Understanding Chronic Pain: A Comprehensive Guide to Mechanisms and Management

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Understanding Chronic Pain: A Comprehensive Guide to Mechanisms and Management

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What is chronic pain and why does it persist?

Chronic pain affects one in five Canadians. If you're reading this article, chances are you or someone you love is living with pain that never seems to go away completely. The good news? Modern science now allows us to better understand why pain persists—and, more importantly, how to manage it effectively.

Chronic pain is not simply acute pain that lasts longer. It is a different phenomenon that involves changes in how your nervous system processes signals from your body. Understanding these mechanisms is the first step toward better managing your condition.

Whether you suffer from persistent shoulder pain, chronic back pain, knee pain that won't go away, or chronic neck pain, the principles you are about to discover apply to all forms of persistent pain.

How does the brain produce pain?

Pain: a sophisticated alarm system

Contrary to what many people think, pain is not simply a signal traveling from your injury to your brain. It is a complex experience created by your brain to protect you.

According to the official definition of the International Association for the Study of Pain (IASP), pain is "an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage."

Two key elements stand out from this definition:

Pain always has an emotional component —it is never purely physical.
Pain can exist without actual injury —your brain can produce pain if it perceives a potential threat.

Think of your pain system as a highly sophisticated smoke detector. Sometimes it goes off because of a real fire. Other times, it goes off simply because you burned your toast. The detector doesn't know the difference—it reacts to anything that looks like smoke.

Why pain persists after tissue healing

Here's something that many people don't know: most of the tissues in your body heal within 3 to 6 months. However, pain can persist well beyond this period. How can this paradox be explained?

The answer lies in a phenomenon called sensitization —what researchers consider to be the "jewel of modern pain science." When your nervous system is exposed to pain for a prolonged period of time, it can become more sensitive—a bit like having the volume of your alarm system permanently turned up. The longer the pain lasts, the more it tends to perpetuate itself, regardless of what caused it in the first place.

This awareness can occur at two levels:

Peripheral awareness The pain receptors in your tissues become more responsive. Stimuli that did not cause pain before can now trigger it. Central awareness Your spinal cord and brain amplify pain signals. The system becomes "over-vigilant," interpreting even normal sensations as potentially dangerous.

This is why a person with chronic pain may experience intense pain from a simple touch (allodynia) or pain that is disproportionate to the stimulus (hyperalgesia).

The biopsychosocial model: understanding all dimensions of pain

Beyond the body: factors that influence your pain

Modern research has shown that pain is influenced by three main categories of factors:

Biological factors:

The condition of your tissues and joints
Inflammation
Your genetics
The quality of your sleep
Your level of physical activity

Psychological factors:

Your beliefs about pain
Your thoughts and concerns
Your stress and anxiety levels
Your emotions
Your confidence in your ability to heal

Social factors:

The support of your family and friends
Your work environment
Your relationships with healthcare professionals
Your financial situation
Access to healthcare

These three dimensions interact in complex and variable ways. Two people with exactly the same injury may experience completely different levels of pain depending on their biopsychosocial context.

The glass of water: Understanding your capacity

Imagine your ability to handle stressors as a glass of water. Each stressor—lack of sleep, tension at work, financial worries, family conflict, physical pain—adds water to your glass.

When the glass overflows, you feel pain. And here's the crucial point: it's not necessarily the last stressor that is "the cause." It's the accumulation of all the factors that causes the glass to overflow.

That is why:

Sometimes a small thing can cause great pain (your glass was already almost full).
Two people with the same injury may have very different experiences (their glasses were not equally filled).
Your pain may vary from day to day for no apparent reason (the water level in your glass fluctuates).

What fills your glass:

A doctor who says, "Your spine is very worn out."
Avoiding any activity for fear of aggravating the condition
Reading catastrophic stories on the internet
Feeling lonely and misunderstood
Stress at work or family conflicts
Lack of sleep

What enlarges your glass:

A professional who explains that wear and tear is normal with age
Do gentle progressive exercises
Learning that most pain improves
Having the support of loved ones who understand
Calm environment and positive relationships
Sleep well and manage stress

This understanding is liberating: you have many ways to influence your pain, not just physical treatments.

10 mini-tips to understand your pain

Those who have had the greatest impact on my patients' lives. 1 per day, 2 min.

The different types of chronic pain

Persistent nociceptive pain

Nociceptive pain comes from the activation of pain receptors in your tissues. It can persist when there is ongoing tissue irritation, such as in osteoarthritis or certain tendinopathies.

This type of pain generally responds predictably to movement and activity. Rest relieves it, and certain movements consistently aggravate it.

Neuropathic pain

Neuropathic pain results from damage or disease to the nervous system itself. It is often characterized by sensations of burning, numbness, tingling, or electric shocks.

Conditions such as sciatica, cervicobrachial neuralgia, or carpal tunnel syndrome can involve this type of pain.

Nociplastic (functional) pain

Nociplastic pain is perhaps the least understood, but it is very real. It occurs when the pain system itself becomes dysfunctional, producing pain without clear tissue damage and without damage to the nervous system.

Fibromyalgia is the best-known example of this type of pain. People who suffer from it experience widespread pain, often accompanied by fatigue, sleep disturbances, and difficulty concentrating.

This type of pain is not "all in your head" — it reflects real changes in how your central nervous system processes information. The good news is that these changes are reversible with the right approaches.

Common myths about chronic pain

Myth 1: "Pain equals damage"

Reality Pain is more a matter of sensitivity than tissue damage. Your level of pain is not a reliable indicator of the condition of your tissues.

Studies show that people with significant disc herniations on their MRI scans may have no pain, while others with normal imaging may suffer greatly. Even more surprising: some people with severe spondylolisthesis (one vertebra slipping over another) have no symptoms. The correlation between what we see on imaging and what you feel is often weak.

Another revealing paradox: typical back pain peaks in people in their 30s and 40s, then often decreases in their 50s and 60s—exactly the opposite of what one would expect if the pain were mainly caused by age-related wear and tear.

Myth 2: "If I've been in pain for a long time, I'll always be like this."

Reality The duration of pain does not predict your ability to improve. Thanks to neuroplasticity—your brain's ability to remodel itself—your nervous system can "unlearn" chronic pain.

Many people who had been suffering for years managed to significantly reduce their pain by understanding these mechanisms and applying the right strategies.

Myth 3: "I need to rest to get better."

Reality Excessive rest is often counterproductive for chronic pain. Avoiding movement can actually maintain and amplify your pain by reinforcing fear and decreasing your physical condition.

Exercise tailored to your condition is one of the best tools for managing chronic pain. It helps to "recalibrate" your nervous system and show it that movement is safe.

Myth 4: "It's psychological, so it's not real."

Reality Pain is always real, regardless of its cause. The fact that psychological factors influence your pain does not make it any less legitimate or intense.

Your brain produces all pain—whether triggered by a fracture or intense stress. Both are equally real and deserve to be taken seriously.

Need professional advice?

Our physical therapists can assess your condition and offer you a personalized treatment plan.

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How does physical therapy help with chronic pain?

Physical therapy offers a comprehensive approach to managing chronic pain by working on several dimensions:

Pain education

Understanding why you are in pain is therapeutic in itself. When you understand that your pain does not necessarily mean you are hurting yourself, your brain perceives less danger—and often produces less pain.

Physical therapists trained in pain neuroscience can help you demystify your condition and reduce the fear associated with your symptoms.

Graduated therapeutic movement

The goal is not to "push through the pain," but to gradually reintroduce movements that you may have been avoiding. This gradual exposure helps your nervous system relearn that movement is safe.

Your physical therapist can design an exercise program tailored to your condition, pain level, and personal goals.

Manual approaches

Manual therapy can offer temporary relief and contribute to your recovery. It works by activating your natural pain modulation systems.

However, manual approaches alone are rarely sufficient for chronic pain. They are most effective when combined with exercise and education.

Work on psychosocial factors

Modern physical therapists are trained to identify and address psychosocial factors that contribute to your pain, such as:

Limiting beliefs about your condition
Fear of movement (kinesiophobia)
Avoidance strategies
Catastrophizing (tendency to imagine the worst)

These factors can create a vicious cycle: pain generates fear, fear leads to immobility, and immobility amplifies pain. Each element reinforces the others. Breaking this cycle—often through gradual exposure to movement—is a key goal of treatment.

When these factors are significant, your physical therapist can help you directly or refer you to other appropriate professionals.

When the healthcare system is part of the problem

Diagnoses that scare people

Sometimes, the healthcare system itself can contribute to maintaining your pain—unintentionally. Certain diagnoses or explanations can amplify your perception of danger:

"Your spine is very worn out."
"You have three herniated discs."
"Your cartilage is destroyed."
"You should avoid lifting more than 5 kg."

These phrases, even when spoken with good intentions, can create an image of fragility that increases fear and avoidance. However, as we have seen, most of these "anomalies" are normal and do not correlate with pain.

Treatments that maintain dependency

Some treatment approaches, although providing temporary relief, can maintain chronic pain in the long term:

Repeated passive treatments without progress toward independence
The systematic avoidance of any "risky" movement
The endless search for a structural diagnosis that "explains everything"
Interventions that reinforce the idea that your body is fragile

A good healthcare professional should give you the tools to take care of yourself, not make you dependent on frequent visits indefinitely.

How to recognize good care

Modern management of chronic pain should:

Educate yourself about the mechanisms of pain
Reassure yourself about the strength of your body
Guide you through progressive exercises that you can do on your own
Address psychosocial factors when relevant
Aim for independence, not dependence

If you have any doubts about your current treatment, check out our article How do I know if I am receiving the right physical therapy?

Practical strategies for managing chronic pain

Take an active approach

Rather than enduring your pain, take control of your recovery. This involves:

Do your exercises regularly
Maintain an appropriate level of physical activity
Apply the self-management strategies you have learned

Passive approaches (massage, manipulation, medication) may help temporarily, but active strategies are what produce lasting change.

Manage your pace

Many people with chronic pain alternate between periods of overactivity (when the pain subsides) and collapse (when the pain increases). This "boom and bust" cycle keeps your nervous system sensitized.

Pacing involves maintaining a stable and predictable level of activity, avoiding extremes. This helps to "recalibrate" your nervous system.

Take care of your sleep

Sleep plays a crucial role in pain modulation. Poor sleep increases sensitivity to pain, creating a vicious cycle.

Simple strategies can help:

Maintain regular bedtimes
Limit screen time before bedtime
Create an environment conducive to rest
Consult if you have significant sleep problems

Cultivate understanding and acceptance

Accepting pain does not mean giving up or resigning oneself. Rather, it means acknowledging the current reality while actively working toward greater well-being.

Constantly resisting your experience of pain ("why me?", "it's not fair," "I shouldn't be in pain") often amplifies the suffering. Acceptance allows you to redirect your energy toward constructive actions.

Stay socially connected

Isolation is a major aggravating factor in chronic pain. Maintaining social connections, even when it is difficult, is protective.

Please feel free to:

Communicate with your loved ones about what you are going through
Join support groups
Maintain social activities, even if adapted

Consult the right professionals

Complex chronic pain often benefits from an interdisciplinary approach. Depending on your situation, your healthcare team may include:

Physiotherapist
Family doctor or pain specialist
Psychologist specializing in pain
Occupational therapist
Nutritionist

A good professional will give you the tools to take charge of your own health, rather than making you dependent on repeated passive treatments.

When should you consult?

Consult a healthcare professional if:

Your pain persists beyond a few weeks
It significantly interferes with your daily life.
You avoid important activities because of pain
Do you feel discouraged or overwhelmed by your condition?
You have "red flag" symptoms (unexplained weight loss, fever, progressive weakness, sphincter disorders).

The sooner you seek medical advice, the more likely you are to prevent your pain from becoming chronic.

Key takeaways

Chronic pain is real —it reflects real changes in your nervous system.
Pain does not equal damage —your pain level is not a reliable indicator of the condition of your tissues.
The brain produces all pain —which means that the brain can also modulate it.
Biopsychosocial factors are all important —it is not a question of choosing between the physical and the psychological.
Change is possible — thanks to neuroplasticity, your nervous system can recalibrate itself.
You have power —active strategies produce the best long-term results.

Chronic pain is a challenge, but it is not a sentence. With the right understanding, support, and strategies, the vast majority of people can significantly improve their quality of life.