What can pain do you for you?
Despite our natural inclination to shun pain, studies have consistently shown its inherent value as a protective mechanism. This innocuous 4-letter word has the uncanny ability to disrupt our daily routines, yet by delving into the mechanisms and behaviours associated with pain, we can actively adapt our perspectives and effectively mitigate its impact on our lives.
In this article I hope to cover the multidimensional and contextual nature of pain, its evolutionary protective purpose, the role of suffering and techniques for addressing chronic pain through brain training and community. Actionable items that both therapists and clients can implement from this article are building support networks, adjusting behaviours and perceptions, educating clients and referring clients to specialized care when appropriate.
Understanding someones pain can be difficult and our understanding of their pain will always be imaginary. As therapists we will never truly be correct in our conceptualization of our clients pain experience. It is invaluable to therefore listen, gather and observe as much as possible, from as many sources as possible. Our clients stories and language around their pain are key descriptive components to their experience and one of our only windows into understanding them. Pain has genetic, experiential and perceptual components making it highly variable between different people and cultures [1, 2]. Therapists must understand clients' unique pain stories and validate their suffering in order to create client trust and open the doorway to communication.
Pain defined
“An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage,” International association for the study of pain.
Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.
Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.
Through their life experiences, individuals learn the concept of pain.
A person’s report of an experience as pain should be respected.
Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being.
Verbal description is only one of several behaviours to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain. [3] July 16 2020
Pain vs nociception
The distinction between pain and nociception are valuable to our understanding of how pain has both positive and negative outcomes. [4]
Nociception refers to the central and peripheral nervous systems processing noxious stimuli and communicating potential damage (tissue damage, temperature increase, etc) via nerve fibres to the brain.
Pain however, is the perception of said nociceptive stimuli and its individualized interpretation. Traditionally this means the nociceptive stimuli must surpass our allostatic load-Allostatic load refers to the cumulative burden of chronic stress and life events-[5] and that once our allostatic load has been surpassed our capacity to manage further input with a regulated response is no longer possible. This is frequently referred to as our ‘window of tolerance’. [6]
The brain controls threat perception and pain interpretation based on sensory inputs. [7] When the window of tolerance has been surpassed the brain reacts to nociceptive stimuli with either a hyper-arousal response or a hypo-arousal response to said stimuli. The hyper or hypo response is the totality of the individuals experience around the stimuli presented, through actual or imaginary stimuli, reactive responses and predicted responses.
The perception and interpretation to the stimuli are mandatory for the pain experience to exist. [8]
Evolutionary Role and Purpose of Pain
Pain serves an important evolutionary function as an adaptive trait driving behavioural changes for self-protection and survival [9, 10]. It has led to positive societal developments like advancements in healthcare and technology.
The knee jerk reaction to suppress pain with medication and/or treatment is normal and acceptable though possibly not always beneficial. Stepping away from our individual experience of pain and reflecting on its possible positive effects is often difficult but may be a necessary component to recovery.
Pain benefits
When allowing the pain experience to be present and not suppressed it acts as an alarm to our increased vigilance and protects us from behavior that could further induce injury and pain. [11, 12] Other benefits exist as well, such as; facilitating pleasure, enabling self-regulation and enhancement and promoting affiliation and community.
Pain provides an essential contrast to pleasure in order for us to enhance our sensory input as well as increase our sensitivity to seek out pleasurable experience. Pleasure and pain are frequently seen as oppositional and though this is may be some what accurate, pain and pleasure do not have a direct relationship. [13, 14, 15, 16] Being nauseous doesn’t always denote pain, nor are painful work-outs always seen as displeasurable.
Self-regulation and cognitive control, as a response to pain experience, have been shown to lead to pain avoidance through a reduction in rumination by taking action quickly in order to avoid discomfort or pain.
Understanding that our experience of pain can frequently (though not always) be within our grasp of control has been shown to have analgesic effects similar to experimental pain study groups. Enhancement of ones self becomes a side effect of perception of control rather than threat. i.e: eating spicy food that induces sweating, tears, increased heart rate, etc is a choice people make, frequently seen as a challenge to strengthen themselves. Pushing our limits of pain during a training to further strengthen our tissue resistance or cardio system are seen as controlled interactions with pain rather than threat inducing interactions. [17, 18, 19]
Pain has a surprising effect on our capability to demonstrate virtues as well, through social context, cues and sympathetic, compassionate responses to verbal and non-verbal observations. Over coming painful stimuli is often seen as a positive social trait, one to be worked at and if possible, strengthened. [20, 21] Morris - ‘tolerance of pain breeds a perception that a person is noble and heroic.’
Sympathy, empathy and social support are often reactions to an expression of pain. [22, 23]
In summary, pain is often unpleasant, but to solely focus on this single component of pain can limit our capacity to properly educate clients on their relationship to pain, how it can assist them in recovery as well as how it can used as a tool to garner positives in life.
Transitioning to Holistic Pain Management
Treating pain requires a holistic approach focused on client experiences, goals, changes in behaviour and building a community of care [24] rather than simply structural or biomechanical fixes. (Though still valuable, structural and bio-mechanical cues for chronic pain are becoming less credible [25] and taking a back seat to the contextual nature of painful experiences.
‘optimal management requires a multidisciplinary team approach with good lines of communication, as well as input from a range of properly educated, specialist healthcare professionals.’
[26] Linton et al. 2011 suggest several guiding principals to help with pain management
Persistent pain naturally leads to emotional and behavioural consequences for the majority of individuals. Psychological concepts of learning can be useful to provide empathy and support without reinforcing pain behavior.
Clients who are depressed or have a history of depression may have more difficulty dealing with pain. A brief assessment of mood symptoms should be part of routine screening and intake procedures for pain conditions.
Persistent pain problems can lead to hyper-vigilance and avoidance, but simple distraction techniques are not enough to counter these behaviours. Clinicians should avoid inadvertent messages that escape or avoidance from pain as necessary in order to preserve function.
Individuals hold very different attitudes and beliefs about the origins of pain, the seriousness of pain, and how to react to pain. Assessment and treatment planning should take into account individual differences in pain beliefs and attitudes.
Personal expectations about the course of pain recovery and treatment benefits are associated with pain outcomes. Providing realistic expectations (positive, but frank and not overly reassuring) may be a very important aspect of treatment.
Catastrophic thinking about pain is an important marker for the development of long-term pain problems as well as for poor treatment outcome. Clinicians should listen for expression of catastrophic thoughts and offer less-exaggerated beliefs as an alternative. A brief assessment might be part of routine intake procedures.
Personal acceptance and commitment to self-manage pain problems are associated with better pain outcomes. Over-attention to diagnostic details and biomedical explanations may reinforce futile searches for a cure and delay pain self management.
Psychosocial aspects of the workplace may represent barriers for returning to work while pain problems linger. Return-to-work planning should include attention to aspects of organizational support, job stress, and workplace communication.
Action Items
Build referral network of medical/health providers to support client holistic pain care.
Educate clients on brain plasticity and perception training to transform chronic pain.
Have clients identify behaviours exacerbating pain fears and develop modifications allowing activity.
In the U.S. alone the annual cost of chronic pain is as high as $635 billion (2013). Johns Hopkins researchers estimate the annual economic costs of chronic pain in the U.S. by assessing incremental costs of health care due to pain and the indirect costs of pain from lower productivity. Because of the large financial impact that pain has on individuals and society it is important that manual therapists correctly understand current research around pain and be able to clearly communicate those findings to their client/patients.
2 NCBTMB Credits
2 hour online class
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