Does Your Practice Support Healing? Understanding the Construct of Chronic Pain

Are you familiar with the clinical pearls from our medical ancestor Hippocrates?

He actually offered the mother of all pearls when it comes to strategically applying recent advances in chronic pain neuroscience and principles of resilience to clinical practice:

“It is more important to understand what sort of patient has a disease than what sort of disease a patient has.”

In the coming decade, patients experiencing chronic pain will become a growing part of your caseload.1 I challenge you to use Hippocrates’ sage advice and act as a facilitator and guide to engage your patient in self-care to optimize their healing. Over the course of this three-part series, I promise that you will gather enough pearls to embellish your practice!

Understanding Chronic Pain as a Construct of the Brain

It is helpful to have simple ways to explain pain. If we accept the perspective that the chronic pain experience is a construct of the brain, then a logical treatment approach is to systematically deconstruct the construct.

The literature on the efficacy of pain neuroscience education suggests that clinicians should include this approach in treatment.2,3 Explaining pain to patients reduces fear of the unknown.

The brain receives a multitude of sensory data from both the outer and inner body environment with a primary mission of moment-to-moment survival. Our basic biological drive is to accomplish survival with the least possible amount of energy expenditure and the most pleasure. Acute pain is necessary to inform us of a possible need for action to avoid harm.4 But chronic pain is understood to evolve when repeated attempts at protective action have failed to resolve a potential threat.5

The data used by the nervous system to inform the construct of a chronic pain experience does not arrive via dedicated “pain tracts,” and there is no real estate in the brain dedicated to “pain perception.” The brain constructs a pain experience by integrating sensory data that has been shared with the limbic system.

We can regard all sensory information as ever-changing, present-moment data on the status of the organism—you. Sensory data is generated from specialized receptors monitoring tissue temperature, chemistry, pressure/load, and position/movement.

Chronic pain is not dependent upon nociception. It is predominantly modulated by fear, catastrophic thinking, and individual beliefs about the reasons for its presence.3

When a person fails repeatedly to resolve acute pain, our nervous systems—the central nervous system (CNS), peripheral nervous system (PNS), and autonomic nervous system (ANS), which includes the enteric nervous system (ENS)—must devote attention and divert resources toward a now-persistent stream of somatic data that the perceptual brain has not successfully assigned to a cause or determined to be a familiar somatic experience.

A construct is made in an attempt to satisfy the mind. The unknown is determined to be a threat.

Immune Suppression—The Consequence of the Body’s Attempt to Protect Itself from Real and Perceived Threats

The body mounts a protective response to real or perceived threat, using the physiology of the stress response, often known as fight, flight, or bite. The body’s first line of defense will initially involve activation of the hypothalamic pituitary adrenal (HPA) axis, which powers our stress response. This includes mobilizing our inflammatory response and elevating blood glucose levels.

When stress response activation occurs repeatedly and without resolution of the threat, as occurs in the chronic pain experience, then we eventually experience immune system suppression.

In Part Two of this series, we will explore strategies to reduce over-protective mechanisms you may be seeing in your patients and offer techniques you can incorporate into your own practice.

  1. Patel, K. V., Guralnik, J. M., Dansie, E. J., & Turk, D. C. (2013). Prevalence and impact of pain among older adults in the United States: findings from the 2011 National Health and Aging Trends Survey. Pain, 154(12): 2649-57. doi: 10.1016/j.pain.2013.07.029.
  2. National Institutes of Health. (2016). National Pain Strategy: A Comprehensive Population Health-Level Strategy for Pain. Retrieved from
  3. Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. (2011). Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. National Academies Press: Washington DC.
  4. Wall, P. D. (1979). The gate control theory of pain mechanisms: a re-examination and re-statement. Pain, 6(3): 388. doi: 10.1016/0304-3959(79)90069-1.
  5. Tabor, A., Thacker, M. A., Moseley, G. L., & Körding, K. P. (2017). Pain: a statistical account. PLoS: Computational Biology, 13(1): e1005142. doi: 10.1371/journal.pcbi.1005142.