• Brad Stulberg

A New Way to Think About Pain

According to best estimates, more than 20 percent of Americans experience persistent physical pain that interferes with their daily life. More than 20 percent of Americans also experience chronic psychological pain in the form of depression, anxiety, and other mental-health disorders.

Unfortunately, we’ve largely got chronic pain wrong. “Conventional thinking on pain may be incorrect at best and harmful at worst,” says my good friend Kelly Starrett, a doctor of physical therapy and founder of the Ready State, a gym and online resource dedicated to helping people relieve pain, prevent injury, and improve their physical performance.

The first way we get chronic pain wrong, says Starrett, is that we assume it occurs in the muscles or bones or, in the case of psychological disorders, the mind. However, more recent work in the field of pain science reveals this isn’t the case. Persistent chronic pain is a bio-psycho-social phenomenon. In other words, it manifests from a combination of issues arising in our bodies, minds, and communities. While acute pain (e.g., a broken wrist, a sprained ankle, or transient anxiety or depression) recedes with targeted treatments, chronic pain does not. Thus, it requires a much more holistic view.

Consider the following examples: mental illness responds well to physical activity, while persistent physical pain can be alleviated with psychological training, such as mindfulness. In order to address chronic pain in a meaningful way we’ve got to focus on the entire system.

The second way we get chronic pain wrong is that we assume pain is always a bad thing, and thus we come to fear it. However, this couldn’t be further from the truth. Pain is a dramatic evolutionary advantage. It is information. It tells us that something is wrong, or that something could go wrong. But sometimes a little bit of pain also tells us that we’re on the right track. Just think about it. Any meaningful attempt toward improvement—be it physical, psychological, emotional, or social—usually involves at least some discomfort, if not pain.

I recently spoke with Dr. Samer Narouze, a professor of surgery and anesthesiology at Northeast Ohio Medical School and chairman of the pain center at Western Reserve Hospital. According to him, persistent chronic pain that has no underlying current pathology (i.e.,whatever was wrong in the body has been fixed) is often perpetuated for two reasons: we become either overly sensitive to that discomfort and pain or insensitive to it, both of which can lead to more long-standing and severe issues.

On the oversensitive side, at the slightest bit of pain, our mind-body system freaks out, which in turn causes more pain. We enter into a vicious cycle of hypersensitivity, with pain begetting more pain. This is common to chronic physical pain and anxiety disorders. On the insensitive side, we endure too much pain without changing our approach or asking for help. The result is that the pain often gets worse. “One of the strongest predictors of persistent chronic pain is how long a person has gone without getting help. The longer that period, the more likely the pain will become chronic,” Narouze says. Learned helplessness is also common to depression, which, unsurprisingly, is associated with chronic physical and social pain.

When we become oversensitive to pain, the solution is often forcing ourselves to experience it, so that we can retrain our mind-body system not to freak out. A person undergoing this kind of exposure therapy learns that sometimes it is their fear and avoidance of experiencing pain that is causing their distress more than the actual pain itself. Exposure therapy is part of a broader model called cognitive behavioral therapy, which, according to Narouze, “has the highest level of evidence, even more than medications, for helping with persistent chronic pain.”

When we accept too much pain, the solution generally involves learning that it’s OK to ask for help, that pain need not be a given, and that we can take action to improve our situations. This is also a cornerstone of cognitive behavioral therapy and other evidence-based therapies, such as acceptance and commitment

In both circumstances—over-sensitivity and insensitivity—problems arise when we respond inappropriately, either by not tolerating any pain or by tolerating too much of it. In both cases, pain tends to become worse.

In the final analysis, perhaps we need to stop thinking about persistent chronic pain in a vacuum and start addressing it more holistically; if we stop focusing solely on the sensation of pain itself, we can start focusing on what it is telling us and how we respond to it, as individuals and communities.

Brad

For more on pain on this topic check out How to Make Friends with Pain; How to Develop Mental Toughness; and our recent podcast on performance, health, and pain with Kelly Starrett.

(Note: A version of this story was first published in my column at Outside.)

Brad Stulberg   |   bradstulberg.com   |  bradstul@gmail.com