Often there is a lot of attention directed towards the ‘condition’ or the ‘pathology’ in chronic pain, and while this is a component, we need to zoom out and look at the whole person.
It is common to think and believe that the pain is the cause of the negative impact on a patient’s life. 
What if we look at it from another angle? 
Perhaps it is multiple factors in their life that are impacting their perception of pain.
Consider the close association between pain and mood related disorders, which in-fact has a much closer relationship than pain and tissue damage. 
Did you know that pain can be reduced by positive mood and emotional state AND pain can be increased by negative emotions, low mood and anxiety (Villemure & Bushnell (2002); Bushnell et al (2013).

Why is this?

Well… How you think influences how you feel.

You may have heard of the term neuroplasticity before? Our understanding of the brain has evolved over the years, where it was strongly believed that the brain was ‘fixed’ or ‘hardwired’ and could not change. We know this now to be a myth. The brain is constantly changing throughout our entire life. Our brain is highly plastic and can be influenced by our environments or surroundings, social interaction and relationships, thoughts, and beliefs along with previous experience and expectations.

The evolution of neuroplastic changes that occurs in our brain is closely associated with the evolution of our understanding of pain. A famous philosopher Descartes (1662) believed that a painful stimulus would cause pulling on a nerve ‘tube’ to cause it to open and animal spirits to flow through the tube to the brain ringing a bell. As science has evolved, so has our understanding of pain, and we now know that pain is a complex and individual experience.

However, Descartes was the first to connect pain to the brain. This concept opened the door to the understanding that the brain is a key component to pain.
One of my favourite quotes, in the words of Descartes is “I think therefore I am” 

What we think influences how we feel and how we behave.
People with pessimistic life attitudes react more strongly to pain (Dimova. 2015)and people with optimistic attitudes have been associated with lower pain ratings. (Geers et al. 2015)
Put yourself in the position of a chronic pain sufferer for a minute…
The longer we think negative thoughts about pain and the prognosis and how it might influence what we can’t do, the more it contributes to worry, fear and stress this may be associated with a lower self efficacy, negative coping strategies and low motivation along with numerous other possible behavioural changes.

These thoughts and beliefs increase the synaptic efficiency through a process called Long Term Potentiation (LTP). Therefore, neurons get far more efficient at firing a particular pathway. 

Think of it like studying for a test, the more you repeat something, and review it the better you get at it. The easier it is to remember, BUT also the harder to forget. (Just like pain)

Neuroplastic changes can be positive or negative. But either way the neurophysiology is the same, it involves repetition and emotion. Emotion helps to solidify memory. 

Understanding the emotional and psychological state of our patients can be a predictor of treatment outcomes. The presence of mental health disorders such as anxiety and depression have been shown to have poorer quality of life(Lansdown, 2018) and poorer outcomes post-surgery for femoroacetabular impingement (Dick et al 2020) and hip osteoarthritis (Marks, 2009).
If pain was as simple as pathology / tissue damage = pain. Theoretically symptoms should resolve after intervention, right? But our body is not a machine, and neither is our brain.

What we as clinicians and our patients think / believe about their condition influence the perception of pain and expectations of recovery. The transition from acute to chronic pain creates functional and structural neuroplastic changes in the brain that influence sensory, emotional, and cognitive components of pain. (Kuner & Flor. 2016)

Rather than focusing on the pain and tissue pathology, zoom out and look at the whole person and remember, the brain is NOT fixed or hardwired, it can change given the right environment. 
This demonstrates the importance of educating our patients about pain and the various other contributors and stressors that can influence pain sensitivity not just structure or pathology.

So while having to consider all these other non-tissue related factors in the assessment and treatment of your patient may seem to complicate matters, it can in fact help to empower you in your treatment.
If you can identify these non-mechanical or pathoanatomical factors in your assessment, you can implement strategies to help the patient manage them better and in doing so, produce greater impacts on their pain experience and more long lasting changes.

I urge you to try this out with a patient this week. See their physical signs and symptoms but dig a little deeper and see what else may be contributing to their current experience, and consider what you could do to move them toward a more positive emotional and psychological situation.