Pain is not only an unpleasant sensation; it is also an emotional experience.
What is Chronic Pain?
Acute pain is often associated with actual or potential tissue damage. Chronic pain, on the other hand, is defined as any pain that lasts longer than 3 months and has no identifiable cause or continues despite complete tissue healing (Nicholas et al., 2019). In this case, pain itself becomes the disease, and it no longer serves its ultimate purpose of protection.
A common misconception is that pain is an accurate measure of tissue damage. However, the time at which pain occurs is before any tissue damage has occurred—because pain was never meant to measure tissue damage, it was meant to protect you from it.
Try an experiment: bend a finger (that is unaffected by an injury) backwards as far as you can and hold it there. It will start to hurt! Once you let go, your finger no longer hurts and there is no tissue damage. Pain simply served to warn you that if you kept going, tissue damage is possible. It is more helpful to view pain as the body’s attempt to protect us, and acute pain serves this purpose quite well.
When pain is chronic, it does not help us, and we (naturally) misinterpret the experience of pain as evidence that we are injured.
The Cause of Chronic Pain
Pain is affected by many factors including the context in which we might experience it.
Imagine you’re running across the street, and you fall and sprain your ankle. Arguably, there is some damage to the ankle, and you might imagine that you feel immediate pain. But what if a bus were barreling towards you? In this scenario, you might not feel any pain until you get up and run off the road.
Pain is also affected by our mental and social health, or what researchers call psychosocial factors. In fact, research shows that psychosocial factors are more important predictors of chronic pain and disability than the amount of tissue damage present (Chester, Jerosch-Herold, Lewis, & Shepstone, 2018; Ivarsson, Johnson, & Podlog, 2013; Goucke, 2006; Olugbade, Bianchi-Berthouze, & Williams, 2019).
For example, anxiety, depression, lack of social support, and fear of movement are all predictors of poorer outcomes for people with everyday injuries, including low back pain (Driver, Kean, Oprescu, & Lovell, 2017; Alhowimel, AlOtaibi, Radford, & Coulson, 2018).
Okay, so your thoughts, beliefs, emotions, and even how supported you feel by others can impact your experience of pain and contribute to the development of chronic pain.
Many people, when they hear that, might think that pain is all in their head or that their chronic pain is their fault. It is not your fault, and it is not all in your head. It is not imagined; your pain is very real.
How Chronic Pain Affects Your Body
In fact, scientists can identify the very real physiological changes that occur in the nervous system that allow pain to persist. For example, imagine your nerves, all the way from your skin to spinal cord and brain, like a row of dominoes. Normally, you must push a domino over, or in the case of a nerve, approach tissue damage for a signal to travel to the brain and be perceived as pain. When pain is chronic, it’s like just blowing air on them causes a nerve to fire; your dominos might even fall over randomly, all in the absence of real or potential tissue damage.
In the case of nerve endings, this is because those with chronic pain literally have more chemical messengers activating their nerve endings in addition to more nerve endings sprouting in an area that your brain thinks it needs to protect (Pinho-Ribeiro, Verri, & Chiu, 2017).
In terms of what happens in the brain and spinal cord, you can think of chronic pain as a less friendly example of neuroplasticity. Neuroplasticity is a popular buzzword, that describes the brain and nervous system’s ability to change over time. Historically, the brain was thought to be hard-wired and unchanging. Years of research has revealed that this is untrue, and that the brain changes significantly across the lifespan. When we repeat an activity over and over, it creates a pathway in the brain and nervous system.
Think of riding a bike: in the beginning, it’s hard because the pathway in the brain and nervous system is new. It’s almost like you’re bushwhacking this new path. With practice, the pathway becomes clean, wide, and groomed—it becomes the path of least resistance, and now, you don’t even have to think about riding a bike. Neuroplasticity is awesome when you’re trying to learn a new skill, but when it comes to pain, it’s sort of like the wonderful plasticity of our nervous system got a bit confused, and now we have created well-trodden pathway for pain to occur (Osborne, Anastakis, & Davis, 2018).
In other words, you are not imagining or creating your pain, but the presence of unhelpful beliefs, fear of movement, stress, anxiety, depression, poor sleep etc. can and do lead to very real and measurable changes in your brain and nervous system which might mean pain sticks around—even when the physical body has healed.
Recovering From Chronic Pain
Sure, your nervous system might be stuck right now, but what if learning that hurt does not equal harm, or that our pain does not mean our tissue is damaged, is actually liberating?
This means that even though it hurts to move the painful body part right now—we’re actually not causing any tissue damage by doing so—our nervous system just got its wires a little crossed. And if your brain can learn pain, it can unlearn pain—because of neuroplasticity!
It is likely very safe for you to do the movements or activities that cause you pain—and doing them gradually might be an important part of your recovery.
Physiotherapists are trained to rule out anything nasty going on in the physical body, and once they’ve done that, you’re cleared to explore movement and the activities you love—even if it’s painful. Many physiotherapists will use a stop light analogy to guide your activities.
- Green means there is no pain, and you want to do lots of those movements and activities.
- Yellow means that there is some pain, but it feels tolerable or acceptable to you. We actually want to do some activities and movement in the yellow zone, because this teaches our brain and nervous system that movement is safe, and thus decreases pain over time.
- The red zone is an amount of pain that does not feel tolerable or acceptable—it might make you sweat or catch your breath. These activities are to be limited, when possible, not because they mean tissue damage has occurred, but because they might strengthen the nervous system’s tendency towards pain.
There is also a considerable amount of research that supports a team approach to the management of pain, so bringing on other health care professionals such as physiotherapists, counsellors, doctors, occupational therapists, and kinesiologists can help you to feel more supported on your path to recovery (Nicholas et al., 2019).
What You Can Do Right Now
If you have chronic pain, it is likely you need the support of a health care team. However, there are some things you can do today! Since pain is experienced by the nervous system, anything that calms the nervous system will help.
A little more background: there are two branches of the autonomic nervous system called the sympathetic and the parasympathetic response—Herbert Benson calls them “fight or flight” and “rest and digest”, respectively.
Fight or flight is a helpful response that occurs when you’re in real or perceived danger. If a bear is chasing you, your fight or flight response will send blood to the muscles of your limbs, increase your heart rate and breathing, dilate your pupils, and so on, so that you’re able to get to safety.
The rest and digest response occurs when you feel relaxed. The heart rate slows, blood is redirected towards digestion, and the body can do important maintenance to keep you healthy (Benson, 2000). With chronic pain, the autonomic nervous system is a bit confused (Yeater et al., 2021). To balance this, you can do any activity that activates rest and digest. This could be a hot bath, meditation, deep breathing, receiving a massage, laying in a hammock, reading a book—the activity doesn’t matter, the lived experience of calmness is a trustworthy indicator that you have activated this branch of the nervous system (Amihai & Kozhevnikov, 2015).
That said, changing the nervous system is hard work, and you don’t have to do this alone. The support of a good health care team can make a world of difference in your recovery.
If you live on Lower Vancouver Island, then visit us at Parkway Physiotherapy & Performance Centre to book an appoint with our team. We can diagnose & treat a range of chronic pain sources.
