Understanding pain: protection, sensitivity and rebuilding confidence

Why can a familiar movement feel manageable one day and much more painful another? Does a flare-up mean something has been damaged again?

Pain deserves attention, but its intensity is not a direct measurement of tissue damage. Understanding that distinction can make symptoms less confusing and help you ask better questions about returning to activity. Lorimer Moseley and David Butler’s Explain Pain work explores pain through protection, drawing together biology and human experience. [1,2]

Pain and danger signals are related, but different

Nociception is the nervous system’s processing of potentially tissue-damaging stimuli. Pain is the experience a person feels. The two are related, but pain cannot be read directly from sensory nerve activity. IASP also recognises that biological, psychological and social factors influence pain to varying degrees. [1]

That is why “How much does it hurt?” is important, but cannot answer every question about an injury. Changes in symptoms need to be considered alongside what happened, your health history and clinical findings. More pain does not automatically establish more damage; little pain does not establish that a tissue is uninjured.

Sometimes the protective response stays sensitive

Pain can continue beyond the expected healing period. In some persistent pain situations, the systems involved become more sensitive, so familiar demands can feel painful or difficult. This is one of the central ideas explained in Pain Revolution’s educational resources. [3]

A sensitive alarm offers a useful comparison: how loudly it sounds does not measure the size of the problem it is responding to. But an analogy cannot establish the cause of your symptoms. Ongoing tissue pathology, nerve-related problems and altered pain processing may all require consideration.

The practical implication is to investigate a flare-up rather than immediately conclude either “I have damaged myself” or “It is only sensitivity”.

The same movement happens in a changing context

Imagine lifting a shopping bag after a previous back injury. The bag has a weight, but the experience also has a history: what happened last time, what you expect now, and whether you understand the advice you have received.

Moseley and Butler’s danger-and-safety framework explores these contextual influences. Their DIMs and SIMs—“Danger in Me” and “Safety in Me”—are prompts for considering information, experiences, surroundings and relationships. They are a teaching framework, not a diagnostic test or a formula for calculating pain. [4]

For the person lifting the bag, a useful next step might be clarifying what their symptoms mean and discussing an appropriate way to practise the task. Reassurance needs to be credible and connected with their circumstances. This is not a request to dismiss symptoms or think positively enough to remove them.

Build the plan around something worth returning to

Education becomes useful when it helps someone make decisions. Choose a meaningful activity—a walk with a friend, a household task or returning to training—and describe what is difficult about it.

An individual plan can then consider a suitable starting demand, what response to monitor and when to review it. Ask: “What would make this activity manageable, and how will we decide whether to adjust it?” Progress can be discussed in terms of function and participation as well as symptoms.

For chronic primary low back pain specifically, WHO’s 2023 guideline takes a person-centred approach across physical, psychological and social needs. Its scope is that condition; it is not a universal prescription for every painful problem. [5]

When assessment matters

Understanding pain does not replace assessment or guarantee that symptoms will disappear. Seek advice for persistent, worsening or function-limiting symptoms. If back pain occurs with loss of limb feeling or movement, or problems controlling your bladder or bowels, call 000 immediately. [6]

References and attribution

1. International Association for the Study of Pain. Terminology: pain and nociception. Source ↗.

2. Moseley GL, Butler DS. Fifteen Years of Explaining Pain: The Past, Present, and Future. Journal of Pain. 2015;16(9):807–813. doi:10.1016/j.jpain.2015.05.005. Source ↗.

3. Pain Revolution. Essential Pain Facts. Current resource ↗.

4. Butler D, Cocks T. DIM SIMs. Noigroup, 2015, discussing Moseley and Butler’s Protectometer framework. Source ↗.

5. World Health Organization. WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings. 2023. Source ↗.

6. Healthdirect Australia. Low back pain. Source ↗.