Pain. Reading the word alone probably makes you wince a little. We all understand it to be rather unpleasant, something one wishes was fleeting, yet we do need it to make sense of our surroundings and ultimately survive. What I am hoping to shed some light on in this story is that we have all believed some fables about what pain actually is and that having a more evolved understanding about pain, makes it less ‘pain’ full. We just have to be more open to different and changing ideas, just as people did when Christopher Columbus said the world was flat…and we all know how that turned out. It’s time to get a little philosophical about pain.
For those reading this who are manual therapists, you may already be familiar with the some of the top experts in the pain field: Lorimer Moseley, David Butler and Louis Gifford. Their work has been pivotal in revolutionising the way the general public and clinicians think about and understand pain. They believe that pain is a cleverly concocted illusion produced by the master illusionist, the brain, in order to protect us from further harm. We have all experienced deception by brains in very vivid ways. If you ever dreamt you were falling from a height only to land in your bed, you know what I mean.
You’re probably thinking, “but the pain I have felt and do feel is very real. I know I have felt or feel it.” This is true. The pain you feel is very real to YOU but the explanation of why you feel pain is not as straightforward as it seems. Not all things produce pain and things that one would assume would be painful, are not always. I still find this a challenging concept for patients to grasp, but it has more to do with their expectations of what they have sustained and what they need to relieve their pain.
It was Descartes who first proposed this notion about the specificity of pain - that pain was a sensation, transmitted from the periphery to the brain, and whose intensity was determined by the size of the injury. Anyone who has had a paper cut knows this actually feels like someone cut your whole finger off, while the evidence remaining is a reddish/pink line, only the width of a hair strand.
Structural models of pathology suggesting that pain is a result of what is going on in your tissues have been accepted by both the general public and clinicians, even today, to describe why one has pain. You may have heard that you have pain in your foot because of collapsed arches that then cause knee pain and so on. Or you may have heard you have lower back pain because of a ‘slipped’ disc. The problem is many tissues get the blame for causing pain. Let’s take a closer look at the physiology to show it is not as simple as that.
What’s going on? Pain is not equal to injury
Our bodies are designed to feel things through very sensitive structures in our skin called receptors. These receptors are the ends of sensory neurons that relay all information from our external environment to our central nervous system (brain and spinal cord). Our brain looks at that information and decides what the best and most appropriate response should be in order to help us. Information that is noxious (potentially harmful) is transmitted by our sensory neurons through a process called nociception.
Believe it or not, nociception may or may not result in pain but it does however result in tissue damage/injury. It’s your brain that decides whether you feel pain 100% of the time, without exception. This may be difficult to accept at first because we want to believe the pain in our limb, back or neck is exactly in that place, but it actually resides in our brain in the virtual map of our bodies that lies along our sensory cortex in a figure called the sensory homunculus. Again, this is not to say that it isn’t a real feeling, just that it is unpredictable.
We have many systems in our bodies that are utilised, akin to having our own personal army, navy airforce and marines to carry out the brain’s chosen response. Our autonomic, endocrine, circulatory, and immune systems are all intimately related to our central nervous system and are triggered to release chemical messengers (hormones or cytokines) that will carry the brain’s message. For example, that message could be to turn down the stimulus so that a person can complete a race despite having a sprained ankle, or a wounded soldier can run off the battlefield despite being shot. They may not even feel pain at all.
Pain, it’s more than a feeling
Pain has many influences on it and influences many things in turn. How many times have you noticed that things hurt when you are more stressed, angry, or just having one of those bad days? Moreover, the loss of a loved one can make you feel like you are in pain that literally takes control of your life and ability to function. This is because pain is an experience and cannot be separated from the person’s mental state, cultural background, environment, past experiences and all other nuances that make you who you are. Pain is unique, just like you.
Other highly influential factors are anxiety / fears about, attention to and social context of the pain. How many of your have felt like an injury will prevent you from continuing in your career? These factors can be so critical that they can actually cause the brain to trigger or abolish the experience of pain independent of what is going on in your tissues. This last remark is more apparent in persistent (chronic pain) states, where pain outlasts the normal tissue healing process, is disproportionate to the injury or is there without any obvious sign of tissue damage. The persistent pain state is known as central sensitisation, and while it occurs in acute pain, it is the cause of all of the problems with persistent pain. We are all sufferers if we’ve had any injury lasting longer than a few weeks. This is where the master illusionist is really at work, making non-painful things painful and increasing pain sensitivity (allodynia and hyperalgesia). It’s like being stuck in a funhouse and never coming out. Not so fun anymore.
Yes, your thoughts alone can be triggers for pain, even without obvious injury. The glue holding these factors together is our evaluative context of the stimulus. What does it mean to us? When the brain decides the stimulus is threatening, in light of the aforementioned inputs, we will feel pain more or less intensely. I have seen people come in for that ‘tune up’ before an event because they suddenly have that all too familiar niggle.
So one person’s pain is another one’s pleasure and vice versa. For the sadomasochists out there, this may ring some bells or crack some whips.
Knowledge is power!
Okay so what? Why bother writing about this at all? Even after completing a Masters in pain science and working with so many different bodies over the last 15 years, either in pain or rehabilitating them from minor or debilitating injuries, I find myself sometimes falling into old schools of thought with my own injuries. Changing ideas or beliefs is not something that happens overnight and part of my duty is to educate my patients and anyone who can benefit, and that is everyone.
Pain is something we can all relate to. We have all been in it for the short or long haul, maybe you are in it now, reading this. Everyone is talking about it; films illustrate all forms of pain or loss; TV adverts discuss numerous quick fix aids; songs, poems, and books try to capture the exact feeling of pain in an effort to help us know that someone understands. It is something that can make you desperate to try anything to relieve it - most of us have had some sort of pain for months or years. Pain is certainly a hot topic, if not THE hot topic.
Research has shown that education and understanding about one’s pain works better than just manual treatment or any pain aid alone, and that even goes for surgery. Furthermore, knowing the brain is affected by all of these different inputs shows there is greater scope for creativity in finding what can decrease the implicit threat and therefore one’s pain. It also gives you more control in a situation where you feel completely vulnerable and defenceless.
The brain is plastic
One’s beliefs and expectations about what will help them are also key in managing pain, so stick to what you know and feel comfortable with. You be the judge. If a movement hurts, try and understand why it does and if more movement is a good thing. Sometimes after performing the movement you don’t have the pain anymore. This is because the brain is malleable like plastic. It can be taken out of a sensitised state and new non-painful neural connections can be made even stronger. Professional athletes often hit their personal best after recovering from an injury.
Graded exercise, manual therapy, acupuncture, massage, psychological help and even surgery and painkillers have all been shown to have placebo analgesia, but more improbably they are all forms of empowerment. Just because something has a placebo effect does not mean it is less effective. The mind is truly a powerful thing. You can change your pain just by changing your attitude and thoughts about it.
Through adequate understanding of the biology of injury (tissue healing and the physiology of pain), you already have a great arsenal of information to help manage your expectations, beliefs, and ultimately pain experience. So, understand that pain does not always signal more damage. It is there to cue us to the potential of threat. The point is to prevent persistent pain from taking over your life and prevent you doing what you love to do by training your brain not to fear movement and to understand that it’s not threatening. By removing the fear, you will remove the threat and ultimately the pain.
About Deirdre Nazareth
Deirdre is one of only 13 practitioners in the UK to have completed her functional medicine training to become a fully certified Functional Medicine (IFM) practitioner.
Deirdre’s career path in health and wellness started in NYC where she worked in the Department of Human Genetics at Mount Sinai Hospital as a research assistant. She simultaneously worked as a personal trainer at the exclusive Crunch Fitness Gym with people of all ages and experience, including celebrities. She was certified though NASM and being one of the top trainers there, was awarded several opportunities on television as a result. She moved to London and completed her osteopathic degree at The British College of Osteopathic Medicine and shortly after completed her masters in pain neuroscience at the prestigious King’s College London. She has also completed the health coaching course through the Institute of Integrative Nutrition and courses in Acupuncture and cranial osteopathy.
She treats many chronic musculoskeletal and visceral issues with osteopathic medicine in patients of all ages while integrating her knowledge about pain and neuroscience in her treatments to educate patients about their pain. Furthermore, she utilises the functional medicine approach learned in her certification with IFM to provide a truly wholistic lens through which she treats autoimmune conditions and other chronic complex diseases that stem from gut dysfunction. She continues to attend courses to further her osteopathic, pain and functional medicine knowledge. She is currently building a virtual practice which allows her to treat patients globally from Brunei, NYC, Argentina, California, Lebanon and all over the UK.