The Pain Puzzle

The Pain puzzle approach involves looking at many pieces in the puzzle that may have led to your pain experience. The aim is to try and make sense of why you are experiencing pain and together plan ways of changing your pain experience back to living well.

It is very likely that we still don’t have all the pieces in place for understanding pain but it is still possible to make a big impact on people’s well-being with improving some of these factors.

There is never just one key to solving pain, there will usually be several of these factors that need to be addressed to gain improvement.

Having back pain very rarely means you are damaged or it is something serious, therefore it is really important that we engage with the things that are most likely to be related to your pain … like you are under stress, you are not sleeping well, your mood, or you are not active and that can trigger a pain event. We know those factors are commonly linked to a flare up of back pain.

Professor Peter O’Sullivan

What’s the problem?

Sometimes physical pain arises from a strain from an awkward movement or overloading a muscle or joint. There are known healing time frames for muscles, joints and ligaments of up to 6 weeks, depending on the injury. When pain extends beyond these healing times we know that the pain is not simply coming from the injured tissue, your body will have healed the injury.

Ongoing physical pain

When pain extends beyond normal healing time frames it is usually because the body is continuing to protect the area. This is often described as sensitisation. A simplified explanation is to think of the pain as an over-sensitive alarm. The body continues to protect itself from harm and if there is any threat of danger to that area from increased pressure through the joints, awkward movements, pressure on the area a pain signal is triggered to tell your body to protect that area. The alarm keeps sounding to protect the area, even though there is very little threat of  actual harm, so you experience ongoing pain with movement and activity. There are many different ways of describing this mechanism, you will understand it best when we can tailor the explanation to your story and your pain.

What’s the Pain Puzzle solution?

Assessment of your problem will help to identify what may have happened and the stage of healing you may be in. Treatment and advice may help to speed the healing process helping you to return to normal activities.

For people experiencing sensitisaton we can try to explain the pain by piecing together the story of your pain experience to try and make sense of why your body has become sensitised. To reduce sensitisation hands on treatment and exposure to movement and activity can be helpful.

With all pain conditions it is important to take into other factors as described in the Pain Puzzle approach to help you to return to living well.

What’s the problem?

I wonder if you have ever thought about how important sleep is for your health and well-being. You will spend about a third of your life sleeping. It is not a waste of time. Whilst you sleep your body and brain are very busy – repairing, storing memories, processing emotions, removing toxins and many other functions.

4 in 10 people do not get enough sleep and 2 out of 10 people sleep poorly most nights.

Are you getting enough sleep?

There are several signs that you might not be getting enough sleep:

  • You could easily fall asleep again at 10 or 11am
  • You are unable to function optimally without caffeine before midday
  • You would sleep on without your alarm clock
  • You have trouble concentrating or reading or you are forgetful
  • You need to sleep longer at the weekends

On average an adult needs 8 hours of sleep. This may vary from 7-9 hours.

If you are experiencing the symptoms above it may be that you are not allowing yourself enough opportunity to gain the sleep you need.

What are the effects of sleep deprivation?

If your body is not getting the sleep it needs every major system, tissue and organ of the body is affected. This means you increase your risk of chronic diseases including high blood pressure, diabetes, depression, cancer, heart attack and stroke. You are at a higher risk of having an accident. Your mood, appetite, energy levels, attention, performance, resilience, immunity, reproductive hormones and even your genes are affected when you lose sleep.

We know that people are more likely to experience pain when they are tired.

What are the benefits of sleeping longer?

Good sleep brings you many benefits:

  • Healthier immune system – less illnesses
  • Easier to maintain a healthy weight
  • Better exercise performance
  • Less risk of accidents
  • Less risk of pain episodes
  • Better performance at work – more efficient, better decision making
  • Able to learn and remember new facts – great tip for students
  • Able to cope better with stress and emotions
What’s the Pain Puzzle solution?

Understanding more about your sleep patterns and habits will help us work together to find solutions to improve your sleep. Often a few small changes can make a big difference to improving your sleep quality and therefore improving your well-being.

What’s the problem?

Physical activity has the most amazing benefits. Exercise and movement are one of the best treatments for people in pain.

How much physical activity should you do?

150 minutes of moderate exercise per week, with two sessions of strengthening.

What sort of physical activity is best for you?

The best exercise is the one that you will do regularly – something you enjoy.

Often a variety of exercise can help with strength, flexibility and general fitness.

What is moderate exercise?

If exercise conjures up visions of a sweating person on a treadmill or someone lifting weights -may be that excites you?? Or maybe that is an awful thought for you?

There are so many ways of being physically active. Maybe you could start something new, or return to something you enjoyed in the past. Gardening, DIY, walking the dog and other activities may provide you with moderate exercise.

Moderate exercise will cause you to get warmer, breathe harder and your heart to beat faster but you will still be able to have a conversation.

What’s the Pain Puzzle solution?

If pain is the barrier to you taking part in exercise we support you to find the exercise or activity that will help you gradually increase your physical activity. For people in pain gradual exposure to activities helps to get the body used to the activity without triggering big pain reactions.

Together we find ways of achieving your goals for returning to physical activities that you enjoy.

When it comes to wondering what you should and shouldn’t eat it can be very frustrating. Every week you seem to read in the papers a different story about which foods are good for you and which are bad. There have been many food fashions in super foods and popular diets.

Nutrition is important.

Health benefits of good nutrition:

Increased energy, improved sleep, improved mood and wellbeing, maintaining a healthy body weight, healthier skin and decreased risk of health conditions such as heart disease, stroke and cancer.

Your body needs food to provide energy, vitamins and minerals. The quality and variety of the food you eat impacts your health and well-being. The key principles are:

  1. Fruit and vegetables – 5 per day
  2. Fish – twice per week
  3. Eat less processed foods, sugar and salt
  4. Limit caffeine intake
  5. Drinking sufficient fluids

Nutrition and pain

Many people with persistent pain may also experience digestive issues, IBS is common in people with long-term pain. When the body spends a long period in a ‘stress state’ it will affect how your digestive system works.

Some people may find they become intolerant to certain foods. There can also be food groups which can help relieve symptoms.

What’s the Pain Puzzle solution?

Understanding your diet and how well your digestive system is working can be part of supporting you to improve your well-being. If nutrition is significant to your situation you may be supported to improve your dietary choices and habits to improve your general well-being. Together we will identify the simple steps that you can take to achieve your well-being goals.

Having social connections and friendships is good for you. It reduces your risk of developing some diseases and helps you to recover more quickly if you fall ill.

Loneliness affects many people today and it has a big impact on your health and well-being. It’s such a problem in the UK today that there is now a Minister for Loneliness in the government.

If loneliness or you lack strong social connections this will be part of your pain puzzle and an important component of improving your health and well-being.

Methods for coping with loneliness include:

  • Getting busy
  • Knowing you are not alone. There are many lonely people and maybe you could reach out to help someone else
  • Boosting your self-esteem
  • Taking up hobbies or interests
  • Trying not to be anxious or comparing with others

Some people find it difficult to stand or sit for long periods which can restrict opportunities for socialising. Pain makes you feel tired and is often depressing making you feel reluctant to socialise. Being busy or taking part in a hobby may seem too ambitious for your situation. These are all barriers to improving your social well-being.

The Pain Puzzle Approach

All people, including people in pain, are healthier and feel better with a supportive social network. We help you identify any barriers which may be preventing you from socialising and help you to find solutions and start to re-build your social networks.

Together we will identify realistic goals for improving your social well-being which may include meeting new people, taking up a hobby. We may need to work towards these goals by improving your resilience for the activities involved through treatment, exercise and gradually increasing activities. Support and encouragement is key to helping you improve your social well-being.

Everyone is affected by stress at some point. Stress is not always a bad thing. It can help you to perform better in an interview or presentation.

The impact of stress on health is a large subject. Stress triggers a hormonal reaction which affects every body system. You can become stressed just by having so many things to do even if those are nice, enjoyable things. Common stressors include relationship and family stresses, financial stress, work-related stress, bereavement.

Stress is well-identified as being a risk factor for a painful episode and often underlies unexplained pain.

Ongoing stress can put the body into a ‘stress state’ which can lead to many health conditions including high blood pressure, headaches, IBS, skin conditions, and persistent pain.

How people respond to stress varies significantly. Some people have much greater resilience than others and may have better coping strategies.

Relaxation and joyful activities

Many people today don’t know how to relax. Phones and tablets result in constant communication and information. You may sit down to watch television whilst simultaneously messaging friends or searching for something on the internet. It is important to take time to relax during your day even if it is just for a short period. This may mean doing a quiet activity that gives you joy such as reading a book, taking a walk, sitting with a cup of tea, meditation, breathing – whatever helps you to relax.

Taking time to have meaningful conversations with people close to you can also be important for relieving stress.

What is the Pain Puzzle approach?

An important first step may be recognising that you are stressed. Identifying what is causing your stress can help to plan solutions. Working together we may be able to plan how you could reduce your stress levels or how you could find time to relax in your day. It may not be possible to change the things that are causing your stress but it is always possible to change the experience.

Spiritual well-being is well recognised as being necessary for general well-being. Spiritual well-being is having a meaning and purpose in life.


Meaning is a feeling that life is of significance, worthwhile or has a target. When your life has meaning you have a reason for getting out of bed in the morning. You are less likely to experience sleep problems or have a heart attack or die prematurely. You will generally have better mental health and satisfaction with life.


A sense of purpose is needed for mental well-being. Purpose is an aim to be met or achieved. This may be goals to achieve, finding solutions in difficult life situations, having someone to love, experiencing nature and culture, enduring suffering.

Meaningful suffering is turning personal tragedy into human growth and transforming despair into well-being by means of one’s chosen attitude.

Having a meaning and purpose in life helps you to keep things in perspective when you are stressed. It can drive you to pursuing a healthier lifestyle so you can achieve your purposes. It reduces your risk of Alzheimer’s disease and cognitive impairment in later life.

Your life is worthwhile – reminding yourself why that’s true may be good for your health.


The meaning of life is something that generations have puzzled over. Every life has meaning and purpose. Many people find their meaning and purpose in life that gives them spiritual well-being through faith.

The Christian faith based on the Bible describes the meaning and purpose of life as follows:

“Our purpose in life, as God originally created man, is 1) glorify God and enjoy fellowship with Him, 2) have good relationships with others, 3) work, and 4) have dominion over the earth. But with man’s fall into sin, fellowship with God is broken, relationships with others are strained, work seems to always be frustrating, and man struggles to maintain any semblance of dominion over nature. Only by restoring fellowship with God, through faith in Jesus Christ, can purpose in life be rediscovered.

The purpose of man is to glorify God and enjoy Him forever. We glorify God by fearing and obeying Him, keeping our eyes on our future home in heaven, and knowing Him intimately. We enjoy God by following His purpose for our lives, which enables us to experience true and lasting joy—the abundant life that He desires for us.”

Deborah is a committed Christian and happy to discuss the Christian faith if you have questions. She will not discuss the Christian meaning and purpose of life with you unless you initiate the conversation.

On the resources page you will find some links to resources if you are seeking meaning and purpose in your life and want to explore what the Bible teaches.

Pain related fears and beliefs are important in your pain experience. Many fears and beliefs are deep rooted from the way that you were taught as a child to understand and respond to pain.


When you have a pain that is going on and on there is a natural tendency to have some fears. There will be fears about the pain never improving, the impact on your life, your responsibilities and your relationships. There will be fears about the future – whether the pain will get worse, whether you will be able to continue with your work, potential increasing disability. Many people have a tendency towards catastrophising – believing the worst case scenario about their situation. Many of these fears can be resolved through understanding more about your pain and making a plan for steps to improvement.


You may have beliefs about the causes of your pain, perhaps from a previous diagnosis or scan or from your history. You may also have beliefs about whether your pain can be improved. Many people have pain-related beliefs about activities they can or can’t do. It is important to explore your beliefs about your pain because sometimes they can be a barrier to your recovery. There are many myths about pain and as understanding of pain has developed medical professionals including osteopaths have realised that some of the explanations we gave patients have now been proved false.

What’s the Pain Puzzle approach?

We will identify and discuss your fears and beliefs and help you to understand more about your pain. Explaining pain can often help to reduce many fears and correct some beliefs about pain to provide a more positive outlook and help you on your journey to improved well-being.

Struggling with your mental health is not unusual. Many people with persistent pain experience depression, it can be hard to persevere and the effects of pain on you and your life can be difficult to bear. Having a good support network is important for helping with your mental health.

One of the best things you can do if you are struggling with your mental health is exercise. Exercise stimulates hormones that improve your outlook and also provide you with opportunity to get out of your environment and potentially socialise.

Stress, anxiety and depression all have an impact on your physical well-being. It can be important to recognise these symptoms as part of improving your well-being.

What’s the Pain Puzzle approach?

Mental health is certainly not a taboo in the clinic. If you are struggling with your mental well-being please say. It’s okay not to be okay. I’m not a counsellor but am very good at listening, which is often the first step towards improvement.

There are some links on the resources page pointing you to sources of help if you are struggling with your mental health.

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