“I would like to make a plea. A plea to stop framing pain as the enemy, a thing to be battled, defeated, beat, eradicated. A thing not to be tolerated, to be vilified and stamped out. Perhaps our emphasis on pain as evil, pain as punishment, pain as suffering is only serving to make pain worse.” –Joletta Belton
I spend my day talking about pain with patients. In a recent discussion with one of my patients, I was asked how we were going to make her pain go away?
She would have good days followed by days with debilitating flare-ups. Right in that moment it became clear that we needed to reset her expectations. Similar to the quote above, she was vilifying her pain, trying to completely destroy it. It was clear that she did not see pain as a normal part of life. Pain is not always bad. Some days we have muscle soreness that reminds us that we had a successful workout. Labor pains can also be considered healthy, and often times make mothers feel closer to their children. Pain can also warn us of potential harm. Imagine fracturing your leg without experiencing pain. We could risk damaging crucial arteries and nerves if not handled in a timely manner. Notice that I used the word potential harm. Sometimes we are the ones that undeservedly intensify pain because of the following:
- Poor pacing strategies that cause flare-ups (i.e. doing an activity until pain becomes unbearable. Often times followed by long durations of rest. This can become a vicious cycle that causes regular flare-ups).
- Poor coping strategies (catastrophizing, pain related fears and avoidance behaviors).
- Lifestyle choices that worsen pain (poor sleep, sedentary, overweight)
- Lack of knowledge about how our mind and body truly work.
Today’s goal is to continue to increase your knowledge about why and how we experience pain. Knowledge is potential power. We must absorb this information and use it to change our behaviors (pacing, coping strategies, lifestyle choices- see bullets above). Big concepts to consider are:
1. Pain is 100% controlled by the brain. No brain, no pain.
Without the brain there is no pain. This is not to say pain is not real. We all remember a time when our brain did not allow us to experience pain because we were too fixated on an activity. Be it work, a game, or maybe dealing with a life-threating situation. It was not in our brain’s best interest at the time to pay attention to the potential injury. For instance, spraining your ankle while crossing the street may immediately stop you in your tracks. But what if in that instant a bus was coming straight for you?! Would that ankle stop you from getting up to sprint back to the sidewalk? It would not, and I can assure you that pain would be the last thing on your mind.
2. Tissue injury does not always equal pain.
Our bodies experience wear and tear on a daily basis. Lucky for us, we only see what is on the outside. In the cases where we do get to see inside of our body, we freak out (i.e. back MRI’s). More than 50% of asymptomatic 30-39 year olds will have spine pathology present on imaging, including disc bulging, loss of disc height and degenerative changes. In a systematic study that reviewed medical imaging, more than 90% of imaging in people over 60 years old showed degenerative changes of the spine. Clearly we can have “tissue abnormalities” without pain.
Consider a scratch on your leg or a bruise. How many times has a bruise shown up on your arm, but you can’t remember bumping into anything? Technically this is a tissue injury, but we don’t have any pain. This goes back to point number one. In this scenario our brain decided that the tissue injury was not significant enough or we had more important things to worry about.
3. Pain does not always mean tissue injury.
A great story that I love to tell is about a guy that shot a nail through his boot. He immediately had intense pain. In order for the emergency room staff to pull the nail out, the man had to be anesthetized because of his crazy demeanor (totally understandable)! When they X-rayed his foot they found something surprising…the nail never went into his foot, it went between his toes! This is a prime example of how our fears of potential harm can contribute to feelings of pain.
Studies are also starting to show improved outcomes (pain, strength and numbness) in groups of people that watch their disc fragments being removed during micro-discectomy surgeries compared to people that don’t watch. Knowing that the potential problem was actually fixed just makes us feel better. It is like watching your mechanic actually replace your oil filter instead of taking his word for it.
We must accept the fact that our emotional pain is strongly tied in with physical pain.
The analogy I am about to use was something I heard from a brilliant physiotherapist named Adriaan Louw (some pieces I have modified or added to):
Pain is like a lion. It is there from day one when we come out of the womb. The lion (pain) is made up of numerous life stressors. As we age the lion often times grows because of the increase in the number of life stressors we have. Stressors like: bills, family issues, work deadlines, being hangry, lack of sleep, being cold, fears… you name it. Our pain can dramatically increase in intensity on any given day or in any situation if the lion gets too large. Stress, worries and fears all cause the lion to become bigger and bigger.
If the lion gets too big it can consume a great deal of our energy, making us feel fatigued with tasks that used to be a breeze. Behaviors like muscle guarding with movement and protective movement eat away at our body’s energy. Worrying, catastrophizing, fear, and depression can also eat away at our brain’s energy.
This is why we must tame the lion or better yet, turn it into a cub again. If we can reduce our life stressors, change our beliefs about pain and increase our knowledge of the body we can reduce feelings of pain.
- The brain uses pain to alert us of potential problems, sometimes based on fears and worry related to misinformed beliefs.
- Pain is controlled by the brain. Your thoughts, behaviors and knowledge all help minimize your pain experience.
- Pain does not always equal tissue damage. Tissue damage does not always equal pain.
- Pain is not something to be defeated; it is something that needs to be tamed. Just like our friend, the lion. Control stressors to lessen pain.
This post was meant to change your feelings toward pain. It was meant to explain the role of the brain on pain. Pain is normal, constant pain is not. Our false beliefs about pain, life stressors, and less than optimal lifestyle choices have the ability to intensify pain. Continue to learn as much as you can. Knowledge is not power, it is potential power. Understanding these principles and applying them to your daily life will drive long lasting change.
If you stuck with me I suspect you have more questions. Please feel free to comment or message us.
Michael Infantino, DPT
- Moseley GL. Unravelling the barriers to reconceptualisation of the problem in chronic pain: the actual and perceived ability of patients and health professionals to understand the neurophysiology. J Pain. 2003;4(4):184-189.
- Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Archives of physical medicine and rehabilitation. Dec 2011;92(12):2041-2056.
- Van Oosterwijck J, Nijs J, Meeus M, et al. Pain neurophysiology education improves cognitions, pain thresholds, and movement performance in people with chronic whiplash: A pilot study. J Rehabil Res Dev. 2011;48(1):EPub ahead of print
- Moseley GL. Joining forces – combining cognition-targeted motor control training with group or individual pain physiology education: a successful treatment for chronic low back pain. J Man Manip Therap. 2003;11(2):88-94.
- Meeus M, Nijs J. Central sensitization: a biopsychosocial explanation for chronic widespread pain in patients with fibromyalgia and chronic fatigue syndrome. Clin Rheumatol. Apr 2007;26(4):465-473.
- Louw, A. (n.d.). Educational Solution for PT, OT, ATC, SLP. Retrieved March 31, 2017, from https://www.medbridgeeducation.com/course-player/play/5178/
- Butler, David S, and G L. Moseley. Explain Pain. Adelaide: Noigroup Publications, 2003. Print.
- Tait MJ, Levy J, Nowell M, et al. Improved outcome after lumbar microdiscectomy in patients shown their excised disc fragments: a prospective, double blind, randomised, controlled trial. J Neurol Neurosurg Psychiatry. Sep 2009;80(9):1044-1046.