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  • Dr. Judy Spilka, PT

Is the pain all just in your head?

This question comes to mind as an issue that has surfaced time and time again with my patients. They come in with thought processes that place a negative connotation behind their pain. “I was told that there is nothing else the surgeon can do, yet, this pain is so intense…how can I not have something wrong with me?” Then their minds begin to drift with a plethora of other thoughts. “I am going to have this pain forever. I can fight through this pain without any help! Maybe this pain is all just in my head.”

We have been driven as a society to evaluate pain as biomechanical or structural. When my patients are left to believe that there is nothing structurally wrong with their body, they begin to question that the pain is just “all in their head”. In physical therapy, a component of what we do is driven by the psychological aspect of what our patient perceives as painful. Part of my education with each patient delves into the topic called “pain science”. The major question is; what causes one body to react so intensely to certain movements with an influx of pain–whereas someone else has no difficulty with similar movements and structurally both patients are healthy?

A main component of pain sciences deals with two different states that our body can be in; one being “flight or fight” (also known as sympathetic) and its opposite “rest and digest” (parasympathetic). Fight or flight increases the stress hormone known as a “cortisol”. Cortisol is a “potent anti-inflammatory that functions to mobilize glucose reserves for energy and modulate inflammation” (Hannibal & Bishop 2014). Cortisol in short spurts is healthy because it allows your body to readily move through a critical situation with more strength and speed. Animals are only in that state when they are fleeing from an attack (a gazelle being chased by a lion), but when the chase ends the animal naturally switches into the parasympathetic state, or the rest state, when the threat is gone. Can you see where I am going with this? As a society, humans have a tendency to not know how to turn off the stress. We are constantly in a chronic stressful state with our busy lives. What are stressors: work overload, financial troubles, unemployment, family struggle, COVID, etc. Cortisol as a result, doesn’t shut off because our daily living habits lead our bodies to believe that they are still in flight or fight mode (even when the stress is low lying, subtle).

Cortisol over the long term is the main influencer of pain. Prolonged or excessive cortisol secretion may result in a down-regulation to pain receptors and decrease our pain threshold (Hannibal & Bishop 2014). Even the threat of the possibility of the pain returning, can increase the hyperactive response, which then increases the stress. As a result, the nature of any potential stressors may promote an “exaggerated physiologic stress response that is likely to initiate, exacerbate, or prolong the pain experience”. A 2012 study monitored humans in various situations that caused them to experience high amounts of stress and anxiety. The results showed that when cortisol levels increased, the subjects reported a higher perception of their pain. They also reversely experienced less pain when the cortisol levels were normal (Choi, Chung & Lee; 2012). What a vicious cycle!

As humans, we have the ability to control how we respond to stress or how we view a situation that is stressful (Hannibal & Bishop, 2014). In a recent first encounter with a new client, I noticed that they appeared stressed when talking about their pain. It only took one question to open up healthy dialogue about where they were at;“How anxious are you right now as you talk about this pain?” That is one of many questions I ask clients that help me begin identifying stressors or fear-avoidance tactics that increases the threat to move in a certain way. As time goes on with each patient, we slowly grade the exposure to retrain patients to be able to return back to healthy movement patterns that they perceived at one time as being a painful threat.


Choi, J. C., Chung, M. C., & Lee, Y. L. (2012). Modulation of pain sensation by stress-related testosterone and cortisol. Anaesthesia, 67(10), 1146–1151.

Hannibal, K. H., & Bishop, M. B. (2014). Chronic Stress, Cortisol Dysfunction, and Pain: A Psychoneuroendocrine Rationale for Stress Management in Pain Rehabilitation. Physical Therapy, 94(12), 1816–1825.

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