Pain is a part of life, but it is far from simple or fully understood
Pain is something we’ve all experienced at some stage in life so it stands to reason that most of us assume we know what it is (a noxious stimulus) and what causes it (bodily harm and tissue damage). The opioid epidemic exemplifies our previously limited understanding of pain whereby individuals wound up on rising amounts of opiates without any pain relief and in some cases, developed opiate hyperalgesia where not only was pain not reduced, but where pain sensitivity actually increased due to opiate use.
In the last decade we have come to understand pain’s nuances in a different light and studies are nowhere near from over. The following article is an introduction to the influencing factors in pain sensation within acute stages (<6 months).
Pain has purpose
Now, the aforementioned noxious stimulus can of course be caused by tissue damage (as in the examples to follow) but pain can also be caused by the memory of a painful event, by the perception of damage vs actual damage, by the threat of new damage, and by a person’s experience and understanding of pain, just to name a few. If that sounds a bit more personal than the straight forward tissue damage theory, then that’s because it is: Who you are, how you got hurt, your understanding of being hurt, your body’s sense of threat, and your emotions surrounding the event will all influence your pain and subsequent recovery (bio-psycho-social theory).
So let’s backtrack a little to our basic understanding of pain: Perhaps one of the first things we humans understood about pain was that it was equated to our body’s alarm system. We NEED to feel pain in order to keep ourselves safe from dangerous inputs and it is important to realize that our pain is present to keep us safe and alive.
- Example: if a child touches a hot stove top briefly, the heat and pressure will get interpreted by the brain as dangerous. In turn, a pain response will allow them to learn that the heat caused them tissue damage, which in turn lends them to be more cautious the next time they see a stove top. Their nervous system has effectively learned a lesson to keep the child both safe and alive and this pattern of caution will likely stay with them for life to avoid having to keep learning the hard way with ongoing harm.
By contrast, if the child touches a hot stove top and doesn’t sense pain (as is the case for individuals with the very rare condition of CIPA), they will leave their hand there for too long, suffer greater tissue damage, and not necessarily reflexively learn of the dangers of a hot stove top. They’ll surely cognitively understand what happened but their nervous system won’t have created a “danger tag” of the event because burning their hand didn’t create an unpleasant sensation.
Pain is personal
The child and stove top example is straight forward enough and presents a biological model for pain whereby tissue damage results in pain as well as a memory to reduce the chances of a repeat occurrence. But as previously alluded to, tissue damage alone is insufficient for explaining a person’s pain experience (and the two can exist without one another): We need to consider the environment and complete picture of “information” going into a system and brain.
Now if we take the same example and add caregivers into the mix, there are ways in which to influence the child’s pain experience, conscious memory and nervous system further.
- Example 1: The caregiver starts screaming and grabs the child then rushes them off to hospital. The child’s system was already aware of pain but the brain and nervous system are now ramping up the importance of the signal in light of the fact that their caregiver is clearly losing their minds over this – there is no sense of safety. This wasn’t just painful, this was apparently very dangerous and stove tops are now life-villain #1 and will never again be touched until said child is 20.
- Example 2: The caregiver picks up the child, runs their hand under water and soothes them with a calm voice. The child starts to calm down, they can see their hand is intact albeit hurt, and they feel safe because there are multiple calming inputs to the nervous system. They’ve learned that it was unpleasant but also that the sky isn’t falling. Later on, they’ll be cautious when approaching a stove top but won’t be as anxious about using one properly.
We can assume that the tissue damage will ultimately heal, as burns do, but the nervous system’s experience and memory of pain will take longer to heal in example #1 than #2: Child #1 might continue to sense pain beyond the point at which tissues have healed and may avoid use of that hand for a longer period out of fear: Fear avoidance behaviour is a documented issue in pain management and is often driven by someone’s understanding of their injury rather than the degree of tissue damage. To be clear, acute avoidance does serve a purpose at the onset of an injury- such as preventing us from walking on a broken ankle- but fear avoidance behaviours applied chronically can lead to learned non-use of the body part, compromised function, and chronic pain.
Environments and Organisms are inextricably linked
Ultimately, the environment in which our pain occurred (inclusive of our sense of safety and control), and our interpretation of the pain experience is enough to change our sensation and duration of pain as well as our timeline to recovery and ongoing behaviour. All of these factors will extend to influence future events should we find ourselves in a similar situation.
“Organisms and environments are not separate or logically distinct entities- the organism-environment system (not just the organism) is the proper, irreducible unit of analysis for understanding functional (or dysfunctional) behaviour.”– D. Vaz et al
The body’s nervous system and our brain’s interpretation of inputs are brilliant at pattern recognition; simply being put into an environment similar to one in which you’ve experienced acute pain or injury is enough to heighten your senses to detect threat. For example, if you’ve hurt yourself falling off a curb, you may notice that the next time you’re near the place in which it happened (or even a similar environment), your HR goes up, your breathing gets a little shallower, your palms might get sweaty, and you may even feel more tissue awareness around your previous site of injury. These are all signs that your body is ramping up adrenaline (which prepares us to fight or flee and can temporarily reduce pain) to prepare for what could come again. Over time, assuming we can’t avoid curbs for the rest of our life, we’ll regain enough positive experiences for our brain to override the threat response and we’ll carry on being sure to pick up our feet properly but not being afraid to walk down the street.
Pain is Complex
So where does this leave us when it comes to understanding influences on acute pain? Hopefully by now you are cognisant of the fact that all pain is real though individual experiences differ dramatically due to multiple factors that lie beyond tissue damage.
Here are a few additional pain pieces and resources to explore that may shed further light on your experiences:
- There is no such thing as a “pain nerve”: Nerves detect a stimulus such as pressure, temperature, or motion to name a few, then they interact with the brain which decides how to interpret those signals based on experience, context, sense of danger, and patterns.
- Not all pain is a result of tissue damage nor is its severity a direct representation of the degree of tissue damage. Athletes have accomplished incredible feats with broken bones: Geraint Thomas finished a cycling race stage with a broken pelvis and was getting set to continue to the next one before they decided to do x-rays. The brain has to interpret signals coming in from the body but the higher priorities (racing & endorphins as analgesics) meant that it mustn’t have immediately computed the crash as dangerous to the point of stopping.
- Hurt does not beget harm: Read about the two construction workers who, on separate occasions (1995 & 2007), suffered nail-related incidents that proved particularly insightful regarding context as it relates to pain perception.
- Pain is deeply personal, real, and not created equal. We can influence our pain based on our environment and our sense of safety: If you know you’re able to take the right steps and are largely safe and sound, you may hurt less than someone who is afraid, doesn’t know what to do, and doesn’t have support.
- “Functional outcomes can be improved by extrinsic environmental modifications without addressing the individual’s intrinsic biomechanical factors.”(Rehabiliation of the Spine, Craig Liebenson). In other words, pain can resolve without specifically addressing biomechanics, supporting the need for whole-person approaches to pain management.
- The nocebo effect in acute pain or injury can result in a person’s negative expectations leading to negative or worsening side effects. Negative expectations can come from a myriad of sources, one of which is poor communication and education around their pain experience. If someone is told they have a herniated disc and is led to believe they are irreversibly broken, they may adopt fear avoidance behaviours that can lead to greater pain and loss of function.
“For each ailment that [practitioners] cure, they produce 10 others in healthy individuals by inoculating them with the pathogenic agent 1000X more virulent than all microbes- the idea they are ill.”– Proust
*The above quote does not reflect the thousands of practitioners changing pain education and conversations with patients/clients for the better. It is simply highlighting the importance of appropriate education around pain and pathology to avoid illness mentality or a fear-based fragility mindset after injury .
- No one can determine your pain: We’ve known of medical professionals informing pre-op clients that “the pain for this surgery will be worse than your other one”, which they may have thought was helpful for mental prep at the time, but in reality is grossly unpredictable and shows a lack of understanding of current pain science and appropriate patient communication.
- Fear of pain can predictably increase soreness from exercise. All the more reason for practitioners, coaches, trainers, and other well-intended people to avoid trying to predict someone’s pain and to instead, create a safe and informed environment.
- Prolonged rest after an injury or pain event can lead to deconditioning of muscles, tendons, ligaments, and the cardiovascular system. Returning safely and progressively to movement is imperative in the recovery process as deconditioning can contribute to prolonged or increased pain sensation, not less, and to further compromised function.
- Lack of movement can lead to widespread joint pain (knees, necks, shoulders, and backs to start): The irony here is that a lot of people interpret pain as a reason not to move, whereas the reality is that 20 minutes of sitting can cause low back pain whilst 20 minutes of walking with an arm swing can relieve it.
“Joints adore movement and regular compression, which are essential for their health. Movement distributes the slippery synovial fluid, and cartilage loves the pumping compression. The brain eagerly welcomes the sensory inputs from the joints as it wants to know what is happening so it can construct the best responses for you”Dr. Lorimer Moseley
- All pain is real, and none of it is “in your head”, though your headspace can help with management of pain events. Context and education from a practitioner you trust is key.
- Pain loves practice. If we focus on it, worry about it, and limit our movement, our brain gets better and better at interpreting sensations as dangerous (thus, producing pain) and at perpetuating fear avoidance behaviours. Chronically, this can lead to chronic pain sensitization and/or loss of function- a complex topic for another day.
- Sleep deprivation can drive pain sensation up: The irony being that pain can often disrupt sleep.
- Dietary deficiencies can contribute to increased muscular pain (tension) and inflammation: Vit D and Magnesium are two of the key players here that are commonly deficient.
- Taking NSAIDs regularly can undermine your body’s ability to handle pain, heal, and process inflammation: Risk of tissue injuries, headaches, and GI distress can all increase with frequent use. It is in your best interest not to simply reach for an Advil or Aleve anytime you have aches or pains but to seek to understand why you have pain and what active care or treatment you can apply to it. *Consult your primary care practitioner or physician, don’t simply self-medicate daily.
As much as pain experiences can be complex and frustrating, your body is always doing its best to keep you both safe and alive. Cultivating curiousness about your potential to heal, your body’s need for safety, and how to navigate your personal factors in your pain or injury experience can see you through it.
“Our bodies recognize patterns year in, year out and when a pattern reminds them of a time when something bad happened, we get warning signals even if we’re perfectly safe this time around… you have to be as willing to let pain go as you are to acknowledge its presence. Seeking to understand it will help in moving through it.”F.Spence
Additional Reading Resources
Why Things Hurt- TED talk by Prof Lorimer Moseley
34 Surprising Ways to Hurt by Paul Ingraham who has built an incredibly comprehensive painscience site and is constantly updating it.
Tame the Beast by Prof Lorimer Moseley & Dave Moen
Recovery Strategies by Greg Lehman
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