What's causing the pain?

It’s the question I am asked most frequently when people come to see me and my job is to find an answer. It is not always a simple answer either, over the years I have looked in different directions to try and understand the complex mechanisms of pain; from massage and manipulation to acupuncture, counselling, and functional nutrition. Physios are taught to look at the mechanics of the body, looking for joints that don’t line up properly or move smoothly, and to identify areas of compression or strain. These mechanical factors can result in physical wear and tear or overloading of specific tissues resulting in pain. The body however is well designed to cope in such situations and this is where the immune system comes in. In the event of wear and tear or damage to the body from injury or foreign invaders, the immune system begins the process of repair and healing with inflammation.

Inflammation

Inflammation was documented by the Romans thousands of years ago, they described the major components, identifying the primary four: calor (heat), rubor (redness), tumor (swelling), and dolor (pain). All four of these symptoms are linked to increased blood supply to the damaged or infected area. Acute inflammation is how your body fights infections and heals tissue dammage. This process works the same if you have a virus like a cold, or a sprained ankle. White blood cells get to work to mop up any toxic pathogens or cell dammage at the site of an injury and to stimulate the cellular activity that will result in tissue repair.

Sounds perfect, what could go wrong?

Often the people that come to see me are aware that something has gone wrong. The ankle they sprained three months ago is still swollen; they have rested it but the pain has not gone. In these cases the immune response has not resulted in healing but got stuck in what is called a cycle of chronic inflammation.

But Why?

Overuse/ misuse

Sometimes it’s what we are doing that is causing the problem, walking in footwear that is lacking in support, doing too much of the same activity, gardening or even just sitting! During an appointment I will analyse postural issues looking to correct overload in specific tissues to allow healing to occur. For example advising on a more balanced exercise programme, including some muscle strengthening and stretching rather than just focusing on cardiovascular exercise (walking, running, cycling) or looking at task variation or breaks in a work place setting. Working to correct postural issues may include specific exercises or in some cases changing furniture or footwear. 

Poor healing

We have to understand that the body’s ability to heal will be affected by age and general health. For some people healing may take longer and in some cases it may remain incomplete (in the case of leg ulcers that won’t heal). There are things that can help to maximise tissue healing including massage, acupuncture, laser and oxygen therapy, the use of castor oil and herbs. I will discuss the effects of some of these in the coming weeks.

Immune system dysregulation

Over the years I have seen many, apparently healthy people who are reporting signs and symptoms of chronic inflammation. As a physiotherapist the most common examples of chronic inflammation that I see are joint pain (osteoarthritis of the spine and knees) or soft tissue pain (chronic tendonopathy in the shoulders and hips or fibromyalgia). For now I would like to use Osteoarthritis as an example.

“Osteoarthritis is a condition that causes joints to become painful and stiff.
As part of normal life, joints are exposed to a constant low level of damage. In most cases, your body repairs the damage itself and you do not experience any symptoms. But in osteoarthritis, the protective cartilage on the ends of your bones breaks down, causing pain, swelling and problems moving the joint. Bony growths can develop, and the area can become red and swollen. “ (NHS Overview)

The NHS overview gives a basic description of the condition but fails to explain the variation in pain levels experienced by different people. In fact it suggests that the more wear and tear you have the more pain you will experience. However there have been many studies showing that there is no correlation between the degree of joint damage as shown on x-ray and reported pain levels. The wear and tear will cause joint stiffness but it is the inflammation that causes the pain. Over the years treating clients with joint pains, I have found that some people will respond well to treatments involving manual therapy, some to acupuncture, others to meditation, breathing techniques and others to dietary changes. I have found it fascinating and impossible to predict which person will respond to any one approach. To understand how pain that is linked to inflammation can be reduced, it is important to understand the way the immune system works. We have immune tissue throughout the body but the majority (approx 70%) of it lies within the lining of the gut. This is why what goes through our gut will affect the immune system and the way it responds. If we eat foods that our gut is sensitive to, or that break down its protective lining it will cause the immune system to be activated. Prolonged gut irritation can result in an immune system that is constantly activated, the consequence of this is chronic inflammation. Interestingly this may occur with or without significant digestive symptoms such as IBS, constipation, acid reflux, bloating and gas.

Many health concerns, such as high blood pressure and diabetes, have more recently been linked to chronic inflammation.

This is where genetics come in, the inflammation in the body will go where our genes direct it . This might be to the heart, lungs or the brain leading to chronic disease of that organ. Another destination for the elevated inflammation in the body is the musculoskeletal system manifesting in chronic soft tissue or joint pain. The medical solution for this pain is chemical, there are many forms of anti inflammatory medications and if these don’t work the next step is to look at immunosuppressant drugs. 

Often the people that come to see me are aware that something has gone wrong. The ankle they sprained three months ago is still swollen; they have rested it but the pain has not gone. In these cases the immune response has not resulted in healing but got stuck in what is called a cycle of chronic inflammation.

The route to managing your own health will be as unique as you are. This is “bio individuality”.

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