Explain Pain With Pain Science Nuggets

Knowledge is power, especially when you are talking about pain science. However, we all know that all information on the web isn’t created equally. 

In fact, a lot is created by people that have no medical knowledge. Or robots.

One group of patients we help at Adelaide West Physio is those with persisting pain.

We feel strongly in our bones that understanding pain science is a key component of overcoming persistent pain.

I decided that creating a regular series on Facebook and Instagram called ‘Tuesday Nuggets’ would give a forum to talking about persistent pain amongst other things. Little bite-sized chunks of info that might help out.

This blog is a collection of these pain science knowledge nuggets.

[Forward this page to a friend with persistent pain. It just might help them out!]

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Pain is always real

NO ONE can tell you that your pain isn’t real. How could they possible know?

The pain you experience is yours and yours only. It can’t be shared. It is only designed to protect one person – you.

Imagine telling someone with phantom limb pain that their pain isn’t real. They’d punch you in the nose! 🤛

The closest that someone can get to knowing how much pain you have is your description, or your grimace, or your grunt when you get up.

They might see the way you move differently. But that isn’t pain, it is ‘pain behaviour’.

Sometimes it would be easier if the therapist could ‘download the pain’ and see it on a monitor – but that can’t be done.

The idea of rating it on a scale of 0 to 10 is flakey too, because it’s not like your 5/10 can be compared to another person’s 5/10.

The main value of that kind of rating is that it helps your therapist to tell if your pain is changing at all.

No one has the right to make assumptions about your pain. Pain is always real. And it can’t be compared.

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You don't even need a body part to have pain in it!

This might seem a bit weird at first, but it says a lot about how pain works!

Phantom limb pain and other phantom limb sensations are common in amputees.

It is pretty hard to rationalise having pain in a body part that is no longer there, UNLESS you consider that a ‘map’ of the body part still exists in the brain and in the rest of the body.

This might make it a little easier for the person with longstanding pain to understand how you can have pain in a body part that isn’t damaged any longer, that may have actually healed.

Anyone with persistent pain should stop and have a think about this example. Ruminate a little!

If you are thinking that your pain is a measure of your tissue damage, phantom limb pain doesn’t make any sense at all.

But what we know about pain science helps:

  1. your central nervous system (including your brain) is always involved in pain
  2. you have a map of your body part held in your brain
  3. pain is about protection, rather than being about measuring your tissue damage

Then phantom limb pain can make sense, and it might help to explain pain that continues, even after the area has healed.

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There are no pain detectors in your back!

Actually, there are no pain detectors ANYWHERE in the body. Or pain nerves. Or pain areas in your brain.

There are danger, pressure, stretch, chemical, heat and cold detectors. Light detectors. Vibration detectors. But NOT pain detectors.

That’s because pain is an experience that you … well … experience.

Like love. You don’t have love detectors. Or anger detectors. Or hunger detectors.

You have chemical, stretch receptors, pressure receptors …

You get the experience of love, anger or hunger after all of the inputs have been fully evaluated.

Just like in pain.

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Pain is your brain's opinion that you need protection

Here’s a tasty nugget! If you have problems with pain, chew on this and let it digest…

Your brain is making decisions all day and all night. It doesn’t stop. And it’s not nearly as simple as taking the incoming information on face value.

Your brain is judging everything against its predictions and expectations that you aren’t even aware of! 

It is continually coming up with ‘opinions’.

The processing is even quicker than Google coming up with search results for you when you type in a query, and takes into account of many more data points

Keep in mind that our brain’s number one job is to keep the show going, and to keep you safe and out of trouble.

It makes sense then that there are times when it might err a little on the conservative side of things, particularly if something similar has happened before.

So if you brain is of the opinion that you need protection, it can produce pain.

But as you know, opinions aren’t always right, and sometimes your brain gets it WRONG.

If you don’t believe me that your brain can get it wrong, ANY visual illusion will prove that your brain can easily get it wrong!!

In persistent pain, it often gets it wrong, and maintains a level of protection that is no longer required.

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Your sensitivity changes moment to moment

Persistent pain is tough. There is no way to sugar coat it. It takes a lot of courage, bravery and determination to beat it 👊
 
You could say that it takes more persistence than the pain.
 
But here is something that should give hope to anyone with persistent pain – your sensitivity changes from moment to moment, hour to hour, day to day.
 
And that is because EVERYTHING is being assessed from moment to moment.
 
As life changes, both inside and outside the body, the context is changing and the opinion of threat is changing.
 
We know that the channels in the nerve cell membrane changes over regularly, some estimates say every 2 days.
 
Persistent pain isn’t fixed – it is changeable with the right strategies.
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Hurt does not always equal harm

Even if you don’t have a problem with pain, it is worth giving this idea some serious thought.
 
Pain has a purpose. It isn’t there to just give you the s**ts.
 
It is our body’s way of letting us know something about us is ‘in danger’ and we need to do something about it.
 
Do you think these are fair comments? 
  • We grow up associating pain with injury
  • We tend to associate the how bad the pain is with the how bad the injury is.

However, you can have pain without tissue injury. Just put your hand under hot water tap that is just a bit too hot.

It can hurt a lot, but without causing injury.

And that’s how it is with persistent pain, osteoarthritis, low back pain and lots of other scenarios.

You can do something that hurts, but it usually doesn’t mean you have done harm.

You have just alerted your ‘protection by pain’ system.

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It only takes 5% weight loss to reduce pain

🍏 This is something nice to chew on!

🍓 It is amazing to think that reducing body weight by 5% is associated with a meaningful improvement in pain and disability in people who are overweight and have osteoarthritis.

🥕 This statement gets thrown around a bit as a little factoid. It appears to be from a study on knee osteoarthritis so it can’t be extrapolated automatically to hip osteoarthritis or anything else (Christensen et al 2017 https://doi.org/10.3945/ajcn.117.158543)

🍎 However, there is strong support for healthier eating reducing body-wide inflammation and therefore reducing body-wide pain.

🥑 Take the emphasis off weight loss and change it to healthy eating, reducing processed foods and eating an anti-inflammatory diet.
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Cartilage can repair

While cartilage doesn’t have the repair speed of other tissues (not having a blood supply certainly counts against it!) it still has the ability to repair.

If your cartilage did have blood vessels, they would get squashed. Instead, your cartilage takes advantage of this squashing – your cartilage gets the nutrients squeezed into it from the joint fluid. This is why moving is so good!

Chondrocytes are the cells that produce the components of cartilage. They need to have a reason to work and repair.

If there is no reason (like if the joint isn’t being used enough) there won’t be enough stimulus to help the repair process happen. In fact, the opposite will happen – the health of the cartilage will suffer.

You can under dose or over dose the stimulus too.

How do you avoid this? A plan and an understanding of how to safely progress is the key.

The GLA:D program is a great way to get the knowledge you need and get your the exercise routine started.

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Pain requires a brain but it is the person that hurts

🧠 This is important to remember!

🧠 When you read about the modern understanding of pain, there is an emphasis on the brain. Sometimes we say ‘the brain produces pain’. But is it really that simple?

🧠 There is no doubt that the brain is an important part of the process (you can’t have pain without a brain). But so is you spinal cord, your immune system, your endocrine system etc

🧠 Pain is a personal experience where the brain is an integral part of the process.

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Things you say to yourself can be potent messages (so are they correct?)

What do you say to yourself about your problem? Maybe you say ‘my back’s f****d’ or ‘I’ve got wear and tear’.
 
These words get more powerful over time as you repeat them.
 
And it doesn’t just have to be what you say out loud. It also matters what you say to yourself. The things you believe to be true.
 
If you are going to reinforce something, YOU BETTER KNOW THAT IT’S CORRECT!
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Acute inflammation has a purpose. So why try to suppress it?

This goes against every Nurofen ad, but think about it … acute inflammation is something that swings into gear with any kind of invasion or injury 🔥

It is your basic immune response. It has an important purpose:

🤜 It starts off the cleanup operation
🤜 It helps damaged tissue to heal
🤜 It protects you by making things sensitive while injured tissue is more vulnerable

So why would you want to prevent it doing its job? 🤷🏻‍♂️

NB: low level systemic inflammation and chronic inflammation are a different story!

Click here to learn about how we incorporate this pain science information into our back pain physio management.

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XRay, CT, MRI, Ultrasound.
They can tell you how things 'look' but they CAN NOT tell you about pain.

Too often, it is assumed that imaging findings tell us about pain levels.

‘A picture is worth 1000 words’, they say.

However, all a picture can do is tell you about how things look. The landscape of your insides.

There is a poor correlation between imaging findings and pain.

That’s because pain is A LOT more complicated (and interesting) than just being about the physical structure of our body.

They don’t take into account all the components that are involved in pain.
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The balance between DIMs and SIMs powers the Protectometer.

Pain is all about DIM SIMs.

DIM = evidence of ‘Danger In Me’
SIM = evidence of ‘Safety In Me’

We are constantly weighing up all the contributors to each of these categories, all day, every day, without knowing it. Even in your sleep.

If the evidence of danger outweighs the evidence of safety, your Protectometer produces pain!

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Can you turn your DIMs into SIMs?

Can you take things that are scary, threatening or overwhelming about your situation or your problem, and take away the threat? 🫣

Can you defuse a DIM (danger in me)? 🤔

Or better still, can you take a DIM and turn it into a SIM (safety in me)? 😁

This usually takes the help of a modern and enlightened health practitioner to guide the way and to show how it can be done.

It usually takes updating your knowledge about your problem, which requires the right people with the right knowledge – but they are out there!

If you can defuse a DIM or turn a DIM into a SIM, it is a critical step in the journey to reducing persistent pain. 👌

Doing this is turning down the ‘Protectometer’.

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Use your SIMs to outweigh your DIMs

On a set of scales, the aim is to have balance on either side. If you add more weight or take weight away, it tips the scales.

Now think of pain like a set of scales.

On one side are things that are likely to ‘contribute’ to pain, on the other side are things that are likely to ‘uncontribute’ to pain.

To help persistent pain you want to tip the scales! 

The aim is to maximise the things on the ‘uncontribute’ side and have less things on the ‘contribute’ side.

That is, more SIMs (safety in me) than DIMs (danger in me). 

You can help tip the scales in your favour by adding more SIMs to your life. They could be anything that promotes good / safe / protection / health / happiness.

👉 Being with people who are fun, happy, reassuring, listen.

👉 Being in places that are positive, light, safe.

👉 Having health care professionals that listen, work with you, collaborative, understand.

👉 Eating good, fresh food with nutritional value (with the occasional naughty thing!)

👉 Learning more about your conditioning (and learning about anything else too)

👉 Having goals that you are working towards that are realistic and really mean something to you.

And that’s just the start. 

Keep working on tipping the scales in your favour!

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How can you 'reassure' your protective systems that you are actually ... OK?

There are many ways to ‘reassure’ your protective systems that you are OK if they have become OVERprotective.

1. Explore your SIMs (your ‘safety in me’ signals and activites).

2. Reduce the effect of your DIMSs (your ‘danger in me’ signals and activities)

3. Get the right information about your problem – a diagnosis that makes sense to you, that you can explain to someone else if you needed to, that is backed by science (not pseudosciencey explanations)

4. Don’t read the wrong information – make sure you are getting it from a trusted source and don’t Google it!!

5. Have a plan (sounds simple, but it’s so true)

6. Deal with health professionals that listen and understand.

7. Move, exercise, meditate, be with positive people.

Remember – you might be someone with pain but YOU ARE NOT YOUR PAIN!!

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Neurons that fire together wire together

🤔 If you practice something, the connections become more efficient at that ‘thing’.

If you practice a skill, it gets easier. This is the basis of neuroplasticity.

A pathway that starts as a dirt road becomes a superhighway.

There are many positives to this neuroplasticity, but it can produce problems.

🤔 If you practice thinking something, you think it more automatically.

So you’d better make sure that what you are thinking is fully accurate and not some horribly inaccurate assessment of what is happening in your body or with your pain!

Persistent pain becomes persistent by your brain ‘practicing’ pain. It becomes better at it, and produces it more easily.

🤔 It is this neuroplasticity that can get you into trouble with persistent pain. BUT it’s also what can get you out of trouble too!

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You've heard of phantom pain. Have you heard of phantom stiffness?

😮 Phantom pain is a weird phenomenon.

It is pain in a body part that isn’t physically there, either because it has been amputated or it wasn’t there from birth.

So why should you care?

Because it shows that pain cannot be a perfect representation of the state of your body tissues.

😮 Phantom stiffness works the same way as phantom pain.

Stiffness is an experience. It is created by your body, particularly involving the brain and spinal cord. It doesn’t have to involve a body part.

As long as the ‘map’ of the body part exists in the brain, that absent body part can experience pain, stiffness, tingling. Even orgasm.

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Edgy and turned on. All our systems can become overprotective with repeated use.

We have protection systems that (usually) work well straight out the box 💯

Like the immune system, the hormone system, the muscle system and of course the pain system.

They work fabulously well until they are made to work often or too much.

The pain system works really well in acute situations. It can save your life!

😳 However if it stays ‘switched on’ and goes from good healthy protection to overprotection, it becomes a real problem.

Don’t think that it is just about the pain system though – all of these systems can get edgy if they are worked too much or too hard.

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Bioplasticity. It's what got you into this situation, and it can get you out of it too.

Bioplasticity is about how we change and adapt. All the way through life. In all our systems. Right until our last breath 😁

Bioplasticity is the thing that makes any comparison between humans and cars completely null and void.

(Like ‘you need alignment regularly like a car needs a wheel alignment or the tires wear out more quickly’)

Can a car adapt or heal itself? No. Not even Teslas.

Bioplasticity is also the feature that is involved in persistent pain. In this case, the adaptation isn’t a helpful one. Becoming more sensitive to normal stimuli isn’t useful.

But the good news is that bioplasticity is also the thing that can get your OUT of trouble, with the right strategies, but it needs to be combined with:

• patience
• persistence
• courage and
• commitment

Together, they are the winning formula for persistent pain 👍

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No one knows how much you hurt.

No one feels what you feel. So no one can possibly say how much you do (or don’t) hurt.
 
When someone grimaces, that is ‘pain behaviour’. It is an expression to others.
 
But some people don’t grimace. That doesn’t mean they don’t hurt.
 
No one – no physio, doctor, nurse, spouse, parent – can say whether you should (or shouldn’t) hurt.
 
If you hurt, you hurt. Full stop.
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Celebrate the wins. Especially the small ones.

It’s pretty easy to brush them off, especially if you continue to have pain.

Instead, it really helps if you can celebrate your wins. Even if you have to look for them!

It doesn’t have to be an overt display of balloons and glitter cannons. Acknowledging them silently will do!

For one thing, it gives you a bit of energy to keep going. If you would like a flood of happy hormones like dopamine and serotonin, just think about something you have achieved that you feel good about.

These help you to remember this step, this moment and gives you a chance to build on it.

Reflection is good to practice for all of us, but particularly people who are on their journey with persistent pain.

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Reduce Your systemic inflammation for pain relief (and much more)

This is a great place to start for helping persistent pain, but also for many health conditions.
 
Imagine a seesaw with pro-inflammatory molecules in your body on one side and anti-inflammatory molecules on the other side.
 
Anything you can do to tip the seesaw in favour of anti-inflammatory molecules will help to reduce your pain:
 
– Thinking and leaning.
– Exercising and moving.
– A diet rich in antiinflammatory foods and without processed foods.
– Being in safe places with people who you enjoy being with.
 
And this is just the start. There is a lot you can do!
 
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More Activity + more knowledge + less systemic inflammation = a solid plan

People with persistent pain often feel like they are at a deadend 🙁
 
However, there are always opportunities to reduce pain and importantly, ways to do more of the stuff that they love in life.
 
This is a solid plan:
1. A graded approach to increase activity and exercise
2. Learn more about pain, get more knowledge about what is going on
3. Reduce systemic inflammation, for example though an anti-inflammatory diet
 
The good thing is that each of these interact. For example, if you exercise more, it helps reduce systemic inflammation and makes it easier to learn.
 
It has a multiplier effect!
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Having goals is important when dealing with pain but this is only half true.

😮 That sounds like a travesty! It’s all about goals, isn’t it?
 
Setting a goal can feel really good.
 
Really, really good. You can get a nice little buzz from writing something down that you’d like to achieve.
 
But there is a big difference between setting a goal and achieving it.
 
The full truth is that the goals MUST be realistic.
 
Otherwise you’ll set yourself up to fail.
 
If a goal isn’t achievable, it’s a wish without any substance.
 
And while it’s good to stretch yourself a little, when you are dealing with persistent pain the first aim is to achieve the goal you set.
 
Get a win. Then another win. Build up the win count 🏆
 
Start with realistic.
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Pain is never detected - IT IS ONLY PRODUCED.

Lots of things CAN be detected 🔍
 
Stretch, mechanical pressure, chemical changes, temperature, joint position, light touch sensation … and danger 🔥
 
But not pain.
 
Another way of saying it is this: pain isn’t an input, it’s an output.
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You have your own internal drug cabinet - YOU HAVE FULL ACCESS TO IT.

It is estimated that your internal drug cabinet is 50 times more powerful than the most powerful drug.
 
Best of all, you don’t have to get a prescription.
 
How do you access to it?
🤜 Knowledge about your condition and the cause of your pain, through reading, talking, listening and watching
🤜 Clever use of movement and exercise
🤜 Healthy therapeutic relationships with your health care providers
🤜 Better nutrition
🤜 Guidance and coaching from therapists who know the best ways to help people with persistent pain
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Your gut produces 80-90% of your serotonin!

A great reminder of the brain-gut link!
 
If your ability to produce serotonin is impaired, that is going to have an effect your mood, mental health, pain system …
 
Another example of how important your gut health is for your overall health.
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There are more than 500 areas in the brain involved in pain

More than 500 areas? That must be why you can’t surgically ‘cut out’ pain from the brain!
 
It makes sense though. Whenever you have pain, you typically hear, see, feel, think and maybe swear as well. It produces feelings and emotions.
 
There’s a lot going on!
 
In the same way there aren’t ‘pain nerves’ or ‘pain receptors’, there aren’t ‘pain cells’ or a ‘pain centre’ in the brain.
 
With so many areas involved, everyone’s pattern of brain activation is going to be different.
 
Sure, there might be similarities.
 
But if your pain is associated with a particular person or event, no one else can possibly have those particular groups of cells involved.
 
Your pain ‘neurotag’ is unique.
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The brain is like an orchestra

The orchestra has different sections: woodwinds, brass, percussion, strings.
 
Normally, they work together to play beautiful music 🎶
 
Some pieces require different sections of the orchestra to rest at different times.
 
There are quiet parts, loud parts, slow parts, fast parts.
 
There is lots of variety. Different composers, different tunes, different sounds.
 
👉 Consider a dysfunctional (painful) orchestra:
 
They might be playing all at the same time.
 
Or sections playing loud all the time and other sections not playing at all.
 
If they practice one tune over and over and over, they start to lose variety and get stuck on the same old thing.
 
They get really good at playing that tune, but start to lose the ability to play a wider repertoire.
 
As soon as the conductor raises his baton, they automatically start playing that tune again without being asked.
 
The pain tune 🎵
 
👉 How to fix the orchestra?
 
Start practicing new pieces. Introduce variety – loud, soft, fast, slow. Maybe play different composers. To different audiences, different times of the day. In different moods.
 
Start changing it up.
 
Make it so that the pain tune isn’t an automatic response!
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Learning about pain helps pain

There is good evidence that learning how pain works biologically can help your pain. 

It can be a relief to find out that there is a reason that things can still hurt, and that it’s not ‘all in your head’

Once you understand why it still hurts, then you can start taking the necessary steps.

Otherwise, there is no incentive to exercise or move if all it does is hurt when you do.

You can learn about pain biology in many ways – there are great books you can read, there are lots of great free videos (just search Lorimer Moseley, Tame The Beast or NOIgroup for starters.

There are great apps like Protectometer and Curable.

Of course, you can speak with one of us! 

We love helping people suffering persistent pain, and helping them take the right path to getting the best our of life.

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Pain isn't your only protective measure (but it's the most noticeable)

Our body has many different protective measures – pain is only one of those but you can’t miss it!

You can detect a danger like fire in different ways using different senses (vision, smell, hearing, touch).

You have systems like your sympathetic nervous system to get you out of danger, your respiratory system kicks in, you might swear a bit, you might switch on different muscle groups HARD to get you moving and away from danger.

It’s just that pain is the protective system that gets our attention the most because it is unpleasant – but that is the whole point of it.

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Pain can be modified by anything - you won't necessarily be aware of it!

Pain is not simple.
All the amazing pain stories tell us that!
It’s how you can be shot and not feel pain. It’s how you can be bitten by a shark and not feel more than a bump (see Explain Pain page 13-15)
If it were simple, being shot or a shark bite would hurt exactly proportionally to how many ‘sensors’ are screaming out.
Instead, there are ALWAYS factors that modify your pain – either amplifying it or reducing it:
  • People you are with.
  • The place you are.
  • What you believe about the pain.
  • The words you use to describe the pain.
  • Distractions.
  • Survival.
  • Smells, tastes, sounds.
All this happens outside of your awareness, automagically in an amazing system of prioritising, processing and decision-making that is faster and more powerful than Google.
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You can't rest persistent pain better

Trying to rest yourself out of persistent pain is reinforcing the message that it is dangerous to move.
This risks making your already hypersensitive and hyperprotective pain system even more sensitive and protective.
‘But hang on, moving hurts!’ you might say!
It sure can. However, if movement is done with good planning and guidance, with an understanding of why you are moving you can ‘train yourself out of pain’. 
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When things continue to hurt, it isn't because something is unhealed

It is natural to think that if things still hurt, something isn’t healed 🤔
Instead, it is most often a situation where your protection systems have continued to be active beyond their usefulness.
If it hurts long after the injury, you are continuing to be protected beyond the time that tissue healing has happened.
The pain is less and less related to ‘stuff’ happening at the injury site, and more and more related to ‘stuff’ happening in your nervous system and immune system, where its main function is to protect you.
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The longer you have pain, the easier it gets produced

If you think of learning a new skill, like playing an instrument, it is hard work to start with. It takes repetition for things to become more natural and smooth 🎸
Pain is no different.
With repetition of producing pain, the system becomes better at producing it. It learns to produce pain more easily, and with less stimulus to do so 🔥
You become more sensitive as your pain system is trying to protect you better and better.
So what’s the solution? 🤔
You have to be more persistent than your persistent pain. More repetitive in practicing good things. Keep achieving ‘wins’.
In fact, so persistent and repetitive that your protection system gets the message – you don’t need to be protected as fiercely!
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It isn't 'all in your head' but the brain is boss.

If it ever seems that your health professional is telling you ‘it’s all in your head’, there’s a good chance that isn’t what they mean at all.
Consider the brain’s role in your body. It really runs the show!
The brain is boss. It takes it ALL in, receives reams of data from the body and itself, it processes everything, and it coordinates your body’s responses.
This includes your protective responses, of which pain is one. And a pretty important one for your survival.
So ‘it’s not all in your head’ (or at least not like that). But it is all coordinated in your head.
There would be no pain without a brain!

Other articles that might be of interest

Nociception and Tissue Injury – One of the biggest errors that you hear from all kinds of clever people is conflating the idea of nociception, tissue damage and pain. They are NOT the same thing!

Low Back Pain – The ‘Pathoanatomical’ Approach – Traditionally, low back pain has been looked on in a ‘biomedical’ or ‘pathoanatomical’ way. What does this mean? And why doesn’t work with persistent back pain?

Words Affect Pain – My aim in this article is to demonstrate that not only can poorly chosen terms reduce people’s expectations, words can directly affect pain.

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About the author

Russell Mackenzie
Russell Mackenzie
Russell is a physiotherapist and clinic owner in Adelaide, South Australia. He is the co-owner of Adelaide West Physio + Pilates and more recently, Adelaide West Headache Clinic, which was formed as a signal of his dedication and passion for headache and migraine treatment. Russell is an avid learner and is engrossed in the best practices of digital marketing to spread the word about health-related topics and improving health literacy in the community.
Russell Mackenzie

Russell Mackenzie

Russell is a physiotherapist and clinic owner in Adelaide, South Australia. He is the co-owner of Adelaide West Physio + Pilates and more recently, Adelaide West Headache Clinic, which was formed as a signal of his dedication and passion for headache and migraine treatment. Russell is an avid learner and is engrossed in the best practices of digital marketing to spread the word about health-related topics and improving health literacy in the community.
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Explain Pain, Physio advice
In your body, change is always going to happen. The good news is that the path of change isn't predetermined. There are things that you can do always. This article should give hope to anyone who is struggling.
Explain Pain
If you haven't heard of 'allostatic load' before, don't worry! Kimberley explains this concept really well using a kid's book in a way that helps you to understand how all kinds of things can all play a role in health or sickness.