Rethinking Pain
The way we understand pain has undergone significant transformation over recent decades. Historically seen purely as a biological response to injury or tissue damage, modern pain science now recognises the interplay between biological, psychological, and social factors. This blog explores how pain theory has evolved, informed by the work of key thinkers and researchers in the field.
Louis Gifford’s contribution to the field was pivotal in challenging the old biomedical model of pain. He advocated for a shift towards the biopsychosocial model, which considers how thoughts, emotions, and environmental factors influence pain perception. Gifford highlighted the roles of peripheral and central sensitisation, where pain can persist or intensify even in the absence of ongoing tissue damage. He emphasised that pain is a protective output of the nervous system and not necessarily a direct measure of harm. For Gifford, educating patients about the nature of pain was a powerful tool in reducing fear and improving outcomes.
Building on this foundation, Lorimer Moseley has made significant advances in demonstrating the neuroplastic nature of pain. Moseley argues that pain is constructed by the brain based on threat perception, meaning that what we believe and fear can influence how much pain we feel. His research showed that even after tissue healing, pain can persist due to maladaptive neural pathways. Moseley’s work supports using graded exposure therapy and education to recalibrate the nervous system and shift unhelpful beliefs about pain.
Expanding the scope of pain theory, Stilwell and Harman proposed the enactive approach to pain, which moves beyond even the biopsychosocial model. In this view, pain arises from the dynamic interaction of the person’s body, mind, and environment. Rather than separating the biological, psychological, and social components, the enactive approach sees them as inseparable and constantly influencing one another. Pain, in this model, is deeply embedded in the person’s life context, relationships, and identity. Treatment must therefore be equally nuanced and integrative.
From a psychological perspective, the Fear-Avoidance Model by Leeuw and colleagues offers insight into how chronic pain can become entrenched. According to this model, people who catastrophise their pain are more likely to avoid movement or activity due to fear of worsening their condition. This avoidance leads to deconditioning and further disability, reinforcing the cycle of pain. Addressing these fears through behavioural strategies and gradual re-engagement with activity is crucial in preventing long-term disability.
Further elaborating on the psychological dimension, Eccleston and Crombez introduced the idea that worry is a maladaptive attempt to solve the 'problem' of pain. Chronic pain sufferers may become hypervigilant, constantly scanning their bodies for signs of worsening symptoms. This excessive focus on bodily sensations can increase anxiety and depression, perpetuating pain. Interventions that foster acceptance, mindfulness, and better attentional control can help to break this cycle.
In summary, modern pain science reflects a deeper understanding that pain is not simply a signal from damaged tissue but a complex, subjective experience influenced by a multitude of factors. By recognising and addressing these dimensions, clinicians can offer more effective, compassionate care that resonates with the lived experience of those in pain.
References
Eccleston, C., & Crombez, G. (2007). Worry and chronic pain: A misdirected problem solving model. Pain, 132(3), 233–236. https://doi.org/10.1016/j.pain.2007.09.014
Gifford, L. (1998). Pain, the tissues and the nervous system: A conceptual model. Physiotherapy, 84(1), 27–36. https://doi.org/10.1016/S0031-9406(05)65884-X
Leeuw, M., Goossens, M. E. J. B., Linton, S. J., Crombez, G., Boersma, K., & Vlaeyen, J. W. S. (2007). The fear-avoidance model of musculoskeletal pain: Current state of scientific evidence. Journal of Behavioral Medicine, 30(1), 77–94. https://doi.org/10.1007/s10865-006-9085-0
Moseley, G. L. (2003). A pain neuromatrix approach to patients with chronic pain. Manual Therapy, 8(3), 130–140. https://doi.org/10.1016/S1356-689X(03)00051-1
Stilwell, P., & Harman, K. (2019). An enactive approach to pain: Beyond the biopsychosocial model. Phenomenology and the Cognitive Sciences, 18(4), 637–665. https://doi.org/10.1007/s11097-019-09624-7