seek some advice, then clearly I would say in the first instance, don’t take them because it’s going to help with that examination and that history taking and help us identify what that problem is. At that point. Once we’ve done that, maybe the advice is then to say, okay, happy we’ve got the information we need. Now this is the advice with your pain medication, whilst we start to introduce actions and activities that we know are going to be beneficial.

Jacob Steyn 23:49
And I think once you once you take the once you understand back to the educational part, once you understand that the The bankers are actually interfering with the healing process number one, maybe by disguising the pain triggers. So you’d be doing something you shouldn’t be doing. You know, if you go through a day and you’re very busy with your body sitting or driving and your job, you name it. And some of these things would cause you pain and you take painkillers and you just carry on actually aggravating the tissue even more. When that tissue needs rest the tissues asking you for a recovery moment. And that’s the first one second one being the fact that we actually if it and it would actually interfere with the the actual healing process and I think once you understand that, from an educational point of view you you can take responsibility. And you’d understand that you like you mentioned, you have to now find the Way find a strategy to refrain from the pain triggers, find a way to actually allow your body whether it’s with relaxation techniques, or also maybe even paying attention to a better food diet strategy, you know, then you’d understand that the whole thing, it’s looking at the big picture, it’s removing the painkillers, removing the lenses that’s going to interfere with the healing process, taking the step to allow the the tissue recovery. If you have to, and you’re not really paying attention to your diet, it’s a huge aspect of your, Rick. What we’re really looking at, as we said, we’re speaking about more the acute situation when it comes to pain at the moment, is that the body goes in there and inflammation in other What you would feel as pain? We saw the situation. But if you’re not allowing your body through the right diet and abatement of you paying attention to the pain trigger, then you’re actually you’re going to most likely allow that acute pain to become a chronic situation.

Ben James 26:21
Yes, yes. And that’s obviously something that will come on to a little bit more in the in the following podcast and discuss the chronic pain and the how we we get into that situation, rather than go into that in too much detail. But I think again, back to one of the points of this podcast, and internet terms of introducing pain, but also that is one of the key goals is not to move into chronic pain, because that’s when things become a little bit more difficult to manage. So I think if you You’re listening and you’re taking painkillers on a regular basis. You know, that’s where we want to start to say, Well, okay, let’s look at these movement patterns. Let’s look at these, the underlying things we’re doing on a daily basis. Let’s look at that pain diary that start to try and move away from those incidents pretty quickly, all those painkillers pretty quickly or certainly reduce the amount that’s been taken. And so that we’re becoming conscious of that discomfort. And where we’re almost tuning into it almost. The message is almost to embrace the pain. It’s there for a reason. The body is giving you signs that there’s a problem. So be comfortable with the fact that you’re aware of it. Let’s now start to manage it through movement advice and through dietary advice as well which again will be will be another podcast within this kind of episode, or series should I say of pain? But start to be aware of it and be comfortable with it but be uncomfortable with it that there’s a problem that needs solving. I think if you view it like that, and you almost embrace it a little bit, then you’re much more likely to take control of it. And you take ownership of that pain, you control the pain, don’t let the pain control you. And I think again, if you take me some of the advice that we’re giving on the website and the podcasts, then I think that’s one of the first and the most important things. It’s the lack of knowledge and the frustration people have that there’s a pain there’s a discomfort What do I do about it? I take some painkillers. I know the pain still there. What am I doing wrong? Am I going to need more painkillers because I’m, I’ve got back pain and I’ve always got back pain. There’s always a solution, as we said at the very beginning of launching the podcast this week. Always a solution to back pain, there’s always a cause of back pain. So embrace that discomfort, embrace that pain. And as long as we can rule out any red flags or any underlying infections or other things that will need medical intervention. And we know that the majority of back issues on mechanical let’s start to take control and look at the movements, the bracing, the postures that we adopt the breaks that we give ourselves on a daily basis to walk and routines that are all going to help the underlying tissues to be at ease as in take away that irritation. Take away that discomfort in doing that over a period of time and that in some cases may be days in some cases may be weeks, it will vary. But by taking away those aggravating factors, then those nociceptors those Pain and interpreting fibrous, shall we say, will not be activated and then gradually you’ll notice that you’re not in pain and in discomfort. So it’s back to as always Jacob, the bracing and the extra exercises we can be doing in terms of relaxation.

Jacob Steyn 30:23
Yes, there are relaxation exercises wanted to say how important that is. Because people don’t realize this. I think people don’t realize this generally because we’re so so busy. And we don’t, you know, we have a moment to moment to to stop and eat and then carry on to go. But if you able to take 10 minutes and do a tummy lying exercise or do a brisk walk, you’re actually relaxing the tissue from the strain of head when you were sitting. This makes just makes a huge difference. Absolutely,

Ben James 31:01
yeah. And I think, you know, that’s really the take home message from from today’s pain is there, it’s there for a reason. And it can be frightening it can be it can be scary, and particularly when we talk about pain because it is one of those subjects as we’ve touched on before where people think, oh, now I’ve got low back pain. I’ve always got low back pain. That’s not going to be the case. If you follow the advice and follow the advice and the videos that we that we have. That isn’t going to be the case but you have to take ownership. Don’t be fearful, embrace that discomfort, embrace that pain, because you can control it. With the right strategies. You can absolutely control that pain, without pain medications, or certainly if you’re taking them already. You can move away from those pain medications very successfully. But you need the knowledge in the education to be able to do that effectively to be able to do that confidently which is what our websites all about. It’s all about giving you the tools to take back control of your low back pain. Be aware of the exercise and the movements that can help you to do that and to help you to build a really strong back. So don’t be afraid of that discomfort and pain. Take ownership of it. And I think that’s a good place to end this podcast. Subsequent episodes going to be about chronic pain. And then I think we’ll talk about the nutrition element, and how that can help with the management of low grade inflammation and how that impacts inflammation. And also maybe come back and circle back and touch a bit about more about painkillers and some of the other painkillers that we see being utilized to manage low back pain. And, once again, as always, thank you, Jacob. Apologies, everyone. There’s a bit of a poor connection at stages today. So thank you for sticking with us. As always, and we say after every episode, try and get over to iTunes give us a rating helps share the message helps get to get the podcast out there to more and more people. And we can continue to try and help with the management of low back pain, give people the advice they need to take back control, take back ownership, and be confident that they can build a stronger back the smart way. Jacob thank you as always speak again soon..

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