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Polyvagal Theory + Chronic Pain

Polyvagal Theory + Chronic Pain
Elisabeth Bahr, OTD, MS, OT/L
March 23, 2023

A woman meditating

The polyvagal theory is beneficial for everyone with a nervous system but especially for people with chronic pain and trauma. 

This is according to Zara Dureno, presenter of the OccupationalTherapy.com course Polyvagal Theory and Chronic Pain. 

Chronic pain is persistent pain that lasts longer than three months. Why three months? Usually, muscles, bones, and ligaments are healed by the 90-day point. Beyond that, chronic pain indicates some type of nervous system dysfunction.

As per the CDC, “In 2016, an estimated 20.4% of U.S. adults had chronic pain and 8% of U.S. adults had high-impact chronic pain. Both were more prevalent among adults living in poverty, adults with less than a high school education, and adults with public health insurance.”

If someone has had one or many traumatic events, such as ongoing chronic pain, it can cause occupational injustices, role disruption, and withdrawal from activities that bring meaning and purpose. 

The Neuroscience of Pain

Pain is interpreted in the nervous system by nociceptors, and the information is sent to the brain to the reticular activating system, frontal lobe, and limbic system. (Treede et al., 2015)

Limbic system activation occurs when pain is present for more than three months. The amygdala, which is responsible for fear, is activated and traps clients in a cycle of pain. This is especially true when pain is from a traumatic event. 

Some people have persistent pain because of:

  • Stress & limbic system activation
  • History of trauma & depression
  • Personality, especially if one is self-critical and perfectionistic (Kempke et al., 2014)
  • Weaker supporting muscles, stretched ligaments, compensatory movements, & muscle tension (bracing), which can cause physical pain

It should be noted that chronic pain may be indicative of a symptom of cancer, arthritis, and nerve damage. People with chronic pain should check with their primary care physician to determine any underlying medical causes of chronic pain. 

What is the Polyvagal Theory?

The polyvagal theory is a neurobiological theory first described in 1994 by Stephen W. Porges, a university scientist, to explain the physiological responses that humans experience in response to environmental cues.

The theory involves the autonomic nervous system, which is responsible for controlling involuntary processes such as breathing, heart rate, and digestion. The nervous system is divided into two branches: the central nervous system (the brain and spinal cord) and the autonomic nervous system (ANS). 

The ANS is further divided into two branches: the sympathetic nervous system and the parasympathetic nervous system. Polyvagal theory explains how the autonomic nervous system works to control how we react to our environment and how this can affect our experience of pain.

The sympathetic nervous system is responsible for the body's fight, flight, freeze, or fawn response. These responses cause the heart rate to increase, increased alertness and attention, and increased blood flow to the limbs.

The parasympathetic nervous system is responsible for the body's "rest and digest" state, which causes the heart rate to decrease and relaxation to occur.

According to polyvagal theory, the ANS is responding to environmental cues and adjusts accordingly in order to keep the body safe and functioning. For some people, a potential threat (e.g., receiving a strongly worded email) might leave them dysregulated for an entire day.

Understanding the body's response to environmental cues can help to explain why some people experience pain more intensely or why some people are more sensitive to pain than others.

The Role of The Vagus Nerve

Vagus means “wandering” in Latin; the nerve “wanders” throughout the body. It is the longest cranial nerve and oversees a range of functions, especially the communication of sensory information.

The polyvagal theory emphasizes that the vagus nerve has two components.

The ventral vagus nerve—which helps us feel calm, connected, and content—is related to the parasympathetic nervous system.

The dorsal vagal is related to the sympathetic nervous system. When there is a perceived threat—even on a subconscious level or from trauma—this system becomes active and causes dysregulation.

The goal is not to remain in a ventral-vagal state.

Polyvagal Theory + Pain

By understanding the body's response to environmental cues, occupational therapists can help to identify triggers that may be causing pain and create strategies to help manage the pain. 

Part of the work of the occupational therapist when working with a client with chronic pain is to help the client feel safe. This can be done with specific strategies and through therapeutic techniques such as therapeutic use of self and active listening skills.

Other ways OTs can help clients:

  • Sensory modulation techniques
  • Helping to stimulate the ventral vagus nerve
  • Teaching meditation & mindfulness
  • Identifying “triggers” & “glimmers”

Glimmer is a term coined by Porges to explain the potential of the nervous system to move to a regulated state. They can be thought of as strategies that bring the body back into a state of balance. Glimmers might include co-regulating with a pet, smelling favorite essential oils, or having a warm herbal tea.

Triggers, on the other hand, are stimuli that cause the body to move into a dysregulated state. Triggers can be environmental (e.g., loud noises, a crowded room) or internal (e.g., thoughts, memories). Triggers can cause the body to go into a fight, flight, fawn, or freeze response.

Helping clients identify their triggers and glimmers can assist occupational therapists in understanding the body's response and create strategies to help their clients move back into a more regulated state.

Occupational therapists can use polyvagal theory to identify triggers that may be causing pain and create strategies to help their clients, particularly those with mental health and chronic pain concerns. The theory focuses on the idea that the body is constantly trying to maintain a state of balance and that it is responding to environmental cues in order to do so. Understanding these responses helps us to help our clients manage their chronic pain holistically.


Kempke, S., Luyten, P., Van Wambeke, P., Coppens, E., & Morlion, B. (2014). Self-critical perfectionism predicts outcomes in multidisciplinary treatment for chronic pain. Pain Practice, 14(4), 309-314.

Treede, R. D., Rief, W., Barke, A., Aziz, Q., Bennett, M. I., Benoliel, R., ... & Wang, S. J. (2015). A classification of chronic pain for ICD-11. Pain, 156(6), 1003.

Learn More

Polyvagal Theory And Chronic Pain: Exploring Treatment Options by Zara Dureno, MOT

elisabeth bahr

Elisabeth Bahr, OTD, MS, OT/L

Elisabeth Bahr is a writer, artist, and occupational therapist. She holds a master of science from NYU and a doctorate in occupational therapy from BU. She is currently a health writer, educator, and advocate. You can find her consulting work at pegasuswellness.co and her writing on Continued and around the internet.

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