Who is driving your pain?

We’re taught to think about pain as a simple equation:

X+Y=Z

I slipped on the ice + fell and broke my wrist = pain in my wrist.

It’s not that simple a lot of the time. Your body and nervous system are complex! To understand pain, we need to ask one question:

Who is driving?  

Imagine your body is a car, and pain has taken you on a roadtrip. It’s a long road trip, so there are three drivers along for the ride. The kind of pain you have depends on who is in the driver’s seat. 

If you just fell and broke your bone, you are having nociceptive pain. 

Nociceptive- the nervous system’s process of detecting harmful or potentially harmful stimuli

This kind of pain happens when there is injury to our tissues. It lets us know that we need to take it easy so that we can heal. When the pain goes away, the healing is done. X+Y=Z.  Nociceptive drivers know the quickest route home and get us there safely without any drama. The classic example is falling and breaking your bone. It hurts when it’s broken, and as it gradually heals you gradually feel better.

If you have a nociceptive driver, your pain will be

• proportional to your injury,

• behave in a predictable manner, and

• reduce in accordance with tissue healing time*

In the passenger’s seat, ready to take over at the next rest stop, is our significant other that can’t sit still when we’re driving.  Once behind the wheel, they drive a bit faster, turn the music louder, and want to take the long way home. In pain language, this is peripheral neuropathic pain.

Peripheral- of the legs, arms, trunk, anywhere outside the brain and spinal cord

Neuropathic- coming from the nerves themselves

Pain- the unpleasant sensory and emotional experience we are discussing

When there is pain for a while, or when the nerve itself is injured, these nerves can get extra sensitive and take over, just like a controlling backseat driver.

If you have a peripheral neuropathic driver, your pain might:

• get worse, not better, as time goes on

• come and go, especially flaring up during times of stress

• worsen during times of increased OR decreased activity

• be felt after, not during activity, especially first thing in the morning

• spread locally (back>>hips>>hamstring>>knee>>foot)

In the backseat of the car is your best friend with ADHD, otherwise known as nociplastic pain, ready to take the wheel. 

Nociplastic-  altered pain processing in the central nervous system

When they are in the driver’s seat, symptoms come and go quite randomly. This road trip may have started a long time ago, even when you were young, with life events that make the nervous system extra sensitive. This kind of pain has more to do with the state of you central nervous system  than anything in your tissues and peripheral nerves.

If you have a nociceptive pain driver:

• you don’t need an injury at all to have pain, it can just start out of the blue.

• there may be symptoms not related to muscles and joints, like migraines, anxiety, irritable bowel, or even frequent urination!

• you might feel like you are paying “wack-a-mole” with areas that hurt

• there might be a history of trauma, adverse childhood experiences, neurodivergence, or you might be a highly sensitive person

• symptoms can increase with stress here as well

At any moment during this grand road trip called having a body, when we have pain, one of these characters is in the driver’s seat. This sets the general tone for how symptoms behave. However, the other two characters are still in the car and play a role! Our ADHD bestie might be in the passenger’s seat, chatting our ear off, while our responsible and grounded nociceptive friend is in the back seat, can’t get a word in edgewise.  Nociceptive pain might be driving while their spouse is turning up the volume on the music, saying  “I REALLY love this song!” Meanwhile, our bestie is in the back seat, offering us a snack and showing us the route with the map held upside down. 

All aspects of pain need to be treated, but the driver needs to be treated first

Physical therapy works best when the driver of your pain condition is identified and treated. Each one needs to be treated differently. Who is behind the wheel for you? 

*Tissue healing times are: 2-6 weeks for muscle strain; 6-12 weeks for bone; 12-16 weeks for tendon; 8-12 weeks for ligament; 12 weeks-6 months + for cartilage, meniscus, labrum;nerves 1 year +.