Pain is an Opinion

How understanding discoveries in neurology can help treat and prevent chronic pain right now.

by Paul Ingraham.

One of the principle qualities of pain is that it demands an explanation. Plainwater, by Anne Carson

Pain is not just a message from injured tissues, but a complex experience that is thoroughly tuned by your brain. These not-so-recent discoveries about the physiology of pain have been painfully slow to reach the public, or even health professionals. This knowledge is useful and needs to be shared. Professionals need it so that they can retreat from some unfortunate old attitudes about pain problems (“if I don’t understand it, it must be all in your head”). Patients with chronic pain need the reassuring perspective, and the real therapeutic effects of greater confidence and mental health.

I can hardly imagine a better argument that to “come alive” has impressive health benefits. The personal development work done by Haven workshop participants integrates beautifully with modern pain science. Your relationship with yourself and others is directly relevant to chronic pain, because depression, fear and anxiety, social isolation, and feeling like a victim are all known risk factors for chronic pain. This is why I send my patients and readers to Haven to practice “the art of healing by growing up.”

Ramachandran said, “pain is an opinion” — which sounds like a flaky New Age mind-over-matter theory. But Ramachandran is no mystic or guru: he is a medical scientist, a neurologist. The passage below, from his book, Phantoms in the Brain, is mainly known for the first handful of words, a brilliantly concise statement of the modern understanding of how pain works.

Pain is an opinion on the organism’s state of health rather than a mere reflective response to an injury. There is no direct hotline from pain receptors to ‘pain centers’ in the brain. There is so much interaction between different brain centers, like those concerned with vision and touch, that even the mere visual appearance of an opening fist can actually feed all the way back into the patient’s motor and touch pathways, allowing him to feel the fist opening, thereby killing an illusory pain in a nonexistent hand.

Phantoms in the Brain, by VS Ramachandran and Sandra Blakeslee

He tells the story of an extraordinary cure of a man with phantom limb pain, tortured by agony in a clenched fist that was not there. With a clever arrangement of mirrors, Ramachandran created the illusion that the man’s amputated arm was restored — a sort of “virtual” limb. The mere appearance of his phantom hand opening and closing normally cured his agonizing “spasms.” He felt better because of the illusion that he was better — because he thought he was better. It is one of the most curious anecdotes in all of pain science.

Since then, “mirror therapy” has been studied and applied in many ways. A good quality 2007 study showed that mirrors aren’t actually necessary to achieve this effect. Mirror therapy is probably just a “fun” way to visualize healthy movement — which also works quite well without a mirror!

The perception of pain in olden times

For most of the history of medical science, pain was believed to work more or less the way the French philosopher René Descartes described it:

1. The flesh is wounded. (“It’s just a flesh wound!”)
2. Nerves send a clear message to the brain about the problem. The intensity of the message is directly proportionate to the severity of the injury.
3. The brain interprets the message at face value — that is, if the message says, “There’s some bad damage here,” we believe it.

But it’s just not that simple. For several decades now, it’s been clear to pain scientists and most health care professionals that this model is hopelessly inaccurate. The real situation is much more complicated, interesting, and in some ways useful.

What goes up, must come down

It turns out that the brain is not just a passive, gullible receiver for whatever pain messages the peripheral nerves send upstairs. And, if you think about, it’s kind of strange that we would ever have thought of it that way, because this is, after all, the brain we’re talking about: seat of consciousness, the generator of your reality. Not only does the brain critically evaluate every pain message it receives — considering it in context, checking it out like a piece of fruit at the grocery before deciding whether or not to buy it — it also sends messages downwards that affect the sensitivity and behaviour of nerve endings.

Everything that hurts involves a conversation, a sort of debate, between the central and peripheral nervous system. It could be dramatized like this:

NERVES Got problems here! Bad problems! Red alert!

BRAIN Yeah? Hmm. Okay, so noted. But you know what? I have access to information — sorry, it’s classified, you’ll just have to take my word for it — that suggests that we don’t have to worry about this much.

NERVESI’m telling you, this is serious!

BRAINNope, I don’t buy it.

NERVESLook, I may not have access to this “information” you’re always talking about, but I know tissue damage, and I am not kidding around, this is a credible threat, and I am going to keep telling you about it.

BRAINActually, you’re having trouble remembering what the problem is. You’re going to send me fewer messages for a while. Also, these aren’t the droids you’re looking for.

NERVESUh, right. What was I saying? Gosh, it seems like just a second ago I had something important to say, and it’s just gone. I’ll get back to you later I guess …

The brain can boss nerves around, tell them how sensitive to be. When anxious, the brain might request “more information” from the peripheral nerves, ordering them to produce more signals in response to smaller stimuli. Or it might do exactly the opposite. In short, messages about pain don’t just go up to the brain, they go down. This two-way functionality in the pain system is the main difference between modern pain science and old-school pain science.

And so pain is less painful when we are confident that we are safe. This was demonstrated quite early in the history of pain research by a famous paper about wounded soldiers in WWII, which showed that they experienced surprisingly little pain considering the severity of their injuries — probably because they were so glad to be off the battlefield.

Can we think pain away?

Alas, no — pain neurology can’t be manipulated simplying by wishing. The brain may powerfully control our experience of painful experiences, but I’m sorry to report that you don’t control your brain. Consciousness and “mind” are by-products of brain function and physiological state. It’s not your opinion of sensory signals that counts, it’s what your brain thinks of it — and that occurs quite independently of consciousness and self-awareness.

Your brain will also modulate pain experience based on a number of other things that are completely our of your control. For instance, although it is technically the brain’s prerogative to ignore painful signals from your tissues, that doesn’t mean that it will — if there is a destructive disease process going on, for instance, the brain will usually not ignore those signals! The pain system evolved to report problems, and it will diligently do so.

But that doesn’t mean that we’re powerless! To wrap up, let’s look at several other ways that you can tinker with pain neurology.

What are the practical applications of this knowledge?

Pain is “another *%$@!! growth opportunity” — another reason to mature as a person, and a particularly good one. For many people with severe and chronic pain, learning coping skills are a necessity. But personal growth may provide an even greater opportunity than merely coping with pain.

We may not control our brains, but we have do have considerable indirect leverage. We can’t micromanage our sensations, but we can change the context and direct our experience at a high level. For instance, we can alter our physiology with the kind of deep breathing that is taught at Haven, instantly creating new feelings — and your brain will go along for that ride, and perhaps re-interpret your experience of pain.

Or we can create new social contexts by doing something as simple as playing a team sport — because other people are counting on you, the painful consequences of intense exercise are usually recontextualized as tolerable, even desirable, and you can put up with quite a lot more. You can’t think your way to that kind of pain tolerance — but you can place yourself in a situation where it is a likely outcome. This is why Haven puts on experiential workshops: to thoroughly “tinker” with your context, especially your social context, because humans beings are so interested in each other that our social experiences utterly dominate our consciousness. Change your social experience, change your brain!

Yet another powerful example is education. Fear and anxiety probably have more power to aggravate pain than any other emotional state, and acquiring knowledge and perspective are superb treatments. A confident and happy brain amplifies pain signals less than an anxious, miserable brain. This explains lots of interesting results in pain research (not to mention clinical observations), such as the fact that the most powerful factor predicting how soon people return to work after an episode of low back pain is whether or not they expect to return to work, or the fact that education alone probably helps to resolve neck pain. So do not let health professionals scare you. Seek out as much information as you can find, because nothing causes more anxiety than uncertainty. These are real defenses against pain.

Another useful context-tweak is to firmly reject the self-hating idea that your pain is “just” psychological. Paradoxically, even though pain is strongly regulated by your CNS, it is certainly not “all in your head.” The idea has always been disrespectful to pain patients, but now it is also scientifically obsolete and can be thrown out with yesterday’s trash. Any health professional talking like that should just be ignored. We know better: if you believe that you have a problem, you will have one.

Finally, fix the fixable — and be honest about what is fixable. Most people aren’t quite as stuck as they think they are. Some problems really aren’t fixable, but a lot of your worst and oldest problems probably are, and they are the source of most stress, anxiety and depression — which means that they also have a direct impact on how much you hurt. There are many examples of difficult problems that can usually be fixed with some hard work and maybe some leaps of faith: bad marriages and toxic friendships, bad jobs and bad bosses, a house or city or climate you don’t like, poverty, addiction, insomnia and many more. Finally taking action to fix such problems is the most direct route to easing your brain’s interpretations of pain.

Paul Ingraham is a science journalist and retired Registered Massage Therapist in downtown Vancouver. He has authored several books and hundreds of articles about science-based care for common pain problems, most notably about myofascial pain syndrome, low back pain, and knee pain. Paul blogs regularly at SaveYourself.ca, and you can follow him on Twitter or Facebook.