Clinicians and researchers have known for years that chronic pain isn’t always related to active tissue damage. The first updated definition of pain in 40 years confirmed it.

For me, the announcement was long overdue. As someone who studied neuroscience from both a physiological and economic perspective, I’ve been seeking to explore the connection between the physical state of our wellbeing into what drives our decision making – and therefore our behaviors. Throughout my career in designing and leading large health system transformations by tackling the social determinants of physical and mental health integration, I’ve seen time and time again how we have historically approached the physical treatment of pain separately from the psychological while both are, in reality, inextricably linked.

I was also glad to hear the news because I knew that we designed Fern Health to address how pain works in the brain. Pain neuroscience education is one of the foundations of Fern’s multimodal program and a core component of how Fern integrates digital therapy with personalized, human-centered care.

For those who haven’t studied pain neuroscience, the concept can be confusing. Isn’t back pain caused by lifting a heavy box the wrong way, or sitting hunched over at a computer for hours on end?

Evolutionarily and functionally, pain serves to alert us to danger. It’s a trigger response that’s hard wired from our nerve cells throughout our body to our spinal cord to our brain that prompts us to quickly make decisions to protect our wellbeing. Stepped on something sharp? Time to take a different path. But sometimes, pain sticks around after the initial danger is gone and the injury has healed.

When the nervous system becomes too sensitive

Central sensitization is a nervous system condition associated with the development of chronic pain – pain that lasts for three months or longer. In central sensitization, the nervous system goes through a process called “wind up,” and stays in a persistent state of reactivity. When the nervous system is in an ongoing reactive state, it lowers the threshold for what feels painful. It can also maintain pain from an injury that has already healed.

People with central sensitization often find normally mild sensations painful. Being bumped into, receiving a massage, or even being brushed against can all feel more painful than they normally would. Once the nervous system maintains a heightened state of reactivity, any stimulation can feel painful.

Why does central sensitization happen to some people in pain, and not others? A person’s mental state before or after the injury plays a significant role, research shows.

If someone is experiencing stress or anxiety before their injury, their nervous system is more likely to become sensitized. Research shows that job-related stress in particular contributes to chronic back pain in the workplace.

Those with a history of anxiety, depression, or trauma are also more likely to develop central sensitization and chronic pain. There is neurological commonality between the sensation and interpretation of pain and emotion. Studies show that patients with persistent back pain have greater functional connectivity between parts of the brain involved in emotion, motivation, and reward-related behaviors.

For some people, the initial injury itself can trigger anxiety and depression symptoms. Feelings of hopelessness and that pain will never get better can cause people in pain to enter a vicious cycle.

What is pain neuroscience education?

For people with chronic pain, it can feel insulting and stigmatizing to be told that there’s a psychological component to pain. But that doesn’t mean the feeling of pain isn’t “real.” The sensations themselves are real and rooted in the body’s physiological reactions – but what someone believes is causing them and how serious they actually are may not be accurate.

Research shows that learning about concepts like central sensitization can help people in pain make sense of their experience.

In Fern Health’s pain neuroscience education program, part of our musculoskeletal employer program, members learn more about the science underlying their pain, how it works in the brain, and how they can reframe their experiences and perceptions of pain. This takes advantage of neuroplasticity – our brains’ unique ability to structurally modify our thinking and behaviors from new learnings, insights, and experiences. Ninety-six percent of Fern members find the skill-building and brain-training content useful in their recovery.

Unfortunately, chronic back pain treatment rarely includes a psychological component. Just 8% of people with chronic low back pain are prescribed cognitive behavioral therapy to address emotional regulation, coping strategies, and cognitive distortions related to their pain, despite best practice treatment guidelines. That’s why it was so important for Fern Health to include pain neuroscience education in our program as an evidence-based method of increasing awareness, dispelling false beliefs, and removing the barrier of stigmatization related to the perception of pain and related mental health conditions.

In a very real and biological way, knowledge is power when it comes to chronic pain. I’m excited to see the medical world continue to acknowledge the role neuroscience plays in chronic pain, and how we can continue developing ecosystems that offer people in pain a way to access its impactful lessons in a personal, humanistic way.

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