Understanding pain and how explaining it to you can really help

Written by Megan Fraumano

Recently Anthony and I completed a 3 day course entitled “Explain Pain”. The cutting edge material presented was neuroscience at its best and is revolutionising the way we think about pain.

Pain is something that we discuss with most of our patients on a daily basis, and we are passionate about helping our patients to understand the science behind pain and how it can be applied to their individual cases to help them. With this in mind, I will attempt to summarise some of the latest facts about pain.

In the past, neuroscientists have used the “gate control theory” to explain pain. This long-held theory basically suggests that pain was an input from the site of injury that travelled to your brain, thus prompting you to “feel pain”. We have known for a while that this theory doesn’t make sense for all types of pain, for example phantom limb pain and chronic pain, and really need to be updated.

There is now a lot of evidence that pain depends on many other factors besides tissue damage, and in fact tissue damage is not even necessary to feel pain. This helps to explain why some people may feel extreme pain from a seemingly minor injury, or why pain may linger even after tissue healing has occurred.

Pain has been redefined as an output of the brain that is dependent on the brain’s perceived threat of danger minus the perceived amount of safety. If we start to look at pain in this way, as a smart, positive protective mechanism that is activated when the brain senses danger, then we can understand that movement causing pain is not always something to fear.


There is also some very interesting evidence regarding the nervous system in chronic pain. I’m sure you can all think of someone who has been in pain for many years. Often the site of pain travels and expands beyond the original injury site, and can linger for much longer than the time taken for the initial injury to heal. This understanding that the initial injury is actually healed but that pain can still be felt is and be “real” is a challenging concept, particularly for those that suffer chronic pain.

The nervous system can become overly protective and react at even the smallest perceived threat. If you have ever heard someone say “even the thought of bending/sitting/throwing hurts me”, then you have a prime example of just how influential the brain’s output can be. It would be easy to ignore these comments by saying “it’s all in your head” – and that’s the point – It actually is! The difference being, that we know that this is REAL pain – it is all REAL pain, produced by your brain.

As osteopaths, we have always recognised the role that not only the whole body, but also many external factors can play in pain. This is why you may often find your osteopath examining areas other than your site of pain, why we take such a detailed history in your first consultation, and why you might find us asking you about stress, sleep, work and family. Understanding that your pain may be worse, or be triggered when you are stressed at work, have the flu or are going through emotional trauma is significant step forward to managing pain.

Practically, this means that one very important element in the treatment of pain is decreasing the perceived threat, and increasing the brain’s feeling of safety. You may find your osteopath explaining your injury in detail, or clarifying some previously held ideas of an injury in order to decrease unhelpful thoughts. These unhelpful thoughts can come from many sources, and often they are anatomically incorrect. It is easy to imagine why picturing your osteoarthritis as “stiffness that needs some movement to help lubricate the joints” is more helpful than picturing “bone on bone grinding away when you move”. Language becomes a very important tool that can be used to manage pain. Decreasing the danger messages to your brain may also require slow progression of exercises and retraining of different postures and positions.

When returning to activity after an injury, it may be helpful to consider the twin peaks model. Often after an injury, patients will either be very apprehensive about returning to activities associated with pain (fear avoidance model), or attempt to jump straight back into what they were capable of before the injury. The twin peaks model is an example of graded exposure, where we gently knock on the door where pain resides and slowly push further and further.


TT = Tissue tolerance     PBP: Protect by pain barrier      BL: Baseline    FUL: Flare up line

In summary, we know a few things about pain:

  • Pain is a critical protective device
  • Pain depends on how much danger your brain thinks you are in, not how much you are really in
  • Tissue damage and pain often do not correlate
  • As pain persists, the nervous system often gets “better” at producing pain.

If you have any questions about how we can help you understand pain a little better, don’t hesitate to ask at your next appointment.