Pain Take 1: Understanding the Two Models of Pain
I was coming down the trail at a slightly faster than usual plod, spurred by some good music I hadn’t heard in a while that got my legs moving. I leapt over roots of trees that crisscrossed the soft single track path, wind in my hair, dappled sunshine on my face, music in my ears. I was actually enjoying myself on the run.
Then, right when things were getting good, I came down without any hesitation or holding back onto my left ankle joint- the bottom of my left shoe glaring pinkly up at me was a surprise. A loud crunch sounded and I felt a giving way and knew I had broken my ankle. This was not my first rodeo as they say. Growing up as a gymnast I had an orthopedic doc by the time I was 11. I knew the instability, the puffy swelling the crunch of a broken bone. And yet- there wasn’t much pain. My iphone skidded along the path and fell down an embankment toward the lake. I was able to scrabble after it. And hike the 1.5 miles back out to my car. Sure, I wasn’t dancing. It hurt. But I also was not in a ton of pain. How is this possible? In order to understand we need to take a look at the medical models that explain pain.
In orthopedic medicine, we have been struggling to help people with their pain. We are in the midst of a nation wide pain epidemic- that is costing billions and creating a deadly opioid epidemic. In orthopedics, for years, we have been instructing people that their anatomy (or injuries and changes to it) is what causes their pain. Disc herniations, ground up cartilage, loose or frayed tendons. This is known as the biomedical model.
While the biomedical model is true- it does not represent the entire pain picture. There is another statement that is also true at the same time: that pain is a complex set of conditions that arises when the person perceives danger in his or her environment. This model is known as the biopsychosocial pain model. Using the two concepts together will provide the best intervention for those of us living with pain.
Using both the biomedical model and biopsychosocial model at once is not as easy as it sounds- many people get tirelessly caught up in degenerative cartilage their orthopedist saw on an MRI. While these anatomical anomalies are going on- so too are they happening in other people around the world. And the strange thing is that some of these people may not experience any pain or loss of function. Pain is not closely associated with anatomical changes or tissue damage. Looking back on my ankle break and knowing what I know about pain and perceived danger- I think I did not hurt a lot because I did not feel unsafe. I had health insurance. I had done this before (literally, it turned out, the exact same kind of break), I am a rehab specialist and knew I could handle the rehabilitation.
This gets even more complex when we add age or neurologic or behavioral health changes into the mix.
And we also know that low dopamine levels can be highly correlated with pain levels. As can fear. As can anxiety. In other words, as we move through our lives we are experiencing the entire biopsychosocial model at once.
And so, the information of the past -to simply treat the biomedical issue (the cartilage, bone, tendon), is no longer getting us the results we need. And it is probably not appropriate to be using that model alone to guide us toward healing (period, even in healthy 20 year olds).
The biomedical model says rest. Get an injection. Don’t do anything for a week. Movement will challenge your anatomy.
What happens when we rest? During our time of rest, our dopamine levels are dropping further. We are becoming more deconditioned and also more fearful about falling. Maybe inactivity has also caused our weight to rise or drop suddenly. We lose strength more quickly. Our lung, cardiac and even cognitive functioning may become depressed.
Rest is so important during the acute phase of an injury. It is the reason I wore a boot while my broken bone knitted back together.
And yet in chronic situations- rest can keep us stuck in pain patterns. The biopsychosocial model calls for movement, and guided visualization of movement- to help make the sensory nerves more tolerant and help with tissue healing and adaptation.
We (western medical practitioners) are giving the same orthopedic advice around activity independent of age or neurologic conditions.
And we need to consider the possibility that our pain is an index not just of what is wrong with our tissues- but also where in our bodies, and lives we perceive or sense danger.
For more information on how to work with your pain levels I highly recommend the following books on the biopsychosocial pain model by the leaders in current pain research education NeuroOrthopedic Institute:
Explain Pain: By David Butler and Lorimer Mosley
The Explain Pain Handbook: Protectometer
I am also going to attempt to write – maybe 3 or 4 times a year- on pain and pain interventions.
Please give us feedback and let us know if this is something you are interested in.
Stay calm and move on.