Most chronic pain sufferers I work with at Square One Active Recovery 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 entirely commendable. However, when it comes to longer term self-management (i.e. drive long-term pain relief without my help), it all comes down to two critical pillars:
- Knowing or understanding the pain experience: Learning how to make sense of your symptoms objectively.
- What to do next to address the pain experience: Knowing what actionable steps to take next.
It’s pretty interesting because virtually everybody knows knowing and understanding what to do is a big part of long-term success. Yet, at the same time, it’s very easy for us to forget prioritising education in favour of quick fixes.
What is Pain Neuroscience Education (PNE)?
PNE is a broad term that refers to educational interventions that aim 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, what we are trying to say is that:
- Pain doesn’t equal tissue damage.
- Tissue damage doesn’t equal pain.
Mind-blowing, huh?
What is Pain, Really?
When you look at the two clinical cases below, which patient do you think suffered from more pain?
This is not a trick question: 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 a 4-inch nail embedded in the head of another construction worker (Dimsdale & Dantzer, 2007). 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 just a physical stimulus and cannot be measured visually. It is, in all fullness, an individualised perception.
The Three Parts of Your Pain Experience
In academic terms, neuroscience breaks down the pain experience into three parts:
- Sensory-Discriminative: Where the pain is located and how intense it feels.
- Affective-Motivational: How unpleasant that pain is to you and how it impacts your emotional state or mood.
- Cognitive-Evaluative: How you make sense of the pain and what meaning you attach to it.
These are really big words, so let’s not stress over them. If we simplify it into terms that are meaningful for you, the three parts to pain are: (1) the actual sensation, (2) unpleasantness/what’s next, and (3) your thoughts and mental processes.
Breaking Down Everyday Pain Examples
Example A: Stepping on a LEGO Brick
- Actual Sensation: High intensity, pressure-like sensation on the bottom of the foot.
- Unpleasantness / What’s Next: “Ouch ouch!” → lift the foot off the LEGO immediately.
- Thoughts: “I am safe. But I don’t need this.”
Example B: Foam Rolling a Tight Muscle
- Actual Sensation: Moderate to high 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 an evidence-based pain management modality. Please reach out to an evidence-based chiropractor in Singapore if you wish to understand more.
Your Pain is Highly Contextual
With these examples, you can see that pain is highly contextual. Even in circumstances where a stimulus is deemed safe, you may respond completely differently based on how you make sense of the pain.
Most of us instinctively consider pain to be unpleasant and try our best to avoid it. Yet within our own lives, we find instances where we actively seek out a painful experience despite its unpleasantness. Just think of your last pain-free massage. If it’s too light, you probably think there’s “no kick” and that nothing therapeutic is happening.
Comparing the Two Real-Life Case Studies
Let’s revisit the actual facts of what happened in those two construction worker cases:
| Component | 7-Inch Nail in Boot Case | 4-Inch Nail in Head Case |
|---|---|---|
| Actual Sensation | Excruciating sharp sensation* | Mild toothache, dull bruise sensation |
| Unpleasantness / Action | Super unpleasant, need hospital emergency care ASAP | Not very unpleasant, continued daily life for 6 days |
| Thoughts / Context | “There’s a 7-inch nail driven straight through my foot!” | “Everything seems okay, just a routine toothache.” |
| Actual Tissue Damage | ZERO damage. Nail passed between his toes. | Severe damage. 4-inch nail embedded in skull. |
*Note: “Sharp sensation” is used instead of “pain” because pain, in precise scientific terms, is an overall brain-generated experience rather than an isolated bottom-up sensory input.
In the nail-in-boot case (BMJ, 1995), the worker required sedation with fentanyl and midazolam because even slight movements caused excruciating pain. Yet when doctors removed the boot, the nail had passed entirely between his toes without breaking the skin. Despite zero physical damage, his pain was 100% real! Conversely, the nail-in-head patient (Dimsdale & Dantzer, 2007) lived with a nail embedded in his skull for six days with nothing more than a mild toothache.
This illustrates how remarkably powerful the brain is. I am not saying your pain is “all in your head.” I am saying ALL of our pain is constructed within our heads.
Modern-Day Flawed Pain Narratives
1. Pathologising Normal Tissue Variations
If you poke and prod anywhere in the body, you are likely to find roughly 30 spots with some form of tenderness. Some practitioners label these as “restrictions” or “adhesions” (engaging in accidental cold reading).
To a huge extent, modern narratives pathologise what is normal. Normal tissue tenderness or stiffness gets negatively framed as something harmful: “Oh my goodness, you are so tight.” By the time you genuinely experience back or neck pain, you’ve been conditioned to believe it stems from damaged, fragile tissues.
2. The Myth of Perfect Ergonomics
For the record, there is no high-quality evidence supporting the idea that ergonomic interventions prevent or cure chronic pain. The Lancet journal in their landmark low back pain series highlighted that workplace ergonomics does not resolve lower back pain.
As office workers obsess over standing desks, expensive chairs, and perfect neck posture, they become fearful of movement, increasing susceptibility to pain. We forget that human bodies are inherently robust and highly adaptable. A thousand-dollar chair is unlikely to be your long-term solution.
3. How False Beliefs Obstruct Recovery
If you believe stairs destroy your knees, you avoid stairs. If you believe your back is too weak for pregnancy, it leads to catastrophic decisions—such as a documented case where a patient underwent an abortion because she was told her core was ridiculously weak.
While structured strength training is one of the best long-term solutions, negative self-talk can negate physical benefits. Passive therapies like massage, stretching, acupuncture, or chiropractic adjustments are not inherently harmful, but framing them as fragile “fixes” reinforces dependency rather than resilience.
The Biopsychosocial Approach: The Pain Cup Analogy
Your pain is real, but it may be misunderstood. You can build resilience even with clinical diagnoses like tendinosis or a slipped disc on an MRI.
Think about how your pain feels during periods of poor sleep or intense work stress. Stressors accumulate in your “cup.” When the cup overflows, you experience pain.
This is why we utilise a solution-focused coaching approach. Rather than endlessly hunting down minor physical flaws, we focus on two things simultaneously:
- Emptying the cup: Optimising load management and stress management.
- Making the cup bigger: Building physical capacity, strength, and tissue tolerance through progressive active recovery.
By addressing the whole person, we aim to transition clients from pain to self-management efficiently without long chiropractic packages or endless maintenance visits.
Key Takeaways
Keep these core pain science principles in mind during your recovery journey:
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1
Pain Does Not Equal Damage: High pain intensity can occur with zero structural injury, and severe internal injury can occur with minimal pain.
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2
Pain is Contextual & Multi-Factorial: Your brain constructs the pain experience based on physical input, stress levels, sleep, beliefs, and emotional context.
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3
Build a Bigger Cup: Recovery isn’t just about avoiding triggers; it’s about building physical capacity and strength through solution-focused active exercise.
