The International Association for the Study of Pain currently defines pain as:
‘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
Our blog page https://www.unityphysio.co.uk/blog/