You would have every right to be offended if someone said your pain was all in your head. But the truth is, pain is constructed entirely in the brain. This doesn’t mean your pain is any less real, it’s just that your brain literally creates what your body feels, and in cases of chronic pain, your brain helps perpetuate it.
A growing understanding of how this happens, and the need to find better alternatives to pain medications, has led to renewed interest in “biopsychosocial pain management.” This type of treatment addresses situations, beliefs, expectations and emotions that cause a person to perceive pain in a certain way.
Unlike drugs, biopsychosocial methods don’t mask or numb chronic pain. Instead, patients learn to manage pain by modifying or changing what their brain tells them. Many say this approach relieves pain without drugs and in some cases, it’s the first time they’ve got relief.
Why You Hurt:
Pain is a complicated warning system to protect you from harm. When you stub your toe, your peripheral nervous system sends signals to your brain which then decides how much danger there is. If it decides the signals are worth paying attention to, the pain volume is cranked up until the problem is resolved, if not, pain is put on mute and dissipates quickly.
This system works pretty well for acute pain like an injured toe but in chronic conditions like osteoarthritis or broken limbs, where there’s no quick fix or like cartilage loss in the knee, the parts of the brain that send and receive danger signals become more sensitive over time. The more the brain processes pain, the more perceptive it gets until it’s always on high alert and depending on the person’s emotions, beliefs and expectations, the brain will likely keep registering an aching knee day after day even if the physical symptoms are pretty mild. This process will continue until pain is almost constant.
This is how people with chronic pain get locked in self-perpetuating pain, but evidence suggests that it’s possible to tone down an overly sensitive brain and moderate chronic pain messages. Here’s what science has found, and how it can work in real life.
For Better or Worse:
Research into pain is being carried out continually with many avenues and strings of research trying to find the “magic” answer with much of the work focussing on placebo and nocebo effects. The placebo effect occurs when patients get better with a replacement or non-active treatment, in a surprisingly high number of clinical trials patients given placebos get better or experience little or no pain simply because they believe it will help. Placebos appear to work in some cases even when patients know they’re not real.
A nocebo effect occurs when patients are told a harmless treatment will make them feel bad, and it does.
Both placebo and nocebo effects are seen as key factors in understanding how the brain works and interprets the signals, especially with regard to pain. The brain uses context, beliefs, expectations and emotion to pre form the outcomes and feelings and just like patients given placebos, patients told that a procedure will hurt or they will suffer pain. Even when the procedure is completely painless.
Filling in the Picture:
Context is the setting where something happens, your doctor’s surgery, for example. If you’ve heard of “white coat” syndrome you’ll understand that a patients blood pressure can go sky high just by seeing a doctor or even just being told that their blood pressure is going to be taken. If you have a history of beneficial treatment with a certain doctor or practitioner this might enhance your expectations for a positive outcome. Likewise, if you have a history of ineffective treatment, this might lead to negative expectations that worsen symptoms. Pure and simple fact and probably something we can all relate to and not just in a medical context.
How many situations have you been going to, a meeting or whatever, and all you think about is the worst outcome? That’s because when the worst doesn’t happen, it’s a “win” that’s how our brains how been programmed to think. Similarly, positive expectations can tone down chronic pain, and negative expectations can ramp it up. In other words, if you expect something to hurt like hell and have a dreadful outcome, it probably will.
And how does this just happen then? Many studies show that positive expectations or beliefs change brain chemistry, causing the body to produce pain-blocking chemicals like opioids and dopamine and literally changing the experience.
There’s less research on the nocebo effect, but evidence suggests negative expectations and beliefs increase anxiety, which in turn causes the release of cholecystokinin (CCK), a hormone linked to anxiety, creating a self-perpetuating loop. CCK has been shown to reduce or block the action of opioid medications and even acupuncture, which may help explain why people who are anxious or depressed are harder to treat. Not just harder to treat but their conditions and pain become self-fulfilling, in a lot of cases take away the pain and you take part of them away.
We all know people that when you meet them and you say “how are you”? the first thing they talk about is their ailments and pain, take the pain away and they have nothing to talk about, part of them is missing. That’s not to say there isn’t pain, it’s just being given too high a priority in their brain and personality.
Power of Emotions:
Pain and emotion circuits overlap in the brain. This shared neural network has been called nature’s “economy route,” because it allows the brain to process a lot of sensations at once. Negative emotions are like petrol thrown on the fire of pain, not only making chronic pain much worse, but even causing it in some cases. Just have a think about that!!
Two-thirds of patients recently surveyed who suffer with chronic Arthritis and long term pain conditions reported that they felt depressed and could not see a way out of their pain.
The opposite is also true. Positive emotions can significantly lower pain when patients stop focusing on how bad they feel, many with chronic pain agree, noting that when they’re “in a worse place emotionally,” they’re less motivated to exercise and see friends and family. These are essential to changing pain patterns because they help break the pattern of ruminating on pain and they trigger the release of feel-good endorphins and the body’s natural opioids.
Taking Control:
Recent studies have shown that a sense of powerlessness helps shape patients’ perceptions of pain. The results recorded that if the patient perceived themselves to be in pain or incapacitated, then they acted like it and adjusted their movements and lifestyle accordingly. Patients were observed in limiting movement, journeys out of the house and any form of social interaction or exercise in the belief it would limit pain. In reality this worsens physician symptoms, increases pain and eventually this situation for most patients spiralled downwards and declined over time. Well, that’s not life, that’s not function, that’s a living sentence.
The key is restoring patients sense of control, which is known to reduce pain-related emotional distress and improve function. Various programs for helping cancer patients control their pain has been trialled with greater or lesser results. What was clear though was patient expectations, realising that pain was part of the condition, they would not be pain free but learning that it did not have to control them.
Pain advocacy focuses on patients’ communication with doctors, practitioners and other medical staff. There’s a dynamic that goes on when a person just complains, so the programs focus on improving that dynamic. Being as precise as possible i.e. I can’t sleep at night, I can’t walk the dog, making conversations around pain concrete and actionable reinstated a feeling of control.
Living with pain can be where the real magic happens, although some people won’t experience a total cure for chronic pain, sometimes you have to accept that pain is a normal part of the human experience, but if we can get pain to the level where it’s not running your life, where you are in control, that can be thrilling.
The problem is resources and finding medical staff who won’t just dish out pills as if they are smarties but try and get behind the specifics of the patients pain, help them manage their expectations and find a way to slowly help them restore normal function.
It has been proven that focussing on nonpharmacological therapies like visualization, distraction and relaxation techniques, hypnotherapy, complimentary therapies, talking therapies and good old fashioned exercise and fresh air go a long way to reducing pain.
The Hierarchy of Pain:
Pain and all it’s facets is a passion of mine and reducing patients pain and restoring normal function is massively satisfying. But something that pops up time and time again is how the pain “moves” around the body. Interesting, but actually in reality it doesn’t, here’s why.
Let’s say a patient comes in with a tight and restricted right shoulder, restricted movement, some headaches and not sleeping well, pretty straight forward. So I get to work, some treatment, some heat and some exercises, after some sessions the pain reduces and after a few more it’s almost gone.
Suddenly their left shoulder starts to have pain and they notice restricted movement, in their mind the pain has shifted. In reality the pain and restriction in the left shoulder has always been there, they just haven’t noticed it.
Here’s how it works: The brain sees pain as a threat and it sees it in a way that is steeped in time, the Fight or Flight complex. If I have pain, I won’t be able to fight, run away or hide, so what I’ll do is notice the area of greatest pain to ensure that if I have to react something has been done about it or I’ll find another way to move or escape, and I won’t get eaten by the Tiger.
So the first biggest threat is the pain in the right shoulder as soon as that’s cleared the brain notices the next biggest area of pain, because that could hinder Fight or Flight, and that’s now the right shoulder and so on and so on. The biggest area of pain could be as issue so let’s focus on that.
So as you can see pain really is a complex issue buried deep in our brain as well as a physical issue. When someone is injured the issue starts off as purely a physical matter and at some point in time this is taken over by the neurological rehabilitation. And in some ways we have created our own monster.
We want to be injury free quickly without any effort and just have an instant “fix” for the issue, we’ve also lost the ability to recognise that pain is a part of life and sometimes we have to accept it for what it is.
When a lot more jobs entailed manual work, or people stood for jobs all day, or there was a lot more repetitive activities people understood that pain was part of life, there was no reaching for over the counter pain killers or prescribed opioids ……. They didn’t exist.
We now have a medical fraternity and a culture where dishing out pain killers like smarties is acceptable and demanded and if everybody was brutally honest, it isn’t working. It’s time to get back to basics and try something different.