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Pain is Complicated: Understanding the Biopsychosocial Model of Pain

Pain - especially chronic pain - is complicated.

Research consistently demonstrates a poor correlation between tissue damage and pain. There are people who have pain and no evidence of tissue damage and people who have evidence of tissue damage and no pain.

For example, 80% of adults in the US will experience low back pain for which they seek care at some point in their lives. And of those individuals, only 10% will receive a diagnosis that points to a specific cause (bone, nerve, soft tissue, etc.).

So, in other words, 90% of low back pain is "non-specific". No cause is ever determined.

To make things more interesting, the chart below summarizes the outcome of a systematic peer-reviewed study. 33 studies met the inclusion criteria and findings included images from a total of 3,110 asymptomatic (pain-free) individuals. That's right, these people were not in pain!

Take a good look at the chart below.

According to the data, 60% of people in their 50s had a Disk Bulge, but were completely asymptomatic.

While modern medicine still focuses heavily on the diagnosis and treatment of pain from a physiological perspective there has been a strong (and welcome) movement toward a more holistic understanding of pain.

In 1977 internist and psychiatrist, John Engel, introduced a biopsychosocial model of pain. Engel believed, "believed that to understand and respond adequately to patients’ suffering—and to give them a sense of being understood—clinicians must attend simultaneously to the biological, psychological, and social dimensions" of their experience. (See graphic below).

One's individual experience of pain is multifactorial. It is an amalgamation of any combination of Biological, Psychological and Social factors, such as genetics, injury history, beliefs, culture, social support, etc. (Check out this blog about how the words clinicians use can influence our experience.)

One has to remember that even though pain is felt in the tissues of the body, it is interpreted by the brain. And sometimes the brain gets it wrong. Sometimes the brain sends signals of pain as a mode of warning or out of habit verses because there is something physiologically wrong.

Still not sure that stress and social factors impact the experience of pain? Polls that looked at self-reported levels of pain found that "In the United States, both the Gallup and NHIS data show pain prevalence rising with age until the late 50s and falling thereafter, with some leveling off after age 70". In the "mid-life" years adults are often coping with career-high demands at work, and wedged firmly between raising teens and caring for aging parents.

In their viewpoint paper, Sticks and Stones: The Impact of Language in Musculoskeletal Rehabilitation the authors call for a “meaningful reconceptualization of pain as a highly complex subjective human experience that is felt in the tissues but interpreted by the mind as a response to a perceived threat”.

Chronic pain is even more complex. Chronic pain is defined as pain that lasts for more than three months.

When a person experiences chronic pain - with or without tissue damage – the neural (nerve) pathways that carry pain messages become more and more efficient over time. In fact, they can become so adept at carrying pain signals that they may continue to do so even after any tissue damage has healed.

A better understanding of the complexity of pain, opens the door to a more comprehensive and holistic approach to pain management.

There’s one more point I’d like to touch on before I conclude…

The benefits of exercise on chronic pain.

Eccleston and Crombez say, “pain is an ideal habitat for worry to flourish”.

If you are dealing with chronic pain, you may worry that exercise will exacerbate your pain. Let me assure you research has shown that exercise helps to reduce chronic pain. I would love to say that it is specific to my areas of expertise – yoga and strength training – but the fact is exercise as a whole has a positive effect on symptoms of chronic pain.

The secret is to start slowly with small doses of movement. It can take a while for your nervous system recognize that exercise is safe. Be patient. Stick with it.

If you need a gentle guide, I’m here to help. Contact me.


  • Crofford LJ, Casey KL. Central modulation of pain perception. Rheum Dis Clin N A. 1999;25:1–13

  • Crofford LJ. Chronic pain: Where the body meets the brain. Trans Am Clin Climatol Assoc. 2015; 126: 167-183

  • Jensen MC, Brant-Zawadzki MN, Obuchowski N, et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N Engl J Med. 1994;331(2):69–73

  • W de Heer et al. The association of depression and anxiety with pain: a study from NESDA. PLoS One. 2014 Oct 15;9(10):e106907. doi: 10.1371/journal.pone.0106907

  • Geneen LJ, Martin DJ, Adams N, et al. Effects of education to facilitate knowledge about chronic pain for adults: a systematic review with meta-analysis. Syst Rev. 2015;4:132. Published 2015 Oct 1. doi:10.1186/s13643-015-0120-5


  • Exercise for chronic musculoskeletal pain: A biopsychosocial approach:

  • Best Exercise Options for Reducing Pain and Disability in Adults With Chronic Low Back Pain: Pilates, Strength, Core-Based, and Mind-Body. A Network Meta-analysis:

  • Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews:

  • Worry and chronic pain: A misdirected problem solving model:

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