An overview of the biopsychosocial model of pain (Tessia DeMattos)
What is pain? When asking that question, you will receive a variety of answers. “Pain is weakness leaving the body,” some might say. Others might say, “Pain means you hurt yourself.” And then again others believe that “pain is a sign that you’re in danger.” To be honest, none of these are correct. Pain is a contextual and multifactorial experience. So what does that mean? That means pain isn’t as simple as “you hurt yourself.” Pain is actually much more complex.
Let’s go over a couple of misconceptions here:
“Pain is a sign that you are damaging yourself.” Well, not exactly. Not at all, really. Pain is an alarm system. Your brain is screaming, “Watch out. This might hurt us.”
“Pain is all in your head.” With the rise in pain science, a lot of people have jumped to the misconception that pain is just in your head. It’s not. Pain is very much real. The pain you feel is a real sensation. However, it is coming from your brain.
Until recently, pain was thought to be a bottom-up pathway, meaning you had “pain receptors” on your body and those receptors would go off and send the signal to your brain. This is known as the Cartesian model of pain. Yes, Descartes came up with that one too. Here is a picture to illustrate what we used to think back during Descartes’ time (the bottom-up theory) versus what we know now (the top-down theory).
Now, however, we realize that pain is multifactorial and contextual, meaning your past experiences, your current expectations, your attention, and even your mood all have an impact on how much pain you experience. So pain isn’t “all in your head” (suggesting it is imaginary and something we can choose to shut on or off), but it is “all in your brain.” That’s why sometimes we might notice a bruise on our body and think, “Hey, I don’t remember hurting myself anywhere.” That’s because when you did bang into something to cause the bruise, your brain weighed it as not important enough to sound off the alarm. Similarly, soldiers in combat can have a limb blown off but not feel any pain, because the brain knows if it pays attention to that, the soldier will die on the battlefield, so the survival instinct weighs more than the sensation of pain.
Bottom line: You can think of pain as an alarm system. When you experience pain, it’s not necessarily because your body is experiencing damage, but rather because in the past when you did this very same action it resulted in damage. For example, you’re walking down a path with your friend and stub your toe on something. It doesn’t really hurt, and you figure you hit your toe on a branch. Ten minutes later, you’re passed out. Turns out, that branch was actually a venomous snake. You survive but barely.
A couple of weeks later, you’re walking down the same path with the same friend and you stub your toe again. But this time you’re screaming in agony. You are in so much pain and can’t bear to put weight on your foot. You look down, and it’s just a scratch from hitting a branch.
So, why did your brain freak out and send you so many pain signals? Because the brain remembers that the last time you did this, you nearly died. What does that mean to us? It means that pain is contextual. Your brain is going to use contextual cues to figure out if that stubbed toe is worth raising an alarm over or not. Contextual cues are typically from past experiences, which is why when we touch a stove, our brain immediately tells us to remove our hand; it knows if we don’t, we’ll burn ourselves. Pain can, however, come from injured tissues, but it’s more than just that. So what happens when people experience pain for several months post-injury? Even when the tissues of said injury are completely healed? It’s something called central sensitization.
Think of your body as your nice house with a white picket fence. Think of pain as your super fancy alarm system to help protect your house. Now, one night you get robbed. You are obviously upset, so to avoid being robbed a second time you turn up the sensitivity on the sensors to avoid getting robbed a second time. Suddenly, a fly minding its own business flies past the sensors of your fancy alarm system and the system goes crazy, raising every alarm possible, making you think there is a robber outside. But really, it was only just a fly. The same thing happens with central sensitization and in chronic cases of pain. You’re not in any real danger, but your body is so sensitive that it thinks you are, so it sounds the alarm.
That being said, since pain is a multifactorial experience, a lot of things can affect our pain, just like a lot of things can affect our training. Sleep is the number one thing here. Sleep is huge and incredibly important for both recovery from training and recovery from injuries. After a poor night of sleep, you may experience more pain if you’ve been dealing with an injury. Does that mean you are actively doing more damage? It depends, but probably not. If it’s an acute injury, meaning this happened a week ago, then things are still inflamed. If the injury was more than a month ago, you are most likely probably not doing more damage (I don’t like to speak in absolutes!). Your mood and stress levels are other large contributors to how much pain you perceive.
So, what should you do with this information?
When you’re experiencing pain, do not automatically panic. Pain is a normal part of the human experience.
Try to think back to a time when you had pain but seemed to have no physical cause for it.
If you have just recently injured yourself, do not stop moving. Motion is lotion! Tell your body it’s okay to move, so you don’t start reinforcing negative processes. Talk to your coach about modifying variables in your training, such as weight, range of motion, and tempo.
If you have been struggling with a nagging injury for the past few months, think of it as a dosage problem and that it comes down to exposure. Talk to your coach about modifying variables and about how comfortable you feel with pushing past pain. “Sore but safe” is the motto you want to go by. If you rate your pain a 1-3 out of 10, it can be okay to push through pain. You experience some pain during exercise but it either stops when exercise stops, or lingers only a few hours after exercise. If your pain feels like a 4-5 out of 10, proceed with caution. This level of pain lasts 24 hours post-exercise and may have been the result of doing too much. Finally at a 6-10 out of 10, you should regress, modify training, or stop. If pain increases as you perform a movement, you should regress next time and aim to repeat the process.
Action Steps
For those of you who wish to go down the pain science rabbit-hole, here is a page with all the best pain science lectures available for free on the internet: www.larsavemarie.com/pain-lectures-with-pain-expert-like-moseley-stanton-butler-osullivan-nijs-oconnell-zusman-lehman-reme-thacker-louw-and-dr-kieran-osullivan
Books
Explain Pain, by David Butler and Lorimer Moseley
Sticks and Stones, By Jarod Hall and Jim Heafner
TED Talk
Why Things Hurt, By Lorimer Moseley
www.youtube.com/watch?feature=player_embedded&v=gwd-wLdIHjs
Podcasts
Pain Reframed, Episode 189 - Adriaan Louw part 1: Pain: More Than Knowing About it
Pain Reframed, Episode 190 - Adriaan Louw part 2: Biology, Psychology, and Social Aspects of Pain
Instagram Accounts to Follow
@drjarodhalldpt
@modernpaincare
@hannahmoves
@adammeakins