Why is it that an ankle sprain rarely develops into chronic pain, while a similar tissue injury in your back often does? It’s not because the tissue in your back makes you more predisposed to pain, says clinical scientist Lorimer Moseley, PhD—it’s because of our complex biopsychosocial reality.
“The meaning of pain is a big determinant of pain itself,” says Moseley, whose research focuses on the role that the brain plays in processing and producing pain. “There are a lot of examples of that. For one, soccer players who score a goal and then their whole team jumps on top of them never hurt or develop chronic pain. But the same individual who had the same physical load put on them by strangers walking down the street is at high risk of developing chronic pain.”
Chronic pain can occur in any part of the body and is defined as pain that lasts twelve weeks or longer. It can come and go, with seemingly no rhyme or reason to where or why it hurts, which can interfere with daily life and be difficult to manage. Many people with chronic pain are underserved by medical practitioners who don’t have the resources or time to educate and provide long-term tools for healing, Moseley says. Understanding the complexity of your pain, he believes, is the key to combatting it.
A Q&A with Lorimer Moseley, PhD
Q What is the burden of chronic pain globally?
A It’s a massive issue: One in five people has some sort of persistent pain. And about half of those people have high-impact pain that reduces their quality of life. Persistent pain disorders are the most burdensome nonfatal health condition, as far as disability is concerned: Those with persistent pain are more likely to develop other conditions that can be fatal, like cancer, cardiovascular disease, stroke, clinical depression, and opioid-related problems.
Q What are some of the symptoms of chronic pain?
A There’s a lot of confusion in my field about what pain actually is. My perspective is that pain is the feeling that you get in your body. The feeling of pain is the symptom, but it comes along with a range of other problems that are also bodily feelings, such as stiffness and fatigue.
Then there are signs of chronic pain that provide evidence that the central nervous system and immune system are on what I call an overprotection setting. If you think about pain in terms of it being a protective feeling, then if you have pain, you are going to have other protective strategies happening, too. For example, your sympathetic nervous system may be on high alert, or your breathing might change. Chronic pain can also be associated with an overactive immune system. The motor system may also be affected in people with chronic pain, causing them to move differently or move less often. The classic example would be a person with back pain who might keep doing ordinary tasks but start to do them in a different way—for example, holding their back stiff. Changes such as these can come at a cost, because our body is best when it’s moving, not when we’re forcing it to hold still.
Q Biologically, why do people experience chronic pain?
A The answer to that question is way bigger than we currently know. But what we have learned in the past fifty years is that the pain system learns. The concept of neuroplasticity states that the central nervous system and the brain in particular are highly adaptable, so their structure and function can change with training and feedback. In fact, we talk a lot about the concept of bioplasticity, which is the same principle applied to all of our body systems—they become better at doing things with practice. We know that muscles get stronger with exercise. If you load bones with weight, they get stronger, too. Our body can even change ligament or a tendon tissue into bone tissue when necessary.
Our chronic pain system is also adaptable: The biology of persistent pain is really the biology of learning at a cellular and systemic level. The more your system produces pain, the better it gets at it, meaning your system can produce pain with less and less of a stimulus—which over time results in overprotection.
Q Who is most likely to develop chronic pain?
A There is a small genetic vulnerability to chronic pain. Age is not a large influencing factor.
The severity or mechanism of an injury is not a big determinant, either. There are rare exceptions to this: If you have a spinal cord injury or a limb amputation where all of the nerves that control your arm are no longer connected to your spinal cord, there is a high chance of your having pain afterward. A stroke in the middle of your thalamus in your brain also gives you a high chance of pain. Acute back pain is more likely to develop into chronic back pain than an acute ankle sprain is to develop into chronic ankle pain, even though the actual tissue injury might be very similar.
“The tissues in our body don’t exist in isolation. They exist within our body, within our social, cultural, spiritual, and cognitive life. And our brain takes all of that into consideration when it’s determining how vigorously to protect us.”
Those of us who are trying to understand these anatomical differences have realized that it’s not because the tissues in that part of your body make you more predisposed to pain. If you do have a bad back injury and you hurt your intervertebral disc, the actual injury that you’ve incurred is very similar to a mild ankle sprain. But a mild ankle sprain doesn’t often result in chronic ankle pain, while a similar tissue injury in your back gives you a decent chance of developing chronic back pain. The difference between those two things is not the anatomy or the physiology of the injury; it’s all of the other stuff that is processed by a biopsychosocial being.
What I mean by the biopsychosocial being is: The tissues in our body don’t exist in isolation. They exist within our body, within our social, cultural, spiritual, and cognitive life. And our brain takes all of that into consideration when it’s determining how vigorously to protect us. What determines whether some people recover or not, is that very complex, individually specific mix of factors from across all of those domains—genetics, the rest of your body systems, and in the psychological domain there are thoughts, beliefs, the social understanding of the problem, the sort of advice you receive, your relationships, your worldview, and your view of your body, as well as the community and society in which you live. The tough reality of persistent pain is that everything matters.
Q Can we reduce our pain through thought?
A Absolutely. We have good empirical evidence that there are a wide range of cognitive manipulation techniques that modulate pain. But this is not to say you can just “think pain better.” It is nowhere near that simple or easy.
In some of my lab’s experiments, we deliver a noxious stimulus that activates danger detectors in the tissue. Then we modify what the brain does with that detector according to information that we give the brain. For example, we might tell the brain that this is a dangerous situation–just by suggesting the stimulating device is dangerous or by suggesting the skin in that area is thinner than usual, which would cause the person to feel more pain.
Alternatively, we could give the person’s brain data to tell them that the situation is safe, for example, by suggesting the stimulating device is not actually dangerous or suggesting the skin in that area is particularly tough. Brain-activity recordings will show that the brain has different pain responses depending on the information it is given.
“One of the most powerful things we can do for people who have persistent pain is to give them a really good understanding of how complex their pain is because most people don’t think it’s complex—they think it’s a simple indicator of the state of their body. And it’s not. It never is.”
We’ve known for years that the meaning of pain is a big determinant of pain itself. There are a lot of examples of that. For one, soccer players who score a goal and then their whole team jumps on top of them never hurt or develop chronic pain from it. But the same individual who had the same physical load put on them walking down the street by strangers is at high risk of developing chronic pain. The pain that’s produced relates to the whole meaning of the data.
Things like mindfulness meditation influence the brain’s response to incoming data and can reduce pain. Stress reduction can also reduce pain, as can relaxation and other types of meditation. We also know that having education about the mechanisms of chronic pain reduces pain in the long term. One of the most powerful things we can do for people who have persistent pain is to give them a really good understanding of how complex their pain is because most people don’t think it’s complex—they think it’s a simple indicator of the state of their body. And it’s not. It never is.
Q What are the most effective treatments for chronic pain?
A Clinical guidelines, which detail how we should treat people with acute pain or persistent pain, state that the first thing any clinician or health professional should do is reassure and educate their patient about their protective pain system. The very best things that can be done for persistent pain are active interventions, such as mindfulness, learning about pain, walking, exercise, psychological therapies, medicinal plants and herbs, and self-management skills. Unfortunately, most people don’t receive those things. Most people receive outdated, low-value, and high-risk interventions, such as opioids.
Recovery is often not seen as an option for many people with persistent pain because they seek only passive interventions, which are things that are done to you or that you might do to yourself, like taking pills or getting massages. But the empirical data tells us very clearly that preventing and recovering from persistent pain is a journey in which you have to be informed and have some good advice. You have to do the work to recover. It’s a really hard message to hear because a lot of the people with persistent pain have been on a journey already.
We also know that health professionals have made a lot of mistakes in the last thirty or forty years in how we have gone about helping people in pain. The most obvious and largest mistake is the opioid crisis, where a range of factors, including ignorance and naivete, meant that millions of Americans were prescribed opioids when they shouldn’t have been. That same naivete lead to a lot of unnecessary surgeries and harmful treatment paradigms.
I would urge anyone in persistent pain to seek a clear understanding of their pain by going to reputable science-based sources. If a clinician recommends something, ask them, “What’s the evidence behind it?” That’s a really important question because there is a lot of money to be made treating people in pain due simply to the sheer number of patients. And there are some health professionals who can’t deal with the implications of pain’s true complexity, so they may be delivering treatments that give short-term relief but are not providing that patient with the resources they need to recover and master their situation.
Q Is it possible to recover from chronic pain?
A The science tells us that there’s a new sense of possibility with persistent pain. Recovery is back on the table. But there is no quick fix, and it won’t be achieved by someone else doing something to you. It will be achieved only by your understanding and training your pain system to be less protective and withstand more load over time. You have to be open-minded and courageous. You have to go and learn.