This article is part of the Expert Guide “Understanding Pain”.

Getting Out of Chronic Pain: Restoring the Adaptive Capacities of the Living Organism

What this article offers

Why does this article matter?

For a long time, pain was viewed as the direct consequence of a lesion: removing the cause was supposed to be enough to remove the pain. This view remains accurate for many acute situations. It does a poor job, however, of explaining why chronic painChronic painPain is called chronic when it persists or recurs for more than three months. It may accompany an identified disease or be a condition in its own right.Read the full entry : Chronic pain sometimes persists long after its initial trigger has disappeared, or why two people with comparable lesions can follow very different courses.

The aim of this article is therefore not to draw up a catalog of available treatments. Instead, it proposes a different reading: understanding which mechanism each family of approaches acts on, in order to identify the levers that can realistically be used in a given situation.

1. Why is there no universal treatment?

Some pain, for example, remains dominated by an identifiable mechanical stress. Other pain is sustained by nervous system hypersensitization. Still other pain results from several interacting adaptive loops: mechanical stresses, nervous system function, behaviors, sleep, and the psychological dimension evolving together, as shown in the previous article.

It is therefore logical that no single approach can address every situation. The choice of care depends above all on the mechanisms that appear dominant in a given person: it is this evaluation, and not a universal hierarchy of treatments, that should guide the decision.

2. The same pain may require several levers

Take the example of pudendal neuralgiaPudendal neuralgiaNeuropathic pain in the territory of the pudendal nerve (perineum, external genitalia, anal region), often made worse by sitting.Read the full entry : Pudendal neuralgia, already covered on several pages of this Knowledge Base. In the same person, the following may gradually combine: persistent mechanical compression at the pudendal nervePudendal nerveThe pudendal nerve arises mainly from the sacral roots S2 to S4. It provides a large share of the sensory and motor innervation of the perineum and the external genitalia.Read the full entry : Pudendal nerve’s areas of vulnerability (see “when does a compressed nerve become painful”), progressive hypersensitization of the nervous system, a fear of sitting that sustains prolonged immobility (see “why a simple sitting position can become an ordeal”), sleep disturbances, and psychological suffering linked to diagnostic uncertainty (see “psychological pain”).

Indeed, each element sustains the others. When these factors are actually present, addressing only one of them may leave other maintaining factors unchanged. The challenge then becomes less about searching for a single treatment than about identifying the main levers capable of gradually modifying how the system functions.

Figure 1 — The same pain, several adaptive loops. In the same person, several mechanisms can combine and sustain one another: acting on only one of them often leaves the others active.

3. The main families of intervention

This diversity of mechanisms thus explains the diversity of treatments. Chronic pain is most often sustained by several adaptive loops at once; each family of treatment acts preferentially on one of these loops. The various approaches are therefore not competing but complementary, each targeting a different link in the same system.

Rather than classifying approaches by profession or by technique, it is therefore possible to group them according to the mechanism on which they mainly act. This reading helps explain why very different methods can sometimes produce comparable effects: they act on the same link in the loop.

Blue Portance’s Aporia ® range is cited here as one example of a postural aid aimed at reducing mechanical stresses, in the same way as other ergonomic solutions: it does not claim to be a universal therapeutic answer, nor to replace the other targets listed in this table.

Reducing mechanical stresses

When pain is sustained by tissue overload or persistent compression, reducing this stress is often a first step: ergonomic adaptation, changes in support points, an orthosis, an assistive device, workstation adjustment, or a surgical procedure when the cause is clearly identified. The goal is therefore to reduce the mechanical stimulus that feeds the pain loop.

Repairing tissues

Other approaches aim directly at tissue repair or regeneration: anti-inflammatory drugs, injections, reconstructive surgery, or platelet-rich plasma (PRP) injections. This last technique clearly illustrates the heterogeneity of the available data: it is being studied in several musculoskeletal conditions, with results that vary considerably depending on the indication, the preparation protocol, and the area treated (Thu, 2022).

Acting on nociceptive transmission

Other approaches act on the transmission of pain signals: analgesics and pharmacological treatments for neuropathic pain. They do not always correct the initial cause, but they can help the system regain conditions more favorable to adaptation. The choice, type, and duration of this kind of treatment are exclusively a matter for individualized medical prescription.

Modulating nervous system activity: noninvasive neuromodulation

In fact, the nervous system has its own mechanisms for modulating pain. Certain noninvasive techniques seek to influence them directly: transcutaneous electrical nerve stimulation (TENS), repetitive transcranial magnetic stimulation (rTMS), and transcranial direct current stimulation (tDCS). These approaches do not act on tissues but on how the nervous system processes pain information. The available data remain heterogeneous: a Cochrane review of noninvasive brain stimulation reports small, short-lived effects for single-dose rTMS, without clearly exceeding the threshold of clinical significance used (O’Connell et al., 2018); for TENS, an overview of several Cochrane reviews concludes that the overall quality of evidence is low despite good methodological quality of the available studies (Gibson et al., 2019).

Invasive neuromodulation

When neuropathic pain remains severe despite the previous approaches, certain invasive neuromodulation techniques may be offered after specialist evaluation: spinal cord stimulation (electrodes placed against the spinal cord, connected to an implanted generator), dorsal root ganglion stimulation, which is more targeted at certain localized neuropathic pain, and peripheral nerve stimulation for very localized pain. The principle remains the same as for noninvasive techniques — modifying the activity of the nerve circuits involved in pain — but the level of intervention differs. These techniques generally require a trial period before implantation, followed by gradual adjustment of the stimulation parameters, sometimes over several months. The available data support their use in certain chronic refractory neuropathic pain conditions — notably after failed spine surgery or in complex regional pain syndrome — after specialist evaluation, and not as a general answer to all chronic pain (Taylor, 2006).

Restoring the adaptive capacities of movement

Pain often leads to a gradual reduction in movement. Indeed, in the short term, this strategy is protective. In the long term, it can reduce physical capacities and sustain certain adaptive loops, as discussed regarding fear of movement in the article on nervous system hypersensitization. Rehabilitation, adapted physical activity, and graded exposure seek to restore these capacities without needlessly worsening symptoms.

Restoring self-regulation capacities

Chronic stress, sleep disturbances, hypervigilance, and certain emotional responses can lastingly alter how the nervous system functions, as detailed in the article on psychological pain. Several approaches aim to strengthen self-regulation capacities: hypnosis, for which controlled trials show significant reductions in pain associated with several chronic conditions (Jensen & Patterson, 2014); mindfulness meditation, for which a review of the literature reports benefits for pain and quality of life in people with chronic pain (Hilton et al., 2017); relaxation, controlled breathing, and biofeedback. Their goal is not to deny the pain, but to act on certain mechanisms that contribute to sustaining it.

Psychological approaches and non-drug therapies

Cognitive behavioral therapies have a relatively solid body of literature for chronic pain, particularly for reducing catastrophizing beliefs and improving day-to-day functioning (Williams et al., 2020). Acupuncture shows a small but statistically significant specific effect beyond sham acupuncture on several types of chronic pain, with larger overall effects versus no-acupuncture controls (Vickers et al., 2018). Yoga shows evidence of benefit for chronic low back painLow back painLow back pain is pain in the lower back, located between the thoracolumbar junction and the gluteal fold. In the vast majority of cases it is described as common (non-specific): it is mechanical in origin and does not stem from a serious disease.Read the full entry : Low back pain, especially in the short to intermediate term; certainty varies across outcomes and follow-up periods (Cramer et al., 2013). Other approaches such as qigong or tai chi are frequently mentioned in the literature, with a level of evidence that varies considerably depending on the conditions and protocols studied: they remain avenues to consider rather than established recommendations.

Figure 2 — The main families of therapeutic levers. The approaches are organized according to the level of the system on which they act — mechanical stresses, tissues, peripheral nerve, spinal cord, brain, emotional regulation, behaviors, and social life — rather than according to the profession that delivers them.

Figure 3 — Therapeutic approaches target adaptive loops. Each family of approaches acts preferentially on certain sustaining mechanisms; combining them in a personalized way makes it possible to intervene at several levels of the system.

4. A pause in pain: a first step out of the loop

People often talk about making pain go away. In practice, however, many people describe a different goal instead, more modest and often more achievable: finally getting a few hours of relief.

Chronic pain often locks the person into a continuous experience of threat. A period of relief, even a limited one, can be the first opportunity to experience once again a body that is no longer associated solely with pain.

In fact, this notion of a pain pause deserves to be taken seriously. A period of relief, even a partial and temporary one, may help reduce hypervigilance toward bodily sensations, allow new positive experiences associated with movement or activity, rebuild confidence in the body’s capacities, and gradually reintroduce movement without experiencing it as a threat. In other words: the pause does not end the adaptive loop on its own, but it can be its starting point.

Figure 4 — A pause in pain, a first step out of the loop. A period of relief, even a brief one, may reintroduce positive experiences that could help initiate the way out of an established adaptive loop.

5. A table, not a catalog: what level of evidence?

6. The approaches are not in opposition: they can be complementary

It would be reductive to set drug treatments, physical techniques, rehabilitation, psychological approaches, and non-drug therapies against one another. In many situations, these approaches act on different dimensions of the same system: combining them can help interrupt several adaptive loops simultaneously. This is the logic followed by multidisciplinary pain management programs, whose effectiveness, superior to that of isolated approaches, has long been documented (Flor et al., 1992) and has been confirmed by more recent reviews of the biopsychosocial approach to chronic pain (Gatchel et al., 2007).

Toward a medicine of adaptation

The question is therefore no longer only “which treatment should be chosen?” It becomes: which adaptive loops are sustaining this pain, and which levers will most effectively modify them?

This change of perspective thus no longer consists solely of treating pain. It consists of gradually restoring the adaptive capacities of the living organism — the most integrative expression of the adaptive system (C7) described in the Blue Portance model.

Concrete levers for restoring movement

In concrete terms, this restoration often relies on simple levers already at the heart of the Blue Portance biomechanical model: relearning movement where immobility has set in — because after a prolonged period of pain or avoidance, it is not just a matter of resuming an activity, but of rebuilding motor patterns that have become cautious or altered —, regaining the micro-movementsMicro-movementsSmall-amplitude movements that can take part in continuous postural adjustments and vary support and stress without a complete change of position.Read the full entry : Micro-movements and continuous postural micro-adjustments that define dynamic balance (C6), and seeking variability in support points rather than fixed support: living organisms tolerate a varying stress better than a monotonous one (C1).

There is, however, no single path: each person presents a different combination of adaptive loops, stresses, and resources. Restoring adaptability therefore requires the practitioner to build an individualized adaptability strategy — in which the gradual relearning of movement is often the common thread — rather than applying a standard protocol.

Figure 5 — Toward a medicine of adaptation. Lastingly restoring the adaptive capacities of the living organism does not consist solely of eliminating pain. It involves gradually reintroducing movement, micro-movements, variability in support points, and functional activity, along a personalized path specific to each individual.

7. One last factor: the care context

Chronic pain appears when the adaptive capacities of the living organism become insufficient in the face of the stresses imposed on it. This interpretation does not replace existing approaches: it proposes a framework for connecting them, in which each treatment becomes a means of restoring these adaptive capacities at its own level. Another element, however, plays a part in the effectiveness of care: how the brain interprets the care context itself — which is what we will address in the next article of this guide, devoted to the placebo effect.

Note: this content presents general knowledge and does not constitute a diagnosis or a prescription. The choice of care, including non-drug care, should be discussed with a healthcare professional, particularly if you are currently taking medication or have a coexisting medical condition.

© Gil Ayache. The concepts, diagrams, terminology, and principles presented on this page constitute a work protected by copyright. They are made available to Blue Portance under an intellectual property license agreement, without transfer of economic rights or of authorship.