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  • Writer's pictureDavid Wilderman

Is Pain All In Your Head?

Updated: Oct 2, 2023

We can’t avoid it.  At some time or another, most of us will experience pain of some sort that could potentially be debilitating.  Some individuals tolerate pain much better than others.  But why is this so?  And where is the pain originating?  Can it be that it is all in our head?

What is pain?

Pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage,” according to The International Ass

ociation for the Study of Pain.  So based on this definition, pain can arise from actual injury to a tissue (i.e., muscle, tendon, bone) or the potential for injury to a tissue.  Regardless of whether the damage is actual or potential, one thing is certain–individuals will perceive pain as real!

How is pain understood?

Pain is one of the main symptoms causing an individual to seek medical help from a Physical Therapist or other health care professional.  But our understanding of what pain is, why it occurs, and where it originates has changed significantly over the past 8-10 years.  10-15 years ago it was thought that pain originated at the level of the tissues (e.g. if you hurt your elbow, pain signals originated at the level of the elbow).  It is now generally thought that pain is not perceived until the brain concludes there is a potential threat to those tissues.  In other words, if you injure your elbow then danger signals originate at the level of the elbow.  Those pain signals are then relayed to the brain, and the brain determines if it needs to respond by sending an output of pain.  And this response is extremely individual, meaning what causes one individual’s brain to respond may not cause another’s to do so.

As a result in this shift in pain perception, the approach to how Physical Therapists determine your care has changed as well.  While many health care fields focused on the treatment of individual tissues in the past, many Physical Therapists are starting to adopt a bio-psycho-social model of pain treatment.  This means that Physical Therapists will no longer focus solely on the tissues of the body (bio), but now also account for psychological and social factors that can be influencing the amount of pain you are experiencing.  This would include incorporating aspects of work or sport into your rehab program (assuming you injured yourself at work or participating in physical activity), as well as discussing any fears you may have regarding movement, and helping to give you the confidence to once again move safely.

How is pain described?

We know that everyone perceives pain differently.  Even though Physical Therapists attempt to “quantify” the pain by having the individual assign a number to the intensity of pain one is experiencing (“rate your pain level on a scale of 0 to 10, with 0 being “no pain” and 10 being “emergency room, call 911” pain), pain is still subjective–what is labeled a “7/10” pain by one person might be labeled a “3/10” pain by somebody else.  We often hear people say “I have a high pain threshold,” but because pain is subjective, science has not developed accurate ways to measure pain tolerance. There are generally 2 ways that a Physical Therapist categorizes your pain:

1. Time-based is the most standard classification of pain, and is simply how long you have experienced your pain: Acute pain is pain experienced for less than 3 months.   This type of pain is usually from a nociceptive trigger (see triggering mechanisms below), where you generally feel the discomfort locally at the injured tissue.  This pain increases when the injured tissue is stressed or provoked, and decreases when that trigger is removed.  As an example, if you injured a tendon in your shoulder and you attempt to reach your injured arm over your head, you may experience pain (due to compression, pinching, or stretching of that tendon during the overhead movement).  When you bring your arm back down, and tension is released, the pain generally lessens or temporarily disappears.

Chronic pain is pain experienced for more than 3 months.  This type of pain is often a result of a central sensitization mechanism (see triggering mechanisms below), which often results in widespread, unpredictable pain.  People who experience this type of pain may be hypersensitive to even the slightest triggers.  Chronic pain is also very often related to psychological factors and has been identified as a characteristic of chronic low back pain, chronic fatigue syndrome, whiplash, TMJ disorder, osteoarthritis, rheumatoid arthritis, and fibromyalgia.

The problem here is that these terms are used to categorize your pain, but they don’t state the cause of your pain.

2. Triggering mechanism states what could be causing your pain, whether from a specific part of the body (localized) that is aggravated by certain movements (meaning the pain has a clear mechanical nature–called nociceptive triggers), pain arising due to damaged or diseased nerve tissue (called a peripheral neuropathic trigger), or pain that is usually not mechanical in nature and unpredictable in response to factors that normally increase or decrease pain (called a central sensitization trigger).

According to research, pain may also result in the following deficits:

Catastrophizingan exaggerated, negative orientation toward pain (“Due to this pain, I feel that I can’t go on”).

Kinesiophobiava fear of moving or exercising (“I’m afraid to return to exercising”).

Fear-avoidanceIntentionally not performing movements or activities due to a belief about the potential negative consequences those particular movements or activities would have (“My work might irritate my back”).

Inability to move as freely as possible Muscle Weakness Difficulty performing daily activities

How can Physical Therapy help?

First and foremost, your Physical Therapist should formulate a specific treatment plan based on your individual level of pain, symptoms, deficits, and goals.  That being said, evidence suggests that simply understanding pain through educational means (such as reading this blog post!) may result in decreased symptoms (“Know pain, know gain!”).  Additionally, your

Physical Therapy treatment plan should include:

Manual therapy – this is specific, hands-on techniques that may include procedures such as mobilization, manipulation, muscle energy techniques (MET), myofascial release, and other such approaches designed to increase motion and decrease pain.

Flexibility and strengthening exercises – you may have heard the phrase “Move it or lose it!”  Mobility and strengthening (in moderation) can significant help you to reduce your symptoms.

Take-home message

Pain is generally unavoidable, as most of us will experience some form of debilitating discomfort at some point in our lives (kudos to you if you’re not in this category!).  We must ultimately realize that pain is our body’s way of telling us that there is a problem.  However, since we all have different perceptions of the intensity of pain, we sometimes minimize or avoid altogether the warning signs which, if unaddressed, can lead to dire consequences down the road.  All the more reason to see a Physical Therapist before you reach the point where pain has affected and altered your lifestyle and has caused you to miss out on activities that you love and enjoy.  Remember these important points:

Regular exercise is important – we know that exercising on a routine basis has many health benefits, one being the improvement of the conditioning of the nervous system, which is responsible for sending pain messages


Relaxation and Imagery exercises can be helpful oftentimes pain can be triggered by noxious stimuli such as stress, uncomfortable situations, and loud noises, all leading to a heightened nervous system.

Bed rest is not always the best thing – this is one area where the thought processes have drastically changed.  We now know that prolonged bed rest (more than 2 days) can actually increase your pain and lead to other medical complications.

Education is critical – by better understanding what pain is and why it occurs, we can better guide our movements and activities.

If you or someone you know is experiencing pain, don’t wait before you lose mobility, independence, or are no longer able to participate in an activity that you love and enjoy.  Be proactive and call our office at (302)691-9055 or visit our website at to schedule your FREE 30-minute consultation to see how Physical Therapy can help.  Don’t delay–schedule now!Image by Steve Buissinne from Pixabay

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