Firstly, before I embark on attempting to explain even part of a complicated topic like pain, I would to give a quick shout out to the guru’s at noigroup. Noigroup are the creators of several brilliant publications to date that literally ‘Explain Pain’ (this is the title of one of their books). Their books are aimed at anyone including and in between: someone who has stubbed their toe, someone in chronic pain, the semi-interested practitioner and the diligent health professional. If you identify with anything I say in the following paragraphs and series, please don’t hesitate to invest in one of their books, or come into the waiting room where we have a copy of Explain Pain, a coffee and a comfy couch all ready for you!
What is pain?
*If we do not grasp this step, then it is impossible to understand anything more of the narrative.Pain is a feeling, just like being happy, sad or anxious. Pain is normal, and ALL pain is real. #performbetter @pogophysio Click To Tweet
Pain is an output of the brain. Pain is a feeling, just like being happy, sad or anxious. Pain is normal, and ALL pain is real.
Pain is not decided by a single thing such as a message from the body alerting the brain to tissue damage. We know this because people in life threatening situations rarely experience pain, eg most shark attack survivors report feeling a bump or a tear! In this situation the brain has decided that it is not beneficial to feel pain.
In fact, the level of actual damage to tissues in your body is very rarely an accurate representation of how much pain a person experiences.
So what else contributes to pain?
An easier question may be: what doesn’t contribute to pain?
Our brains are constantly evaluating millions of messages from inputs like touch, smell, sight, noise, thoughts and beliefs, social context, mood, life endangering situations and cognitive state. The resultant sum of all inputs equals whether or not our brain believes it is beneficial to feel pain in that moment.
Let’s think like a Stock Broker;
A Stock Broker is always either buying or selling. Our bodies are always either in pain or not in pain. A Stock-Broker does not decide to buy and sell on one small piece of information eg 25deg celsius tomorrow in Brisbane. He must gather all information possible about a stock and then decide whether to buy or sell. Our brains are the same! They gather all of the information they can and then use it to decide whether we should feel pain or not.
A key concept in the understanding pain is changing our terminology. Messages from the body to the brain indicating tissue damage (eg paper cut) should not be referred to as pain messages, rather, they should be called ‘danger’ messages, because as we have learnt, they are only a small part of the whole pain story. Medical imaging for musculoskeletal pain can often lead us down the wrong path. A recent study found that over 60% of people between 30-80 years old who DO NOT have back pain have some form of disc injury (bulge or prolapse) (Jensen et al., 1994).
Inflammation is a very interesting topic!
Inflammation actually helps tissue healing by bringing in blood and nutrients to the area, a recent study found that regular gym goers may gain less muscle when regularly taking anti-inflammatory medication to curb muscle soreness (Schoenfeld, 2012). Inflammation also sensitizes our danger messages. In effect, it places an amplifier over danger messages going to the brain so that the brain will listen more to messages from that part of the body. Danger messages can also be amplified in the brain! Our brains are awesome at learning, and unfortunately, that does not exclude pain. If our brains are making us feel pain for a long time, we can become so good at feeling pain that we no longer need any danger messages to feel pain. The best example of this is phantom limb pain: often people who get amputations after a long standing pain continue to feel their pain in a limb they no longer have!
There are many ways that our bodies amplify or reduce danger messages. These include but are not limited to; thoughts and beliefs, special small nerve interfaces in the spinal cord, hormones and movement. We are also learning more and more every day about the role of stress and hormones in our pain experience. A stressful situation causes a response in our bodies to emit certain hormones. These hormones can turn up the volume of danger messages coming from the body causing you to evaluate a smaller stimulus as painful. So, if one day you stub your toe after winning your Grand Final and a month later you stub your toe walking out of work very stressed, it is very likely your pain experience would be different. After winning your grand final your overall mood will be happier and less likely to warrant pain. However, on the day you are stressed about work you would have more ‘stress related danger message amplifying hormones’ circulating in your body and therefore, the situation is likely to be more painful.
Where does all of this information leave us?
Well, unlike magic tricks and your parents’ underpants drawer, the more you know about pain, the better. Gentle movement is often one of the best ways we can de-sensitize a brain that has become very good at feeling pain. Taking it slow is always a good idea and building up your resistance to exercise is a huge part of long term success.
If you have been in pain for more than 3-6 months, it is likely there is a large component of sensitization, so maybe it is time to begin your journey toward pain enlightenment! And lastly, find practitioners that can educate you about pain and empower your journey!
I hope you find this article interesting, helpful and maybe even inspiring. This article only begins to scratch the surface of pain and I have attempted to keep it as accurate as possible (while being entertaining). Thanks again to Noigroup for their stimulating work.
Featured in the Top 50 Physical Therapy Blog
Butler, D. and Moseley, G. (2015). Explain pain. Adelaide: Noigroup Publications.
Moseley, G. and Butler, D. (2017). Explain pain supercharged. Adelaide: Noigroup Publications.
Jensen, M., Brant-Zawadzki, M., Obuchowski, N., Modic, M., Malkasian, D. and Ross, J. (1994). Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain. New England Journal of Medicine, 331(2), pp.69-73.
Schoenfeld, B. (2012). The Use of Nonsteroidal Anti-Inflammatory Drugs for Exercise-Induced Muscle Damage. Sports Medicine, 42(12), pp.1017-1028.