Pain Explained: Understanding & Managing Chronic Pain

1. Understand the Science of Pain

   • Clearly explain how pain signals are created, processed, and interpreted by the body, including the difference between acute and chronic pain.

2. Identify Common Pain Conditions

   • Recognise and differentiate between common chronic pain conditions (e.g., back pain and arthritis), understanding their symptoms, causes, and management strategies.

3. Implement Effective Pain Management Techniques

   • Apply a variety of pain management strategies, including exercises, lifestyle adjustments, and mindfulness techniques, to manage chronic pain more effectively in daily life.

4. Enhance Daily Functioning with Pain

   • Integrate pain management principles into daily routines to improve mobility, reduce discomfort, and enhance overall quality of life despite chronic pain.

MODULE 1

INTRODUCTION TO PAIN SCIENCE

WELCOME

Hello, and welcome to Pain Explained. I’m so glad you're here, taking the first step toward understanding and overcoming persistent pain. But before going on to explain any details about pain, I want to make one thing perfectly clear. I am not a researcher of the information I am sharing. I am not advocating that this information is of my discovery. I am simply sharing. I am an entertainer. That is to say, in the same sense that when you go to a concert and you listen to someone play Mozart they have nothing to sell except the sound of the music – they are not attempting to portray that this is their music. I approach you in the same spirit. I simply with for you to enjoy this information, this POV which I see people change their lives with everyday. Now then, having said that…

Congratulations on beginning your journey to resetting your pain system. I am honoured you have invited me into your life, and I am excited to support you during this journey of personal vulnerability. You might be dealing with pain right now that feels like it’s never going away, but I’m here to tell you that your brain has the power to change, and that change can help you reset your pain. Most of us think of pain as a direct result of an injury, but what if I told you that pain is not always what it seems? In this tutorial, we’ll explore how your brain influences pain and learn practical strategies to reset your pain response and regain control of your life. We’re going to explore how pain is generated and unpack how understanding pain can drastically improve our ability to manage it. Specifically, we’ll be guided by the research-based insights of David Butler and Lorimer Moseley, two leaders in the field of pain science, and explore their revolutionary approach to explaining pain.

WHAT IS PAIN?

Let’s start by addressing a fundamental question: What is pain? Pain is one of the most basic and universal human experiences, but it’s also one of the most misunderstood. Pain is a complex experience that involves not only physical injury but also how our brain and nervous system interpret and process that information. We think of pain as something just physical, something that happens because of damage to our body. 'My back hurts because I have a slipped disc' or 'My knee aches because of arthritis.' But the truth is pain is much more complicated than that - is not something that happens just in the body. It involves your brain, your nervous system, your thoughts, and your emotions. Pain doesn’t always correlate directly with tissue damage —it's a brain-based experience. Your brain – think of it as your own personal control centre – is constantly processing signal (or information) received from your body, making decisions about what’s safe and what’s not. And one of its most important jobs for you brain is deciding whether or not to create pain. You see your brain doesn't just react to those signals…. It interprets them, based on everything it knows from your past experiences, your emotional state, your belief systems and even your current environment. Pain is an output of the brain, not an input from the body.

WHY IS PAIN NOT ALWAYS AN INDICATOR OF HARM?

So a common thought might be: ‘But if I’m feeling pain, doesn’t that mean something is wrong with my body?’ The answer - Not necessarily. Sure, we have all learnt the lessons from acute temporary pain that goes away once the injury heals. For example, if you cut your finger, your brain will register that injury and produce pain as a protective mechanism.

Chronic pain is complex, it's persistent – lasting longer than expected, and often there’s no obvious injury at all. But it’s not permanent. persistent pain is not caused by ongoing injury, but by the brain continuing to signal pain even after the body has healed. Remember, Pain is an output from the brain, not an input from the body. Your brain – acting as a pain conductor – is receiving and processing all this information from your body, then decides if there’s a need to create pain. And it’s not just a simple 'injury = pain' formula. Sometimes, the pain we feel doesn’t match the extent of the injury or tissue damage. In fact, research has shown that persistent pain can exist even without any tissue damage at all. This is the fascinating and frustrating thing about persistent pain – there’s not always a clear-cut sign of injury; without your consent your brain is "learning" pain and becoming more sensitive to it, even in the absence of injury. And the tricky part is that persistent pain doesn't just feel bad—it can change the way the brain functions. Your brain can even rewire itself to become more sensitive to pain over time.

Now, this doesn’t mean that pain isn’t real. Far from it – Pain a very real experience. But pain doesn’t always mean you have tissue damage, and the amount of pain you feel doesn’t always correlate with the extent of injury. Let’s take a common scenario: You’ve been out in the sun for a bit too long, and you’ve got sunburnt. Now, you’re trying to take a shower, but as soon as the warm water touches your skin, it feels incredibly painful - even though it’s just warm water. And here is where the fascinating pain science research is revelling breakthrough concepts – Your skin might be mildly burnt, but the pain you feel from that warm shower is more than just the sunburn itself. Because you are sunburnt, your brain has become hypersensitive to any kind of sensation in that area. Even a small touch or heat stimulus feels intensely painful. Your brain has learned to amplify the sensitivity as part of its protective response. It’s trying to protect you by increasing the sensitivity to heat or touch, which is why something as mild as warm water feels like a sharp, unbearable pain. This phenomenon is known as neuroplasticity.

MODULE 2

THE NEUROLOGICAL BASIS OF PAIN

NEUROPLASTICITY - The Brain’s Ability to Change

Consider the countless examples of people who have severe injuries and don’t feel pain, like athletes who don’t feel pain until after a game, or soldiers who don’t notice wounds during combat because their brains are so focused on other things. This all confirms that if your brain can learn to create pain, it can also learn to unlearn it. Think of it like this: Your brain is like a muscle. When you repeat an action, your brain strengthens the pathways associated with that action. In the case of pain, your brain may have learned to strengthen the pathways that keep pain signals active. And just like any muscle, you can change it through practice.

There is an infamous story of a man who suffered a snakebite which brilliantly illustrates pain science in the brain– let me share it with you as an effective tool to help understand how the brain processes pain in a way that goes beyond simple injury or damage. In this story, a man was bitten by a venomous snake - something that would usually cause immediate and excruciating pain, yet he didn’t feel any pain it at all. The reason for this is that the man’s brain was in a state of high stress and adrenaline (our primitive fight or flight response) - his brain was processing other intense stimuli like survival and had blocked out the pain of the snake bite. His brain was so focused on the immediate need to survive that it temporarily suppressed the pain signals from the bite. Now, here’s where the story takes a fascinating turn. The man survived to tell the tale but when he was next out walking, a stick brushed against his body. The moment that stick touched his skin, he immediately collapsed to the ground in extreme pain. Why? The brain was no longer in fight-or-flight mode, and it became more sensitive to stimuli that previously had been ignored. The stick—something completely harmless—triggered an intense pain response. His brain, now aware of his vulnerability and the damage to his body, interpreted that touch as a threat and amplified the pain sensation. The feeling of the stick, which would have been a minor, almost insignificant sensation under normal circumstances, was now perceived as extremely painful because his brain was focusing on the previous experience. One of the most important concepts in this story, which has been the backbone to Butler and Moseley’s Explain Pain research emphasizes that pain is not always an indicator of harm. Just because you feel pain doesn’t necessarily mean you’re injured. And just because you don’t feel pain doesn’t mean you’re not injured.

This re-wiring of the brain is called “Neuroplasticity” - and refers to the brain's ability to change and adapt over time. It’s a good thing in most situations, as it helps us learn new skills and recover from injuries. But, when it comes to pain, neuroplasticity can also have a downside. When pain becomes persistent, the neural pathways involved in pain processing have become overactive, over sensitise. Essentially, the brain becomes more sensitive to sensory input, so it starts to react more intensely - even to harmless sensations. In Pain science language this is known as “central sensitization”.

CENTRAL SENSITISATION – The Overactive Alarm System

Think of your brain as a security system, and your body as a building. When your brain detects a potential threat—whether it’s a physical injury, emotional stress, or even an imagined danger—it triggers an alarm: pain. The louder the alarm, the more your brain believes that there’s a real threat to your safety. This is a protective mechanism, designed to keep you safe. But what happens when that alarm goes off even when there’s no danger? An overactive alarm system, or “central sensitisation”, happens when the brain becomes too sensitive to these pain signals. The cycle continues as the brain, now in a constant state of alarm, keeps creating pain, your alarm system becoming more and more sensitive over time - even when there’s no physical reason for it. This can make pain feel like it’s completely out of your control.

As a Physiotherapist the most common example I can share is an almost daily encounter with a patients experiencing persistent back pain even though their back is structurally healthy. In these cases, their brain has learned to amplify the pain response, even though there is no physical damage. This can happen after an injury that doesn’t fully heal, or after prolonged stress or emotional factors. Their sensitised brain is on high alert, amplifying pain signals even when there’s no actual injury or ongoing tissue damage. Their brain has learned to interpret normal sensations—like bending over, walking, or lifting—as potential threats, triggering pain responses even when there’s no immediate harm.

Imagine you hurt your lower back. Initially, it might have been a muscle strain. But over time, if you continue to worry about the pain, avoid activities, or become anxious every time you move, your brain starts to form a pattern of pain expectation. Every time you think about that movement, or every time you feel tension in your back, your brain might send out a pain signal, even if there’s no physical damage. This is where the pain loop starts: Your brain expects pain, and then it creates it. It’s almost like a feedback loop, where the brain is stuck in a cycle of creating pain, even after the injury has healed. But remember, neuroplasticity allows for change.

THE BODY MAP – Mind Body Connection: How the Brain “Maps” the Body

Another key idea from Moseley and Butler’s work is the body map, or body schema. The brain doesn’t just process pain in a localized way—it actually creates a mental map of your entire body. This map helps us move and interact with the world. It tells us where we are in space, what parts of the body we’re using, and, crucially, where there might be danger.

Lets discuss the example of phantom limb pain to reinforce the core idea that pain is not simply a direct result of injury. Working as a Physiotherapist in the rehabilitation setting, I often encounter patients suffering the interminable phenomenon of pain in an amputated limb, that is to say they experience genuine distressing pain in the area where their limb used to be. So, why does this happen? There is no tissue in the right foot to be injured anymore, yet the person experiences very real pain in a limb that no longer exists. The brain still “feels” that right hand, even though it’s physically gone. Phantom limb pain often improves or even resolves once the brain gets the message that the limb is gone and begins to reorganize itself.

But here’s the interesting part: This map isn’t fixed. It can change based on experience. When someone experiences persistent pain in a particular part of the body—say, in the lower back—the brain may start to treat that area as more sensitive, as though it’s a threat. This can create a distorted body map, which makes even normal sensations feel painful. For example, Moseley conducted a study where patients with persistent pain showed changes in the representation of their body in the brain. Areas of the body with persistent pain appeared smaller, more “compressed” in the brain’s body map. This is a direct reflection of the brain’s altered perception of those areas.

This is why two people can have the same injury, and one might experience pain and the other might not. So, what we’re learning is that persistent pain can actually re-map the way the brain perceives the body. Understanding that your pain is a complex brain-generated experience in which you can reset and reprogram with the right strategies, we can start to rebuild or 'retrain' that body map.

MODULE 3

RESETTING YOUR RELATIONSHIP WITH PAIN

UNDERSTANDING PAIN AS A WARNING SYSTEM

Hopefully by now you are beginning to understand that you pain is a protective alarm system – and not a life sentence. When your alarm system is ramped up, or you are centrally sensitised, your nervous system is overly responsive to stimuli – and your brain is treating normal sensations as threatening. Let return to our ‘Snake and Stick’ man; his response to the stick is a similar process which occurs during persistent pain. The normal, non-threatening, sensation of the stick touching the man’s body after the snake bite, triggered an intense pain. His brain, in this case, learned to be hyper-sensitive, and those pathways become stronger and more ingrained over time.

Take a moment to consider your alarm system – has your brain learned that certain movements, postures, or sensations are dangerous? Just as there are many ways to manage a car alarm - by calming it down, resetting it, and understanding why it went off – we have various tools to manage pain alarms.

REWIREING THE BRAIN

The key to overcoming persistance pain lies in "resetting" the brain’s perception of pain. Evidence based Pain Science reveals that we can rewire the brain to respond differently to pain through various strategies, including; mindfulness, relaxation, and graded exposure to movement. So, while persistent pain may seem like something that’s out of your control, with these strategies, you can begin to change the way your brain processes pain.

1. Education and Awareness

Persistent pain often becomes a cycle that feeds itself – and while breaking this cycle can seem daunting, you are already taking the first step – education and awareness. I can’t stress how important it is to understand that it’s not about ignoring the pain, but about changing how your brain interprets and reacts to pain. The goal is not to pretend the pain doesn’t exist, but to teach your brain a new, healthier way of processing those pain signals. Respecting that the more pain we feel, the more our brain learns to keep the pain going, even when the initial injury has healed. This cycle of hypervigilance and pain amplification can make it difficult to break free – understanding that pain is not always linked to damage, but rather to the brain’s interpretation of danger, can help you feel more in control. Just knowing that pain is not always a sign of harm can be incredibly powerful.

2. Mindfulness and Relaxation Techniques

Next tool you need is a strategy to calm your brain and reduce its sensitivity - mindfulness and relaxation techniques help our brain disengage from the pain response, teaching the brain to stay calm and focused, rather than reacting to every sensation with pain. This involves breathing exercises, meditation, and becoming more aware of the thoughts and feelings and beliefs that are influencing your pain.

Let’s do a quick exercise now. Close your eyes and take a deep breath. Inhale for a count of 4… hold for 4… and exhale for 6. Feel your body relax with each breath. This simple act of deep breathing tells your brain that it’s safe, and helps switch off the pain alarm system. Never underestimate the power of four slow deep breaths.

3. Graded Exposure

Graded exposure to movement involves gradually reintroducing physical activity in a way that doesn’t overwhelm—to desensitize the brain to pain. Gradually reintroducing feared activities or movements can help "teach" the brain that they are not dangerous. If you’re afraid to move or engage in certain activities because of pain, take small, manageable steps to gradually desensitize your brain. Over time, you can rebuild your confidence and tolerance to movement, as the brain learns that movement isn’t threatening, it begins to reduce the pain response.

Let’s return to our sunburnt analogy – if you’re avoiding hot showers because your skin is too sensitive, over time the more you avoid heat, the more your brain amplifies the sensitivity to heat. But if you start to gradually reintroduce warm showers, your brain will begin to reset that sensitivity. The same concept applies to persistent pain. Small, gradual exposure can help retrain your brain.

SELF EMPOWERMENT

Recognizing that pain is often influenced by how the brain interprets signals rather than just the physical state of the body, we can begin to feel empowered to take active steps toward reducing pain and improving quality of life.

I like to teach my patients visualization techniques. Picture yourself moving without pain, engaging in activities you love. Imagine your brain rewiring itself and sending out signals of comfort, rather than pain. Let’s say you’re dealing with knee pain. Instead of just thinking about your knee as an injured area, start to visualize it as strong and capable. The more you visualize it working well, the more your brain will start to believe it.

MODULE 4

BEHAVIOURAL STRATEGIES FOR MANAGEING PAIN

Now that we’ve talked about some of the ways to retrain your brain, let’s focus on daily practices you can incorporate into your routine to help reset the pain system.

MOVEMENT AND EXERCISE

Contrary to the common belief that resting with pain will help, research has shown that graded movement (when done properly) helps retrain the brain and reduce pain sensitivity. This can include stretching, strengthening, and even gentle aerobic exercise. Movement is essential for resetting your pain system. Even if you start small, gentle movements, you’re teaching your brain that movement does not have to result in pain.

In 2008, The Journal of Pain published a study by Lorimer Moseley which discussed the scientific evidence of exercise as a treatment for chronic pain. This study was a catalyst for understanding persistent pain, revealing that 60% of the participants showed clinically significant improvements in pain and disability within 12 weeks. In his research, Moseley emphasizes the importance of graded exposure for individuals with persistent pain, especially when returning to exercise. Rather than jumping straight into high-intensity activities, Moseley suggests starting with low-intensity exercises that can be progressively increased as the body adapts. Gradually returning to movement, particularly through a structured walking routine, is a proven strategy for managing persistent pain. Research is consistently indicating that low-impact, gradual activities, such as walking, can help reduce pain and improve function over time. A gradual approach helps to prevent overloading the system and reduces the risk of exacerbating your persist ant pain. By slowly increasing both duration (so the length of time walking) and intensity (speed and surface; ie incorporating hills), you can regain confidence in your physical abilities, rebuild strength, and improve function without overwhelming you sensitised pain threshold. This approach not only supports physical healing but also boosts mental well-being by restoring a sense of control and accomplishment.

POSTURE AND ERGOMONICS

There is an unwritten law in Physiotherapy that most injuries are caused by either repetitive overuse or poor posture. Posture and ergonomics play a crucial role in managing persistent pain. By using your body efficiently and adopting proper body mechanics, you can prevent further strain on muscles, joints, and tissues, which is vital for reducing and managing pain over time.

How is your posture right now? Your posture refers to the way your body is aligned while standing, sitting, or moving. Are you slouching or hunching forward – effectively placing more strain on your spine, particularly in the neck, shoulders, and lower back, exacerbating your pain. How many times in your day could you catch yourself doing this ?? And instead, correcting yourself to a neutral spine position, maintaining the natural curves of your spine and reducing strain on the body. And what is your head doing ? How is it aliged with your spine? Avoid leaning forward or looking down for extended periods. Instead, aim to keep your head aligned with your spine, which can help prevent neck and upper back pain. Whether you’re cooking, cleaning, or walking, maintaining awareness of your posture and alignment during all daily activities and making small adjustments in how you move can make a big difference in reducing pain over time.

But what if you spend a lot of time sitting at a desk? I would encourage you to make the most of ergonomic adjustments such as using a chair that supports your lower back and making sure your computer monitor is at eye level. Using a keyboard and mouse that allow your arms to stay relaxed and at a 90-degree angle can also prevent neck, shoulder, and wrist pain. Have you thought about trying to teach yourself how to use the mouse in your non-dominant hand? Training your non-dominant hand to perform tasks normally reserved for your dominant hand not only significantly reduces wrist, elbow, neck and shoulder over-use injuries, it also challenges your brain’s motor skills and can boost neural connections. Using your non-dominant hand encourages better communication between the left and right hemispheres of the brain. This promotes greater mental flexibility, problem-solving, and creative thinking. Double bonus right?!

If your job is labour intensive be mindful to keep your movements balanced – for example when lifting or carrying something, ensure that you balance the load evenly and keep the object close to your body to reduce strain on your spine. A little know secret to pain free manual labour is utilising deep, diaphragmatic breathing to help engage the core muscles and stabilize the body while you move - reducing unnecessary strain on other areas.

Pay attention to how long you are maintaining a particular posture or position. Standing or sitting for prolonged periods can contribute to pain, so take regular breaks to stretch and adjust your position throughout the day. Have you heard of the Pomodoro Technique??? This brilliant concept (although thought to be Japanese) but is actually associated with Italian productivity expert Francesco Cirillo - involves working in 25-minute intervals (called "Pomodoros"), followed by a 5-minute break. After four Pomodoros, you take a longer break of about 15-30 minutes. Although initially designed for productivity of the brain – it also handily sits in well with managing pain.

Take the time to set up your workstation, modify your favorite reading chair and practice mindfulness when you move throughout the day; making small adjustments to reduce strain and prevent injury. Be aware of how your body feels and where you might be holding tension. Breath and Relax. How is you posture right now?

SLEEP AND REST

Sleep is another crucial factor. When you sleep well, your brain has a chance to reset and process information, including pain signals. Poor sleep can worsen pain sensitivity, so creating a good sleep routine can help heal your nervous system.

Importantly - Scientific research suggests that adjusting your sleep position can play a role in managing pain, particularly for conditions like back or neck pain. Multiple research studies have been published in The Journal of Pain and Sleep Medicine Reviews on just this topic. Research suggests we change positions throughout the night to prevent stiffness and pressure buildup which can exacerbate pain; indicating that staying in one position for too long can strain certain muscles or joints, especially in individuals with persistent pain conditions. For example, switching between sleeping on your back with a pillow under your knees and sleeping on alternating sides with your pillow between your knees. This rotation can help maintain a more neutral alignment of your head neck and spine, helping to reduce muscle strain and reduce pressure on sensitive areas during sleep.

POSITIVE SELF TALK

Positive self-talk can be incredibly powerful. If you constantly tell yourself, 'I’ll never get better,' or 'This pain will never end,' you’re reinforcing the pain pathways. Instead, try affirmations like, 'I am capable of change' or 'I am healing with every breath I take.' These small shifts in mindset can begin to alter the way your brain responds to pain. Take charge using the knowledge and tools we have discussed – remain positive that you can now take an active role in your pain management. Feel empowered, with clarity and control – launch yourself into pain-free living and relief.

CONCLUSION

MOVING FROM DISCOMFORT TO EMPOWERMENT

persistent pain is not a life sentence. It’s a challenge that can be understood, managed, and, with time, reset. Pain is not just about injury— It’s a brain-generated experience, shaped by many factors. Understanding how your brain creates pain is the first step toward reducing persistant pain and regaining control over your body.

Your brain is constantly in a state of rewiring, neuroplasticity always at work – perceiving and processing potential threats … a protective mechanism that can sometimes go awry, becoming hyper-sensitized and making everything feel more painful.

The good news is that this neuroplasticity works both ways, and just as pain pathways can become more sensitive over time, they can also become less sensitive as we retrain them with the right activities – Knowledge is power, and by understanding pain and how it works, you can manage and reduce it.

This is the essence of resetting your pain – understanding your pain in a way that empowers you, reduces fear, and helps regain control over your body. Remember everyone’s experience is different. But you have the power to retrain your experience, resetting the cycle of brain-based pain amplification and with the right strategies. You owe it to yourself to commence these simple daily practices such as graded exposure, mindfulness, and ongoing self education to break the cycle and regain control over your life.