The Pain Paradox

“The aim of the wise is not to secure pleasure but to avoid pain.”

- Aristotle

Pain in the simplest of terms is the “physical suffering or discomfort caused by injury or illness.” This, however, does little to address the complex nature of our pain experience.

The International Association for the Study of Pain (IASP) has proposed the following definition:

An aversive sensory and emotional experience typically caused by, or resembling that caused by, actual or potential tissue injury [1].

Now things are getting more interesting. Before delving into this more telling description, it is important to get a little insight into the science behind pain.

With the definition above in mind, we can think of pain as a warning sensation that is relayed to your brain to tell you that a stimulus is causing or may cause damage (and that you should probably do something about it!). We want to avoid pain so this warning sensation or signal is telling us to take action: what can we do to make that pain go away?

Let’s start with a basic nociceptive (pain) pathway: placing your hand on a hot stove (see image below for a simple visual depiction that was proposed by Rene Descartes over 300 years ago).

1. Contact with the stimulus (can come in many forms, but in this case, placing your hand on a hot stove)

2. Reception - nerve endings (receptor) registers the stimulus (“this is very hot”) 

3. Transmission - the receptor communicates the information back to the central nervous system (your brain)

4. Processing - the brain collects the information and figures out an appropriate action to deal with the pain (simple in this case: “pull your hand away”)

Image from Gotham Physiotherapy [2]

Most of us are quite comfortable with this pain model and relate our own pain experiences to this quite easily. The problem, however, is that this model does not address more complex pain experiences. What it does do is help illustrate the immense challenge we face with chronic pain (which should be called persistent pain: while the pain is persistent it is changeable; chronic implies that is static and unchanging, which it is not). While our body wants to take action on a painful stimulus (i.e. pull the hand away), it is left in an often confused, further stressed state when there is nothing to pull away from (think of phantom limb pain as a good example of this).

To be able to get a better understanding of the science of pain, we need to be comfortable with one very uncomfortable concept, that is bluntly (and accurately) stated by a world-renowned expert on pain, Lorimer Moseley:

“100% of the time, pain is a construct of the brain” [3].

This can be hard to swallow. It often goes against our long held beliefs about pain. And this is particularly tough because our early lessons in pain come from our own life experiences that are repeated frequently and embedded deep in our mind. “Touching sharp things hurt,” “hot things hurt,” “jumping from too high hurts.” Our early messaging from our pain system helps us A LOT. In fact, it is critical to our survival. The unfortunate piece, however, is that all these lessons leave out all the more complicated sides of our pain system. It’s typically not until we experience one of those less straight-forward cases that we run into potential “pain problems.” Even then, the majority don’t realize that there was a notably more complicated process at play. People that have surgery and experience pain for a year or more attribute that pain to “healing” from the trauma without realizing that the healing likely finished months prior. 

Given our inherent trust in our nervous system (which is only natural: by relying on it we made it to maturity, a Darwinian success story!), many of us are hesitant about current pain modeling. A common complaint is that people feel they are being told, “it is all in your head” and that their pain is not being validated and isn’t real. 

It is in your head but…

… so is every other human perception. Pain is not “special” in this regard. And this is both a good and a bad thing. 

So the bad news. As mentioned, pain is a motivator: when we experience pain it strongly encourages us to change our behaviour, to take action to return to safety (it is VERY difficult to not pull your hand away from something that hurts). So why is this a bad thing? Sometimes safety isn’t possible: it can be unclear or it can be unavoidable. And unfortunately, when this is the case, our brain simply worries too much. 

“I’ve had a lot of worries in my life, most of which never happened” - Mark Twain

Our fear of events most often far outweigh the event itself. We are masters of catastrophizing as our brain is creative, imaginative, and dreadfully hard to control. A perfectly innocent example of this is blushing. It’s an often cruel betrayal of our inward emotions to the outside world. The more we try to hide it, the worse it gets. Pain, too, comes from an ancient part of our brain that is seemingly immune to logic. Much like an optical illusion, we can’t “un-see” it even when we know it’s a trick (which is why learning about persistent pain doesn’t simply “solve” the problem).

But there is good news, too. While our brain isn’t easy to manipulate, it is definitely changeable (more details on neuroplasticity and the malleability of the brain to come at a later date…). On one hand, pain can be absurdly persistent and disproportionate, on the other it never seems to lose the ability to shift and dissipate. 

But what can you do?

1. Be confident

With the use of cognitive functional therapy (CFT; this is cognitive behavioural therapy with the focus on restoring function, aka “movement”), individuals consistently reported reduced pain. Reframing the individuals’ understanding of their pain, correcting maladaptive movement patterns, and changing averse lifestyle habits played major roles in one’s pain experience. In summary, anything that helps restore confidence in your function “reassures” your brain and helps correct pain cycling.

2. Don’t rely on “external” symptom relief 

When comparing treatment for moderate back pain, functional/behavioural change (CFT) was far more effective than manual therapy [4]. If we rely on “externals” we are telling our brain that pain relief will come from the “outside” and is ultimately not in our control. This reframing and putting the onus on “self” is very important. 

3. Focus on MANY things… especially the ones you can fix

This can sound confusing and overwhelming but the point here is that there is NOT a silver bullet. But, rather, it is important to understand that there are many contributing factors to our pain experience and that we are able to influence these things on many levels. Often the best approach is to focus on your personal growth (broadly speaking). But, these must be the ones that are, in fact, changeable. We can’t change the fact that we had a history of abuse or a serious injury, but there are many things we can change (including our perspective on these events). 

As cliché as it sounds, a happy, fulfilled brain will amplify danger signals less. 

4. Address pain early wherever possible

When we let pain linger, we are giving our brain the opportunity to practice sending those pain messages. It becomes “skilled” at telling you it hurts and there is opportunity for the maladaptive changes: anxiety, altered movement, lifestyle changes.

5. Positive movement

Our bodies are built to move, but moving mindlessly is not going to (necessarily) reduce your pain. Find the ways that are meaningful and positive to you. Sometimes this can be as simple as walking with a friend. This is where a physiotherapist could work with you to find the movements that are positive and support your recovery.

6. Stop being dramatic (even though you want to be!)

The pain experience is individual, but we can agree that it sucks. We can also agree that it is hard for people to understand how we feel. Often, then, we find ourselves trying to explain how we feel (especially when we are not feeling very good). We get dramatic, we get emotional. And, unfortunately, in doing so, we elevate our nervous system and its sense of concern, fear, and anxiety. As best we can, we need to try to regulate the way we act around our pain experiences. This is where meditative practices of various forms have been used with a fair bit of success.

7. Don’t give up!

Pain is complicated, but there is hope! Many professionals are doing their best to learn more and more to help in pain recovery. This resource is one of many available and I will continue to provide resources over time that cover this complex and very important topic.

If you have any questions or want to learn more about any topics discussed in this post, please reach out. We are here to help and you are not alone!

-Tyler

References:

1. https://www.iasp-pain.org/PublicationsNews/NewsDetail.aspx?ItemNumber=9218

2. https://gothamphysicaltherapy.com/what-you-dont-know-about-pain-could-be-making-you-worse/ 

3. Lorimer Moseley from TED talk, “Why Things Hurt” at 14:33. 

4. Vibe-Fersum K, O’Sullivan P, Skouen JS, Smith A, Kvåle A. Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial. Eur J Pain. 2013 Jul;17(6):916–28.