Pain Questionnaire Answers

Posted on: Mon, 04/21/2014 - 5:33pm By: Alice

About a week ago I put up a pain questionnaire.  

As promised, we're providing the answers, courtesy of Zac Cupples, PT.

Cupples, a physical therapist in Plainfield, IL, had such great answers to these 
questions that I asked him if I could borrow them and he agreed. A few sentences were edited out for brevity and to keep it where we non-PT folks can understand. Read his unedited answers and the rest of his article on pain education here. Also highly recommended is his series on the book Explain Pain. If you haven't read it, this is a great chapter-by-chapter summary. If you have, it's a great review.

Thanks, Zac! 

And now for the answers:

“The best way to treat chronic pain is to prevent it.”


Pain receptors convey the pain message to your brain: FALSE

Why – Tissues only send danger messages. Compare suffering an ankle sprain on a sidewalk versus a busy street. The latter would not necessarily hurt.

Pain only occurs when you are injured: FALSE

Why – Injury and pain are not synonymous. Think about when you get a bruise and are not aware of it.

Fun fact – Tissues heal in 3-6 months. This includes your bulging discs.

The timing and intensity of pain matches the timing and number of signals in danger messages: FALSE

Why – In acute pains that end quickly, danger messages make their way up to the spinal cord and then the brain, but the brain sends endogenous opioids down the system to turn the dial down on danger messages.

Nerves have to connect to a body part in order for that part to be in pain: FALSE

Why – Phantom limb pain, duh! The somatosensory homunculus [body map in the brain] is what allows for this phenomenon to occur. When areas are used less, such as in pain states, the area of that body part becomes less clear. These changes can occur as fast as 30 minutes. The research shows the more “smudging” of these areas you have, the more pain you have. So in phantom limb pain, the body part is gone, but the brain representation of that area remains.

In chronic pain, the central nervous system becomes more sensitive to danger messages from tissues: TRUE

Why – Interneuron death plays a role, but also descending influences from the brain contribute. Because more danger messages are occurring, the brain is less likely to utilize endogenous opioids to calm the system down. From a survival standpoint this makes sense. In chronic pain, the future becomes less certain, and your top priority is to stay alive. If I can make you more sensitive to your environment, I can better protect you.

The body tells the brain when it is in pain: FALSE

Why – The brain is what produces pain. The body can only produce danger. The brain activates many areas in the pain experience, making pain multi-sensory. And the more this pain map is run, the more efficient your brain becomes at producing it.

The brain can send danger messages down your spinal cord that can increase the danger messages going up the spinal cord: TRUE

Why – If there are enough danger signals reaching the brain, the brain will want to know more; thus impacting the periphery.

Nerves can adapt by increasing their resting level of excitement: TRUE

Why – Action potential are key. Every nerve has a resting amount of activity, and a certain amount of stimulus is necessary before this action potential occurs. When someone is extra sensitive, the nerves increase their resting excitement level so action potentials more readily occur. Adding more ion channels to less myelinated areas can further compound this sensitivity.

Fun fact – Ion channels change every 48 hours, and therapy can positively influence the change.

Chronic pain means an injury hasn’t healed properly: FALSE

Why – Read, like, everything I have ever written ever. Pain and injury are not the same thing. Tissues heal, tissues heal, tissues heal.

Receptors on nerves work by opening ion channels in the wall of the nerve: TRUE

Why – See above.

The brain decides when you will experience pain: TRUE

Why – Pain is a brain construct. Tissues can only send danger messages.

Fun fact – Laughing at a joke requires 5 different areas to be active in the brain.

Worse injuries result in worse pain: FALSE

(Scroll half way down this page to the video clip of a weightlifter whose biceps tendon ruptures while doing a dead lift and he doesn’t realize it until afterward.)

When you are injured, the environment that you are in will not have an effect on the amount of pain that you experience: FALSE

Why – Injuries and pain occur in an environment, not a vacuum. An ankle sprain may hurt on a sidewalk, but likely won’t if a bus is about the hit you.

Fun facts – Injuries in high stress environments are 7-8 times more likely to produce chronic pain. Also, kids who play contact sports early in life have less chance of developing chronic pain.

It is possible to have pain and not know about it: FALSE

Why – Pain is a conscious decision by the brain. No brain, no pain.

Nerves can adapt by making more ion channels: TRUE

Why – I already answered it duuuuude.

Second order messenger nerves post-synaptic membrane potential is dependent on descending modulation: TRUE

What did I just say? – I don’t know.

Why – The brain has the abilty to inhibit information coming up from the periphery via endogenous mechanisms. This is how placebo works.

Nerves adapt by making ion channels stay open longer: TRUE

Why – Because I said so...directly above. The brain will also make g protein ion channels, which can stay open for several minutes. This type allows for more danger messages to fire.

When you are injured, chemicals in your tissue can make nerves more sensitive: TRUE

Why – Much was previously mentioned, but the stress response plays a huge role here. When you go into a more sympathetic [“fight or flight”] state, adrenaline, cytokines, and cortisol pump throughout the body. This change increases sensitivity of nerves throughout the body systems, and those in chronic pain are more geared toward this state.

Put it all together, and what do you got???

So with all the above information, we can see there are many misconceptions regarding pain. So it becomes very important to define what pain is. Here is a great definition:

“Pain is a multiple system output activated by an individual’s specific pain neural signature. The neural signature is activated whenever the brain concludes that body tissues are in danger and action is required.”

Exerpted from Zac Cupples’ “Course Notes: Therapeutic Neuroscience Education”

Used with permission. Thanks, Zac!

Hello Alice,
Thank you for providing this blog, along with all the others (that I have finally found). It is very informable, as the others I am working on reading.
What do you think about peripheral nerve axon damage? In specific, the axon which is unable to regenerate.
"Tissues heal, tissues heal, tissues heal"
For those of us that have experienced extreme pain from acute demyelination of the peripheral nervous system (do to an autoimmune response), how would pain be explained throughout the following years of regeneration of the myelin sheath (which repairs very slowly), yet damaged axons are unable to repair themselves. In short, this is a type of chronic pain occurring with tissue damage.
Any thoughts?
Kindest Regards,
Tamara Foxen, LMT,
Liaison (Guillain-Barre Syndrome/CIDP/MMN/Variants)