The Nature of Pain and Restorative Effects of Touch
A Manual Physical Therapist’s Perspective
Ask anyone whether they or someone close to them has ever utilized the skills of a physical therapist, and the answer is almost always “yes.” The American Physical Therapy Association defines physical therapists as “highly-educated, licensed health care professionals who can help patients reduce pain and improve or restore mobility-in many cases without expensive surgery and often reducing the need for long-term use of prescription medications and their side effects.” PT’s treat a wide array of disorders and conditions, from back pain to difficulty walking after a stroke. A common feature to many conditions we see is pain. Pain tends to inhibit muscles from activating properly, and our bodies are expert at compensating for painful movements, which can go on to cause new movement and pain problems.
There are roughly three types of pain that people suffer from, and most of the time, there is more than one present at a time: nociceptive, peripheral neuropathic, and central sensitization.
Nociceptive pain is most familiar. The pain is localized to the area of injury. If you fall down and scrape your knee, it hurts on the scrape, and when you bend your knee, stretching the skin on top, it hurts. There is a clear mechanical nature to the occurrence of pain. Once the scrape has healed, bending the knee no longer causes soreness.
Peripheral neuropathic pain is the pain that occurs when there has been an injury or strain to a nerve, such as the leg pain that occurs when a lumbar disc is protruding (herniated) on a nerve root, causing sciatica. Here, the relationship between mechanical compromise and pain occurrence becomes a little fuzzy. Peripheral neuropathic pains can, and often do, get aggravated without any movement or stretch. Even psychological stress can trigger severe peripheral neuropathic pain.
Central sensitization is the result of pain that has gone on for months after the original injury to the tissue has healed. The pain does not have a clear mechanical nature, and is the most unpredictable and disabling of the three types.
Here is an example of central sensitization: Like many Saturdays, you finish an afternoon of yard work, and your back is a little sore. You go to bed, get up the next morning and for the first time, can’t straighten up. There is a searing pain in your back and buttock, instead of just the usual stiffness. You miss three days of work because you’re flat on your back in bed, taking as much Tylenol as possible. Fast forward many months later, and many appointments with physicians, chiropractors and physical therapists, who all concur that the MRI you had to beg for shows nothing more than the degenerative disc changes that would be expected for someone your age. Although you’re able to work and carry on with family life, you’ve been “babying” your body, because your back and buttock hurts a lot. It can still “go out” if you’re not careful, and hurts worst in the morning, then eases up a bit, only to worsen again after an afternoon on the computer and commute home. You’ve given up yard work and your regular recreational softball league. You find yourself yelling at the kids more and even your love life has suffered.
This type of pain persists beyond the typical few weeks to 2-3 months healing time. You’re frustrated because your MRI results do not reflect the lingering and disabling pain you feel. Surely, there must be more damage that is not showing up on the MRI? Research is showing that some types of pain, like central sensitization, persist not because there is ongoing damage to the tissues, but because of cellular adaptations in the pain circuitry of the spinal cord and brain. The nerves are more sensitive to the pain input from the tissues, and the signal is actually amplified before signaling the brain. The brain itself is also “sensitized” and interprets even non-pain input from the tissues as painful stimuli. As well, thoughts and beliefs can alter the brain’s interpretation of input from the tissues. At this point, pain sufferers are taking opiate analgesics, NSAIDs, topical medications, and anti-depressants with varying results.
Aside from the use of medication, many PT’s use their manual therapy skills and knowledge of movement to ease all three types of pain, even chronic pain driven by central sensitization.
Manual therapy is specific hands-on techniques that may be used to manipulate or mobilize the skin, bones and soft tissue. All physical therapists have some manual therapy coursework in physical therapy school. Some PT’s pursue additional training after licensure. Manual therapy certification can come from a number of sanctioned physical therapy continuing education companies and organizations, and will often appear as “COMT” (certified orthopedic manual therapist) or “CMT” (certified manual therapist), “CFMT” (certified functional manual therapist) after the professional degree: DPT, MPT, MSPT or PT.
The use of touch to assess and treat is not used exclusively by manual physical therapists, but more expertly. Unlike massage therapists and other hands-on healers, we perform a very thorough interview of the patient as part of the initial evaluation. The remainder of the evaluation is spent observing movement, checking reflexes, and checking active and passive movements of the joints and soft tissues, like muscles, tendons, ligaments and fascia. The exam is a process of ruling in and ruling out possible causes for the pain and movement problem. For the manual physical therapist, the passive exam, with the patient lying comfortably on the treatment table, is particularly informative. The resilience of the joints and tissues, along with other information gained from the exam, informs the manual physical therapist of the physical therapy diagnosis, the prognosis, and the mutually agreed upon goals of physical therapy treatment.
The sense of touch has recently been getting much attention in the scientific and popular press. We are learning more about the way touch, or tactile stimuli, are processed in the central nervous system.
Many of us were taught that touch is sensed at the skin and joints by specialized cells in the skin and joints, called mechanoreceptors and proprioceptors. The message about the type of sensation is rather predictably relayed to the brain by nerve fibers and the message is unaltered. Now, we are finding out more about, not just the way sensation is processed in the periphery, but how touch sensation is perceived and interpreted to have beneficial effects on our health.
In his book, Touch: the Science of Hand, Heart and Mind, neurophysiologist David Linden describes how therapeutic touch can lower heart rate and blood pressure and stimulate “feel good” hormones and neuropeptides to boost our mood. Additionally, he explains how the sensation of touch is altered by the emotional context of the person.
Individual studies have also described the calming effect of touch in infants and its role in cognitive development, and the role of therapeutic touch on decreasing stress-related cortisol levels in widows.
While touch-mediated therapeutic effects do not require the skill and training of a manual physical therapist, we are happy to help our patients with any pain or movement problem. Give us a call today to see how we can help.
