A 7-part Series on Chronic Pain

by Josh Meyers, PT, DPT, OCS

Pain is good. It helps one to avoid danger, survive an injury, and protect oneself when confronted by physical or emotional threats. The problem arises, however, when pain persists after a danger is removed, an injury heals, or a threat is no longer present. Medical providers call this persistent type of pain chronic pain, and it is the leading cause of disability in America.

Hope, however, lies in the fact that chronic pain is treatable. Through this series, readers will learn how chronic pain develops, recognize common symptoms, and understand how chronic pain is treated. Our goal is to empower readers to take action and regain control of their pain. Comments at the end of each post are welcome. Be sure to ask questions and share experience to help others with similar symptoms.

Part 5: Regaining Control

Most people with chronic pain do not feel they have control of their pain. They have been led to believe that pain is “something that happens to them” – not the other way around. As a result, fear and anxiety paralyze them, and they find it hard to move in a direction of control. Pain treatment aims to restore that control, and nothing works better than education. When one understands pain and how to influence it, changes begin almost instantly.


Fear is normal, and it contributes to one’s survival. No one wants to step on a nail or slip on the ice a second time. The brain learns from past mistakes and generates a healthy fear of situations or environments that may cause harm. The problem arises when the brain prematurely causes a pain experience because it fears normal situations or environments.

Neuroplasticity allows a brain to arrive at the point where movement is seen as a threat. With injury, the brain couples pain with movement and becomes conditioned to fear and avoid that movement. (Injury often drives this process, but pain occurs without injury as well.) As a result, one begins to avoid movement. While this conditioning typically starts on a small scale, enough time and repetition cause one to fear and avoid movement altogether. Thus, the cycle of disuse, disability, and depression begins. The brain chooses to avoid use of a body part to avoid pain. This disuse leads to disability as the body part becomes weaker or neglected from lack of movement. In the end, depression sets in when one realizes the loss of an ability to perform tasks or common activities.

Attitude contributes to this cycle as well. Those that take the attitude of “all pain is harmful” tend avoid movement or exercise when even a hint of pain is present. The attitude of “pain is uncontrollable” develops in others and leads to despair. Others catastrophize, or assume “my pain is going to get worse”, and become paralyzed by the unknown. Regardless of the reason, movement stops and the cycle of disuse, depression, and disability continues.

Yellow Flags

While fear and attitude indirectly limit movement, other factors drive chronic pain and limit recovery in other ways. Medical providers call these factors yellow flags, and their presence indicates a high likelihood for a patient to develop chronic pain. Yellow flags may not appear significant on the surface, but they drive chronic pain just as much as fear and anxiety.1

Yellow flags can be external stressors; job stress, financial stress, stress from loss of independence, stress from social status changes, or stress from family concerns.1,2 This chronic stress causes elevated cortisol levels in the body and makes a nervous system “extra-sensitive”. What would normally be brushed off as a benign stimulus, now causes pain when these stressors are in the picture.

Other yellow flags are more psychological in nature. It is hard for one to have confidence moving forward after “failing” treatment or receiving conflicting explanations for the same condition.1 Self-medication with alcohol or recreational / prescription drugs promotes inactivity and hinders one’s body from maintaining an environment of healing. Behavioral changes affect recovery as well. When one takes a passive approach to recovery by using extended periods of rest or withdrawal from usual activity, it slows physical healing and negatively affects motivation to recover.

Yellow flags take the identity of social interactions as well. An overprotective spouse or friend can be “lovingly” harmful by encouraging too much self-protection or inactivity after an injury. This inactivity leads to weakness and a slower recovery overall. Conversely, spouses that are unsupportive during an injury leave one isolated and promote a feeling of helplessness. This helplessness makes it difficult for one to process recovery and move forward in the healing process.2

“You Are Going to Be Okay.”

The words, “You Are Going to Be Okay” are some of the most powerful words providers can say to a patient. These six words relay to a patient the fact that tissue heals, nervous system hypersensitivity decreases, and activity tolerance improves with treatment and time. Those with chronic pain best understand these concepts with education, and that is what the previous 4 posts are about. When one learns how pain works and the triggers that cause the brain to cause a pain experience, one can begin to restore normal sensitivity in the nervous system and brain.3,4,5 Furthermore, when providers use encouraging language it gives patients hope – and that is all that some need to break a cycle of disuse, disability, depression.

When providers help a patient define reality, it changes chronic pain. Beliefs that “Pain is a part of life” or “Pain will not resolve because friends or family members have unresolved pain” present a barrier to the healing process. Providers work with patients to identify those barriers and systematically address each one. It may mean bringing in support from family or friends, encouraging a person to join a support group, or simply talking through issues to help “reset” appropriate views of pain or “perspectives” on stress. Effective management of yellow flags keeps these factors from negatively influencing movement or activity.

A reason to get out of bed each day provides motivation and breaks the cycle of disuse, depression, and disability as well. Providers work with patients to identify goals, break them into achievable parts, and walk them through the process of achieving them. Not only does this help a patient with chronic pain realize purpose, it ensures that physical activity, a necessary part of healing, occurs daily. The right motivation ensures that people move more frequently, voluntarily, and naturally.

The next post will help readers understand how movement helps to treat chronic pain and show the difference between active and passive treatment.


Let’s Hear From You

What are your experiences with pain? What “Yellow Flags” have you had to overcome? Share your experience in the comments below.

Need Help?

If you suffer from chronic pain, there is hope. Call us today to find out how physical therapy can help treat your chronic pain.




  1. Watson P, Kendall N. Assessing psychosocial yellow flags. In: Gifford LS, ed. Topical Issues in Pain 2. Falmouth: CNS Press; 2000.
  2. http://www.acc.co.nz/PRD_EXT_CSMP/groups/external_ip/documents/internet/wcm002131.pdf
  3. Greene DL, Appel AJ, Reinert SE, Palumbo MA. Lumbar disc herniation: evaluation of information on the internet. Spine (Phila Pa 1976). Apr 1 2005;30(7):826-829.
  4. Morr S, Shanti N, Carrer A, Kubeck J, Gerling MC. Quality of information concerning cervical disc herniation on the Internet. Spine J. Apr 2010;10(4):350-354.
  5. Woolf CJ. Central sensitization: uncovering the relation between pain and plasticity. Anesthesiology. Apr 2007;106(4):864-867.