Many sufferers of persistent pain have been there, the final set of scan results come through.. all completely normal. Or the final phase of treatment comes to an end and their doctor utters those 5 fateful and scientifically murky words ‘It’s all in your head’! In my own professional lifetime alone I have heard this one recounted literally hundreds of times. So not only do you have heaps of pain and huge uncertainty about what to do about it.. you are a bit crazy too! Now this new reality sucks at a whole other level because you know that navigating your way out of cloud cuckoo land is not easy for anyone, let alone someone who is hobbling around with false back pain, phantom plantar fasciitis and imaginary heel pain. Thank Doc.
I have worked with countless people over the years who have been through the process, from failed back pain treatment to failed diagnosis and subsequent ‘its all in your head status’. Over that time I have developed a massive amount of sympathy for anyone who finds themselves with the uncertainty and fear of being told their suffering ‘is not real’. Pain itself is bad enough without uncertainty over its causes, and yet another layer of uncertainty about ones own sanity. This is of little interest or seriousness to bystanders, but of profoundly serious for those living with stubborn pain. Pain that as we shall see is very real and has very clearly proven causes, that science is well aware of.
The first and most basic issue with this assessment in the medical context is that in the majority of cases the scan and/or the treatments are not biomechanical or psychosomatic in nature. The overwhelming majority (perhaps more than 95%) of aches and pains in what we call somatic tissues (joints, muscles, connective tissues, nerves) are caused by mechanical issues in combination with emotional factors. That means that they are caused by our life stories, by injuries, and by issues with movement as opposed to food intolerances, toxicity or disease. Knowing this means that we can only conclude that assessments of movement and injury outcomes must occupy 90% of our investigation
No matter what kind of pain you have, all pain is complex. Every pain there is, from touching a hot stove through to chronic plantar fasciitis and back pain are all wildly complex process within the body/nervous system. Processes that even top researchers are only just starting to gain a basic understanding of.
Phantom Limb Pain
Life helpfully rubs our collective nose in how poor our understanding of pain is by baffling us with the phenomena of phantom limb pain. In case you didn’t know the startling fact is that 80% of amputees suffer from pain in the limb they have lost. The phantom limb pain phenomena blows our minds a little because it brushes up against the seriously over-simplified cultural understanding of pain we are born into. We are taught to believe pain fundamentally happens in the body, so it seems outlandish that someone (let alone huge numbers of people) should have pain in a limb that was removed 10 years previously, and even stranger that the pain be ‘real‘ pain. But make no mistake, phantom limb pain checks all the boxes for qualifying as real pain, no less real than back pain, hip pain or knee pain. Phantom limb pain is most certainly different in nature to most cases of back pain and plantar fasciitis, but it is not less real.
Now if you are in pretty good health apart from the odd sprained ankle, and happily in possession of all your arms and legs it’s easy to shrug phantom limb pain off as a bit of weirdness. The truth is though amputees are not weird at all, they are just like you and me. For phantom limb pain sufferers their pain is as real as any other pain. Perhaps we can normalise this aspect of pain a bit more for you with the news that we can make you feel pain in the back of a rubber hand, by using mirrors that trick your brain into thinking it’s your own hand.
The bottom line is this, you live in a world where a higher percentage of people without legs have leg pain than the percentage of people with actual physical legs. This isn’t weird, it isn’t bizarre and it definitely isn’t unusual.
There is another fact about pains like back pain, heel pain, shoulder pain, plantar fasciitis and the like that further serves to demonstrate the true complexity of what pain actually is. The majority of people with stubborn and recurring pains find that periods of stress are a major trigger for their pain. Research has shown that workplace stress an infinitely more common cause of significant back pain than heavy lifting for example. International guidelines for back pain acknowledge stress as a far more accurate predictor of pain than physical injury. It may be that what we are observing here is based on some of the same nervous system changes that lead to phantom limb pain.
In any case,.what all this talk of crappy jobs, haunted ghost legs and rubber hands is not designed to freak you out, it is supposed to tangibly and soberly acknowledge that pain overwhelmingly happens deep in the brain. Because what other explanation can there be, unless you believe that a predominant side effect of limb amputation is insanity; or that everyone with back pain triggered by work stress is having a strange form of hysteria.
Pain Endurance – Switching Pain Off?
Another area of curiosity that has the potential to teach us about pain is that of people who seem to be able to endure unimaginable pain. In many ways this is an observation of what exists right at the opposite end of the pain spectrum from supposedly imagined pains.
It is a relatively well known fact that certain people have an astonishing ability to endure pain, either by way of straight up grit or by an ability to ‘switch off” pain. There are enough anecdotal reports from those who achieve great feats of endurance for us to consider the possibility that there is a place ‘beyond pain‘, such that it can be ‘switched off‘ within the mind.
Ex Navy Seal David Goggins famously ran 100 miles on a foot full of broken metatarsals and achieved a world record by performing thousands of pull ups with the skin on hands opened up almost to the bone. Thích Quảng Đức, a Vietnamese Mahayana Buddhist monk burned himself to death on 11 June 1963 to protest the persecution of Buddhists by the South Vietnamese government. Thich sat silently in the lotus position as all the flesh burned off his body, over 100 other monks are known to have repeated this feat in modern times. There are of course countless other examples of humans willingly embracing levels of suffering that seem almost impossible to comprehend for those of us on the sidelines observing their hardiness. Polar explorer Sir Ranulph Fiennes who has endured unimaginable hardship in his various solo Polar exploits springs to mind. Sir Ranulph once famously and calmly went down to his garden shed and sawed the ends of his own frost bitten fingers off, having become fed up with his doctors refusal to do so for him.
It is very hard to say whether these individuals experience the same amount of pain as the rest of us might do under the same conditions. Speaking intuitively it seems almost too implausible that a man could douse himself in fuel and sit quietly as is his body turned to a charred black mass, unless he has found a way to somehow not experience pain in the way the rest of us do. Bearing in mind most of us struggle to hold the tip of 1 finger in a flame for 10 seconds with any dignity whatsoever.
Characters like Ranulph, Goggins, and Thich more often than not seem to have spent long periods ‘building up‘ to their most epic moments of pain endurance. They may simply have forged themselves into pain experts. Having digested Goggins’ material, I can confirm he certainly appears to be a pain expert, and he teaches others how to more artfully and effectively endure hardship. I can personally vouch in my own small way for the effectiveness of his techniques. Goggins claims that there is a place in the mind that lies beyond the normal limitations placed upon us by pain. It is impossible to know for sure if men like him don’t just start out with a different neurological constitution to those of us who fear paper cuts. It seems obvious to me that there is both a genetic spread of pain tolerance and that early childhood experiences affect pain tolerance on top of whatever training is undertaken in adulthood. It certainly does not seem likely that these characters ‘do not suffer‘, perhaps their pain is every bit as sharp as my own. If it is, and they can endure as they have, it does in an indirect way shed light and possibly hope on the type of pain we are predestined to talk about in an article of this nature.
Irrespective of what the unseen physical components are, feats of pain endurance are compelling evidence for a more complex inner process than most of us credit pain with being.
Pain & Exercise
A study published in the International Association for the Study of Pain (IASP) in 2017 demonstrated that adults who are more active have a greater ability to tolerate pain. More specifically they found that adults with higher levels of physical activity have ‘pain modulation patterns’ that might help lower their risk of developing chronic pain.
In tests of pain processing by the central nervous system, physically active older adults have lower pain perception and are better able to block responses to painful stimuli, according to the research. “This study provides the first objective evidence suggesting that physical activity behaviour is related to the functioning of the internal pain modulatory systems in older adults,” the researchers write.
Dr. Naugle and colleagues performed a series of experiments on 51 healthy adults, aged 60 to 77. All the participants wore an activity monitoring device to measure their level of physical activity. They then underwent two tests of pain tolerance. As you might expect those who exercise regularly can handle more pain. The fascinating thing however is that the research revealed that the exercising adults actually experienced less pain, their central nervous systems ‘modulate’ pain signals in a way they are they are not felt in the same way.
The more active test subjects who could handle more pain actually physically felt less pain from the same stimulus. The possible learning here is that pain can be adjusted up and down deep inside the brain without any need for it to be imagined or unimagined.
Research like this further reveal the complexity of pain, beyond concepts like ‘am i imagining it’. In a sense this is pain heading in the reverse direction of imagined or exaggerated pain, as the subjects had every reason to feel the pain but there was less of it.
So Can Pain Be All In Your Head
Yes is most definitely the answer to this question, in fact if you want to get straight down to business all pain happens in ‘the head’ and not the body. As you will see though, all pain is real pain, whether it happens in the head (like phantom limb pain) or in the body (like back pain).
To really understand the true nature of pain once and for all it is first important to understand that our senses often betray us, especially when they interact with complex realities. If you have no concept of a bullet you will assume it is the sound and flash of the gun that kills, because the sound is all there seems to be. If I trusted my senses over what I know about physics I would have a very hard time understanding my smartphone. To grasp the idea that the music and pictures are actually being sucked out of thin air rather than generated from within the phone itself would have been too much of a stretch for our great great grandparents. It is afterall, highly counter-intuitive that a music video viewed on a phone screen is invisibly beamed into the phone from thin air. The true nature of pain is every bit as counter-intuitive to the casual obserever as smart phone data. Familiarity with scientific principles like ballistics and wave form data can however enable us to separate out the basic appearance of things from how they really are.
The physical message that we think of as a ‘pain signal‘, the part that actually happens in the sore foot with plantar fasciitis or a prickle is called ‘nociception’. Nociception is the raw information that comes in from the injured body. When it is processed in the brain nociception can give rise to all the flavours of burning, aching, stabbing, dull feelings, tightness and itching, just depending on what the brain does with it. ‘Pain’ is what happens deep in the brain when this nociceptive input is received, but not a moment before.
Nociception is like a radio signal and the brain functions like the radio receiver, there isn’t any sound until the circuitry of the radio responds to the signal and converts it into sound. Pain itself arises deep in the circuitry of the brain, music arises deep in the circuitry of the radio. The nociception itself is a lot like the radio waves when they are floating through the air outside the radio, completely silent and invisible. So the part of pain that happens in the body cannot be felt outside the brain.. hard to get your head around but nonetheless true.
The bottom line is that the experience of pain is always happening deep in the brain regardless of whether it is the phantom limb version or the scar tissue in the back pain, plantar fasciitis pain or sprained ankle version.
The raw information that arises in the body that we call nociception is not pain at all and cannot be felt in and of itself. There is however no question that the vast majority of pains are interpretation of very real and important information being sent from the body. Pain is in essence feedback about actual or potential damage to the bodies tissues. As with all the bodies functions things can go wrong, that’s pretty much what phantom limb pain is after all.
The deeper interpretation behind the ‘it’s all in your head’ statement is ‘you are imagining this problem’. As you may have gathered I am going on record here and saying that there us no such thing. Everyone who says they have pain has pain or they are lying, none of them are imagining it.
With deeper understanding it is possible to see that ‘its all in your head’ is an observation that does have some relationship with the truth of some pains. These pains are those that have their cause is more in the central nervous system than in the tissues of the body. As we have seen phantom limb pain is on the list of such pains. The most common causes of pain within the central nervous system however are emotional trauma and significant stress.
Pain, Stress & Trauma
Please forgive me if I am mistaken here but my interpretation of the ‘it’s all in your head’ concept is in some way an acknowledgement that we might have deep mental and emotional issues going on for us rather than a physical issue. ‘It’s all in your head’ is a statement that expresses a deep lack of understanding of the true nature of pain relating to ‘mind’, it does however flirt with the truth. And that truth is most often the truth of how trauma and stress can create very real pain with little or no help from the bodies physical processes.
Research indicates 40 to 60% of women and at least 20% of men with chronic pain have a history of abuse during childhood and/or during adulthood. This means that the incidence of abuse is two to four times higher than in the general population in chronic pain sufferers.
Patients with a more severe or frequent abuse history, usually during childhood have been found to often develop specific syndromes or combinations of pain syndromes. The term we use to describe the inner workings of this type of pain is Central Sensitization!
Central sensitization is the term we use for the changes deep within the brain and spinal cord that lead to the development and maintenance of the worst cases of chronic pain. Central sensitization is basically a process whereby the nervous system becomes over reactive to stimuli and up-regulates into a persistent state of hyper reactivity. In human terms what this means distressingly is that ‘everything’ hurts.
Central sensitization has two symptoms that are considered to distinct from one another. Both involve a heightened sensitivity to pain and touch. They are called allodynia and hyperalgesia.
Allodynia is the experience of pain triggered by things that are normally not painful, like being touched. The nervous system that has been exposed to trauma produces a sensation of pain and discomfort instead of normal sensations related to touch and pressure..
Hyperalgesia is a symptom that causes a stimulus that is typically painful to be perceived as being far more painful than normal. Basically, this means that things which cause mild pain and discomfort to register within a normally functioning nervous system are felt as extreme pain.
When we consider what an uncommonly sad and heart breaking impact these symptoms can have on a persons life and their relationships it does perhaps start to become clear how the myth of imagined pain comes about. If I love you very much and I try to give you a gentle hug and you recoil in pain there is clearly something very wrong, and of course for all I know you are imagining the whole thing. It is after all common knowledge that some people are hypochondriacs and imagine that they are extremely sick even when there are no physical changes or even symptoms in the body.
Even the individual experiencing the pain can be lead into doubting its reality. Life and health are hard enough to figure out for those without exposure to trauma and abuse, so with those ingredients in the mix it is all too easy to get in a pickle over whether your pain is actually real or not, even when it is felt as strongly as any other more ‘tissue based’ types of pain.
It is worth mentioning here that both hyperalgesia and allodynia can be the result of disease and injury states within the nervous system. I have deliberately set aside these far more rare medical causes so that we can focus on the far more common and far more misunderstood forms. It should go without saying that stubborn pain is always a reason to get checked out by a qualified health professional/professionals who can conduct the relevant tests required to exclude the possibility of diseases and injuries to the nervous system.
3 Types of Pain
Maybe it is useful for us to distill all this into a very simplistic but accurate understanding of the different ways that pain can manifest. After all, if we know what pain is we can be gain more clarity over what it is not.
Pain Generated Primarily By Activity in the Body
When you touch a hot stove a very strong nociceptive signal travels from your finger to the pain centres in your brain. On receiving the signal your brain translates this signal into an experience of pain in order to assist with the prompt removal of the finger from the source of heat damage.
While the pain associated with the hot stove undeniably arises in the brain it’s essential reason for being is the physical threat posed by the burning of the finger. In a manner of speaking this is a highly physically oriented type of pain.
Pain Generated ‘Equally’ By Activity in the Brain & Body
When you have an extremely weak core, and you have a great deal of stress in your workplace we know you have a potent recipe for acute back pain. If you have a major build up of scar tissue in the soles of you feet and you are in an abusive relationship you have a perfect recipe for plantar fasciitis.
These types of pain syndromes are a mixture of the more physically based type of pain where there is actual strain occurring in the tissues, and the type of centralised pain where the central nervous system is winding up into a pain generating state. These type of complaints more often than not represent the worst of both worlds. Thankfully though when the weakness and stress are milder so is the pain.
Particularly extreme cases of back pain, neck pain, shoulder pain, plantar fasciitis, hip pain knee pain and fibromyalgia are usually driven by histories of trauma and abuse, by severe ongoing stress or by both. Milder cases are generally at the more ‘body‘ end of the spectrum and relate predominantly to weakness and misalignments.
Pain Generated Primarily By Activity in the Brain
Some people lose a leg in a mining accident and find they still get aching in their toes every night 20 years later. They definitely qualify for pain that is generated within the brain. In these instances the pain pathway is activated and generates very real pain in the absence of any physical nociceptive input.
Some spend a significant portion of their childhood being mistreated but their carers; then as an adult find that even the lightest caress from their partner triggers pain. These people are also very deep into the brain activated pain spectrum. The presence of touch is required for the pain to trigger, but it is the traumatised brain that is the pains reason for being as opposed to anything more physical.
Perhaps what we are talking about here in one sense is a simple pain spectrum. At the one end we have those who are able to endure and disassociate from unimaginable pain stimuli. At the other end of the spectrum there are those of us who find that a light touch feels like it will bruise. In the middle we find the common man or woman with stubborn back pain or shoulder pain that is impacted both by stress and by physical weaknesses, and which sits somewhere in the middle of the pain sensitivity scale.
The happy news is that there is more than enough circumstantial and scientific evidence to support the belief that if we aren’t happy where we find ourselves we can move on. There are a broad spectrum of both established and proven ways to decrease ones physical pain and increase ones pain tolerance. From floatation tanks and chiropractors (for back pain) through to virtual reality and manfulness (for phantom pains). My closing thoughts here are ones of hope and encouragement. If you have had pain for a long time you may feel broken, if you are struggling to make sense or abuse and trauma you may feel broken… but you are not. Learning to 0ver come chronic pain is nearly always like getting fit, if you are willing to put in the work you can expect results. I intend to write a follow up to this blog with some comprehensive ‘how to’ style content..stay tuned.