Understanding Pain

Written by Tele Demetrious


For optimal recovery following injury, it is important to address any factors which may impact the recovery process. Whilst most injuries are caused by physical forces, such as trauma or overuse, other social, biological, cultural, environmental and psychological factors such as the way we think about our injuries can play a significant role in accelerating or impeding our recovery, sensitising or desensitising our nervous system and moderating the degree of suffering and pain experienced due to injury.

In this article, we explore pain and some bio-psycho-social strategies that may be utilised to assist with achieving an optimal outcome following injury.

Understanding Pain

What is Pain?

Pain can be defined as an unpleasant sensory or emotional experience associated with actual or potential tissue damage. Pain, whilst unpleasant can be extremely useful, keeping us safe and guiding our choices to prevent injury (i.e. a lack of pain lets us know it’s ok to touch a warm stove, but touching a hot stove, burning your skin and causing pain, may not be such a good idea). Pain is also a very useful guide to choosing appropriate activity levels following injury (i.e. for most injuries, it is generally appropriate to participate in levels of activity that do not cause an increase in pain), therefore preventing further tissue damage and allowing the natural healing process to take place.

However sometimes, particularly in the case of chronic injuries, pain experienced by an individual may be less about tissue damage and more about the sensitivity of the nervous system. One example of pain experienced in the absence of tissue damage includes those phantom limb pains experienced by amputees whereby ongoing pain is experienced in the amputated limb days, months or years following the amputation (clearly in the absence of further tissue damage). Whilst this is an extreme example, a very similar physiological process can occur in many individuals with common injuries that persist beyond normal healing times. In fact, it is estimated that around 1 in 4 individuals has a chronic pain state that defies tissue healing times.

Not only is it possible to have pain without tissue damage (e.g. in the phantom limb pain example described above), but it is also possible to have tissue damage without pain. For example there are many reports of soldiers in wartime having extensive injuries to their limbs, but yet are able to rescue their injured comrade without noticing any pain of their own injury. Another example is the person who goes back into the burning house to save a loved one without noticing the pain from the extensive burns to their feet.

Recent research utilising MRI scanning has further expanded our understanding of pain. We now know that many areas of the brain (up to 400 areas) are active simultaneously when an individual experiences pain and that this pain pattern varies between individuals. Areas of the brain previously thought to be uninvolved in pain, such as those areas responsible for processing smell, taste, sound, vision etc., are often activated during a pain response. We also know that 100% of pain is created by the brain and that negative emotions, such as stress, anxiety, depression, anger, fear etc., can directly stimulate pain pathways.

The sensitive nervous system

Certain social, biological, cultural, environmental and psychological factors may act to sensitise the nervous system (brain, spinal cord and associated nerves) so that pain signals may be experienced as more painful than they would normally be (i.e. hyperalgesia) and normal sensations (such as tissue stretching or compression) may be perceived as painful (i.e. allodynia). Collectively these bio-psycho-social factors that sensitise the nervous system may be broadly categorised as ‘danger’ signals. These factors may act in isolation or combination causing individuals to experience greater degrees of pain than they would otherwise. There are many potential factors which may act as danger signals, with significant variation between individuals. As a general rule, a factor can only be a danger signal if it is perceived to be so by an individual. Some examples of potential danger signals may include:

In contrast, other bio-psycho-social factors may act to desensitise the nervous system and counteract ‘danger’ signals so that pain signals may be experienced as less painful than they may otherwise be. Collectively, these factors may be broadly categorised as ‘safety’ signals. There are many potential factors which may act as safety signals with marked variation between individuals. Factors can only act as safety signals if they are perceived to be so by an individual. Some potential examples of safety signals may include:

Danger / safety signal balance

The balance between the number and type of danger and safety signals present in an individual’s life can directly influence whether pain is experienced in a given situation and the severity of the pain experience. For example, a patient with whiplash from a car accident may experience more neck pain after having an argument with their partner, hearing about a friend whose neck whiplash never resolved and driving their car through the intersection where the original incident took place. In contrast, the same patient with whiplash from a car accident may experience little or no neck pain when driving their car on a beautiful sunny day, listening to their favourite music, with a close friend as a passenger who has just told them a great joke and they are both having a belly laugh.

Subsequently, to help desensitise your nervous system it is useful to:

Remember that the brain is bioplastic (capable of physical and biological change). This means that factors that have caused sensitisation of the nervous system are reversible – we simply have to train the brain (like a muscle) and exercise alternative neural pathways by finding more safety signals and less danger signals in your life.

The role of attention in pain

Another factor to consider in the overall pain pattern is the influence of attention on a pain experience. We all know that in order to experience pain, we have to be conscious. For example, we don’t experience pain when we are asleep or under anaesthetic (such as during surgery). The converse can also be true – the more conscious and aware we are of an injury (i.e. the more we pay attention to it or think about it), the better our brain becomes at picking up signals in that injured area, sensitising the nervous system and increasing our pain experience. Subsequently, it is generally not productive to excessively monitor, think or talk about an injury.

The opposite extreme of the attention spectrum is also not useful, i.e. patients who ignore their pain (giving it no attention) and work or exercise through pain (such as adopting a ‘no pain no gain’ attitude) typically cause ongoing tissue damage and may slow healing or prevent healing altogether.

Subsequently, a more balanced approach is required to allow tissue healing whilst preventing excessive attention (and potential nervous system sensitisation). This should generally entail listening to your body and responding appropriately when required (for example when you have overdone it and your condition is overall worse as a result) and then giving yourself some mental space by ensuring it is not on your mind at other times. Every significant flare up of your condition is an opportunity to learn how much activity is appropriate for your condition and then use this information moving forwards. If you find you are thinking about your injury excessively, practise instead focusing your full attention on whatever you are doing or perhaps other sensations in your body (be curious in your exploration and pay full attention to your other senses – such as what you can hear, see, smell or taste, the feeling of breath coming into and leaving your body, the feeling of your feet touching the ground with each step or the sensation of water on your skin as you wash your hands etc.). Another strategy is to participate in activities you love that can be happy distractions.

Understanding Pain – Hurt vs. Harm

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Natural Pain Relief

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Strategies to reduce pain and suffering

Things to avoid

Other Useful Strategies

In summary pain (particularly chronic pain that defies tissue healing times) can be complex, but when looked at from a broad biopsychosocial perspective offers many opportunities to positively impact the recovery process, desensitise the nervous system, retrain the brain and minimise pain and suffering experienced due to injury.

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