PHYSICAL THERAPY
Patients often jokingly refer to “PT” as “Pain and Torture” rather than Physical Therapy. While I can appreciate the humor—and try not to take it personally—it actually highlights an important topic in orthopedic care and rehab: pain. If you’ve ever sought orthopedic treatment, you’re likely familiar with one of the first and most frequently asked questions: “How would you rate your pain?” This question may seem straightforward, but it opens the door to a much more complex conversation about what pain really is and how it should be approached and managed during the rehabilitation process.
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Pain: It’s More Than Just Tissue Damage
While it’s natural to think of pain as a straightforward warning signal from the body, research shows that it is not merely a direct reflection of tissue damage. For example, a 2019 study found no correlation between degenerative changes in the lumbar spine observed on MRI and the reported intensity of pain or the ability to predict the presence of neuropathic pain(1). This debunks the idea that pain is simply a direct measure of physical tissue damage and suggests there must be more factors at play that influence how and why we feel pain
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Pain is the result of our brain making sense of sensory information and it plays a powerful role in shaping our perception of pain. External factors such as emotions, stress levels, past experiences, and even beliefs about pain can significantly amplify or diminish what we feel. A study from 2024 found that “emotional state significantly affects the body’s ability to modulate pain. Positive emotions like happiness enhance pain inhibition, while negative emotions such as sadness and anger impair it”(2). Recognizing pain as a complex experience that is influenced by multiple factors allows us to approach rehabilitation with greater confidence and less fear, ultimately leading to more effective pain management and recovery.
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Central Sensitization: When the Pain Alarm Stays On
Pain is not just a straightforward warning signal from the body—it’s a protective response carefully managed by the brain. As Lorimer Moseley, a renowned pain science expert, explains, our nervous system acts as a highly sensitive alarm system, designed to alert us to potential danger. Central sensitization occurs when this alarm system becomes overly sensitive, causing it to go off even after the threat has passed. In other words, the brain continues to amplify pain signals long after the tissues have healed, making even harmless stimuli feel threatening.
To put it simply, it’s like having a smoke alarm that goes off not only for fires but also for burnt toast, or steam from your shower. This phenomenon helps explain why some people experience persistent pain despite no ongoing tissue damage. As Moseley emphasizes, this heightened sensitivity isn’t about tissues being damaged but about the brain’s interpretation of threat based on past experiences, emotions, and beliefs about pain(3,4). Viewing central sensitization in this way helps us adopt a more informed strategy for pain management, moving beyond the outdated ‘no pain, no gain’ mindset."
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When Should You Push vs. Rest?
With all of this new perspective on pain, one of the biggest challenges in rehabilitation becomes even more apparent: how do we know when to push through discomfort and when to rest. Not all pain is bad—mild discomfort during exercise or stretching can indicate that tissues are adapting. However, sharp, lingering, or progressively worsening pain can be a warning sign that you’re doing more than your body is ready for. Finding the right level of intensity is a bit like the story of Goldilocks and the Three Bears: too much is harmful, too little isn’t effective, but just the right amount can support recovery and progress to your goals.
Listening to your body doesn’t mean avoiding all discomfort—it’s about distinguishing between healthy pain and harmful pain. This is where your physical therapist can provide valuable guidance and support and why it is important to communicate openly with your therapist about how you’re feeling throughout the rehab process.
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Reframing Pain in Rehab
Reframing how we think about pain can also lead to better outcomes in rehab. Pain isn’t an enemy to be defeated but rather information to be understood. Below are some effective strategies that have been shown to help better manage pain:
1. Pain Education: You are doing it right now! Understanding why pain occurs can help reduce fear and anxiety, making it feel easier and more within your control to manage.
2. Graded, Progressive Exposure: Gradually increasing movement and load to build tolerance without triggering excessive pain. We want to avoid too much, too soon, too fast.
3. Mindset Shifts: Adopting a positive outlook on recovery can influence pain perception and help break the cycle of fear and avoidance.
A review from the Journal of Orthopaedic & Sports Physical Therapy supports these strategies, showing that patients who understand the nature of pain are more likely to stick to their rehab plans and recover faster(5).
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Conclusion: Embracing a New Mindset on Pain
In the rehab setting, the “Pain and Torture” mentality can hinder the recovery process. Modern pain science shows that pain is a complex and personal experience shaped by much more than just physical injury—requiring a multifaceted approach to treatment as well. By viewing pain as valuable information rather than an obstacle, patients and therapists can work together to make smarter decisions in rehab, prevent chronic issues, and build a stronger, healthier relationship with the body.
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More Resources
This post only scratches the surface of the complexities of pain science. If you found it interesting and want to learn more, here are a few additional resources that I recommend:
1. Pain and Perception: A Closer Look At Why We Hurt by Daniel S. Harvie & G. Lorimer Moseley
Explores the science of pain perception, challenging common misconceptions about pain and offering insights into why we hurt.
2. Explain Pain by David Butler and Lorimer Moseley
A highly accessible book that uses clear language and illustrations to explain the science of pain and how our brains interpret it.
3. Tame the Beast: It’s time to rethink persistent pain – Video by Lorimer Moseley
An engaging YouTube video that explains why persistent pain doesn’t always mean ongoing damage and how understanding pain can empower recovery.
Watch here
4. “Why Things Hurt” – TEDx Talk by Lorimer Moseley
A popular and entertaining TEDx talk that delves into the complexities of pain perception and why pain doesn’t always mean harm.
Watch here
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Sources
1. Vagaska, Eva MDa,b; Litavcova, Alexandra MDc; Srotova, Iva MDa,b,d; Vlckova, Eva PhDa,b,d; Kerkovsky, Milos PhDc; Jarkovsky, Jiri PhDe; Bednarik, Josef PhDa,b,d; Adamova, Blanka PhDa,b,d.
Do lumbar magnetic resonance imaging changes predict neuropathic pain in patients with chronic non-specific low back pain? Medicine, 98(17), e15377, April 2019.
DOI: 10.1097/MD.0000000000015377
2. Lang-Illievich, K., Klivinyi, C., Ranftl, J. et al.
Change in Endogenous Pain Modulation Depending on Emotional States in Healthy Subjects: A Randomized Controlled Trial. Pain Ther, 13, 1287–1298 (2024).
DOI: 10.1007/s40122-024-00642-1
3. Harvie, D. S., & Moseley, G. L.
Pain and Perception: A Closer Look at Why We Hurt. NOI Group (2021).
ISBN: 978-0-6480227-5-6
4. Butler, D. S., & Moseley, G. L. (2013). Explain Pain (2nd ed.). Noigroup Publications. ISBN: 978-0-9727412-2-9
5. Meehan, Karen; Wassinger, Craig; Roy, Jean-Sébastien; and Gisela.
Seven Key Themes in Physical Therapy Advice for Patients Living With Subacromial Shoulder Pain: A Scoping Review. Journal of Orthopaedic & Sports Physical Therapy, 50(6), 285-a12 (2020).
