I cannot recount the amount of times someone has come to Sullivan PT, sat down in my treatment room, and said something to the effect of “I don’t know, maybe this pain is just in my head.” They usually feel this way because no one has been able to tell them why they hurt or maybe because someone has already said “maybe it’s in your head.” What I usually tell people is this: Yes, the pain is in your brain, but that doesn’t mean it’s a figment of your imagination.
To fully understand why we hurt and what we can do about it, we need an understanding of what pain is. Our body doesn’t have pain receptors. It doesn’t. Our body, instead, has something called nociceptors. Nociceptors are sensory nerves that pick up threatening signals, signals that may mean damage, carry those signals to our spinal cord and then to the brain. The brain interprets this data and decides whether or not that threatening signal results in pain.
Let’s use an example that I did not come up with but rather heard in a presentation by Adriaan Louw, PT, DPT, pain science guru, at a conference in 2016. The story goes as follows:
If you were crossing the street and sprained your ankle, would it hurt? Of course it would hurt. You would probably sit down and clutch your foot, roll around and yell some unpleasant things, loudly. Now, let’s take this one step further. If you were crossing the street and sprained your ankle, but a bus was heading straight for you, would it hurt? Would you fall to the ground and clutch your foot? Of course not. You would hop right back up and run out of the way, at which point once it was clear you were safely away from this life threatening hunk of metal, you may start feeling that sprain.
So what is this story meant to illustrate? Pain is not a straightforward, simple thing that should be taken at face value. It is a complex experience created by a number of factors, but in all cases pain is felt when your brain decides that your nerves have picked up on something threatening. Your brain determines your level of pain based on the danger it thinks you are in, not the amount of danger you are objectively in.
This system would be great if your nerves never sent false signals and your brain never had poor judgement, but for people experiencing chronic pelvic pain, both of these can happen. Your sensory nerves can become that little boy that cried wolf, but your brain may be more gullible than the villagers. Let me explain further through another analogy.
Your central nervous system includes your brain and spinal cord. This is what collects the sensory input from your body, interprets it, and responds to it. Your central nervous system is like an alarm system. However, just like my crummy, 150 year old building fire-alarm system in graduate school, your alarm system can malfunction. That alarm system was hypersensitive. It went off every morning I made toast and I had to stand beneath it waving a magazine for 5 minutes until I could convince it nothing was about to go up in flames. In someone with chronic pain, the body’s natural alarm system, or the nervous system, does the same thing. In those with chronic pain, the nerves start sending signals to the brain over and over with and without reason. The brain continues to create pain that isn’t in response to any particular tissue damage, or burnt toast.
This is why neurologist and scientist VS Ramachandran wrote “Pain is an opinion on the organism’s state of health rather than a mere reflective response to an injury.” Pain is not an inalienable truth that we necessarily experience, and while we may not be able to stop our pain by wishing really, really hard, we can influence what we feel by how we understand what we’re feeling.
The brain has the ability to be smarter than our alarm system. It has the ability to both heighten the sensitivity of our nerves, making them more and more active and reactive. It also has the ability to calm our nerves by telling them over and over, “yes, I know you sense imminent danger but I promise you there is none.” An important part of this is teaching our brain that pain does not mean damage. Our nerves can be wrong, our brain can be wrong, and we may end up in pain even if nothing is harming us.
Entire books have been published devoted to helping us understand that even though our pain is absolutely, 100% real, we may not be in harm’s way. Research has even shown that understanding pain can quickly and effectively reduce the pain we are actually feeling. One particular study, by the same Adriaan Louw, PT, DPT, pain science guru, previously mentioned illustrated just how powerful understanding pain can be.
In this study, the subject was a 30 year old professional dancer who had a 4 year history of back pain, radiating into both of her legs and thighs. They asked her to fill out some outcome measures, which if you have been to any health care provider recently you may be familiar with. She filled out a few of these forms that indicated how significant her pain was at the time, how affected she felt by her pain while performing daily tasks, as well as how her fears and beliefs regarding her pain affected her symptoms. She then also had an fMRI, which is a type of MRI that measures brain activity by detecting the change in blood flow between regions. 1
The intervention in this study, or the treatment, was a 30 minute educational session allowing for questions and answers, to help her better understand her pain. This session included the alarm system analogy, as well as some additional pictures and information to assist in reconceptualizing pain. The outcome was, in my opinion, quite amazing. Upon completing the same outcome measures just thirty minutes later, she reported less pain, less disability, more positive beliefs regarding her pain, and even decreased brain activity while completing painful tasks as compared to before the education session.
I know, pretty cool.
In summary, I’ll leave you with four points inspired and clearly outlined by Lorimer Moseley in his article “Reconceptualizing Pain According to Modern Pain Science.”2
- Pain is not an objective measure of the health of your physical tissue
- Pain is regulated by a number of physical, social and emotional factors
- The accuracy of your body’s perception of pain as compared to the health of your physical tissue may decline as pain persists and becomes chronic in nature
- Pain is your brain and body’s way of expressing that your nerves believe your tissues are in danger
If you have any questions or comments, please leave them anonymously in the comment section below or email me at firstname.lastname@example.org.
Interested in reading further on this topic? Here are two great reads!
-Rebecca Maidansky, PT, DPT
- Adriaan Louw PT, PhD, Emilio J. Puentedura PT, DPT, PhD, Ina Diener PT, PhD & Randal R. Peoples MS, MD (2015) Preoperative therapeutic neuroscience education for lumbar radiculopathy: a single-case fMRI report, Physiotherapy Theory and Practice, 31:7, 496-508, DOI: 10.3109/09593985.2015.1038374
- Moseley, L. Reconceptualising Pain According to Modern Pain Science. Oxford Centre for fMRI of the Brain. Oxford University, Oxford, UK. https://bodyinmind.org/resources/journal-articles/full-text-articles/reconceptualising-pain-according-to-modern-pain-science/