PAIN - What The Heck Is It?!?!
We are going to kick off 2022 with a “light” blog discussing: PAIN! We know, we know… a pretty heavy topic especially when everything feels painful these days. But, stay with us, because this is SUPER important and 99% of the time why folks reach out to us - they are in pain.
The Basics: What is Pain?
Pain is our body's alert system, which lives in our brain. It is designed to keep us safe and out of danger. For example, if you touch a hot pan you will experience a sensation that tells you to remove your hand quickly. Pain is even experienced as muscle soreness after an intense workout, which many of us are familiar with. Put simply, pain is a protective mechanism and it is essential for survival.
There isn’t a single “pain center” in our brain. Neuroscience shows that pain is a “diffuse neurological process,” meaning there are multiple areas of our brain that contribute to the experience of pain.
Acute Pain vs Chronic Pain
Acute: short-term pain, resolves within 3 months
Chronic: Greater than 3 months or beyond expected healing times. Chronic pain can be linked to a condition, like Fibromyalgia, or have no known cause.
Both acute and chronic pain can be experienced anywhere in your body.
The Not-So Basic: What areas of the brain process pain?
Cerebral Cortex: thought center - what we think and how we think
Limbic System: emotions center - how we feel
Prefrontal Cortex: attentional processes/executive functions - deciding between good/bad, same/different, prediction of outcomes…our decision-making center
Woah, woah, woah. Pause. Think about that…
Pain is constructed in the brain where we process emotions, thoughts and beliefs, physical environment, traumatic experiences, AND social factors. Meaning:
Pain = Bio-psycho-social
Bio: genetics, tissue damage, inflammation, diet, sleep, etc
Psych: thoughts, beliefs, emotions, coping behaviors, etc
Social: family, friends, socioeconomic factors, culture, etc
Problems that we see:
It was believed that pain was purely biological/biomedical, which would mean that if you have pain it is only because there is a body tissue or structure that is damaged. We know now, this simply isn’t true 100% of the time. However, this is often how we continue to treat pain. We get x-rays, MRIs and other medical workups and are provided with “solutions” like pills, surgeries, injections, etc.
To be more specific on pain transmission…
We have pain receptors (nociceptors) that are activated and send a signal up a nerve to the spinal cord up to the neck.
The pain signal is transmitted across the spinal cord (in the dorsal horn) by chemical messengers (neurotransmitters) and passed up the spinal cord to the brain.
The signal reaches the thalamus which sorts the signal to: somatosensory cortex (physical sensation), frontal cortex (responsible for thinking), AND the limbic system (responsible for emotions) in order to determine a pain response.
Let’s back some of this all up with research before going any further…
A systematic literature review in 2015 looked at Spinal Degeneration in ASYMPTOMATIC populations. To be clear, this study looked at back images for folks who were experiencing ZERO pain. They utilized 33 articles that met their criteria that included 3110 people ages 20’s to 80’s years of age.
Findings?
Disc Degeneration: 37% of 20 year old individuals to 96% of 80 year olds
Disc Bulge: 30% of 20 year old individuals to 84% of 80 year olds
Disk Protrusion: 29% of 20 year old individuals to 43% of 80 year olds
Annular Fissure: 19% of 20 year old individuals to 29% of 80 year olds
Conclusions?
Imaging findings of spine degeneration are present in high proportions of asymptomatic folks and it increases with age. This is an example of how the body can have tissue damage/degeneration without pain. Study found HERE.
One of our favorite examples that really drives home how your brain is the ruler of all is found in these two case studies. These are most interesting because they relate to acute pain.
A construction worker jumped off a plank at a construction site and straight onto a seven inch nail that penetrated his boot through the top of his boot. His pain was so severe that he was rushed to the hospital and sedated with pain medication. When the doctors removed his boot, they discovered that the nail had miraculously passed through the space between his toes. His skin was never penetrated, not even a scratch. Was his pain fake? Heck no, he was feeling severe pain. By looking at the nail coming out of the top of his boot his danger detectors were going off like the New Year’s Eve fireworks. The thoughts, beliefs, and emotions coupled with panic and fear sent his body into a cascade of biological and neurochemical processes. In this case, given the situation, the brain made pain and the body responded to protect this man from additional harm. This was a case of real pain in the absence of actual tissue damage.
Another construction worker. This man was using a nail gun that backfired and hit him in the face. He had a mild toothache and a bruise under his jaw, he didn’t think he was injured and continued working. Six days later he went to the dentist. So, six days of normal life…to his surprise an x-ray revealed a four-inch nail embedded in his head. He had hardly any contextual cues and his pain system remained quiet despite the need for a serious medical intervention. A case of little to no pain in the presence of tissue damage.
Lastly, to highlight how we know that pain is constructed in the brain, there is a phenomenon called phantom limb pain. If you’ve ever worked with or known someone who has lost a limb it is pretty crazy. Folks who have undergone an amputation can experience severe pain in the limb that is missing. How can you have pain in your body when you don’t even have that body part anymore? Because pain lives in the brain.
Takeaways?
Hurt does not always equal harm.
Pain does not always equal tissue damage.
How Does Pain Work?
Our brain and spinal cord are part of a system referred to as the central nervous system (CNS); you’ve probably heard of this term. Your CNS is your command center. As mentioned earlier, there is always two-way traffic in your spinal cord sending messages from your body up to your brain and down from your brain to your body.
Information from your nociceptors (pain receptors) travel up to your brain and your brain interprets these signals and determines how to respond. When your brain thinks protection is required, it creates pain. This means that the context, thoughts, prior experiences, memories, emotions, and the meaning that you assign to your pain all change your experience of it. This is why the above statement “hurt does not always equal harm” is true.
The context matters. An arm pinch feels differently if it is a needle from a shot vs a friend giving you a little squeeze. Have you ever played a sports game only to realize you had blood on your leg only after the game ended? Got into the shower and noticed you had a bruise and no idea how it happened?
I remember a very specific example of this. I was about 12 years old and flying through the woods on my bike down a four wheeler trail. I hit something, was stopped in my tracks and went all-out OTB (over the bars) sailing through the air. I completely knocked the wind out of myself. As I was walking out of the woods gasping for air, I was unaware of the fact that my thigh had a puncture in it from a small stump that I landed on and there was a steady stream of blood going down my leg. My friend, in horror, alerted me of the blood. I didn’t feel pain in this area until I lifted the bottom of my shorts up and saw the open wound.
In that case, my brain prioritized breathing as my primary need and the wound second, allowing me to catch my breath.
Don’t Panic - It’s not all bad.
This might have your head spinning, but fear not, our pain system is “plastic” meaning it is malleable. Read on.
Our brain has a remarkable ability to grow and change, this is termed neuroplasticity.
Most folks who experience chronic pain feel hopeless, but there is hope because our body’s are incredible at adapting and changing over time.
Neurons that fire together, wire together.
What does this mean? The more you practice a skill, the better you become at it. No one is magically good at playing the piano from the get-go. It takes time and dedication and with what was initially clumsy key-to-key transitions becomes your fingers just playing the music without thought. With practice, your brain and body developed a “piano pathway.”
Similarly, if you “practice pain,” your body becomes exceptional at making your pain pathway strong. This means that your brain has become sensitive to pain. You can think of this as a pain dial and it’s turned up loud.
Let’s pause for a moment here because what we often find is that people get very defensive at this point.
We want to be clear: your pain is very real, but is there immediate danger? With chronic pain, the prefrontal cortex of your brain is on high alert with this sensitivity, constantly scanning your environment for danger. Think of this as your nervous system is really “good” at pain and your body’s response is louder. In this case, the pain response is an unreliable indicator of actual tissue damage.
Desensitizing is a critical part of breaking the pain cycle.
Our “pain dial” is influenced by stress and anxiety, mood and attention. Remember, this is because of where our body processes pain in the different parts of our brain.
What we think affects how we feel emotionally, how we feel physically, and how we act and behave.
With a trigger, this circle can go round and round, in any direction. For example:
Trigger = Pain
Thoughts/Beliefs (I’ll never get better, pain = physical damage) →
Emotions (stressed, frustrated) →
Body Responses (muscle tension, pain) →
Behaviors (avoid activities, isolate from friends/family)
Negative thoughts and stress have a direct connection to pain.
And, here is why:
If you look at our human evolution, we were hunters. We had to hunt for our food, and other animals hunted us. If a saber-toothed tiger was approaching you, your body’s stress-response system - your sympathetic nervous system (SNS) and hypothalamic-pituary-adrenal axis (HPA) get you ready for action. Stress hormones like adrenaline are released into your bloodstream. This prepares you to either: fight, flight, or freeze. Adrenaline affects our body in many ways in order to react: accelerates heart rate, stops digestion, tenses muscle, triggers feelings of fear, etc. These are normal responses and are essential for survival. You don’t want your brain to interpret a saber-toothed tiger as “oh, look at that big-toothed cat, how cute, I should go give it a pat on the head”.
Fortunately, we don’t have to fight off saber-toothed tigers anymore, but unfortunately and fortunately we still have the same basic nervous system. It goes off all of the time, in the same way, throughout our daily life: if you are reading the news, have a work deadline approaching, etc. Your body ALSO releases stress hormones when you are sick and in pain. Stress keeps this emergency system activated, which sensitizes your nervous system, which in turn, you guessed it, causes a higher pain volume. (Side note - anxiety and depression are also biopsychosocial in nature, but we aren’t going to dive into that).
Having an awareness that our body is designed to respond this way, and that the response may not be as helpful as it may seem, is the first step in changing your relationship with pain.
In response to stress and anxiety, your body also produces pro-inflammatory cytokines, these are chemicals that trigger inflammation, along with other neurotransmitters and neuropeptides which impact immune functioning. This can trigger headaches, stomachaches, and muscle pain. Stress affects pain and there’s a real biological link between stress, anxiety, mood, and pain.
Additionally, negative thoughts, emotions, and memories ALSO trigger the release of cytokines. Research also demonstrates that negative expectations amplify pain resulting in increased signaling from the spinal cord to the brain. If you think poorly about your outcomes, pain will increase and this doesn’t mean it’s all in your head - there is an actual body response that occurs.
THE GOOD NEWS.
For everything that we’ve highlighted the opposite is also true. Thoughts and memories that provoke happiness, relaxation, gratitude, optimism, etc facilitate improved immune functioning, reduced risk for disease, and better overall health. The bottom line - this will turn down your pain dial. Sounds crazy, but when it comes to pain, changing our thoughts can actually change our pain by reducing our nervous system responses. Our brain is amazingly powerful and it can build us up or tear us down. See resources below to learn more.
We hope this sheds some light on what pain actually is and if you’ve been feeling hopeless about ongoing pain that you’re experiencing, reach out to us so we can have a conversation and find ways to get you back on track.
All information used to write this blog was adapted and generated from: The Pain Management Workbook by Dr. Rachel Zoffness. This book is designed to be a tool to help you how to regain control of your life and teach you techniques to manage pain. It is jam packed with science, stories, and strategies to reduce pain.
You can also listen to Dr. Zoffness discuss pain in this fun and engaging conversation on the Ologies Podcast: Dolorolgy.