House of Pain: Are We “Jumping Around” Pain?

“Pack it up, pack it in, let me begin…” — House of Pain

By: Austin Sheldon PT, DPT, DSc, Cert. DN, OCS, FAAOMPT

Assistant Clinical Professor at Northern Arizona University

Program Director for the NAIOMT-Messiah University Orthopedic Physical Therapy Residency Program

When House of Pain dropped their 1992 hit “Jump Around,” they weren’t singing about cortical reorganization, central sensitization, or descending inhibitory control. But if you treat people in pain, the title “House of Pain” probably resonates more as a clinic descriptor than a 90s throwback. Welcome to your caseload: the real house of pain. It’s a complex house of pain where a “one size fits all” approach actually doesn’t fit anyone.

Cue the Beat: Pain Is Not Just a Symptom

Despite decades of pain science advances, many clinicians still approach pain like it’s an opening band to the headliner. We may listen a little bit and pick up on a dope beat here and there but we’re still waiting for the headliner. We’ve all heard this, seen it, and maybe even said it to ourselves and to others: “Patients come to physical therapy because they can’t do something, and pain is keeping them from doing that something. Maybe you’ve heard “focus on function, and the pain will take care of itself” or “increase the dosage of the exercises you’re prescribing” or any variant of the above. I don’t think those sentiments are necessarily misguided or even wrong, but I do think it may reflect our own profession’s discomfort with uncertainty and all the “gray” in the science behind pain. Pain isn’t just a byproduct of injury or dysfunction. It’s a complex experience, produced by the brain, influenced by biology, psychology, and social context. Pain is EMBODIED¹. We know now:

Nociception (the detection of tissue damage) is not the same as pain².
Pain can exist without injury, and injury can exist without pain².
The nervous system can become hyper-responsive, a process called central sensitization, where normal input starts producing abnormal output³.

Your patient with chronic low back pain? Their lumbar MRI might show disc bulges, but what they’re feeling could be the result of a sensitized nervous system, altered cortical maps, fear, and catastrophizing, not just tissue pathology (and perhaps after any tissue pathology has resolved).

Pain is Brain: Neurobiology in the Mix

Here’s where it gets real funky:

Neuroplasticity can be a double-edged sword. Yes, the nervous system can adapt but, in pain states, it often adapts in unhelpful ways (think: smudged somatosensory maps, motor inhibition, and maladaptive movement patterns)^4,5,6,7.
Descending modulation matters. The brain can dial pain up or down based on mood, attention, beliefs, sleep, past experiences, and social context⁸.
Pain is protective until it becomes maladaptive. It’s not always about fixing tissue – it’s often about retraining perception⁹.

Emerging research shows that interventions like graded motor imagery, pain neuroscience education (PNE), and cognitive behavioral strategies can help rewire the brain’s response to pain. But we’re still figuring out how to tailor these tools to individual patients^{10, 11, 12}. This is where clinical artistry meets science.

Clinical Jam Session: Challenges for PTs in the House of Pain

Treating patients in pain can be frustrating. You might hear:

“But my MRI says I have three herniated discs…”
- I listen to patients say this weekly, if not daily. Look at this situation as an opportunity to educate the patient on his/her/their level if the patient is willing to listen. A gentle “nudge to lessen the smudge….”
“I’ve tried everything. Nothing works.”
- Here’s another quote. Again, walk this statement back a bit with the patient in front of you. What is “everything?” “How long did you try x, y, z,?” “What are your expectations for “x, y, z” intervention?
“If I move, I’ll make it worse.”
- This is a great opportunity to explore movements relevant to the patient in front of you. Exploring graded movements, communicating with the patient all the while, and coming alongside their experience as a supportive coach rather than a paternalistic “fixer of things” may surprise you both.

Welcome to the biopsychosocial conundrum.

Here are common challenges physical therapists face:

Over-medicalized beliefs that reinforce a purely biomechanical view of pain¹³.
Time constraints that limit deep education or reassurance.
- What are some things you can do to create patient education handouts to help reinforce what you do with the patients in the clinic? Can you have your patients use a pain journal? Are there apps you can instruct your patient to do? Are there interprofessional relationships you can cultivate and curate? Don’t be afraid to ask for help from other healthcare professionals.
Pressure to produce quick results, even for problems that took years to develop.
- Maybe you share the same frustration with this scenario: “A four-week trial of physical therapy….before an MRI is approved…..for a pain condition that has persisted for years…..” Yeah….that’ll do the trick {insert your “favorite” insurer here]
Burnout, from seeing patient after patient trapped in cycles of suffering.

To counter these, PTs need to embrace and step into roles as educators, movement coaches, and pain science translators more fully. We also need to check our own biases, practice patterns, and frankly, ego. A dualistic approach has gotten us in the predicament we are in.

Remix the Message

So, how do we help patients jump out of the house of pain?

Validate the experience – pain is always real, even if its source is complex¹⁴.
Shift the narrative – from damage to danger (or potential danger), from fragility to resilience¹⁵.
Move meaningfully – graded exposure, not graded fear. Say “NO!” to nocebo!
Build alliance – the therapeutic relationship itself is analgesic¹⁶.

And maybe, just maybe, we remind them that healing doesn’t have to be serious all the time. A little laughter, some music, and a solid hip hinge (only after two weeks of plinth-based exercises and very specific manual therapy…..kidding, seriously though) can go a long way.

“I came to get down, I came to get down… So get out your seat and jump around!”
— House of Pain (and your nervous system’s descending inhibitory pathways)

P.S: The next blog post by Austin will explore sub-acute pain.

References

1) Tabor, Abby, Edmund Keogh, and Christopher Eccleston. “Embodied pain—negotiating the boundaries of possible action.” Pain 158.6 (2017): 1007-1011.

2) Moseley, G. Lorimer. “Reconceptualising pain according to modern pain science.” Physical therapy reviews 12.3 (2007): 169-178.

3) Woolf, Clifford J. “Evidence for a central component of post-injury pain hypersensitivity.” Nature 306.5944 (1983): 686-688.

4) Melzack, Ronald, et al. “Central neuroplasticity and pathological pain.” Annals of the New York Academy of Sciences 933.1 (2001): 157-174.

5) Tsao H, Danneels LA, Hodges PW. ISSLS prize winner: smudging the motor brain in young adults with recurrent low back pain. Spine. (2011) 36:1721–7. doi: 10.1097/BRS.0b013e31821c4267

6) Hodges, Paul W. “Pain and motor control: from the laboratory to rehabilitation.” Journal of Electromyography and Kinesiology 21.2 (2011): 220-228.

7) O’Sullivan, Peter. “Diagnosis and classification of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism.” Manual therapy 10.4 (2005): 242-255.

8) Gebhart, G. F. “Descending modulation of pain.” Neuroscience & Biobehavioral Reviews 27.8 (2004): 729-737.

9) Wiech, Katja, Markus Ploner, and Irene Tracey. “Neurocognitive aspects of pain perception.” Trends in cognitive sciences 12.8 (2008): 306-313.

10) Moseley, G. Lorimer. “Graded motor imagery is effective for long-standing complex regional pain syndrome: a randomised controlled trial.” Pain 108.1-2 (2004): 192-198.

11) Louw, Adriaan, et al. “The efficacy of pain neuroscience education on musculoskeletal pain: a systematic review of the literature.” Physiotherapy theory and practice 32.5 (2016): 332-355.

12) Turner, Judith A., Susan Holtzman, and Lloyd Mancl. “Mediators, moderators, and predictors of therapeutic change in cognitive–behavioral therapy for chronic pain.” Pain 127.3 (2007): 276-286.

13) Quintner, John L., et al. “Pain medicine and its models: helping or hindering?.” Pain Medicine 9.7 (2008): 824-834.

14) Edmond, Sara N., and Francis J. Keefe. “Validating pain communication: current state of the science.” Pain 156.2 (2015): 215-219.

15) Louw, Adriaan, et al. “Know pain, know gain? A perspective on pain neuroscience education in physical therapy.” journal of orthopaedic & sports physical therapy 46.3 (2016): 131-134.

16) Ferreira, Paulo H., et al. “The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain.” Physical therapy 93.4 (2013): 470-478.