The good news is, there’s good news, so read on :-)
One in five Americans suffer from chronic pain and most of them believe they do so because of an injury or breakdown of their tissues. This is called the biomedical model. The biomedical model assumes that injury and pain are the same issue; therefore, an increase in pain is seen as sign of increased tissue injury. Similarly, it is believed that increased tissue injury leads to more pain. This model (called the Cartesian model of pain) is over 350 years old, and is no longer believed to be correct. While there is, in acute pain, often a correlation (although varied, and never absolute) between tissue injury and pain, in chronic pain this correlation starts to fall apart, and fails to provide a complete explanation of the issue.
One reason for this is that tissue injuries heal, and pain that persists months after an injury can logically not be due to said, one-tie, tissue injury. Sometimes there is not even a distinct injury precipitating the onset of pain, but the onset is gradual. Pain is also highly dependent on our attention, stress, emotions, learned behaviors, beliefs and expectations, including beliefs about what the pain means, whether we feel safe or not, whether we feel empowered or helpless. Psychological factors have actually been found to be more predictive of the development of chronic pain than physical ones.
Modern pain neuroscience has enhanced our understanding of pain
The fundamental thing that modern pain neuroscience research has shown is that chronic chronic pain may not correctly represent the health of the tissue, but may be due to extra-sensitive nerves and modulated by our beliefs and expectations.
You could describe the peripheral nerves leading out to our tissues as wires picking up various signals (touch, temperature, pressure etc) and our brain as the processor that interprets these signals. In a well-functioning system the signals are interpreted correctly. Touch is interpreted as touch, movement as movement etc. But this system can malfunction, and the nervous system can start to misinterpret or over-interpret these signals, so that eg stimulation of receptors in muscles and tendons that should result in a sensation of movement instead results in a sensation of pain.
Pain is created and experienced in the brain
Nociception is the word we give our ability to detect potentially harmful stimuli. It is a protective process that helps us avoid harm by either creating a reflex to pull away from the stimulus, for example a thumb tack you just stepped on, or a sensation that is so unpleasant (read:painful) that it results in behavioral strategies on our part to avoid the stimulus (to look around and step carefully in order to avoid stepping on more thumb tacks). Our “wires” lead the signal of a certain input to the brain, the “central processor”, which then makes an executive decision about whether the stimulus is worthy of our attention, and if so, how much of it. If the brain interprets the signal as a result of a potentially harmful phenomenon, it creates a sensation of pain. Worry, fear, negative beliefs and expectations, previous experiences and many other psychological factors affect the brain's decision-making process.
In some people the alarm system gets stuck at a higher level of sensitivity. With the alarm system extra sensitive and close to the “firing level,” it does not take a lot of movement, stress or activity to activate the alarm system. When this happens, it is natural to think that something must be wrong, even though there is no injury or damage to your body. This is called central sensitization. Central sensitization produces hypersensitivity to pain and other sensations by changing the sensory response elicited by normal inputs. Now even those inputs that usually evoke innocuous sensations such as touch, movement etc may be perceived as pain or other worrysome sensations.
Pain in a person with central sensitization may arise spontaneously without any sensory input such as touch, movement or pressure and it can be elicited by normally harmless stimuli such as gentle touch (this is called allodynia). It is exaggerated and prolonged in response to normally painful stimuli (hyperalgesia), and spreads beyond the original painful area (secondary hyperalgesia).(By the way, these fancy terms are just names for the phenomena we observe, not an additional diagnostic label to be worried about!)
The pain in central sensitization is in other words not proportionate to what is going on in the body.
Sometimes this heightened level of responsiveness of the nervous system is felt only in particular part of the body. Chronic episodic pain is pain that, as the name implies, occurs in episodes, instead of always feeling the same. Pain can be triggered by eg stress, and fear of pain and disability can be a powerful stressor. Individuals with chronic or recurring pain therefore have to work diligently at controlling their thoughts and emotions through education, awareness -building practices such as meditation and other means of keeping levels of stress and catastrophizing thoughts low.
Why do some people develop chronic pain?
There are genetic differences in our pain threshold (how quickly we would characterize a stimulus as painful). Hormonal levels affect our sensitivity to pain. As an example, low level of the sex hormone estrogen, as experienced during certain parts of the menstrual cycle and even more so in menopause increase pain sensitivity. Cold this be part of the reason why middle-aged women are the group most often diagnosed with fibromyalgia? More than anything, our thoughts, beliefs and expectations affect pain.
Sometimes an acute injury leads to an adaptation to pain (think of someone with acute low back pain and how they tend to move) that includes altered movement strategies and a decreased levels of movement that in turn set the stage for chronic pain and malfunction that seems seamlessly connected to the initial injury, but actually is arising from the changes we, consciously and not, made in response to the acute pain. Now the initial injury or muscle spasm is long gone, but the patient has made permanent changes to how they view and use their bodies which create ongoing pain.
Central sensitization represents a more fundamental shift in how the nervous system perceives pain, and all of the reasons for this aren’t well understood just yet. However, we know that anxiety, stress and depression are also present in 30–45% of patients. Other factors that may contribute to symptoms include endocrine dysfunction, psychosocial distress, trauma, and disrupted sleep.
Adversity in childhood can set the stage for central sensitization, and so can traumatic events leading to PTSD.
It is as if though the brain learns that the world is a dangerous place and remains a bit more on high
alert, and over-interprets potential signals of danger.
Examples of situations where you’ll find central sensitization are whiplash that persists a long time after the original accident. Fibromyalgia is the prototypic example of central sensitization. Less often, but in a percentage of cases of low back pain, tendon problems, shoulder pain, osteoarthritis, rheumatoid arthritis, pain following cancer treatment, tennis elbow, headaches, shoulder pain, tendonitis of the elbow, knee and ankle central sensitization plays a role. Sometimes central sensitization presents as a heightened sensitivity to pain that seems to move from place to place or be felt in many body regions at the same time. Opiod use can actually lead to an increased pain sensitivity, so called Opioid-induce hyperalgesia.
It may be helpful to think about sensitization in chronic pain as existing on a spectrum, so that you don't either have it or don't have it, but may have more or less of it. All of this also means that when you experience acute pain, you can think and behave in ways that may help prevent chronic pain.
Incorrect beliefs about the nature of pain and a belief that the body is inherently fragile, and subsequent
avoidance of movement out of fear of further damaging what the patient believes is an already
damaged body, are called Fear Avoidance Beliefs and have been strongly correlated with chronic pain.
Is chronic pain always a nervous system problem?
The reason developing a better understanding of the nature of pain is helpful is that it empowers us to take the correct action. This action is not to power trough the pain, but at most to gently "nudge:" it, to move despite moderate pain, through through gritted teeth. To know when to heed it's call and when to call it's bluff.
When we approach out bodies with this enhanced understanding, we don't risk overloading tissue in conditions, such as hypermobility disorders , where there may be chronic overload on certain tissues, contributing to pain. These underlying issues have to be addressed, because, at best, they keep the flame burning under the enhanced, chronic pain.
If you have had pain for a long time and haven't been getting better, you know or suspect that central sensitization plays a role in the pain you’re feeling, or have been wondering why seemingly innocuous activities often make you hurt so much, or lead you into a spiral of pain, take heart! The reason central sensitization develops in the first place is the so called plasticity of the nervous system, in other words it’s ability to change and learn. If your nerves have learned to become too trigger-happy and your brain has learned to exaggerate signals they can also gradually learn to calm down. Working with a qualified healthcare provider and trusting that the sometimes initially counter-intuitive things you’re learning are true is key. After all, pain in central sensitization feels just the same as any other pain, and it can at first be hard for some patients to understand that it is not a discrete physical injury that is driving the pain, but rather a hypersensitivity of the nerves.
It can also be hard for patients with chronic pain to take in the fact that pain does not go away by waiting for "healing" (of tissues that aren't injured) to take place before increasing movement. That is actually placing the cart before the horse. Even acute pain heals faster and better when appropriate movement is part of the treatment plan!
Here are some key points to consider:
Learn to understand chronic pain. It is important to understand that you are not hurting simply
because of a broken body or injured body part. Understand that pain may not correctly
represent the health of the tissue, but may be due to extra-sensitive nerves or incorrect usage of
Understand that movement, properly introduced and performed, is your friend and will not
injure you. Your body is not fragile! Feeling sore after movement does not mean that you have
been injured or hurt.
Approach movement through graded exposure. Graded exposure means that you are, through
gradually increasing exposure to movement, decreasing the sensitivity of the nervous system
and correcting movement-related pain associations. Your fear of movement, pain and of
"getting hurt" will decrease slowly but surely through gradual, positive experiences .
Find the right provider. Some healthcare professionals may not be quite familiar with current
pain neuroscience. If you are only being treatment with drugs, passive treatment modalities or,
conversely being encouraged to completely disregard pain and work
harder, find a provider that can more appropriately guide you through the
process. You need to find and accept a "Goldilocks-level" of gradually increasing exposure to
Learn to not interpret initial discomfort as a sign that your body is being hurt or injured. Your
body is not fragile. Learn to not focus on sensations of discomfort, and be disciplined abut
redirecting you attention to other sensations and phenomena. What part of your body feels
good? Were you able to make some progress with your exercise program? Did you tolerate
more movement before reaching a familiar level of discomfort? A
brain that fears the sensations it experiences creates much more pain than the
brain of person that is informed and feels safe, not scared. Fear of the pain
itself also increases the intensity of pain.
Focus on progress and ability, not on pain and disability.
Think long-term. No matter how seductive various treatments that only temporarily relieve pain
may be, understand that they are not a way out of chronic pain, and actually
may distract you from the important work at hand. When you are
tired it may feel like you need coffee, and coffee would of course temporarily
help. But the actual problem is not that you haven’t had enough coffee, it is
that you haven’t had enough sleep, and that is the problem you actually need to
solve. If you continue to drink coffee instead of getting some sleep, you’ll
soon be in deep trouble. Remember, the problem causing the heightened I pain intensity
doesn’t primarily lie within the tissues, but in the sensitized nerves, incorrect beliefs and incorrect
You need active work more than passive, palliative treatments.
Normalize your body's function. When your body works more like a well-oiled machine than a
cart where the wheels are slowly coming off, you will be loading your bod's tissues isn a way that
strengthens them, instead of weakening and irritating them. Note: in chronic pain conditions
you need a physical therapist to guide you through this process. You already now that
simply trying to move more makes you feels worse!
Knowledge is power. When your brain understands that the
sensations you are noticing are not a sign of danger to your body, it will
actually immediately produce less pain! Remember, the type and amount of pain we
experience is very directly and strongly dependent on our beliefs about the
pain and what it means. Be your own coach and remind yourself of this every day!
A healthy body feels pain sometimes, and gets better by adapting to activity,
not by avoiding it. Waiting for pain to completely go away before returning to
activity is putting the cart before the horse, because resting makes
you weaker, not better adapted for activity. But sudden dramatic increases in
activity may be just as ill advised to the sensitized person. Start low and go
slow is a useful mantra. The body in chronic pain is like a scared cat. You can’t
force it, but you can entice it, and gradually convince it that it is safe to come
out to play.
You are not a passive recipient of pain. It may not feel like it, but pain is a process that takes
place within your own brain, and you have a lot of control over it. By educating yourself,
disciplining your thoughts, finding proper guidance for movement and lifestyle (deep sleep, a
good diet, emotional support, mindfulness and other aspects of a health-supporting lifestyle all
have immense effects on the amount of pain we feel) and trusting your body's inherent strength
and capability you can make powerful changes that help you suffer less.
Remember, the way out of chronic pain lies not in avoiding it, but in understanding it and transcending it. You transcend it by understanding its very nature, that it is not warning or guiding you, but deceiving you. It is simply a sign of a nervous system set on high alert, of having ended up in the dead end of avoiding pain instead of confronting it. The opportunity available to us is to slowly but surely reclaim our health and freedom to move and enjoy life.
Do you have questions about how to address or avoid chronic pain? Comment below!
Actionable ideas for the tired, overworked, fearful, pain-ridden, injured and concerned.
We all know there are benefits to be derived from regular exercise, but most aren’t aware of quite how great they are. In order for us to be motivated to do something we need to find our why, our motivation to devote time and energy to said enterprise.
Sooo many benefits you'll love
This study showed that with regular exercise, 70-year olds had muscle mass and strength identical to their 40-year old counterparts. The authors conclude that the loss of bone, muscle, strength and balance over time is due to increasing levels of inactivity, not age. This is great news, and completely contradicts the commonly held false belief that aging inevitably has to be a period of gradual decline.
Multiple studies and review papers such as this one show the effects of regular exercise on mood, cognition and its power in warding off dementia. As a matter of fact, the great news is that those genetically most at risk for Alzheimer’s disease (those with one or two copies of the so called ApoE4 gene) seem to reap the greatest protective effects from physical exercise! There seems to be justice in the world after all!
Add to this the fact that regular exercise helps prevent the most common diseases (75% for breast cancer, 49% for cardiovascular and heart diseases, 35% for diabetes, 22% for colorectal cancer). Imagine if there was a pill that could do that! We have such a "pill" at our disposal in the form of exercise and with only positive side-effects at that. When exercise is combined with other simple constructive behaviors such as sleeping in a pitch-black room, eating nutritious food and cultivating a peaceful mindset the effects are even more pronounced.
Given how fantastic the effects of exercise are, why aren’t we all out there, reaping the many benefits? (After all, physical exercise even gets you closer to that coveted “look better naked” status.)
But (almost) no-one spontaneously prefers exercise to a comfy seat on the couch, and in a real-world situation many obstacles seem to keep so many of us from reaping the tremendous benefits of regular exercise. To help you move from passivity to physicality I have listed some of the most common obstacles below, along with some hopefully helpful and actionable work-arounds. If you are experiencing obstacles or concerns that aren’t listed below, reach out to me in the comments section!
Time to troubleshoot!
I don’t have the time. Yes, you do. But your available time may be found in small increments during the day. Work by a desk? Type standing, stand and do toe-raises while on the phone, take 30-second breaks (which enhance creative thinking and make you more productive) to do push-ups against your desk, squats over your chair etc. And take the stairs every time. The elevator is for lazy people, and you’re not lazy, just busy. This advice applies to stay-at-home parents as well. Take advantage of the opportunities you may have been missing to strengthen arm and trunk muscles while holding a baby, or leg muscles by performing little lunges carrying groceries.
I’m too tired. If you are truly exhausted, you should not perform strenuous exercise. Yet. You need to work on your burnout and nurture yourself back to health. When tolerated, start with slow, short walks. During your recovery, perform stretching and meditation to stay in touch with your body and its intrinsic value. You know you suffer from this level of exhaustion when any exercise leaves you drained instead of invigorated.
Those who feel tired and therefore unmotivated, but feel awakened and a bit better after some exercise actually need physical exercise to overcome the fatigue. The mitochondria, the little energy factories in your cells, multiply in number in response to exercise. The body rises to the challenge. They key is to re-enter the world of exercise gradually and keep your focus on your improvement, not your challenges.
I have pain. If you’re in pain from the type of acute injury that truly means you should lay off your usual exercise, such as a broken bone, exercise the part of your body that isn’t injured. Most other types of injuries respond better to activity modification, rather than cessation. In other words, lift a lighter weight fewer times, run or walk a shorter distance with a shorter stride length etc.
If you suffer from chronic pain, know that waiting for the pain to go away before starting an exercise program is putting the cart before the horse, and a mindset that will lead you deeper into pain as your body and its tissues keep getting weaker due to inactivity. Exercise decreases pain, and being decondition increases it, so pain is an added reason to exercise. Seek the advice of a physical therapist who will guide you through, and accept that there is going to be some discomfort before you feel better again. A simple rule for how much discomfort is safe is what I call the traffic light test:
Red- severe, sharp pain that takes your breath away - Stop doing what you’re doing
Yellow- Some discomfort that doesn’t seem to get worse with what you’re doing -
keep moving, with awareness
Green- movement feels great, or discomfort is decreasing - Keep right on moving cap’n!
Every time I exercise I get injured. Your amazing body adapts to what you’re using it for. Is your body adapted to sitting? Then you need to give it time to gradually adapt to movement. Want to run? Lengthen your hip flexors, strengthen your glutes, start walking and give your bones, ligaments and muscles time to gradually adapt. Want to lift weights? Work on a stable trunk
( planks, dead bug ) before you add any weight to your extremities, then strengthen buttock muscles and stretch your body to improve your joint range of motion.
And why not add some collagen to your diet (preferably before exercise and before bed and with some vitamin C) to give your body the building blocks for all the connective tissues it will be building.
Remember, an injury means that you are doing something wrong. If you can’t, despite following the above guidelines, figure out exactly what that is, consult with a physical therapist for some additional troubleshooting. Don’t give up on reaping all the benefits of regular exercise because of a few false starts!
I have special limitations. Not everyone can engage in all kinds of movement. If you have spinal stenosis, for example, you may not enjoy uphill running, but you may very well tolerate working out on an exercise bike. Learn how to get the most out of it (doing sprints on the bike, for example, adds a whole new layer of benefits) and you may over time find that other types of exercise get easier. If you can’t run, then walk, use an elliptical trainer or a bike. If you don’t have access to a gym, exercise class or a work-out buddy, use your body weight, household objects and the great outdoors for an equally beneficial experience.
If you are recovering from an injury, progress at a pace that allows all of your tissues to grow stronger. Muscles grow strong faster than ligaments, tendons and bones, so if you feel discomfort in theses tissues simply slow down the pace a bit. Older individuals and those on the hypermobility spectrum need to give their bodies more time to recover and progress.
I am just not motivated enough. Ask yourself what you are motivated to do or want to experience, and how that will play out in a gradually weakening and deteriorating body. Not so great, huh? Tough love, yes, but it is also part of a rather absolute reality that the physical body needs strain (aka exercise) in order to remain healthy.
Ask yourself what you need your body for. Is it playing with the grandkids? Travel? Long hours of work? Attracting a mate? Aging comfortably, with dignity and joy? Exercise is the key for all this, and more. See: the beginning of this post.
And lastly, the close cousin of lack of motivation:
I have to suffer in order to benefit. While vigorous exercise can certainly be a special kind of uncomfortable, it also offers immediate feelings of wellbeing of an even greater magnitude. And for a beginner, exercise does not need to be vigorous. The habit of seeing the world in black and white / can or can’t / good or bad is a counterproductive one, and prevents you from seeing the opportunities you do have. Don’t ask yourself whether you can or can’t do something, ask yourself instead how you can do it. If you are unsure about performing squats, don’t rule them out, but find a safe way to do them (over a chair? holding on to the kitchen sink?). If you have trouble running or lifting weights, don’t give up because of what you can’t do. Ask yourself, instead what can I do? Perhaps you’ll decide to start walking and doing some simple body weight exercises instead. And if you can’t walk yet, you might decide that what you can do is stand up every 15 minutes.
Remember, age is not an excuse (see above). Not having exercised before is not a reason not to start now (the body responds at any age). Injuries should end in recovery. Not possessing the know-how is no problem (make an appointment with a movement expert and learn).
Your quality of life depends on your physical health, and your body, unequivocally needs some form of movement and strain to stay healthy. Find your why and your how and the what will appear!
What would you like to be able to do?