Physiotherapists deal mainly with people in pain. Pain problems vary immensely from patient to patient. In most cases the situation is pretty straightforward where the pain serves an important purpose – indicating damage and helping to protect the affected area as healing occurs. In such cases, the pain is a very efficient indicator of safe levels of loading. An example is someone who has sprained their ankle and then experiences pain when walking. This changes their behaviour to encourage protection of the healing ligaments by limping. As the tissues recover, they become less sensitive and the pain reduces. Consequently the limp lessens, until normal walking is possible and the pain disappears. An interesting fact about this type of pain and indeed all types of pain, is that whilst the pain of a sprained ankle (or any other body part) feels as though it emanates from the injured area, the reality is that pain does not come from injured tissues. The truth is that all pain comes from the brain 100% of the time. Now if you have just whacked your thumb with a hammer, this fact is difficult to accept. However, such an unfortunate and painful experience is simply an example of how good the brain is at projecting pain.
The basic neuroscientific fact that 100% of pain is produced 100% of the time by the brain is fundamental to understanding why some people suffer from persistent pain. Persistent pain is a big problem. The definition of persistent pain (also termed “chronic pain”) is a pain that has been present for more than 3 months and it has been estimated that between 30-50% of the adult population in the UK could be affected. This type of pain may initially be caused by a straightforward injury, such as a back strain. However, instead of the pain resolving as in the above sprained ankle example, the pain just doesn’t go away. Some people can experience persistent pain for months or years after the initial onset.
Persistent pain invariably changes people’s behaviour in many ways. Those affected, often move awkwardly and avoid normal day to day activities. Persistent pain impacts on their work and social lives and causes depression and anxiety. In these situations the brain simply produces too much pain and the reasons for this are usually numerous and different for each patient. However new understandings of how and why pain is produced, have helped research clinicians to formulate more effective treatment approaches for persistent pain.
The key to effectively dealing with persistent pain is to perform a comprehensive physical examination and link these findings to a thorough subjective examination. The subjective examination takes a detailed look at all of the factors that have been linked to the perpetuation of pain conditions. These include lifestyle issues such as sleep patterns and exercise and activity levels. Patient beliefs are also evaluated as are other cognitive factors such as fear, anxiety and depression. All of these factors are known to ramp up pain. The good news is that many of these pain producing factors can be addressed with clinical interventions. The other positive piece of news is that the brain and central nervous system are extremely adaptable systems and can be trained to turn down the pain volume control.
“100% of pain is produced 100% of the time by the brain”
G. Lorimer Moseley “Reconceptualising Pain According to Modern Pain Science”
“30-50% of the UK population suffer from persistent pain”
Fayaz A, Croft P, Langford RM, et al
Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies
BMJ Open 2016;6:e010364. doi: 10.1136/bmjopen-2015-010364
Greg Lehman is an American Physical Therapist and Chiropractor who has written an excellent guide to persistent pain – understanding it and how to deal with it. It’s free and can be obtained from: