An Introduction to Pain Neuroscience

Chronic pain

What Pain Neuroscience Is and Why It Matters for You

Pain neuroscience is the science of the nervous system and the brain, and how they relate to pain perception. In this two-part article, you’ll learn the most important ways pain works and what you can do to alleviate it! In part one, you’ll come to understand how the nervous system and brain create pain, what influences pain, and how the process can go awry. In part two, you can take this knowledge and learn how to work with the system to turn down your pain responses and find avenues to improve when it is improperly sending you pain signals.

The Basics of Pain

Pain is necessary to your survival, even though the experience is purely a negative one. Curiously, the amount of pain you experience isn’t necessarily related to tissue damage. It may not even indicate an injury.1 Pain happens when the brain interprets something as a threat to your body, and therefore, your life.2 It’s your brain trying to keep you alive by alerting you to something that is sensed or thought of as a danger, so that you can end interaction with the trigger. Whether it is acute or chronic pain, it is an alarm telling you to stop and address what’s causing it.

Acute pain is straightforward–a trauma occurs, and you do your best to deal with that trauma and move on. Unless the damage is severe, usually the pain ends after the incident, like a stubbed toe. After the moment passes or you put some ice on it, it’s never heard from again. Chronic pain is much trickier. The onset factor may be long gone, yet the pain persists or worsens whether tissue damage is still occurring or not. This is the case with the nerve pain I developed from autoimmune disease. You have to learn to function within chronic pain to get anything done. Whether you’re able to get to the root causes of your pain and drive it out, or if it’s here to stay, the following information will give you an introduction to pain neuroscience and help you lower your pain!

Proper and Improper Pain Creation

Pain Neuroscience Proper and Improper Pain

Your body has millions of sensors at the ends of nerve cells called neurons, which gives them the ability to convey information throughout the nervous system.3 Some sensors are triggered by physical stimuli, such as touch or movement.4 Others activate due to temperature, either hot or cold.5 The final kind of sensors are stimulated by chemical changes from internal and external sources such as adrenaline or pollen.6 When those nerve endings reach a threshold, they fire off an alarm signal to the brain. This process of alarm signaling is called nociception.7

The brain then determines whether the threat is legitimate or not and can send a pain signal that makes you hurt. For example, if you touch a hot burner on a stove, the extreme stimulus triggers nociception from your hand that sends a signal to your brain. Your brain detects the start of tissue damage and elicits a pain response in your hand, making you want to pull your hand away from the heat to cease the damage.

However, the brain’s interpretation of a nociceptive alert and reaction to trigger pain from those alerts can be incorrect, such as in phantom limb pain, where the brain’s memory of an amputated part of the body causes a hurting sensation in a part of the body that no longer exists. Yes, just a memory can evoke pain, even when that part of the body isn’t there! The main reason for this is that pain is not actually at the site where you feel pain in the body. Pain is created in the brain and is intertwined with your experience, emotions, and memory, and sent to the location the brain deems appropriate.8,9 According to physical therapist Adriaan Louw in his book Why Do I Hurt?, “the point is that pain depends on many different factors and it is the brain which decides whether something hurts or not, 100% of the time, with NO exceptions.”10

The concept of pain created in error has critical implications for chronic pain sufferers. A more easily relatable example involves neuroscience professor Lorimer Moseley.11 While Moseley was hiking in the Australian Outback, a snake bit him on the back of his left leg. He nearly died from the encounter but was fortunately taken to safety by a friend, and he recovered. The next time he was walking in similar surroundings, he felt something in the same place on his left leg as the snake bite. He immediately collapsed with agonizing pain.

Then his fellow hiker pointed out that a twig had poked him in the leg. Moseley examined his leg and saw this was correct. Despite having a completely different trigger that was not dangerous, he proceeded to have groin pain for a week, just as he did after the snake bite.12 His brain recognized that he was in the same surroundings and had a similar stimulus, and had learned a protective pattern to elicit pain from stimuli similar to the snake bite.

To get Moseley to stop and address the problem, his brain put him on maximum alert to get away from the stimulus in the same surroundings in case it was a mortal danger to him as the snake bite was. In this case, he was getting an intense pain response from a non-dangerous stimulus. His brain mistakenly created his pain without any significant tissue damage because of his previous legitimate learned experience.

Pain Neuroscience Snake Bite

Pain can also fail to trigger when it should. This is of less concern to individuals with chronic pain–I include it here only to indicate another way the system can be fallible. There are many accounts of soldiers having limbs amputated and feeling no pain. 13 Another well-known account of this is when Ronald Reagan felt no pain when he was shot during an assassination attempt.14 To summarize what is occurring in these situations, David Butler and Lorimer Moseley write in their book Explain Pain, “if there is no pain, it means that these changes in tissues are not perceived by your brain to be a threat.”15 The brain rejected these incidences of tissue damage as non-threatening to survival and thus sent no pain to the site, likely due to similar stimuli which were non-threatening in each individual’s past experience.

In chronic pain, the body can send alarm signals for many reasons, some involving the same mistaken pain process as in the phantom limb and Moseley examples. Another situation where mistaken pain can arise is after tissue damage from trauma has healed. There is no longer any damage occurring in these cases, so the neurons’ alarms and the pain shouldn’t be present. This particular process is often involved in the experience many with chronic pain have with exercise. This signal occurs because you can have mistaken pain even when the movement doesn’t cause tissue damage if the brain has associated the activity with danger. Recognition of this phenomenon has led to the phrase “hurt doesn’t not always equal harm”16 becoming widely accepted in neuroscience circles.

The Mind’s Role in Pain

Pain Neuroscience Mind's Role in Chronic Pain

The mind is involved in all pain. In an eloquent demonstration of the connection of mind and body, one’s consciously held ideas can affect a pain response, as is shown in the following example.

In a scientific study, experimenters told participants that a machine would pass a current through their heads, causing pain. During the experiment, the participants experienced pain increases in line with what they were told was happening by the machine’s operator, even when no stimulation was put through the machine. The expectation of pain evoked pain in the subjects.17 Tying back to the point about exercise, you can get pain even if you are merely convinced that something will hurt you.

Again showing the mind-body connection, pain can also increase for someone based on how important a value is to them. For example, suppose someone is a massage therapist, and their hand gets hurt. In that case, it can hurt more than an identical injury in someone else simply because the therapist fears that they will lose their livelihood due to the injury.18,19,20

Further, any thought can play a powerful role in driving pain and pain intensity. Again from Explain Pain, “ANYTHING that increases the brain’s perception of the need to protect you can increase your pain.”21 This is a crucial point that is terrifying, yet empowering when grasped since we are all in control of our minds thanks to volition. All pain and experience involve many thoughts, values, and emotional components.22 These include your desire to survive and how dangerous you deem a situation or stimuli. Whether or not it was clear to you mentally in the moment of the pain, there was an experience and thoughts connected to it in the brain. When you stub your toe, there’s an equivalent thought of: “hitting hard objects hurt. I don’t want to do that again.” There’s also a connected emotional feeling such as displeasure, anger, or surprise. Your default approach to thinking in relation to the world will feed you an automatic response, and determine such thoughts’ intensity. Because of this, these reactions are individual, and can be flawed, just as with any other choice you make. The choice could’ve been made long ago or at the moment of the pain. Some individuals can react to a minor threat with a thought such as, “that was the worst thing ever, and I never want it to happen again!” Ideas like these affect pain response. They can program the system to cause more intense pain. If you decide something is a threat to you, your brain adjusts accordingly. It tries to protect you by sending strong pain responses to stop you from doing such things again. In the above example with the experiment, individuals decided they should feel pain, so they did. That is the power of volition.23

Pain Neuroscience All in Your Head

It turns out that pain is “all in your head,” but not in the cruel way intended with that phrase. To quote Butler and Moseley, “pain depends on many different factors and it is the brain which decides whether something hurts or not, 100% of the time, with NO exceptions.”24 All pain starts in the brain, but that doesn’t mean you are inventing it or that you’re crazy, as most insensitive and ignorant individuals mean with that callous statement.25 Just because your thinking can influence your pain doesn’t mean there wasn’t some trigger or injury that set the whole process off. Most pain begins with a physical onset factor. This revelation about thinking affecting pain should be looked at as an opportunity for improvement, rather than a self-condemnation.

The Prevalence of Fear in Chronic Pain

Pain Neuroscience Fear

Of all the thoughts and feelings one can have, fear is worthy of extended focus due to how much it can affect pain.26,27 Fear is a nearly ever-present emotion when dealing with chronic pain. It creeps in with thoughts about wondering what is wrong with you, if the pain and symptoms will ever go away, and what they mean for your future. Like pain, it is an essential part of life to keep you alive, but it can increase or create pain in several ways. Fear is heavily tied to the brain region known as the amygdala.28 The amygdala controls overactive emotional reactions and rumination, or getting fixated on something. We will revisit the role of the amygdala and rumination shortly.

The mistaken pain with exercise, mentioned above, or something like sympathy pains, where you can feel pain from merely hearing about or seeing what happened to someone else, are both primarily fear-driven.29

Fear can also cause and increase pain because it sets the entire body on high alert and makes the neurons more sensitive by triggering the fight, flight, or freeze stress response.30 This pumps you full of chemicals like adrenaline and cortisol, making you ready to take action and shifts your sympathetic nervous system into overdrive. Those chemicals have other harmful effects on the body if released for a prolonged period, causing muscle wasting and inflammation, and possibly tissue damage. Additionally, adrenaline is thought to more easily trigger alarms that can become pain.31,32

Fear can also cause pain by making and keeping the nervous system hypersensitive. Again, Louw writes, “it has been shown that fear of injury, or re-injury, and fear of exercise or movement will keep the alarm system turned on, rather than off.”33 This means that being in fear and staying fearful makes it easier for a neuron to react and send an alarm signal to the brain. This can elicit pain, and ties in with the next concept necessary to understanding pain, central sensitization.

Given the ever-present nature of discomfort when one has chronic pain and how fear works with the amygdala, obsessing about pain is a crucial issue for most with an extended health problem or injury. What I refer to as obsessing about pain encompasses two ideas: observing your pain with fear, and continually checking in with it. Obsessing about your pain kicks in all the major negative effects of fear. Thoughts such as “I can’t take this! It must stop now! I can’t do anything because of this!” are all gasoline on the pain fire. This is thanks to fear, and it’s previously mentioned qualities. It can be challenging to break out of obsessive thought loops since the stress response kicks in the amygdala and the process of rumination, essentially stacking the deck against you. Because of this, you can easily become completely fixated on your pain in a pit of despair. These cycles can send you in a spiral of increasing pain and pain sensitivity and are some of the single worst experiences of having a chronic health problem.

So just considering fear, there are many ways in which that one kind of thought or emotion can generate pain signals and intensify pain. Imagine the possibilities across the full spectrum of thought and emotion.

Central Sensitization Triggers the Alarms More Easily

Another vital issue for pain concerns prolonged health problems. If the neurons in an area of the body are in a continued state of sending alert signals to the brain, they begin to fire more easily and thus more often.34 Irritated nerves can cause chemical reactions in the body that inflame the areas and set off alarm signals in an entire region or side of the body from one source.

Many baffled medical professionals call this “complex regional pain syndrome”, or one of many other symptom description diagnoses such as fibromyalgia or non-specific neuropathic pain. Their solution is often to throw opioid pain medication at you, which ironically, makes you more sensitive to pain if you’re on them for too long.35

Pain Neuroscience Central Sensitization

The more accurate term for this situation is central sensitization. In this state, the neurons get more excited by continually sending the alarms to the brain and fire progressively quicker with less intense stimuli required to do so. This state is the neurons and the brain trying harder to get your attention to address the root cause of the alarming stimuli and make them stop. This vicious cycle is a nightmare situation. It is the one I lived in for many years, which explains my curious pain reactions to innocuous things such as sight and sound. In this state, pain persists, spreads, and worsens, movement becomes more painful, pain becomes less predictable, and pain links even more to your thoughts and feelings, along with perceived threats.36

Pain Neuroscience Deconditioning Muscles Fascia

A similar situation to central sensitization involves disuse of your body leading to pain or making you more likely to feel pain that is already present. Anyone who’s laid around with an illness for a few days can tell you that tissues become deconditioned from lack of use. This leads to weakness and soreness. Muscles can quickly shorten and tighten,37 and fascia, the tissue layer covering your muscles and connecting all your tissues, can rapidly constrict.38 A lack of movement can also cause acid buildup in tissues that don’t get flushed out while you’re immobile. This shortening and tightening and acid accumulation causes physiological problems that trigger more pain alarm signals.39 The tissues can then hurt when idle and become sore from basic movement. This process can become a vicious cycle in a hurry in a chronic pain situation. When you’re in pain, you want to stop moving–that is the correct response to an acute pain. But when the pain is continuous, you’ll likely end up never wanting to move, as I did for over a decade of disability. And when you develop pain, your nerves increase their sensitivity to protect you.40 It then takes even less stimulation to cross a threshold that causes a nerve to fire an alert to the brain, so your lack of mobility can cause new pain through tissue damage and increased sensitivity.

Neuroplasticity and Pain Neurotags

The final concepts of importance for this introduction to pain neuroscience are neuroplasticity and pain neurotags, also known as pain maps.

Pain Neuroscience Neurotag

While many specific areas of the brain have specific functions, there is no pain center in the brain.41,42 One of the many amazing qualities of the brain is that it’s dynamic in how it works, rewiring its resources to facilitate whatever need is greatest at the moment. Neuroplasticity is the term for the brain’s ability to do this. It can form and reorganize synaptic connections, especially in response to learning or experience or following injury.43 The brain can rapidly change specific neurons’ function and devote additional brainpower to a stimulus in your body, what you draw your conscious mind to, or what activity you are currently doing.

If you are typing, the brain devotes more neural activity to your hands so that you can function better. An example that shows how quickly and effectively the brain can do this is that merely taping four of your fingers together for 30-minutes can rewire the brain in how it treats moving the fingers thereafter. You can quickly lose efficacy in the ability to move each finger independently, which is known as cognitive smudging.44,45

If you’re repeatedly in pain, then the brain rewires to report pain more efficiently. It will also develop more patterns in the brain and more chemicals in the body to activate the alarm sensors in the neurons to more easily trigger pain.46 Troublingly, the longer your pain continues, the more advanced and complex the changes in the brain become.47,48,49,50 The brain will even cause smudging in the brain to make the hurt body part more difficult to use or nearby body parts painful to try to get you to stop using the area.51

Each time pain occurs, the brain makes a pain neurotag. A pain neurotag is a set of neurons that wire together in multiple areas of the brain based on the onset of what caused a particular pain.52 What happens with these neurotags is that the brain starts pulling resources away from areas of the brain responsible for essential functions for sensation, movement, focus and concentration, fear, memory, motivation, and stress response to make the neurotag and to cause pain instead.53 The neurotag then activates when any part of that map is triggered, whether it is a memory of an event or a movement tied to the onset of pain. Any activation of one part of the neurotag can trigger all the other areas of the brain associated with the neurotag, and an entire orchestra of neural energy can be devoted to creating pain. This means there can be many triggers for pain that shouldn’t be painful, such as the mistaken pain signals mentioned earlier. The brain areas that are part of a pain neurotag is completely individual for each pain situation.54,55

Remember Lorimer Moseley’s pain from stepping on a twig that was similar to a snake bite? That is an example of a pain neurotag. The brain takes a snapshot of everything at that moment that led to the threat–the sensations, movement, your emotions, and memory.56 Any of those factors can become triggers to cause the same pain. In an effort to keep you alive, your brain can wire a pain pattern across multiple brain regions immediately around a pain experience, such as in Moseley’s case. Moseley went for a walk in a similar location and environment and experienced a similar stimulus to a snake bite. Thus, his brain activated the pain neurotag for a snake bite when a twig poked him. The more times the pain gets triggered, the more efficient the brain becomes at sending pain in similar circumstances, and the easier it becomes to trigger it again in the future. So if you wonder why a certain kind of music, a specific smell, or specific surroundings could be triggering pain for you, it’s not that you’re losing your mind. Those stimuli are likely associated with some first pain you felt, and the pain neurotag formed around that experience.

One consequence of having a pain neurotag is that you can lose capability in any or all those involved areas in the brain, since that gray matter is now devoted to pain instead. So your pain can cause problems with sensation, difficulty with moving, tremors, or an inability to concentrate. You can also experience wild outsized fears, forgetfulness, a lack of motivation, and more easily slip into fight/flight/freeze when you’re in pain.

On to Solutions!

This brings an end to this introduction to the core concepts of the neuroscience of pain. Pain is remarkably complex. There is even more to the subject, which I’ll discuss more completely in my book with Dr. Lemons and future articles here on my site. It incorporates physical, mental, and emotional experiences that indicate tissue damage or simply a pattern that keeps firing that the brain has learned. Now, you are better armed to start building a framework to counter all these processes that could be running in your brain. You can also better understand and explain your pain and why your pain could be worse than the pain someone else gets in a similar situation. If someone doesn’t understand your pain, refer them to this article.

You’re likely feeling overwhelmed by all this information and wondering what you can do with this knowledge to start changing your relationship with pain. You’re possibly even feeling discouraged to find out that your brain could be creating pain without any tissue damage occurring. Or perhaps you’re feeling guilty to think that fear of your situation could be perpetuating your pain. That’s all completely understandable.

But I included every revelation in this article about the brain’s role in pain for good reason: you can do something to address every point raised here! There are many mental and physical actions informed by neuroscience that you can take to influence pain, whether there is tissue damage ongoing in your body, or the damage has ceased and the pain signals are still triggering. You are in control of your mind and body. You can use this knowledge of the nervous system and neuroplasticity to rewire your brain and pain responses to make them less intense and trigger less often. You can address mistaken pain, and all the rest! May this information be the life-saving foundational force for others that it has been for me and my clients. In part two of this article, you’ll find simple solutions to retrain your brain and tame your pain.

Recommended Resources

Explain Pain Second Edition by David Butler, Lorimer Moseley

Pain Neuroscience Education by Adriaan Louw, Emilio Puentedura, Stephen Schmidt, Kory Zimney

Why Do I Hurt? by Adriaan Louw

Lorimer Moseley has a highly entertaining, humorous, and very technical TEDx talk on his snake bite experience here: TEDxAdelaide – Lorimer Moseley – Why Things Hurt


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