The Pain Puzzle

When you have pain and seek help often one of 3 things happens:


Investigations find a condition or some changes on an x-ray or MRI. Maybe degenerative changes in your spine, or your knee joint. You are told to keep active, and take some pain relief when needed. You were doing that already. You are then told you have to ‘live with the pain’. But you have no idea how to do that.


They don’t find any obvious physical cause for your pain. It is implied that your pain is just ‘emotional’, or all in your mind, but it feels real and physical to you. You are told to try mindfulness, which helps a bit, but you feel like you are disbelieved and that’s really hard to live with.


A postural or mechanical issue like pelvic asymmetry or scapular instability is found. You do the exercises and treatments for this for a while. They don’t actually help, so eventually you give up. When you don’t get better you are blamed because you didn’t do your exercises enough.

Ok, yes, this is a bit cynical…

Some people with persistent pain do get excellent care and are helped to recover or manage themselves well long term. Or at least they are treated compassionately and given some hints of what to do for the best.

But I see people who have been through one of these scenarios all the time.

You have been handed just one piece of a jigsaw puzzle e.g.

But from that one piece you have no idea what the overall picture on the box is. What about all the other pieces of the puzzle?

Just some examples of what might be in a pain puzzle – mind AND body are always involved.

Everyone has a different combination of pieces in their pain puzzle. Sometimes one piece is much more significant than the others. But it is never one single thing that is 100% the cause of the total severity of someone’s’ pain.

This is because pain is product of physical factors: ‘issues in the tissues’ like

  • inflammation,
  • degeneration or injury,
  • changes to your nervous system that make it fire off more easily
  • muscle tension

AND mind factors:

  • worry, stress, poor sleep etc.

You have probably noticed your pain being worse when you are tired or stressed? So, you have experienced that pain isn’t just a ‘read out’ of damage in your body. Other factors come into how bad your pain feels. And these factors are something you can influence!

What’s the puzzle piece you have been handed?

If you have been handed a ‘degenerative changes in spine’ piece of the puzzle, then knowing that pain is this complex thing is good news. If the physical changes in your back aren’t the whole story, then there is hope that you can reduce your pain. You will not inevitably get worse with age, because the condition of your spine is only part of the picture.

Maybe that physical puzzle piece is a really important part of your pain picture, and sadly, maybe not much can be done about it. But that still means there are plenty of other pieces that can be influenced. You aren’t powerless.

(btw ‘degenerative changes’ is putting it more accurately than ‘crumbling spine’, which is not a great way of putting it, but words that still sometimes are used)

If you have been handed ‘anxiety’ or ‘depression’ for your pain puzzle piece, then please know that your pain is real, not just ‘in your head’. Is the ‘emotional’ puzzle piece a factor for you? Probably, yes. But it is for nearly everyone in pain. Wouldn’t it be weird not to have a low mood when living with constant pain, especially if no one is helping you? Low mood and anxiety often come after pain arrives, but then get the blame as if they were the cause. Pain is always more complex than x=y.

Even if psychological factors are important for your pain, just because there was nothing to see on an x-ray doesn’t mean that your body isn’t involved. There may be (reversable) changes in your nervous system for instance. This is a physical change in how your body is operating. So, movement, and physical factors in your pain need to be thought about as well as treating clinical depression, managing anxiety or whatever psychological intervention your doctor may think appropriate.

If you have been diagnosed with an ‘asymmetry’ or ‘bad posture’, such as an excessive lumbar curve this problem could well be an exacerbating factor in your pain. But would ‘correcting’ your postural issue in a way that just makes you look more even actually fix the pain completely? Or is it a bit more complex than that?

Spoiler alert: just correcting often isn’t helpful because good posture isn’t the same as alignment – there is much more to it than that. True, easy posture gained incrementally can make big shifts for people: this isn’t the same as ‘sitting up straight’ or tucking your chin in.

And posture may not be your only problem puzzle piece, so doing something that looks at you as whole person is essential.

Your Unique Pain mix

Is your pain about your special condition, or is it more about the special things about you?

I get asked a lot if Alexander Technique will help particular conditions. For instance, rheumatoid arthritis say, or scoliosis, or an old disc injury. Because of the way pain is dealt with it can feel like treatments need to be very specific to the condition or they won’t work. Exercises need to strengthen or stretch particular muscles. Manipulations or treatments need to be specific to the condition.

But actually pain treatment needs to be specific to the PERSON.

Your pain is unique and needs a tailored approach for you. That includes thinking about your condition and what particular thing helps that, for sure.

But a lot of the uniqueness of pain is in the messy mixture of contributing factors to your pain, rather than whether you have a specific condition or not.

Have you got a stressful job, with long hours? Are you struggling with sleep? Do you get wound up and anxious? Are you guarding yourself because you don’t trust your body to do what you need it to do? Do you try and forget that you have pain and soldier on through it – and cause it to keep flaring?
These kinds of factors (and there are lots more to consider) can sometimes turn out to be bigger problems than the physical problem you have been told you have.

Obviously you might have a big physical problem that is never going to go away, or needs a specialist treatment, and no self management is ever going to ‘fix’ it. In your Venn diagram, the physical might be a big circle, with just a little overlap from the other two areas. But that doesn’t mean that you don’t have some of those of factors going on with you.

And those, you have the power to do something about.

Flipping the Puzzle Pieces

It is really helpful to know that there are all sorts of factors in our pain. But what do we actually do about it?

What we want to do is change our puzzle picture from ‘pain’ to ‘non pain’.

To do this we can think of flipping the puzzle pieces over. Working on several different contributing factors at once, or in sequence, to change your mind/body and nervous system and calm the pain.

Examples of ‘flipping’ puzzle pieces – changing factors that are contributing to your pain

Pain is a complex system, like the weather

Many, many interacting factors are involved. It is this complexity which means a minor (and sometimes weird, just spend a few minutes searching pain relief on social media!) intervention can have an amazing effect on a person and completely eliminate their pain. This is like the proverbial butterfly effect – a tiny change causing the whole system to shift dramatically.

But obviously a sudden shift from one small change is extremely unusual – for nearly all of us, we need to change several factors for a good length of time to make a change to the overall picture. Especially when pain has been persistent for a long time.

Because pain is complex changing the whole ‘picture’ from pain to non- pain one isn’t a straight-forward ‘do this = this result’ situation.

But if you are just working on just one puzzle piece: exercise say, or mindfulness for relaxation, you will be missing all these other pieces that are significant to your recovery.

You are both body and mind: you are a complex whole, not a machine with a broken part.

Puzzling out your pain means you can focus on the strategies that are most likely to help you. And spend your precious time and energy on them.

Alexander technique and evidenced based approaches to pain looks at many parts of the puzzle. Movement, relaxation, release of muscle tension…. Luckily many factors interlink and complement each-other, so flipping a few key puzzle pieces can cause a big shift in a lot of areas and maximise the chances of making a big change to your pain.

For instance one of the first things I teach is something called ‘Active Rest’. I really encourage people to establish this as a daily habit.

It’s a lie down, but with extra va va voom!

Active Rest ticks a lot of the ‘help pain’ boxes:

  • It helps with relaxation generally: learning to stop and take a little break to re-set is so important.
  • It teaches tense muscles to let go: muscle tension can ramp up pain.
  • It teaches body awareness: so, you notice your tension and habits more when up and about.
  • It’s a powerful pain self-management tool: I wouldn’t have been able to have an active life without it when my back pain was very bad.

But Active Rest is just the foundation skill.

Learning to undo muscle tension, calm physical reactions to pain and stress, and move with more ease while going about your everyday life is something you can layer up. You can start with simple everyday things like how you clean your teeth, or how you walk, or stand to do the washing up.

Then you can bring these skills to more difficult things like complex tasks at work or a sport. It’s about weaving self-awareness, calm and ease into everything you do.

Do you need to puzzle out your pain and work out how to flip the puzzle pieces?

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