Understanding pain is crucial when overcoming an injury or chronic condition, so I often begin by asking my clients, "What is pain?" It's essential for me to grasp their perspective on pain and why they are experiencing it to effectively assist them. It can be very frustrating for individuals to encounter differing beliefs and explanations within the pain and rehabilitation fields. Apart from nutrition, there may be no other area of medicine as prone to misinformation as pain science. This misinformation, although often not done with malicious intentions, could be contributing to the rising number of people with disabilities each year.
I feel one of the most effective strategies to address the increasing prevalence of chronic pain conditions is through improving public awareness. This pain awareness literacy should be a part of early education in schools. A population informed about pain from a young age is better prepared to navigate life's challenges. The same is true for physical activity and nutrition. While I recognize this idea may seem idealistic given recent challenges in public health initiatives, consider this: teaching children about emotions and sensations – happiness, sadness, anger, frustration, love, joy, laughter, anxiety, boredom, fear, calm, confusion – is a fundamental aspect of parenting and public education. Unfortunately, discussions about pain are often overlooked, mainly because parents and educators themselves may not fully understand pain.
Na Pali Coast - Kauai, Hawaii - Summer 2023
So, why not kickstart this pain education conversation with a Pain Quiz? Even though it feels a bit juvenile at times it’s interesting to see how well this quick quiz helps open up the discussion to finding solutions for chronic pain. I've also been pleasantly surprised by how well younger kids grasp these concepts compared to adults. Some of this may be due to their decreased exposure to the dogmatic tendencies of the biomedical model of medicine. Let’s get to the quiz.
Pain Quiz
True or False
The brain decides when you will experience pain?
Pain only happens when you’re injured?
Chronic pain means that your injury hasn’t healed properly?
Worse injuries result in worse pain?
Stress directly impacts your pain response?
Pain Quiz Answers
The brain decides when you will experience pain?
True - Pain is 100% produced in the brain. No, I am NOT saying that pain is all in your head! Sensory receptors throughout the body give input to the brain, and the brain decides if the input is dangerous or safe. The brain sends this signal back down to the body as danger (pain, limited movement, agitation, etc) or safety. The brain's job is to protect you and keep you alive! But the brain is also a prediction machine working off of past experiences. Many factors make up a “Pain Recipe” – current mood, nutritional status, functional capacity/strength, how well you’ve slept, stress levels, thoughts and beliefs about the experience, etc. The good thing is if the brain has a “pain recipe”, it must also have a “healing recipe”.
Pain only happens when you’re injured?
False - Have you ever noticed a bruise but you don’t know where you got it? Tissue damage doesn’t always equal pain, and pain doesn’t always equal tissue damage. Rachel Zoffness, a pain psychologist and educator does a great job of explaining this with her “Tale of Two Nails”. I recommend reading her linked article, but here's a quick summary if you don't have the time:
The first nail is a true story of a construction worker who jumped down onto a wooden plank with a 7-inch nail sticking out. The nail went completely through his boot. In excruciating pain, he was quickly driven to the emergency room and pumped with opioids. A few minutes later the boot was removed and miraculously the nail had gone directly between his toes, not even breaking the skin. The second nail true story also took place on a construction site. This time a nail gun was unknowingly fired and directly hit a man in the face. Outside of a tender jaw and a toothache, the worker was relatively uninjured. Six days later he went to the dentist and had X-rays performed. They discovered he had a 4-inch nail embedded in his head and pressing on his brain! Fascinating right!? How is this even possible? Well... pain is very complex. The brain of the first nail victim never received the all-clear sign of safety, whereas the brain of the second nail victim incorrectly assessed the situation as just a close call. "Hurt" and "Harm" are not always the same thing.
Chronic pain means that your injury hasn’t healed properly?
False - Tissues heal typically in 3-6 months, and often much quicker if you are healthy. Pain that lingers longer than 6 months (persistent pain) is typically a byproduct of a hypersensitive nervous system (aka pain system). Remember that “pain recipe” I mentioned above? Well if variables like stress, nutritional status, functional capacity, sleep, and mood are all dysfunctional then it’s much easier for your brain’s “pain recipe” to quite literally “get good at pain”. It becomes hypersensitive and goes into ultra-protection mode – stuck in a limbo state of constant persistent pain. After all, the purpose of the brain is to keep you alive, predicting off of past experiences. Now this may sound despairing, but in the end it is GREAT NEWS! If tissues typically heal in 3-6 months, we can focus more of our attention on the nervous system, instead of just treating symptoms. By addressing lifestyle factors such as stress, nutrition, functional capacity, and sleep, we can reduce the sensitivity of the nervous system, turn down the pain dial, and alleviate persistent pain!
Worse injuries always result in worse pain?
False - The opposite is actually true. In more dangerous situations the brain often shuts down the pain response so it can react appropriately to the very stressful situation. Think of an injured person in a car accident fighting to get out of the damaged vehicle to safety even though they have multiple fractures and wounds – yet minimal pain. The pain may not come on until later, but in the moment there are more important things to focus on to get to safety. Another prime example of this is soldiers in battle often not even realizing they’ve been shot until several minutes afterward when a teammate acknowledges the wound. The brain's response to a painful stimulus is influenced by the circumstances of the environment of the injury, as well as your thoughts and beliefs about that situation. This explains how Tiger Woods can go out and win a US Open championship on a freshly torn ACL and fractured tibia.
Stress can directly impact your pain response?
True - When you are stressed the body produces more cortisol and adrenaline. These hormones alert nerve receptors and can make them more sensitive – think more cranky and agitated. The downstream effect doesn’t stop there. The increase in cortisol and adrenaline triggers an immune cascade that heightens our pain system by dialing up its sensitivity. A heightened pain system negatively impacts our sleep and the consequences can quickly spiral out of control. As always, if the body created this painful unhealthy state then it also has the ability to work its way out of it.
A quick break from all the Pain Talk... Here's my podcast recommendation for the week
With the NBA Finals coming to a close earlier this week I felt this podcast might be a good addition to the conversation on healing persistent pain. Michael Porter Jr is an NBA star who has also suffered from chronic back pain since he was in high school. He’s had multiple unsuccessful back surgeries and struggled throughout his basketball career to stay healthy. This past season he started every regular season game and averaged 30+ minutes per game. I highly recommend you give this podcast a listen as he shares his unique experience of how he cured his persistent back pain.
Definition of Pain:
“An unpleasant sensory and emotional experience associated with, or resembling that associated with actual or potential tissue damage.”
Let’s break down all the variables from the definition of pain.
Pain is always a personal experience. A sprained ankle to you may be completely different for me. The pain experience is biopsychosocial – meaning it is influenced by varying levels of biological, psychological, and social factors.
Pain and nociception are not the same phenomena. Pain refers to the subjective experience of actual or impending harm. Whereas, nociception refers to neural inputs of impending or actual tissue damage. Often nociceptive inputs will lead to pain, but research and MRI studies show that one can exist without the other.
Here’s a quick video to explain: Pain vs Nociception | In 2 minutes!!
Our life experience directly impacts the pain experience. Our brain is a prediction machine. It works off of past experiences with the overarching goal of keeping you alive. Therefore, pain should be viewed as evolutionarily adaptive. A pain response recipe builds throughout our lives depending on childhood experiences, cultural background, educational inputs, thoughts, and beliefs. It’s not just the past that plays a role… the current state of our internal neuroimmune, musculoskeletal, and endocrine systems regulates the pain recipe.
Although I mentioned pain is typically adaptive in nature, it can have significant adverse effects on daily life – for example, limiting our ability to work, decreased functional capacity, and impaired social/psychological well-being. It can overcompensate and overprotect. As I mentioned above, the brain and body can literally “get good at pain”. This phenomenon is known as persistent pain can be extremely debilitating. The cycle can be broken by establishing quality lifestyle behavior change including sound nutrition, tolerable movement practices, respecting sleep, and being mindful of current and past stressful or traumatic experiences.
“Pain is often just your body’s request for change.”
A final note… nobody knows more about your body than you! That sounds like a dumb statement, but my point is a person’s report of a painful experience should always be respected.
Thanks for reading!
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