23 Sep A Contemporary Understanding of Pain
Living with persistent pain can be extremely frustrating and drastically affect quality of life. Our understanding of pain is evolving, and so too is the way we approach treating pain. We asked Accredited Exercise Physiologist, Ben Davis, to break down the history of pain and explain how exercise can be used to manage it.
A History of Pain
The early theories of pain can be traced back to the Ancient Greek era, when Aristotle and Hippocrates, as well as many others, had competing theories around the root cause of pain. However, in 1664, René Descartes theorised that tissue damage was directly proportional to pain. He also expressed a concept of Dualism; an idea of a material body that interacts with an immaterial mind.
These concepts have stood the test of time. Many health professionals still use the underpinnings of his theories within their beliefs around what pain actually is. It’s a very mechanical concept, where by pain is related to damage; and then if we can’t find any damage, pain must be in the mind.
Jumping forward to the 20th century…
There’s many other proposed theories of pain. Most of these continued to provide a mechanical rationale, but slowly started to acknowledge the key role that the brain plays in the pain experience. Beforehand, if no obvious or clear “damage” was found, people that suffered with persistent pain would simply be labelled as psychologically disturbed. Imagine the trauma that these people would have endured due to the flawed understanding of pain at that time.
The Biopsychosocial Model
In 1977, the American Psychiatrist, George Engel proposed the Biopsychosocial Model.It started to look at the biological, psychological and social aspects of health. Importantly, this model acknowledges the complex relationship between all three components. We must avoid separating them and attempt to understand the dynamic relationship between them. Pain cannot simply be either biological, psychological or social – it’s an individualised experience based on a complex affiliation between all three components.
Pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”.
Diving a little bit deeper, but without going into the scientific jargon, pain is essentially an alarm system that is built to protect us.
Imagine putting your hand on a hot stove and not feeling pain… Your flesh would burn. Imagine breaking your leg and not feeling pain and then trying to carry on walking… You would risk further damage.
Pain is necessary for survival. But, sometimes this alarm system over-does its protective job. This is often the case for those suffering with persistent pain.
What is persistent pain?
Pain can sometimes persist past expected healing time and our nervous system might “over-do” the protective response. Lots of factors can influence this, such as:
- a person’s pain beliefs
- coping strategies
- mental health
- previous experiences
Imagine coming home from work to find your house has been burgled and your belongings stolen… You’d probably purchase an upgraded, more efficient alarm system to prevent this negative experience from occurring again. Now imagine a few weeks later, a cat walks by your house and sets off the alarm system. The cat poses no actual threat to your house, but the alarm is very sensitive and alerts you to potential danger.
This basic concept is what can happen with those who suffer with persistent pain… The nervous system can become hyper-vigilant to potential danger and pain may therefore be experienced during movements, postures or tasks that were previously tolerated well.
A simple way to think about pain is it being an interplay between the stress we experience in our life vs our ability to tolerate this stress (potentially physical, psychological, emotional or social stress).
When the stress we experience outweighs our ability to tolerate this stress, we may experience pain. People suffering with persistent pain may not only have more stress in their life, they may also find they can’t tolerate this stress as well as they did before they suffered with their pain.
The overflowing cup…
In an attempt to make this concept easier to understand, Greg Lehman, a renowned Canadian Health Professional, coined a metaphor that explained the experience of pain as an “overflowing cup”.
Consider the things listed inside of the cup as our “stressors”. Sometimes any or all of these may increase enough for the level of water in the cup to rise until the water overflows; which represents a pain experience.
We can then either attempt to bring down the level of water in the cup (reduce the level of stress) or build a bigger cup (increase our ability to tolerate stress). Exercise can help to achieve both of these!
Exercise benefits for persistent pain
Evidence tells us that understanding contemporary pain biology can be extremely beneficial for those suffering with persistent pain and is a necessity for comprehensive biopsychosocial treatment.
You’re probably thinking “well, all of this is great, but what can I do to help my pain?”.
Research shows that there’s one thing that builds physical resiliency, self-efficacy, the feeling of control over your pain and a healthier lifestyle… EXERCISE! But it’s complex and multifactorial, which is why it’s essential to be individually assessed by an exercise physiologist.
An exercise physiologist can not only help you to understand your pain in a more comprehensive manner, they can also assist you in exposing you to painful and feared movements in a controlled approach.
Your body adapts to exercise well
One of the amazing phenomenon’s of the human body is our ability to adapt. With graded exposure to problematic movements, our system slowly learns to tolerate the same input in a more effective way. Think of hopping into a hot shower after coming in from being outside on a frigid winters day… At first, we experience some pain as the hot water hits our skin, but over time, it feels normal. The temperature of the water hasn’t changed; we simply adapt and learn to tolerate it.
Whilst helping you understand your pain and address fear-related movements, an Exercise Physiologist can also assist you with improving your general exercise tolerance and help you to resume the meaningful activities that you may have ceased since suffering with your persistent pain.
What type of exercise is best?
No single type of exercise is more beneficial than another. But to be effective, exercise programs need to be tailored to the individual and based on the multifactorial nature of their pain and the goals of the person.
1. Pain is an individual, lived experience that fundamentally serves to protect us, but this protective system may sometimes “over-do” the protective response
2. Pain is multidimensional and multifactorial, and is based on the dynamic relationship between biological, psychological and social factors
3. Research shows that exercise is beneficial in helping people in pain, particularly persistent pain
4. Exercise interventions need to be individualised, goal-orientated, and graded. The emphasis is always on restoring movement confidence. Always get advice from an expert, like an exercise physiologist. To find an Accredited Exercise Physiologist near you, click here.
Written by Ben Davis. Ben is an Accredited Exercise Physiologist at Guardian Exercise Rehabilitation. He is passionate about musculoskeletal health, adopting a biopsychosocial approach to help his patients make sense of their pain and develop sustainable self-management strategies.