Generally speaking the understanding of pain is poor. The vast majority of patients with persisting pain whom I see are unable to explain what is happening. This is clearly not their fault but rather that they have not had the biology of pain explained to date. We learn from an early age that if something hurts we must have done some damage. This message stays with us and it makes sense in most cases because usually when we cut ourselves or bang our heads, it hurts and there is an actual injury.
Where the tissue is injured is painful albeit the area may enlarge (central mechanisms at play, yet a normal response). Everyone is happy with that, and the fact that the intensity of pain can vary according to how we are feeling and the context of the injury. Classic examples include the ‘laughing off’ of a stubbed toe when we are on top of the world yet a persisting soreness when we are less happy. Equally, if we sustain an injury and need to keep going such as in an important game, the level of perceived pain can be low or non-existent in order to keep going. Variance is normal, even in acute situations.
In cases of persisting pain there is often no damage. Yes, the tissues may not be as healthy or mobile due to changes in activity and use as a consequence of the pain, but the relationship between the body structures and pain becomes increasingly unreliable. Scans can show disc herniations, disc bulges, joint degeneration and other changes however this is not pain. Pain is subjective and an emergent experience from the body yet the underpinning activity is within the brain, both in the case of acute and chronic pain. A structure is objective and hence cannot represent pain. Pain is personal, contextual, protective and modulated by many factors such as the environment, emotional state, attentional bias and prior experience.
On-going pain is a manifestation of changes and adaptations within the neuroimmune system with accompanying modification in behaviours, thinking and decision-making. To tackle any form of pain means to firstly give a meaning that makes sense. Why does this hurt? Is it useful for this to hurt right now? If there is a healing process in action, yes it is very useful, vital in fact. Otherwise, what is being protected? And pain is part of the way in which we protect ourselves alongside activity within the autonomic nervous system, endocrine system, sensorimotor system etc.
Tackling acute and chronic pain requires different thinking and a different set of strategies. Targeting the aforementioned systems is key within a treatment, training and coaching programme that addresses the different dimensions of that person’s pain experience.
Specialist Pain Physio Clinics, London