Understanding the science of chronic pain is pivotal to a patient’s recovery. Many pain patients won’t yet have been given the information they need about their chronic pain, so it becomes even more vital to educate them.
The concept of central sensitization can be a tricky one to explain, but once a patient has this knowledge, they can take great strides forward in their recovery.
Why a Clear Explanation Is Vital
Pain Neuroscience Education (PNE) is vital for so many reasons. It can feel incredibly scary not to understand how and why pain is being created in your body. This fear and uncertainty can lead to fear avoidance through an understandable sense of self-preservation.
By explaining the concept of central sensitization to patients, they can understand that their pain doesn’t mean their body is damaged. This can be very reassuring and help to build more positive perceptions of pain. It can also build confidence as patients replace thoughts of ‘being broken’ with more positive thoughts and hope for recovery.
Understanding that pain doesn’t need to be feared, and it isn’t going to ‘hurt’ you, can be so freeing. This can actively tackle hypervigilance, pain catastrophizing and fear avoidance head on. I know that personally, the moment when I found out that my pain wasn’t going to damage me was absolutely pivotal in my recovery. Without that moment, there’s no question that I wouldn’t have come as far as I have today.
Providing patients with the understanding that what they do and how they cope actually makes a big difference to their pain levels not only gives them that sense of control back, but actually empowers them to want to make positive changes. No pain sufferer is happy being in pain: we all want to improve our situation. Unfortunately we often don’t know that we have that option. When we learn that we have that power, it can be very liberating and motivating.
Once patients have this base understanding, they are more likely to understand why and how treatments can work. This encourages more active participation in treatments, more hope for the future and more motivation to recover.
Navigating The Conversation
When explaining pain, as with most things, you’ll need to tailor your explanation for the patient.
The pivotal moment you want to reach is where the patient has an empowering realization that pain doesn’t equal damage, and that our pain levels are influenced by much more than just the state of our body. All while avoiding pitfalls such as: you think the pain is all in my head?
Spark their curiosity
To start out with educating the patient you first need to explain your reasons for doing so, and grab their attention. You can say something simple like:
“I’d like to help you understand your chronic pain by explaining some of the science behind what you’re experiencing. This can be really useful for you moving forward.”
If you have a patient that’s particularly frightened of their pain, you could mention that:
“Learning about the science behind your chronic pain should help you to be less afraid”.
If you’ve had a similar patient who was receptive to your explanation, you could say something like:
“I had a patient with a very similar struggle to yours, and he found it very useful to learn some of the science behind his pain symptoms. Are you up for learning a bit more?”
Explaining how the brain creates all pain
A good place to begin is telling the patient that the brain creates all pain. And everytime the brain creates pain, the better it gets at creating the pain experience the next time round. Just like we learn any new skill or habit, our brain can also learn pain.
Pain can become a wired and automatic response to certain situations, events and triggers.
If you’re working with a patient who’s keen to get into the details, you could touch on two other topics here: neuroplasticity, and that pain is an output, rather than an input.
First – neuroplasticity. You could mention that our brain’s circuitry is constantly adapting based on our experiences. These changes can be positive – helping you get better at mental arithmetic, for example – or negative – e.g. when we learn pain. With the big takeaway being that we can reverse neuroplasticity gone wrong (maladaptive neuroplasticity). We can train the brain away from pain.
Second – some patients find it helpful when they discover that the body doesn’t tell the brain what hurts and how much. The body simply sends danger messages to the brain. It’s up to the brain to interpret these messages (along with hundreds of other signals), and decide in fractions of a second whether or not pain is needed to protect you.
Pain is a protective mechanism, but sometimes it can become overprotective. Chronic pain can be thought of like an overly sensitive car alarm. Sounding the alert when someone just walks by (more analogies coming up).
Explaining That Chronic Pain Doesn’t Equal Damage
Once the patient understands the basics of central sensitization, it’s important to reinforce the message that chronic pain doesn’t equal damage. The following examples are a few great ways to help demonstrate this, dispelling negative pain beliefs and myths.
Pain moves and changes
We know that chronic pain will often move around the body, as well as vary in severity from day to day. This is something that all chronic pain patients will have experienced themselves to some degree, but they often don’t realise that it demonstrates that the pain isn’t coming from damage.
By asking them to describe how their pain changes from day to day, you can then explain that this change shows that their pain isn’t stemming from tissue damage: if it was, it would be more consistent and in one place.
Phantom limb pain
Phantom limb pain is another excellent example of the fact that pain is not equal to damage. You can explain to the patient that those with phantom limb pain experience completely real pain in a limb that isn’t even there! It’s important to be clear that the pain isn’t at the amputation site, but where the limb actually used to be.
The brain needs to be trained to stop creating the pain experience. And with techniques such as graded motor imagery, it’s possible to recover from this condition.
Allodynia and hyperalgesia are two common chronic pain symptoms which can also be used to emphasise central sensitization. Allodynia is pain caused by a stimuli which shouldn’t normally cause pain. Allodynia patients can feel very real and severe pain, even from a light touch, the feeling of clothes on skin, or water from the shower.
We know that these actions aren’t causing tissue damage; but the nervous system has become sensitized.
Another great way of explaining this is by saying it’s like the ‘volume button’ on the nervous system has been turned up and everything is too loud. This also gives room to turn the volume back down.
Sensitivity to external stimuli
An overactive nervous system can lead to patients being highly sensitive to external stimuli. This can include sensitivity to noise, light and other environmental factors. Often when we’re in a crowded room, our senses can become overloaded and it can just be too much.
Sometimes when we’re having a flare in symptoms, we need to lie in a dark room because the light exacerbates our symptoms. Often small noises that might not bother someone else, can be extremely grating and cause irritability.
This again helps to demonstrate central sensitization. You can ask your patient if they’ve had this type of experience and use it to help them understand why this occurs.
An example I personally use to help loved ones understand this experience, is relating it back to when you’re going through something emotional. When you’re very stressed and emotions are running high, you’re feeling very wound up. It’s like your emotions are amplified (just like the nervous system in central sensitization).
Small things that wouldn’t normally irritate you, might make you very annoyed. Things that might not usually make you cry, make you burst into tears. We’ve all been there, so this is a really relatable example.
Scans and abnormalities
Despite your explanation, patients will often think that central sensitization doesn’t play a full or major part in their pain experience. They will often have lingering worries that something is broken inside of them. That’s often the result of clinical imaging results they’ve received in the past.
It’s well known that abnormalities such as herniated discs, bulging discs, arthritis, and even tendon/ligament tears are present in significant numbers of the pain-free population. It’s a normal part of aging, yet many would have been told that this is the cause of their persistent pain.
If this is the case with your patient, it’s important to dispel these negative beliefs. The following analogy is useful:
“Imagine the next hundred people that walk past this clinic. Around half of them will have abnormalities such as herniated discs, spinal stenosis, and so on, but experience no pain.”
Conversely, people can be in pain in a specific area of their body and have a scan, and no abnormalities will show up. The Integrative Pain Science Institute states, “research consistently shows that imaging results and pain do not correlate.”
Explaining this provides further evidence to the patient that there can be damage and it doesn’t cause pain, and likewise that there can be pain and no damage.
Tying It All Together
To finish you can tie all of the information together in an easy to understand metaphor or analogy. This helps to recap what you’ve gone over and is a great way to help the patient gain a clear understanding. This study explains, “analogies and metaphors, it seems, may help patients to understand the complexity of chronic pain in an accessible way that likely reduces resistance and helps them to rethink preconceived notions about pain.”
Here at Pathways we value the alarm analogy: you could use a car alarm or a house alarm. On the Pathways pain relief program, we start out explaining that acute pain is like a functioning alarm system; it alerts you when there’s danger.
You could use examples such as if we touch something hot, the brain creates the pain experience to get us to protect our hand. This is helpful, and essential in keeping us safe.
We then move on to explaining that chronic pain is like a faulty alarm system. It’s stuck in an ‘on’ position, sending out constant alarms at every passing person, assuming they’re a threat. We explain that our nervous system has learnt to continue producing pain messages, making the alarm system unhelpful.
Let Us Explain Pain For You
Shameless plug alert! At Pathways, our app (update Aug 2023: Pathways is now a web app! Start our program here) for chronic pain includes a pain relief program. Within our first few video sessions, we explain all of the above. Many pain clinics introduce patients to central sensitization, and then refer patients to our web app to help build out their understanding on these topics.
With limited face-to-face time with patients, it’s hard to cover topics like pain science education, graded exposure, CBT, pacing, and so on. That’s why we created Pathways. get in touch If you’d like brochures you can hand out to patients.
Our app (update Aug 2023: Pathways is now a web app! Start our program here) is free to download , and 1/4th of our content is free. For those who choose to purchase our paid plan, we offer a no fuss money back guarantee if someone tries our program and doesn’t find relief.
Other Important Factors
There are some other important factors you should take into consideration when explaining central sensitization to patients.
It’s not ‘all in their head’
Many of us have been told that our pain is ‘all in our head’, or ‘isn’t real’. When we hear you start to explain that pain comes from the brain, it can make us defensive and even lead to us tuning out of the conversation. It’s vital to make it clear to patients that all pain is created in the brain and that their pain is not ‘all in their head’.
It’s so important that you validate their experience, letting them know that you believe them and that you are taking them seriously. This can truly make the world of difference. It will build trust between you and your patient, and make them so much more likely to engage with the education and treatment process.
Making it work for the individual
There’s no ‘one size fits all’ approach. Tailoring the education to the patients level of medical knowledge, type of chronic pain condition, and personal life experiences, will be key to helping them gain the understanding needed.
Before you get into the topic, it’s also essential that you’ve given the patient plenty of time to talk, and explain their pain.
Bearing in mind past experiences
It’s important to bear in mind that as chronic pain patients, unfortunately we may have faced stigma and had poor experiences with medical professionals in the past. For some of us, this might have been going on for years.
Understandably this creates an inherent distrust of doctors. If we appear defensive or reluctant, try to understand this isn’t because we don’t want to engage with you or get help for our pain (quite the opposite is true): it’s because we’ve been let down in the past.
You need to be patient and understanding. Acknowledging that your patient may have had bad experiences in the past but that you are here because you really want to help them, can be a great, honest way to open the lines of communication from the start.
The line between responsibility and blame
A big part of helping patients overcome their chronic pain is, of course, to teach them about pain-creating behaviours. They need to learn this to alter maladaptive behaviours and implement adaptive coping strategies.
However you need to be careful with how you phrase this so it doesn’t sound like you are blaming the patient for their chronic pain: this will only make them feel upset and less likely to engage with you.
A really simple way to deal with this when talking about pain creating behaviours is to simply say, “it’s not your fault”, “these behaviours are completely understandable” or “we’re going to talk about maladaptive behaviours, please know this doesn’t mean you’re to blame for your pain – this is just how pain works”.
When you’re finished educating the patient, openly inviting questions can be so useful. We might feel embarrassed to ask questions if we haven’t understood something, because we don’t want to appear ‘stupid’. Asking if we’ve understood what you’ve explained and if we want you to go over anything again can be invaluable.
It can be tough to remember what’s happened during a normal medical appointment when we’re anxious and often flustered: when we’re trying to take in a lot of information, this can be even more difficult! Providing resources to take home which recap the information you’ve provided can be so helpful.
Always give hope
Last but never least, please never leave a pain patient without hope for their future. Use every opportunity you have to emphasise that there is hope and that there are treatments that can help them regain their quality of life. This is not something most of us know, and certainly not something we hear as standard from doctors. Making this clear could change someone’s life.
Coakley, Rachael & Schechter, Neil. (2013). “Chronic pain is like… The clinical use of analogy and metaphor in the treatment of chronic pain in children.” Pediatric Pain Letter. 15.
Integrative Pain Science Institute, (2018), “How imaging may harm those with pain.”