Physical therapist Kerri Tuttle starts her patients off with a quiz.
Most, she’s found, miss two key questions: Do pain receptors send a pain message to the brain, and does pain come from the brain?
Those familiar with recent pain-brain science breakthroughs know the answers, but newbies are often surprised to learn that the first answer is no, and the second is yes.
Jacob La Shot, a physical therapist with Tucson Medical Center, explains it this way: Pain messaging is like the children’s game of telephone, in which a sentence is whispered, from one child to the next, until the last one says the new version out loud.
Chronic pain is that garbled message.
“Pain is only a decision by the brain to warn you (of an injury), but it can get chronic, warning you all the time,” he said. The message, in other words, keeps getting sent long after the injury should be healed.
Helping patients understand this as part of their physical therapy is a way to help avoid ongoing pain and reduce the need for pain medications.
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Problems with Ashley Shulski’s right knee started in her 20s when an injury — dismissed as a sprain — was actually a slightly torn ligament. In 2014, she re-injured that knee at her gym, and had to have her anterior cruciate ligament, or ACL, replaced with a cadaver ligament.
Last spring, they opened that knee again, this time to repair torn cartilage and clean up scar tissue.
Shulski has been working with Tuttle for some time and says what’s she’s learned about pain has been very helpful, not only personally, but also for her work as a clinical social worker. Shulski helps people who have experienced complex psychological or emotional trauma.
For the people she helps, she said, pain can arise as a response to a threat, or a perceived treat. She thinks of it as “an inner-red flag going up.”
“When (Tuttle) did the pain protocol intervention for me, it was almost mind-blowing because of the work I do in mental health,” she said, “and knowing how people can become dependent or reliant on opioids.”
What’s the connection?
Over time, and as life has become more modernized, people have moved beyond primitive states of fear and escaping danger — say being chased by a lion or bear — to dealing with modern-day stress. Modern times have brought about many “maladaptive, unhelpful adaptations,” said Tally M. Largent-Milnes, an assistant professor with the University of Arizona’s Department of Pharmacology.
By studying this, experts are finding there can be a clear connection between emotional pain and body pain, she said. Furthermore, some people wind up using opioids to self-medicate for emotional pain.
Emotional and psychological trauma “is one of the number one predictors of chronic pain,” Largent-Mills said. “That really drives home the fact that these are not separate systems.”
Ineffective, unnecessary treatment
There is now greater understanding that physical pain can occur for psychological reasons, leading to changes in a person’s nervous system. This pain could be the result of traumatic emotional or psychological experiences, such as childhood abuse or neglect, according to Dr. Bennet Davis, director of Sierra Tucson’s Pain Recovery Program.
Davis, who could not be reached for an interview for this story, has written extensively on this topic.
Medical care for people with pain has been “wrought with ineffective and unnecessary treatment, including the misuse of opioids, largely because we do not have an accurate conceptualization of pain,” he wrote in the Journal of Family Practice.
Brain science now extends beyond sprains and fractures, burns and bruises, beyond what’s called neuropathic pain.
Kerri Tuttle, physical therapist, left, holds up a flashcard towards Marcy Mudd, during an appointment at Athletico Physical Therapy, 3234 E Speedway Blvd on June 15.
Typically, Davis wrote, doctors have been taught to think of pain as the result of an injury, and “assume that emotional factors merely modify how the physical damage is perceived.”
The problem is that seeing pain this way is incomplete, he wrote, and can lead to misdiagnosis about the cause of the pain, unnecessary treatments, and missed opportunities to help.
Only one body
Pain, when it’s doing what it should, is the body’s way of bringing attention to an injury so it will heal faster. This primal need started so a person would no longer be in danger because of limited mobility: In other words, pain is there to bring attention to an injury.
Problems arise when a person’s nerves become extra sensitive to that danger signal, Tuttle said.
One of the newest ways to help is what Tuttle and her colleagues now employ: pain neuroscience education. In basic terms, she said, it’s about using education to help with desensitizing the brain’s neural pathways over time and, thereby, reduce pain.
Athletico is partnering with the SAFE Project — which stands for Stop the Addiction Fatality Epidemic — to offer patients access to this approach.
One of the least helpful areas of the brain that gets lit up when pain messages get garbled are fear signals, said TMC’s La Shot.
That’s when cognitive behavioral therapy might help, he said. Over time, a person caught in the fear loop can disrupt the patterns, and also then start slowly reintroducing movement in areas that have previously felt very painful.
Other things that sometimes hinder progress include lack of exercise, poor sleep patterns, and unhealthy diets. Addressing these things, he said, can help a person “turn down the nervous system.”
Taking care of one’s body should be as normal as taking care of one’s teeth, said Brian Zukowski, regional director of Athletico Physical Therapy.
“Just like they have only one set of teeth, they have only one body,” he said of patients. To take it one step further, the more people can understand their brain’s signals, and their brain’s responses to those signals, he said, the less frightening it is when pain arises.
“Understanding why we feel a certain way, why we have pain, and what we can do about it, helps to diminish the fear.”
Another change: It used to be that when something hurt, he said, the way to help was to not move it.
That’s generally not the approach anymore. Instead, the therapists remind their patients, “Motion is lotion.”
“People with back pain were told to just lie there, don’t move,” he said. “Now we know that moving, just a couple of short walks a day, can make a big difference toward easing that discomfort.”
Get their life back
So, what about those opioid pills and how to use them, either temporarily, or over time?
“If your pain medication takes you from an eight to a four, that’s great,” said Largent-Milnes, with the UA’s pharmacology department. However, she said, people need to have realistic expectations, and not think that a doctor can “prescribe a magic bullet.”
The drugs should be used with close supervision, and ongoing conversations.
“Opioids are great for post-surgical pain,” she said, as an example. “That’s what they were designed for.”
A common misconception is that most people using pain medication become addicted over time, said Dr. Jennifer Schneider, a retired Tucson physician whose specialties included addiction medicine and pain management. She now gives talks in the community, and teaches other prescribers about opioids, pain, and addiction.
“The evidence is that most patients on more than minimal doses of opioids for more than a couple of weeks develop withdrawal symptoms if they stop the drug suddenly,” she wrote in a 2019 publication of the Pima County Medical Society. “This is not addiction, but rather physical dependence.”
Pain medications can be life savers, she said. Patients who are reliable may “get their life back,” be able to function and enjoy life again — and can safely take the drugs, with medical oversight, for years.
“Pain killers have gotten a bad reputation over the years, and I personally know some people who are ashamed they take them,” she said. “The stigma is related to misunderstandings about opioids and addiction. Most people believe that anyone who takes opioids is an ‘addict,’ which is a shameful thing.”
As more scrutiny is given to doctors treating chronic pain with opioids, she said, one thing that’s become more evident: there must be a clear understanding of the person’s relationship to pain, the context and the level.
Schneider said a good starting point for health providers is asking, “What is a day in your life like?”
The Arizona State Museum on the University of Arizona campus has a new exhibit that highlights cultural end-of-life practices. "Walking Each Other Home: Cultural Practices at End of Life" will be up until Februrary 2023 and the museum plans an interactive day in November where the community can learn more about the subject.
Executive Director of the Southwest Folkslife Alliance and exhibit curator Leia Maahs talks about the importance to the community while Lisa Falk, head of community engagement, explains the work involved in putting the exhibit together. John Amoroso, executive director of the David and Lura Lovell Foundation, shared the story behind the interactive concepts in the exhibit. The exhibit will be up until Februrary 2023 and the museum plans an interactive day in November where the community can learn more about the exhibit's subject.
Video by Pascal Albright / Arizona Daily Star.
