I wrote an article about pain as an illusion a few months ago and I appreciated the mix of responses I received from you all. This idea is sensitive because it can leave people feeling invalidated, suggesting their pain isn’t real. So, it’s important to acknowledge that all pain is real. Your pain is real. While pain is never “all in your head”, technically, all pain is constructed and experienced in the brain, regardless of the cause. However, SOMETIMES information from the body partly informs the brain’s decision to create pain. The first step in pain recovery is to establish clarity about the role of the body, if any, and to reduce fear. Mostly by educating people that pain is ALWAYS a brain-driven process. Also important is to trust that the body is reliably self-healing. Once people feel safe, trusting the body isn’t in danger and that the brain is the reason they hurt, then we can work to get back into the body and prove to the brain that the world is safe again. This drives change through the remarkable phenomenon of neuroplasticity and reliably leads to lasting relief.
So, my goal is to evaluate the body thoroughly to see if there’s a clear pattern that might point to structural issues (broken bone, tumor) or mechanical issues (stiff joints, patterns of weakness, or other movement-related issues) that partially explain why someone hurts. Usually, mechanical changes are the RESULT of a nervous system in a state of danger alarm. But regardless, if body changes are present, we can treat them to offer short-term relief. I call this treating the brain from the bottom up. But these body-based issues are still only a small part of the brain’s decision to make pain. Remember, pain is also ALWAYS influenced by the psychological and social factors in one’s life. These include fear related to the pain itself but also fear related to other things going on in life. These things will amplify any structural or mechanical issues, creating a vicious cycle that often leads to pain sticking around way longer than it needs to. For many, even after the body stuff clears up, pain sticks around, becoming chronic.
One of my readers, a psychology professor, thoughtfully commented that “just because pain CAN be brain-mediated and independent from peripheral structural issues, doesn’t mean that it IS.” He continued saying, “You also used several other examples of the brain tricking our perceptions. Again, in the case of pain, just because it CAN doesn’t mean that it IS.” He suggested that the example of my back pain client who couldn’t find his car had relief because of “a temporary stress-induced increase in circulating or central endogenous opioids which MASKED the pain generated by a structural issue.” While this was not the case for my client, it’s possible he’s right that the brain can turn pain off in an extremely stressful or survival situation. If you’re being chased by a lion and sprain your ankle, your brain will likely keep pain turned off until you get to safety.
My clinical experience is that when there’s a real structural issue, this kind of relief tends to be very short-lived and incomplete. The brain won’t usually turn off a structural issue for long, especially if the person is doing something VERY physically strenuous and it happens to be the exact thing that normally triggers their pain day to day. However, when the relief is due to the brain in the absence of a body problem like it was in my client, relief can last days, weeks, or months, if it comes back at all. My client’s pain did not return once he found his car because he suddenly saw evidence that his body was safe. Seeing how his pain COMPLETELY disappeared during an acute stressor was a “click” moment. Evidence that sparked the start of his recovery after 20 years of suffering.
My son races mountain bikes for Boulder High School. Last week at a race in Fruita, CO, he crashed hard heading out onto lap 2 (moments after the video below). His leg got caught under the bike, and he slammed and twisted his knee as the rider behind him crashed over him. He got up despite the knee pain and bravely rode the rest of the 30-minute lap. He said despite the adrenaline and intensity of the moment, while he could still pedal, his knee hurt, and he had sharp pain that limited his power.
When he crossed the finish line, I ran over to find him sitting on the ground crying and hyperventilating. He’d finished the race but was now in a lot of pain and his knee was locked at a 45-degree angle so he was unable to straighten it. Nor was he able to weight bear on it. The front of his knee was bleeding and he had a lot of pain over the medial side of his knee. I put my arm around him and rubbed his back, encouraging him to slow his breathing and modeling calm, reinforcing that he was going to be ok. Despite no obvious signs that his knee was badly injured, he was very stressed and in a freeze state. I wasn’t 100% sure that his knee was structurally ok. He could have torn his ACL, his meniscus, or subluxed his joint. But I wasn’t going to assume anything until I had more evidence. I knew the fear, panic, and emotion in the moment was part of the reason he hurt so much and adding to that was not going to help. In his case, while adrenaline turned his pain down to allow him to finish, it was not enough to turn pain off for long; and his came back wicked strong the minute the race ended.
But, after about 5 minutes of soothing him and validating his experience, he began to calm down. I helped him visualize getting his knee straight again by relaxing his calf and hamstring muscles, which were in spasm. Then I asked him to contract his quad a few times to show his brain that his knee could straighten safely and with good control. Once he saw he could do this mostly pain-free I helped him stand up. With his arm over my shoulder, he limped a few steps, reluctantly bearing weight on his sore knee. Within a few steps, he saw evidence he could walk and I could feel him start to relax. He wanted to do it himself so I calmly encouraged him to try a more normal gait and see how that felt. It took him a minute but he suddenly began to walk almost normally. When I asked how he felt he said “It’s ok Pop, I think it’s just my brain”! Within 15 minutes he’d gone from severe pain, panic, and intense emotion to calm, regulated, and walking normally again. This is how fast neuroplasticity can happen when conditions are right. He had no pain the rest of the day and when I asked him how his knee felt the next morning he said “It feels totally fine”!
Hypothesis, theory, and debate aside, my empirical clinical reality is that nine out of ten of my clients fall into this category. They suffer from very real pain that’s brain-mediated with minimal or no contribution from the body. This type of pain is not only the most common, but also the most painful. Often far more painful than actual injuries. But I never start by assuming the body is ok. Nor do I rely on any one piece of evidence to make a diagnosis of primary or neuroplastic pain. No one bit of evidence stands alone. So I would never tell a client that their pain going away during a time of stress PROVED that it was simply due to their brain. Like a good detective, I need LOADS of evidence to build that case. Otherwise, neither of us would feel safe shifting belief enough to do the brain-based work that leads to long-term recovery.
So let’s talk about evidence. My goal is always to make my clients more autonomous. For two important reasons, I like people to be able to look for their own evidence when something starts to hurt.
If they can interrupt the symptoms earlier in the process, pain never becomes chronic and they can become their own best healers.
Pain is a normal part of life. The last thing I want to do when I have pain is to have to run to the doctor or physio every time. Most of you can use this knowledge to build the skills that will save you a lot of time, money, and frustration.
If you can stay curious about your pain, most of the time you’ll see enough evidence that you can watch and wait. You’ll be able to keep fear low while you stay active and watch it pass. Here’s a list of 10 variables I inventory when I have pain, and when my clients are looking for answers for why they hurt. The more boxes you check, the more likely your pain is not structural, nor mechanical, but due to your brain and nervous system. Even if you had an injury or surgery originally, once the body heals, the brain can learn pain and it’ll stick around for months or years. Luckily, once you see the evidence, shift your belief, and engage in a new process, pain can be unlearned.
Was there a clear mechanism of injury when pain started? Some physical stressor that happened with high force, high speed, and/or with some physical evidence of tissue damage. A loud pop, a moment of instability or dislocation, visible swelling or bruising, feelings of instability, consistent audible clicking or popping. Remember, the body is hard to hurt so it’s going to take more than picking something up or putting on your shoes. If you find yourself making up a story based on loose evidence, or if pain came on days after some physcial stressor, this is unlikely to be due to bodily injury. Dom (below) is an example of how durable the human body is. While he walked away from most of these fails without an injury (aside from the first one), it gives you a sense for what it takes to actually injure the body. Most people’s pain starts without a clear injury and this an important starting point in building an evidence list.
If there was no obvious physical cause, was there a clear life stressor that paralleled the onset of pain? Think about something stressful or overwhelming that happened the moment or the day the pain started. This connection can create a powerful a-ha moment for people offering a new explanation for and meaning about the symptoms. Alternatively, an ongoing stressor might have spiked or changed around that time. Remember, life stressors that trigger big emotions are common triggers for pain. But even more positive emotions (like life change around moving or starting a new relationship) can also create stress physiology that triggers the brain into creating pain. The brain’s job is to keep you safe and alive. It’s fully altruistic. While it doesn’t always feel like it, subconsciously, your brain is making decisions based on many bits of information based on many past experiences. So, pain doesn’t always make sense logically or consciously. But with a little investigation, pain often offers deeper meaning.
How long have you been living with pain? Muscles heal in a few weeks, tendons in 6-8 weeks, ligaments in 10-12 weeks, nerves and spinal discs might take 3-6 months. Healing is reliable, predictable, fairly linear, and nearly impossible to stop. Additionally, if you sustained a real injury of had surgery, pain generally turns off long before healing is done. So pain that sticks around longer than 3-6 months is, by definition, no longer due to tissue damage. Trusting this is important and a powerful bit of evidence in the direction of the brain. That said, it still doesn’t stand alone.
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