I recently participated in two workshops for therapists about understanding pain, particularly long-term (chronic) pain, and how to help people with such pain to improve their situation. The sessions were very intense with a huge amount of information and were led by a local therapist, Hedd Piper, who, although is a chiropractor by training, is moving more towards a cognitive functional therapy approach to pain, alongside his traditional skills.
My ‘one sentence’ summary of the training is: ‘Persistent pain felt in the body is real, but in cases where there is no obvious (remaining) structural or other damage, it is more likely to be a result of a complicated combination of how the brain interprets signals, along with past and current life experiences including stress.’
If you know this already you can probably skip this blog post. If this is new to you, read on!
This more holistic approach to pain (rather than the approach from the 1600s and Descartes onwards) is seen within a bio-psycho-social model (biological, psychological, social), with pain as an output, rather than an input. This approach focuses on the nervous system, and wait for it, the fact that we do not have pain receptors, as such. We have sensory receptors which respond to various things, but they do not detect pain. We have thermoreceptors (temperature), chemoreceptors (chemicals), mechanoreceptors (pressure, stretch) and they are our sensory nerves, and we also have nociceptors and they respond to (perceived) danger or damage. You don’t pull your hand away from the fire because you felt pain, but because the thermoreceptors detected heat and the specialist nociceptor nerves detected danger or the threat of danger, and they sent a message to the brain, and the brain interpreted it and decided that this heat was not good and sent a motor signal back to move the hand (I simplify somewhat…).
In essence nociceptors operate a bit like a smoke detector and alarm system: it detects smoke, it knows this is bad, so it sets off the alarm and you take action. The nociceptors, or noxious (danger) receptors respond to stimuli which are deemed to be a threat to the body. Pain is essentially your body saying you are in danger and you should take action. So you must not ignore pain! It is your body’s protective response mechanism. The brain interprets the nociceptor’s signals and considers previous experiences and other factors to weigh up how dangerous something is, and if it deems it to be dangerous, pain is produced (the alarm goes off) and the body takes protective measures e.g. moving away, grabbing hold of the injured part, stiffening up, freezing etc.
This is a very good system and it works particularly well for acute incidents – the stubbed toe, the hand on the hot pan etc. However, the brain can also set the alarm off when either nothing has gone wrong, or, the alarm might fail to go off. We can experience danger and damage without any nociceptor signals (something bad happened but didn’t hurt), and, we can have signals being sent when there is no nociception (pain felt but there is no danger/damage).
There is a lot to absorb in this 5 minute video and I have watched it several times. I find it helpful to pause it whilst I watch it as I find it goes quite fast! (Also, personally I find the drawings a distraction – listen with your eyes closed if you feel the same!)
Anyway, the main things to note in terms of persistent pain are:
- all pain is produced in the brain
- we do not have ‘pain’ receptions, but ‘damage or danger’ warning receptors, and our brain interprets the messages sent by these nociceptors
- experience of pain can be seen like a volume control dial, and we need to learn ways of turning down the dial, or de-sensitising the body. Or, to continue the smoke detector analogy, sometimes only the merest hint of smoke is enough to set the alarm off – for some reason it has become too sensitive. The body is the same and for some people even seeing a picture of someone bending over to lift a heavy object can make them feel pain in their own lower back – their system is too sensitive.
- the nervous system has a huge role to play in our experience of pain
- managing stress is key to managing pain
- things like massage and deep breathing practices can help de-sensitise the body, reduce the pain volume and calm the nervous system down
- keeping mobile is helpful, especially when the persistent pain is still there long after the tissue damage has healed (generally about 3-6 months for most common injuries). Start with simple and gentle exercise which you can comfortably manage, and this will help you overcome the (subconscious) fear that moving will increase the pain or cause you damage, and you will gain in confidence and then be able to do more.
Worrying about pain in the body is natural, but the problem is that the worrying causes stress and other negative nervous system responses, which then amplify the pain… a vicious circle.
To try to break that circle, we need to find ways to calm the nervous system down. If you suffer from persistent pain that doesn’t have a clear physical reason (i.e. I’m not talking about if you’ve just stubbed your toe), then try to find ways to relax, do things you enjoy, have a massage, practice deep breathing, play with a dog – basically improve your physical and emotional well-being in any ways you can.
Also review your lifestyle in terms of diet, activity, sleep etc, and aim for more healthy eating, more general activity, and better/more sleep. Not easy if the pain affects how you move and sleep, so take baby steps to change things.
Dealing with stress is also important as this is one of the most common causes of the body feeling vulnerable or under attack, and the ‘fight, flight or freeze’ reaction leads to a variety of processes in the body such as an increase in adrenaline and cortisol, which affect sleep, increase inflammation and affect sensitivity. All these affect how much pain is produced. To simplify, if you live with constant stress your body is likely to operate like the over-sensitive smoke alarm, and smaller incidents or less and less is needed to trigger a pain incident.
Also think about your history and previous times when you had pain and what was going on in your life then, what is going on in your life now, and if there are any things that could be contributing to underlying stress levels, including adverse childhood experiences (ACEs). If you felt vulnerable (physically and emotionally in danger or unsafe – the landmark ACE study has 10 factors) in your childhood, the body and brain’s experience will mean you are likely to feel less safe in other situations and therefore may experience greater pain and stress than other people. You may want to see a professional counsellor if you have deep issues which could be traumatic to acknowledge or deal with.
In summary, our beliefs, expectations, fears, anxiety, experiences, social and cultural factors all affect how the nociception is, or isn’t, converted into pain by the brain. Basically, if your brain and body feel vulnerable and that there is a risk of danger or damage, your experience of pain will be more than if your brain and body feel that you are relatively safe. We need to find ways to make the body and brain feel safe, to have less fear.
Pain is one of our survival mechanisms, and in short bursts it’s excellent – but if it carries on when there is no real physical danger to the body, it becomes problematic.
This is a very brief and simplistic overview of a very complicated topic. If you want to read more there is a very good booklet called ‘Understanding persistent pain’ produced in Tasmania which you can download for free. The NHS in the UK also has a good free booklet about managing persistent pain on the Healthshare website.
One of the main things to note is that it’s not all doom and gloom, the brain can be re-trained, neural pathways can be re-wired, and through small changes to lifestyle, outlook, routines and taking steps to de-stress such as through massage, diaphragmatic breathing, yoga and other beneficial movements and exercise, the body can be encouraged to feel safer, less under attack and thus reduce the pain levels.
You may want to look at some of my free handouts for gentle yoga movement routines, a de-stressing breathing handout, and some short videos for shoulders and neck, all accessible from my Free Stuff page. There is a useful video about diaphragmatic breathing here which also talks you through a guided practice and some free guided relaxation tracks on this website.