‘An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage’, and is expanded upon by the addition of six key Notes and the etymology of the word pain for further valuable context.

• Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.
• Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.
• Through their life experiences, individuals learn the concept of pain.
• A person’s report of an experience as pain should be respected.
• Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being.
• Verbal description is only one of several behaviours to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.’

Pain is a Protection Response

Pain helps keep us safe, it’s a response to actual and potential damage.  It’s part of our survival system (fight-flight system), our brains are wired to detect threat and keep us safe from harm, its part of our evolution.  Our brain creates pain from its best guess to predict what is needed, using all the information it has available (eg current sensory feedback, previous experiences, beliefs and expectations), and if protection is deemed as needed we experience pain.  This all happens really quickly!  Pain is contributed to by the whole person and their world, not one body area, it is a whole person experience.

So, it is understood that pain is part of our threat system, it is there to protect us and keep us safe.  What does pain do?  It changes our behaviour, how we move, how we think and how we interact with our world.  These things are important as they can be part of the suffering or part of living well with pain.  Having awareness and understanding of these things helps us create some balance and make changes.  Awareness of what is happening within the whole of you in relation to your world is important in making changes, seeing the possibilities within what you once thought was impossible, and learning to live well with pain whilst it changes in the background.

Sometimes our nervous system gets a little too good at protecting us, creating a pain response when there isn’t really any danger, this is believed to be the case in persistent pain.  Part of changing, and living well with pain, is providing our nervous system credible evidence of safety through experience.  This needs daily practice.

Overprotective systems doesn’t mean that we can think ourselves out of having pain, it doesn’t work like that!  Although cognitive factors and mindset are important in making changes.  Nor does it mean we can ignore things and push on through to get things done, this commonly turns up the pain volume and increases sensitivity to certain stimuli associated with pain, for example: certain movements, standing or sitting still, certain activities can all be associated with suffering.  Responses to all of these things vary depending on the context, previous experiences, and what evidence your brain has of safety.

Anything that ramps up the threat system has potential to turn the pain volume up, this includes: worry, rumination, self-criticism, guilt, anxiety stress, lack of sleep, how we see pain, how we see ourselves (for example, people commonly lose trust & confidence in their body and consequently in themselves), and feeling there is a lack of support or understanding from others.  Understanding what’s activating our threat system and what helps balance this (soothing system activities) are helpful in modulating things and living well.

Have you ever noticed what happens when your threat system is stimulated?  What happens when pain increases or when you are expecting it to increase?  Commonly there are breathing changes, people hold their breath and there is excess tension in the body.  I know I have done this, have you?  When we are aware of our responses and how we are embodying pain we create the most opportunities for making changes.

Pain is Weird

Can you imagine life not being able to feel pain?  This may seem appealing at first glance and yet is isn’t!  This is the reality for a small percentage of people who have a rare congenital insensitivity where they can’t feel physical pain, not even a low level discomfort.  This makes life very challenging and only a few people with this condition reach adulthood, as their assessment of potential risks is affected and they don’t get any early warning signals that something is potentially dangerous.  Imagine not knowing your hand is on something hot and the consequences of leaving your hand on it, burns are one of many risks for these people.  When pain persists we know that the early warning signal goes off too much & too early, when it’s not really needed.  It’s a bit like a brake light sensory reacting to a leaf or when there’s nothing there.

We now know that pain is often a poor reflector of what is going on in the tissues, you can have lots of tissue damage and no pain, or no damage and pain.  This is a famous story that was written up in the British Medical Journal, picture this, a builder jumps off a ladder as he was coming down it, he had a lot of work to get done.  He saw a nail heading for his foot, the nail went through his boot (note your reaction to reading this), he is screaming in agony.

He is taken to hospital and had to be sedated due to the level of pain.  The boot was removed and it was found that the nail had gone through his boot and in-between his toes.  No tissue injury and lots of pain, amazing isn’t it.  What he visually saw during the jump will most likely have ramped up the threat and potential danger messages which were interpreted as danger, the brain deemed protection was needed.  Did you notice a reaction as you read the first sentence where the nail went through the boot, if so what? Maybe it was a hold of your breath, a gasp, or a visceral reaction, maybe you didn’t have a reaction.  It is amazing that we can have a physiological response to reading a few words isn’t it.

Another example of a lot of pain and no tissue damage is phantom limb pain.  For example, have you heard of someone having pain in their toes when their foot has been amputated.  Isn’t our body and brain amazing.

On the flip side of this there have been many reports of people sustaining serious injuries and not having pain, including soldiers losing limbs and not needing medication.  The understanding of the latter being the soldiers were returning home which decreased the threat.

Changes in structure of the body do not necessarily mean there will be pain, suffering, or loss of function.  Think of Usain Bolt, he is the fastest man on earth, he has scoliosis and he isn’t slowed down by this and doesn’t suffer with pain.    Changes in structure don’t necessarily equal pain.  One big myth is associated with changes on MRI scans, we know that pain is poorly correlated with things like disc bulges and disc degeneration which are normal age related changes which are found in a high percentage of people.

Vicious Cycles in Pain

It is important to build awareness of the cycles we get stuck in to be able to make changes.  These are two common vicious cycles:

• Pain decreases someone’s sleep which increases the sensitivity to stimuli and turns up the pain volume. Lack of sleep affects stress levels and this turns up the pain volume too.  When we are stressed we sleep less well and so it goes on until we learn what can help.  Can you relate to this?
• Each time an activity is done and the pain is worse, it becomes linked to causing pain and expectations of this experience.  Gradually people commonly stop doing the activity.  This commonly affects their mood as they are no longer doing what is meaningful to them, this also increases the suffering.  Other things happen as consequences of doing less and less, including fitness decreases which means the tissues tolerate less load, as well as being sensitive (reacting to stimuli more quickly).

Why does Understanding Pain Matter?

It helps us to understand how we can live well with pain whilst it changes in the background.  Understanding pain helps us to understand a number of things including:

• Pain is a protection mechanism that is contributed to by many things and doesn’t necessarily reflect what is going on in the tissues.  Hurt does not necessarily equal harm
• Systems are always adapting and we can influence this, one part of this is calming systems down
• When pain persists we know messages are more easily sent to the brain from the body and the brain gets really good at providing protection.
• We can see how avoiding activities, or pushing on through ignoring pain to get things done, are both unhelpful.
• Our brains predict what’s needed, when protection is deemed to be needed we experience pain.  This is contributed to by many things including: how MRI scans have been explained, previous experiences, how we are engaging in activities and our whole life, sleep and stress.
• It helps us see things can change, even if pain doesn’t fully go away, and that we can learn to live well whilst pain changes in the background.

(Image adapted from Nivens, Shutterstock)

I help people make sense of pain neuroscience in relation to themselves in their world as part of exploring how they can live well with pain, whilst pain changes in the background. Understanding this on a cognitive level alone is not helpful as we learn through experiences.   This means it’s important to explore understanding through experiential learning.

Know that the suffering can change, you can live well and have a life full of meaning even if pain comes along too (it’s ok you would rather it didn’t, that’s normal).  This doesn’t mean it won’t go away, it might and does for some, even though for many it doesn’t.  Instead it means being able to fully engage with life whilst pain is in the background rather than putting life on hold and trying to ‘fix’ it.  This generally isn’t helpful and commonly has the opposite affect and increases pain and suffering.

Pain is Always Real & What You Say it is

There is one thing I really want to highlight here and that is that pain is never all in your head, I know some people can be made to feel this.  When people first see me in clinic, or for an appointment online, they are often grateful when they realise that they don’t have to prove what pain they are in and it is exactly what they say it is.  Feeling not believed and like you have to prove your experience of pain stimulates your threat system and can turn up the pain volume.  Pain involves body and mind, these can’t be separated, it is a whole person experience.

Change is Possible

Pain can and does change even if it doesn’t fully go away it doesn’t mean suffering with it.  A number of things are important in changing pain including: understanding pain, awareness of your whole self, self-compassion, acceptance (this isn’t passive and doesn’t mean giving in, it means dropping the struggle, calming the threat system down, being able to be present and enjoy life), physical activity/exercise, sleep, calming the nervous system down, connecting to meaningful activities, and daily practice as part of a way of life.

A mantra at Unity Physiotherapy & Wellbeing  is:

‘Connect to Yourself & Others With Compassion, Calm Your Nervous System, Create a Life Full Of Meaning’

A Few Important Points to Remember:

• Hurt doesn’t necessarily equal harm (pain is a poor reflector of what is happening in the tissues).
• Pain is there to protect us, sometimes our systems get too good at doing this, as is the case with persistent pain.  Calming systems down can help you make changes.
• Understanding pain can help you change pain – ‘know pain all gain.’  Though this is not enough in isolation, we learn through experiences (we can reinforce where we are or make changes through our experiences).
• Pain is always real and it’s a whole person experience.
• Awareness is a foundation for change.

Here are some links that could be helpful:

A patients understanding of persistent pain

http://livingwellpain.net/a-patients-understanding-of-persistent-pain

Our blog page https://www.unityphysio.co.uk/blog/

The post What is Pain? appeared first on Unity Physiotherapy and Wellbeing.

These things are common when struggling with pain and can be changed.  We are going to explore the invisibility of pain and the associated disconnection and isolation a little in this blog.

The invisibility of pain is linked to feeling isolated and disconnected from others, disconnected from ourselves (commonly disconnecting from our body and not trusting/loving our body) and our world in general and not feeling understood.  Isolation can show up in many ways, for example feeling isolated from work colleagues and not understood/or feeling isolated from friends and family, stopping meaningful activates and disengaging from activities & withdrawing. Part of changing pain, healing and thriving needs a number of things including compassionate reconnection to ourselves, learning to trust and love our bodies again, along with reaching out and reconnecting with others.

Something I often say to people is that you can’t tell by looking at someone how they are feeling, this includes how much pain they are in or even whether they are in pain at all.   Yes, things like, people’s facial expressions, body posture, voice tone and behaviour give us an idea how they are, yet we really don’t know and won’t understand unless we ask them and really listen.   When we ask someone how they are the answer we get will depend on a number of things, including their perceptions of whether they will be fully heard and how they will be judged, what’s expected in society & their culture, their previous experiences of sharing how they are really feeling & how safe they feel in the context. Judgement is part of being human and how our brains our wired, judgement can help to keep us safe & can over protect us too.  We need compassion and courage to both share our distress/how we are really feeling and to be able to be fully present and hear what’s being said.

One consequence of the distress of the invisibility of pain, and contributor to it, is stopping engaging in what matters most, disconnecting from others, our values and what’s meaningful.  Many people tell me they have stopped socialising as much as they used to, or altogether as they don’t feel people understand, they feel that they are being negatively judged as they ‘look ok’ and feel like it is expected that they ‘should’ be doing more.  Disconnecting and feeling isolated commonly increases pain and can contribute to further secondary suffering (e.g., anxiety, depression, shame, guilt, isolation, self-criticism).  Certain thoughts are common, including ‘they won’t understand why….maybe I should…I’m not good enough… I am rubbish at pacing as I still can’t…’  These sorts of thoughts are common and part of being human, yet getting hooked in them and their associated feelings is part of the secondary suffering, we can learn to notice these thoughts, step back from them a little & then choose what’s helpful (this is one of the ways that mindfulness & compassion can be helpful).   Becoming hooked in some of the many threat based thoughts, emotions and feelings that go alongside isolation and disconnection, for example, self-criticism, anxiety, guilt frustration and shame are all part of secondary suffering.

Stopping meaningful activities and disconnecting from others increases the perceived need of the nervous system for protection, it makes pain more of a focus & it takes centre stage.  This means that what’s most meaningful (usually connected to our values) is backstage, this in itself increases the pain volume and the secondary suffering.  People also stop or reduce meaningful activities for other reasons like fear of a flare-up, although this is another discussion it’s looped into the isolation & the invisibility of pain too.  Also by doing less & less, when we disconnect & withdraw, we lose tolerance for doing a variety of activities, this creates another cycle in pain.  The great news is one we are aware of the cycles relevant to our experience we can start to change them.

Our human minds are tricky in that they have been wired to protect us, so watching out for things that put our basic needs at risk is a priority that’s happening all the time to a degree and depends on our current context and previous experiences.  This is helpful until the parts of our nervous system that do this end up on hyper-alert, which means for example a feather blowing in the wind towards us could be perceived as something that could be harmful to us, so more like a rock than a light feather.  This happens for many reasons including when we are struggling with pain and have become isolated and disconnected from ourselves and others, combined with our previous experiences.

Belonging is linked to perceptions, expectations and social norms.  Being part of a social group is part of our basic needs, it’s how we have evolved as humans, so it’s perhaps no surprise that when our sense of belonging changes it contributes to our threat system being on hyper-alert.  One consequence being things that previously wouldn’t have been perceived as a risk start to be automatically seen that way and we start to disconnect more from the world, those around us and ourselves.  The irony here is that when our threat system is on hyper-drive our self-critical self, one of the versions of ourselves (we all have multiple selves), commonly shows up more often which also increases threat system sensitivity.  This becomes a vicious cycle until we explore different aspects and learn to stop the cycle.    If you’re interested in learning more about belonging there are various greta resources including Brené Brown’s work.

Pain doesn’t have objectification which is part of what makes it difficult to express, this along with the many myths about pain that exist in society, perceptions of being negatively judged and a decreased sense of belonging are all part of what can contribute to us disconnecting from ourselves and others, going quiet & withdrawing, and feeling isolated.  Lacking objectification makes pain tough to understand and explain to others, yet it is possible with understanding of what helps us to explain pain and also by changing the myths in society and cultivating a compassionate trauma-informed society.

(picture modified from Sergey Nivens Shutterstock)

Invisibility of pain and isolation can contribute to us blaming our bodies/ourselves, although this is a natural reaction over time it contributes to a lack of trust in our body and not liking/loving our body & increased shame.  When we disconnect from our body in a loving way we only see it through the lenses of pain, shame and criticism which increase the pain volume and the secondary suffering.

We could summarise what happens when we feel isolated and have disconnected from ourselves & others and our world in general by remembering that the threat system is on hyper-drive, shame is commonly present, the secondary suffering increases, and we stop engaging in what’s most meaningful in life.   Some of the important points so far:

• We feel like we don’t belong and feel disconnected from others which contributes to self-criticism & pain & causes us to disconnect & withdraw more
• People can be surrounded by others and yet feel alone if they don’t feel people understand
• We feel ‘negatively’ judged by others from our perceptions of what they are thinking, or analysis of things that have been said, previous experiences & beliefs
• Our threat system being on hyper-drive has many consequences & contributes, including when we are lacking a sense of belonging, feeling disconnected/go quiet/withdraw/isolate ourselves
• We disconnect from ourselves and connect in a certain way (commonly through self-criticism), we lose trust in out body/self in general
• We get hooked up in things like self-criticism, guilt, frustration, and anxiety – our threat systems becomes more dominant, the nervous system is dysregulated more often.  These are all part of secondary suffering.

When we become aware of the actions we are taking and understand the feelings and emotions underneath our behaviour in a compassionate way we can see the different choice points and then take different action, wise action (from our compassionate self, alined with relieving suffering & aligned with our values).

What can help?

• Break the stigma and keep talking to others rather than hiding and pushing how we are feeling away.  This takes courage and compassion from those sharing and those listening
• We can keep sharing stories of living with persistent pain to help those living with and without persistent pain to understand pain.  I share stories in clinic every day, it’s what we all relate to and helps us make sense of things
• Creativity can be used to help explain pain to family, friends and healthcare professionals. It can also help the person living with pain understand things more and often helps them to connect some more dots.  Creativity and explaining pain includes metaphors, using stories, and drawing/art
• Changing the myths in society about pain – there are many pain specialist clinicians & patient advocates (people who’ve learnt to change/live well with pain) working to do this
• Reading & sharing evidenced based literature on pain, check out the resources section on the Unity Physiotherapy & Wellbeing website for a list of some resources
• People living with pain can get involved in healthcare conferences, communicating with healthcare professionals on social media, and research, this is already happening
• Self-compassion practices.  These and compassionate mind training/other compassion practices (self-compassion is part of this) are being used more & more in pain management.  Compassion has been shown to help in many ways including decreasing self-criticism, guilt, shame & stress.  It’s also been shown to increase wellbeing in general and it connects us in a supportive way to ourselves and others
• Being aware of our self-talk and which version of ourselves is showing up (for example our compassionate self or our self-critical self) and changing this to be supportive and nurturing
• Creating a sense of safety within the body and around us
• Reconnecting to the body in a way that builds trust & compassion changes many things including that it can improve nervous system regulation & decreases secondary suffering (expressing gratitude/appreciation for our body can help with this, as well as compassion & trust practices).

There are many more practices/strategies that can help.

Remember we can’t judge what someone is going through by what they look like, or how they seem, and only they are experiencing it (there are similarities in people’s experiences of living with persistent pain).  We can do our best to be curious & compassionately understand, walk alongside them and explore helping in some way if that’s what they would like us to do.  We can help to change the invisibility of pain by talking about pain, sharing stories of lived experiences, reading and sharing evidenced based information, and nurturing compassion.  Compassion & curiosity help us turn towards what’s tricky/the distress, to share what feels difficult, to take the action that’s aligned with our values even if there are lots of tricky things that show up (we can overcome the blocks), it helps us stay connected to ourselves and others in a supportive way.  If you’re feeling isolated with pain and/or not understood know that many people have been there and change is possible, including through regulating your nervous system, reconnecting to yourself in a compassionate way and connecting to nature, pets & those around you.  If you are struggling please reach out to someone, this could be a friend, colleague, family member, persistent pain specialist, or other healthcare professional/relevant professional.

The post The Invisibility of Pain, Disconnection & Isolation appeared first on Unity Physiotherapy and Wellbeing.