Video and Transcript: Why Do I Have Persistent Pain

Hi, everyone! Dr. Orit Hickman here from Pain Science Physical Therapy. 

I wanted to talk about a concept, one that we work with patients who’ve been experiencing persistent pain with something that we have to work really hard to help them understand about why it is they’re experiencing persistent pain. And, the underlying reason is that your alarm system, which is the-the whole-it’s the system that its whole job is to let you know that something bad is occurring in your body. That system is actually not working properly. It’s actually dysfunctional. 

So, what does that mean? Your alarm system functions to help protect your body. So, if I go to do something that harms my body, let’s say I step on a nail, then I need my alarm system to respond very, very quickly to let me know, “Hey! You just stepped on a nail.” I’ve got to experience some sort of discomfort or pain in my foot. I have to take my foot straight to the hospital where the doctor will get me a tetanus shot if they need to get me a tetanus shot. They’re going to remove the nail. They’re going to hopefully stitch up the foot. And then, afterwards, for a period of time, my foot is going to stay sensitive and sore. And, I’m going to limp. And, I’m going to protect the foot until that tissue has fully healed. That’s a normal alarm system response. Right? Something dangerous happens to the body, and your brain responds, and you experience pain, and so you take care of it. Ok. 

So, what’s happening with somebody who’s experiencing persistent pain? Well, if you’ve been experiencing pain for a long period of time, then your alarm system actually becomes dysfunctional because that alarm system is not supposed to go off all the time. Can we agree? We are not supposed to feel pain in our bodies all the time. That is not a normal system function. Right? Your alarm system is supposed to function in the moment when you experience damage, and until that injury has healed, it needs to be protecting you to a certain degree. But, the pain shouldn’t be the same all the way through. And, that pain should get better over time as the tissue heals. 

The problem with persistent pain is that the alarm system in and of itself is behaving incorrectly. It’s not doing what it’s supposed to be doing. It might be very, very, very hyperprotective or hyperresponsive. 

So, what does that mean? That means that you go to brush your hand up against something very gently, and you experience great gobs of pain. That’s not normal. Maybe when you go to sleep at night, you have the bedsheets over your feet, and that’s really painful. That’s not normal. If you’re sitting for a period of time, [you] shouldn’t feel pain. That’s not normal. If I go to a-for a walk for five minutes and I feel pain in my back, that’s not normal. These are all abnormal alarm system responses. 

So, one of the ways I try to explain this to patients is I give them the analogy of what if you-what if you have a new puppy. Ok? For those of you who’ve ever had a new puppy, one of the things you know is that the puppy is very, very young and having to learn how to behave properly. Right? If you let the puppy do whatever the heck the puppy wants to do, the puppy is going to wreak havoc on the house. Right? [It’s] going to chew up all your shoes. [It’s] going to chew up all your furniture. [It’s] going to pee and poop all over the place. That’s a misbehaving puppy. And, that is not the way-unless you want to live in chaos, which I don’t, it’s not the way you want the puppy to behave. So, what happens is you train the puppy. You teach the puppy how to go outside, how to signal to you that the puppy needs to go outside to go to the bathroom. You teach the puppy not to chew on certain things. Right? First of all, you try to remove all those things, but then you slowly introduce those things. You introduce pieces of furniture. You take the puppy around the house. You teach the puppy how to behave properly. If the puppy is misbehaving… Ok? If the puppy jumps on your bed and chews your pillow to shreds and you say to the puppy, “Good job! You did a great job! Nice work,” you have just reinforced bad behavior. And, most of us can agree that’s not how we want a puppy to behave. 

So, when your alarm system is dysfunctional… Ok? If your alarm system is telling you that sitting is dangerous… It’s telling you standing is dangerous. It’s telling you light touch is dangerous. That system is not behaving properly. So, if you say to the system, “Ok. Great. Thank you for letting me know that. I don’t need to be feeling pain when I’m sitting,” you’re taking a step in the right direction. But, if instead you say, “Ooo. I sat for too long. I better get up and move,” or “Ooo. I walked for too long. I better sit down and rest,” or “Ooo. I better avoid everything that’s light touch. I’m going to make sure I have no garments that are next to me that-that-I’m going to wear loose-fitting clothing all the time. I’m not going to let things touch my body,” then you are reinforcing bad behavior. Your alarm system is not doing what it needs to be doing correctly. And, you are reinforcing that programming, so, overtime, that system is going to continue to do the same thing. 

In fact, it will get more sensitive over time. So, let’s say you can tolerate 20 minutes of walking right now, and after 20 minutes, you’re like, “I’m done. I’m going to rest.” As time goes on, that system is going to get more sensitive. You might tolerate less and less and less. 

So, the question is how do we fix a system that’s misbehaving? Well, there are many, many answers to this, and it is individualized. We don’t do the same thing with every patient. But, in general, graded exposure is one of the top things that we’ll do with a patient. So, for example, if you say to me, “Orit, I can’t tolerate standing for more than five minutes,” I say, “Ok. Well, let’s start with five minutes.” But then, I want you to nudge that system to six minutes. And then, I want you to nudge that system to seven minutes. See what we’re doing? We’re taking control of the system. And, you have to reinforce. You have to say to the system, “You’re not behaving properly, so I’m doing this thing, and I know it feels uncomfortable, and I know it even feels a little dangerous, but it’s not actually dangerous.” But, your system doesn’t know that because it’s misbehaving just like a misbehaving puppy. 

So, I hope that that was a helpful analogy, a helpful thought. Let me know what you think. Feel free to give a comment below. Give a like if you like it. Subscribe if you want to hear more. And, I’ll keep giving you videos to learn about your dysfunctional pain system. And I hope you guys have a great day!