Understanding pain changes everything

Pain is an unpleasant feeling - something we feel in the body, and something we usually want to stop. In many ways, it’s like fear: both are protective, both demand attention, and both are shaped by context. But unlike fear, pain has a location. It feels like it lives in the body, even though it is made by the brain.

This is why pain feels so real. Because it is real. Even in the absence of tissue damage - for example, in phantom limb pain - pain is real. You don’t need a visible injury for pain to be true.

But pain is not always the same. The unpleasantness of pain can be greater or smaller depending on how we make sense of it. Pain that we understand or expect is often easier to bear; while pain that feels uncertain or threatening often feels worse.

That’s because pain doesn’t just tell us what’s happening - it also hints at what might happen next.

Paradoxically, this unpleasant feeling is not always unpleasant. Sometimes, people experience pain as tolerable - or even enjoyable. This doesn’t contradict the idea that pain is typically unpleasant. It actually supports a core insight of modern pain science: pain is shaped by meaning, control, and context.

For example, the burn in your legs after a long run can feel deeply satisfying. In certain intimate and cultural settings, pain is even sought out as a form of challenge or release. What these situations share is agency. When pain is expected, chosen, and interpreted as meaningful, it becomes far less threatening - and sometimes even welcome.

So when we say “pain is an unpleasant feeling” we’re describing its default mode. But pain isn’t one-size-fits-all. Pain is a complex feeling that is shaped by our thoughts, feelings, and circumstances. That’s why the same problem can feel different from one person to another - or even from one moment to the next.

This is what makes pain so personal - and why the same pain can feel different from one moment to the next, or from one person to another.

One of the most important ideas in modern pain science is that all pain is real. This is true, even if we are unable to determine an exact cause for the pain. Pain is a feeling. And like all feelings, the only reliable test is to ask the person experiencing it.

If it hurts, it’s pain. And if it’s pain, it’s real.

This is important, because it means that we should take all pain seriously. Pain research also tells us that we should not take all pain literally. This is because while all pain is real pain, pain is not always what we expect. People with serious injuries may feel no pain at all. Others may feel intense pain, even when the painful area is healthy and uninjured.

Modern research offers some interesting examples. People who lose a limb will often feel pain in the missing part of their body. This is called phantom limb pain, and is incredibly common in amputees. While the limb is gone, the pain is very real

Researchers have also used illusions to trigger painful feelings, even when there is no injury at all. These feelings are just as intense, real and unpleasant as the pain associated with a burn or broken bone.

In this way, pain is like fear: we can fear things that aren’t dangerous, just as we can feel pain in the absence of damage. The reverse is also true, and some people with serious injuries don’t feel pain until long after the injury occurred - usually after they get themselves to safety.

Pain is a protective system. It responds to perceived threat, not just injury or disease. Pain is influenced by stress, beliefs, attention, context - even the way scan results are explained. That doesn’t make pain “psychological” - it makes pain human.

By learning to think differently about pain, we are not ignoring the problem - we’re expanding the picture.

When scan results show changes in a part of the body, then this information is part of the story. But it’s not the whole story. And this is good news. Lots of things contribute to pain, and so lots of things can be used to improve it. And by learning more about pain, you can identify new targets for change.

Because pain and injury so often occur together, it’s natural to assume that pain equals damage. For many people, this makes perfect sense: you twist an ankle, and it hurts. You cut your skin, and it stings. Over time, this pattern builds an assumption - if I feel pain, then something must be damaged.

But while this connection is often true for injuries in their early stages, it’s not reliable - especially over the long term. And the longer pain persists, the more this rule seems to fall apart.

Pain researchers now believe that pain is never a direct readout of tissue damage. Instead, pain is a protective response—a feeling created by your nervous system in response to what it perceives as a threat. Tissue signals of damage are just one type of threat. Pain can also be triggered by stress, fear, poor sleep, emotions, or even the way scan results are explained to you. Anything that affects your body’s assessment of danger can change your pain.

This is why people with the same scan results can have different pain. For example, many people live with disc bulges, arthritis, and even tendon tears - all without pain. And others live with severe pain, even when tests reveal an otherwise healthy body. In one study, researchers found that half of 40 year old adults without back pain have a disc bulge on MRI.While scan results are sometimes part of the story, they are never the whole story. Pain never responds to structure alone.

This doesn’t mean that pain isn’t real. It is real - it’s just not a reliable guide to what’s happening in your tissues. That’s why pain is better understood as a “call to pay attention,” rather than a damage report.

This idea may seem like a technicality, but it has real consequences. If pain isn’t a damage detector, then managing pain means more than fixing the tissues. It means addressing the whole system - our biology, psychological, and social factors - that give rise to pain in the first place.

This means that pain can happen with or without tissue damage, and tissue damage can exist with or without pain. Pain is always real - but it doesn’t always mean something is wrong in your tissues.

Pain is not just a feeling, it’s a decision. More specifically, it’s your body’s protective decision, and it’s based on all the information available to you in a particular moment.

It’s not a damage report - it’s a warning. That’s why pain can show up even when you’re not doing anything dangerous, and why it sometimes doesn’t appear until after an injury has healed. Pain doesn’t tell you what has happened, it tells you what your system believes might happen.

We describe pain as a “predictive protector.” This means that the brain weighs up all sorts of inputs - bodily sensations, memory, emotion, context, attention, social cues, and past experiences - and uses that information to make a prediction: Is pain likely to be a useful feeling for the body, right now?

If the answer is yes, pain is produced. If the answer is no, even severe injuries may not hurt - at least not right away.

This explains why the same injury can feel very different to different people, or even to the same person on different days. The difference isn’t in the tissue - it’s in how the brain interprets the situation.

Pain is intelligent, but not perfect. It errs on the side of caution. Like a smoke detector that goes off when you burn toast, pain can sometimes respond to situations that aren’t truly dangerous. It’s not random, made-up, or “all in your head.” It’s a real, bodily feeling - just sometimes it doesn’t mean what we think it does. Sometimes the alarm is too sensitive, or too loud. 

The good news is that your system can learn. With the right inputs - for example new movement, ideas, and experiences - you can retrain your pain system to be less protective. You can learn to turn the volume down. 

While learning about pain might not turn your pain off, this understanding gives you a new way to work with it - encouraging a new response to an old problem.

We often think of pain as something that reflects what’s happening in the body. But the truth is more complex. Pain isn’t just influenced by physical injury—it’s shaped by a wide range of biological, psychological, and social factors. These are sometimes called biopsychosocial (BPS) influences, and they explain why pain can behave in such confusing ways.

For example, it’s possible to have pain without any clear sign of damage - and it’s equally possible to have tissue damage without much pain at all. This means that while pain is often associated with injury, it doesn’t require injury to occur.

Your brain produces pain when it decides that protection is needed. And that decision is based on context.

Context includes everything you’re thinking, feeling, and sensing in a given moment. It includes your beliefs about your body, your trust in your diagnosis, your emotions, your social environment - even the colour of a light in a lab. One experiment found that a painful stimulus felt worse when paired with a red light rather than a blue one, simply because red is more strongly associated with danger

This may sound surprising, but it’s good news. If many things can increase pain, then many things can also be used to reduce it.

You can’t control every factor - but you can learn to influence the system. You can change your responses, build trust in your body, reshape your environment, and learn new ways to move and think.

Pain is complex. But complexity isn’t the enemy - it expands the possibility for recovery by identifying new targets for change.

Pain is meant to protect us. But sometimes, the pain system can become too protective - sounding the alarm even when there’s no real danger. When this happens, pain can shift from being protective, to being destructive. Pain can even stop us doing things that are necessary for recovery. 

Like every system in the body, the pain system learns. When the pain system learns to protect us too well, we call it sensitisation. This process occurs throughout multiple biological systems, and is almost always part of the problem of persistent pain.

Sensitisation means that pain shows up more quickly, more often, more intensely. Things that didn’t used to hurt become painful, things like light touch, gentle movement, stretching, and even memories.

This overprotection is not a conscious process, and it is not your fault. It’s a sign that your pain system is doing its job - just too well.

Fortunately, these changes can be reversed. In the same way that the pain system can learn to be overprotective, it can also learn to be less protective. While this doesn’t generally happen overnight, it is always possible to retrain the pain system. These treatments generally use graded activity to trigger positive adaptations that help your system to recalibrate and adjust.

Like going outside on a bright day, and noticing you vision return to normal - exposure can help your system to return to a sensitivity that is useful, rather than restrictive. 

Just as the pain system can become overprotective, it is also possible to retrain the system to be less protective. This process is based in a concept known as bioplasticity, and uses the body’s built-in ability to adapt through experience.

Retraining doesn’t mean pushing through pain or pretending it’s not real. It means taking a different approach. It starts with recognising that your current understanding or strategy may not be working. From there, it involves learning how pain works, noticing patterns in your own experience, and using new actions to trigger helpful changes within your body.

The goal isn’t to eliminate pain instantly. It’s to generate new experiences that encourage your system to feel safe again. This happens slowly, through repeated activity over time - and by changing the way that you relate to and understand your pain. 

Instead of waiting to solve problem before you get back to life, this means that getting back to life is an important part of the solution. 

Retraining pain is a skill you can learn, but this process takes patience and effort. It is about consistently building on small wins, and making more helpful decisions - and less unhelpful ones. In most cases, it is important to work with a coach. This person can help to keep you safe, and guide you through difficult questions. While pain does not mean damage, having pain does not mean there is no damage - and a skilled guide can help you to make informed decisions.

Your understanding of pain isn’t just academic - it has real, felt consequences.

Pain is not just a passive signal that happens to you. It’s an experience shaped by how your brain makes sense of what’s going on. And one of the strongest influences on that process is what you believe about pain itself.

When pain feels dangerous or out of control, it often feels worse. But as you change the way you understand pain, it often starts to feel different. This change can be subtle at first, but over time, it matters.

When it comes to pain, knowledge isn’t just abstract. It becomes part of the context your brain uses to decide whether you’re in danger. And because pain is your system’s way of protecting you from perceived threat, what you believe about pain influences how much protection your system thinks you need.

Imagine two people with the same injury. One believes their body is fragile, that moving will make things worse, and that their scan means permanent damage. The other understands that pain can be overprotective, that movement is safer than the risks of rest, and that recovery is possible. Modern research suggests that these people who have very different pain. 

Your nervous system constantly weighs up information to decide whether or not to produce pain. That includes not just what's happening in your body, but also your thoughts, memories, beliefs, and expectations. If pain feels mysterious, scary, or out of control, it often feels worse. But when you start to understand it, fear goes down - and pain often does too.

This doesn’t mean pain is "just in your head." It means your head - and your understanding - are part of your body’s protection system. When you understand pain differently, you relate to it differently. You move differently. You respond with more confidence, and less fear.

And over time, these changes trigger effects that change both your body and your pain. 

Knowledge can change pain: not by magic, but by changing the story your body is telling itself about whether or not you are safe, and encouraging actions that lead to recovery. 

The biopsychosocial model is a way of thinking about health that resists the temptation to simplify. It recognises that biology doesn’t act alone - that our thoughts, emotions, relationships, memories, and environments all shape the way we feel, heal, and hurt. It’s not a rejection of science, but an invitation to look wider. To see the person in their context. To ask “what’s wrong with the tissue”, but also ask “what’s going on in the system”. By looking at how different parts of the system interact, this approach helps us to identify problems that maintain our pain - and once we are aware of them, we can improve them.

The biopsychosocial model is often framed as a modern, more holistic response to the shortcomings of biomedicine. We don’t see it that way. It’s not a soft alternative - it’s a broader lens on the same system. Biology doesn’t stop at the edge of the cell. Thoughts are biological. Emotions are biological. Social interactions are biological. If they’re not, what are they? Rather than dismissing the biomedical model, the biopsychosocial model extends it - zooming out to consider the real impacts of the different factors that affect our lives. We’re not saying a biological approach is wrong; we’re encouraging people to broaden their understanding of biology to include very real interactions that are not always obvious.

Many people approach pain through a mechanical lens - searching for a single cause that can be fixed, removed, or replaced. But pain doesn’t come from one place, and healing involves the whole body. Health is the product of complex interactions across multiple different body systems, and it is shaped by history, context, load, and adaptation. Problems don’t exist in isolation - they exist in networks, and emerge through interactions. This approach means that problems are more complex, but it also means that problems are easier to treat. Given that many things contribute to pain, many things can be used to improve it. Learning more about these interactions can help you to identify effective targets for change.

For a long time, these ideas about pain felt like speculation - observations without mechanisms. But that’s changing. We now have solid evidence that inflammation changes mood, that expectations influence nociception, that loneliness alters immune function. We’re finally seeing that “soft” factors like stress and social connection have hardwired biological consequences. That doesn’t make the problem less complex - but it does make it more real. The lines between systems are blurring. The idea that biology acts in isolation is fading. New knowledge is expanding our sense of what is possible, based on real biological factors we are just starting to understand.

The body is not a machine that wears out after so many hours - it’s a living system, built to change. When you lift something heavy, walk further than usual, or face a difficult challenge, your body doesn’t just survive - it adapts. This principle applies across all body systems, not just muscles and joints. The nervous system, the immune system, even the way we process pain - all of these systems respond to load. Recovery from chronic pain is not generally about doing less. It’s about choosing the right kind of load at the right time, and pairing it with the rest and support your body needs to grow stronger. By selecting the right load, we can choose the adaptations we want to encourage in recovery.

Avoiding load can make the body more fragile - not because rest is bad, but because unused systems lose capacity. When we stop challenging the body, it adapts. Muscles get smaller, bones become weaker; the pain system can even become more sensitive. The trick is select loads that will trigger adaptation towards meaningful change. Strength is our body’s response to doing more, not less.

All body systems respond to load. It’s not just muscles or bones that adapt - your heart, lungs, immune system, nervous system, even your mood and memory are shaped by the demands you place on them. Load is the body’s way of sensing what matters, and where to send its energy. Too little, and systems quietly wind down to conserve resources. Just enough, and the body builds capacity - becoming more robust, and harder to break. The goal isn’t to avoid stress, but to dose it wisely. Load send a message, telling out body to “grow here”. By getting these messages right, we can regain control and start adapting towards recovery.

We often focus on the risks of doing too much, while forgetting about the risks of not doing enough. Avoiding load can feel safe in the short term, and doing new things will often lead to a short-term increase in pain. But over time, a more cautious approach becomes risky. By steering clear of challenge, we invite decline - losing strength, confidence, capacity, and even connection. Change carries uncertainty; but if nothing changes, nothing changes. And here’s the good news: when used wisely, load carries less risk than we might assume - and over time, it actually reduces it. Load is a tools to make your body stronger, and getting it right can make all the difference.