Note: for the purposes of this discussion, when I use the phrase “physical injury”, I am generally referring to an injury for which the physical point of origin is not my brain. This is bad terminology, given that the brain is just as physical as the rest, but I haven’t yet been able to come up with a better shorthand.
My back pain became chronic about 10 years ago. I had occasional experiences with back pain before 2004, but none of it was ever the sort of all-the-time pain that I started experiencing after a particularly intense sparring test in kung fu that summer. I experienced what a few doctors would later refer to as a “spasm” of the muscles in my back, and, after the pain didn’t go away quickly, decided to take some time off from kung fu to heal.
I waited, and waited, and waited, but every time I experimented with practicing kung fu again, the pain got worse. Even when I wasn’t experimenting with kung fu, I was in pain. Eventually, I started seeing doctors to try to get some decent diagnosis and treatment for the injury.
One doctor said it was that my vertebrae and my sacrum were out of alignment, and I should do some PT and some exercises and wear an SI belt. That didn’t work. Another doctor said it was a muscle tension thing and recommended muscle relaxants and anti-inflammatories. That didn’t work, either. Another doctor said it was core weakness and I should do some strengthening exercises for my core. That didn’t work, either. Another said it was that my leg lengths were different, another said it was a muscle in an ongoing state of spasm, another that it was networks of muscle knots…
No matter how many different doctors I went to and treatments I tried, none of them ever seemed to consistently help.
After about seven years of trying different doctors and treatments, I started going to a physical therapist who was more up on chronic pain research than most of the others I had been to. He would talk amiably through our PT sessions, and one day in the course of conversation, he said something that completely changed my perspective. He told me that there was almost certainly nothing wrong in the tissues of my back; he told me that the pain I was experiencing was almost certainly not a response to a physical injury.
I hadn’t considered that possibility before, because I didn’t know that this sort of pain could happen without being a response to a physical injury. Up to that point I had been convinced, without even consciously being aware that I was making an assumption at all, that the pain I was experiencing had to be a result of a problem with the tissues in my back.
Physical pain begs for a physical explanation, and because of that I searched for a diagnosis and treatment for a problem with the tissues in my back for years longer than I should have.
The thing I needed to understand about pain is that it is an artificial construct, not a direct feed of information. Pain in your foot doesn’t happen because of tissue damage in your foot, it happens because tissue damage in your foot sends danger signals to your brain, and your brain decides, based on those signals and historical context, that pain is an appropriate response*. Danger signals from the tissues are neither necessary nor sufficient for pain – they are one piece of context out of many that your brain uses to make a decision about whether or not to create a pain experience. Your brain can get danger signals and decide not to cause pain, and it can also decide to create pain in the absence of any danger signals whatsoever.
Metaphorically speaking, there’s an artist in my brain who looks at all of the physical inputs from all over my body, and all of the historical context from my life, and paints a picture that becomes my conscious experience. My pain isn’t a photograph of the state of my tissues, it is an artistic rendering of the state of my tissues based on what the artist thinks is exciting or important. The same physical input will produce different sensations for me versus for anyone else, and for me now versus for me a year from now**, in much the same way you might expect different artists to paint the same scene with different styles and emphasis.
If I’m going to really take this metaphor all the way, then we could say that the problem with my body is that sometimes the artist gets drunk, and for some reason, when he’s drunk, he gets obsessed with my low back. The pictures he paints, and the pain I experience, do not correlate with what is actually going on in my tissues in any useful way whatsoever, they’re just a bunch of renderings of my lower back in violent red and orange.
For the last year or so of my life, my back pain has been better than at any other time in the last ten years, and I attribute that entirely to the fact that I learned these things about pain and have been able to apply them in useful ways. I may always have some difficulty with back pain, but for me, personally, no doctor or treatment has been as useful as learning about the process of how pain is produced.
My education about pain has enabled me to view my lived experience of pain through a skeptical lens. When I experience pain, I don’t assume that it is because of an injury. In the same way that a person with phantom limb pain isn’t going to worry that they’ve injured a phantom limb, I have learned not to worry that I have injured a part of myself when I experience “phantom pain” in a body part that just so happens to still exist.
In my day-to-day, this means that instead of responding to pain by not doing the thing that “caused” the pain, I respond to it by asking myself if it is likely that the pain is a response to actual damage, or a response to my brain making a mistake. If I think it’s the former, then I treat the pain like it’s an actual injury. If I think it’s the latter, then I use various strategies I’ve developed to accomplish the basic goal of telling my brain that it’s getting things wrong, and slowly increasing my exposure to the things that it mistakenly thinks are causing me damage.
In short, the single most useful tool for me, personally, in managing my chronic pain has been developing the ability to be skeptical of my experiences of pain***.
In the next post: the story of how I came to apply this same type of skepticism to my experiences with depression.
* In reality, the process is significantly more complicated than this — there are, for example, many different forms of modulation that can happen between the tissues and the brain — but I have made this simplified explanation as true to the actual process as I can without going into the less necessary fiddly details.
** Those of you who remember when you got your first cell phone may recall your first experiences with “phantom” cell phone vibrations. “Phantom” cell phone vibrations did not occur for any of us before we owned cell phones — not because our pant legs rubbed against our legs differently, but because our brains had not learned to interpret that type of input as possibly indicating the vibration of a cell phone. Same input, different context, different output.
*** I should note, here, that the strategies I use are not a cure for my chronic pain, but a major help, and that they are generally not easy or quick fixes, but take a lot of work, and that they will not, of course, work the same, or necessarily at all, for everyone. Not all chronic pain works like mine, not all of it stems from a purely neurological source. All pain does come from the brain, not the tissues, whether it’s phantom limb pain, actual limb pain, or pain resulting from the fact that you’ve just lost a limb, and as such I think education about these aspects of pain is probably always useful for chronic pain sufferers, but it will not always work as well as it has for me.