Pain is never purely physical. It’s never only bodily harm that’s causing our hurt. So says Dr Rachel Zoffness, a leading pain psychologist who trained at prestigious Brown University and has studied the science of pain for 35 years. Pain is our body’s warning system, she explains, “an interpretation” by the brain of how much danger we’re in — and so how we feel and think about our pain is critical to how we experience it.
That certainly doesn’t mean that if our doctor can’t find anything physically wrong then the pain is “all in our head,” says Zoffness, who is based at the University of California’s School of Medicine in San Francisco. “It is real.” Zoffness’s patients find it helpful when she describes pain as “biopsychosocial” — meaning that biological harm and our emotions, psychology, situation and life experience all factor in our pain intensity.
“Just as pain is never purely physical it’s never purely emotional,” says Zoffness, the author of a new book, Tell Me Where It Hurts: The New Science of Pain and How to Heal. “The brain and body are connected 100 per cent of the time. Our physical health and our emotional health are always intertwined. It’s adaptive, it helps us survive.”
Dr Rachel ZoffnessAdam Gray for the sunday times
Because of what we’ve been told, though, most of us do assume that our aches, twinges and pain are caused purely by that old running injury or a herniated disc. “People can really struggle to wrap their heads around the fact that pain can be caused by a much more complex set of processes than bodily injury,” says Dr Lafina Diamandis, a GP and lifestyle medicine physician who specialises in helping people with chronic pain at her clinic Deia Health in London.
“Painkillers are good for acute short-term pain — you’ve sprained something, done your back in, you have a headache, period pain. They absolutely have a role. But painkillers are often not so effective for treating chronic pain,” she says. “Consider whether they are giving you a window of opportunity to move or function better, or are they masking an underlying problem? We should not demonise painkillers — they offer relief to many — but we should always ask ourselves what else we might need to address or consider?”
Knowing that there are many ingredients to pain gives us the agency, and hope, to help ourselves to get better. Here, these two leading pain experts give their advice.
Dr Lafina DiamandisSTE MARQUES
Pain is a mixture of physical and psychological factors
“Back pain affects an estimated 80 per cent of people in the US at some point in life,” says Zoffness, citing studies indexed by the National Library of Medicine. Meanwhile, the Health Survey for England 2024, published this year, indicates that back pain affects around 10 million people annually. “Everyone will be told that the cause of their back pain is the finding on the back scan — it’s the slipped disc, spine degeneration,” Zoffness says. “That messaging will amplify the brain’s pain alarm.” Meanwhile, she explains, research consistently shows that MRI findings of bulging and degenerated discs rarely correlate with the intensity or even the presence of back pain.
Embodying the fact that harm (tissue damage or anatomical abnormality) and hurt (pain) aren’t the same is the elite athlete Usain Bolt, who has scoliosis. “Usain Bolt has the most twisted and abnormal spine, and he’s the fastest man alive and he has very little pain.” Zoffness says.
Pain is never just the physical damage, she adds — it’s a mix of physical, psychological and social factors. “Hurt is the subjective experience of pain we have — harm is the damage done to our bodies.” But if a doctor tells you your hurt is caused only by the harm — “If you believe that your knee pain is because it’s ‘bone on bone’, you’ll believe movement is dangerous” — you won’t do the things (be active, socialise, build confidence) that help to quieten the pain alarm.
Never push through pain with exercise — know when to rest
Acute pain (usually sharp, sudden, intense and short term) tends to be caused by injury or illness, and you must rest and heal, says Diamandis, though she notes: “Often the necessary period of complete rest is shorter than people expect, which is why physio and rehab and getting a diagnosis is so important.” But what about niggles — neither chronic pain nor acute injury — that flare up, usually after exercise? If your back aches after deadlifts, is it madness to continue without investigating why? “I would always consult with a physio or personal trainer if there is a history of significant or recurrent pain or injury,” Diamandis says.
Working out alone, she experienced terrible back spasms after deadlifts so stopped doing them. “Never push through a high level of pain.” She subsequently found a personal trainer, who noted that she was hyper-mobile in her lower back, and overextending. “Now I just take the dumbbells to my knees. And I start with a lighter weight and build up.” Train around the “niggle” by changing technique, load, or range of movement, she suggests. “Or try a different movement that works the same muscle — like glute bridges or hip thrusts.” She notes, “A little niggle or stiffness, that’s a signal from your body to ‘just be mindful here’. It can be something as simple as, ‘That joint hasn’t warmed up yet.’”
Why pain continues after an injury heals — and what to do about it
An estimated 43 per cent of adults in the UK live with chronic pain, defined as pain lasting more than three months, according to a 2016 study published in BMJ Open. Why does pain so often persist after injury heals? Zoffness recalls learning to play the piano, practising until it became intuitive. Similarly, the longer we have pain — the longer our brain and spinal cord, our central nervous system “practise” it — the better we get at producing it, she says. Our pain no longer reflects tissue damage, “It is stuck in this high-alert mode.” Thankfully the brain can change, which means our pain can change, she says. We “unlearn” it by “pacing for pain”.
“Pacing is so effective because it changes your central nervous system,” Zoffness explains. “It changes the input your brain is getting.” Broadly, it teaches your brain that you’re safe. First, Zoffness tells patients, “I need you to move your body. But we start where it’s comfortable for you.” Pacing for pain is like pacing for a marathon. You increase activity over time. She asks: “What’s an activity you miss, that pain has taken away?” It might be dancing, sport or cooking. “Then we put together a pacing plan to aim towards achieving that. I find that to be magic for my patients. They’re motivated.” One patient, bedridden for four years, wanted to play football again. Week one entailed standing on his porch in the sun for five minutes. Week two was walking to the post box. (Activity, daylight, chatting to neighbours all helped.) Eventually he got back to playing football.
Your brain can be overprotective — and catastrophise your pain
You lift a box, and tweak your back. You start panicking and swearing internally. “I call that voice Pain Voice,” Zoffness says. “It says, ‘Shit, shit, it’s happening again, I’m not going to be able to exercise or have sex…’” These thoughts are normal and come from our overprotective brain. “But anxious, catastrophic thoughts will amplify pain volume in the brain.” The result is you’ll do less, move less, then think more anxiously and catastrophically — and repeat the cycle.
Learn to recognise your pain voice, Zoffness advises (she calls hers “Petunia”) and ask yourself: “When it goes off, how am I feeling? Scared, anxious, sad? Are my muscles tensing?” Also, “What are the behaviours I’m engaging in as a result of this twinge?” And crucially, “How can I take care of my brain and body in this moment to keep pain volume low?”
Laughter can help to beat pain
Zoffness cites research that finds people can keep their hand in freezing water for longer if they’re laughing at a TV show. “It works because your prefrontal cortex is one of the parts of the brain that makes pain, and when you’re focusing on pain your prefrontal cortex dials in and focuses on the pain and amplifies the sensation.” Distraction, therefore, is effective. “For me it’s watching stupid TV,” she says. She asks patients: “‘Have you ever been so absorbed in a hobby or activity that you briefly forgot your pain?’ And everyone says: “Yes — when I was gardening, cold-water swimming, watching a movie with my husband.” Identify the strategies that work for you.
Stress and anxiety can make pain worse — don’t doomscroll
Emotions such as fear, anger, frustration and anxiety make pain worse. “The parts of the brain that make emotions also make pain. Our limbic system, our amygdala — those are part of the emotion machinery — they are critical parts of the pain machinery too,” Zoffness says. No wonder pain worsens when we’re stressed. “Our bodies go into fight or flight mode. Our muscles tense. We know muscle tension is bad for pain. Plus, brain chemicals that lower pain volume, like endorphins, our natural opioids, go down. Ultimately the pain dial in the brain dials way up.”
Zoffness recommends identifying your stress triggers and controlling and managing those you can. “For me, doomscrolling at night, watching the news at night — no, no. Bad for my brain, my pain, my sleep.” She practises and teaches breathwork. Diaphragmatic breathing (deep, low, slow) calms us and lowers our pain alarm, she says, whereas breathing shallowly from our chest when stressed sends danger cues to the brain and keeps our pain system hyperactive.
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Don’t dismiss mindfulness techniques
“People do roll their eyes at mindfulness because they’re not sure whether it’s credible,” Diamandis says. “But when we’re practising meditative or mindfulness-based therapies for reducing pain we’re actually retraining the brain to reinterpret those pain signals.” Mindfulness exercises — such as paying attention to your thoughts, feelings, breath, and sometimes combining this with visualisation exercises — enable us to put some space and objectivity between us and our pain, she says. “You’re increasing activity in the frontal lobe area, responsible for reasoning, decision-making and objectivity, and reducing activity in the emotional centre of the brain. It also reduces the stress response, one of the biggest factors in amplifying pain.”
Brain scans of people who regularly meditate or practise mindfulness show that it decreases activity in the regions responsible for processing pain, Diamandis says (she’s a fan of yoga nidra). “You can’t meditate away a broken arm, but in chronic pain, where that pain signal has become disrupted, it’s really helpful in starting to rewire some of that circuitry.”
Research from the University of California San Diego found that pain intensity was reduced after 20 minutes of meditation daily for four days.
Zoffness teaches patients relaxation techniques including breathwork and body scanning, and says if you have a smartwatch you see the power of your mind on your body as your heart rate slows. “There’s incredible power in using biofeedback as a pain-management tool.”
Learn to access your brain’s natural painkillers
Research shows that placebos can alleviate pain in conditions from IBS to migraines, Zoffness says. How? The “placebo effect” works when — primed by context and belief — our thoughts, expectations and emotions activate our body’s natural pain-relieving chemicals, she explains. “Our brains produce endogenous opioids, they’re called endorphins, and endocannabinoids, which are also chemicals that lower pain volume, and serotonin and dopamine, which also regulate and adjust pain volume.”
So how do we access this innate pharmacy? Spending time in nature, with people you love, better sleep, and good nutrition change your brain chemistry. Exercise too is key. As well as stimulating bone, muscle and tissue repair, it activates mood-boosting neurotransmitters and pain-reducing neurochemicals. “There are so many things we can do to change the pain volume in the brain,” Zoffness says.