Chronic Pain? How to address persistent pain.
Shoulder Pain

What exactly is chronic pain? Well, the easy answer is “pain that has been going on for a while”. But let’s dive into the details a bit. We’ll try to provide a high-level explanation of pain & chronic pain and what the research shows is effective in treating it.




So, let’s start with pain. Take a look at the official definition of pain according to the International Association for the Study of Pain: “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”[5] Simply put, our sensory system (like our brains) create the sensation of pain to protect us from tissue damage or the threat of tissue damage. So, if our brain thinks something could potentially cause damage, we can still feel pain.



How does this work? Normally, our pain response results from acute tissue damage [1]. For example, touching a hot stove causes pain because the burner damages the skin and other tissues. The heat from the stove stimulates nerves that send a signal to your brain, and your brain says “Oh, this is causing damage. We need to get out of this.” So you get the feeling of pain, and that’s usually enough to get you to jerk your hand away from the stove. There was a threat. Your nervous system put out the alarm. And your body responded. And so, you save your hand from burning to a crisp. That’s the way it’s supposed to work.


Sometimes, however, our brain and sensory system get it wrong. There is a great example of this happening where someone was working at a construction site and fell on a nail. The nail was sticking right out of the top of their boot. The person was in agony, saying that every tiny movement of their foot caused searing pain in the foot. When they got the person to the emergency room and cut the boot off, they noticed something interesting: the nail had gone through the boot, but in between the person’s toes, not even breaking the skin of any of their toes. So they shouldn’t have experienced any pain, because there was no tissue damage, yet, they experienced high levels of pain until they saw that the nail didn’t pierce the foot.


So what about chronic pain?


Unlike, acute pain resulting from tissue damage, chronic pain is more complex. Tissue damage (like a burn) may still play a role in this type of pain, but often, there is no structural damage causing the pain [1]. In fact, many times, people experiencing chronic pain have pain long after the timeframe for normal tissue healing. Basically, this means that you’re experiencing pain, which means the nervous system is sending out the alarm signal, even though there isn’t any tissue damage taking place.


Interestingly, some studies suggest that in many patients experiencing chronic pain, there is often no identifiable anatomical cause of pain [2]. Since pain is a protective mechanism created by the brain to alert us to bodily threats, sometimes we may experience pain even when there is no actual threat to the body [3]. This often referred to as “neuroplastic” pain. In essence, your brain “learns” pain and it becomes chronic.


And think back to the definition of pain. It involves both a sensory and an emotional experience. That means, that pain can be influenced by and tied to memories of past painful experiences. This also includes the emotions of fear and avoidance. When you fear and avoid pain, your brain and nervous system may actually reinforce that the pain itself is actually dangerous. This causes a cycle that goes like this: 1) pain leads to fear and avoidance 2) fear and avoidance lead to more pain.


Since we take a biopsychosocial approach here at ProActive, we understand that this cycle can be uniquely different for each patient. For example, this cycle may look different depending on your past experiences with pain and past injuries.


So the question becomes, how can you mange & overcome this type of chronic pain?


Chronic & Neuroplastic Pain: What the Research Says


Let’s first start with dealing with chronic pain. What can you do when movement causes pain? The reality is, especially if you’ve been in pain for a considerable amount of time, even little movements can cause intense sensations of pain. This is where fear, avoidance and “learned” pain comes into play.


The first thing to do in this instance is find a physical therapist that has experience treating patients who have that level of pain. Then, have an open discussion with them about the pain you are feeling. That therapist should be able to explain to you what we know about pain and the neuroscience and how pain is a protective mechanism of the brain or nervous system. The pain you feel is designed to keep you “safe” and prevent you from damaging yourself. Sometimes though, that protective mechanism becomes hyper-responsive, and any movement can send alarm signals to the brain.


Take a look at this quote from a recently published article about pain:


“There is not a single chronic pain state where any radiographic, surgical, or pathological description of peripheral nociceptive damage has been reproducibly shown to be related to the presence or severity of pain.”


This reinforces the idea that we’ve already looked at about pain being a protective mechanism designed to keep you safe from tissue damage or injury; whether that threat is actually there or not. Again, if your nervous system misinterprets a sensation, or if pain patterns are reinforced, you can feel pain even if you’re doing something that is perfectly safe (like walking, or getting up from a chair).


How do we understand & address neuroplastic pain?


Because changes in neural pathways affect pain & pain perception, when a you experience pain again and again, those neural pathways become strengthened and sensitized [4]. In essence, you (and your brain/CNS) learn the pain and it becomes chronic. Fear & avoidance play a critical role in this neurplastic pain formation.


In cases of neuroplastic pain, the brain interprets sensory input as dangerous (or potentially dangerous). Therefore, the first step to addressing this type of pain is to attempt to correct the misinterpretation and retrain the brain that those sensations are, in fact, safe. We basically need to reteach the nervous system about what movement is safe.


How can Physical Therapy and Occupational Therapy help?


The first step is to begin calming the nervous system down and retraining those alarm signals so you can tolerate more and more movement without pain. PT & OT can do this through techniques such as graded exposure, motor imagery, Pain Reprocessing Therapy, and the like. Then, once you can move with little or no pain, “traditional” techniques of exercising/strengthening muscles and tissues can reinforce those neural pathways of safety and then to both build resilience and strength to prevent future injury.




In the end, chronic pain can be complex and challenging to manage and overcome. The underlying factors that affect your pain and your pain experience should influence the type of treatment and techniques that will work best for you and your specific situation.


The main takeaway from the research is this: movement is the most effective pain medication that we have available to us. That means you need to do what is necessary to get moving again. Sometimes, you can do it on your own and sometimes you may need the help of a qualifies clinician like a physical or occupational therapist. If you’d like to learn more about how ProActive can help you overcome your pain, then reach out to schedule a pain consultation now.



[1] Clauw DJ. Diagnosing and treating chronic musculoskeletal pain based on the underlying mechanism(s). Best Pract Res Clin Rheumatol. 2015 Feb;29(1):6-19. doi: 10.1016/j.berh.2015.04.024. Epub 2015 May 23. PMID: 26266995.

[2] Kosek E, Cohen M, Baron R, Gebhart GF, Mico JA, Rice ASC, Rief W, Sluka AK. Do we need a third mechanistic descriptor for chronic pain states? Pain. 2016 Jul;157(7):1382-1386. doi: 10.1097/j.pain.0000000000000507. PMID: 26835783.

[3] Tracey I. Getting the pain you expect: mechanisms of placebo, nocebo and reappraisal effects in humans. Nat Med. 2010;16(11):1277-1283. doi:10.1038/nm.2229

[4] Seymour B. Pain: A Precision Signal for Reinforcement Learning and Control. Neuron. 2019;101(6):1029-1041. doi:10.1016/j.neuron.2019.01.055

[5] Raja, Srinivasa N.; Carr, Daniel B.; Cohen, Milton; Finnerup, Nanna B.; Flor, Herta; Gibson, Stephen; Keefe, Francis J.; Mogil, Jeffrey S.; Ringkamp, Matthias; Sluka, Kathleen A.; Song, Xue-Jun; Stevens, Bonnie; Sullivan, Mark D.; Tutelman, Perri R.; Ushida, Takahiro; Vader, Kyle The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises, PAIN: September 2020 – Volume 161 – Issue 9 – p 1976-1982 doi: 10.1097/j.pain.0000000000001939

Are you dealing with pain?

We understand that struggling with the stress and strain of pain can be tough…Whether it’s waking up feeling stiff or severe tension after walking, running, or playing, no one wants to spend each day dealing with the soreness that pain brings. While many people choose surgery or injections for pain relief, at ProActive Rehabilitation & Wellness, we offer non-surgical therapies which prevents patients from going under the knife.


If you’d like to book a pain consultation now, with one of our top clinicians, click the button bellow or have your provider fax over a referral. We only book a limited amount of these consultations each month, so act quickly before they’re gone.

Rafi Salazar OT

Rafael E. Salazar II, MHS, OTR/L (Rafi) is the CEO & President of Proactive Rehabilitation & Wellness, as well as the Principal Owner of Rehab U Practice Solutions and the host of The Better Outcomes Show. Rafi’s career trajectory includes 10+ years of experience in healthcare management, clinical operations, programmatic development, marketing & business development. He even spent some time as an Assistant Professor in a Graduate Program of Occupational Therapy and has served on numerous boards and regulatory committees. Today, Rafi helps innovative healthcare companies humanize healthcare through his consulting workHe also leverages his experience as a professor and academic to speak and train on the topics around humanizing the healthcare experience.

Rafi also authored the book Better Outcomes: A Guide to Humanizing Healthcare