Got Chronic Pain? It’s Time to Think Differently

I’m not here to say that your pain is all in your head… but it is literally, 100%, with no embellishment, all in your head. There’s no way around it. Everything is “just in your head.” That incredible three dimensional landscape in front of you? Constructed entirely in your head based upon the input of two tiny sheets of light-sensitive retina. All of those distinct objects that are so clear to you, like your computer monitor, or that oncoming car, or your dear mother’s face? All fabricated in post-processing by your team of faithful visual nuclei, all working together to make sense of the mishmash of light that smashes into our eyes (our ability to distinguish objects is an incredibly complex trick of the brain).

I’ve Got Some Upsetting News For You…

The rich green of the grass outside of your window, my friend, isn’t even fucking there. There is no “green.” We create color after we’ve processed the scene in front of us, giving different visual flavors to the wavelengths of light striking our eyes. Unable to distinguish between different wavelengths? Your brain fills in colors anyway, because your brain is incredible. I’m color deficient (“color blind”), but I never really notice it unless I pick the wrong crayon when coloring and people proceed to make fun of me. Hell, for all I know, my blue might be your chartreuse.

As you might imagine, the same goes for all of your senses. Audio is extremely muddy at the level of the ears, but yet we can pick out our name in a crowded room. We can locate a songbird in a distant tree because of how fantastical our brains are at creating 3D maps. Our sense of taste is as sophisticated as a doll made of a single stick (I call her Tabitha), but we seamlessly combine it with our sense of smell to create flavor. Oh, and half of the things that we perceive aren’t even fucking there. Consider how we can take 24 still frames per second and turn them into movement. Consider how you have a big-ass blind spot in each eye. Notice those? Nope, your brain creates visual information to plug the holes, all in real time, all before it even chooses to make you consciously aware of what you’re seeing.

Trying So Hard Not to Reference “The Matrix”…

That, dear reader, is kind of the crux of the matter. Our experience of the world is not created directly from our sensory equipment. It’s run through a huge meat-based supercomputer, new shit is added in, unimportant shit is discarded, and we get this really neat Reader’s Digest version when all is said and done, about 100-200ms later. Did you notice the delay? Of course not.

What This Means For Pain

Pain, just like everything else, is the product of your supercomputer. Sure, it’s based upon sensory input (you’ve got these little nerve endings called nociceptors that notice when a stimulus is “too much,” like too much heat or friction or pressure), but the brain takes this about as seriously as anything else.

Photo credit: Corey Seeman via Flickr

You’re getting nociceptive input all the time, but your brain usually chooses not to tell you about it. If this wasn’t the case, your shoes would bug you all the time (pinchy bastards), your ass would be perpetually uncomfortable when sitting, and your head would be a nightmare of itchy madness. Instead, your brain will let you know when you’ve worn your shoes for too long, or when you’ve done enough dancing for one evening. You are left blissfully unaware of your ass until it starts to fall asleep, at which point you may shift a bit. Instead of trying to peel your scalp off, you unconsciously give it a scratch here and there to keep it exfoliated (and you probably don’t even notice).

This is the case with all pain. What does your brain let through? What does it filter out? More importantly, what does it flag as “super fucking important, hey Ian you should pay attention to this”? That sense of importance is not a part of the input, but rather like the color green. It’s something that your brain, in its vast-but-limited wisdom, adds on after the fact. Take 15 minutes and watch this TED talk by prominent pain researcher Lorimer Mosely. You will find that he is charmingly Australian:

If you didn’t get a chance to watch, the upshot is this: Pain is incredibly intense when the brain thinks that it really needs to get your attention. Broken knee? Important. Painful. Scraped knee? You might not even notice until you get home and find your jeans glued to your leg.

Your Structure Is Not Your Destiny

This all becomes especially relevant when we consider the pain industry here in the West. If you go to a doctor with pain, they will find a structural cause, even if it means doing three different kinds of scans and five nerve conduction tests. Scan a body enough times and you will fucking find something weird about it. A spinal disc that’s squished out like jelly from a poorly-constructed PB&J. A joint that has rough cartilage, or that’s at a weird angle. Reduced space between bones. Bursitis, tenosynovitis, arthritis, bone spurs, etc. I once had a client who was diagnosed with “calcified trigger points.” Yes, a chiropractor was responsible.

Could these be the issue? Sure (except for the last one, which doesn’t exist). Are they the cause of your pain? Well, no. Your brain is the only thing that can cause pain. Think I’m just being a supercilious prick? Consider the following:

  • Severity of knee osteoarthritis does not predict pain. Patients with mild osteoarthritis can have severe pain, and patients with severe osteoarthritis can be pain-free. People with the same amount of joint degradation can have a wide range of pain.
  • “Sham surgery” can be just as effective for curing pain “caused” by meniscus problems in the knee as actual surgery. They simply don’t do the damned surgery, and people get better at the same rate.
  • Talk therapy is an effective intervention for pain. Swedish massage is an effective intervention for pain. Acupuncture (both real and sham) is an effective intervention for pain.

How can these be true if your structure determines your pain?

Okay, structure is involved. If you break your knee, it will hurt. If someone pinches you really hard, it will hurt. Nociceptors exist, and they will report to the spine/brain when shit gets really bad. So how do we explain the weirdness above?

I’ve got two explanations: Pain thresholds and the psychosomatic effect (more on the second one later).

Central Sensitization and You

Why does a teeth cleaning hurt some people more than others? How come some of my massage clients need light touch, while others would like me to club their muscles with rocks until my arms give out? Why does my pain get worse when I’m depressed/anxious?

The answer to all of these is likely central sensitivity. This is how far your brain has its “pain knob” turnt up. Another way of putting it would be your “pain threshold.” How much abuse can your body take before your brain presents you with the perception of pain? How willing is your brain to create pain with minimal input from your body, or no nociception whatsoever?

It turns out (as you may have seen in the video above) that this is a variable phenomenon that is influenced by many sources. Stress can reduce your pain threshold. Lack of sleep can reduce your pain threshold. And, perhaps most crucially, pain can reduce your pain threshold.

This phenomenon, called “central sensitization,” is the real turd in the punchbowl of life. The more pain you experience, the harder your brain “listens” to pain inputs. It’s as if it realizes that you’re in an increasingly dangerous environment, so it makes you hyperaware of danger. It’s using pain as a lever, as a compliance tool, to keep you from getting into any more trouble.

It’s kind of sweet when you think about it. It’s trying to be your bro and keep you safe, but it mostly just ends up causing you to take time off work and hate getting up in the morning.

Fiddling With Your Pain Knob

Ahem. Phrasing.

So, if pain causes pain, what can you do? Aren’t you kind of stuck in a vicious circle? Not really. As we’ve figured out so far, when you’re in pain, your body listens. Well, it also listens when the pain chills out. As pain decreases, pain sensitivity decreases. If you do a lot of painless activities, you can kind of trick your brain into not paying so much attention to nociception.

This, in my informed opinion, is why massage works for pain. It gets your central nervous system (your brain and your spinal cord) used to the idea of the body being able to move and interact in a pain-free way. Sure, that hip used to be a hotbed of pain and despair, but there’s this hour every week where it feels kind of nice. Maybe it’s not the shitshow that your brain has become accustomed to.

How should you, the pain consumer, go about reducing your pain threshold? Move in low-pain ways. Go on walks, even when your knees complain a bit. Move your arms around, even if you’ve got frozen shoulder. Stretch, do yoga, and swap massages with someone you love.

Finally, think differently. It turns out that just being more informed about pain science can improve your pain outcomes. You’re welcome.

What do you think? Are we capable of changing our pain threshold, and can it make a long-term difference? Leave me some comments!

11 thoughts on “Got Chronic Pain? It’s Time to Think Differently

  1. Welcome back! It is so weird that you would write this today as I was thinking about how I often feel compelled to label my pain. For example, I was sitting at my desk for a long time and decided I needed to get up. I stood up and thought, “oh, my feet really hurt.” Then, I stopped and said to myself, “Do they really hurt?” And I thought, “No. They are just a little stiff.” And then I noticed they hardly hurt at all.

    I think I have an ongoing dialogue in my brain about what hurts and how bad it hurts. And guess what – I always have something that hurts because I am always paying attention to it! I have been diagnosed with fibromyalgia. I think that diagnosis has “trained” me to pay attention to to every little signal and attach the word “pain” to it. Then I spend lots of time trying to figure out what I did to cause it or a lot of time being angry at my body for causing all this agony or a lot of time depressed because I am in pain.

    After listening to the TED talk and reflecting on my experience today, I am thinking maybe my brain just has a habit that I need to help it break. I am going to start paying attention to that voice that says, “ouch, that hurts.” Maybe relabeling the experience will modulate the perception. I’ll let you know how it goes. Thanks for your post!

    1. Anne, everything you just wrote was amazing. I really do think that our cognitions about pain do a lot of the work coloring those perceptions… and now I want to write a blog post about that idea.

      Let me know how the reframing goes, and definitely let me know if you hit on anything that seems especially useful in your life. It can be easy to slip into self-judgment and self-distancing once we’ve been given a diagnosis, so it’s pretty neat that you noticed that and would like to play with it a bit. Let me know if I can support you in this!

  2. I used to hear people say that we can control our thoughts or learn to deal with pain and I just didn’t get it. Then a MT recommended a book called “You Can Be Happy No Matter What.” (I hope I remembered the title correctly. I believe the author was Richard Carlson.) And guess what? You can change how you think about your feelings! I won’t say my life is perfect, but I spend a lot less time being unhappy now. Great book! Enjoyed the article, Ian.

    1. Thanks for sharing that, Kaye! How we approach our own feelings, even our own thoughts, can change a lot about how they affect us. I definitely agree with your central thesis!

    2. The book you refer to is “You Can Feel Good Again.” While it is a somewhat slap-happy title, his premise is excellent – you cannot think your way out of depression. The chief thing I have learned from this book is that I am not my thoughts. My thoughts are just the activities of my brain trying to solve problems, mostly problems that my brain thought up and now tries to solve.

      One of my favorite quotations of Dr. Carlson is, “No one is born skeptical or negative. Self-doubt, self-criticism, negativity and pessimism are a result of negative thoughts that you learned to take seriously.” He teaches you some very practical skills for dismissing these negative thoughts.

      His methods have helped me understand that I don’t have to pay attention to my thoughts if I don’t want to. I can just observe them come and go and choose whether I want to give them any attention at all. These methods have kept me from letting a “bad mood” (which is an experience common to all) evolve into the “pit of despair.” His chapter on Moods is great.

      Like paying attention to pain, paying attention to depressing thoughts will take you no where good. I recommend this book as an excellent guide on understanding and dealing with the mind.

      1. The book you mentioned seems to be by the same author and probably contains much of the same information. I double checked and mine is definitely You Can Be a Happy No Matter What. But the take-away is the same: we can control the path of our thoughts, and we can be much happier when we do. 🙂

  3. Good topic to read after my own hiatus from both massaging clients and social media.
    Two months ago I had what can only be described as a 3 Stooges moment which resulted in a fractured ulna and sprained wrist. Not the best thing to happen to a massage therapist. After 8 weeks of recovering, I finally got back into the swing of things and saw 2 clients yesterday. Earlier in the week I gave each of my daughters a massage. Nice and soothing…just the way they prefer. My arm and wrist feel great. The rest and rehab work I’m doing is/has been effective. But toward the end of my second session yesterday I could tell my back would be achy today…and I began to beat myself up over the notion that it would feel this way after only 2 clients! Had I really gotten that out of practice?! I didn’t take into account that I had also walked a great distance that morning, worked out, and stretched a lot early in the way before making my way to see those two clients and maybe was going to be feeling those effects even had I not done the massages….which happened to be booked back to back (I have little control over that scheduling, unfortunately).

    So…pain. Delt with it, dealing with it and letting it run it’s course. My concerns about doing too much too soon creating a chronic pain syndrome has me moving more conscientiously and slowly with my clients.Two things that had begun to escape me as I was becoming increasingly preoccupied with certain frustrations with the realities of a massage career and my own personal challenges. Truth is, my wrist had been bugging me…just vaguely…for some time. I have sprained it 4 times in my lifetime. And days I would worry over it were also days that it ached more…Or was it aching more so I was inclined to worry more? Not sure which is which…but… I think the “break”…both physical and metaphorical, has been good for me. I had to take stock of a few things. It set me back on a road that I’d been struggling to get back on for a while….in terms of self-care and overall health/well-being. Slowed me down…slowed my mind down. Allowed me time to reflect….to do some healing and regain perspective.

    I tend to think it is all circular. Our minds, our pain…how we approach and/or respond to it. Difficult to know where it begins and where it ends. The neurological laws was one of my favorite topics in school. I find it all pretty fascinating.
    Another interesting book that touches on this topic is Scott Jurek’s “Eat & Run”…about his journey to running ultramarathons. He reflects on why someone would run such a distance as well as endure the inevitable pain involved….both emotional and physical. Interesting stuff even if you are not a runner at all. 🙂

    And here I am rambling again in your comments section… 🙂

    Welcome back!

    1. You can ramble at me all you like, Sandra, because you’re damn good at it! I think it speaks to your level of mindfulness that you’re able to catch yourself in a self-perpetuating loop. The pain feeds the worry, the worry feeds the pain… and sometimes they blend together inextricably, forming a hearty stew. The good news is that, with this awareness, you can find many avenues for keeping things from going too far.

      I really like the idea of slowing down, whether its in your massage, your activities of daily living, or your self-judgments. I think that much pain and suffering could be prevented by letting go of the need to rush.

      …. in fact, that would be a damn good blog topic. 🙂

      1. Awareness is key. Nothing is worse than a hurried anything…especially a massage. I once interviewed with a pretty well established MT that I thought would be fabulous to work with. I was brand new and pretty nieve and very flattered that I was possibly going to work in that setting…much less jaded than I am now. The MT wanted to give me a massage to show me what is expected at that particular practice. I thought it was going to be great. Was so looking forward to this massage by this knowledgable and experienced therapist. Well, it was dismal. Rapid movements, hurried speach, and general abruptness. I left feeling confused and disappointed. It helps to remember that experience. It also helped me to know that I don’t have to conform to another’s idea of how I should function as a MT. Their way is not always my best way.

        This may have gotten off topic just a bit…but not that far. It is sort of all connected, isn’t it.

        P.S. Call me Sandy. I’m not sure why my full name is on my profile…need to change that. Sandra may be my given name but I am so much more a Sandy. 🙂

  4. I have a herniated disc toward the spinal cord. When it swells it pinches nerves that tell my brain there is something wrong with my shoulders, hips or ankles when i know there is nothing wrong with them but the pain can be debilitating at times. I’ve learned to work through the pain by walking and stretching with resting flat on my back and pillow under my knees.

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