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Myths and Misconceptions about Explaining Pain

 •  • by Paul Ingraham
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Weekly nuggets of pain science news and insight, usually 100-300 words, with the occasional longer post. The blog is the “director’s commentary” on the core content of a library of major articles and books about common painful problems and popular treatments. See the blog archives or updates for the whole site.

Many moons ago I started trying to understand and explain pain, gradually producing an article: Pain is Weird.

I was only dimly aware as I worked that I was re-producing some much more mature ideas. I knew that modern pain science and treatment has deep roots, insights and research going back to the 1960s and Melzack, gate control theory and cognitive behavioural therapy, but my explaining was eerily similar to a recent and popular “packaging” of pain science known as Explain Pain (EP), from Drs. Lorimer Moseley and David Butler: “a range of educational interventions that aim to change one’s understanding of the biological processes that are thought to underpin pain as a mechanism to reduce pain itself” (Moseley). There’s a book of that name — Explain Pain — and many other interpretions and riffs on the key ideas (like my own). It’s not that I invented my own version of Explain Pain independently, I was just trying to explain pain, you know? Lowercase!

Explaining Pain according to Dr. Moseley is about “wanting people to actually understand how and why they can be in horrible pain yet not in horrible danger.” According to me, explaining pain (might) help to reduce it, and it’s inherently fascinating even if it doesn’t do a lick of good.

There have also been a lot of misunderstandings. Because explaining pain is tricky. (There are still plenty of unanswered scientific questions, too.) And because Explain Pain as a “brand” might be a little bit of an over-hyped upstart, maybe given too much credit by too many people too soon — especially the idea that it actually reduces pain, which remains highly speculative. Nevertheless, for the record, here are some key misconceptions about EP …

  • Explaining pain is not about managing or coping with pain. That’s another (important) kettle of fish.
  • It’s not just about chronic pain. Acute pain needs splainin’ too.
  • Explaining pain does not encourage people to move despite their pain — it’s just about teaching them that pain is often “overprotective.” Just because the brain worries too much doesn’t mean it’s wrong.
  • It’s not about the regulation of “pain messages” or “pain signals,” because there are no such things. It’s about the regulation of danger messages, and how only the brain can amplify or mute pain.
  • The point is not to reassure people that pain is “just” a perception and not real (ugh) — it’s about reassuring people that the danger implied by pain may be exaggerated.
  • Many people seem to think that Explain Pain ignores biology, biomedical, and structural factors in pain. Nope: the point of explaining pain is to explain the “it’s complicated” relationship between these things and pain. Tissue damage is real, and pain arising from it is real … but it’s complicated.
  • It’s not just about central sensitization (for which there is no known cure). Sensitization is an important sub-topic, but it’s important to explain unsensitized pain too. (The central message of explaining pain is that pain often exaggerates the danger that tissue is in. In central sensitization, the exaggeration is pathological and entrenched: danger signalling is consistently and severely exaggerated. But that’s an extroardinary situation. Pain is also routinely out of proportion to the danger even when there is absolutely no sensitization going on at all.) And the explain pain movement is actually rather optimistic (maybe even too optimistic) that learning the right things can actually change pain — even when it’s the product of sensitization.

But the mother of all misunderstandings is the popular idea that if pain is an output of the brain, then we must be able to think our way out of it. It’s such an important and difficult topic that most of the rest of the article is devoted to it.