If you have moved past the title of this post it is most likely because of one of two things. You know what fractals are and curious to how that may tie into pain and the patients you treat. Alternatively, you have no idea what a fractal is and are curious what they are. In mathematics, a fractal is an abstract object used to describe and simulate naturally occurring objects. A Fractal System is a complex, non-linear, interactive system that has the ability to adapt to a changing environment. There are many fractal systems that can be found: a person, the nervous and immune systems in that person, the economy, businesses, culture, and even the unpredictability of the weather is due to it being a fractal system.

Why would I say pain behaves like a fractal system?

Primarily the nervous system is a fractal system and pain does emerge from the nervous system. In addition, if we dive into the definition of a fractal system it becomes apparent that pain has all the components of a fractal system.

• I think most of us would agree pain is complex. If you don’t think pain is complex, as Kevin O’Leary would say: “You’re Dead to Me!“.
• Pain also is non-linear in nature. By non-linear, we are referring to being the opposite of linear and having an exact cause and effect response. Gravity is more of a linear function in how it works in nature. Every time you drop something, gravity causes the effect of that object to fall to the ground in a specific measurable way. Pain is a bit more complex and non-linear. Pain does not have a linear response to injury. Not every injury causes pain, and not all pain is associated with an injury. There are the stories of a person being stabbed in the back and not feeling pain and stories of a person with a nail through his boot and feeling pain, even though the nail missed his foot.
• Pain is also interactive and changes based on the environment and context of everything the person is experiencing.

Why this might matter, has more to do with understanding the properties of a fractal system. These properties can give us insights into treating and caring for those with pain. These are a few of the properties of fractal systems to consider:

• Emergence: Emergence is phenomenon when larger entities arise from interactions among smaller or simpler entities, such that the larger entity has properties that the smaller entities do not have. Understanding this we know that looking solely at the individual parts of a pain experience will never give us the full picture of the pain experience. This is where taking a biopsychosocial view of pain is helpful to look at all parts and not just a biological or just psychosocial approach.
• Co-evolution: All systems exist within an environment and are part of that environment. Consequently, as the environment changes they need to change to ensure best fit. This is where recognizing that we need to change the environment around a person in pain. Doing the same thing over and over will most likely get you the same response. Clinicians should look to make changes in the person’s “environment”; this can come in many forms. Maybe change the language of saying you have a “bad back” to something less threatening. Get them exercising/moving differently. Reducing the overall stress of the individual through various methods. These are just a few of the changing “environments” we as therapist can get help guide our patients toward.
• Simple rules: Fractal systems are complex with many interconnected parts, but are not complicated. The emerging patterns of pain can come in lots of variety, but often the rules that govern the function of the system are simple. In most cases, we have a good understanding of how pain works. We should also be able to explain this process to our patients.
• Iteration: Small changes can have significant effects as they go through a feedback loop a few times (often times referred to as the butterfly effect). Clinically this process is getting patients to work on patience and persistence with activities that are healthy for the system (exercise, diet, meditation, etc.) and that learning has to take place for these to beneficial.
• Self-organizing: There is no hierarchy of control. Thus, we cannot guarantee that “fixing” the one thing that we think is in controlling the pain experience will actually change the pain experience. Because of the self-organizing property, there is constant re-organizing to find the best fit within the environment. This is the hope we should always be providing our patients that their pain experience can change because of this re-organizing process.

Fractal systems are everywhere, and pain behaves like a fractal system. The individual components of a fractal system exist (posture, strength, nociception, immune cell activity, endurance, psychological beliefs, and many more), but are totally unaware of that they feed into a system. This lack of knowledge of input into the system does not change their contribution to the system. This creates a situation where everything could be useful, but not everything is needed to change the system. Thus clinician and patient must work together to find the best path for that patient. This does not give us free reign to do anything the patient or us as the therapist wants, but should provide many paths to explore.