One of the principle qualities of pain is that it demands an explanation.
Plainwater, by Anne Carson

Pain Is an Opinion

What discoveries in neurology can do for your chronic pain problem right now

by Paul Ingraham, Vancouver, Canada MORE
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Credentials and qualifications

I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.

For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.

The only time I have “flare-ups” seems to be when I'm in a very “stressed-out” period. For instance, just this weekend, I was trying to film a short film that I helped write. However, I am no actor. On the first “shoot,” I was super anxious, lots of adrenaline pumping through me, and it was like I could actually feel the nerve endings in my wrists and hands becoming ultra-sensitive … like they were going to flare up if I did anything. And … they did. Just from lifting some light equipment that day, it pushed me over the edge. That experience alone made me more interested in the “nervous system” aspect of my problem.
Jamie Vance, musician struggling with tendinitis

Pain is not just a message from injured tissues, but a complex experience that is thoroughly tuned by your brain. These not-so-recent discoveries about the physiology of pain1 have been painfully slow to reach the public, or even health professionals. This knowledge is useful and needs to be shared. Professionals need it so that they can retreat from some unfortunate old attitudes about pain problems (“if I don’t understand it, it must be all in your head”). Patients with chronic pain need the reassuring perspective, and the real therapeutic and effects of greater confidence and mental health. I can hardly imagine a better argument that we need a more biologically literate society.

Ramachandran’s excellent phrase

Ramachandran said, “pain is an opinion” — which sounds like a flaky New Age mind-over-matter theory. But Ramachandran is no mystic or guru: he is a medical scientist, a neurologist. The passage below, from his book, Phantoms in the Brain, is mainly known for the first handful of words, a brilliantly concise statement of the modern understanding of how pain works.

Pain is an opinion on the organism’s state of health rather than a mere reflective response to an injury. There is no direct hotline from pain receptors to ‘pain centers’ in the brain. There is so much interaction between different brain centers, like those concerned with vision and touch, that even the mere visual appearance of an opening fist can actually feed all the way back into the patient’s motor and touch pathways, allowing him to feel the fist opening, thereby killing an illusory pain in a nonexistent hand.
Phantoms in the Brain, by VS Ramachandran and Sandra Blakeslee

He then tells the story of an extraordinary cure of a man with phantom limb pain, tortured by agony in a clenched fist that was not there. With a clever arrangement of mirrors, Ramachandran created the illusion that the man’s amputated arm was restored — a sort of “virtual” limb. The mere appearance of his phantom hand opening and closing normally cured his agonizing “spasms.” He felt better because of the illusion that he was better — because he thought he was better. It is one of the most curious anecdotes in all of pain science.

Since then, “mirror therapy” has been studied and applied in many ways. A good quality 2007 study showed that mirrors aren’t actually necessary to achieve this effect.2 Mirror therapy is probably just a “fun” way to visualize healthy movement — which also works quite well without a mirror!3

The perception of pain in olden times

For most of the history of medical science, pain was believed to work more or less the way the French philosopher René Descartes described it, a straightforward signalling system:

The flesh is wounded. (“It’s just a flesh wound!”)
Nerves send a clear message to the brain about the problem. The intensity of the message is directly proportionate to the severity of the injury.
The brain interprets the message at face value — that is, if the message says, “There’s some bad damage here,” we believe it.

But it’s just not that simple. For several decades now, it’s been clear to pain scientists and most health care professionals that this model is hopelessly inaccurate. The real situation is much more complicated, interesting, and in some ways useful.

What goes up, must come down

It turns out that the brain is not just a passive, gullible receiver for whatever pain messages the peripheral nerves send upstairs. And, if you think about, it’s kind of strange that we would ever have thought of it that way, because this is, after all, the brain we’re talking about: seat of consciousness, the generator of your reality.Not only does the brain critically evaluate every pain message it receives — considering it in context, checking it out like a piece of fruit at the grocery before deciding whether or not to buy it — it also sends messages downwards that affect the sensitivity and behaviour of nerve endings.4

Everything that hurts involves a conversation, a sort of debate, between the central and peripheral nervous system. It could be dramatized like this:

NERVES	Got problems here! Bad problems! Red alert!
BRAIN	Yeah? Hmm. Okay, so noted. But you know what? I have access to information — sorry, it’s classified, you’ll just have to take my word for it — that suggests that we don’t have to worry about this much.
NERVES	I’m telling you, this is serious!
BRAIN	Nope, I don’t buy it.
NERVES	Look, I may not have access to this “information” you’re always talking about, but I know tissue damage, and I am not kidding around, this is a credible threat, and I am going to keep telling you about it.
BRAIN	Actually, you’re having trouble remembering what the problem is. You’re going to send me fewer messages for a while. Also, these aren’t the droids you’re looking for.
NERVES	Uh, right. What was I saying? Gosh, it seems like just a second ago I had something important to say, and it’s just gone. I’ll get back to you later I guess …

The brain can boss nerves around, tell them how sensitive to be. When anxious, the brain might request “more information” from the peripheral nerves, ordering them to produce more signals in response to smaller stimuli. Or it might do exactly the opposite. In short, messages about pain don’t just go up to the brain, they go down. This two-way functionality in the pain system is the main difference between modern pain science and old-school pain science. But there’s more.

There is extensive recent evidence that the peripheral nerves can even physically, chemically change, perhaps in response to brain requests, tissue conditions, or both. To extend the analogy, this isn’t just twiddling the volume knob, but changing the equipment, changing the signal before it even gets to the “amplifier.”

More simply, and probably more importantly, we only feel what our brains allow us to feel. Even “loud” sensory messages can be filtered down to almost nothing by the central nervous system … or, conversely, “quiet” sensory messages can be amplified. The quality and intensity of the final experience is clearly the product of an elaborate set of neurological filters.

Pain is less painful when we are confident that we are safe. This was demonstrated quite early in the history of pain research by a famous paper about wounded soldiers in WWII, which showed that they experienced surprisingly little pain considering the severity of their injuries — probably because they were so glad to be off the battlefield.5 Ever since, researchers have been trying to understand just how that actually works. Although many questions remain to be answered, we do seem to have a rough outline.

Can we think pain away?

Alas, no — pain neurology can’t be manipulated simplying by wishing. The brain may powerfully control our experience of painful experiences, but I’m sorry to report that you don’t control your brain. Consciousness and “mind” are by-products of brain function and physiological state. It’s not your opinion of sensory signals that counts, it’s what your brain thinks of it — and that occurs quite independently of consciousness and self-awareness.

Your brain will also modulate pain experience based on a number of other things that are completely our of your control. For instance, although it is technically the brain’s prerogative to ignore painful signals from your tissues, that doesn’t mean that it will — if there is a destructive disease process going on, for instance, the brain will usually not ignore those signals! The pain system evolved to report problems, and it will diligently do so.

But that doesn’t mean that we’re powerless! To wrap up, let’s look at someways that you can tinker with pain neurology.

What are the practical applications of this knowledge?

Pain is “another *%$@!! growth opportunity” — another reason to mature as a person, and a particularly good one. For many people with severe and chronic pain, learning coping skills are a necessity. But personal growth may provide an even greater opportunity than merely coping with pain.

We may not control our brains, but we have do have considerable indirect leverage. We can’t micromanage our sensations, but we can change the context and direct our experience at a high level. For instance, we can alter our physiology with the kind of deep breathing that is taught at Haven, instantly creating new feelings — and your brain will go along for that ride, and perhaps re-interpret your experience of pain.

Or we can create new social contexts by doing something as simple as playing a team sport — because other people are counting on you, the painful consequences of intense exercise are usually re-contexualized as tolerable, even desirable, and you can put up with quite a lot more. You can’t think your way to that kind of pain tolerance — but you can place yourself in a situation where it is a likely outcome. This is why Haven puts on experiential workshops: to thoroughly “tinker” with your context, especially your social context, because humans beings are so interested in each other that our social experiences utterly dominate our consciousness. Change your social experience, change your brain!

Yet another powerful example is education. Fear and anxiety probably have more power to aggravate pain than any other emotional state, and acquiring knowledge and perspective are superb treatments. A confident and happy brain amplifies pain signals less than an anxious, miserable brain. This explains lots of interesting results in pain research (not to mention clinical observations), such as the fact that the most powerful factor predicting how soon people return to work after an episode of low back pain is whether or not they expect to return to work,6 or the fact that education alone probably helps to resolve neck pain.7 So do not let health professionals scare you. Seek out as much information as you can find, because nothing causes more anxiety than uncertainty. These are real defenses against pain.

Early intervention is critical to prevent acute pain from turning into chronic pain.8 It is clear that chronic pain involves significant neurological changes, both in nerves and in how pain is processed in the brain. Once those changes occur, recovery is much more difficult, at an incredible cost in suffering and medical expense. Persistent pain should not be ignored.

All of this suggests that a more enlightened, progressive approach to medicating pain is required.9 Patients and doctors alike shy away from the powerful pain medications for fear of their addictive properties. Due to simplistic, obsolete views of how pain works, a widespread attitude that pain should be tolerated instead of treated, and a fear of drug addiction that verges on the hysterical — and is irrelevant to rational, medical treatment of serious pain — countless people are deprived of medication that could not only relieve enormous suffering, but actually serve to treat serious chronic pain conditions by helping to interrupt the vicious cycle of fear and pain.

Another useful context-tweak is to firmly reject the self-hating idea that your pain is “just” psychological. Paradoxically, even though pain is strongly regulated by your CNS, it is certainly not “all in your head.” The idea has always always been been disrespectful to pain patients, but now it is also scientifically obsolete and can be thrown out with yesterday’s trash. Any health professional talking like that should just be ignored. We know better: if you believe that you have a problem, you will have one.

Finally, fix the fixable — and be honest about what is fixable. Most people aren’t quite as stuck as they think they are. Some problems really aren’t fixable, but a lot of your worst and oldest problems probably are, and they are the source of most stress, anxiety and depression — which means that they also have a direct impact on how much you hurt. There are many examples of difficult problems that can usually be fixed with some hard work and maybe some leaps of faith: bad marriages and toxic friendships, bad jobs and bad bosses, a house or city or climate you don’t like, poverty, addiction, insomnia and many more. Finally taking action to fix such problems is the most direct route to easing your brain’s interpretations of pain.

What’s New In this Article?

Friday, May 7, 2010 — Updated references related to mirror therapy, added some perspective about “mind over matter,” and re-wrote and upgraded the practical recommendations in the final section.

Notes

Modern pain research was kicked off in the late sixties by the work of Dr. Ronald Melzack and Dr. Patrick Wall. Return to text.
Brodie et al. Eur J Pain. 2007. Return to text.
Moseley et al. “Is mirror therapy all it is cracked up to be? Current evidence and future directions.” Pain. 2008. Full Abstract:
Despite widespread support of mirror therapy for pain relief in the peer-reviewed, clinical and popular literature, the overwhelming majority of positive data comes from anecdotal reports, which constitute weak evidence at best. Only two well described and robust trials of mirror therapy in isolation exist, on the basis of which we conclude that mirror therapy per se, is probably no better than motor imagery for immediate pain relief, although it is arguably more interesting and might be helpful if used regularly over an extended period. Three high quality trials indicate positive results for a motor imagery program that incorporates mirror therapy, but the role of mirror therapy in the overall effects is not known. Obviously, more robust clinical trials and experimental investigations are still required. In the meantime, the relative dominance of visual input over somatosensory input suggests that mirrors might have utility in pain management and rehabilitation via multisensory interactions. Indeed, mirrors may still have their place in pain practice, but we should be open-minded as to exactly how.
Return to text.
Jackson. Pain. 2002. Return to text.
Beecher. Journal of the American Medical Association. 1956. Return to text.
Schultz et al. Pain. 2004. This study identified factors affecting return-to-work time after an episode of low-back pain. From the abstract: “The key psychosocial predictors identified were expectations of recovery and perception of health change.” Return to text.
Brison et al. Spine. 2005. This is one of a few studies showing a benefit to education for neck pain. The researchers showed a reassuring educational video to more than 200 patients with “whiplash associated disorders” (i.e. whiplash injuries that become chronic neck cricks), and found that they had less severe symptoms than about the same number of patients who received no educational intervention. The effectiveness of education probably depends a lot on the type of neck pain and the type of education, making it very hard to study. A recent review of the scientific literature found that most such studies are negative, but I believe that there are many reasons to be optimistic about education for pain problems: see Haig for more information. Return to text.
Muscle Pain Return to text.
Jackson. Pain, pp283–296. A standout chapter in an otherwise only average book, Jackson thoroughly reports on the case of Dr. Frank Adams, a credible and earnest American physician who moved to Canada in the hopes of finding a more enlightened political environment for the treatment of pain ... only to find his new home just as problematic as his old one. A fascinating look at our culture’s puritancial, head-in-the-sand attitude towards narcotics. Return to text.