Massage therapists work with a lot of people in pain. In fact, although many people come to get a massage in order to relax, the vast majority of clients I see specifically seek massage treatment for pain relief. It is worth understanding, then, what pain actually is. Let’s consider this definition of pain from the International Association for the Study of Pain (IASP). They define pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”
This definition is broad and invites further exploration to begin to unpack it. Understanding how pain works is empowering. It has changed the way I practice massage, and it has changed the way I interact with painful experiences personally. By sharing the basics of pain, my intention is that you too can begin to relate to pain differently in your life. The more you understand pain, the less of it you feel!
Pain doesn’t equal tissue damage
The most common myth about pain is that it is always the direct result of tissue damage. This makes us reflexively fear pain instead of getting curious about the message it has for us.
Pain as tissue damage may be most accurate in the event of an acute injury, for example when you cut or burn yourself cooking. This is what people normally think of when they think of pain: tissue damage occurs, you feel pain according to what happened, and then the injury feels better as it heals.
Other times pain results from overuse or misuse of a part of your body gradually over time. This may be from a repetitive wearing down or from what I think of as “last straw” injuries, like when your back suddenly spasms doing nothing in particular. Even not moving enough can cause pain. These situations are more likely to be persistent since they are related to habitual overuse, misuse or underuse of your body. This type of pain may be less clear than an acute one time event, but often with informed professional support, people put the pieces together and listen to what their body needs: more rest, more or different movement, or a shift in habitual patterns. I commonly support this kind of awareness with my clients.
But sometimes you don’t feel pain with tissue damage. Sometimes you get a minor injury and there is no pain. For example, you may notice a bruise or scrape on your body but can’t remember the injury happening. Or what about when you have a serious injury in the midst of an intense situation such as a violent incident, a car accident, or a high performance athletic event, and don’t feel any pain at all until hours later? In the first case your brain may assume that you aren’t in enough danger to register the injury, and in the second that situation is so intense that your survival depends on not feeling the pain to make it through and out of there.
And why do people sometimes experience chronic pain in the absence of any identifiable tissue damage? In these cases, there may have been an initial injury where the tissues have had time to heal but the pain is still present. Or perhaps there isn’t any clear physical cause for the pain, yet the pain persists. It is always important to rule out any more serious issues during a thorough examination and testing with a licensed medical doctor. However, once pain cannot be linked to a clear cause it can remain unaddressed, and people can easily get stuck without guidance and support. You may even be invalidated or not believed (unfortunately more common for women, black people, and other oppressed groups), given pills to help manage the pain without support to discover and address root causes, or left to just deal with it on your own. Just because someone can’t solve your pain does NOT mean it isn’t real, valid, or “all in your head.” Pain is real, even if the causes aren’t yet clear to you or those who you go to for help.
I will discuss more about chronic pain in my next blog post, including how physical pain itself can become habitual or manifest from other circumstances. Today, I will share tips that can change your experience of pain no matter the flavor. For now, how do we explain all these disparate experiences of pain listed above? And if pain often doesn’t correlate with tissue damage, why not? Remember in the definition above that pain can also be associated with potential tissue damage or even experiences that resemble tissue damage? The pain you feel is real, and the brain plays an important role.
“Pain is an output of the brain”
What we experience as pain is actually the end result of a complex automatic and subconscious process designed to keep us safe. Pain is not the injury or tissue damage itself, it is the way your brain decides what the messages it gets from your body’s pain receptors mean, and what needs to be done about it. This happens faster than we can decide consciously how to feel. “Pain is an output of the brain designed to protect you, it is not something that comes from the tissues from your body” -Lorimer Mosely, pain researcher.
Remember in the above definition, how pain is a sensory AND emotional experience? The way you react to pain has a lot to do with your past experiences and your current environment. First, signals from your body from nerve receptors in and around the (potentially) damaged tissue, called nociceptors, send signals to the central nervous system, which includes the spinal cord and the brain. In the brain the signals are filtered through your brain’s interpretation of your current internal and external environment. Faster than you can think, it evaluates the information from the nociceptors in light of how safe you are in the moment as well as past relevant experiences. Your brain then decides the quality and intensity of the pain to produce based on all these factors, and only then do you even feel the pain.
Pain researcher quoted above Lorimer Mosely has an amazing Tedx talk from 2011 that illustrates these points quite clearly. There’s a remarkable personal story at the beginning of this video, which blends this science with a humorous retelling, and I highly recommend taking the 14 minutes to watch the whole video. The rest of the video shares fascinating experiments proving how pain is malleable.
I’ll give two scenarios as an example of how this works in a common way.
Scenario A You seriously injure your back. The doctor says it is a disc issue, and you can barely get out of bed. The pain is intense and completely upends your life. You get support, learn a lot, and slowly your back feels better. Five years later, at the end of a long stressful day at work when you are trying to get your fussy toddler into the car in a busy parking lot, you tweak your back. The pain receptors in your back get pinched and pulled a little. They send a message through your spinal cord to your brain. Your brain scans your body and notices that you’re under a lot of stress, your brain scans your environment and notices that you are in a parking lot with an unpredictable toddler and unpredictable drivers, and then your brain scans your history of back pain and remembers how awful that back injury was five years ago. This all happens before you can blink, and you suddenly notice a lot of pain in your back and are overcome by intense worry that you completely screwed up your back, again.
Scenario B You are helping your happy toddler get into the car at home to go on vacation, and you tweak your back. The pain receptors in your back get pinched and pulled a little. They send a message through your spinal cord to your brain. Your brain scans your body and notices you feel relaxed and excited about the upcoming trip, your brain scans your environment and notices you are in your familiar driveway far from any traffic, and then your brain evaluates your history of back pain and nothing stands out. You will notice a pinch and pull and stop to address it. You feel the urge to stretch it out a bit and lay on the ground, you get some ice and a pillow to support your back in the car, and then you move on with your day.
In scenarios A and B you tweak your back with the same movement causing the exact same amount of tissue damage, but your experience of pain differs wildly. Then, based on your present and past circumstances your conscious mind will also differ in how it relates to the pain. This includes the stories, ideas, and conclusions about what the pain means, the emotions you feel experiencing it, as well as what you choose to do about the pain signals. In scenario A, it would be easier for anyone to fall into catastrophic thinking based on the past. Luckily, this is where you get a say in the matter!
Remember, since the definition of pain also mentions that pain is an unpleasant experience, it is very valid, common, and natural to want to end the pain as quickly as possible. Your reactions and responses are all contextual and make sense. However, if we don’t move beyond trying to get away from the pain or fixing it right away, we can easily miss the important messages our body and our experience of pain has for us. Within these messages lies information you need that will support you through the pain and towards resolution. I am continually amazed by the way pain that seems intractable can in reality be highly malleable, and I see this regularly both in myself and in my clients.
Relating to pain differently can significantly diminish or even get rid of pain
This is all good news, because just understanding the basics of how pain functions alone can diminish the intensity of the pain you are experiencing! Then, you can consciously choose to shift your relationship with your experience of pain, and get clear information from your body that will support you in taking the empowered actions most likely to mitigate the pain.
If you are in pain right now, or next time you notice pain, you have the opportunity to use these pain basics to make a difference in your experience. Instead of replaying habitual and deeply understandable reactions to the pain, you now have new choices.
First, validate that you want the pain to stop through avoidance, distraction, numbing, or denial. It is understandable, very human, and even necessary for survival under certain circumstances. Validate it if you feel angry, scared, hopeless, worried, or sad. Pain is no fun, and your thoughts and feelings make sense. It is especially important to validate yourself in complex, traumatic, intense, invisible and long lasting experiences of pain.
Here are some steps to consider in relating to physical pain differently when you are safe and willing enough to do so. This is not a set protocol, rather it provides a framework for you to explore and consider when you are in pain.
- First, notice what you need right now and meet those needs. Care for an acute injury yourself, get emergency care, or engage in routine coping strategies for chronic pain.
- Now that you’ve met any pressing needs, if you still notice that you are very worried, overwhelmed, hopeless, or shut down, or if the pain is so intense it is absorbing all of your awareness, you must first support your whole body to come back into balance. You cannot follow the next steps and be curious about the pain if you are not in a somewhat regulated state. Offer yourself anything that will resource you to de-stress and feel more like yourself. Some things I do are: eat a nourishing meal, drink water or tea, spend time in nature, get in the sun, take a warm bath or shower, use heat or ice, use herbs or medication, spend time with a loved one or pet, rest, enjoy non painful movement, do something I love, enjoy music or art, or go see a healing provider who helps me feel safe supported and nurtured. Anything you can think of that supports you in moving your whole system back towards balance and taking the edge off is key.
- Remind yourself that no matter how unpleasant or all consuming, pain is a safety and survival mechanism. Your nervous system only produces pain in order to protect you, keep you out of harm’s way, and keep you alive, and it’s doing the best it can with the information you’ve got. Now that you have new information, you can remind yourself that pain doesn’t necessarily equal tissue damage. Remind yourself that pain is a complex, automatic, and subconscious communication and sense making process. Tell yourself that your brain uses information from the pain receptors in the tissues of your body (which send signals in the case of both actual and potential tissue damage), and then interprets these signals through the context of your environment and your history of experience. Know that the pain you feel is determined by the way your brain packages and outputs the information. Remind yourself that this moment is new no matter the past you’ve endured and survived.
- With this in mind, it is time to get curious about your pain. Pain is an unpleasant sensation that may be more or less intense. Ask yourself lots of questions such as these or any others you can think of. When does it hurt? Is it with certain movements? At certain times of day? In certain positions? What helps? What makes it worse? How intense is it? Does the intensity change or stay the same? How would you describe the sensation? Getting into the nuance of the sensation can actually provide a ton of information. Does it have a clear location? Is it more diffuse? Or does it seem to start from somewhere and then radiate elsewhere? What about the quality of the sensation? Is it: dull, achy, bruisey, sharp, pinchy, icy, hot, shooting, stabbing, burning, throbbing, constricting, or cramping? Is there tingling or numbness? Does it feel or look inflamed? What does this inquiry tell you that you didn’t notice or realize before about the pain you’re experiencing?
- Notice how you are reacting to the pain. Is there protective muscle guarding? Are you holding stiff in a certain position? Are you holding your breath? What are the emotions associated with the pain? What are the thoughts in your head about the pain? Do you know if the stories, thoughts, or worries are true? What steps can you take to choose your responses in your body, breath, and mind to ease your experience of pain? There may be things you feel ready to change, and things you still need to do to cope, let yourself be honest about what reactions are still necessary and which are not.
- Based on your exploration of the pain, ask yourself what is it telling you? What have you realized or learned? Are there some simple shifts you can make in the ways you work, play, move, or sleep? Does your body have needs you’ve been overriding or ignoring that you can meet? Is there anything you can change in your internal or external environment that will give your system more cues of safety so your brain can downshift the pain or no longer create a painful output? What self talk can you engage in to help your brain differentiate from past pain and current pain? The inquiries above may have given you all that you need to take care of the pain by yourself or with help from a friend or family member, and in this case, time to celebrate! And if not….
- Get professional support. A professional can work together with you to interpret your pain signals to explore possible causes and solutions. After you’ve ruled out anything medically serious, manual and movement therapists such as therapeutic massage therapists, PTs, chiropractors, osteopaths, acupuncturists, and personal trainers often have experience and information to help you decode the information your pain is transmitting in order to ease or resolve pain. For example, describing the quality of your pain can help a professional pinpoint what type of tissues may be involved such as muscle, nerve, or joint. Describing when it does and doesn’t hurt can help guide exploration of common issues and injuries that cause similar pain patterns in many people. Describing what helps and what exacerbates the pain can help identify habit patterns and other body parts that may be connected to the pain. All this information guides effective treatment. Remember, you are always the expert on your body and your life context, and have often already intuitively discovered things that help. The professional has the knowledge about the anatomy, body systems, common pain and injury patterns, and healing process, all combined with hands-on experience. They can partner with you to find relief. Trust yourself and your experience and work with a provider who you trust too.
Thank you so much for reading! May this serve you now and in the future. In my next blog, I will speak more about chronic pain, and how pain itself can become habitual. I offer more recommendations for how to interrupt cycles of pain to find more relief.