Research shows that certain parts of the nervous system control how you feel pain by acting like the volume control on a stereo. Many factors can turn the ‘pain volume’ up or down, which influences the pain you feel. If you have long-term pain, your pain volume can be turned up too high for too long, long after known tissue healing time has passed.
A heightened pain response usually results in avoidance of provocative activities and movements. Unfortunately, this often results in a vicious, debilitating cycle of pain-inactivity-pain. Over time, avoidance of certain movements and activities leads to a loss of tissue tolerance (TT) (meaning a reduction in soft tissue strength, endurance and flexibility; this is also termed deconditioning). This is demonstrated in the diagram below (click to enlarge). It also results in a lower ‘protect by pain’ (PBP) threshold, meaning your body will produce pain at lower levels of activity compared to pre-injury.
The combination of lowered tissue tolerance and protect by pain threshold can make returning to pre-injury capacity very challenging, and is often a frustrating experience. However, research has shown that slowly reintroducing aggravating movements and activities is an essential part of turning the pain volume down. Importantly, it is a fundamental step in regaining the meaningful things in life. The key is using a strategy called ‘pacing’.
To start the pacing process, make a list of things you have been avoiding or would like to start doing again, then choose one or two of these. The key is to start very small and stay below the flare up line (see diagram above). Because your pain volume is turned up, you can expect to work into some discomfort. This is a normal and expected part of the process and is different from a full blown flare up, which is debilitating pain that lasts for days, or even weeks. Over time, your discomfort will decrease as your protect by pain threshold increases. This is when you can choose to increase either the duration or intensity of your activity. By systematically increasing every 1-2 weeks, your tissue tolerance will improve (muscles will get stronger and more fatigue resistant) and your pain volume will decrease, meaning you can do more for longer without an increase in pain.
Your Physiotherapist or Accredited Exercise Physiologist can help you through this process. Your therapist can assist in all aspects of your physical rehabilitation and will work with you to achieve your unique goals. Importantly, they will help you become more active without using your painful area. Exercise is a powerful tool to improve your health and lifestyle. In association with a pacing plan, exercise can help to turn the pain volume down naturally.