Pain is one of the most common complaints that bring people to the doctor. In fact, one in ten Belgians suffer from chronic pain. "Chronic back pain ranks as the number one condition globally that most limits functioning," says Anneleen Malfliet, a physiotherapist and professor at VUB. Together with her colleague, Professor Liesbet De Baets, she coordinated a large-scale study into better treatment options for chronic pain patients.
From acute headaches to a painful muscle injury or persistent back and neck complaints, pain comes in many forms. Yet all types of pain have one thing in common. “In every case, pain is a product of our brain,” explains Professor Malfliet. “Imagine touching a hot stove. Your hand sends danger signals via nerve pathways to your brain, which interprets the information. Where do these stimuli come from? Have I felt this before? Only then does our brain decide: do I perceive this as pain or not? It’s our brain that determines whether we feel pain, not our body.”
"We must teach patients that their pain is produced by the brain"
Your Body as a Pharmacy
In some cases, this sensation of pain occurs more slowly. “I sometimes explain it with reference to the Tour de France. Even after a bad fall, cyclists often manage to finish the race. That’s because of our brain-controlled pain suppression system. Physical activity makes the brain produce neurotransmitters like serotonin, adrenaline, and cortisol, which block danger signals. So, you don’t feel the pain immediately but only later.”
You don’t have to be an elite athlete to activate that smart pain suppression system. “A brisk 30-minute walk can relieve your headache without the need for medication.” Pain is often seen as a warning signal, but this is a misconception. Pain does not necessarily mean something is wrong. “For most chronic muscle and joint complaints, the link between medical imaging and the pain reported by patients is weak,” says Liesbet De Baets, physiotherapist and professor at KU Leuven. “Pain doesn’t always equate to tissue damage. Particularly in cases of lower back and neck pain, there is rarely a purely structural explanation.”
Chronic Pain: Your Brain in Overdrive
Despite this, back and neck pain are incredibly common. “Lower back pain is the most common chronic condition worldwide,” says Malfliet. “One in five Belgians suffers from it, and chronic neck pain affects one in ten. We consider pain to be chronic if symptoms persist for more than three months, although that timeframe shouldn’t be viewed too rigidly.”
The impact of chronic pain is enormous. It not only affects quality of life but also brings a significant financial burden, both for the patient and society. It’s one of the leading causes of sick leave in Belgium. “Helping patients starts with providing accurate information. In cases of chronic pain, the entire pain system—the brain—is in overdrive. We must teach patients that their pain is produced by the brain and is not the direct result of tissue damage. The body is in a kind of alarm state that doesn’t accurately reflect what’s happening inside. Knowing that your brain can produce pain on its own can relieve a lot of anxiety, and that reassurance is crucial.”
Linked with Other Health Issues
Understanding and treating chronic pain better is the life mission of both professors. “It’s clear that multiple mechanisms play a role in chronic pain,” says De Baets. “We know there’s a significant overlap with insomnia. As many as 50 to 90% of pain patients suffer from sleep problems. The figures are highest among fibromyalgia patients, and though insomnia is less prevalent in those with back pain and osteoarthritis, it’s still far more common than in pain-free populations. Overweight and depression also often go hand in hand with chronic pain.” Many misconceptions exist about the causes. “People sometimes think their weight strains their back, causing chronic pain, or that poor sleeping posture is to blame. But it’s not that simple.”
A Body in Inflammation
“The real issue is at a metabolic-inflammatory level,” continues De Baets. “People with chronic pain often experience a low-grade inflammatory response in their bodies.” This is a mild but long-lasting inflammation that occurs throughout the body. “As a result, their pain system becomes hypersensitive. We see the same low-grade inflammations in patients with sleep problems and depression. Previously, these medical issues were treated separately, but now we know they must be viewed together. We need to break away from compartmentalised thinking.”
What you eat, how you sleep, and how physically active you are—all of it matters. “It’s important to know that low-grade inflammation is completely different from the typical inflammation people are familiar with,” Malfliet clarifies. “This is not an acute inflammation that causes local redness, heat, and pain. A low-grade inflammation occurs system-wide. In blood tests, we see that inflammatory markers are consistently higher than normal.”
These low-grade inflammations contribute to the overactivity of the pain system. “Stimuli from the body cause the brain to produce pain even when it’s not necessary. In fact, stimuli strong enough to be recognised as painful are also experienced more intensely. Low-grade inflammations make pain quicker and more severe.”
Sleep Therapy Offers New Hope
What came first, the chicken or the egg? It doesn’t matter, according to Professor Malfliet: “What’s important is that issues like insomnia and obesity are included in pain therapy. If they aren’t, the results are less effective.” As researchers with the Pain in Motion group at VUB, Professors Malfliet and De Baets participated in a large-scale study into the treatment of chronic pain and insomnia. In the study, 123 patients with chronic back pain and insomnia were divided into two groups. The first group received only pain therapy, while the second group also underwent sleep therapy. “The sleep therapy goes far beyond the standard sleep tips you find online and focuses on behavioural changes, which is no easy task. Many patients with sleep problems, for example, fall asleep on the sofa but can’t sleep once they go to bed. With cognitive behavioural therapy, we try to restore the connection between sleep and the bedroom.”
Education is also an important part of sleep therapy. What does normal sleep look like? How does your sleep need change over your lifetime? In our study, we also used sleep restriction. People with sleep problems often spend more time in bed than they actually sleep. By reducing time in bed to the number of hours someone truly sleeps, sleep quality often improves quickly. Then, we adjust that sleep window to the amount of sleep needed. There are many misconceptions about this too. People often think that seven to eight hours of sleep is ideal, but our sleep needs are highly individual.
Both groups underwent fourteen weeks of therapy and were followed for a year. “All participants experienced a reduction in their pain complaints. The group that also underwent sleep therapy reported significant improvements in their sleep and depressive symptoms. This demonstrates that attention to sleep is crucial for chronic pain patients.”
The Pain in Motion and Brain Body and Cognition research teams at VUB, together with the SPINE research group at UGent, conducted a large-scale study into the treatment of chronic pain and insomnia.
Need for Broader Care
Today, patients can only access sleep therapy through psychologists and certified therapists. And that’s where the problem lies. “Waiting lists are long, and the mental hurdles are often high,” says Professor De Baets. “The need for help is much greater than the supply. In our study, sleep therapy was provided by physiotherapists. This shows that other healthcare professionals, with proper training, are also capable of offering sleep therapy. Physiotherapists already treat many patients with chronic pain. If they are aware of the impact of sleep, overweight, and mental health on pain, patients can be helped more effectively. Physiotherapists can detect such problems more quickly, address them, or refer patients and also identify unhelpful behaviours, such as regularly napping after a bad night or adjusting sleep based on data from a smartwatch, which is often far from accurate. Such behaviours can be early signs of long-term sleep problems.” As a key point of contact, physiotherapists play a major role in the treatment of chronic pain patients, but they can’t solve the problem alone. “GPs, dieticians, nurses, psychologists, and others all have a critical role to play. We must aim for a multidisciplinary approach.”
Breaking the Fear of Movement
Exercise therapy also remains an important part of treatment. Rest, as they say, rusts, and this is true even for chronic pain complaints. “Avoiding painful movements only helps with an acute injury,” says Professor Malfliet. “Your body needs rest to heal in such cases. With chronic complaints, however, avoidance behaviour only makes the problem worse. In therapy, we teach patients to use their bodies again, including all the movements they did before their pain started. Think, for example, of lifting with a bent back—something back pain sufferers often fear.” Misconceptions in society also play a major role here. “We see illustrations everywhere on how to protect your back, but you can—and should—use your back. It’s made for that purpose.”
Anneleen Malfliet
Exercise helps, but doing it on your own isn’t a good idea. “In reality, chronic pain patients deserve a sort of health manager to guide them through the complexity of their condition. A pain system that has been disturbed for a long time isn’t resolved overnight. With chronic pain, for instance, some people’s natural pain suppression system no longer works. After physical exertion, patients often feel worse, sometimes even experiencing flu-like symptoms. This is particularly common in complex pain conditions like fibromyalgia.” A gradual build-up of activity under professional supervision is essential. “In extreme cases, that means starting with just a few minutes a day. By gradually taking on more activities, people rediscover how valuable life can be. Even if their pain isn’t completely gone, it no longer dominates their lives. That in itself is worthwhile, because we know that focusing on pain is linked to higher pain intensity.”
"Rest, as they say, rusts even for chronic pain complaints"
The Need for More Understanding
“When I explain in simple terms how the pain system works and why pain doesn’t go away easily, chronic pain patients can sometimes be moved to tears,” says Anneleen Malfliet. “That gives me satisfaction, but it’s also heartbreaking. The basics of what we’re discussing here have been known for decades. Yet it’s still not ingrained in the wider public consciousness.” One of the main goals of the Pain In Motion research group is to spread this knowledge and make a broader impact. “The gap between scientific research and the actual implementation of new insights can be as long as 15 years,” adds Professor De Baets. “That’s a missed opportunity. Chronic pain is extremely debilitating—physically, socially, and mentally. This is still often underestimated. As long as patients don’t have access to the right information and care, the road to recovery will remain long and frustrating. It’s our mission to spread new knowledge about the importance of diet, sleep, and exercise more quickly, so that pain patients can be helped more effectively.”*
Do you suffer from pain, sleep problems, and/or obesity and wish to participate in future research? Contact the research team at chronischepijn@vub.be or slaapartrose@kuleuven.be.
* "This is a machine translation. We apologise for any inaccuracies."