What is Persistent Pain?
Let’s start by discussing what pain is.
It may surprise you to know that pain is actually a very useful thing. Pain’s main job is keep us out of harm’s way and protect us. Interestingly, it is not something we are normally taught about - we tend to learn it through experience. If you can think back to when you were a child, you may have found yourself touching something hot and burning yourself; your body would learn through that experience that touching hot things can be painful and you would then learn to be a bit more cautious touching them in the future. In other words, the painful experience has taught you not to touch things that are too hot as they might harm you.
This rather simplified way of describing how pain works is generally what most people (even some of us healthcare professionals) understand and accept about how pain works. However, through research (experiments and investigations on people with and without pain), we now know it is much, much more complicated than this.
So, are there are different types of pain?
Yes there are.
You may have heard of the terms ‘acute’, ‘chronic’ or ‘persistent’. We will be focusing on persistent pain in this discussion.
What is acute pain?
Acute pain is short-term and tends to be more associated with damage or possible damage to your body. For example, if you sprain your ankle it is likely you will feel pain. The pain will be a useful part of the healing process as it will make you use the ankle differently (not stand for so long or limp when walking) whilst it gets on with the job of healing. This is acute pain. Usually it will settle as your body heals, because the affected part no longer needs protecting. Healing usually takes less than three months, even for quite severe injuries. Think of acute pain as useful - it can help you learn i.e. try not to step in rabbit holes and twist your ankle again!
To use an analogy, think of pain and your nervous system (which controls it) as a stereo amplifier where the volume can go up and down. Normally, the volume will sit at 0 most of the time, but if you hurt yourself, the volume will turn up to make you aware that something hurts and you need to do something about it. Normally, the volume (let’s say it gets turned up to 5) doesn’t stay that loud for more than a few weeks and will gradually turn itself down to 0 as the healing is completed. This is the ‘pain system’ working normally.
What is persistent pain?
Firstly, the term ‘persistent’ is simply a term that is used in healthcare to describe how long your symptoms have been with you. The term ‘persistent pain’ is used to describe pain that has been with you for longer than three months. It is not a term used to describe the severity or how bad your symptoms are. We tend not to use the term ‘chronic’ very much anymore, as it tends to give the impression of things being worse or unable to be changed.
Persistent pain is essentially pain that has outlived its usefulness. In other words, it is pain that is hanging around after the healing process has completed. Most pain starts because of a reason (twisting ankle/touching something hot etc.) and as described above in the ‘What is acute pain?’ section, this pain will normally settle within a number of weeks once the healing is complete. Persistent pain tends to continue after the healing has completed and therefore does not have a strong link to the healing process. It is something that goes ‘wrong’ in the nervous system which essentially keeps the pain going for longer than is needed.
Using our stereo amplifier analogy again, persistent pain is when the volume gets turned up (normally after an injury or sprain/strain) but gets ‘stuck’ i.e. stays at 5 instead of turning back down to 0 when the healing is over. Essentially, the pain system is turned up or ‘sensitised’. This is the pain system not working normally.
Why are you telling me about this?
Pain is such a complicated thing and one of the main things in being able to manage it better is to understand it better. This is why we’d like to help you understand what might be happening with your pain and help you move forwards with dealing with it.
So, when you have an injury (touching something really hot or a sprained ankle), information messages are passed by your nerves from the body part you have injured, up to your brain where it does some really interesting things with the information. Your brain will look at a number of things at the same time as looking at the messages coming from your injured body part. Amongst many other things it will look at: the situation you are in (are in you danger or are you safe); how you are feeling (are you scared, feeling threatened or calm and relaxed); who you might be with (friends or someone you don’t like); your ‘pain’ memories (have you done this before or have you heard about someone doing the same) and your beliefs about pain (“oh no, am I going to be able to work again?” or “my grandmother had this and she was in real trouble” or “it’s probably just a muscle tweak”). It takes all this information and in a fraction of a second makes a decision if something needs to be painful. You’ll see why this is important later on in the discussion.
Hold on, have you just said that my brain tells me when something is painful?
In short, yes. In other words, without your brain, there would be no pain. Your brain, along with all of your nerves, forms your ‘pain system’ and it will decide for you what needs to be painful and what doesn’t.
I’m struggling with this, can you help me understand what you’re trying to tell me?
Its ok - remember, understanding pain is a very difficult thing as we’ve all been brought up to think of it of a simplistic thing i.e. damage = pain (see ‘What is acute pain?’ section). However, think for a moment about if you have ever had a bruise on you that you have no idea how it got there, or have cut your finger but only notice it when you wash your hands. You would expect that you would have felt pain when you bruised or cut yourself, but you didn’t. Weird, isn’t it? It goes to show how amazingly complicated and unpredictable pain can be, and is a good example of your brain making a decision for you about if something needs to be painful or not.
Any more examples to help me understand this a bit better?
Sure. Think of a paper cut - normally small but surprisingly sore. It’s often the same with a mouth ulcer, often small but really, really uncomfortable. Now think of the times you may have heard of people having serious injuries (broken bones, unpleasant diseases) but have felt no pain. This shows that pain is not consistent and is very hard to predict. In other words, pain can be a poor indicator of what is actually going on in your body.
A great example of how damage isn’t always as well linked to pain as you would think is the story of surfer Bethany Hamilton. In 2005, she had her arm bitten off by a tiger shark whilst surfing in Hawaii, but despite losing her arm up to the shoulder, she reported very little pain during the incident. It appears that her brain made a decision for her at the time to limit the pain she felt to allow her the ability and clear mind to paddle to shore to safety and not get completely eaten. Click the button below to read the full story.
So, just to get this straight, my persistent pain might not be linked to my body being damaged?
While persistent pain may feel a lot like acute pain, it tends to act differently.
With persistent pain, simple things like movement, touch or cold can sometimes be enough to cause you pain. It is normal to think that these things may be causing you harm, especially if they are painful, but they are not. As discussed earlier, with persistent pain your ‘pain system’ can be sensitised or ‘turned up’, which may make simple, normal things like touch or movement being felt more strongly and may even result in pain. The pain is associated with the sensitised ‘pain system’ rather than your body tissues.
Let’s use our stereo amplifier analogy again. If the volume is stuck on high (as is the case in persistent pain), you may find the music harder to ignore, difficulty focusing on things, and it may distort which makes it sound unpleasant to your ears. Generally, with the volume too loud it gets in the way and interferes with you doing or enjoying normal things. This is a bit like the pain being hard to ignore and getting in the way of the things you want to do.
But my scan or X-ray says I’ve got arthritis/disc bulge, so we know what’s causing my pain, right?
Unfortunately, as you might have guessed, it isn’t always that simple. X-rays and scans are often very useful in helping see what you look like on the inside, but there is a growing amount of research showing that lots of common ‘abnormalities’ are seen almost as much in people WITHOUT pain, as those with.
In a large study in 2015, Brinjikji and colleagues looked at CT scans and MRI scans of over 3000 people of different ages. They found, amongst other things, that at the age of 30 around 40% of people had disc bulges; that at the age of 60 nearly 90% of people had disc degeneration; and by the age of 80 nearly 85% of people had arthritis in their lower backs. The most interesting thing about this study was that all of the scans and all of the patients had NO BACK PAIN! In other words, all of the ‘abnormalities’ detailed above were found in pain-free people with no history of back issues.
Why is this relevant to me?
Great question. The reason why it might be relevant is that this page is aiming to try and help you understand a bit more about the interesting world of pain and this might mean that we challenge your understanding of what it is, and even why you think you are in pain. In other words, good healthcare and effective rehabilitation will look to help you, not your diagnosis or your MRI scan result.
OK, so I think I agree that I might have persistent pain, should I be worried about it?
Let’s be clear - persistent pain is not dangerous and it is not something you choose.
Of course, it is important that you consult with your GP, nurse practitioner or physio to rule out any other causes for you still being in pain. Normally a thorough assessment (talking and possibly a physical assessment) is enough to rule out most concerns. Scans and imaging are not normally required unless specific concerns are raised.
If no other obvious cause can be found to explain your pain, then it is likely that it will be persistent pain that you are suffering with.
I’m finding all of these words difficult and I’m struggling to understand.
That’s fine - it might be useful to explore different ways of understanding what is a difficult subject.
Do remember to come back to this page once you’ve finished exploring different ways of understanding about pain.
Try these excellent websites:
Or try these short videos (3 to 5 minutes):
Understanding Pain: Brain Man Stops His Opioids
Understanding Pain: Brain Man Chooses
Understanding Pain in Less Than 5 Minutes
Tame the Beast
The Mysterious Science of Pain
Persistent Pain Explained
Or try these booklets (longer reads):
OK, some of this sounds like me, but what can I actually do about it?
Well, trying to help and move forwards with persistent pain is often more difficult than with something like a twisted ankle. Thankfully, we (most healthcare professionals) know that persistent pain is different to acute pain and therefore requires a different approach to management.
You now have some options:
- You can explore the separate pages that we have created to help break down the steps towards managing persistent pain. Click the button to be taken back to the main 'Understanding Pain' page.
- If you have had your interest peaked and think you would like to move forwards with your management but prefer a different approach to your rehabilitation, you can consider attending our free NHS ‘Live Well with Pain’ webinar that we run jointly with the Wellbeing Service. You can refer yourself here.
- You can discuss your options or any thoughts, concerns or questions you have about pain and what the next step might be with your physiotherapist. Contact us on: