What Is Pain?
Pain is an individual experience, which means that we all feel pain differently. Pain is part of our “alarm” or “survival” mechanism. When we have pain, we notice and stop. Without pain, we most likely wouldn’t have survived as a species. There are different reasons why you may experience pain, such as inflammation, an injury, or surgery. This type of pain is called acute or nociceptive pain and it tends to come and go (intermittent) following a pattern and the pain improves over time. The purpose of this pain is to protect our body and allow healing.
Internally, the nervous system (brain, spinal cord, and nerves) is in charge of protecting us from any “potential threat” (AKA stimuli) to the body. Stimuli are constantly perceived by the nerves from our skin and muscles. These stimuli are then carried toward the spinal cord to reach the brain. The brain is in charge of processing these stimuli based on the level of potential threat to the body (intensity of heat, pressure, inflammation, tissue damage, etc) Then, the brain translates these stimuli into sensations based on the level of threat identified. Some may be painful (burning, throbbing, sharp, dull ache, etc) and others may be non-painful (pressure against a chair, cold drink, woolly jumper, etc). How the brain translates these stimuli differs from person to person due to genetic factors, learning behaviours, and past painful experiences. Also, there are other internal (age, gender, hunger, tiredness, stress, lack of sleep, etc.) and external (culture, home and work factors, etc) factors that also influence how we feel our pain.
When this protection purpose is no longer necessary (the initial tissue injury is healed), but you still feel pain and it is not getting better, you may be experiencing another type of pain. When this other pain persists and lasts more than a few months (typically 3-6) it is then called chronic or persistent pain. Persistent pain may be a result of an underlying issue or it may not have a clear cause at all. Persistent pain is different from everyday aches and pains. It may be constant, very disabling, and extremely frustrating to the person with pain and to those around them. Above all, persistent or chronic pain is not just an acute pain prolonged over time. Chronic or persistent pain has different mechanisms of action than acute pain and, therefore, the treatment and management tools should be different.
General Differences Between Acute and Chronic Pain
| Acute pain | Chronic pain | |
| Purpose | Protective | Overprotection (maladaptive) |
| Duration | Less than 3-6 months | More than 3-6 months |
| Natural time course | Improves over time | Constantly fluctuating or worsens over time |
| Aggravating and easing factors | Clear and easy-to-identify patterns | Unclear and can change |
| Time pattern | Comes with specific movements | Pain at all times. Can have flare-ups |
| Medication | Over-the-counter or NSAID work | Strong painkillers only “take the edge off” |
| Supplementary test | Show inflammation, fracture, etc | Inconclusive |
What is Chronic or Persistent Pain?
When pain persists for a longer time than it should, your nervous system becomes hypersensitised. It is like having an overprotective and territorial dog or a house alarm that goes off with the wind.
Your brain is in hyper-protection mode so you keep experiencing pain; therefore, to “keep you protected” your brain develops new “grooves or pathways” to adapt to this new, (not real) present and constant danger. This is called “maladaptive neuroplasticity”. Your brain has developed the “bad habit” of giving and remembering the pain. Interestingly, these new groves also influence other areas in the brain that deal with fears and emotions, and, simultaneously, these emotional areas also influence the new grooves. This biological and psychological loop (body and mind connection) is very important because it explains why people with chronic pain also experience other symptoms such as anxiety, fear avoidance of movement, difficulty sleeping, fatigue, brain fog, poor memory, and changes in mood. This is called the biopsychosocial model of pain.
When you have chronic pain, everything seems to make it worse. Your nervous system starts to act as if gentle movements, muscle contractions, and pressure on your body are, somehow, a threat. Many things that were not painful before, suddenly become painful or uncomfortable, like pressure from sitting on a chair or lying in bed, doing daily home activities, or walking. As time goes by, it starts to take less movement to increase the pain, which leads to moving less and our muscles weakening.
Additionally, simple activities like socialising, relaxing, or sleeping become quite difficult. Even if you manage to sleep, you may still wake up tired (”tired but wired”). This downward pain cycle affects relationships and self-esteem and can get to include EVERY aspect of your life. You are not alone. Chronic or persistent pain is quite common.
Interestingly, pain scientists are also gradually finding more evidence suggesting aberrant neuro-immune cross-talk (so far only in animal testing in the lab). These findings may have implications in terms of pharmaceutical options. However, self-management and physiotherapy options would remain to be key in your pain management journey.
Click on the link below to view Professor Moseley’s lecture explaining the role of the brain in pain and its protective role (1h 30 mins) https://youtu.be/lCF1_Fs00nM
Click on the link below to view Dr. Furlan’s video on explaining chronic pain with no cause https://www.youtube.com/watch?v=JwpGYL3zLg8
Click on the link below to see a video about the biopsychosocial model of pain in children and teenagers https://www.youtube.com/watch?v=6rjS_GisaM0
Can Chronic Pain Be Treated?
Pain cannot be identified in blood tests or seen in X-Rays or MRIs. Evidence shows, that in a large majority of patients, changes found on an MRI do not correlate with the intensity of the pain experienced. We also know that images from scans and X-rays only show a picture in time of large anatomy sections and it doesn’t show small anatomical lesions, low-grade inflammation, the reaction of your immune system, or how the nervous system is functioning. All this can be really frustrating!
However, be reassured. This lack of clear explanation or identification of the cause of pain doesn’t mean you are not in pain. You are not imagining your pain. But it does mean that there is no one magic pill to fix it. The nature of neuroplasticity means that we have to undo the maladaptive “grooves” and develop new “good” ones. Remember the house alarm that was sensitive to the wind? We need to rewire the alarm or, in our case, retrain the brain.
Due to the biopsychosocial nature of chronic pain, it may be relevant to see different pain specialist healthcare professionals (physiotherapists, psychologists, pain consultants, etc) to best address your individual needs and treat you as a person.
Click on the link to watch Prof. Lorimer Moseley’s “Tame the Beast” video (7 mins) https://www.youtube.com/watch?v=ikUzvSph7Z4
Why Does Pain Persist Over Time?
Chronic or persistent pain is complex. There are many factors that influence pain persisting over time. Some of the most common factors are:
- lack of understanding of your pain as an overprotective mechanism that prevents recovery.
- reduction of self-compassion
- poor sleep
- not-very-balance dietary intake
- being regularly physically inactive leading to an increase in deconditioning (pain cycle)
- having outbursts of physical activity followed by days of exhaustion (boom and bust cycle)
Click on the link to watch me explain the biology of chronic or persistent pain (20 mins) https://vimeo.com/771983580
The Journey from Patient to Person: What Can You Do About It
Living the best possible life that you can despite having pain, requires a change in how you think about your pain and your life. You need to move away from the cycle of pain towards a cycle of health. There is a range of skills and techniques that you can do to retrain your brain and return to doing what you love. Small and consistent changes go a long way.
Skills include understanding your pain cycle and deciding where to break it, accepting that pain has changed your life and empowering yourself to take control of your life back from the pain to return to doing what you love. We focus on realistic short- and medium-term functional goals that are important to you, always considering your sensitive nervous system.
Click on the link to watch Prof. Peter O’Sullivan describe a cognitive functional approach to chronic pain https://www.youtube.com/watch?v=ySJ5O2NnnuE
You can contact me at hello@mariagalvevilla.com
First published 8th of December 2022