PAIN 101: An introduction to the biopsychosocial model
Pain is a complex and multifaceted phenomenon that involves intricate interplay between structural, psychological, and social factors that all influence our perception of pain. This three-dimensional theory, often referred to as the Biopsychosocial Model of Pain, recognizes that pain is not solely a result of physiological factors and structural damage, but is also influenced by our thoughts, emotions, core beliefs, feelings of belonging to a group and having social (friendly, familial, team, coach/teacher) support at our disposal.
This model has profound implications for practitioners like physios, doctors and coaches, as well as for athletes, who often encounter various types of pain due to the physical demands of their sport. Current data suggests that field sport athletes experience 1-3 injuries per year (severity not included in the analysis), so learning how pain develops, how we perceive it, and how to rehabilitate it effectively is a critical skillset for practitioners and athletes alike.
Pain Perception
How we perceive pain as “painful” is a remarkable outcome of the intricate processing that occurs within the brain in response to both external and internal sensory inputs. When the body encounters potentially harmful or threatening stimuli - even a “known” stimulus, like a max effort sprint, where we have injured ourselves before - specialized nerve endings known as nociceptors detect these signals and transmit them to the brain. This process is called Nociception and initiates a cascade of complex neural activities that culminate in the sensation of pain as an output of the brain.
The brain's role in pain perception extends beyond mere transmission of signals. It receives and interprets sensory inputs from our immediate environment, integrating information from various sources to create a coherent and contextualized experience of pain. This integration involves regions of the brain responsible for sensory processing, emotional responses, and cognitive functions.
The sensation of pain can arise from physical injuries, temperature extremes, fear and anxiety, potential threats to our person or egos, or other stimuli. Internally, the body's own signals can trigger pain, such as inflammation or muscle tension. These alert signals are relayed to the brain as neutral information, following which the brain then employs its neural networks to analyze the incoming information. Factors such as the location, intensity, and duration of the stressor are all assessed, and the brain cross-references this data with past experiences, emotions, and learned responses.
Emotions and psychological states can further modulate pain perception. Anxiety, stress, and fear can amplify pain dramatically, while relaxation techniques, rhythmic movement and purposeful, positive emotions might mitigate it. This intricate interplay between sensory input and emotional responses is a testament to the brain's remarkable ability to shape our experience of pain.
In essence, pain is not a direct reflection of our external or internal world, but rather an intricately crafted output of the brain's processing according to its assessment of our available resources and threat level. This processing synthesizes information from various sensory and emotional inputs, ultimately generating the sensation that guides our actions and decisions. Understanding this complex interplay, specifically understanding that pain is neither detrimental or an accurate sign of damaged structures in the body, underscores the importance of a multi-faceted approach to pain management—one that considers not only the physical (structural, biological) aspects, but also the cognitive, social, and emotional dimensions that influence our perception of pain.
A simplified graphic explanation of neurological sensorimotor processing, including nociception (processing of pain as an output).
The Biopsychosocial Model of Pain
Let’s get into all three factors in depth, but first, let’s take on an overview. I work primarily in global football, meaning I treat, train and talk to soccer players pretty much constantly. These athletes are excellent examples for explaining this pain model: their fitness is very sport-specific, they are largely very injury-prone and generally more sensitive to pain than other sports (American football, literally goodbye), and tend to pick up overuse injuries very quickly, due to a disregard of load management by sport coaches.
Soccer is a physically demanding sport that exposes athletes to various types of pain, including acute injuries, chronic overuse injuries, and post-match soreness. Applying the three-dimensional theory of pain to this sport, though, reveals that their pain experiences are not solely rooted in physical trauma, such as spraining an ankle, a sore patella tendon after an intense training, and difficulty returning to play after a complete ACL rehabilitation. Psychological factors like fear of reinjury, low resilience, lack of self-belief or performance anxiety, as well as social pressures to return to the field quickly, can impact their pain perception and overall well-being. Additionally, being set apart from the team during the rehabilitation setting can cause even more difficulties in this process.
So let us access every dimension more deeply:
Biological Dimension:
The biological dimension encompasses the physiological processes and perceptions of pain. This is usually the starting point for athletes and practitioners alike: Athlete X has pain in his knee, so our initial step is to inspect the joint and its surrounding structures, looking for a threat or damage. However, pain is not solely determined by tissue damage; factors like genetics, inflammation, and neural pathways also play crucial roles in shaping an individual's pain experience. The biological dimension of the pain equation encompasses three primary mechanisms: nociceptive, nociplastic, and neuropathic.
Nociceptive pain arises from the activation of nociceptors, specialized nerve endings that detect harmful stimuli like heat, pressure, or chemical irritants. This mechanism is essential for alerting the body to potential injury or damage, serving as a protective response.
Nociplastic pain involves changes in the way pain signals are processed within the central nervous system. It's characterized by heightened sensitivity to pain, even in the absence of ongoing tissue damage. Conditions like fibromyalgia exemplify nociplastic pain, where the brain amplifies pain signals, leading to widespread discomfort.
Neuropathic pain results from damage or dysfunction of the nervous system itself. Nerves may become injured, compressed, or irritated, causing abnormal pain signals. Shooting, burning sensations and numbness are common in neuropathic pain, often seen in conditions like diabetic neuropathy or sciatica.
Understanding these mechanisms is crucial for tailoring effective pain management strategies that do not focus solely on structural damage, as each type of pain requires distinct approaches to treatment, as does each individual. It is entirely possible to experience pain without structural damage; if I had to put a number on how many athletes I have treated who still present with joint, muscle, or ligament pain after a complete, successful rehab and after a physician has cleared them to play with no remaining damage to see on MRIs or XRays, the number would be over 50 in the last five years alone. Thus, we need to be move innovate and curious about where pain comes from, how we perceive it, and how we can change that perception without a sole focus on biological pathways, inflammation and tissue damage.
Psychological Dimension:
The psychological dimension highlights the influence of cognitive and emotional factors on pain perception. Our thoughts, beliefs, attention, emotions, and expectations all change our experience.
Emotions such as anxiety, fear, depression, and loneliness can negatively influence an individual’s perception of pain, while positive emotions, such as love, appreciation and gratitude might alleviate it. Past pain memories influence current pain perception as well. A great example for this influential relationship is a common dilemma in football: the fear of pain or re-injury can lead to avoidance behaviors, such as limiting physical activity or never training at high intensity, which perpetuates pain and may lead to less fitness, thus raising injury risk again.
Where we put our focus matters: Placing energy and attention on our pain can increase its intensity, while diverting attention away from it through distraction with activities or mindfulness techniques can reduce its impact until the patient learns how to accept the discomfort as an alert signal and a passing experience that is simply providing them more information about their bodies.
Beliefs and thoughts about pain influence its intensity. Catastrophic thinking can amplify pain, while positive expectations can ease it. This applies even to non-sport-related thoughts, beliefs, and emotions, which then exacerbate the pain in daily life.
Likewise, beliefs and thoughts about ourselves influence our perception: if we view ourselves as strong, confident, resilient, and open to learning and tackling challenges, our perception of pain will likely differ strongly from an athlete with no self-confidence, extreme self-criticism, low self-worth and self-efficacy.
Expectations and placebos: Anticipating pain during a movement, training, competition, or simply daily life shapes the experience of it asa well: higher expectations that pain will occur also correlate with heightened pain perception! No shock. On the other side of that, though, we see the potential beauty in expectation: Believing in the effectiveness of a treatment, even if it is a placebo and studies find no significant influence worth a mention, can lead to pain relief due to the brain's role in expectation and conditioning.
(Yes, this is usually a good thing but can definitely be a bad thing… that is why there are so many poisonous, grifting personalities and companies who market around rehabilitation and performance with huge promises of pain relief: it sounds amazing, the promise is almost as big as the price tag, and people get some kind of result that they see positively and reinforces the expectation - but the intervention itself literally does nothing.)
Social Dimension:
The social dimension recognizes the impact of social interactions, culture, and environment on pain experiences. Social support, family dynamics, socioeconomic status, and cultural beliefs all contribute to an individual's pain perception. For soccer players, social pressures to perform, expectations from coaches and teammates, and the availability of proper medical care can significantly influence their pain journey.
Team & Coach Support: Team support and camaraderie provides emotional comfort and belonging for athletes in rehab, who are often separated from their teams during training sessions. The bond between teammates can be largely positive in this regard: shared goals and camaraderie create an environment where pain is not merely an individual burden but a collective challenge to overcome. Teammates' encouragement and shared experiences during training, matches, and recovery phases forge a sense of unity that helps players endure pain more resiliently. This can also divert attention away from pain and trigger the brain’s reward centers - hello dopamine! - which can modulate pain.
On the negative side, high expectations from coaches and teammates about returning quickly, still playing critical matches, and taking risks might pressure players to conceal pain, fearing it signifies weakness. Additionally, cutting athletes off from the team during this period or not reaching out as their coach can be damaging: players need to feel part of a team, like they belong, and like they have a spot in the squad to return to in order to keep motivation, resilience, and effort high in rehab, as well as to mitigate pain sensations.
Cultural norms within the team and sport subtly mold how players perceive and express pain, striking a balance between resilience and acknowledgment. There is a difference between pain expectation in soccer and American football: a football player will have to be removed by a stretcher while unconscious with a concussion or while screaming in pain from an ACL tear, and that will be accepted as pain, although the migraine he picked up from the 400x per training that he hit his head with minor concussion-level force will be largely ignored by all. Most soccer players will remove themselves from training with a slightly uncomfortable, twinging muscle or force themselves too early back into the game due to external pressure or stress over squad decisions. For global football, the accepted norm is a wider span, while in American football, complete resolve to endure pain is pretty much expected.
External Pressures: In high-level sport, media scrutiny, fan hopes, and federation expectations intersect, compelling players to endure pain for the sake of achievement, creating a complex relationship between pain and success.
Friend and Family Support: The unwavering presence of friends and family, regardless of outcomes in Rehab or on the pitch, can provide emotional comfort and understanding. Their empathy and encouragement serve as a powerful distraction from pain, redirecting focus towards positive interactions and shared experiences. This diversion not only alleviates psychological distress but strengthens the feeling of belonging, fulfils our social needs, and also triggers the release of endorphins – one of the body's natural pain-relieving chemicals.
Three-Dimensional Rehabilitation
During the rehabilitation phase, addressing an athlete's foundational needs on all three dimensions enhances the effectiveness and speed of recovery.
Physical Needs: Proper diagnosis and treatment of injuries are fundamental. This might involve physical therapy, medication, or surgery when necessary. However, it's also crucial to focus on preventive measures, such as injury-specific training regimens and adequate rest to reduce the risk of future injuries. Ensuring proper nutrition and hydration supports the body's healing processes. Tailored rehabilitation, guided by physios and sport scientists/strength coaches, will aid in restoring appropriate strength, mobility, and power through the painful area. Adequate sleep is equally important, as it facilitates tissue repair and overall recovery.
Psychological Needs: Providing athletes with a sense of control over their recovery journey is essential. As the central person in the equation (the patient!), they should be able to make both big and small decisions in their recovery process, which strengthens their feels of autonomy and competence in their bodies and sport, giving feelings of control. Setting achievable milestones and celebrating progress can boost their confidence. Techniques like mindfulness and visualization can assist in shifting their focus away from pain and onto their recovery process, or to help players see themselves as strong and successful on the field again. Establishing open communication and checking in regularly with a sport psychologist can provide a safe space for athletes to express their concerns and manage any mental or emotional barriers to recovery.
For athletes who severely struggle with the psychological aspect of pain, integrating psychological interventions like cognitive-behavioral therapy can help athletes manage pain-related anxiety and stress. There is no shame in bringing in a psychotherapist or counsellor who can help athletes to (re)build up their psychological skills in the rehab process!
Social Needs: Maintaining a strong social support system is crucial, both inside and outside of sport. Athletes should feel comfortable discussing their pain and rehabilitation progress with teammates, coaches, and medical staff. This involves allowing adequate time for recovery without inducing guilt and maintaining transparent communication about the rehabilitation process. A supportive network can provide encouragement, reduce feelings of isolation, and reinforce a positive outlook with small and large future goals. Additionally, coaches, medical staff, and teammates can collaboratively influence recovery, showcasing that true healing and recovery extends beyond the physical realm, intertwining with relationships, emotional support, shared experience, and shared goals. Emphasizing that recovery is a mutual goal for a team or group of athletes can alleviate social pressures to be constantly top fit and perform at 100%.
In conclusion, the three-dimensional theory of pain offers a comprehensive framework for understanding and treating pain in the general population and in athletes alike. The key takeaways from this model are that context always matters, the brain is more powerful than we think, and that we have control: we can influence pain more than we think, even when the situation seems dire.
By addressing pain through a multi-fasceted approach that considers all three dimensions, athletes can experience a faster, more effective and well-rounded rehabilitation process that puts them and their needs in the center of decision-making. Focusing on fulfilling their foundational needs during the recovery phase not only aids physical healing but also promotes psychological well-being, social health, and a smoother return to peak performance. As the sports world continues to evolve technologically and yet continues to treat athletes even more like products to be thrown in the trash as soon as they stop delivering to standard, embracing this multi-dimensional perspective on pain is essential for optimizing the health and success of athletes in both the short- and longterm.
Further Reading:
Edwards RR, Dworkin RH, Sullivan MD, Turk DC, Wasan AD. The Role of Psychosocial Processes in the Development and Maintenance of Chronic Pain. J. Pain. Sep 2016;17(9 Suppl):T70-92.
Farrell, S., Edmunds, D., Fletcher, J., Martine, H., Mohamed, H., Liimatainen, J. & Sterling, M. (2023) Effectiveness of psychological interventions delivered by physiotherapists in the management of neck pain: a systematic review with meta-analysis. Pain Reports: Musculoskeletal Review.
International Association for the Study of Pain (IASP) Terminology. Dec 2017; https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698.
Simpson P, Holopainen R, Schütze R, O’Sullivan P, Smith A, Linton SJ, Nicholas M, Kent P. (2021). Training of physical therapists to deliver individualized biopsychosocial interventions to treat musculoskeletal pain conditions: a scoping review. Phys Ther;101:pzab188.
Tscholl, P. M., Vaso, M., Weber, A., & Dvorak, J. (2015). High prevalence of medication use in professional football tournaments including the World Cups between 2002 and 2014: a narrative review with a focus on NSAIDs. British Journal of Sports Medicine, 49(9), 580–582.
Van Erp, R., Huijnen I., Jakobs M., Kleijnen J., & Smeets R. (2019). Effectiveness of primary care interventions using a biopsychosocial approach in chronic low back pain: a systematic review. Pain Pract; 19:224–41.