For decades, the prevailing treatment of chronic pain has been based upon the biomedical model of pain. The biomedical model of pain suggests that there is a lineal relationship between tissue damage and pain. In simple terms, the more damage there is to a tissue, the more pain you will experience. Therefore, once you resolve the underlying tissue damage, e.g. through surgical intervention, the pain should also resolve. Say that you injured your back at work, lifting a heavy object off the floor. Your first stop is your GP, who would then send you off to get scans done of your lower back. Upon getting the scans back, the doctor would then invariably tell you, ‘Oh, this doesn’t look good, you’re going to require surgery to fix that.’ The doctor would then send you off to see the surgeon, the surgeon would operate, repair the damage, and just like that, you’d be pain free. Or would you?
In reality, many patients who undergo surgery still experience pain, despite their injuries having been repaired. If the biomedical model of pain held true, these patients should be pain free. It became clear within the medical community that the biomedical model was lacking, it was an unreliable model to explain pain, and over the years this began to become evident within scientific literature. Increasingly, studies have shown there to be a poor correlation between tissue damage and experiences of pain, and that correlation only gets weaker the longer pain persists[1]. For instance, two reviews of MRI imaging of the spine, one of the lower back[2] and one of the neck[3], found evidence of spinal degeneration in large proportions of populations of people who do not have symptoms of pain or disability. Another study comparing MRI imaging of both shoulders in people who presented with one-sided shoulder pain found that abnormal findings in the painful shoulder were commonly also found in the non-painful shoulder[4]. This is not to say that tissue damage does not cause pain, because it can, but rather it isn’t the whole picture of chronic pain. It would be as if Leonardo da Vinci only painted the background of the Mona Lisa and called it a day.
So if tissue damage is the background of the Mona Lisa, what makes up the rest of the painting? Well, the rest of the painting, and what we now understand about pain, is conceptualised within the biopsychosocial (BPS) model of pain. First theorised by George Engel in 1977[5], the BPS model of pain recognises that pain is real, that pain is complex, and most importantly, that pain is influenced by many different factors, not just tissue damage. These factors can include your personal thoughts and beliefs about your pain or the cause of your pain, your sleep quality, whether you have depression or anxiety, your sex, or the level of support you receive from those close to you[6]. This isn’t an exhaustive list of factors that can influence your pain experience, and not every single factor will be relevant to your pain experience. However, each of them is another brush stroke, together forming the complete picture.
Now, if you were to ask anyone what made the Mona Lisa the world’s most famous painting, they would tell you it was the smile. Therefore, the brush strokes that make up the smile are arguably more important than the brush strokes elsewhere on the canvas. If you were to paint your own Mona Lisa, the brush strokes that would make up you your smile would be unique to you, just as the factors that are central to understanding your pain experience would be. No one pain experience is the same and therefore can’t be treated as such; what might factor greatly in one person’s experience with pain might be completely irrelevant in another’s. On your own, it can be a daunting, near impossible task to determine what factors might be influencing your pain, and which aren’t, however, know that you do not have to undertake this journey alone. As exercise physiologists, we can help you sift through each of these factors, determine what might be contributing to your pain, and most importantly, help you get back to a life uninhibited by pain.
It’s time to stop thinking of pain as a direct correlate of tissue damage and start thinking about what else might be contributing to it.
It’s time to ask, what makes up your Mona Lisa’s smile?
If you have any questions, concerns, or feel that we may be able to help you with your pain, please don’t hesitate to slide into our DMs on instagram or facebook, or send us a message through the website.
References
[1] Moseley (2007) Physical Therapy Reviews. 12
[2] Brinjiki et al (2015) Am J Neurosurg. 36(4)
[3] Nakashima et al (2015) Spine. 40(6)
[4] Barrett et al (2019) JSES. 28(9)
[5] GL Engel (1977) Science. 196(4286)
[6] Meints & Edwards (2018) Prog Neuropsychopharmacol Biol Psychiatry. 87(Pt B)
