In 2003, a 13-year-old girl by the name of Bethany Hamilton was attacked by a tiger shark at her home surf break in Kauai. Luckily she was around family members and other surfers in the lineup who took her to safety and stabilized her until emergency professionals arrived. She ended up losing her whole left arm as a result.

Despite the injury she has since continued a career in surfing and has become one of the elite champions in the sport. I’ve watched and read interviews of her recollection and I’m amazed at her description of the event. When it occurred, she reported that she felt normal during the experience, and did not feel very much pain from the bite at the moment, and actually was numb all the way to the hospital. This speaks to the amazing phenomenon of pain.

The Physiology of Pain

Pain is a conundrum. It can be overwhelmingly paralyzing and encompass all of our attention, it can be insidious, slowly building momentum until we finally notice, it can manifest only when our attention is drawn to a previously unknown injury, or it can never occur at all even when we know it should. Essentially, pain is whatever the person with pain says it is.

To understand this, we must understand that pain is a result of physiologic context of the brain and the environment. Pain was initially defined by a tissue-based model, where it is a result of some dysfunction in the surrounding tissue where the sensation is felt. Modern pain scientists such as Robert Melzack, Eyal Lederman, and Cary Brown are shifting away from this model and determining that pain, and more so chronic pain, results from the nervous system being alerted of a threat to the body.

Modern pain science describes pain as coming from three pathways, nociceptive, peripheral, and central.

These three categories are collectively described in a theory called the neuromatrix theory of pain. This idea proposes that “pain is a multi-dimensional experience produced by characteristic “neurosignature” patterns of nerve impulses generated by a widely distributed neural network.”This means that there are pathways in the brain which when collectively activate, manifest the experience of pain.

Nociceptive pain is the normal acute pain you feel when you stub your toe for example. There is a physical stimulus to a region of the body, and that stimulus travels up a ‘nociceptive’ (pain) receptor to the brain where we interpret it as pain.

Peripheral sensitization is more an explanation into the realm of chronic pain. This occurs when there is no longer a physical insult to the body, but the nervous system has an amazing memory and it remembers the insult. What the nervous system does is simulate the sensation of pain and is trying to prevent us from recreating it.

It does so by sensitizing the same pain neurons that were turned on during the initial injury. As a result, even though the tissue that was initially damaged is healed, the neural ‘pain’ tracts that run up to the brain are still firing.

Central sensitization is an explanation of pain that occurs for seemingly no reason at all, in difficult pain syndromes such as fibromyalgia and chronic regional pain syndrome. Normally the brain acts as a filtration system that filters stimuli that is coming from all parts of the body. This is necessary to be able to respond to change in our environment appropriately, we use this aspect of the brain to be able to function normally.

In central sensitization this filtration system in the brain is dysfunctional, and we no longer are capable of differentiate painful from non-painful stimuli. So someone can interpret what is normally a non-noxious signal as severely painful.

The Neuromatrix of the Brain

We are beginning to shift away from a strict tissue based biomechanical model and learning more about the neuromatrix of the brain. This is important because it is giving us a better understanding on what and why things work. The resolution of change doesn’t come from healing broken tissue but from having a conversation with the nervous system and promoting changes from aberrant pathways.

There are numerous ways to support this change, and it includes manual therapy (adjustments, massage, etc.), biochemical ‘persuasions’ (medications, supplements, regenerative injections therapies, neural therapy, etc.) and mindfulness practices.

In the end providers don’t make those changes in neurology, the body does. We cannot force it to change but only learn to speak its language.

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