Understanding Pain: What Is Pain Neuroscience Education?

Most chronic pain sufferers I work with want to get straight into the “treatment” aspect of recovery. That is to get the exercises going, to get them strong and fit again so they can return to their daily lives without pain.

That is a great attitude towards chronic pain management. The can-do, let’s-go, take-action mentality is commendable.

When asked about what it would take to increase their confidence to self-manage (i.e. drive long-term pain relief without my help), it all comes down to:

1) Knowing or understanding the pain experience, how to make sense of it
2) What to do next to address the pain experience

It’s pretty interesting because virtually everybody knows knowing and understand what to do is a big part of long-term success but, at the same time, it’s very easy for us to forget prioritising education.

What is Pain Neuroscience Education (PNE)?

PNE is a broad term that refers to educational interventions that aims to change someone’s understanding of what pain actually is, what function it serves, and what biological processes are thought to underpin it.

Depending on the audience we are dealing with, we also market it as Pain Science or Explain Pain.

This is a lot to process but at the very foundation, in the context of chronic pain, we are trying to say is that:

• Pain doesn’t equal damage
• Damage doesn’t equal pain

Mind blowing, huh?

What is pain?

This is not a trick question: When you look at the two images above, which patient do you think suffered from more pain?

The image on the left shows a 7-inch nail that went through the boot of a 29-year old builder after he jumped on a plank (Fisher et al, 1995). The image on the right shows 4-inch nail that is embedded in the head of another construction worker (Dimsdale & Dantzer, 2007).

Again, this is not a trick question. These are real-life cases!

Most of you would probably struggle to decide which patient experienced more pain. This preludes to the biggest problem we have in pain science: We cannot see pain.

Pain is a subjective experience. It’s not a stimulus and cannot be seen.

It is, in all fullness, an individualised perception.

There are three parts to your pain experience:

1) Sensory-discriminative i.e. where the pain is, how intense it is
2) Affective-motivational i.e. how unpleasantness is that pain to you, how does it make you feel from an emotional or mood perspective
3) Cognitive-evaluative i.e. how do you make sense of it

These are really big words so we should stress over them. Let’s just leave these technical terms for the pain scientists to figure out.

If we were to simplify it in a way that is meaning for you, there are three parts to pain. They are (1) the actual sensation, (2) unpleasantness/what’s next and (3) your thoughts and processes.

You cannot see pain nor the sub-components that contribute to a pain experience.

Let’s say if I were to step on a lego brick and it hurts. Here is what you could break it down to:

• Actual sensation: High intensity, pressure-like sensation on the bottom of my foot.
• Unpleasantness/what’s next: “Ouch ouch!” –> lift the foot off the lego.
• Thoughts = “I am safe. But I don’t need this.”

What about when you are foam rolling yourself?

Do you fancy giving a shot on what may be the components of the pain experience?

• Actual sensation: Moderate intensity, pressure-like sensation
• Unpleasantness/what’s next: “Ouch ouch!” –> let’s try to bear with this.
• Thoughts = “I am safe. Pain is weakness leaving the body.”

p.s. I do not endorse foam rolling as a pain management modality. Please reach out to me directly if you wish to understand more.

Your pain is contextual

With these examples, you should be able to guess that pain is highly contextual.

Even in circumstances where pain is deem to be safe, you may respond completely different based on how you make sense of the pain.

Most of us instinctively consider pain to be unpleasant and that we always try our best to avoid pain. Yet within our own lives, we are able to find instances where we actively seek for a pain experience despite its unpleasantness.

Just think of your last pain-free massage. You probably think there’s “no kick” and that nothing good is happening.

We are circling back to these two images because they are real-life cases and not stuff we are just making up to prove a point.

I’ll like to invite you to take a couple of minutes here to consider what are the actual sensations, the unpleasantness/what’s next response, as well as the thoughts involved in these two cases.

For a recap of what happened, both cases involved construction workers. The left was a 7-inch nail that had gone through his boot as he jumped on the plank. The right was a 4-inch nail from a nail gun that was embedded in the head.

• Actual sensation: __________ (foot case) vs __________ (head case)
• Unpleasantness/what’s next: __________ (foot case) vs __________ (head case)
• Thoughts = __________ (foot case) vs __________ (head case)

If you are participating in this exercise, please do not read ahead until you have completed the exercise.

With this process, were you able to guess which was more painful?

Let’s look at the facts of what happened.

The nail in boot case on the left was reported in British Medical Journal in 1995. The 29-year old worker was admitted into the hospital. He was sedated with fentanyl (opioid) and midazolam (benzodiazepine) as any slight movement resulted in excruciating pain.

When the doctors managed to remove his boot, they realised the nail had passed BETWEEN his toes without penetrating his skin.

There was zero damage to his foot! Not even a scratch.

Despite sustaining no damage or injury, he experienced intense pain. His pain was also 100% real (i.e. he wasn’t making it up)!

Isn’t that curious?

With the nail in the head case on the right, the nail gun went off unexpectedly. The worker didn’t think of the incident and went about his own business. Six days later, he consulted with a dentist for a mild toothache. To their surprise (or perhaps horror) a 4-inch nail was found in his head.

Despite living with a nail in his head, this patient was able to go about his daily life from working to eating to brushing his teeth with nothing more than a low grade toothache!

Let’s look compare the responses you had written down against what was published about these cases:

• Actual sensation: excruciating sharp sensation* (foot case) vs  mild toothache, bruise sensation (head case)
• Unpleasantness/what’s next: super unpleasant, I need help ASAP (foot case) vs not very unpleasant, let’s go on with life (head case)
• Thoughts = “There’s a nail in my foot!” (foot case) vs “Everything seems okay!” (head case)

*I chose to use sharp sensation instead of pain to avoid confusion. Because pain in the most accurate of terms is not an actual sensation but an experience.

As shocking as these cases may be to most of you, I’ll like to take this opportunity to invite you to marvel at how immensely powerful the jelly-like organ sitting within your head is.

We are indeed wonderfully made.

Do you now see the value of ‘pain does not equal damage’ narrative?

If you are interested to explore this further, I’ll encourage you to practise this for the next two weeks. Each time you experience pain, take a few minutes to consider – what is the actual sensation? How unpleasant is that sensation? What are the thoughts that are running through your head in that moment?

If you find it challenging to separate these components from your pain experience, perhaps start with reflecting on how unpleasant or not unpleasant is the sensation to you. Are you able to tolerate it without reacting or responding (e.g. stretch, self massage, crack the joints)? If so, remind yourself that pain is not always damage.

You may be thinking that I am saying that your pain is all in your head.

Not quite.

I am saying ALL of our pain is ALL in our heads.

Modern day tissue-based pain narratives

If you poke anything and everything in your body, you are likely to find  about 30 or so spots with some form of pain or discomfort.

Some chiropractors or physiotherapists will refer to this as restrictions or adhesions. (I think these clinicians are accidental cold reading experts.)

If you think about it, somebody must have told you that you have the tightest trapizeus, low back, shoulders, insert-body-part, they have ever seen.

You may not even have pain at that region when they made those passing comments!

To a huge extend, we pathologise normal.

What is normal tissue tenderness, tightness, or soreness is now negatively framed as something harmful.

“Oh my goodness, you are so tight.”

By the time you genuinely experience back pain or neck pain, you would have been conditioned to think that your pain is coming from perfectly healthy tissues!

Modern day ergonomic-based pain narratives

For the record, there is no good evidence/data to support that ergonomic interventions have any meaningful effect on chronic pain.

The Lancet journal in their low back pain series mentioned that workplace ergonomic does not help with back pain.

With the growing interest in ergonomic chairs and standing desks, people are starting to question if their workstation is suitable for them. Office workers start to worry about their posture, sitting positions, workplace setup. They become afraid and the direct result is an increase in susceptibility to pain.

Interestingly, my chiropractor/physiotherapist friends overseas who used to provide ergonomic training would observe a spike in pain reports after they have conducted their workshop.

From a business point of view, that’s probably a pretty neat strategy to create demand for your services. As for workplace wellness, I am not so sure.

Again, we pathologise normal. We give people the reasons to feel pain.

We forget that our bodies are robust and highly adaptable.

Sure, we all can do with a decent table and chair.

However, a thousand-dollar chair is unlikely to be your long-term pain solution.

False beliefs can get in the way of healthy behaviours

If you think climbing stairs is bad, you’d just avoid it.

If you think your back is too weak to support a pregnancy, you will opt for an abortion.

This may sound shocking to you but I am not making this up. A study examining pain narratives did find a patient who underwent an abortion because she had been told her core was ridiculously weak. She didn’t think she could cope with the extra weight at her stomach.

While exercise may be one of the best long-term solutions to chronic pain, negative self-talk could negate the benefits entirely.

It’s not just about doing what works.

It’s also about using accurate narratives to help yourself find freedom from chronic pain.

Just telling some one they are weak can reinforce the wrong beliefs and have truly devastating and irreversible consequences.

Massage, stretching therapy, acupuncture, or even chiropractic adjustments are not inherently harmful. Our words and how we frame these treatments, however, have the potential to negatively influence a patient’s aches and pains.

The biopsychosocial approach to managing pain and injury

I am not saying that your pain is not real.

It is perhaps misunderstood.

You can build a person up even if you don’t get rid of their tendinosis or slipped disc or whatever not. A lot of what works in treatment is about increasing resilience, tolerance, and or coping with these stressors.

It’s not just merely on finding just one thing to fix.

It might not sound intuitive but think about how your pain experience was like during periods of poor sleep.

What about the very busy work week you had just a couple of months ago? Did you experience more aches and soreness all over the body?

Patients are able to identify that their pain experience is worse when sleep is poor or stress levels are high. These interactions is not foreign to us. We were just conditioned to look past them.

There are many reasons why you may be experiencing pain. Too often we tunnel-vision into focusing on only the physical factors.

Sure, you may have been given a medical diagnosis to explain for your pain experience.

However, the medical diagnosis goes into the “cup” along with the other stressors that may also contribute to your symptoms.

This is why I choose the solution-focused approach over the problem-based approach. There are simply too many factors within the cup for us to address independently.

By taking a whole-person, big picture approach, I am able to get you from pain-ful to pain-free in as little as four to seven visits. No chiropractic packages, no maintenance physiotherapy treatments.

I can’t emphasised enough that there is data to show that the problem-based approach doesn’t work.

The cup analogy takes a big picture view of all the potential contributors or stressors that may lead to a pain experience. All of these things go into the cup and the cup starts to fill.

Once the cup overflows, you get a pain experience.

Here is the amazing part: You don’t have to just take things out of the cup, you can also make the cup bigger!

We can build the cup up (with exercise) as we decrease what is in the cup – load management, stress management, you name it!

If your cup is overflowing and you really need help to make restore your quality of life, book in an appointment with Square One Active Recovery to discover the difference the right care can make. I promise it will be nothing like what you have had experienced before.