Reframe your pain

Arthritis Today|March/April 2020

Reframe your pain
You would have every right to be offended if someone said your pain was all in your head. But the truth is, pain is constructed entirely in the brain. This doesn’t mean your pain is any less real – it’s just that your brain literally creates what your body feels, and in cases of chronic pain, your brain helps perpetuate it.

A growing understanding of how this happens – and the need to find better alternatives to pain medications – has led to renewed interest in “biopsychosocial pain management.” This type of treatment addresses the particular situations, beliefs, expectations and emotions that cause a person to perceive pain in a certain way.

Unlike drugs, biopsychosocial methods don’t mask or numb chronic pain or falsely promise it will go away completely. Instead, people learn to manage pain by modifying or changing what their brain tells them. Many say this approach relieves pain without drugs – in some cases, it’s the first time they’ve gotten relief.

Why you hurt

Pain is a complicated warning system to protect you from harm. When you stub your toe, your peripheral nervous system sends signals to your brain, which then decides how much danger there is. If it decides the signals are worth paying attention to, the pain volume is cranked up until the problem is resolved; if not, pain is put on mute. This system works pretty well for acute pain, like an injured toe – but many things can go wrong.

For example, in chronic conditions like osteoarthritis (OA), where there’s no quick fix for, say, cartilage loss in the knee, the parts of the brain that send and receive danger signals become more sensitive over time. Scientists say the more the brain processes pain, the more perceptive it gets until it’s always on high alert looking for perceived dangers. And depending on a person’s emotions, beliefs and expectations, the brain will likely keep registering an aching knee day after day.

This is how people with chronic pain get locked in a self-perpetuating pain story. But there’s plenty of evidence to suggest that it’s possible to tone down an overly sensitive brain and change or moderate chronic pain messages. Here’s what science has found, and how it can work in real life.

For better or worse

Lauren Atlas, PhD, heads the section on affective neuroscience and pain at the National Institutes of Health. Much of her work has focused on placebo and nocebo effects. The placebo effect occurs when patients get better with a sham treatment because they believe it will help; placebos appear to work in some cases even when patients know they’re not real. A nocebo effect occurs when patients are told a harmless treatment will make them feel bad, and it does.

Both placebo and nocebo effects are seen as key factors in understanding how the brain works, especially with regard to pain, because they use the same mechanisms: context, beliefs, expectations and emotion.

Filling in the picture

Context is the setting where something happens – your doctor’s office, for example. Atlas says just stepping through the door activates beliefs and expectations you’ve developed through experience.

“If you have a history of beneficial treatment with a certain doctor, this might enhance your expectations for a positive outcome. Likewise, if you have a history of ineffective treatment, this might lead to negative expectations that worsen symptoms,” she explains.


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March/April 2020