Pain and the

Movement System
Dr. Parth Naik, PT, DPT, CSCS
About Me

● Doctor of Physical Therapy -

University of Maryland School of
Medicine.
● Specialize in sports medicine and
outpatient orthopedics.
● Decade of experience working with
clients around movement education,
strength and conditioning, and
rehabilitation.
What does a Physical Therapist do?

● Physical therapists work in many ● As a physical therapist, the

settings to address the human foremost issue I help patients
movement system. This includes
with is managing, reducing, and
multiple body systems including:
○ The nervous system relieving pain that limits their
○ The musculoskeletal system movement and functioning.
○ The cardiovascular system
○ The pulmonary system and more
Overview

● What is pain? How does our nervous system create the experience of pain?

● What can influence the experience of pain?

● What does pain tell us? What does it not tell us?

● How can we use movement as a tool to change and manage the experience of pain?

*The information presented in this presentation is not intended or implied to be a substitute

for professional medical advice, diagnosis or treatment.
What is pain?

● Pain is an experience generated by

our nervous system
○ Informed by our peripheral nervous
system - the nerves that carry
information regarding our senses from
our sensory receptors
○ Interpreted by our central nervous
system - using information regarding
our present and past experiences
What is pain?
1 Sensory Input 222 Central
Central Processing
Processing
Sensors in the peripheral This sensory information is
nervous system detect relayed to the brain through
information about our nerves and the spinal cord,
environment and body. where is then interpreted by
the brain.
33 Painor
Pain Experience
No Pain
The brain takes current
sensory information, as well
as information regarding past
experiences and future
expectations into account to
decide when and how much
pain is experienced.
What is pain?

1 Sensory Input

We have nerves and sensors throughout the body that provide information to the brain regarding our
senses e.g.:

● Touch and pressure

● Temperature
● Sound
● Light
● Taste
● Nociception*
What is pain?

● While there are no “pain sensors” in the body all ● Nociceptors are a part of an adaptive
of our senses can contribute to the experience alarm system intended to warn us about
of pain. potential danger.
● Nociceptors are special sensors that detect
extreme sensations (known as noxious stimuli)
which are potentially dangerous.
● In a healthy and well regulated system
nociceptors are only activated when a sensation
reaches a high level of intensity, or when a
tissue is releasing inflammatory chemicals.
What is pain?

1 Sensory input

● Once our peripheral nerves have encoded a stimulus, the

information is transmitted to the spinal cord in the form of an
electrical signal.
● This signal is carried up the spinal cord to a region of the brain
called the thalamus.
● The thalamus functions as a relay station where sensory
information is sent to other parts of the brain for processing.
What is pain?

2 Central processing

Our thalamus relays nociceptive

sensory information to multiple areas
of the brain which include the frontal
cortex, parietal lobe, hypothalamus and
hippocampus. These areas are
responsible for integrating the current
experiences with other information in
order to assess possible danger.
What is pain?

2 Central processing

● This information may include:

○ The intensity and location of the nociceptive signal
○ Other sensory information including sounds, visuals, smells, temperature, taste, etc.
○ The current state of the body (physical and emotional)
○ The current setting and location in which a person is present
○ Past experiences with similar signals
○ Beliefs regarding pain, danger and safety (contextual or global)
What is pain?

2 Central processing

● Many factors can play a role in how sensitive our

danger detection system behaves.
○ Biological factors
○ Psychological Factors
○ Social Factors
● The biopsychosocial perspective allows us to
account for non-mechanical factors that influence
pain.
● When trying to understand pain everything is
important!
What is pain?

3 Pain Experience

● With all of this information take into consideration, the brain then decides
whether it believes there is sufficient danger to warrant a pain experience.
● If so, a person will experience pain, intended to motivate them to avoid the
potential harmful stimulus
● If the brain concludes that there is no danger present, it can release chemicals to
downregulate nociceptive signals coming from the peripheral nervous system
effectively minimizing or completely avoiding the experience of pain.
So…what is pain?
● Pain is a subjective experience generated by the brain, which takes into
account (1) present sensory information, (2) information from past
experiences, and (3) predictions and beliefs regarding the future.

● Pain is a multifactorial phenomenon. The brain takes more than just a

physical stimulus into account to decide whether or not we experience pain,
and the same stimulus may generate different responses at different times.

This does not mean it is “made up” or “imagined”. The experience of

pain is very real, however the existence of pain outside of the brain is
not.
Pain is created by the brain, 100% of the time. It does not
exist outside of the brain.

● For example some people experience

pain
Pain in aExperience
body part that no longer exists
e.g. post amputation. A phenomenon
known as “phantom limb pain”.

● If the limb “where pain is felt” no longer

exists, the experience must be generated
elsewhere.

● Treated by focusing on the brain and its

perceptions, rather than treating the
non-existent limb directly.
What is pain trying to tell us?
What does pain tell us?
● Pain is a danger detection system,
which encourages us to create a
protective buffer between
ourselves and potential harm.
● It is our brain’s appraisal of threat
to the body.
What does pain not tell us?
● Pain is not a damage detection
system, it does not tell us how
much damage or danger there
actually is.
Pain as an adaptive alarm system
● Pain does not always equal mechanical damage
or changes,
Pain and physical changes do not always
Experience
result in pain.
“>50% of asymptomatic individuals 30–39 years
of age have [spinal changes]” - Brinjikji et al.
Pain as an adaptive alarm system
● As mentioned before, pain is part of an
adaptive alarm system intended to warn us
about potential danger so we can protect
ourselves.
● Furthermore, the brain is neuroplastic
meaning it the change in response to
experiences and learning.
● Sometimes the learning that occurs is
adaptive, and helps us predict the future
more quickly and accurately.
Pain as an adaptive alarm system
● Sometimes this learning can become maladaptive, when a learned response or
neural pathway no longer reflects an appropriate response to the situation at
hand. An example of this is central sensitization.

● Peripheral sensitization - refers to the increased sensitivity of peripheral nerves

to a stimuli.
○ E.g. a cut in the skin will release chemicals making the area more sensitive to touch, pressure, and
stretching. Usually resolves following healing.

● Central sensitization - refers to increased sensitivity of the brain to all stimuli.

○ In some experiences such as prolonged or repeated pain or trauma, the brain can lower the
threshold required to trigger a pain response from any incoming stimuli.
Pain as an adaptive alarm system
● If pain is a protective alarm system, central sensitization creates a
Pain Experience
situation in which the alarm system is set off too easily.

● The brain has learned to be hypervigilant for any potential threats, and
has become overprotective.
1
1
Pain as an adaptive alarm system

Paindo
So what Experience
we do with a system that has learned to be hypervigilant to
danger?

We recalibrate it to help it understand when it is safe!

Movement as a tool to work with pain

● As pain is a multifactorial experience, the treatment of pain (and

Pain Experience
especially chronic pain) must address its multifactorial nature.
○ Biological factors - tissue health, sleep, nutrition, inflammation, etc.
○ Psychological factors - stress, mental illness, pain beliefs and
expectations, self-efficacy
○ Social factors - community support, access to resources and care,
social messaging

● Movement can function as a tool to address multiple facets of pain,

and be a very powerful tool to recalibrate our system.
Movement as a tool to work with pain
● When pain is present, we tend to
avoid the activities that increase
Pain Experience
our pain.
● When pain persists, or we are
especially concerned about our
pain, we can engage
fear-avoidant behaviors which
can perpetuate our pain.
● Continuing to expose ourselves
to non-painful (or minimally
painful) movements and
activities can keep us from
spiraling into fear-avoidant
behaviors.
Movement as a tool to work with pain
● Graded Exposure Therapy seeks
to address
Pain the fear avoidant
Experience
behaviors associated with
chronic pain by addressing:
○ Pain beliefs
○ Identifying fear and pain
triggering behaviors
○ Planning graded exposure
to physical, social, and
psychological triggers
○ Gradual and progressive
exposure to triggers
Movement as a tool to work with pain
● Loading our body's tissues (e.g. muscles, tendons, ligaments, cartilage, and bones)
inPain
a gradual and progressive manner can increase their strength and resilience.
Experience
● Exposing our nervous system to movements that may currently provoke our pain in
a gradual and progressive manner, can help our brain and body recalibrate its pain
response.
● Continuing to expose ourselves to non painful movement and activities can keep us
from spiraling into fear-avoidant behaviors.
Movement as a tool to work with pain
● If you are dealing with pain that is limiting
Painyou in someway seek help from a qualified
Experience
medical professional:
○ To rule out red flags including injury and
other other illness
○ To provide guidance on finding a safe
starting point
○ To help with progressing your activities
towards your goals
● Professionals to consult first when dealing
with pain:
○ A Physical Therapist
○ Your Primary Care Provider
Movement as a tool to work with pain
● In general, regular physical activity tends to
reduce the risk of chronic pain.
Pain Experience
● Physical activity can have an analgesic effect
through multiple mechanisms:
○ Regular exposure to loading
keeping our “pain detection system”
in check
○ Release of chemicals from the brain
that reduce pain
○ Engaging in social activities
○ Engaging in activities that increase
self-efficacy
○ Engaging in personal meaningful
activities
Movement as a tool to work with pain

● So what kind of movement or exercise is best for you? Well…It depends!

Pain Experience
● There is no single best activity to maintain health and minimize our
pain. Choose something within your current abilities THAT YOU ENJOY.
● Since pain is such a complex phenomenon, each individual is likely to
have a different experience and benefit from different activities.
Movement as a tool to work with pain

● If you are not currently dealing with significant pain, here

Painare
Experience
some basic guidelines to start building a healthy
“movement diet”:
○ Try to do an activity that elevates you heart rate for
about 20-25 minutes a day (150 minutes/week)
○ Try to do an activity that challenges your strength
1-3x/ week for about 20-45 minutes.
○ FIND ACTIVITIES THAT YOU ENJOY!
Closing thoughts

● Pain is a multifactorial experience - it is influenced by much more than

damage to our body. Pain ≠ Damage or injury.
● Pain is part of a warning system that reflects how much danger our brain
perceives.
● If you are experiencing significant pain, seek help from a qualified health
professional such as a physical therapist or physician.
● Regular movement and exercise can be helpful in keeping our pain system
calibrated. Find way to get moving that you enjoy!
 ● Email: DrNaik@NaikPT.com

● “Explain Pain” by David Sheridan Butler and

Contact and G. Lorimer Moseley

further resources:
● Explainpain.org

● TEDxAdelaide - Lorimer Moseley - Why

Things Hurt
 Adams, Leah & Turk, Dennis. (2018). Central sensitization and the biopsychosocial approach to
understanding pain. Journal of Applied Biobehavioral Research. 23. 10.1111/jabr.12125.

Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal
degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-816.
doi:10.3174/ajnr.A4173

Du Y, Liu B, Sun Y, Snetselaar LG, Wallace RB, Bao W. Trends in Adherence to the Physical Activity Guidelines
for Americans for Aerobic Activity and Time Spent on Sedentary Behavior Among US Adults, 2007 to 2016.
JAMA Netw Open. 2019;2(7):e197597. doi:10.1001/jamanetworkopen.2019.7597

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