Physiotherapist Richard Fernandez brushes photographer Amy Thompson’s left hand, which is covered from her view, while brushing a rubber hand in view during a workshop at the at the 2019 San Diego Pain Summit, Feb. 20, 2019. (Photo by Nick Ng.)
Pain is an unpleasant sensation, but it isn’t always an indication that there’s tissue damage, disease, or abnormalities in your body. After all, there are many people who have shoulder “abnormalities” or leg length discrepancies with no pain and can function well. Some amputees have pain in their leg or arm that is no longer there, hence phantom limb pain.
Current research finds that pain is influenced by a combination of biological, psychological, and sociological factors.
Each factor doesn’t function by itself in its own bubble; they’re constantly interacting and are hightly contextual based on your environment, previous pain experiences, knowledge about pain, and what pain means to you.
For example, you’re working at a stressful desk job for many hours and have low back pain from sitting too long. But you might be able to sit and play Halo or binge watch a TV series for many hours with little or no pain because the activity is enjoyable.
Let’s take a look how pain works.
Types of pain
Pain is generally boxed into acute, subacute, or chronic pain.
- Acute pain is short-term, lasting less than three months
- Chronic pain lasts more than three months
- Subacute pain is about six weeks to three months.
Sometimes pain is categorized based on location or its nature, as defined by the Internation Association for the Study of Pain (IASP):
- Neuropathic
- Nociceptive
- Nociplastic
While these types of pain are often diagnosed and treated differently, research finds that treatment and management should have common grounds based on the biopsychosocial model of pain. This includes giving reassurance to patients, listening to the patients’ narrative, and treating the person, not just the body part.
“Some say it is a reminder that they are broken, that their spine is ‘out’ or that their disc is ‘slipped’ (note to self: discs never slip. Ever.). Others say it is punishment for their sins or a test of their faithfulness.
“Some scientists say pain is a particular pattern of brain activity; dodgy motivational talks might call pain ‘weakness leaving the body’ or profess ‘No pain? No gain!’” ~ Prof. Lorimer Moseley
What causes pain?
Pain isn’t just the degree of tissue damage, “poor” posture, or “bad” biomechanics. Instead, the pain experience comes from a mix of information that our brain gathers from our environment and inside our body. While we do not havea “pain receptors” or pain nerve fibers, we have specialized nerves and sensory organs in the skin that detect changes in our environment, such as temperature, pressure, and infections.
One of these is called “nociceptors,” which sends signals to the spinal cord and the brain. But these aren’t pain signals; instead, the brain and spinal cord process these signals that may or may not generate the pain experience.
Sometimes the nervous, immune, and endocrine systems can get highly sensitive to certain stimuli that normally do not cause pain. When this happens, it’s called central sensitization.
Diagnosis
Physicians and physical therapists recognize that pain is an individual experience that can occur in the absence of tissue damage. Diagnosing pain can be challenging in the traditional medical model that relies heavily on the “bio” part of the biopsychosocial model because it’s not always easy to find the root cause of the pain.
The tests used include:
- MRIs
- X-rays
- Electromyography
- Spinal fluid tests
- Urine tests
- Manual/joint movement tests
- Reflex tests
Oftentimes the chronic pain diagnosis is given as a last resort when all other conditions have been ruled out. Basically, chronic pain is what you’re left with when all the things that should’ve helped have failed. Once pain has become chronic, there are several ways that can be used to track its intensity and how it affects quality of life.
How pain is measured
Wong-Baker faces is often used with children as young as age 3.
Researchers have developed several scales and patient reported outcome measures (PROMs) to allow clinicians to find the tool that fits best with your condition. These include:
- Numerical rating scales: For those with acute or chronic pain, but can only measure pain in the past 24 hours.
- Wong–Baker faces pain rating scale: For children as young as three, this uses a spectrum of happy to painful faces to measure pain.
- Verbal descriptor scale: For older adults who uses a combination of a thermometer graphic and pain descriptions.
- McGill Pain Questionnaire (MPQ): A form that includes a simple body diagram where you can indicate where you’re having pain.
McGill Pain Questionnaire
- Defense and Veterans Pain Rating Scale (DVPRS): Similar to the Wong-Baker Scale, this is specifically used for those in active military and veterans with acute or chronic pain. It also measures sleep, mood, and stress.
- Face, Legs, Activity, Cry, and Consolability Scale (FLACC): For children aged 2 months to 7 years who are unable to communicate their pain level.
- Critical-Care Pain Observation Tool (CPOT): For adult patients in the ICU who are unable to communicate their pain levels.
- Pain Assessment in Advanced Dementia Scale (PAINAD): For patients with dementia who may be experiencing pain.
Treatment and management
Pain management specialists can offer non-surgical or surgical options for a variety of conditions, including medications, injections, nerve blocks, or minimally invasive surgeries, such as radiofrequency ablation or spinal cord stimulators.
Acute pain treatment
Acute pain has historically been treated by physicians with the R.I.C.E. (rest, ice, compression, elevation) method with anti-inflammatory and pain-reducing medication. These meds may come in the form of oral medications, injections, or even creams that are applied to the painful area.
In a perfect world, anyone being treated by a pain management physician is also seeing a physical therapist, whose role is to not only address the pain but also how it’s interfering with activities of daily living and overall function.
They can address acute pain with non-invasive modalities, such as using electrical nerve stimulation, ice, heat, taping, exercise, and joint mobilization. Their goal is to help you move as much and often as you can that may relieve the pain but doesn’t exacerbate it.
Acetaminophen
Acetaminophen (Tylenol) is a pain reliever and fever reduction. It’s found in many over-the-counter medications that treat common conditions, such as colds and the flu. They’re used to treat pain by decreasing inflammation and acting on the areas of the brain that sense pain.
Acetaminophen is typically ingested orally but can also be in IV form when fast pain relief is needed, such as emergency care. Acetaminophen may block pain by stopping the production of prostaglandin, which is the chemical in the body that starts the inflammatory process.
The most common side effects of this medication include rash, hives, itching, bleeding in the stomach or intestines, nausea, stomach pain, loss of appetite, headache, or changes in urine or stool color.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Nonsteroidal anti-inflammatory drugs are also generally used to address pain and fever. These include aspirin, ibuprofen, Advil, Aleve, naprosyn, naproxen, Celebrex, diclofenac, and Voltaren.
NSAIDs act on enzymes called cyclooxygenases (COX). By inhibiting the COX enzymes, pain and inflammation are also prevented or reduced.
Side of effects include:
- Increased blood pressure
- Upset stomach
- Peptic ulcers/stomach bleeding at higher doses
- Liver or kidney toxicity
- Tinnitus (ringing in the ears)
People with liver or kidney problems should avoid NSAIDs. They can be problematic in those with heart failure or cirrhosis. Before taking NSAIDs, determine whether or not it contains aspirin because it may be contraindicated if you have bleeding disorders. These drugs should not be taken for longer than 10 days without a prescription from a physician.
Opioids
Prescription opioids can be highly addictive but also highly effective. When used as directed by a physician, opioid pain relievers are safe. These drugs, commonly in the form of hydrocodone (Vicodin), oxycodone (OxyContin), Percocet (oxycodone and acetaminophen), and morphine.
Opioids act on the brain to activate receptor cells that are involved in feelings of pain and pleasure. Once the drug binds to the receptor, feelings of pain are muted while feelings of pleasure are amplified. However, taking opioids may also cause drowsiness, confusion, constipation, nausea, and slow breathing.
Using opioids can cause feelings of relaxation or being “high,” which is why they have become popular for non-medical reasons as well. These drugs are extremely addictive and are a well known cause of overdose and even death.
Before taking opioids, it’s important to discuss why this is the appropriate prescription as well as how long the drug will be taken. You may need to wean off opioids, even with short-term use. Patients should discuss how to taper from the medicine before they start taking opioids. Patients with a history of addiction (in themselves or their family) should be sure the prescribing physician is aware of this.
Opioids should be stored in a locked cabinet if there are children or adolescents in the home because the fallout of accidental overdose can be fatal. Also, any unused opioids can be given to a drug “take-back” program or flushed down the toilet (the FDA has a list of medicines they recommend you flush).
“The most common treatments for acute and chronic pain that the public are aware of, and commonly directed to, are passive treatments for physical symptoms, or cognitive behavioral treatments for the emotional symptoms,” said occupational therapist Linda Crawford, who practices at Brave Therapy in Denver, Colorado.
Despite decades of studies and the gradual increase of understanding how pain works, Crawford said that the percentage of patients going from acute to chronic pain continues to rise with the overuse of opioid medications.
“We have evidence that ‘doing with’ instead of ‘doing to’ practices are more effective,” Crawford said. “We have evidence that validating a person’s lived experience, encouraging self-efficacy, and facilitating self-compassion can significantly improve their pain experience. And we have evidence that the more a person understands their pain experience, the better able they are to live their best lives with less pain.”
R.I.C.E.
The R.I.C.E. approach (rest, ice, compression elevation) has been the “go-to” method to managing acute injuries for decades. It has lasted the test of time because it’s easy for healthcare professionals to teach it to their patients.
Ice causes vasoconstriction which limits how much inflammation gets to the injured area. Inflammation carries metabolites that are critical to the healing process, so the goal should be to control it, not eliminate it.
Although R.I.C.E. is still widely used, it has come under scrutiny in recent years as newer evidence shows that it may not be the best approach. In a review published in the Journal of Athletic Training, researchers found that early mobility after an ankle sprain seems to be preferable to rest.
Chronic pain treatment
While some of the treatment for acute pain can be used for chronic pain, there are some methods that may provide chronic pain relief.
Nerve blocks
Nerve blocks are procedures that block specific nerves from sensing pain, which can be short or long lasting. Non-surgical nerve blocks tend to provide more short-term relief while surgical nerve blocks provide complete or near-complete pain relief.
The most common type is a rhizotomy or radio-frequency ablation. During this procedure, the surgeon destroys the root of the nerve where it exits the spinal canal so that sensation can no longer travel on that pathway.
Nerve blocks are common during childbirth but are also used for cancer-related pain, post-surgical pain, low back pain, chronic regional pain syndrome, severe arthritis, and headaches.
Heat or cold therapy
Both hot and cold therapy can be helpful for chronic pain. It’s easy to apply at home and has little risk of a set-back.
If ice is tolerable, use it to slow nociceptive signals, which may break the pain-spasm cycle. Heat, however, doesn’t act on nociceptors the way that ice does. But it typically feels good, which creates a relaxation effect that reduces pain.
Heat causes vasodilation which leads to increased blood flow and circulation, which can reduce feelings of pain, spasm, or stiffness in and around the area where the heat is applied.
Transcutaneous electrical nerve stimulation (TENS)
TENS units work by applying electrodes around the painful area. The stimulation is often described as similar to the “pins and needles” that are felt when your arm or leg “falls asleep” but is a more comfortable version. The nerves that carry this sensation are faster than the nerves that carry nociceptive signals to the brain, which allows the stimulation to block the pain sensation.
TENS can be used at home. These electrical stimulation units are readily available at local drugstores and online for around $30 or more. There are more expensive options, but the price is related to the number of pre-programmed settings, not the quality or effectiveness of the device.
One drawback is that TENS does not have much (if any) carry over when the unit is no longer on the body. That said, a TENS unit could easily be worn under clothing so that pain can be addressed while you go about your day. There’s no limit to how long a TENS unit can be used.
Surgery
Surgery may be the best choice for some conditions, such as hip or knee arthritis. For other conditions, such as chronic neck or low back pain, surgery may be an option that provides some relief but also comes with potential long-term implications, such as restricted motion, impaired sensation, or bowel or bladder changes.
Surgeons have options for approaching chronic pain, but it’s tough to know which treatment will be the most successful. Oftentimes multiple approaches and procedures are needed to provide even partial pain relief.
Psychotherapy
A psychologist can be part of your chronic pain care. During psychotherapy sessions, you are encouraged to discuss your pain experiences. This can range from where and when it occurs to what makes it better or worse to how it impedes everyday activities.
Psychotherapy can also help you deal with the stress and anxiety that accompanies chronic pain. The goal of psychotherapy is to teach coping strategies for managing pain. This may include relaxation techniques, reframing old experiences and beliefs about pain, coping skills, learning new ways to think about pain, or how to distract yourself from your pain.
Cognitive behavioral therapy (CBT)
Cognitive behavioral therapy is sometimes called “talk therapy” which can help you change negative thoughts and behaviors by reducing arousal in your central nervous system.
While your actual pain may not change, cognitive behavioral therapists think that changing negative thoughts and behaviors can improve the way you cope. CBT also seeks to change the physical response from your body when it’s under stress.
You may be asked to keep a journal of your thoughts and feelings that occur when you have pain so that the therapist can help you foster life skills and coping mechanisms.
Massage therapy
Massage therapy can help manage pain symptoms through reducing tension in the muscles and creating an overall feeling of relaxation. It may also increase local blood flow and lymphatic drainage to decrease inflammation. Notably, massage may help release neurotransmitters that play a role in stress, mood, happiness, and pain sensation.
There are several types of massage that may be effective:
- Swedish massage
- Trigger point massage
- Deep tissue massage
- Myofascial release
- Shiatsu
- Thai massage
- Self-massage (e.g. foam rolling)
Physical therapy
Physical therapy for chronic pain focuses on finding out what you’re having trouble with and then developing ways to get you back to those things. The goal is to ensure you are able to safely interact with your environment in and outside of your home.
It should approach pain management from multiple angles where the therapist can use modalities, such as ice, heat, and e-stim to address your pain. Where available, the therapist may suggest aquatic therapy to give your joints and muscles a warm, relaxing environment to function in.
Physical therapy may also incorporate land-based exercises to improve your strength and function to restore your activity to the highest possible level.
Janice Lacey, owner and operator of Heaven’s Massage Garden, gives Kimberly Brown a free massage during the Military Spouse Appreciation celebration at the Community Activities Center. (U.S. Air Force photo/Staff Sgt. Tonnette Thompson)
Exercise (physical activity)
Many clinicians used to recommend rest and activity avoidance for people with chronic pain. Nowadays, they recommend exercise and regular physical activity because research has shown many benefits of managing pain.
Benefits include:
- Reducing fatigue and improving sleep quality
- Decreasing pain sensitivity
- Decreasing inflammation
- Improving mood via reduce depression and anxiety
While there’s no consensus on what type or how much exercise is best for chronic pain, there are some factors to consider.
- Make sure you can perform it safely
- Work through ranges of motion that don’t cause or increase pain
- Avoid pain exacerbation
- Start slowly and add duration and intensity as you increase your tolerance for the activity
Meditation
Meditation has been shown to be beneficial in the management of several mental health conditions (stress, anxiety, and depression) that have been associated with chronic pain. The goal is to connect your mind to your body, which makes you more aware of your body without necessarily seeking to change what is happening. It helps you live in the moment by becoming aware of your condition and moving forward without judgment.
A 2024 systematic review of 18 studies found that meditation changes brain activity in areas linked to pain, emotion, and thinking. Increased activity in the insula, anterior cingulate cortex, and orbitofrontal cortex of the brain was linked to better pain relief, while reduced activity in the amygdala and medial prefrontal cortex was tied to less pain.
Supportive, social environment
A supportive environment for chronic pain management should not be under-valued. Many patients with chronic pain report that they feel unheard. And so, find a team of healthcare professionals who listen to your concerns.
People with chronic pain may also fear becoming a burden to their family. And so, be open to discuss what you’re feeling and ask for help from those closest to you.
Find a support group online or in your community that can help you stay active and engaged. Simply knowing you’re not alone can reduce the mental burden of your condition and help you feel connected.
Pain theories: how they change treatment
Pain as we understand it today comes from nearly 500 years of research and wonder. Although various cultures throughout history have their own beliefs and narratives about pain, science and humanities have revealed more about how it works and how it could be treated.
Gate control theory of pain
(Image: OpenStax College, Anatomy & Physiology, Connexions Web site. CC BY 3.0).
While there have been many theories about pain since the early 19th century, the major breakthrough in pain research is the gate control theory of pain. Developed by Dr. Ronald Melzack and Dr. Patrick Wall in the early 1960s, the gate control theory of pain says that non-painful stimuli, usually from the peripheral nerves, can close the “gate” of the neurons in the spinal cord that relay messages to the brain.
Neuromatrix theory of pain
The neuromatrix theory of pain is an update of the gate control theory, where it shifts the focus away from the peripheral nerves and toward the spinal cord and the brain.
Melzack described the neuromatrix as a network of neurons in the brain that loops between the cerebral cortex, the thalamus, and the limbic system. This “loop” is different for everyone because it is shaped by unique experiences, environments, social upbringings, and genetics, which create our personal neurosignature.
The neurosignature is the pattern of neural impulses that the neuromatrix produces.
Enactive approach to pain
The enactive approach to pain expands on the biopsychosocial model of pain by integrating the environment to the pain experience. Proposed by Dr. Peter Stillwell and Dr. Katherine Harman, the enactive approach emerges from the dynamic interaction between a person and their environment rather than something that simply happens to the body. It emphasizes how perception, movement, context, and meaning work together to shape how pain is experienced and expressed.
They applied the concept of “4E,” a framework that explains cognition—and by extension, pain—is embodied, embedded, enactive, and extended. This means it arises through the body, is shaped by the environment, enacted through interaction and can involve tools or external supports.
Further reading
Does Narrative Medicine Have a Place in Massage Therapy?
How Immune, Endocrine, Nervous Systems Influence Pain in a Lifetime
Penny Goldberg, DPT, ATC
Penny Goldberg, DPT, ATC earned her doctorate in Physical Therapy from the University of Saint Augustine and completed a credentialed sports residency at the University of Florida. She is a Board Certified Clinical Specialist in Sports Physical Therapy.
Penny holds a B.S. in Kinesiology and a M.A. in Physical Education from San Diego State University. She has served as an Athletic Trainer at USD, CSUN, and Butler University.
She has presented on Kinesiophobia and differential diagnosis in complicated cases. Penny has published on returning to sports after ACL reconstruction and fear of movement and re-injury.
Outside of the clinic, Penny enjoys traveling, good cooking with great wine, concerts, working out and playing with her dogs.
Nick Ng is the editor of Massage & Fitness Magazine and the managing editor for My Neighborhood News Network.
An alumni from San Diego State University with a bachelor’s degree in graphic communications, Nick had completed his massage therapy training at International Professional School of Bodywork in San Diego in 2014. In 2021, he earned an associate’s degree in journalism at Palomar College.
When he gets a chance, he enjoys weightlifting at the gym, salsa dancing, and exploring new areas in the Puget Sound area in Washington state.
