Maverick Life

WELLNESS

Tell me where it hurts: Pain is real, but it can also be in the mind

Image by Joyce McCown for Unsplash

Pain – the subject of ongoing study – is yet to be fully understood. Many experts in the field argue that physical pain may have far more to do with our perceptions than actual physical damage.

“Some 40% of the UK population and 20% of the world population live with daily pain. This has led the World Health Assembly to declare that pain relief should be a basic human right,” says London South Bank University’s renowned Professor of Pain, Mick Thacker, in his January 2020 TED talk on the subject of pain, titled “Predictive processing as a theory to understand pain”.

A little closer to home, according to statistics published by The Institute for Health Metrics and Evaluation (IHME), an independent global population health research centre at UW Medicine, part of the University of Washington: in 2007, lower back pain was ranked as number six on the list of disability causes in South Africa. A decade later, in 2017, it moved up in their rankings to number four, after HIV/Aids, headache disorders – also a category of pain ailments – and diabetes.

Thacker argues that rather than a strictly physiological sensation, pain is more a matter of perception. In illustrating his point, Thacker uses several well-publicised examples of situations where we might experience pain without damage, or the opposite, damage without pain.

One such example was published in the British Medical Journal, where a 29-year-old builder jumped off a scaffolding onto a nail, which went through his boot. The builder screamed, was in intense pain and had to be sedated. Once sedated, the nail was removed, only to find out that the nail went between his big toe and second toe, and never caused any actual tissue damage. Yet, the builder experienced the pain as though the nail had actually gone through his foot.

Thacker goes on to illustrate the opposite, with other examples of people who had experienced actual physical damage, but who did not experience pain until they saw the physical damage. He argues that our existing understanding of previous pain is far more influential when it comes to predicting how we will perceive pain.

Maverick Life contributor, biokineticist, and pain management consultant Jonathan Joshua concurs: “When it comes to how we understand our experience of physical pain, the last word is far from written. In the last 10 to 15 years, there’s been some really nice frameworks that we can use to understand pain.

“We now know that the contextual story is very important. That’s why medical professionals have to make time to understand the patient’s story; and understand what else is happening in that person’s life. Of course, there’s the mechanical aspect, there’s no denying that, but what are the contributors to the experience of pain?

“Often when you go to the physiotherapist or a doctor, the common response is a completely mechanical answer. If you have knee pain for example, they might only ask ‘what have you done? How do you sit? How do you drive? How do you train?’ The result then is going to be a mechanical-based solution, which is an incomplete answer.

“We need to get more of a structured idea of how emotions, stress, sleep, and even relationships play a role. In this way, as clinicians we can be more resourceful with the patient’s time and more targeted in our advice and prescriptions, therefore leading to more favourable outcomes,” says Thacker.

That pain plays an important role in human life is arguably beyond debate. Take for example the Congenital Insensitivity to pain with anhidrosis, also known as Congenital analgesia, a condition where a person is unable to – or has never felt – physical pain.

According to the US National Library of Medicine, “in most cases the patient doesn’t live over the age of 25. Although some of them can live a fairly normal life, they must constantly check for cuts, bruises, self-mutilations, and other possible unfelt injuries. Self-mutilation is an almost invariable feature of this disorder, most often involving the teeth, lips, tongue, ears, eyes, nose, and fingers”.

Acute pain, such as the kind that comes from cuts and bruises, warns us when we’re approaching a situation that, if continued, may cause tissue damage, and in turn, we’re able to avoid future situations that might hurt us.

“Pain is not a bad thing. One of the lesser understood reasons for why we experience pain, is that it is for our protection. Pain is like a ‘pause’ moment… like the mind saying, ‘look around, what is happening here? Can we do this differently? What can we change?’” says Joshua.

Beyond acute pain, one of the least understood forms of pain is chronic pain, especially when it comes to joint pain.

“I think it’s very helpful to know that the joints: the ankles, knees, hips and spine, are designed to take load. For example, even if one has arthritis, avoiding load is not the answer, but rather a graded effort towards re-acclimating the joints to load and movement.

It takes a lot for a body to be damaged. We need to realise how resilient our bodies are. Pain does not necessarily mean there is tissue damage. In fact, most chronic pain examples do not relate to actual damage in the part of the body where one might be experiencing the pain. Hence I say that medical professionals need to look at pain contextually,” emphasises Joshua.

Beyond protecting us, our pain perception – combined with previous pain experiences – can also lead to fear avoidance belief, according to a paper titled Fear-Avoidance Beliefs and Chronic Pain published by the University of Texas’s J Journal of Orthopaedic & Sports Physical Therapy:

“The anticipated threat of intense pain will often result in the constant vigilance and monitoring of pain sensations, which, in turn, can cause even low-intensity sensations of pain to become unbearable for the person. Just the anticipation of increased pain or reinjury can further stimulate avoidance behaviours.

“A vicious cycle may develop, in which fears of increased pain or reinjury contribute to the avoidance of many activities, leading to inactivity and, ultimately, to greater disability. Anyone who assesses and treats pain-related disability should also be prepared to assess and treat pain-related fear avoidance.”

That is not to say that pain is something to be ignored. As per Joshua and Thacker, pain is protective and predictive, as well as being a continuous and as yet incomplete field of study. Hence the importance of consulting a medical professional.

But in a world where pain prescription medicine such as opioids are increasingly leading to addiction, a growing number of studies and experts encourage a more holistic look at the causes and experience of pain. DM/ML

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