What is Pain? Even Clinicians Struggle to Answer the Question



Like all areas of medicine and physical rehabilitation, understanding pain is always evolving. I will not be able, nor will I try, to cover every aspect of pain. As someone who previously firmly fell in the camp of misinformed, I understand the feelings of frustration when learning pain is more complex than originally believed, much more complex. In some ways learning about pain science is comparable to experiencing the five stages of grief:


  • Denial: Bullshit. There is no way pain actually works that way. Why would my school or previous doctors and therapists teach it differently? Are you telling me I was taught wrong my whole life?

  • Anger: Are you telling me I was taught wrong my whole life?!

  • Depression: Not only am I six figures in debt for an education riddled with misinformation, but I have also been telling my patients the wrong information all this time. I even told someone his spine was like a jelly donut and therapy would push the jelly back in! (more on this popular analogy and my unfortunate use of it to come)

  • Bargaining: Perhaps I can blend the two models and it won’t be a total waste. Surely there are some benefits of the previous education I received. It can’t all be a sunk-cost right?

  • Acceptance: Bring on the pain science. I’m ready to educate the hell out of people.


This is not to say my grief was the same as losing a loved one, but the stages were certainly there. Unfortunately, many clinicians are either still stuck in Denial or are ignorant of the research. Pain is a complex, multifactorial phenomenon that cannot be simply addressed with a pill or wrapping some copper around your knee. To understand what pain really is, we first need to clear up what it is not.


Pain ≠ Damage

If you receive an MRI on your low back tomorrow, there is a decent chance it will show multiple levels of disc bulges (called herniation), arthritis, decreased space (stenosis), and bone spurs (osteophytes). (source) These “abnormal” findings on an MRI are quite normal. Our bodies degenerate over time; it is a part of life. Most symptomatic patients have normal MRI reports while a significant portion of asymptomatic patients have “abnormal reports.” This is not exclusive to the low back. Imaging studies on the shoulder, hip, and neck show similar findings.


This does not mean the damage is irrelevant. If you cut your finger or tear a muscle, you will more than likely feel pain. But the damage is only a small piece of the puzzle.

Arguably, the most accepted current model — including the World Health Organization — is the biopsychosocial model (BPS). It proposes that the experience of pain is the result of biological (e.g. tissue damage, genetics, etc.), phycological (e.g. mood, personality, etc.), and social factors (e.g. cultural, socioeconomic, etc).


Psychosocial factors, including anxiety, depression, attitudes and beliefs, social context, or work status may all play an important role in the pain experience. We don’t simply have ‘pain fibers’ that are turned on and off. While we do have nociceptors, which have often been misclassified as ‘pain fibers’, they are influenced by many psychosocial influences and are not the only source of a pain stimulus.


Our brain receives an abundance of information constantly and must filter out the most important and relevant details. If our attention is drawn away from the stimulus that usually causes pain, it will be diminished and potentially non-existent. Conversely, if you are hyper-aware and focused on the pain, then it is intensified.


Have you ever looked down at your leg and wondered when you received that cut and why you didn’t feel any pain? Now compare that to the papercut that caused searing, burning pain. The first likely was not experienced because your attention was elsewhere and your brain did not perceive that stimulus to be a threat at the time, whereas you were anxiously praying to avoid the paper cut while licking your stack of 30 thank you notes.


Our emotional status and history of pain can significantly impact our pain experiences as well. This is a primary reason why chronic pain is so prevalent and difficult to treat. When we experience pain for a prolonged period — that is, beyond the duration of normal tissue healing — our nervous system is hypersensitive. Other stressors such as poor or insufficient sleep, poor dietary habits, inactivity, other medical conditions, and…well, stress (for example, racking up six-figures of debt for school, living with kids who think sleep is optional, being a Miami Dolphins fan, and other completely random things I know nothing about), can lead to a heightened pain response. This causes traditional treatment approaches — such as surgery and medication — to be ineffective as they fail to treat the nervous system and the multiple factors contributing to the pain. This is a primary reason why MRIs are not very helpful, except in the case of serious medical pathology, such as a malignancy.


Common Pain Myths

1. Poor posture is causing my back pain.

Current research does not support posture as a driver of pain. Simply sitting up straight will not eliminate or prevent pain. Even lifting with a rounded low back likely does not contribute to the development or maintenance of low back pain or neck pain. Furthermore, our bodies do not fall out of ‘alignment’, and pain and injury are not caused by ‘imbalances.’ Asymmetries in the body are normal as we respond to daily stresses we put it through.


2. Bed rest is best

Our bodies are meant to move. Across clinical practice guidelines, research is clear bed rest should be avoided. While we can immobilize (cast or split) or offload (crutches) injured areas of the body, we should continue to move in other areas. Research repeatedly shows bed rest does not work for treating pain.


3. Pain medication will fix the problem

Pain medications do not address the underlying cause of the initial pain experienced or the mechanisms causing the persistence of pain. They are primarily a masking effect.

Medication has its place in pain management, but outside of surgical or traumatic experiences, it should not be the first line of defense, especially if it is prescribed as the only line of defense. This is one of the primary reasons for the current opioid problem in the U.S. Not only do pain medications, such as opioids, fail to address the root cause of pain, but they also bring unwanted side effects into the equation. The CDC has attempted to reverse the current trend in opioid reliance and stated in its Guideline for Prescribing Opioids for Chronic Pain that the number of side effects, paired with the addictive nature of the drugs, make them inappropriate as a first-choice treatment.


4. I need surgery to fix my pain

A 2018 systematic review in Pain Medicine found that surgery is ineffective for chronic pain across the board. This included surgeries for the spine and extremity. Surgery ignores the psychosocial contributors to pain. Surgery also does not address the cause of pain and often leads to future surgery. Here is how the authors summarized their findings:

The risks of surgical and invasive procedures are not minor and appear to be higher with real compared with sham procedures. Risks in both groups include anesthesia, permanent injury to the body, psychologic stress, and time, cost, and productivity losses. Without more rigorous examination, large numbers of patients are exposed to risky and possibly unnecessary procedures. Furthermore, new procedures will be invented and applied with the belief that they are specific and necessary without knowing whether this is true. It is currently felt to be unethical to deliver new drug treatments without testing them for their specific effects against placebo comparison arms. Why should it be different with invasive procedures?

This does not mean surgery is useless, but in most cases, particularly regarding musculoskeletal care, people are better off seeking conservative treatments first. It is rare that the surgery, especially musculoskeletal surgery, addresses the root cause of the problem.

What does work for pain?

The answer to this question is evolving every day. There is no one-size-fits-all approach. In addition, there are many different pain experiences. The severity, duration, frequency, and type of pain differ between people.


Acute pain is often the result of tissue overload, either the workload was too great or the recovery time was too little. Often this results in an injury, but you may also experience pain — a warning bell of sorts — prior to the damage. Most acute pain resolves without intervention — just a gradual increase in activity — as the body naturally takes care of the healing. It is when the pain reaches a chronic state that it becomes more complex.


Understanding the complexity of pain and common fallacies in education and treatment can allow patients and clinicians to make more informed decisions. Some people may read these myths, and when paired with their past and current experiences, determine all hope is lost. There is a belief among some people that their pain cannot be resolved, and they are doomed to live with it. There are many ways to address pain that is grounded in the evidence.


I do not say this to discredit pain or past efforts to address it. When I say patients can do something about it, it may also be small steps and over a long time period. Pain looks different for everyone and its effect on someone’s daily life is individual as well. The good news is there are a plethora of conservative treatment approaches without the side effects of medications and many are self-driven such as exercise, nutrition, sleep, and improving emotional health (stress, happiness, purpose, etc.).(source) Finding the right clinician — whether it be a physician, a physical therapy, a psychologist, or another health professional — who can provide the best-personalized plan of care and build self-efficacy is key to getting and staying on the right track.


Addressing misinformation in healthcare and social media

My journey in understanding pain has been met with frustrations. Now, when reading about a treatment or assessment approaches on a message board or Facebook group, I focus on being curious and open rather than closed-minded and ready to attack. I then follow-up that curiosity with a thorough assessment of the claim and current research. At the same time, I am cautious of misinformation in both common, unedited sources such as Facebook and “peer-reviewed” journals.


When able I engage in clinical conversations to challenge misinformation. For non-clinicians, this can simply be asking for sources and research to back up claims. When seeking treatment for pain, consult multiple providers, and do your own research. Doing your homework and checking the validity can be a valuable learning experience, even if you discover the information was wrong, regardless of the intent of the author or provider.


Pain is often misunderstood by all parties. That will not change until we are willing to read and listen to new research, address our biases, and challenge misinformation.