Explaining pain to people with chronic pain

One of the most challenging jobs we do in chronic pain management is help people get their heads around what chronic pain is…without giving them the idea that we think they’re imagining it, they’re mentally unwell, they’re ‘pretending’, ‘malingering’ or otherwise ‘not coping’.

While I can’t say I’ve got the answer, after explaining what pain is for a few years (not telling how many!), there are some things I find work better than others…

The first thing is to have a bunch of examples of everyday pain (mainly acute pain) to act as examples – mine include getting a flu jab, sunburn, a stubbed toe, sports bruises, and shark bites!  This helps people understand that pain is a normal, everyday experience that is understable.  Challenging, but understandable!

I use two different models of pain to help give people a bit of an understanding of their pain.  The first is a biopsychosocial model – so I have three circles, and while I’m talking with the person and getting them to tell me what their pain is like and how it’s affecting them.  The three circles are the ‘bio’ or biophysical factors, ‘psycho’ or psychological factors, and ‘social’ which includes social and cultural factors.

I find that working from what people already agree about (ie what they identify for themselves) and working with that to develop an explanation using a framework, like the one above, avoids saying which comes first (the pain or the irritability), and helps people acknowledge that each part influences the other.

Another option is to use Loeser’s ‘onion rings’ model.  This is a model that helps place the pain experience in context – it helps put the biophysical factors in the centre (whether as initiator or maintainer of the pain), while ensuring that the other aspects of pain such as the behaviour and context are also in place.

At the centre of the ‘onion’ is nociception – today we might instead think about neuromatrix dysfunction – which initiates and probably maintains the biophysical aspects of the pain experience.  But without the next few components, the pain experience does not actually exist.  We need to attend to or judge the meaning of the information being transmitted to the brain before it can be experienced…

So the next part is the actual quality or experience of pain – this is the part we can’t share with another, no matter how much we want to.  This is directly influenced by the nociception/neuromatrix part, but is also influenced by the next layer – which is our judgement of the meaning of that experience.  Loeser describes this as ‘suffering’ – but while experiencing pain may not be optional, suffering certainly is!

Suffering is all about how we interpret the sensations we become aware of, arising from the neuromatrix or nociceptors.  Suffering includes our predictions of the implications of the pain, what we think the pain means (something serious? something that will mean we can avoid something unpleasant? something to worry about…).  Some pain we can interpret as good – the pain after exercising, or the pain of childbirth (really!), while other pain we are concerned about (is it cancer? am I dying?).

What we do about pain is action, or behaviour.  Pain behaviours are directly influenced by what we think is going on – we run away if we think it’s something harmful, if we think it’s helpful we’re more likely to tolerate it (think about the flu jab compared with being jabbed with a dirty syringe in a dark alley).  At the same time, pain behaviours are influenced by our social setting – we do different things depending on who is around us, and where we are!

So the final ring is the social context – where we are at the time, the response of other people, our culture and even the legislative setting in which we live and work – these all make a difference to our pain behaviour (think of the response to stubbing your toe in your garage compared with your response to stubbing your toe on a pew at a funeral).

Working from what the person tells us, to a framework or model, seems to help people understand that we know what’s going on for them, we understand they’re not going nuts, and that we do know what we’re talking about.  A bit of reflective listening doesn’t hurt either.

I’ve also attached this description if you want something more complex…simple-explanation-of-cp

I hope this post has helped – if you’ve enjoyed it, and want to see more, you can subscribe using the RSS feed above, or you can bookmark and visit again. I post most working days, and I do love comments! I usually reply asap, and if you think I haven’t seen your comment you can always email me.  Go to my ‘about’ page and you’ll find my contact email.  I hope to see you back again soon!


  1. Do you know of any references to the onion skin model in the medical literature? I have searched pubmed for a reference by Loeser, Fordsyth, and just the model without authors to no avail. Lots of refs through google, but all are people refering to Loeser, but no medical references. Seems strange.

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