Pain Is a Feeling, Not an Output

I'd like people in our industry to stop telling clients that pain is an "output".

"Output" is a recognised term for pain in academia, but a client's experience is a better description. "Output" usually describes the action a client takes because of the stimulus that caused the feeling of pain — not the pain itself.

Having pain versus being in pain

Defining the reason for pain is complicated. It helps to separate a client having pain from a client being in pain. A single pain is a feeling that lasts a few seconds. Being in pain is an experience — a combination of repeated pain feelings over time.

A feeling is an interpretation of the proprioceptive information the peripheral nervous system has let through to the brain. Interpreting that information is called cognition.

The loop the body runs

Arousal is what triggers cognition from an awareness of something — you hear or see something, hormones and muscles ready you to respond. Your environment is constantly changing your arousal levels and using cognition to choose your action. Here's the loop:

1. Stimulus — seeing a player pull off some skill in front of you.
2. Emotions — muscles and hormones change; the initial feelings.
3. Cognition — interpret all the available information.
4. Feeling — if asked, this is what you'd name out loud.
5. Cognition again — is the feeling valid, and does it need an action?
6. Action — the "output" movement (or lack of it), which then reinforces or corrects your reading of the stimulus for next time.

If the brain reads opportunity, the next response is positive. If it reads danger, it's met with freeze, flight or fight. Freeze buys time to decide; flight keeps you away from the stimulus; fight faces it head-on.

Pain, then, is the feeling associated with a specific set of filtered feedback that a client has perceived, or has knowledge of and experienced before. It's specific to the individual — their experiences, knowledge, perceptions and expectations.

Why blaming the tissue is a cop-out

Pain is generally unpleasant, which attracts solutions that seem like common sense but aren't held up by research. A run of technique-based examples all point the finger at tissue:

• Massage — rub the pain out of the muscle.
• Acupuncture — a needle to relieve "tightness" at the site.
• Myofascial release — squash the site of pain.
• Cupping — suck out "stagnant blood" to increase circulation.
• Kinesio taping — some tape to "decrease tension".

Each treats the tissue as the sole cause and ignores the psychology of the person and the social factors around them. Blaming the tissue lets a therapist perform a short-term fix — so the client keeps coming back when it returns.

The classic version is the trigger point or "knot". Unanimously debunked by science: trigger points don't exist. Explaining them to a client as the reason for their pain is unethical — all it adds is a layer of negative influence on how they interpret the feeling. (Go and try to find a photo of an actual trigger point, not a drawing. If you find one, send it to me.)

Pain is useful

People with congenital insensitivity to pain show us the cost of not feeling it — significant injury goes unnoticed. Pain is an important signal that something might be wrong, which is exactly why a client should see a doctor before anyone works with them. Some skip that and crack on anyway, when something more serious could be going on.

Pain is also not tied to the injury. Clients with phantom limb pain feel it in body parts that no longer exist — proof the pain is part of the experience, not the tissue. One client of mine described his phantom pain as a chronic itch. The feelings vary: dull aching, sharp spiking, stabbing, crushing, throbbing, burning, pins and needles, tension.

What trainers should actually do

Chasing solutions can send a client on a tour of practitioners and leave them with a longer list of "what's wrong" — more reasons to feel pain, not fewer. So-called fixes I've heard from clients over the years: stop moving; move "properly"; rebalance your posture; get stronger; the stress is coming from another body part. All are incomplete or irrelevant, based on little understanding of the whole process.

The approach isn't to cure or remove pain. It's to change the sensation or the interpretation for the client. Someone could have had chronic pain for 25 years; our job is to find the stimulus, movement or task that positively changes how they read their situation. We have a lot of tools to help people — so don't get bogged down in fixing, curing and correcting. Focus on the person beyond their pain, find their goal, and help them clear the hurdles in the way. Sometimes the pain isn't even the main hurdle.

Papers to start with

• Le Doux, Quintner & van Rysewyk (2012). Rethinking the emotional brain. Neuron, 73(4), 653–676.
• Moseley (2003). A pain neuromatrix approach to patients with chronic pain. Manual Therapy, 8(3), 130–140.
• Lumley & Cohen (2011). Pain and emotion: a biopsychosocial review of recent research. 67(9), 942–968.
• Quintner, Bove & Cohen (2015). A critical evaluation of the trigger point phenomenon. Rheumatology, 54(6), 1127–1128.
• Vlaeyen et al. (2001). Graded exposure in vivo in the treatment of pain-related fear. Behaviour Research and Therapy, 39, 151–166.
• Roelofs, Hagenaars & Stins (2010). Facing freeze: social threat induces bodily freeze in humans. Psychological Science.