Episode 4: Everything matters when it comes to pain

The pain we experience is always real and it is always influenced by a combination of our biology (such as our muscles and nerves), our psychology (such as our thoughts and emotions) and social factors (such as our family relationships and work situation).

In this first part of Episode 4, I am going to give you a mind-blowing insight into how your pain system works. It is really challenging and, in many ways, hard to believe.

The best way to understand how your pain works is to understand how our senses work. Usually, I would use vision as my example sense but it is hard to do visual illusions over an audio podcast. So instead, I am going to talking about how our hearing works.

What we hear is not necessarily the same as the sound occurring in the external environment. In this example, we learn what we hear is our brain’s interpretation of what is occurring in the world around us.

Take a listen to this audio illusion.

When you listen to it with the cough removed, you realise that there is literally a full syllable missing in the clip, but with the cough, people tend to hear the full word even though it was not said.

This illusion is known as ‘temporal induction’: your brain fills in the missing information to make sense of the world, so that you hear something coherent and logical.

So, why do we sometimes hear things differently to how they really are?

We can understand this by understanding the underlying physiology of hearing. Sounds in the external environment, create vibrations in the air, which beat against the eardrum. This pushes a series of three tiny bones called the hammer, the anvil and the stirrup, causing them to tap against a tiny membrane, a bit like Morse code. This triggers tiny little hair cells or sound receptors, that stimulate the nerves in the ear converting sound energy into electrical messages that travel along the nerve to the parts of the brain that deal with hearing.

In this part of the brain, imagine there is a little person, let’s call her Penelope. Penelope is surrounded by millions of virtual jigsaw pieces. As the sound information comes in, in the form of electrical messages, Penelope constructs an idea of what she believes is going on around you in real-time to give you an instantaneous coherent sound-image of the world.

Do not think of hearing as an input from the ears to your brain: it is an output of your brain based on messages from the ears. It is a creation of your subconscious. My voice that you are hearing right now is pieced together by your brain. Everything you hear right now is not necessarily what is there, but your Penelope’s prediction of what is there. And, when it comes to that prediction, everything matters, not just the sound information coming in via your ears but also your previous experiences, your expectations, your understanding of the world, your beliefs, and attitudes. All these things will influence the sounds that Penelope creates for you.

In the case of the audio illusion we just heard, our hearing system is tricked. The sound of someone saying a real sentence in the external environment, creates vibrations in the air that stimulate the eardrum, that cause the hammer, anvil and stirrup to tap on a tiny membrane causing sound receptors to convert that sound information to electrical nerve messages that travel to Penelope. When Penelope gets this information, she would usually conclude that part of the word was missing and give you the sound of ‘Leg … latures’.

But she does not, because when it comes to hearing, everything matters. Penelope takes into account past experiences and expectations, like what is likely being said. She concludes based on the context of the sentence that the word being said is ‘legislatures’. And so, Penelope makes a decision based on this: she fills in the blank, creating the word in full so you hear the full word, ‘legislatures’, even though it was not actually said.

Penelope is quite amazing, and her predictions allow us to do things like hold conversations in noisy social environments and to hear specific sound patterns and noises in busy environments like jungles. You can imagine this ability has been extremely useful to our early ancestors when they were hunting and gathering to survive. It gives us a great biological advantage, this predictive system, which is why we are designed this way. But occasionally Penelope can be tricked to get things wrong, as in this case here.

So, what we hear is not necessarily an accurate representation of what is physically going on. It is our subconscious brain’s interpretation of what is there. Our subconscious brain decides what we hear 100% of the time, all of the time. When it comes to hearing, Penelope is in charge.

You don’t consciously control what you hear, your subconscious automatically creates if for you, but it is very real, and happens to everyone.

While this example is of hearing, actually all of our senses work in the same way: vision, taste, touch and smell are all outputs of our subconscious brains. I want you to start thinking about pain in the same way!

Pain is not an input to your brain from the body: pain is an output of your subconscious brain. Danger messages, scientifically known as nociception, which are electrical nerve impulses carrying messages of danger from your body, are inputs to your brain. These can influence what you feel, just like light can influence what you see. But the brain is boss: it decides what you feel 100% of the time, all of the time.

Let’s meet Penelope’s pain equivalent, the subconscious part of the brain that deals with pain. Her name is Assumpta. She is from the department of Health and Safety: no-one likes Health and Safety, but where would be without it? Unhealthy and unsafe, that’s where.

Imagine Assumpta to be like Lady Justice, with a blindfold, sword and scales. Her job is to do risk assessments and, where necessary, enforce strict safety measures. That’s why she carries the sword.

What happens if Assumpta makes an assumption (see what I did there) that, on balance, based on all the information she is getting, you are in danger? She will want to draw your attention to it to get you to do something about it and protect the body. The best way of doing that is to give you pain.

That is because the purpose of pain is to protect you. Let’s say that again and feel free to say it out loud: the purpose of pain is to protect you. If Assumpta assumes you are in a small amount of danger, she will give you a small amount of pain. If Assumpta assumes you are in a large amount of danger, she will give you a large amount of pain. But whether the pain is small or large, that does not mean that you are actually in any amount of physical danger. Think back to Episode 3: hurt doesn’t always mean harm.

The following scientific experiment makes this point beautifully. A group of 16 normal individuals, (well, I say normal, but they volunteered for a pain study so they might not be completely normal) participated in an experiment where a laser was projected onto their skin. I always imagine the set up looked a little bit like the famous laser scene from the James Bond movie ‘Goldfinger’: you remember Bond is strapped to table with a laser about to chop him in half and he says, “Do you expect me to talk?”, and Goldfinger responds, “No Mr. Bond, I expect you to die!”.

Anyway, in this research study, the laser was providing a very low-level stimulus and was completely safe, but the participants did not know this. Participants were asked to tell the researcher if the laser hurt and how much it hurt on a zero to ten scale.

The researcher then told participants that before the experiment, they needed to identify safe places on the skin to apply the laser. They did this by examining different areas on the skin of the foot, and stating out loud to the patient whether the area was ‘safe’ or ‘unsafe and would cause serious harm’, or ‘was possibly safe: might cause serious harm, and should be monitored carefully’. After this, the researcher said they would not apply the laser to the unsafe areas as this would be too dangerous, and so they would only apply the laser to the safe and possibly safe areas. This sowed the seed in the participants’ minds that the ‘possibly’ safe area was equally possibly not very safe at all, it was potentially dangerous, putting their Assumpta on alert and giving her some vital additional information, or cues, in advance of the information coming from the body when the laser was applied.

The researchers then applied the laser a number of times to the ‘safe’ and ‘possibly safe’ areas. The participants were aware what areas were being lasered, and were asked after each laser stimulus whether it hurt and how much. Remember, on every occasion the same safe laser stimulus was applied, the only difference was the location to which it was applied and the participant’s belief that one location was completely safe and the other was potentially dangerous.

So, what happened? Here are the results. Participants were more likely to report the laser as painful when the ‘possibly safe’ (or high threat) area was stimulated compared to the ‘safe’ area. Additionally, the amount of pain reported when the ‘possibly safe’ area was stimulated was higher than when the ‘safe’ area was stimulated. Remember, in reality, there were no physical differences between these different skin areas or between the lasers applied to each area!

In both ‘safe’ and ‘possibly safe’ areas, the same amount of danger messages from the skin would have reached Assumpta: remember, all of this is happening within a split second without conscious awareness, and Assumpta asks the question, “how dangerous is this really?”

When weighing up the evidence, she weighs up the evidence for safety against danger. When she saw the laser projected on the ‘safe’ areas, she was more likely to assume the body was safe and thus less likely to want to draw conscious attention to danger and thus less likely to give pain. In contrast, when she saw the laser projected onto the ‘possibly safe’ areas, she was more likely to assume the body was unsafe and therefore more likely to produce pain and indeed higher levels of pain. The only difference between the areas was the reassurance given beforehand, and that was made up by the researchers!

This pain was being created without any tissue damage and was influenced heavily by Assumpta’s understanding of how dangerous the situation was. That is what we mean by Flippin Pain’s key message: everything matters when it comes to pain. Assumpta is not just influenced by the messages coming from the tissues in the body, she is interested in the whole context of the situation: the biological, the psychological and the social factors. In this case, simply being told that one part of the body was more at risk of injury than another was enough to influence if the person experienced pain or not, and how strong that pain was.

So why are we built like this? Why do we need an Assumpta? Would it not be better if we simply experienced pain when we are injured and did not experience pain when we are not injured?

While this would seem logical, it would be a really bad protective system. Don’t forget the purpose of pain is to protect you: it is the body’s alarm system. What use is a protective system if it only goes off after the fact? How useful would reversing sensors on your car be if they only went off after you crashed into the wall behind you? How useful would a burglar alarm in a bank be if it only went off after the robbers had broken in, stolen the money, and made their getaway?

An ideal alarm system is preventative. It stops the bad thing from happening. Pain works in the same way: the purpose of pain is to protect you. Pain occurs not because you are injured, but because your subconscious believes your body is at risk and it wants to prevent damage from happening. Pain is brilliant at achieving this: once pain kicks in, it will stop you from doing things that your subconscious thinks is risky and it does not want you to do. For example, it can stop you running for the bus if it thinks that might be dangerous for your ankle. It can also make you do things that might seem protective, like going to your GP, requesting an x-ray, or avoiding activity. In the next section, we are going to dive into this a bit deeper and explain the biology that underpins this alarm system! I suggest you take a break here and pause the podcast to absorb what we talked about. Do something active like taking a walk, or potter in the garden, or do something creative. This helps learning more than a passive activity like watching TV or scrolling on your phone. To flip pain, we need to put time into understanding it.

Welcome back. Earlier we learnt that pain is a perception, just like our senses. We learnt that pain is an output of our subconscious brains, a creation of our unconscious minds. We learnt that whether or not the part of our subconscious brain (that we’ve called Assumpta) creates pain is dependant on how dangerous she thinks the situation is. When she is making this decision, she is influenced by everything: not just the biological messages coming from our body, but also our previous experiences, our expectations, our beliefs and attitudes, the environment we are in. All of these things will influence whether Assumpta creates pain and indeed how much. Don’t forget she creates this pain to protect you, to draw your attention to a potential problem and get you to do something about it. She is doing it with the best of intentions, to help protect you.

This is the science bit. I’m really going to need to you to sit up and concentrate for this bit. You might need to listen to this section more than once. But you can do it, I know you can! So here goes.

Let’s talk through the following scenario and slow the pain experience right down. You are hammering a nail into the wall to hang up a picture when you strike your thumb instead of the nail head. Meanwhile, you are drawing back the hammer ready for the next blow. If something doesn’t happen, you will keep hammering that thumb: not a good idea!

When the hammer hits, this will stimulate receptors at the end of nerves in your thumb. Whilst we don’t strictly have ‘pain receptors’ in the body, what we do have are danger receptors that respond to different types of input, such as hot and cold and mechanical stimulation. These receptors, when stimulated enough (and a hammer blow will probably be enough), will send a nerve impulse or danger message from the top of the nerve in the thumb, all the way to the nerves in the spinal cord. This is just one long pathway.

When the danger message gets to the end of the first nerve and reaches the second nerve that sits in the spinal cord, there needs to be a way of passing the message on between the small gap between them. This is done through special chemicals called ‘neurotransmitters’, which are released from the end of nerve one to communicate with nerve two. Neurotransmitters travel across the gap and bind with receptors that sit on the skin of nerve two. When this happens, little gates on the skin of nerve two open up and allow electrically charged particles floating around outside the nerve into nerve two. When enough of these electric particles come into the nerve, this causes the second nerve to fire, relaying the danger message up to the brain. When the message reaches the brain where Assumpta sits, she asks the question: ‘how dangerous is this really?’

Remember: up to this point, there has been no pain. This is an entirely unconscious process, happening within a split second.

Assumpta now must decide, based upon a range of factors, whether or not to produce pain. This decision is not consciously controlled by you: you are completely unaware of it. The decision is not just based upon the danger message coming from the body, but also previous experiences, expectations, beliefs, attitudes, knowledge, and the external environment.

So Assumpta will be thinking: “OK, I have received lots of danger messages from the thumb. The thumb region is roughly where I am hammering, so the likelihood is that the tissues in the thumb are in danger. There could be a fracture or wound. Also, the arm is in backswing for another strike! I need to draw conscious attention to it and get something done immediately. So, I will give pain with the perception it is coming from the thumb.” She now passes this message to the conscious ‘you’ in the form of pain and…

…Immediately you shout out in pain. You drop the hammer and you clutch your injured thumb. Protection is initiated: well done, alarm system!

Incidentally, it’s worth mentioning that you probably shouted a swear word. Have you ever asked yourself why we swear when we hurt ourselves? There is good evidence to show that swearing can reduce pain: so don’t hold back, let it all out!

Now, Assumpta doesn’t just receive messages coming up the spinal cord. She also sends messages down the spinal cord to the gap between the first and second nerves, so she can increase or decrease danger message transmission. She does this by unlocking the inbuilt natural drug cabinet that sits within our brain. Assumpta has the key!

If Assumpta thinks the situation is dangerous, there will be pain. However, if she thinks the situation is really dangerous (because of evidence coming to her from the body and the rest of the brain), she can send excitatory messages down the spinal cord.

These cause the release of more neurotransmitters into the gap between the first and second nerves, which results in more of these neurotransmitters binding with receptors on the skin of the second nerve. This results in more gates being opened and more electrically charged particles flowing into the second nerve, making it fire more frequently. As a result, you get more danger messages sent up the second nerve to the brain without any changes in the thumb.

This is what’s called a positive feedback loop: the brain sends messages down the spinal cord, which can directly increase the amount of danger messages coming back up it. When Assumpta receives these additional danger messages, and balances everything up, there is an increased likelihood that she will interpret the situation as more dangerous and thus give even more pain. Think back to the builder with the nail between his toes who was in excruciating pain even though he had no injury, and how this process can help us understand the biology of why he was in so much pain.

Alternatively, if Assumpta thinks the situation is less dangerous than the evidence coming to her would suggest, she can send inhibiting messages down the spinal cord. In this case, she unlocks the drug cabinet full of our body’s own pain medications, like endorphins and even natural opioids, and sends them down the spinal cord. These cause the release of chemicals that block neurotransmitters in the gap between the first and second nerves. This results in less binding of the neurotransmitters with receptors on the skin of the second nerve, fewer gates opening on the skin of the second nerve, and fewer electrically charged particles flowing into the second nerve making it fire less frequently. As a result you get fewer danger messages to the brain without any changes in the thumb itself.

This is called a negative feedback loop: the brain sends messages down the spinal cord, which can directly reduce the amount of danger messages coming back up it. When Assumpta receives fewer danger messages and balances everything up, there is a reduced likelihood that she will interpret the situation as dangerous and thus there is less pain. Think back to Hannibal who pulls vans with meat hooks attached to his back, and how this process can help us understand the biology of why he’s in little or no pain.

Now, let’s move rapidly forward through the days and months after your hammer and thumb incident. On the day of the accident, your thumb swelled up to the size of a balloon. You went to A&E, got an X-ray, and you were told it was a really bad fracture but that they don’t tend to put thumbs in a cast, and it would heal in time. They gave you pain medication and sent you away.

But the pain just kept getting worse. It was stopping you sleeping, so you went back to your GP two weeks later. Your GP gave you more pain medication and said to rest the thumb, try not to do too much with it and allow it to heal. Eight weeks later, the swelling has gone and the thumb looks normal, but it feels weak and is still really sore. Even light touch is excruciating, and now the pain has spread to most of the hand and up the forearm. Your GP requests another X-ray. The X-ray shows that the fracture has healed, and the healthcare professionals are now scratching their heads. Now they think it might be one of the tendons or the ligaments. Six months down the line you have been off work with the pain for a long time. No-one seems to know the cause: they tell you it has healed but it feels worse than ever. You now have persistent pain: how can we explain this?

Well, let’s go back to our biology. At the gap between the first and second nerves there is a bit of a bottleneck. The system simply cannot deliver all the messages that want to be sent.

The body in persistent pain is a bit like the Post Office over Christmas time. It gets more messages to deliver than it can usually cope with. The Post Office overcomes this by employing more staff during this period and extending working hours: if you have ever received a parcel on 23 December at 6:30am in your pyjamas, all bleary eyed, you will know what I mean.

Your danger message system adapts in a similar way. Your body builds more receptors for the neurotransmitters to bind to. It makes the gates on the skin of the second nerve stay open longer: it does this by placing a small wedge, just like a doorstop, in between the gates, and it increases the number of electrically charged particles in the second nerve when it is at rest, making it easier to fire.

These changes are part of a process called ‘sensitisation’. Which makes sense: your nerves are becoming more sensitive to potential danger. Furthermore, these chemical changes spill over to neighbouring nerve pathways, like a community neighbourhood watch scheme, recruiting more help to protect you. When this happens, the pain appears to spread, and the area of pain can get bigger. Has this happened to you? Can you recognise this pattern? Did the pain start in one area and then seem to move or become more widespread?

These physiological changes, which occur due to the super adaptability of our nerves, is called neuroplasticity. Far more danger messages are able to be sent to the brain, even though the tissues in the thumb itself are improving and the fracture is healing well. Once this sensitisation occurs, it can become slow to shift and can stay even after the tissue has fully healed. It is a bit like an overactive fire alarm that keeps ringing long after the fire has been extinguished and the fire brigade has been and gone.

Poor Assumpa is working in overdrive. All the information she is getting is that your thumb (and now even your hand and forearm) is in danger, and doctors have said that there is nothing that can be done! She sees this as very dangerous, so she needs to protect that thumb. And the best way to do that is by giving lots of pain, because the purpose of pain is to protect you.

Before we move on from the biology of our pain alarm system, I want to talk about stress. Stress and pain are closely linked, but much like Ross and Rachel, their relationship is a bit complicated.

Our physiological stress response was designed for our caveman ancestors. When we were attacked by lions, the chemicals we released as part of the stress response, such as adrenaline, increased our heart rate and blood flow to our muscles, preparing us to either tackle the lion or run away. This is called the ‘fight or flight’ response. In these situations, the stress response, working in partnership with Assumpta, can help to reduce or indeed eliminate pain in the short term if it helps us to survive. Think back to the shark attack and the war wound examples: this pain-blunting role of the stress response is a brilliant piece of protective design.

However, we no longer live in caves and most of us rarely have life threatening encounters with lions. Our stresses are different now. Instead of short-lasting, physically demanding stressors, we have the daily grind of modern life including traffic jams, mortgage repayments, unemployment, childcare, line management, line managers, social media: the list in endless. We and our nervous systems are not really designed for these continuous, ongoing, psychological stressors.

Long-term stress has a different effect on pain to short-term stress. It can actually ‘ramp-up’ the pain experience. In this situation, the stress chemicals feed into the sensitisation of the pain alarm system.

There are many instances of this in scientific literature, where life’s stressors can increase the pain experience. For example, in students, their pain levels are higher during exam time when they can be super-stressed. In another example, those who are more stressed about dental procedures are more likely to report higher pain levels when undergoing dental procedures. Also, those who perceive they are under greater financial stress are more likely to have higher pain levels.

Clearly, everyday daily stresses can make pain worse. Does this sound familiar to you? Do you find that when you are stressed, your pain can be worse? Biologically, this is completely understandable. Stress can grease the wheels of the pain system. Of course, don’t forget that the pain itself is a stressor, as well as the associated stress of wondering about what the pain might mean or if it will ever go away. This is one reason why treatments such as mindfulness and relaxation therapy can be so helpful for some people with persistent pain.

I would like to set you a homework task for between now and the next part: I would like you to sit down with your friends over a cup of tea and explain your pain to them.

Think about everything you have learned over the past few episodes. Go back and listen again if you wish. I want you to try and explain it to them as clearly as you can. Try to explain the biology if you can. Try and explain why our bodies work this way. Tell them about Assumpta. If you can, come up with your own descriptions and your own way of explaining it. Do this as many times as you can to anyone who will listen.

Once you have done this a few times write the explanation down. See what you come up with. It is difficult to explain this stuff, but nothing helps you to learn information better than having to teach it to someone else. Good luck!

This next section is probably the most important section of the Flippin’ Pain Formula Podcast. We are still discussing that key message: everything matters when it comes to pain.

If you remember, in Episode 3, we discussed the role of scans in people with back pain, and how it is common for scans, even in healthy people with no back pain, to show many anomalies which are easy to misunderstand and wrongly attribute to be an injury or cause of pain. Scientific evidence shows that people with back pain who receive an unnecessary scan soon after their pain begins are more likely to have poorer outcomes in the long-term than people with similar symptoms who don’t get a scan. They end up having higher levels of pain and disability, and are often off work for longer. I don’t know about you, but I find this pretty amazing: the idea that simply having a scan, which has no physical effect on the body, can lead to a poorer clinical outcome.

These are called ‘iatrogenic effects’: it means that your condition is mistakenly made worse by healthcare instead of made better. It is a bit like collateral damage.

So why is this the case? Take five or ten minutes to write down why this may be. If you are doing this with friends and family, ask their opinion. Try to consider the examples we have discussed in earlier sections when coming up with your answer.

Here’s what I think: see if it is close to what you wrote.

Here is my ‘two-second rule’ theory: when I drop a chip on my kitchen floor, I reach down and take a quick look at the floor and the chip. If all looks ok, I pop it in my mouth and say “two-second rule”, meaning it only dropped for two seconds it will not be dirty in such a short space of time on this floor and thus it is perfectly fine to eat. In this case, I don’t let a few floor germs get in the way of my chips. Do you do the same thing?

Now, what if I were to get out a microscope and forensically analyse the state of my kitchen floor where my three young, messy children and I usually eat. This would reveal all the microscopic moulds and larvae and moth eggs and insects etc. It would be like watching a David Attenborough documentary on the Serengeti! If I did this, do you think I would still eat the chip? No way! Would you?

Even though, in reality, 99.9% of the time these things would be harmless (and if anything, might actually help me build up a stronger immune system), nope: I still wouldn’t eat it.

I believe something similar happens with scans. Scans are unbelievably sensitive and are a bit like putting a microscope to your floor. They reveal everything, even the small things that are completely harmless but can look and sound terrifying. When Assumpta hears about these things, such as ‘disc generation’ and ‘wear and tear’, she is more likely to conclude that your back is in danger. Thus, she is more likely to give pain, and more likely to send exciting messages down your spine, increasing the amount of danger messages coming back up and likely leading to more pain: a double whammy. The ‘two-second rule’ is neatly demonstrated by this quote of Pete’s experience of receiving a scan:

“I did actually get to have an MRI scan, and it showed up that I had degeneration of discs in the lower back and two lower vertebrae, and what showed was bone rubbing on bone, really. But the words they used at the time I guess frightened me: they used the term ‘degeneration’. I was thinking, “god, well if I’ve got something degenerative, I better just be really careful with what I do. I better not be too active in case I wear things out even more.

“They also told me, “Your spine is like a digestive biscuit”. Again, I thought if I move at all, I may make things worse. But by not moving, as I found out later on, I actually was making things a little bit worse”.

Imagine that! Imagine telling someone that their spine is like a digestive biscuit. Think about the effect that will have on Assumpta. The healthcare professional couldn’t even pick a more robust biscuit, like a Hobnob! What should Pete do now? Should he avoid tea, just in case his back dissolves?

This description of Pete’s back was completely incorrect, totally misleading, and actually harmful. His back was not crumbling like a digestive biscuit: a nonspecific scan finding age-related changes was taken and misinterpreted, blown out of all proportion. I know this, because I know Pete 15 years on. He is managing his back pain well and has yet to dissolve from drinking too much tea. Spines are strong and it’s inaccurate to describe them as weak or crumbling!

It is not so much having the scan that has the negative affect on a person’s outcome, but it is hearing the results and having those results presented in a way that is poorly explained and sounds terrifying: that is the problem. A really nice study supports this by comparing different ways of giving scan results to patients. In one group, all the various scary microscopic findings were given to the patient in a standard letter. In the second group a statement was put at the end of the standard letter saying the following:

“The following findings are so common in people without lower back pain that while we report their presence, they must be interpreted with caution and in the context of the clinical situation. In people without low back, 91% have some form of disc degeneration.”

On average, those patients who received the results along with the statement had better clinical outcomes. These things make a real difference. Scans have the potential to be misinterpreted in a negative way, and can inadvertently have a really negative effect on the patient. The information is given for no good reason at all, It doesn’t help them, it hinders them. This is what I meant earlier by saying that scans have the potential to be a menace. The scans in themselves are not necessarily the problem, just the results. But what’s the point in having a scan without results? It would be like jelly without ice-cream!

OK: at this point I want you to do the most important activity of this entire podcast. I want you to draw Assumpta’s weighing scales. Underneath the left scales, I want you to write the words, ‘danger in me’ (or DIM for short). Under the right scales, I want you to write the words, ‘safety in me’ (or SIM for short).

Above the left scales, I want you to list all the DIMs that you can think of that might negatively influence you and your Assumpta. These are things that will close the drug cabinet in your brain, and likely increase the pain experience, such as things that can make you worried, angry and frustrated. For example, if you have had a scan, and it said you had degeneration you could write that above the left DIMs scale.

Now, above the right scales, I want you to list all the SIMs that you can think of that might positively affect you and your Assumpta. These are things that will open the drug cabinet in your brain and likely reduce the pain experience, such as things that can make you feel confident and in control of your condition. For example, if you went to your GP and they told you, after carefully listening to your symptoms and a thorough physical assessment, that your back was in good condition and robust despite the pain, you could write that on the right side.

Remember, these don’t have to be biological things: everything matters. For example, what if you were told that you couldn’t come back to work until you were fully fit and that would mean that you could default on your mortgage? How dangerous is that? How worried would Assumpta be about that? Would you believe that there is good evidence to show that people who feel financially insecure experience more pain?

What about if you have wider stresses going on, like family, work, or other health issues? Remember that stress can grease the wheels of the pain alarm system. Try to think of the wider biological, psychological and social context related to you and your pain.

Take your time with this. Spend at least 10 minutes on each side of the scales and remember that everything matters, even if it seems really small and significant. If it comes to mind it is probably important.

How did you get on? Here is a list of DIMs and SIMs that I have created from what people have told me. How does it match to what you wrote?

Common ‘Danger in me’ factors include:

·       “they’ve said my back is full of arthritis”

·       “they don’t know what it is”

·       “they said it is inoperable”

·       “they’ve said it’s my age: and I’m not getting any younger you know!”

·       “what if I can’t go back to work?”

·       “what if this never goes away?”

·       “how am I going to pay the mortgage?”

·       “this happened to my uncle, and he ended up in a wheelchair”

·       “I’ve been told this never really heals”

·       “how will I be able to care for my family?”

Common ‘Safety in me factors include:

·       “my doctor said that it is not serious.”

·       “I’ve been told that my back/neck/leg is strong”

·       “my family have said they will support me”

·       “my brother had this, it was tough but he is fine now”

·       “this happens to most people at some point”

·       “I’ve been told that it is safe and important to keep active”

·       “I’ve been told it is ok to stay at work”

·       “I’ve been told to try and do my usual things”

When it comes to pain, our subconscious brain Assumpta weighs up all of these things. If she decides, on balance, that you are in danger, she will want to draw your attention to it and get you to do something about it. That is her Health and Safety role!

The DIMs that you have put on your list: have a think about them. can any of them be changed or addressed? Can you think of any way to increase the SIMs or to counteract the DIMs?

Thinking about what these factors are, and how they might be influenced, is an important step in understanding your pain: and understanding your pain can be an important step forward in better managing it. Over time, other things may pop into your head, or your thoughts on some of these things may change. If so, you should come back and update your list.

This is your homework between now and the next episode. I want you to spend another ten or fifteen minutes pondering your list and thinking if there’s anything you would change or add.

A key thing to remember is that change is rarely immediate when it comes to pain: remember what I said in the introduction. Change can take time, but it might not take as long as you think. You cannot consciously just decide to tip the scales.

Do you remember when we talked about how the eyes can deceive you? The subconscious takes over. However, just as your alarm system can learn over time that the situation is dangerous and it needs to protect you, it can also learn over time that the situation is safe, and it does not need to protect you! Neuroplasticity has been part of the problem, but it can also be part of the solution, given time and encouragement.

Let’s finish off by reminding ourselves of the key message from this episode:

The pain we experience is always real and it is always influenced by a combination of our biology, our psychology and social factors.

OK: thanks for listening and we will catch you in Episode 5 of the Flippin’ Pain Formula Podcast.