I want to say this upfront: If you feel pain, it does not mean you're broken. In this article we will see why. We will explore what pain is, what it isn't and importantly what you can do about it to live the life you want.
I will talk about quite a few things in this article that will hopefully help you to be a little more informed about the sensation of pain:
- The experience of pain
- How you can have damage without pain - and pain without damage
- Pain as our built-in smoke alarm
- High alert & fear and their role in chronic pain
- How to let your body & brain heal
- 2 powerful ways to understand & address your pain
So...pain. What's this thing?
What I can tell you is this: Pain is complex. It's complex because it happens in the brain. Yes, that's right - it's not your body giving you pain, it is your brain. If you make it to the end of the article you will know how that works (well, I will do my best to explain important, yet often neglected, parts of it), and you will hopefully be able to make a better judgement about the pain that you might be experiencing.
You might say: "But my back hurts. Surely there's something wrong with my back, not my brain!"
Maybe :) But there is a big chance that this is incorrect.
Pain vs damage - damage vs pain
The IASP defines pain as: "An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage"
Let's break this down:
- It is an experience
- it is associated with something...
- that something is actual or potential tissue damage
Actual or potential tissue damage. This is the all-important detail here. Let's break these down.
Actual tissue damage: You get a message (pain) when you burn your hand. This is a potentially life-saving mechanism. It is pain that makes sure you pull your hand away from the flame. It allows you to avoid any further damage, so it's a really good thing. Imagine if we didn't have that. Imagine what our bodies would look like!
There is actually a condition called congenital insensitivity to pain (CIP), where people cannot feel pain. If you're now saying "oh that must be the dream" ...not quite: Usually these people don't live a long life (around 25 years) because they keep accumulating injuries without knowing about them. It's really not an easy life without pain...
Potential tissue damage:
Another definition that I love, which also taps into this 'potential damage' comes from neuroscientist V.S. Ramachandran:
"Pain is an opinion on the organism's state of health rather than a mere reflexive response to injury"
An opinion. When you burn your hand, your organism comes to the conclusion that this is not good for you, and that you better pull that hand away to avoid further damage. Bang, pain.
But: It is "not a mere reflexive response to injury." Or from the IASP's definition: it's an experience associated with "potential tissue damage".
That means, you can feel pain without actual damage. And you can have damage without feeling pain! In fact, the latter is the case for the almost everyone as we age:
37% of 20 year olds (yes, young people!) with NO PAIN show degenerated discs in their spine (Brinjiki 2015)
Of 80 year olds without back pain, 96% of them show degenerated discs. But none of these people experience back pain. Mind-blowing, right?
87% of people between 20-70 have bulging discs with NO PAIN (Nakashima 2015)
57% of 20-50 year olds with NO HIP PAIN show cartilage and ligament tears in their hips (Tresch 2016)
Have you been told that there is some degeneration in your spine? You'll be pleased to know: You're in good company!! :)
Wear and tear is just normal. We use our bodies just like we use other everyday items. All of them will undergo some wear and tear. But you can still use them just fine, right? Even if the colourful painting on your mug is starting to fade, you can still use that mug to have a really nice cup of coffee.
So we can conclude that:
Damage does not equal pain.
Some people might now think "Yeah okay, but...I do have an MRI showing degenerated discs and I do feel pain. Why is that then?"
I'm not saying that this cannot be a cause of pain. What I am saying: it is a little more complex :) Otherwise we would just fix a spine and pain would disappear. This however, is not the case:
46% of patients who underwent spinal fusion surgery experienced the same level of pain or worse after surgery (Chan 2011). 🤯
Let me make this clear: When the area that was thought to be causing the pain was repaired, absolutely nothing changed for those people! How is that possible? There is even a name for this, which itself I find crazy: Failed back surgery syndrome.
(Of course there are the remaining 54% for whom it works. So you can see that there might be value for some people - I'm not trying to dismiss surgery as an option here, I'm trying to inspire some critical thinking around it.)
There are two possible reasons for this. We will look at each one:
Even after surgery, the body has no other option but to keep loading the back in the same way. The surgery didn't address the cause of the problem. (Ever wondered why hip replacements need replacing so frequently? Is the body just moving in exactly the same way as before the surgery, still overloading that hip?)
The brain misinterprets signals from the body, amplifying a pain experience.
We will look at the second point first, because this article is mainly about what influences the pain experience.
As the data above shows us, damage does not equal pain. And getting rid of damage does not necessarily eliminate someone's pain. In order to understand that, we need to understand that part of the pain definitions above: an opinion on potential damage.
How pain works
Your body sends signals to your brain. It's like super highways of information. Information about joints, muscles, ligaments, temperature, pressure - everything is relayed to the brain. This happens constantly. When it reaches the brain, all of that stuff needs to be processed. What does it all mean in this particular moment in time? It doesn't matter so much what is sent up to the brain - what matters is what your brain makes of those signals in a given situation.
The brains of all those pain-free people mentioned in the statistics above also receive signals, for example from their spine and bulging discs. But their brain regards these signals as normal, wear and tear is not a huge deal. It's safe.
The brain of a chronic pain sufferer however interprets them as dangerous. It perceives the signals as a potential threat and it lets that person know about it by creating a pain experience.
Sadly, this consideration is not part of a standard treatment. And that is why so many treatments fail.
Since pain is 100% produced in the brain however, it is just as important! We'll see why:
Pain is our smoke alarm
Pain is like a warning signal. You get a warning which motivates you to take your hand off the flame. Generally, a warning signal can be quite useful. It makes us aware of when something bad happens, or is about to happen unless we change something:
You get a warning before your boss can fire you.
There are severe weather warnings!
You get a warning in sports before you're sent off (unless you really mess up!)
Warnings are there to prepare us, so that we can respond accordingly.
When it comes to pain, your brain does the same thing. It creates that experience, that warning for you. It's letting you know that something's not right here and you better do something about it. It's there to protect you. It's brilliant.
Pain is your smoke alarm. You have a smoke alarm in your house so that you can do something before things get really bad, right? In your brain, that alarm centre is called the amygdala, which together with 43 more regions of the brain come to the conclusion that this is now painful.
But how often has your toaster set off your smoke alarm because it somehow ended up on the highest setting? (seriously, who uses anything more than a 3?? Or is that just me?)
When this happens, it's not really that bad, is it? Apart from your breakfast tasting a little more bitter than you'd like, everything is actually pretty okay. Your toaster didn't even burn (thank god!)!
Your smoke alarm didn't know that though... Your smoke alarm did what it was meant to do: Detect smoke. Regardless of how dangerous or not it actually is.
Would we want to get rid of the smoke alarm because the toaster is annoying us? Definitely not. We absolutely rely on our pain smoke alarm to survive, but it can become really sensitive so that every little candle makes the fire brigade turn up at the front door! (The brain actually gets really good at calling them faster, thanks to neuroplasticity.)
We want to change that. We want to change how the brain interprets all those signals that come in so that it can differentiate between a candle and a full-on wildfire.
What constitutes a candle or a wild-fire depends on the context of a given situation. This further highlights that not all signals lead to the same pain outcome:
Pinch yourself. How much pain did you feel?
If you asked your partner or friend to pinch you, that would hurt quite a bit more.
If you asked a stranger on the street to pinch you - that would bloody hurt! What a bastard with his claws from hell!
Even if all 3 of you applied the exact same force, your pain experience would be very very different. If you're reading this and you don't believe it, go try it (but don't blame me afterwards!).
You yourself don't pose a huge threat (or do you?? More on that later!).
Your partner, in this context a little more.
But a stranger? Tiny pinch, a lot of pain because you have no idea what this person might do to you. The signals from the tissues were the exact same, the level of threat was different. And that is what makes the pain experience so different.
See, told you pain is complex :) But also pretty fascinating!
High alert & fear and their role in chronic pain
The above is the case because our organism is inherently cautious. It wants to survive. Our pain smoke alarm is part of the toolbox to help with that survival. But just how cautious is it? What's perceived as a dangerous fire, what's okay?
The interpretation of those signals comes down to the level of alertness and the context. Funnily enough, it's not just about being pinched by someone else - it applies to anything in life. See for yourself:
It's the end of the day. Your partner or friend asks you to go to the shop to buy a yogurt that he or she likes so much.
It's a nice warm Saturday. You spent the whole day doing what you love doing and you had a great time with your partner. After an absolutely wonderful day together, exploring nature, breathing fresh air, watching the local wildlife, your partner is cooking dinner and asks you to get that yogurt please. Your response might be something like this: "Oh of course darling. No problem at all! See you in 20 minutes. Love you!"
On your way to the shop you feel great because of the selfless act you're undertaking. You're happy that after such a great day you even get the chance to make him/her happy with her favorite yogurt.
It's a Monday. Mondays suck anyways. You have that weekly meeting with your boss and as always, he dumps everything that he doesn't want to do himself...on you. That's on top of the work that you didn't finish on Friday, of course. Then that bloody computer crashes before you got the chance to save that spreadsheet - 3 hours of work gone. Hallelujah!!
To top it off, on the way home you're stuck in traffic because god knows why, and your boss calls you to check that you really did that thing - that thing that he didn't even tell you about! WTF!
Finally home. Finally! It's late and you realise it's only Monday...
Then you hear it from the kitchen: "Hey honey, would you mind driving to the shop again to buy my raspberry yogurt?"
That bloody yogurt that you don't even like !!!
In order to spare you the swear words I will skip the (internal?) dialogue you might be having :). But can you see how our reaction in that context might be the complete opposite to scenario 1??
It was the same request. But in scenario 2 we were on such high alert, that it took the same friendly request to make us go through the roof. Similar to the pinching experiment.
The more alert or vigilant I am, the more likely I'm going to react like you do when there's an alert. Or how a smoke alarm reacts to smoke.
The more alert I am, the more I look for danger around me. It's inevitable, it's natural. Whether I like it or not, whether I'm aware of it or not, I start seeing everything and everyone around me as a potential threat.
How about you? Would you say you're frequently in a state of high alert, only waiting for something to happen? Has this become the norm? This doesn't have to be a boss who annoys you like scenario 2. This could also be your need to do everything perfectly. Is there a constant (more or less hidden) fear that something might happen "if..." ?
Does that resonate? Can you relate to that at all? Are you just waiting for something to happen?
How 'on edge' are you? How often, or how quickly do you feel like 'everything is too much' or like situations are out of control?
How sensitive to, for example, noises, or sudden movements in the corner of your eye are you?
How much do you worry? How many what-if scenarios go through your head? Do you expect the worst as a default?
Are you anxious? How do you react to (self-) criticism? Are you often looking for faults in your own or others' doing? Looking for what's wrong or could be better?
If you can relate to this, then you might have just realised that you tend towards a state of high alert. This is really really important because:
High alert feeds the the smoke alarm. It's ready to go off any second! Waiting for something (a signal, perhaps?) to come so it can start ringing.
A high alert state shifts our nervous system into a state of fight or flight. Our nervous system responds to an argument with our boss in the exact same way as it does when a lion comes around the corner. It is the same response when you worry that you won't be able to fit in at that dinner party. It's the same reaction when you feel like you will never find a partner. It's the same reaction when you have to check your social media every 2 minutes.
For the nervous system this is all vigilance, probably hyper-vigilance. It's stressed and it's ready to fight. This sets the smoke alarm - All. The. Time.
If there's the need to be alert all the time, left, right and centre, it might actually upgrade your smoke alarm to a Mission Impossible style alarm system. Are you in a state where you detect everything?
So what if you live your life in constant state of high alert?
How much more smoke, that you may not see at the moment, is there?
And how quickly do you detect anything that's there?? How sensitive is your alarm system due to that hyper-vigilance?
If you've tried everything and you're still in pain, especially if you're in pain seemingly everywhere, this is something we absolutely need to understand. I will go into more detail on how we do that later.
Pain is simply the messenger that is letting you know that you are not safe. Our brain evaluates the whole situation with this question in mind: How dangerous is this for me here right now?
What however leads to a perception of danger is fear of danger. Physically, emotionally, socially. Fear feeds pain. Pain then feeds more fear and you enter a vicious cycle. The fear-pain cycle.
If you've received an MRI finding, how did you feel about that? Did it make you feel calm or more worried because you had confirmation that som^ething is seriously wrong with you? Research shows that simply telling people that something is wrong with their body creates pain, even in the absence of actual damage. That is because it instills fear and worry. We all know the feeling when we google a symptom, and every cough is probably the first sign of cancer, right?
There are fascinating studies on this:
Castro et al. ran a study in which they set up a fake car accident. They called it a placebo collision. Participants however believed that they were in a real collision (the set up was pretty clever). So: no accident, but people believed they were in one. What did the participants report? 20% of the participants reported symptoms of whiplash. Physical injury however was impossible. Crazy, right? It was the fear and the belief that lead to very real pain, when structural damage was not possible at all.
Schweiger & Parducci found that people were experiencing headaches and pain when they were told that an electrical current was sent through their head and that these currents can cause pain as a side effect... Only that the current didn't actually exist! Nothing was sent through the participants' bodies. Their pain however, was real.
It works the other way too: You know what's the most powerful drug in the world? A sugar pill. The placebo effect actually solves people's problems if they believe they're taking a real pill.
Earlier we concluded that damage does not equal pain. Now we can also conclude that:
Pain does not equal damage!
This is really good news! This is something to celebrate because it gives us something to work with.
Our beliefs drive all of that. Our beliefs exist in our brain - the same place where pain is created. This doesn't mean it's all in our head though (I mean...it is, because the brain is inside our head :)). Our brain has simply made certain associations over the years. It connects the dots based on what it "knows". If I learn that my spine is messed up (even if it isn't, but I trust the person in a white coat), this 100% affects what my brain makes of any back movement. Now every time I do move my back, those "I'm messed up, be careful" neurons fire together with neurons that are involved in the movement of the spine. This eventually starts going hand in hand, and firing one neuron automatically triggers the other with it: Neurons that fire together, wire together.
But unfortunately the science behind this is not communicated like that:
Of course, when something hurts we expect that something is wrong with us. So we see a doctor. It's the pain, the worry and the fear that makes us go see that doctor. But what happens next, is often not very helpful for the person. I hear it on a weekly basis that these conversations often go like this:
"Hey doc, what's wrong with my back? What did you see on that MRI?"
"Well let me tell you, that disk there around L4/L5... Oh man, I'm surprised you're still standing! That's really not looking good mate."
What do you think does language like that create in the patient?
Exactly: fear, worry, desperation. Effectively: Danger. The fear-pain cycle is in full swing.
Fear creates pain.
Pain creates more fear.
More fear creates more pain.
More pain then creates...you get the idea!
Now imagine what happens if you do get back surgery and it fails. As we saw above, almost half of those patients still experience the same pain or worse after surgery. But now you get a label for yourself: You suffer from failed back surgery syndrome that no-one can explain to you. Not only do you worry even more that something is truly wrong with you, it might even become your identity. Does that help you, does it empower you? Or does it set the stage for even more pain and that civious cycle?
(I appreciate that not all doctors speak to their patients like that, but this is what my clients tell me over and over again. This is exactly the reason why I wrote this piece - to provide clarity and education for those that can relate to this example.)
How to let your body & brain heal
Okay, so to recap:
Pain is useful to protect us, like a smoke alarm
That smoke alarm may be triggered by signals from our body
Whether we experience pain - the alarm going off - depends on which signals are coming in, and how the signals are then interpreted
Due to that (mis-)interpretation it is possible to feel pain without any damage, and also to have damage without any pain
Alertness, worry and fear are the breeding ground for more pain, which in itself tends to create more worry and fear: the vicious fear-pain cycle that we need to break.
So then, what does it take to change that?
On paper (or on a screen) the answer to this is fairly simple: We need the opposite of threat, the opposite of fear. We need safety. Or more precisely: we need experiences of safety that our brain can work with.
Remember, the brain constantly asks: "How dangerous is this for me right now?"
If your doctor tells you about how messed up your spine is, this is quite the opposite to feeling calm and safe. Especially if they don't tell you why that is the case.
So is this all psychological? No, but it's potentially a big part of it.