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Bio-psycho-social models of pain: Is pain all in my mind?

Developments within neuroscience have led to a greater appreciation of the importance of psychosocial factors and the impact of human cognition and behavior on pain perception. Pain has a useful physiological purpose; it serves as a protective mechanism helping us avoid behaviours that may cause injury and harm, enhancing our chances of survival.  But is pain only in the  mind?

Understanding of neurophysiology has shown that far from being a direct product of the sensory information (nociception) from tissues, pain is a ‘feeling’ generated by the mind in response to an elevation of perceived levels of ‘threat’.  ‘Sense of threat’ is not solely based on sensory information and is not necessarily proportional to tissue damage, but is influenced by a whole multitude of factors including conscious reasoning, past experience, context, environment, cultural background and so on.

There are times when pain is useful, for example when we touch something hot, or if we have injured ourselves, reflexive responses to pain prevent further damage.  In times of extreme danger, pain maybe counterproductive.  As such, pain levels are subconsciously elevated or reduced in lines with what is ‘biologically advantageous’.

Whilst pain often reflects levels of tissue damage in acute conditions (e.g. bone fractures, soft tissue sprains and strains), neuro-psychological factors seem to play a greater role in determining the pain experience in chronic conditions such as ongoing low back pain, when pain can be present even without tissue damage or in injury.  Does this mean that chronic pain is only in the mind?  Is pain imagined?

Whilst ‘pain is in the mind’, it does not mean that pain is imaginary or that we can wish it away.  It simply means that pain is a highly integrated psychosocial phenomenon.  Bio-psycho-social models of pain rehabilitation attempt to gain greater understanding of the psychological driving forces behind a person’s condition by understanding more about that person’s individual pain experience.  What caused their original injury, how does the person feel about that injury, what meaning does pain have for that person, what neurophysiological changes (e.g. hypersensitivity, altered sensation, loss of co-ordination) have occurred as a result of the initial injury and what characterizes the patient’s ongoing pain experience.

Practitioners using a bio-psycho-social approach have discovered that addressing some of the underlying assumptions a patient has about their condition can make dramatic changes in pain perception and function.  Research has demonstrated that simply by explaining to a patient how pain works and why pain manifests can rapidly reduce anxiety, pain and functional disability.  The key message is that pain is not always an indication of damage; rather that pain is a reflection of perceived threat, a threat that is often heightened by psychological stress, an individual’s conscious fear of re-injury and fear of movement.

Ironically pain can often be exacerbated by a patient’s experiences with clinicians who frequently highlight structural deficits, postural abnormalities and label people with a biomedical diagnosis, all of which heighten fears rather than address them.  Particular criticism is aimed at manual therapists who may highlight potentially catastrophic consequences if a patient does not subscribe to a long and intensive course of treatment at great personal cost.  Encouraging dependence on prolonged passive approaches that downplay rather than promote personal control and self-help should be discouraged.

It is important that all physical therapists account for bio-psycho-social factors in chronic pain.  Adapting how we communicate in order to reduce feelings of stress, fear and anxiety such as challenging unhelpful beliefs such as fear of movement and catastrophization, avoiding jargonized bio-medical diagnosis such as spinal scoliosis, spondylosis and osteoarthritis (pseudonyms’ for natural wear and tear that bears very little relationship with levels of pain or disability), avoiding unnecessary medical imaging the result of which are frequently unrelated to pain.  Practitioners should encourage return to normal activities as quickly as possible, encourage movement, promote self-reliance and active coping strategies and highlight areas of strength and improved function in ‘clients’ (not patients) as often as possible.

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