Pain is a complex subjective, sensory and emotional experience occurring as a result of damage or potential damage to tissue (skin, ligaments, muscles, bones). Pain is most commonly caused by a specific injury however, in some cases an injury mechanism is absent.

Types of Pain (Simplified)

There are three different types of generalised pain:

Nociceptive Pain

Nociceptive pain occurs when there is damage to a tissue (like burning your finger). This pain can be local or it can be referred (ie. the pain is felt away from where the tissue is damaged). An example of referred pain is, “sciatic” leg pain which is associated with tissue damage in the lower back.

Neurogenic Pain

Neurogenic pain occurs when the nerves behave abnormally by conducting nociceptive pain where there is no apparent tissue damage or pain source.

Psychogenic Pain

Psychogenic pain arises from the mind (such as the memory of a bad past experience).

Nociceptive Pain (Peripheral Pain)

Nociceptors are sensors found in the body which detect the possible threat of injury or actual injury to tissues such as bone, ligaments, skin etc. They then relay this information to the central nervous system (CNS) – spinal cord.

There are two types of nociceptive fibers, C fibers and A delta fibers which respond to different sorts of pain stimulation.

  • A delta fibers carry signals from the body’s periphery (such as the fingers or feet) back to the CNS very quickly and are responsible for the acute pain experienced when a tissue has been injured.
  • C fibers carry signals more slowly from the periphery to the CNS and are responsible for sub-acute/chronic pain.

Sensitisation

When a tissue has been injured, the nociceptive fibers become sensitised. As a result, the nociceptives threshold for activation and subsequently sending pain signals back to the CNS is much lower. For example, following a bump on the head a light touch to the injured area will be painful. In the case of chronic pain, abnormal sensitisation of nociceptors contributes to why pain is easily triggered, why the pain is often disproportionate to the trigger and why pain is felt long after the initial injury stimulus has gone.

Spinal Cord and Brain Involvement

The information carried by the A delta and C fibers is then transmitted back into the CNS where it is processed in a part of the spinal cord called the “dorsal horn”. The dorsal then determines whether the information needs to be relayed up the CNS to a higher brain centre for processing and response. Or, it may determine the response can occur locally from the dorsal horn, called a “spinal reflex response”. An example of this would be the inflammatory reponse following an injury involving muscle spasm and increased blood flow.

Managing Pain

Non-pharmaceutical Interventions

Chiropractic adjustments are postulated to manage spinal pain by affecting the higher brain centre, the nocipetive fibers in the periphery of your body and through the spinal cord reflex response.

Acupuncture or dry needling is another treatment intervention for managing pain. Needling affects pain at the periphery by desensitizing the nociceptive fibers so they are not stimulated as easily, while also triggering a local muscle relaxation response.

Exercise therapy and physical activity is another intervention that is beneficial in the management of pain, including pain associated with musculoskeletal conditions like osteoarthritis and low back pain.

These are all interventions The Shannon Clinic use as a part of our holistic approach to patient care.

Read more about chiropractor Dr Nicholas Shannon. [Click through to About the Shannon Clinic page]

Pharmaceutical Interventions

Pain medication (analgesics) such as paracetamol (Panadol), ibuprofen (Nurofen) and diclofenac (Voltaren) work on desensitising the A delta and C fibers and hence reducing pain at the source (in the periphery). Pain medications which are codeine based (Opioids) like Panadeine work by affecting how the body interprets pain in the higher brain centres (centrally, rather than peripherally).

It is important to remember when taking pain medication that long term use of analgesics can have harmful side effects like gastric ulcers, renal disease and cardiovascular disease. In addition to this there is strong evidence indicating paracetamol and NSAID’s are ineffective in the treatment of low back pain.

Achilles Tendinopathies

Achilles tendon pain is a prevalent condition that is an extremely frustrating and challenging condition to treat for both patient and practitioner. Fortunately there is a strong and ever growing body of evidence that supports the use of heavy tendon load exercises in the treatment of tendinopathies, especially achilles tendinopathies (AT).

In September I published an article in the Chiropractic Australia, COCA News magazine examining AT and what the evidence currently tells us.

Taming Achilles Tendinopathies

To kick the year off, there was an article published in the Annals of Internal Medicine journal on January 3, 2012 that was picked up by the New York Times that looked at the efficacy of spinal manipulation, home exercise and medication on acute and subacute neck pain in the short and long term. So here are the results from that study.

It was a randomised controlled study of 272 people between 18-65 years old. who had non specific neck pain of 2-12 weeks duration.
Those 272 people were then split up randomly into 3 different groups, those being treated with spinal manipulation, those being treated with home exercises and those being treated by medication.
  • Those in the spinal manipulation group received adjustments to the neck and thoracic (middle back) over a 12 week period.
  • Those in the medication group received non-steroidal anti inflammatories as a first line intervention, if these failed or the participate couldn’t tolerate them they were prescribed narcotic drugs and muscle relaxants.
  • Those in the home exercise group received two one hour sessions spread over 2 weeks, one on one and were instructed to perform a certain set of tailored exercises at 5-10 repetitions 6-8 times per day.
The results were as follows:
For pain relief spinal manipulation had a statistically significant advantage over medication at 8, 12, 26 and 52 weeks. By 12 weeks 57% of people reported a 75% reduction in pain and by 52 weeks 53% of people still reported a 75% reduction in pain.
Home exercises were also superior to medication at 26 weeks. By 12 weeks 48% of people reported a 75% reduction in pain.
Only 33% of the medication group had experienced a 75% reduction in pain by 12 weeks, and by 52 weeks only 38% had a 75% reduction in pain.
One concern that did arise out of the study, as commented on by one of the leading authors Dr. Bronfort, “the people in the medication group kept on using a higher amount of medication more frequently throughout the follow-up period, up to a year later.”
If you have acute or subacute non specific neck pain, spinal manipulation and exercises should be part of your first line intervention.
To read the article in full it can be found here Annals

Many millions of people all over the world see there Chiropractor for maintenance or preventive care, where they receive an adjustment or correction every 2, 4, 6, 8 weeks. The length of time is dependent upon the chronicity of their problem and lifestyle. As a Chiropractor we recommend maintenance care because we know it keeps the spine aligned and functioning at its best and as a result patients tend to feel happier, healthier and experience less pain and discomfort.

Unfortunately this area of maintenance care isn’t supported by a wealth of scientific evidence, its grounding is in our experiences as Chiropractors and what we see day-to-day in our clinics. But the Spine Journal in February will be releasing an article which looked at the role of maintenance care in patients who suffered from chronic lower back pain.
This study split 60 patients who had been suffering lower back pain for more than 6 months into 3 groups, one group received 12 sham spinal adjustments over 1 month, the second received 12 spinal adjustments over 1 and no follow up treatment for 9 months and the final group received 12 treatments over 1 month and maintenance adjustments every 2 weeks for 9 months. The results showed those in the second and third groups had significantly reduced pain and disability after 1 month over the first group. But only the third group showed future improvements in pain and disability over the following 9 months, with the second group returning to pretreatment pain and disability levels after the 9 months.
This study is the first stepping stone in supporting what we have long known, that maintenance Chiropractic care is beneficial in reducing patients pain and disability, keeping them happy and healthier. Hopefully be the impetus for future research into maintenance care.