• Nicholas Kent

Pain... (the first amendment)

Updated: Dec 1, 2021

Pain, in general, is a complex concept in itself which needs to be somewhat better understood in order to best accurately surmise exercise and it’s role with pain management.

Firstly, it is important to understand that pain in general is a human, subjective and emergent experience that is strongly influenced by overlapping physical, psychological and environmental factors and is not merely a phenomenon of pure physicality and structure. In a nutshell, there’s more to pain than it being something that is just inflicted upon us, but more important to understand is that it is something that is generated within us and many intrinsic factors such as beliefs, attitudes, learning and personality can have the strongest and most perpetual effects when it comes to managing pain, overall. This is critically important to understand when it comes to the more common and widespread issues of pain such as musculoskeletal related pain (low back pain, neck and shoulder pain, arthritis etc) which arguably have been most (inadvertently) mismanaged traditionally through poor understanding, inaccurate or incomplete solutions therefore leading to unhelpful and often harmful broad conceptualizations around the mechanisms of pain by both patients and professionals, translating into generally poor outcomes overall.

The broad understanding of pain, particularly for most common chronic pain cases such as low back pain etc, has seemingly overemphasized the physical, or biological, component of the pain experience with both patients and professionals placing too much focus on potential physical factors, idealised anatomical structure and “dysfunctions” of movement, all whilst ignoring other more discreet yet powerful factors such as emotional, social, behavioural and cognitive (psycho-social) influences around pain. As more and more research emerges, the notions of physical factors such as “ideal” or “correct” anatomical structure, “bad postures”, movement dysfunctions, even tissue deformity seemingly have poor correlation as the main cause of pain, particularly chronic pain. So, with the mechanical structures of muscle, tendon, bone and the like not being the absolute panacea of pains root cause, shedding light to an accurate understanding of the other factors at play and addressing these issues competently is important. If history has showed us anything, a patient of long-suffering pain led down the wrong path whilst not accounting for intrinsic factors of psychology, personality and attitudes towards pain can be a very slippery slope.

The over-medicalisation and pathologizing of seemingly normal physical structures and movements that likely is not causative of pain, combined with ignoring or inaccurate information about the dynamics of pain as a broad multidimensional concept, and the various factors that shapes and influences it has seemingly set many people up for failure by way of a mere concoction of bad ideas, beliefs and actions around the causes and solutions to their pain, often leaving them to believe they’re more fragile than they are and that the solution is more beyond their own power and control than it really is.

Long story short: pain is not only because of structural damage, postural problems or movement deficiencies. Often times, in the absence of a recent major trauma (broken bone) or rare sickness such as a tumour, pain due to structural “abnormalities” are not the problem at all. Reconfiguring this conceptualization and association of pain is an important step to “getting it right” or getting on the more accurate path toward managing and solving pain issues, long term.

Let’s roll up our sleeves…

Pain does begin with nerves though, or nociceptors for the boffins, which can detect specific and unpleasant stimulus (noxious stimuli) which prompts specific messaging to the spinal cord, and possibly all the way up to the brain, basically. This ‘stimulus-into-messaging’ dynamic is known as ‘nociception’. Nociception is essentially information about potential danger or threat to the tissues in an area, information that gets subconsciously assessed and relayed by various structures within the central nervous system, interpreting and assessing the severity or threat of this stimuli as it is relayed further up the chain to the higher centres of our brains, where deeper interpretations, decisions and meaningful actions around this stimulus are warranted, or where and when it finally gets ‘felt’, to a degree. The spinal cord is a structure which starts the first assessment of a noxious stimulus, essentially deciding, based on many factors, if this stimulus is a big threat or not. If it is deemed dangerous, the signalling up toward the higher brain centres are strong and urgent. If it’s deemed not so dangerous, the signalling to the brain is kind of weak and chill about the whole thing. Either way, how the stimulus is first assessed by the spinal cord kinda “sets the tone” for the higher brain’s interpretation and response, be it a high alert (painful, panicked, fearful and protective) or a more relaxed, less painful response. The volume either gets turned up, or turned down, depending on how the spinal cord understands and assesses this stimulus, so to speak. How the spinal cord understands, interprets and relays this high or low volume pain messaging to the brain is actually shaped by the brain’s descending instruction to the spinal cord about the urgency or non-urgency of certain stimuli. This is called descending inhibition (volume down), or descending facilitation (volume up). This is the brain conditioning or teaching, or more importantly, sensitizing the spinal cord as to how responsive it needs to be to various stimulus. So the brain can sorta train or prime the spinal cord to be on a high alert, to be very sensitive to types of stimulus that comes through and thus relay that information to the brain with a manner of strength and urgency which can prompt for strong and aggressive psycho-somatic/pain responses from the higher brain centres. This heightened awareness or priming of our internal alarm system so to speak is quite handy and smart if you think about it. Say in the context of walking through high grass in the jungle, of which we know there are many poisonous snakes or something – a danger – then having this highly sensitized, ready-for-anything system on high-alert can be good. We can notice and be careful of anything that feels odd, or out of the ordinary whilst we’re walking through the high grass and thus respond accordingly because this is a perceived dangerous situation. Everything about our knowledge of poisonous snakes, snake bites and toxicity indicates that this is dicey. Our experience, understanding, fears and attitudes kinda shape the subconscious high-alert to help us navigate this dangerous situation as safely as possible. This is an incredible protection system to have embedded into our software, but that doesn’t mean that it can’t be corrupted, or is sometimes too smart for our own good. When the alert system is so jacked, the possibility of a false alarm goes up. The system isn’t perfect after all, so fairly harmless and benign stimulus can also trigger very high alert responses and even warrant adverse physical reactions to mostly harmless things. Say you get scratched by a twig whilst walking through this high snake-filled grass but didn’t see it was just a twig and you therefore believe it was a real snake bite (because context says it likely could be a poisonous snake bite and the stakes are high) you could have a highly painful, stressful response to this otherwise innocuous event. This is, in a way, the catch-22 of this very cool protective mechanism, in that it can become overprotective, or overactive and sometimes stuff-up or just inundate the relay of messaging and stress responses to the brain and potentially create a mountain out of a molehill by way of a heavy traffic of strong, urgent, “action required!” types of messages, even when there is no real danger. Like, if you sat at your desk and your inbox started filling up with tonnes of emails with subject lines all in caps saying “URGENT!!”, you’d think something crazy was happening. Now, this would make sense if there was something crazy happening, like an asteroid hurtling toward earth and we were all 24 hours from certain death. If you’d specifically instructed everyone you know who has your email address to urgently inform you of such an event, this would be handy. But this could also be very annoying if the urgency of this instruction meant that every shooting star or plane in the sky was mis-interpreted as being an asteroid (you know.. just in case), leaving you to just being constantly inundated with false alarms and getting nowhere. This is analogous to the over-sensitized pain alert system accidentally causing us more harm than good, because we kinda told it so…

Now, ultimately the brains role in all this is the primary role. Everything else to this point, as with all bodily systems, is just apparatus and the brain is essentially underpinning the dynamics of how this apparatus serves it, ergo us, in order to live and survive. The end game, really. Anyways, when it comes to pain, we’ve established that pain is a multidimensional, emergent and subjective phenomenon and we’ve got all this other stuff like nociception at the tissue level, and the spinal cord serving as a mediator of information to the brain - the very nifty alarm system to keep us out of harms way. But in the end, what decides what is harm is ultimately shaped and ends with our brain (us) and the complex, layered and multidimensional intricacies of our subjective interaction, experience and understanding of the world. Without getting too reductive, realistically this doesn’t mean we need to learn that a broken bone hurts before it hurts. Yes, without really understanding otherwise, when you break a bone, it will hurt. A bone break, in the moment and in isolation is a highly traumatic, physical event that will incur such a triage of physiological responses to deal with it and prevent further damage that we don’t need much prior conditioning to get the picture. But that doesn’t mean that the pain response to even a bone break can’t be modulated by context and circumstance. In isolation, a non-life-threatening bone break will hurt beyond measure, rendering most people to agonising helplessness. In an emergency situation, say a car crash, where you sustain a broken arm but in front of you a small child is bleeding out and you’re the only person who could possibly intervene, the bone break, whilst painful, is probably not at front of mind and will not stop you from acting. This is an extreme, adrenalin fuelled, fight or flight example but is useful because it starts to lead us down the path of how context, conditioning and reason have powerful subconscious control over the physical painful sensations. Remember, pain is a subjective experience, not an objective input, always.

So continuing on from this, what we know is that it is the brain that ultimately decides (subconsciously, of course) what is potentially harmful, threatening and thus invokes a painful response, or not. Because this dynamic of decision making is subconscious, it’s not always straight forward or logical to our conscious selves and the influence of factors are never really isolated. Essentially, this is where the complexity of subjectivity plays in and the mix of individual variance by way of our own prior learning, understanding, experiences, fears and personality – forces that all embed themselves deep within our consciousness over the course of our lives – come together to construct a decision. Everything we know of the world and what something means plays in, basically. This all sounds very woo woo, and that is probably the most common sticking point for people when it comes to comprehending the real dynamics of pain – a very physical feeling, explained by a seemingly very metaphysical cause. I get the frustration. But if we go back to the high grass and the snake bite; if we’re told and we believe that there are no snakes in that grass, at all, then the twig scratch would’ve been interpreted as basically that. There wouldn’t have been any pre-emptive priming of our peripheral nervous system to be on high alert for danger. We’re told, thus we understand that there is no danger, so our conscious selves register the context of walking through this high grass as being safe. So when we do feel something, we consciously understand it should be harmless and we just carry on. No real visceral response driven by fear and understanding of the dire consequences of a poisonous snake bite. Just a twig scratch. Now, if you specifically are somebody who has historically had a bad time with snakes and high grass, say when you were a child you got bitten by a poisonous snake whilst walking through high grass (just like this scenario) and it nearly killed you, how easily do you think it could be to simply un-do that baggage so you can easily walk through this high grass, stress free, today? No matter how much someone can tell you that there’s no snakes in the grass, you’ll still be jumpy about the whole thing, and understandably so. Maybe you’re a very relaxed person and can overcome personally stressful situations, grit your teeth and push through. That’s probably better than being paralysed by fear, but this doesn’t mean it won’t affect you. Maybe your personality is quite neurotic, hypervigilant and fearful and no matter what anybody, any expert can tell you; you physically cannot walk through that grass. We’re kinda wading away from pain specifically into the psycho-somatic nature of stress and how it can physically affect us, but this is the exact domain that pain lives in. We perceive; therefore we feel, in a nutshell. And there are many layers contributing to those perceptions, therefore those subconscious decisions and assessments about what is threatening, dangerous, therefore painful – even if they aren’t, or shouldn’t be.

How does all this stuff translate into the more relevant and most common clinical domains of chronic pain, musculoskeletal issues and the like?

First, we need to sidestep back into a theme already touched on a few times now but is critically important to drill down into and get a bit of clarity around, if all this isn’t as clear as mud already. But this theme is probably the most prevalent fall-back misunderstanding of the root cause of pain and where the wires consistently get crossed, and the whole message of a more accurate and complete understanding of pain falls down for the lay person. The notion that physical/structural “damage” or what seems or looks like damage is always synonymous with pain and vice versa. This is the trickiest thing to unhook because it is so logically embedded within our understanding of how pain works, and in certain circumstances it is true. Take broken arm example from before; obvious damage = obvious pain. No second guessing that and is a clear demonstration of the math of damage and pain, so we logically follow this principle down the line regarding any version of physical pain. But in the cases of more chronic, fluctuant, episodic pain where there’s no specific event per se, or said event was from a long time ago, then that’s where things get a bit greyer. Think common complaints like low back pain from a lot of sitting, shoulder and neck pain from a lot of screen time, irritated knees even in the absence of a lot of running, lifting something “the wrong way” all those years ago, your “out of line” hips, weak glutes and so on. These are all logical, yet misguided connections of a symptom and what must be the cause. If this area hurts, this area must be broken. In some cases of persistent, un-mitigating pain, there can be a physical deformity at an area, but these cases are rare and usually because of more serious things like ongoing disease or tumour, rather a mere tweak or niggle. Evidence tells us that the look of our internal physical structure doesn’t need to be perfect for us to be pain free. Often times, people already have standard “deformities” or an imaged diagnoses most commonly associated as being an injury or painful, such as a bulged disc, stenosis, soft tissue wear and tear, calcified joints and so on – without pain! These are not freak occurrences for the lucky or gifted either, these are usually the status quo features of maturing structures over the course of a lifetime, not symbols of a fragile, damaged therefore pain riddled body. This traditional (yet understandable) rationale fostered within healthcare of damaged looking anatomy being the single vector of pain, perpetuated with better technologies like medical imaging really placed the emphasis almost exclusively on our physical form and structure as being the sole responsible cause of our pain. In turn, inadvertently creating many offshoots in terms of treatments, education and drugs aimed primarily at attempting to “fix”, “repair” or “un-do” very natural, normal and adaptive physical changes, as well as merely blunt the pain feeling, as opposed to more comprehensively addressing the layered and complex root causes of pain.

So, with our contemporary mainstream understanding of pain, the unacceptability of pain, one-dimensional beliefs and treatments around pain, as well as the association of pain being because of damage, adverse movements, dysfunction, and so on, we get back to a theme that perpetuates a huge, very influential, yet very nuanced factor in the pain problem. The covert big problem, flying under the radar.

The narrative.

If we live life under the pretense that the normal attributes of living and ageing and all of the adverse and unkind sensations that can couple with that; like a bit more stiffness in the mornings, or joints a bit sorer after that run, or neck screaming at me after a stressful work day or that nagging back pain that comes and goes from years ago and we are told that any trace of these normal sensations are pathological, dangerous and need to be fixed, then what happens, or seemingly has happened, is a deranged relationship with pain, with our bodies as well as a problematic abundance of caution and hypervigilance. The thing about pain, and any other sensation we experience is that it can truly become the pink elephant – if you’re told to not think about pink elephants, what is it you can’t stop thinking about? If the modern mainstream ideals around pain and its best treatment is to be extremely wary and avoidant of pain, to only move certain ways or that there are “correct” ways to move, to get scans to see where you’re “broken” and that any pain, in any capacity, equates to damage or pathology, then problems that urgently need to be fixed – usually with some pricey or specialized method – are everywhere. This can make living and moving seem as kind of a dangerous proposition that need to be somewhat approached with caution, and with every interpretation of pain being deemed a medical issue, combined with the hyper-focus single mindedness of addressing only the physical, as well as (expected) heavy handed medical treatment regimes – it can leave people with a deranged sense of what’s truly going on, as well as no control in the matter. The narrative is that I am hurt, therefore broken and somebody needs to fix me, or it’ll just get worse.

Now, much of this can also understandably seem to be an undermine of one’s pain experience, which for many, can be horrific, persistent and sometimes seemingly beyond resolution… So to reduce this down to a case of “mere narrative”, is that really helping? Well, like anything, there’s a bit from column A, a bit from column B. As much as it’s integral to fully grasp an accurate understanding of the very complex nature of pain, it’s just as important to not diminish something like a chronic pain syndrome that can present and kinda ‘live’ in someone in a very physical way, for years and years. Tell a person in chronic, life altering pain, off the bat, that this is all a game of the mind and you’ll very likely get a swing to the mind. So, it’s important to convey and consume this information carefully and then attempt to accurately find how this applies into one’s individual situation. Again, unpacking this can be extremely complex, because bottom line; pain is a human experience - probably the most complex of domains, therefore an open mind and extreme tact are integral, for both parties.

But when one does approach all of this with an open mind, whilst being aware of the facts of what we understand about the mechanisms of pain with a few old myths de-bunked, then what can begin to take place is a cognitive re-framing, of sorts, of why one might feel pain, what it means and what we can do, for ourselves. Like, reconceptualising ideas that despite there being some internal mild deformities, of “wear and tear” in a joint; this is not a forever sentence and doesn’t have to mean pain, at all. Or that sitting at your desk and being a productive worker is not the unhealthy bullet you just have to cop because of “bad posture” or “sitting being the new smoking”. Or that your running or lifting technique probably isn’t the sole reason why your knees hurt when you train, there are more avenues to explore to solve this and you don’t have to concede. There are many ways to skin a cat, and usually, the more complex the nature of any syndrome, the more nuanced the solution, but the new age understandings of pain and its causes can also essentially free us up to a vaster range of more high value, lower stakes interventions. Before jumping to highly invasive, costly, high-risk and specialized interventions like surgery, drugs, gadgets, manual therapies or injections as a whole solution, one can work on experimenting with re-engaging with movement, exercise or activities we’re told or believe to avoid under a renewed conceptualisation of pain, it’s complex causes and that most times it’s something not to be feared!

If living with pain and ceasing to enjoy your normal activities and such is analogous to being afraid of sleeping in the dark, then understanding your pain and thus embracing it through movement, exercise or whatever else you’ve been told to avoid is you turning your night light off. A constructive and gradual building of tolerance of pain/fear, reducing the once perceived dangerous and scary, back to the normal. This is the heart of the pain solution, or better put, the completion of the answer. When the cognitive and environmental components of pain are recognised, and addressing these elements are warranted and respected, then the whole picture can be seen, the relationship with our pain can be more accurately configured, and the power of solutions can be more in our own hands. This is our knowing the language of our pain.

The old saying goes that good advice not followed is still bad advice… So what’s this all mean, in real time? Like, please convert these somewhat esoteric themes of the phenomenology of pain, into a real-world application, for the lay person…

Again, I’ll forever disclaim that this stuff is complex and highly individual, but there are some rules of thumb that can help guide the way.

“Start with an open mind”

If all this stuff sounds too esoteric, “woo woo”, Big Pharma / “this is what they’re NOT telling you” / conspiracy-theory-esque, then I get it. There is still much resistance and friction even amongst professionals when it comes to this type of paradigm shift, despite all this being very much rooted in the evidence base. So if you want a change, or a solution, it starts with being open to it.

“Pain is our ally, not our enemy”

Pain is a subjective experience influenced by physical, psychological and environmental factors and serves us as a protective mechanism – pain only operates as a way to help us.

“Pain usually doesn’t equate to pathological damage”

Pain usually doesn’t equate to pathological damage.

Pain usually doesn’t equate to pathological damage.

Pain usually doesn’t equate to pathological damage.

Pain usually doesn’t equate to pathological damage.

Pain usually doesn’t equate to pathological damage.

Pain usually doesn’t equate to pathological damage.

“You are stronger than you think”

The human body is a highly adaptable, robust, anti-fragile organism, that can cope and adapt to most things if given the opportunity to.

“There are no bad movements, really”

Our bodies don’t do anything “correctly” or “incorrectly”, it just builds tolerance or fosters intolerance. This is important when thinking about exercising, training, moving, sitting or whatever activities. There is nothing inherently “bad” about certain movements or postures, it’s just whether you are tolerant of them, or not.

“Time heals all wounds”

Time is usually the best/realest mode of “pain” healing. Often, after an injury or tweak or whatever, time, patience and simply keeping things as normal as possible will usually see off any injury, tweak, niggle or painful episode.

“Imaging as a prognosis, not diagnosis”

Imaging, scans and that stuff can serve as a helpful tool to identify or rule out any red flags – such as tumours, major fractures, contusions, internal ruptures and the like; things that can signify the need for escalated medical intervention. Absent of these types of things, anything else seen on a scan is usually an innocuous occurrence that often times can sort itself out with time and appropriate management.

“Other therapies still help”

Massage, manual therapy, heat packs, needling, scraping, foam rolling, injections, pain killers and whatever other external modes are still useful, but need to be contextualised appropriately so as to keep an accurate picture of what they’re really doing. These things can help make us feel differently, usually temporarily and can be great to offer short term relief – but they’re not modes of advanced healing, or biomechanical adjusting, do not really seem to alter tissue, or permanently change nociception/pain sensitization in the long term. If not understood carefully, these type of interventions can become more like a “nocebo” (negative outcomes due to belief) by way of ultimately creating problems through over-reliance/need for pharmaceuticals, massage, adjustments or other external interventions as ones only way to deal with pain or physically function.

“Being generally healthy really matters”

It sounds obvious, but it’s amazing how overlooked the factors of things like better nutrition, exercise, decent sleep, stress management, good relationships and such can really be the “glue” when mending ourselves. Modern medicine has segmentalized health so much that often just our inherent health behaviours and stress status are an afterthought when it comes to these things. And they do matter, significantly. So do a self-assessment and try to sort these things out best you can and see where that in of itself, lands you…

“Pain ought not be avoided”

In the end, when dealing with pain and ultimately, in a way, “curing” it, we need to bake into our expectations that to better tolerate pain as a path to minimising it, we must be brave enough to lean into it and face it – appropriately. Pain is a normal sensation, like hunger, that will always be present within us as part of living. So expecting to eliminate pain is not an accurate representation of the real goal. We need to reconfigure our sensitivity to it, back to a normal level as best we can, and first step towards that is by embracing it to a degree. So when re-engaging back to normal activities, doing exercise, resisting the pain killers and generally moving again, we must be okay with this being a bit painful - at the start. Then, bit by bit, with our renewed understanding of this pain as just my “over-enthusiastic protector”, that my body is resilient and robust and that things are not actually damaged in there, then we can accept the initial resistance, the initial pain, before we eventually start to re-teach ourselves and give ourselves the opportunity to adapt back to normal. This is the ultimate “2 steps forward, 1 step back”, non-linear process, but it’s the highest value, realest process of “cure.” To change ourselves, internally.

In the end, all of this can be somewhat of a difficult picture to bring into play and may be kind of tricky to self-apply, despite the simplicity of the best practices when it comes to pain management. We must understand that everyone is different and that how these principles are applied to one’s individual circumstances are going to depend on a number of factors, therefore I would still advise that one seek some guidance to begin to walk this path. But if that guidance or plan is not rooted in fostering a concept of long-term agency, self-efficacy and a “DIY” reconciliation with pain, of sorts, through behaviour change and “movement optimism” (to quote Greg Lehman), then I would hold that into consideration. In the end, your best path is your best path, however that looks, for you. If that means recapturing a level of agency over your own health and pain, then that’s how your intervention ought to look. If it’s better for you and your circumstances to have everything outsourced to a degree, where the fix lies in external interventions, techniques and specialists – then that too is fine. Our expectations are what dictate our satisfaction with things, all we can do is find out all the realest information and our best options and go from there, with eyes truly open.

** We all stand on the shoulders of giants, and by no means do I consider myself the authority on such nuanced topics as the pain sphere... Therefore I feel it important to acknowledge actual experts;

A) because they provide the footing for the rest of us to share better information, in our own way

B) because they can probably still give the best insight to these complex topics and ought to be listened to

Here are a couple of the best spots to look which inspired this post