Introduction
Chronic or Persistent pain affects around 15.5 million or 34% of the adult population of England (versus arthritis, 2017). This is pain that persists for more than 3 months and impacts on people’s functioning on a daily basis. It might include migraines, headaches, back pain, shoulder/neck pain, joint pain or widespread pain to name a few. People often seek help through surgery, medication, Physiotherapy, Osteopath, Chiropractor and acupuncture, mostly with the aim of getting rid of their pain. It often doesn’t work, but why?
Firstly Chronic Pain is real and it is very complex. The why you experience persistent pain is very individual and will depend on a complex interaction between your biological world (your body), psychological world (your mind) and social world (your life around you). These three parts interact and that is why often, many of the treatments for pain that just look at the physical often fail for people with chronic or persistent pain. This way of looking at a physical health condition is nothing new and has been around since 1977 when George Engel proposed a challenge to the traditional biomedical model in the form of the bio-psycho-social model. He found that it wasn’t just a person’s biology that impacted patient outcomes from treatment but also their thoughts, feelings and beliefs could affect how someone might adhere to medication or rehabilitation and how successfully they might recover from an operation. He also recognised that patients didn’t live in complete isolation so factors such as education, community, relationships, discrimination, inequality and environment could also impact on a patient’s health and wellbeing.
This model can help you to understand why your pain might be worse when you have a lot on at work or if you’re feeling more anxious your pain might increase or if the weather changes you feel it in your joints. You need to understand the interaction between the mind, body and world it lives in to understand your persistent pain. This can then help you to know what might be helpful to manage it in a different way and to stop being so scared of the pain. This will be different for everyone but there are some common things in each area that can be helpful to understand.
Let’s start with the body – The Biology of Pain
It can help to first of all understand why we experience pain. Pain is normal and we need pain. Why? Pain stops us in our tracks and makes us change what we are doing. You will stop putting weight onto a twisted ankle because of the pain you experience or remove your hand from something hot when the pain comes. There are some people for genetic reasons who do not feel pain and often they do not live long lives because they do not know when they are hurt or if they have something life threateningly wrong with them because they can’t feel pain. Pain keeps us alive and safe.
The body is covered with a nervous system or sensors which look out for temperature, pressure, touch and chemicals. The nervous system helps us to understand our world and keep us safe. When the sensors detect a change they send information through our nerves to the spinal cord. Not all of this information reaches the brain though as the spinal cord decides which information needs to be sent. This is why you don’t constantly feel your clothes or you can get a bruise but not remember how you got it. When enough messages of concern are sent through to the spinal cord then they send them up to the brain to decide if the body is at risk of harm or injury. If the brain feels the body is at risk then we experience pain in that area to get us to act.
This is what happens in something called acute pain.
What about chronic or persistent pain?
You first need to understand something about our nervous systems, they are plastic and adapt to our needs. When we need to learn a new skill the nervous system changes. It physically changes so it can monitor an area more closely and the information is passed more quickly to the brain. This is why when you start to learn a new skill such as playing an instrument to begin with you are clunky and not very skilled but by continued practice you get better and better to the point that it becomes an almost automatic thing that you can do.
This process of the nervous system laying down more sensors and sending information more quickly also happens when we have an injury as the body wants to monitor the area more closely until it has healed. However sometimes this process can become stuck in overdrive (because of the mind or social factors) and this can lead to a vicious cycle where the body is monitoring the area more closely and messages being sent quicker leads to the body concluding that it needs to be more concerned. The more concerned the body is, the more likely pain will be triggered leading to more monitoring. The system becomes over sensitive like a car alarm that’s set too sensitively and goes off when a cat brushes past the car rather than for when it’s actually being broken into. If we think of the example of back pain, an injury may have led to pain but overtime less and less movement might be needed to the point that watching someone else bend over can trigger your pain.
Heard the term use it or lose it? This is important because if we don’t move then we decondition. The less we move, the less we are able to move and that is why there is such a big emphasis on rehabilitation to get us moving again after an injury or an operation. This can feed into the system above as well leading to pain being more likely to be triggered.
Fact: You can’t cut the brain from the rest of the body.
Yes pain is physical but the brain decides whether we should experience pain in a certain set of circumstances.
The mind – The Psychology of Pain
The brain is constantly taking in all the information that the rest of the body senses from it’s internal and external environment and is deciding if we need to act on it and what that action needs to be. We have a threat focused brain that reacts more and quicker to negative things than positive as this is what is likely to keep us alive. This would have been evolutionary advantageous as those who were most aware and quick to react to danger would have been more likely to stay alive long enough to have children and pass on their genes.
We have three systems that drive us and help us survive in the world. The threat, drive and soothe systems. The threat system is there to try and keep us safe from danger. When triggered it makes us want to act in a way to either fight the danger or escape from the danger by taking flight or freezing. The drive system helps us to get up in the morning and motivates us to meet our needs by giving a little dopamine hit when we gain something. The soothe system helps us to calm down and connect with our loved ones so that we can rest, digest and heal. We need each of these systems in order to survive and thrive.
In regards to pain, the threat system is triggered by pain but also the threat system can trigger pain. When this is combined with the sensitised nervous system further vicious cycles can happen in relation to persistent pain.
The world we live in
The world we live in has changed rapidly over the last 100 years, even in the last 30 years there have been technological advances that have seen the way we exist in the world change. This has brought numerous medical advances, opportunities and given us more choice than we could ever have imagined. Every aspect of our lives has changed from what it would have been like for our ancestors and even the ways we communicate are changing. While much of this is good, our brains were not made to live in this world. We were designed to live like cavemen where we focussed on getting our basic needs met and living for the here and now because you never knew if the plentiful food would be there tomorrow. Evolution takes time and our brains have not yet evolved to this constantly changing world.
There is so much information for our brains to constantly process and it can’t help but sometimes get overwhelmed or see things as threats or stresses. Micro-stressors have become a new term for the daily hassles that we experience but the accumulation of these can have a big impact on us and our world is now full of them. Every phone notification and email ping is designed to trigger us to act, triggering our threat system. We are not made for our system to be out of balance for too long without it having a big impact on our wellbeing but the modern world is valuing bigger, better, faster with more and more choice and we are just not designed for this.
We can end up spending much of our daily lives in our threat and drive systems without spending enough time in soothe. Our modern world values independence and individuality while our soothe needs connection and community. Loneliness is a big issue that has been made all the worse with the Covid pandemic.