Making sense of pain

Author: Sarah Walsh

It is really scary when pain doesn’t make sense, when it is not follow the pattern we expect or have experienced in the past. Often patients report that it stabs when they are resting, or it is less when they are laughing some days but then worse other days. It makes it hard to have certainty as to how the day will go.  

When pain continues, in a sporadic and unpredictable way it poses threat to many domains of our functioning. This may include our capacity to work, to run around with our kids or to engage in hobbies we love.  

When things don’t make sense, we find that certain behaviours reduce the threatening sensation (in this case pain). The behaviours that reduce the threat are more strongly reinforced. Although we are aware of our change in behaviour to some degree, this is often not a conscious process, just like you don’t think about chewing on the other side of your mouth when you have a tooth ache.  

In the case of pain, the behaviour that reduces is generally movement, which results in moving less and doing less.   

Recent research has found that helping patients to “make sense” of their lower back pain was linked with improved perceived control over pain and/or their response to pain. Pain control appeared to increase though learning alternative movement strategies and adjusting attention from the threat of pain towards valued goals. The study focused on two pathways to reducing fear.  

  1. Reducing fear by decreasing the threat of pain
  2. Reducing fear by changing emotional responses to pain  

The first pathway involves creating an alternate explanation of the cause of lower back pain that is less threatening and helps to promote more flexible problem-solving cognitions and behaviour. This suggests that the goal when working with this population is to understand pre-existing beliefs, then assist them to make sense of their pain and start to feel safe to gradually do things that may initially cause them pain or some level of distress, rather than doing anything they can to avoid feeling pain. 

This process involves communicating diagnostic certainty that can explain unpredictable symptoms, that replaces erroneous beliefs about the relationship between pain and danger/damage, and prescribes strategies for controlling or resolve the symptoms.  

This is delicate work, being told that your beliefs are impacting your pain recovery can be incredibly confronting, threatening even. Why should we be trusted ? I often encourage my patients to be skeptical, but to try the techniques and prove me wrong! As practitioners working with pain patients, it is an important for us to strive to create an environment of trust and therapeutic safety. Therapeutic rapport is a key component of pain education, and demonstrating empathy is crucial! It has been said that when working with pain we have to build rapport to be able to burn it down.  

The second pathway involved addressing emotional responses to pain, namely fear. It was found that when the consequence of activity was perceived as controllable enough to engage in it, then the behavioural strategy is considered effective. This involves providing individualised active strategies and psychological techniques that cultivate a sense of mastery in our patients. Helping patients to develop a new conceptualisation of their pain and providing them with graduated exposure techniques that gently desensitise the fear response gets them doing more, doing things differently and feeling more confident.  

In summary, the use of this cognitive model within treatment of persistent pain involves developing an understanding of patients current beliefs, clarifying how any misconceptions may have been formed, identify how these cognitions are impacting behaviour (e.g. guarding, protecting, avoiding), presenting new information and an alternative diagnosis that helps to explain their pain experience and fills in misconceptions may assist with reducing patient’s fear response.  

Helping to shed a new light on this confusing, ongoing and unpleasant physical sensation has been shown to decrease the threat and fear response and helps them start their active journey to recovery.   

For more information please read:  

Bunzli et al., 2017 Making Sense of Low Back Pain and Pain-Related Fear. Journal of Orthopaedic & Sports Physical Therapy.