By Cora Tomowich, MScPT, HonBKin
Person One: “Quit faking this pain, it’s all in your head!”
Person Two: “I’m not faking, this really hurts!”
Ah pain… the incredible construct that we’ve all experienced at one point or another. What causes it? What’s the point of having it? What can we do to get rid of it? Well, let’s take a deeper look into what pain really is and what it means to our daily lives. Here are some things you may not already know about acute and/or chronic pain:
1. Pain is Complex
After decades of studying the plethora of causes, descriptors, purposes, and treatments of pain, one thing is for sure: we still don’t have the full story. Pain is an incredibly unique experience that can be influenced by many different factors. It is a highly complex system that is specific to the individual; and is experienced differently depending on whether it is acute or chronic. I’ve included a brief video here to try and help explain the pain phenomenon, as well as, how it is experienced by the brain:
2. Pain has Many Contributors
Pain can be influenced by stress levels, emotions, and can easily be changed depending on what we see, smell, hear, touch, and/or taste. Our beliefs about pain can also influence how we experience it, for example, if you wholeheartedly believe that a tap on the hand is going to hurt, it will! Pain can also be influenced by the thoughts and words we use to think about and describe it. Our pain experience can also depend on the people with whom we choose to surround ourselves. Negative people can tend to bring us into a negative state of mind, which can increase the intensity or duration of our pain, and vise versa. Think about this: if you stub your toe on the greatest day of your life, chances are you’d feel some pain but would continue on your merry way without dwelling on it, making the pain experience seem like no big deal. Conversely, if you stub your toe on the worst day of your life, you are much more likely to feel a more intense pain that lingers on and on, making the pain experience seem like the worst thing ever. In truth, pain largely depends on our inner and outer circumstances!
3. Pain is an Expression of the Brain
We all agree that immediately after an acute injury to a specific body part, we may feel pain in that body part indicating that a potential injury has occurred. We aren’t likely to have pain in the elbow if we just stubbed our toe, agreed? Okay, now think about a soccer player who collides with another player and immediately experiences pain in her knee. Historically, we believed that the nerves in her knee were warning the soccer player of potential or actual tissue damage that required immediate attention; but are the nerves in the knee really deciding all of this? No. There are no specific pain sensors, pain pathways, or pain nerves in the soccer player’s knee; pain is an expression made by her brain. We now know that there are sensors in the knee, and all other body parts for that matter, that constantly detect what we do and report our activities back to the brain in an unbiased fashion. It is then up to the brain to decide whether or not we feel pain. Simplified: our tissues collect data; the brain analyzes that data. There is no specific ‘pain centre’ in the brain for this analysis, but instead, data is analyzed by many different areas of the brain over time. Since pain is a protective warning system for the body, the brain will only decide to express pain when the threat of danger outweighs the sense of safety; thus inferring the need to protect the body. Although they are expressed differently, this is true in acute and chronic pain. It is important to recognize that although pain is an expression of the brain and not the injured tissues, it is always real and always something to consider.
4. Acute Pain is NOT the Same as Chronic Pain
There is so much to be said about the differences between acute and chronic pain, but for our purposes, I will summarize that the brain behaves differently if the pain experience is new (acute) or recurring (chronic). Immediately following an injury or almost-injury, we may experience acute pain as a way for the body to either protect the injured area from further tissue damage or prevent an almost-injury from happening. Since we know that pain is one of many protective outputs, we also know that when tissue is threatened, the body is capable of activating multiple protective systems including pain, immune, motor, endocrine, autonomic, and emotional. Sometimes, in cases of excessive up-regulation or long-term activity of these protective output systems, they can become overprotective and cause us to experience chronic or recurring symptoms. With hyperactivity, these systems can perceive tissue threats where there are none and behave much like a highly-sensitive car alarm that gets triggered by a passing breeze. When describing the difference between acute and chronic pain to my patients I often say that acute pain is what we experience immediately after a threat or injury to the body, while chronic pain is what we experience because our brains are on high alert and hypersensitive to keeping any threat or injury from happening again. Chronic pain is also the result of our now-highly-sensitive brain having re-mapped and/or changed the way it analyzes the data from our body tissues. Both acute and chronic pain are treatable, however, there are notable differences in the overall treatment approach.
5. Pain does NOT Always Indicate Tissue Damage
Pain is an unreliable indicator of the presence or extent of tissue damage, as either can exist independently. As the body’s built-in warning system, the pain experience has been carefully molded over years of evolution to keep us from engaging in certain movements, situations, or scenarios that would ultimately cause tissue damage and/or compromise our safety. After years of studying pain, we know that it is often felt before actual tissue damage occurs in order to protect us from going beyond the “point of no return”. This is certainly true for acute pain; but what about chronic? As we’ve discussed, chronic pain is more a sign of the entire pain system having been up-regulated like an easily-tripped car alarm and rarely indicates actual tissue damage. That’s why MRIs and X-rays often cannot detect tissue damage or explain the source of chronic pain. So, when treating acute pain, we must focus on treating the injured tissues to help remove damage and promote healing; while chronic pain management requires more attention to all the protective systems, especially the up-regulated nervous system.
6. Pain is NOT the Enemy
As we’ve seen so far, pain is a protective mechanism designed to keep us safe. Studies show that people who don’t experience pain have a shorter life expectancy, as there is no warning system in place to protect the body from harm. I often remind my patients that our goals with physiotherapy should not be to eliminate pain from our lives but to normalize its response to threats or damage. We need pain in order to survive and protect ourselves from injury; otherwise, it would be like living in a house without smoke alarms, how would we know of a fire before it’s too late? Well, pain is our internal alarm system designed to warn us of potential or actual threats to our safety; it is not our enemy.
7. Pain is Always Real
Historically, our questions about the realness of pain were in whether or not the pain was indicative of actual tissue damage; but we have since learned otherwise. Now we know that all pain experiences are normal (albeit unpleasant) and don’t always link with tissue injury. They may instead indicate a hypersensitivity of our internal protective alarms, such as the nervous system. We also know that pain is only experienced when the brain determines that the threat of danger outweighs the sense of safety, and so it is the brain that determines the realness of our pain. Without getting too philosophical, if it is true that our brain, beliefs, and perceptions give shape to our reality, then everything we experience is always real to us. A fellow named Descartes once said: “I think therefore I am”. Well, he was right and with his words in mind, think about how we all have our own definitions of what “pain” is or what a “painful” experience feels like. Some of us think that a deep tissue massage is wonderful, while others think it hurts. The pain experience depends on the individual, not a textbook definition. So, instead of discounting pain as fake, understand that the pain for that individual is quite real. We must respect and allow each person to express how they feel; otherwise, by failing to recognize pain, we make things worse. Whether it is trying to tell us about tissue damage or a hypersensitive nervous system that needs attention, all pain is real. What we resist, persists. Acknowledging the pain is the first step in the healing process.
8. Pain Education is a Powerful Ally
Knowledge is one of our best tools in the treatment of pain as learning about pain and what causes it is a therapy all by itself. Once we understand why we hurt, we hurt less. Once we realize how the brain works to interpret pain, we can develop new strategies to overcome or manage our pain a lot better. We are also comforted to know that there are others out there with similar pain experiences as our own, and that there are many researchers and clinicians working to find ways to help. It is also extremely helpful to know that we are bioplastic beings that have an incredible capacity to change and adapt. As I mentioned earlier, while all protective mechanisms can become overprotective or hypersensitive, the idea of bioplasticity suggests that we can undo these changes in our favour. It is biologically impossible to suggest that acute or chronic pain of any kind cannot be changed; and once we understand that, we can explore new ways to cope and normalize our pain once again.
So there you have it folks, a very brief look into the world of defining and understanding pain; and this is just the tip of the iceberg! If you are interested in learning more about pain, I suggest reviewing the works of Lorimer Moseley, David Butler, and Bahram Jam. If you have any specific questions regarding how to manage pain for yourself, please do not hesitate to reach out, I’d be happy to answer any questions for you. Let me leave you with one final thought: although pain may be an expression of the brain, it can always be treated, it is always your friend, and it is definitely not all in your head!