Audience: Patients with any type of pain or injuryPurpose: to learn a little about pain and convince you that pain is not in your head even though your brain plays a big role

Why? Understanding pain helps decrease pain and helps us make better choices in the treatment of injury

Some brief pain information tidbits

you don't need a leg to feel pain in that leg (e.g. phantom limb pain)
you always need a Brain to feel pain
pain can become a habit - and like all habits lots of factors help keep it going
Changes in how we feel pain can also come from changes in the brain and the nervous system
tissue damage or degeneration does not have to lead to pain - but it certainly can

Damage does not always equal pain

The idea that lots of pain equals lots of damage is a very difficult concept to shake. It is entrenched in how we think about pain, arthritis, surgery and injuries. When we have pain we want to know what is causing it. We assume there must be something damaged and that causes our pain. The problem with this is that the majority of us are walking around with some degenerative joint disease, disc protrusions, tears in our shoulder rotator cuff and all kinds of things that look like damage YET we have no pain. Conversely, you can have a lot of pain and all the imaging shows that there is no damage. This can be extremely frustrating for someone in pain. Take a look at this rather dry post that details a number of research studies showing the poor relationship between joint damage and pain.

However, sometimes damage certainly does lead to pain. If you break your arm it will hurt. But in a week, that arm will still be broken but you can be out of pain. I also know, that many people with hip degeneration are in a lot of pain, they then get a hip replacement and they are out of pain. This is wonderful.

So why does some damage end up leading to pain and other damage doesn't?

Several factors can contribute to our experiencing pain. The leading theory on pain is the Neuromatrix Theory. In a crude nutshell, it suggests that the brain ultimately decides how much pain you will feel. The brain takes in all kinds of information and then makes a decision. With a recent injury we think that you feel pain, swelling, weakness, tightness, guarding all because the brain is trying to protect you. The area of the injury will get more sensitive and your brain can get better at producing pain. The brain thinks that pain is a good thing. Unfortunately, pain can persist for a long time after the pain is useful. For whatever reason the brain, your nerves, your muscles, your immune system, your endocrine system all stay sensitized. Its now easier for you to feel pain.

But none of this is all in your head. In fact, this is how athletic excellence works

The brain learns and you become a better athlete/guitar player/knitter

In some ways we can think of pain as habit. Our nerves and brain get better at making pain. Now, I know this sounds like I am saying this is psychological because I'm talking about the brain. But would you ever say its psychological when you get stronger after working out for 6 weeks? Of course not, but after exercise training much of the reason we get stronger or perform better is because the brain and nervous system become better at the task. This is similar to what happens with pain. We get sensitized and better at producing pain.

Pain is neither a barometer or a GPS

The pain we feel gets out of whack with any damage we have. The pain becomes the bigger problem than any wear and tear. Pain is now a poor guage of how much injury there is. Pain is also horrible for telling us where the problem is. Where do people feel pain when they have a heart attack? Their arm, neck, chest and back. There is nothing wrong with their arm. This is how we need to think about pain. It is just an alarm that goes off.

The overly sensitive alarm

If a fire alarm goes off in a building we have no idea if the alarm is due to a large fire, lighter held underneath a sensor, a little bit of smoke or even some problems with the wiring. We can even put of the fire and the fire alarm will still go off. This is how we can think about the pain alarm that goes off in our body. It can stay on long after any damage has healed. You can even think of pain as a cranky toddler. The pain or response of the toddler is often out of proportion to their injury. At an unconscious level this is what can happen with our body. A disconnect between damage and pain and we are left with screaming joints or muscles.

Again, the pain is not in your head

You might ask why I keep talking about cranky nerves and a cranky brain when you know that there are problems with your muscles and your joints. I would probably agree with you. When we have pain for awhile we move differently. We can get weaker, we can get stiffer, muscles can compensate, you might slouch or limp or move poorly. All of these things can either be caused by your pain or can be contributing to it. Addressing them can be helpful but surprisingly it is not often necessary. Often, we can change your pain immediately and you will have immediate change in strength or range of motion.

Treatment is about decreasing the sensitivity of the system

You have threshold to where you feel pain. Treatment is about increasing this threshold. This can be done a number of ways. Good treatment should try to address as many different factors that influence pain.

The significance of everything above means that you can have damage. You can have joint degeneration and certainly can have the normal wear and tear associated with arthritis. Whats great is you can change the amount of pain that you feel without ever changing the amount of arthritis, wear and tear or even damage in different body parts.

Treatment helps turn down the sensitivity of our nervous system.

See here for a description of my treatment approach. But what we need to remember is that since pain is influenced by many factors many things can influence the pain we feel.

Your cranky nerves: A primer for patients to understand pain

Damage does not always equal pain