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Pain really is in the mind, but not in the way you think

Everybody hurts, but not everybody keeps hurting. The unlucky few who do end up on a downward spiral of economic, social and physical disadvantage. While we don’t know why some people don’t recover from…

We don’t know why some people don’t recover from an acute episode of pain. Kennedy/Wikimedia Commons

Everybody hurts, but not everybody keeps hurting. The unlucky few who do end up on a downward spiral of economic, social and physical disadvantage.

While we don’t know why some people don’t recover from an acute episode of pain, we do know that it’s not because their injury was worse in the first place. We also know that it’s not because they have a personality problem. Finally, we do know that, on the whole, treatments for chronic pain are not particularly successful.

This sobering reality draws up some interesting reflections on pain itself. What is pain? Is it simply a symptom of tissue damage or is it something more complex? One way to approach this second question is to determine whether it’s possible to have one without the other – tissue damage without pain or pain without tissue damage.

And you can answer that one yourself – ever noticed a bruise that you have absolutely no recollection of getting? If you answered yes, then you have sustained tissue damage without pain. Ever taken a shower at the end of a long day in the sun and found the normally pleasantly warm water, painfully hot? That’s not the shower injuring you - it’s just activating sensitised receptors in your skin.

Such questions and their answers are of great interest to pain scientists because they remind us that pain is not simply a measure of tissue damage.

Ever noticed a bruise that you have absolutely no recollection of getting? Rebecca Partington

What is pain?

The International Association for the Study of Pain defines pain as an experience. Pain is usually triggered by messages that are sent from the tissues of the body when those tissues are presented with something potentially dangerous.

The neurones that carry those messages are called nociceptors, or danger receptors. We call the system that detects and transmits noxious events “nociception”. Critically, nociception is neither sufficient nor necessary for pain. But most of the time, pain is associated with some nociception.

The exact amount or type of pain depends on many things. One way to understand this is to consider that once a danger message arrives at the brain, it has to answer a very important question: “How dangerous is this really?” In order to respond, the brain draws on every piece of credible information – previous exposure, cultural influences, knowledge, other sensory cues – the list is endless.

How might all these things modulate pain? The favourite theory among pain scientists relies on the complexity of the human brain. We can think about pain as a conscious experience that emerges in response to activity in a particular network of brain cells that are spread across the brain. We can call the network a “neurotag” and we can call the brain cells that make up the neurotag “member brain cells”.

Schematic of cortical areas involved with pain processing and fMRI. Borsook D, Moulton EA, Schmidt KF, Becerra LR/Wikimedia Commons

Each of the member brain cells in the pain neurotag are also member brain cells of other neurotags. If we have the phrase “slipped disc” in our brain for instance, it has to be held by a network of brain cells (we can call this the “slipped disc” neurotag). And it’s highly likely that there are some brain cells that are members of both the slipped disc neurotag and the back pain neurotag. This means that if we activate the slipped disc neurotag, we slightly increase the likelihood of activating the back pain neurotag.

Using this model, thinking that we have a slipped disc has the potential to increase back pain. But what if this piece of knowledge we have stored is inaccurate, just like our notion of a slipped disc? A disc is so firmly attached to its vertebrae that it can never, ever slip. Despite this, we have the language, and the pictures to go with it, and both strongly suggest it can.

When the brain is using this inaccurate information to evaluate how much danger one’s back is in, we can predict with confidence that, if all other things were equal, thinking you have a slipped disc and picturing one of those horrible clinical models of a slipped disc will increase your back pain.

Self-perpetuating pain

This is where our understanding of pain itself becomes part of a vicious cycle. We know that as pain persists the nociception system becomes more sensitive. What this means is that the spinal cord sends danger messages to the brain at a rate that overestimates the true danger level.

A disc is so firmly attached to its vertebrae that it can never, ever slip. Jason Sullivan

This is a normal adaption to persistent firing of spinal nociceptors. Because pain is (wrongly) interpreted to be a measure of tissue damage, the brain has no option but to presume that the tissues are becoming more damaged. So when pain persists, we automatically assume that tissue damage persists.

On the basis of what we now know about the changing nervous system, this presumption is often wrong. The piece of knowledge that’s turning up the pain neurotag is actually being reinforced by itself! I think it goes like this: “more pain = more damage = more danger = more pain” and so on and so forth.

The idea that an inaccurate understanding of chronic pain increases chronic pain begs the question - what happens if we correct that inaccurate piece of knowledge?

We’ve been researching the answer to this for over a decade, and here’s some of what we’ve found:

(i) Pain and disability reduce, not by much and not very quickly but they do;

(ii) Activity-based treatments have better effects;

(iii) Flare-ups reduce in their frequency and magnitude;

(iv) Long-term outcomes of activity-based treatments are vast improvements.

There’s compelling evidence that reconceptualising pain according to its underlying biology is a good thing to do. But it’s not easy. Our research group is continually looking for better ways of doing this, and we’re not the only ones. The idea of explaining pain has taken off in pain management programs and outpatients departments the world over.

Clinicians need to rethink too

“For example, if the fire A is close to the foot B, the small particles of fire, which as you know move very swiftly, are able to move as well the part of the skin which they touch on the foot. In this way, by pulling at the little thread cc, which you see attached there, they at the same instant open e, which is the entry for the pore d, which is where this small thread terminates; just as, by pulling one end of a cord, you ring a bell which hangs at the other end…. Now when the entry of the pore, or the little tube, de, has thus been opened, the animal spirits flow into it from the cavity F, and through it they are carried partly into the muscles which serve to pull the foot back from the fire, partly into those which serve to turn the eyes and the head to look at it, and partly into those which serve to move the hands forward and to turn the whole body for its defense” Descartes, On Man, 1662 From René Descartes' Traite de l'homme/Wikimedia Commons

What we know about how pain works is not just relevant to how we teach it to patients, we need to base our clinical decisions on it. This means abandoning Rene Descartes famous model of 1654. His drawing depicts a man with his foot in the fire and a “pain receptor” activating an hydraulic system that rings a bell in his head. Of course no one believes we have hydraulics making this happen, but the idea of an electrical circuit turning on the pain centre is still at the heart of many clinical practices across professional and geographic boundaries.

The type of thinking captured in Descartes' model has led to some amazing advances in clinical medicine. But the evidence against it is now almost as compelling as that against the world being flat.

Of course, those sailors who never leave the harbour might hang on to the idea of a flat world. And, in the same way, there are probably clinicians who hang on to the idea of pain equalling tissue damage. I suspect they either don’t see complex or chronic pain patients, or, when they do, they presume that those patients are somehow faulty or psychologically fragile, or, tragically, are lying.

Perhaps they can continue to practice without ever leaving the harbour. The problems I want to solve clearly exist on the open seas.

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30 Comments sorted by

  1. John Michael Wardell

    logged in via Facebook

    As a person suffering from a "chronic pain syndrome" I can certainly relate to what is being described but would love to see what it can mean for me in real life. The "downward spiral" is so so real, the pain seems to feed upon itself even when one knows quite well that it is "all in the mind". I saw an interesting BBC documentary where researchers working at Liverpool University demonstrated that as time goes by the area of reception in the brain grow larger and they were using magnetic pulses to reduce the area of the brain which receive the pain messages with good outcomes. Does anyone know if this type of work is being done in Australia?

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    1. Emma Anderson

      Artist and Science Junkie

      In reply to John Michael Wardell

      Do you happen to recall which area of the brain they referred to? Also, what type of magnetic pulses?

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    2. Danny Hoardern

      Analyst Programmer

      In reply to Emma Anderson

      G'day Emma

      The specific type is Trigeminal neuralgia, and cannabis can help nearly all (if not all) types of pain.

      We're all equipped with an endocannabinoid system and we produce endogenous (internal) cannabinoids to naturally alleviate some pain - exogenous (external) cannabinoids give this process a boost. The video above provides fantastic insight into this system, and there is plenty of literature on the web.

      Ask someone in their early 20's or so about cannabis and pain and they might be able to help you out. If the pain is really bad, there are states in the US where you can legally obtain it to manage pain.

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    3. Emma Anderson

      Artist and Science Junkie

      In reply to Danny Hoardern

      That sucks..I can see why cannabinoids might relieve some of the pain in a case like that though.

      I don't want to pry too much but my curiousity gets the better of me. If she goes for longer intervals without eating, does that seem to correspond with worsened pain when she eats, or less pain, or is there no difference?

      Assuming this is mandibular..

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    4. Danny Hoardern

      Analyst Programmer

      In reply to Emma Anderson

      I'm not entirely sure Emma, will ask her next time I see her but she does have to be careful when she's eating or brushing teeth.

      This just came through in my news alerts:

      Cannabis-based medications prove effective in relieving pain:

      Cannabis-based medications have been proved to relieve pain. This is the conclusion drawn by Franjo Grotenhermen and Kirsten Müller-Vahl in issue 29-30 of Deutsches Ärzteblatt International.

      Cannabis medications can be used in patients whose symptoms are…

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  2. Danny Hoardern

    Analyst Programmer

    An interesting article, thank-you. In my case, I have a close relative who lives with chronic neuropathic pain as a result of a damaged a nerve which erroneously sends pain signals to the brain.

    We should be doing everything in our power to provide relief to those living with pain. Cannabis does provide pain relief[1-7] (highly recommended video demonstration: www.youtube.com/watch?v=Mf5JytQDlfE), is a safer than painkillers[8-9] and according to the Single Convention on Narcotic Drugs, 1961[10…

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  3. ann moffatt
    ann moffatt is a Friend of The Conversation.

    retired

    i have chronic pain in my feet and ankles following a head on car crash nearly 20 years ago when my feet and ankles were badly crushed.

    i find that tofranil greatly helps my condition. i take one 25mg tablet each night before i go to bed.

    whilst not stopping the pain, this medication changes my attitude towards my pain so that i do not feel 'weighed down' by the pain and i can perform very effectively in spite of constant pain. at the same time, it allows me to identify when my activity is such that i should perhaps reduce what i am trying to do.

    i note that 'Imipramine is similar in structure to some muscle relaxants, and has a significant analgesic effect and, thus, is very useful in some pain conditions.' and yet i find very few people who have chronic pain have been offered this medication.

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    1. Emma Anderson

      Artist and Science Junkie

      In reply to ann moffatt

      http://en.wikipedia.org/wiki/Imipramine
      I know, I know, wikipedia but it's a good start

      Imipramine (Tofranil) has multiple sites of action, and side effects, and is classed as a tricyclic anti-depressant.

      I'd hope that people aren't prescribed it without due consideration for other symptoms, especially ones that might be associated with the sites of action (and notably the side effects).

      There are lots of reasons why people experience pain, and in some conditions, it would seem that the cause is unknown. If the cause is unknown, or the cause is associated with a site of action where the effect of a given medication would have an undesired effect, it's probably unwise to prescribe it.

      I'd call you lucky for knowing the cause (your car accident) and having an effective treatment, except for the part where you were in a crash & have pain to begin with.

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  4. Jennifer Gait

    logged in via LinkedIn

    I like the idea of neuro-tags, but suggest that you should not limit them to the physical. In my experience people who suffer from psychological/emotional pain but no physical injury, may also develop physical pain, which may quickly disappear once they recognise and address the emotional factors (sometimes all they have to do is to recognise it). The latter also applies to those who have an injury, as many are also suffering from emotional pain. One way of helping them to recognise the emotional…

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    1. Emma Anderson

      Artist and Science Junkie

      In reply to Jennifer Gait

      I think you'll find that the concept of neuro-tags is probably a mechanistic term that can be applied to associative memory and emotion as well.

      i.e. Having a conversation with someone and altering their perceptions does alter their brains. So in people where this particular pathway/means is effective at reducing pain, it does.

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    2. Yoron Hamber

      Thinking

      In reply to Emma Anderson

      Pain seems definitely deeply connected to faith, beliefs and what deeply rooted expectations we might have of what we will feel/perceive. There are a lot of examples of cultures in where pain was/are 'ignored' at times, and so presumably lessened too. The brain is adaptable to a lot of different input, as your beliefs, imagination, and emotional state. But there are also physiological reasons for it, not be ignored. Pain keeps you healthy in a way, as without it you might hurt yourself horribly, not even noticing it. There are some people not feeling pain, and they experience hell trying to live a normal life, as they can't feel pain.

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    3. Emma Anderson

      Artist and Science Junkie

      In reply to Yoron Hamber

      Some of that, it occurs to me, may be due to the fuzzy areas of defining pain. Emotional pain is analogous to physical pain and one can lead to the other, but the analogy is not 1:1, and language might play a role in the [mis]understandings of the experiences. But language doesn't "cause" pain (even though verbal abuse can!), it's just another crude way of wading through the fuzzy experiences we go through. So the self-talk issue (words we think about) with pain, well, it can influence it I suppose…

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    4. Yoron Hamber

      Thinking

      In reply to Emma Anderson

      People differ Emma, and thank god for that btw :) and pain thresholds do too.
      When someone is asked to describe his/her pain in Sweden doctors normally use a ten graded scale in where you 'subjectively' place yourself, 10 being really bad disabling chronic pain and 1 rather okay, sort of.
      And yeah, anxiety is part of having a constant pain, as in waiting for it to hurt more as you try to do something you just 'know' will hurt.
      But keeping yourself socially active, meeting friends, and just trying to have as good time as you can will help with your management of the pain, and maybe even 'minimize it' for you as I understand. The worst thing I think one can do is to stop interacting with those that make one laugh, and feel good about life :)

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  5. Kate Rowan-Robinson
    Kate Rowan-Robinson is a Friend of The Conversation.

    Registered Nurse/Sexology Student

    Great article, thank you.

    Having been diagnosed with Chronic Regional Pain Syndrome earlier this year, post work injury and I've been doing everything I can to try and alleviate this condition. Thankfully I have an incredible pain consultant, who has helped me this year go from being unable to leave my house to now considering a new job.

    Having had a personal insight into chronic pain I am now choosing to utilise this as a learning experience to help me better care for chronic pain patients when I return to work. I have learned so much about why chronic pain patients tend to behave the way they do and the fight they have for recognition and to be taken seriously.

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  6. Dianna Arthur
    Dianna Arthur is a Friend of The Conversation.

    Environmentalist

    15 years ago I thought I had measles, so did my GP, then my joints became swollen after about a week. Apparently this was a variation on glandular fever, although I had had infectious mononucleosis when a child.

    I returned to a stressful job after 3 weeks, far too soon, but had to due to pressure from manager and financial concerns.

    Top up with miscarriages, break up with partner, workplace bullying, overwork and having to keep a roof over one's head - all this went on for years. Eventually…

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    1. Emma Anderson

      Artist and Science Junkie

      In reply to Dianna Arthur

      I am so glad you made this comment. I won't say why for now, as it's a bit complicated, but I think you've just helped me out with something. If I can let you know I will.

      But until then, is there any particular reason why you use panadeine forte, rather than aspirin?

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    2. Dianna Arthur
      Dianna Arthur is a Friend of The Conversation.

      Environmentalist

      In reply to Emma Anderson

      I cannot tolerate aspirin. Since developing this illness I can no longer metabolise alcohol, aspirin, to a lesser extent coffee (although I have no trouble with tea), have to eat non-processed foods (which is not a bad thing), feel ill if I am in the CBD for more than a few hours (presumably due to pollutants), same if in sealed airconditioned buildings/planes/ships for too long. Resultant symptoms are mostly fatigue, but also migraines or nausea.

      Paracetamol doesn't do anything, but don't want to take Oxycontin although that helps.

      Understand if you cannot tell me anything.

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    3. Emma Anderson

      Artist and Science Junkie

      In reply to Dianna Arthur

      Now I'm really going to be prying here, but have you ever suffered from asthma or atopic dermatitis?

      Thanks for understanding about me not saying anything yet.

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    4. Dianna Arthur
      Dianna Arthur is a Friend of The Conversation.

      Environmentalist

      In reply to Emma Anderson

      This is a bit weird. I already feel I went OTT.

      OK

      I have had occasional attacks of asthma. And occasional break out of dermatitis. But neither chronic.

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    5. Emma Anderson

      Artist and Science Junkie

      In reply to Dianna Arthur

      Sorry, I didn't mean to cause any discomfort...

      I wish I could explain myself a bit better but my situation is still under investigation. I do, however, see some similarities between your experiences and what I've gone through. That doesn't mean it's the same thing, and in this case I would say, in hindsight, that it is probably not. For starters, dermatitis for me has been a chronic life long condition.

      On the other hand, it has been mostly explained by a food intolerance in my case, and in your case some of the experiences sound like various sensitivities / chemical intolerances as well. I find that interesting.

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  7. Peter Thomson

    Project Manager

    Iv'e read some of Lorimer Moseley's stuff before.... It's great to see someone in Australia making some headway's into the Nightmare of chronic pain and the backwards treatment patients are given in this Country.

    What i don't understand however is how a researcher can not even mention or implement Dr John Sarno's technique for treating chronic pain as his success rate is undeniable and truly works.

    I don't have the time to explain Sarno's entire theory here nor do i care to.
    What i will say…

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  8. soula mantalvanos

    logged in via Twitter

    after my 5.5 years of pelvic chronic pain my theory is correct diagnosis leads to lower pain levels and recovery. at 4.5 years Lorimer put me in touch with a brilliant physio in melbourne and its been successful treatment and lower pain level since. my pudendal nerve, a pelvic nerve was enough to prevent me from working, socialising, lifting a glass of water even and had me in pain all the hours i was awake. to have the relief i have now astounds me. that one nerve can cause all that inability!
    if you have pelvic pain like a toothache in the butt, spasms, heat (or should i say fire), pain running down the legs, feel like you have your finger stuck in a power point, have increasing pain with noise, trying to speak, vibrations from the ground/floor, etc etc then read this: www.pudendalnerve.com.au

    good luck to everyone. pain is AWFUL.

    lorimer you are WONDERFUL.
    soula

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    1. John Michael Wardell

      logged in via Facebook

      In reply to soula mantalvanos

      Soula, whilst the origins of my story are clearly different to yours our paths seem to have crossed several times!
      My work accident occurred in February 2006 but it wasn't till August last year that the claim was finally accepted after Court appearances and Medical Panel determination. One of their IME's (what a joke) even came up with a story that my testicular injury was in fact adductor tendinitis even though a Urologist had by that time removed the epididimy of one of my testicles! I then went…

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    2. soula mantalvanos

      logged in via Twitter

      In reply to John Michael Wardell

      hello john,
      i get furious reading about workcover frustrations and the additional mountains they put up in front of honest injured workers who may well have life long health issues. the system is putrid and out of date. until those ama guidelines are updated they will do as our government legislation instructs - not acknowledge our injuries! 'independent' practitioners, case managers, conciliation officers have full approval to treat us the way they do, in fact i'm wondering if they get bonuses…

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  9. Paul Turner

    Osteopath

    Why all the focus on pain and symptoms? I feel one of the issues for lack of success with chroninc pain is just this. We spend so much time researching treatments and methods that look at pain/symptoms and tissues causing pain that we miss uncovering all the predisposing and causivive patterns of dysfunction setting up the area/tissues causing symptoms (or otherwise slowing recovery) in the first place. Pain and any tissue that is painful is simply the end effect (not the cause) and it occurs in…

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  10. Caroline McIntosh

    President/Owner of a staffing firm

    More than three years ago, I became ill for a whole number of reasons which I will not detail out here except to say for eight months I was in excruciating systemic pain.. Peripheral Neuropathy, Systemic Neuropathy, as well as a whole whost of complications from undiagnosed Shingles as well. (I had uncontrolled diabetes and other issues that contributed to this. I wish i could convey the level of pain I was suffering from at this time. The Peripheral Neuropathy was literally being in excruciating…

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    1. Jennifer Gait

      logged in via LinkedIn

      In reply to Caroline McIntosh

      Caroline, you have done a lot of work here - congratulations. But please don't assume that you will be on meds for the rest of your life, or will have pain for the rest pf your life. You are creating a self-fulfilling prophecy. Focus on what you want, not on what you don't want.

      You may find these webinars useful. The links are at the bottom of the page under Patient Education Webcasts. http://www.lifeisnow.ca/hcp/pain-management-education/

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