September 28, 2021

 Is it okay to venture into pain (do we poke the bear)?

There is a conservative saying around the physical therapy and fitness professions that goes something along the lines of“if it hurts, don’t do it”. Naturally this makes sense right? The body uses the pain as a protective intervention to decrease the likelihood for further tissue damage doesn't it? This may not always be the case. Pain is a complex, multifactorial experience! Although the intention behind this ideology is good natured, this is not a realistic way to live life. We cannot live in fear of certain movements because the belief is that we are going to increase pain, discomfort, or worse do damage.  We need to be able to work, pick up our children, and engage in recreational activities we love (for our own sanity!). Saying that we should avoid painful movement without a comprehensive understanding of the variables that factor into pain may be missing a great opportunity to educate someone in pain on the complexity of their pain experience. This view is also not very optimistic. It is the job of a good physical therapist to be able to succinctly explain how pain works to patients, and make the case that in certain instances it is okay, and sometimes necessary to push into pain. 

It is important to understand that pain is a multifactorial experience (READ HERE)  and is often  poorly related to tissue damage. This is a perfect time to educate a patient about pain and address any negative beliefs that they have about pain. The way you perceive pain and views your ability to rehabilitate successfully is critical to positive outcomes.  This will certainly take time and trust, but the initial consultation can be a great occassion to lay a foundational understanding.

 So with this being said, when is it OK to poke into pain?

When you are attempting to habituate to painful activity. 

This idea would typically be used in patients with more chronic issues (pain that persists longer than three months). The central nervous system can impact the body in two ways: it can either sensitize the system or habituate the system.  Habituation is the idea of taking a painful activity and slowly working your way into becoming more and more comfortable with it. Think about when you first started weightlifting and built calluses or built calluses when learned to play guitar. Or think about how nervous you were to start your new and how easy and typical that job is now. Not very fun at first, but you built a tolerance to these activities and received and continue to recieve great gratification out of it. This is the same thing with habituation. Let’s find a movement that is meaningful to you that you are currently avoiding and slowly work your back into it to get you back to doing the things that you love. Your brain and body have an amazing ability to adapt and change (called plasticity) and by having an optimistic disposition we can work to decrease sensitivity.

When there are structural findings that correlate with pain, it can still be ok to dip into pain (certain instances!).

This concept is can be used for impairments  such as joint replacements, muscle strains, or tendinopathies. There are some aspects of therapy that may not always be rainbows and butterflies, but that is just fine (especially after reading this article!). Sometimes we need a stimulus to disturb our current homeostatsis in order to adapt and grow. The takeaway from this section is to find a baseline level of tolerance to pain and progressively load ourselves as long as symptoms typically reside over the next couple days. An example of this would be someone who is rehabilitating from a Achilles tendinopathy. Supposed the patient presents to therapy with a mild baseline discomfort of 2/10. The goal of therapy is to utilize exercise for therapeutic purposes with the understanding that going one or two point levels (3-4/10) pain is acceptable and sometimes necessary to do. Understanding when to respect pain and when to poke into pain is a important delineation and will certainly differ from patient to patient. 

It is important to remember that these instances may not be applicable to every case and you should consult a physical therapist to ensure that you are on the right track. Contact us at Portland Physical Therapy for further inquiries at 207-828-4455. 

 Author: Brandon Drinan, PT, DPT, CSCS