Pain
A visual guide and new tools
In fact, if we are to understand ourselves better than we do now, I have no doubt that we must try to unravel all these complicated activities of the living matter in our brain.
-E.D Adrian
Without a doubt, we grossly over-estimate the power of our frontal lobes (the conscious thinking we are aware of) and grossly under-estimate everything else that is going on in our amazing brains. Pain is a perfect example. Old ways of thinking separated mind and body and really treated our brain as if it were a simple tool for data analysis. We thought the level of pain directly correlated to the level of tissue damage - wrong. We thought the pain always occurs where the problem is - wrong. We thought pain meant tissue damage - wrong again. It’s amazing to think that we could possibly underestimate our brains to this degree. In this post I will attempt to simplify the complex web of mind, body, conscious, subconscious, chemical, electrical, mechanical, present sensation and past memory that is a pain experience. First let’s start with the various inputs that collectively create pain (this is an incomplete list). Each pain experience is unique and can vary how much any one input is contributing.
Once triggered, the pain neuromatrix actually does much more than just generate pain. The image below shows how there are 9 areas of the brain involved in every pain experience and much more than just pain is triggered. This has huge implications for pain treatment, particularly when it becomes chronic pain.
By now it should become clear as to why pain can be so complex to treat. It is a very complex creation of a very complex and dynamic system that is constantly changing, even in response to pain. Below, I highlight some key reasons why pain can be particularly complex to treat in today’s world.
First, because our healthcare system is still strongly rooted in the older pain theories of Descartes, Bell, Nafe and others who kept mind and body separate. We still do the same with health education and treatment. Rare is the psychologist or psychiatrist with a strong knowledge in the physical body and rare is the physical therapist or surgeon with a strong understanding of the mind. I will briefly toot my own horn and the horn of every other Therapeutic Pain Specialist out there. If you want someone who will treat all of your pain and not just your mind or just a body part, we are the ones you need to seek out. If acute pain treatment properly assesses and addresses associated social, cognitive, and emotional factors then the risk of developing chronic pain diminishes. Chronic pain is virtually impossible to treat if you don’t understand the changes to the nervous system, movement patterns, cognitive, emotional and social aspects of pain.
Let me be 100% clear here. Pain is a physical and an emotional experience. Physical pain can be 100% caused by emotional distress and this is NOT A BAD THING. This is NOT SOMETHING SOMEONE MADE UP, this is not poor coping. This is a biological system in distress alerting the cognitive mind and the other minds around it that there is an issue here that needs to be addressed. If we continue to only look at the physical inputs to pain and only look for a physical cause we are doing far more harm than good. Look up again at that picture, if you are only looking at the physical, you are easily ignoring 2/3 of factors that can be generating a pain experience. In a future post I will clarify further the difference between conscious and subconscious thought, emotions and why I feel our society is way to hard on people with emotional pain.
Second, because our population is poorly educated about their own bodies and minds. Most people struggle to name their major muscles, or embrace their full rainbow of emotions. So how can we be skilled in self-care? Our education system focuses more heavily on competition, fact gathering, and memorization. While I hugely support education, particularly when it comes to the basics of reading, writing, math, science, history and most importantly creative thought and critical thinking, we are hugely lacking in providing real tools for self awareness and self care and it has huge implications for our population health. This one body and mind are all you have for your entire life, they are with you day in and day out. Get to know them! If you think I am off my rocker just look at the numbers.
‘This epidemic (chronic pain) is growing at an alarmingly fast rate and is taking a significant toll on the economy as well as patients and providers. In fact, there are reports that the cost for chronic pain patients is anywhere between 560 to 635 billion dollars annually!’ -Trachsel et al
Third, because our insurance companies make billing and hence treatment crazy complex. The reason you see the biopsychosocial models of treatment struggle is because the insurance companies like to keep everything separate. They can’t handle allowing a PT to assess 2 body parts in one day (you need separately scheduled evaluations even if the injuries came from the same accident) let alone have a PT bill for mindfulness training. It’s so new for a physical therapist to talk to someone about mindful awareness of how their brain and nervous system can generate muscle tension and chemical cascades that promote nerve irritation and pain that our insurance models lag. The science backs up the connection between mind and body time and again yet our healthcare system continues to operate in silos. Sadly, our attempts at bringing it together create programs that are way too time consuming or complex for most people to find time for, let alone have interest in.
Fourth, because we are fed a steady diet of messages that say pain is bad, and emotional pain is a weakness. Just take a pill, have a surgery, etc., we still run for pain relief before seeking information. While healing from an injury some pain is to be expected for a period of time and serves to keep us quiet. The same is true when experiencing grief. Yet many doctors will still prescribe a pill before educating a client. Additionally, rare is the practitioner who asks about a patient’s emotional health, beliefs about their pain, or offers helpful tools to address emotional pain in particular. If they do ask, the response is typically one of, ‘oh it will get better with time.’ This does little to help a patient struggling in the moment. Look back at that picture, if stress and fear are not addressed then the pain experience is only amplified. It becomes a horrible negative feedback loop. So if your surgery fixed something anatomical, but didn’t address your fear of movements that you have to do every day then pain will persist. We fail as healthcare providers when this is the result.
Sadly, when a surgery or pill does not address the psychological or social side of pain, or the rehab is insufficient leaving physical weakness, the pain is amplified because we did not get the expected result of pain relief and the threat level went up. I frequently see patients like this in my office. Pain didn’t resolve so they are sent to another specialist, given more tests, all while fears increase, activity decreases, muscles get weaker, joints tighter and nerves more sensitive all leading to a pain that is amplified. A patient who started with a healthy stress that prompted them to seek help is now in a state of continual distress. The physicians keep looking for answers without recognizing that pain is now the problem because it was never fully addressed in the first place.
So how do we make meaningful change in treating pain?
Recognize that every pain experience is real and complex. They are not created by our conscious mind.
Embrace the beauty of a mind and body that are deeply connected and working hard, eloquently, and often silently and effortlessly to keep you doing all that you do.
Acknowledge that pain may be alerting you to more than just a physical problem.
Accept your emotional rainbow and get tools for addressing emotional distress. Learn to say ‘this is too much for me emotionally’, just like you can say ‘this is too much for me physically.’ Honor that in one another.
Talk about your fears and if needed find someone skilled in mind and body to help you understand and address them.
Educate yourself, your loved ones, and your healthcare practitioners about pain.
Don’t allow yourself to be passively treated. Understand what the benefits and risks of your treatments are. Verbalize your fears and seek tools to address them. Ask questions and expect answers.
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With compassion and gratitude to my son Oliver who helped me with the graphics on this post,
