Context Matters with Pain
Lucy's Story
Lucy is in her late 30’s and has experienced on and off hip/low back pain for several years. When I first started working with her 4 years ago, it seemed to originally be triggered by her yoga practice as she would push into her natural flexibility.
She began to strength train regularly for the first time in her life, and has since gotten amazingly strong. Her back pain disappears for months at a time, sometimes longer and then occasionally makes re-appearances. Sometimes the trigger is easy to target – she went too hard/fast in a workout or she was slouching on the couch for long hours while doing computer work. But sometimes, it’s less easy to pinpoint.
For the past few months, Lucy’s back pain began to spread to nerve pain down her leg. She had no acute injury incidences or any discomfort during exercise or heavy lifting that would make a disc herniation likely. Actually, movement, walking, and strength training always made her symptoms decrease. She was understandably worried. And though she tried not to focus too much on it, the pain was disrupting the flow of her day and occupying space in her mind consistently.
Then something amazing happened.
Lucy had to fly to Israel for a family emergency. During her time away she was surrounded by close family and friends. She was consumed with the socialization and community gathering that traditionally takes place in Jewish communities after a death in the family. She spent time with her young nieces whom she loves and joined her sister-in-law in attending regular strength classes at a local studio. During this time, she emailed me to report that her leg and back pain disappeared completely. When she returned to her normal life in the US, the pain returned as well.
Is it all in your head?
What does all of this mean? Lucy emphatically concluded, it IS all in my head!! While I knew exactly what she meant, I offered that we change the phrase. To say “it’s all in your head” often sounds like we’re fabricating pain, or we’re crazy, delusional, and can’t be taken seriously. Patients with unexplainable pain symptoms, and women especially, have a history of being told by doctors who have no answers, “It’s all in your head.”
What Lucy meant was that it was clear that a tissue injury wasn’t the problem. Before her trip, Lucy went to a PT who confirmed there was nothing wrong with her musculoskeletal system. But even if there was, her nerves/vertebrae/back muscles couldn’t have healed and gotten reinjured in such a short amount of time to explain such a sudden shift in symptoms. She now had experiential proof that the change in her environment and social setting had an immediate impact on her pain experience. Within a couple days, a pain down her leg she had been complaining about for months completely disappeared. And a month later, it returned, albeit with less intensity. For her, that meant the only other explanation for the pain was that it was psychological.
Chronic Pain is Learned, Context Matters
The more nuanced explanation is that her nervous system, in the context of a new environment, received new signals and processed them differently creating a different result.
Chronic pain is actually a learned skill. You may have heard of the phrase “neurons that fire together wire together.” This came from Donald Hebb, a neuropsychologist in the 40’s who discovered that the brain, like the rest of the body, likes to conserve resources and stay efficient.
When certain neuronal patterns in the brain fire together repeatedly, they become “wired” or more easily triggered. It’s like a short cut for the brain. What gets wired can sometimes be a very large pool of circumstances. In Lucy’s case, her home, her couch, her computer, the hours of her workday, anxieties associated with daily living in New York, etc, is a grouping of data that her brain has become practiced in responding to with pain. Lucy’s musculoskeletal body did not change when she went to Israel. But her environment did. The data her brain was processing was different, and so a different output (no pain) was produced. And upon return? Her neurophysiological response was basically like, “Oh we’re back home? I know this environment! This is associated with pain!”
Barbara and Chandler
Changing one’s environment is a low-hanging fruit when it comes to chronic pain management. Here are two more quick examples:
Barbara has knee osteoarthritis in both her knees and will often mention stiffness and pain both before our sessions and as a result of our more strenuous sessions. She lives a busy life, taking care of a full household of children and grandchildren as well as multiple homes. When she came back from a two week cross country ski trip, she reported not a single moment of discomfort, soreness, or pain. Yes, we trained her up for this trip. But it’s no coincidence that the positive change in her environment (being outdoors, doing a sport she loves, being with a group of like-minded women, no one to take care of but herself) meant a change in the data her brain was processing. A change in input will often create a change in output.
Chandler has a significant fear of movement having been diagnosed with degenerative disc disease up and down his spine several years ago. Even gentle cat/cow or walking barely a mile will often trigger soreness in the moment and the next day. Chandler and I only worked together for two sessions which wasn’t enough to create much change in strength or mobility at the musculoskeletal level. However Chandler embarked on a group hiking and kayaking trip in Puerto Rico after our two sessions armed with some confidence based on conversations we had that degenerative disc disease was a bit of a misnomer, and that in fact he had a very healthy spine from his mid back up to his neck. Chandler came back from Puerto Rico to report 5 full days of kayaking and hiking several miles with no pain!! While our conversations may have helped, I believe the change in context was quite powerful -- sun, fun physical activity, and community gave his brain new data to process, which contributed to a different output – no pain.
Breaking the Association
While sometimes the pain comes back, as it did in Lucy’s case, the disappearance of it in a new environment is a powerful moment of proof that chronic pain is not a result of what’s happening at the level of the tissues. Situational contexts can trigger pain outputs just like situational contexts can trigger other feelings. Have you ever walked into the kitchen and all of a sudden felt hungry even though you had lunch only an hour ago? The hunger signals aren’t coming from your body’s hormones. It’s your brain’s response to the context – “Oh I’m headed to the kitchen, therefore I must be hungry!” It’s a learned, associative pattern – neurons that fire together, wire together.
You probably can't just pick up and head to vacation tomorrow. But what parts of your environment do you notice are always present in the context of your chronic pain? What are some changes you could make for your brain to register a new context and give you reprieve from the habituated response? It could be as simple as sleeping in a different bedroom, or changing up your morning routine. And when you do travel next, notice what happens to your pain. Does it change in any way? What does this tell you?