Pain can a useful and potentially life-saving protection mechanism. You only have to touch something unexpectedly hot to appreciate that the resulting OUCH was helpful because it made you pull your hand away and prevent possible further injury.
20% of people experience ongoing pain, a condition that extends beyond the expected healing time of injury. It’s a debilitating and often invisible part of their daily life. While increasing evidence shows that medication doesn’t help resolve long-term pain, just managing is no longer acceptable either. Patient education is crucial and often the missing key to unlocking the toolkit to live a pain-free life. Interestingly, the longer someone experiences pain, the more highly skilled in their brain and nervous system will become at protecting them from more pain, we know this as a protective response.
Over the last 20 years, there has been a revolution in our understanding and knowledge of how we humans experience pain. Scientists and pain specialists have learned how and why the brain makes us experience pain and unlocks some keys to curing pain too. Unfortunately, very little of this information has reached the wider public and people who live with it.
Fortunately, while this is a complex science, much of it can be simplified. Some leaders in pain science including Lorimer Molesley, David Butler and Mick Thacker, are also engaging people-centered teachers, who have stated that, knowing why we feel pain will help us heal. Bold statements but ones they support with gold-standard research, hundreds of published papers, and in the cases of Prof. Molesley and Dr. Butler globally best-selling people-friendly books.
But, what exactly is pain?
The truth is this is a tricky question to answer, even for the experts. When asked this question back in 2016, Prof. Lorimer Molesley, a pain scientist wrote this “Pain scientists are reasonably agreed that pain is an unpleasant feeling in our body that makes us want to stop and change our behaviour. We no longer think of pain as a measure of tissue damage – it doesn’t work that way even in highly controlled experiments. We now think of pain as a complex and highly sophisticated protective mechanism.”
Pain is an unpleasant sensory experience that can range from mild localised discomfort to whole-body encompassing physical and emotional agony. The world of science often classifies pain in differing ways, which can lead to misunderstandings and confusion to those affected and the loved ones who care for them. The terms acute and chronic might be familiar to you but let’s try to unpack these a little, by using the example of stubbing your toe on the way to the lavatory. A random example perhaps, but we’ve all done it, or know someone who has, and it can be excruciating.
- Acute pain is the pain felt when you first stub your toe – the short-term big ouchy, ouch!
- Sub-chronic pain is when your stubbed toe is still painful six weeks later.
- If your toe is still hurting 12 weeks after the injury, your injury has now become a chronic condition, which is sometimes also known as persistent or ongoing pain.
Doctors also classify pain from the place where it originates. Visceral pain comes from the internal organs, the viscera such as the digestive system, appendix, kidneys, bladder, or uterus. Infections, inflammation or tumours cause this pain. Visceral pain can refer to joints and muscles, meaning it’s often felt away from the original source. While this might seem like it adds to patient confusion, it’s also a brilliant alarm mechanism. Just think of the warning sign that is the arm or jaw pain some people experience during a heart attack, it can be a real lifesaver.
Pain from other body tissues is called somatic from the Greek word to mean the body – Soma. For example, health professionals will diagnose most neck and back pain as somatic. It can come from our bones and joints, from muscles and ligaments or from the nerves, usually because of inflammation or micro-tearing associated with a strain or sprain.
What does chronic pain feel like?
Pain does not feel the same for everyone, and it’s difficult to describe clearly. The range of symptoms can be mild to severe; it can come and go or be constant When people can express where their pain is, what it feels like it, how bad it is and when it happens. It can make it easier for health professionals to help them find the best treatment options. Symptoms can include any of the following:
It takes about 6-8 weeks for most bone and soft tissue injuries to heal and for the pain to go away. While more severe injuries can take longer. For example, a fractured leg that needed surgical pinning or plating and a period of non-weight bearing won’t be better in 8 weeks, but it will still get better. Doctors now understand that outside of these cases, pain beyond 3 – 6 months is in most people, not because of tissue damage.
What health professionals and those working in pain science and rehabilitation understand well is that tissues need mechanical loading to remain healthy, in simple terms that means movement. Being static, guarding or protecting an injured body part for too long, will increase the chances of persistent or chronic pain.
Chronic pain is a real condition, not something just in your head. Where pain continues for over 12 weeks; it will be described as either persistent, ongoing or most often as chronic. It’s a real condition, not something just in people’s head, pain persistent beyond tissue healing time for many reasons. There is now a more in-depth understanding amongst scientists and health professionals that the brain can become oversensitive after even the most insignificant injury and become primed to trigger more quickly to the next episode which can be a real or perceived threat of pain. While pain experts accept that pain is not merely imagined, or only in our head. Our emotional state can influence how we experienced unpleasant sensations and feelings [pain]. It will often be worse when people are tired, depressed, anxious, grieving or living through any traumatic or stressful situations.
During these states, the brain senses threat more readily and will trigger a stress response to protect its self and your body.
The sciency bit.
The consequences of this can be a vicious cycle that goes something like this. Pain sets off a sequence of emotions such as fear and anxiety, which accompanied by a cascade of chemicals and hormones, part of our natural stress response. These result in an inflammatory reaction in the body, which causes muscles to become tense and achy. If these chemicals hang around for too long, the discomfort will get worse, and the stress response will increase also, and so, the cycle continues. For some people, this is a familiar pattern, one that can leave them in a state of sheer despair.
Chronic pain is a cold caller!
Chronic pain is a tricky character; it persists long after the trauma or injury has healed, and in some people can occur in the absence of any trauma. Some specialists divide it into two groups:
- Inflammatory pain due to ongoing physical injury, such as nerve damage, also called neuropathic pain. or due to a tumour also called nociceptive pain
- The other group is brain-induced pain or neural-pathway induced pain because the nervous system is the root cause.
Chronic pain can move around from one body part to another, can vary in intensity, be triggered by the most innocent of situations and be difficult to attribute to a specific event or cause. All of which can be very upsetting and stressful for those affected and their loved ones too. Worst of all, some health professionals still have a poor understanding of the complexity of this pain and therefore, do not serve their patients well.
It is not uncommon for chronic pain to appear long after the original injury; this could be months or years later. Think of it’s much like a cold caller, uninvited, unwelcome, and often appearing without a clear purpose. But with a little detective work, sometimes an association with a significant life event such as a divorce, house move or bereavement can be made to explain the sudden return of pain or an increase in its intensity. However, it’s not just adverse events of life that can impact on the body or mind. Sometimes pain can be triggered by joyful and happy occasions, such as weddings or a big holiday.
Our brain is quite simple and looks for patterns to match in its attempt to keep us from harm; stress is just stress! Exploring connections between life events and pain is worthwhile as this can cause lightbulb insights which can open powerful ways forward to a resolution of symptoms for those affected. It is also important to understand people’s beliefs about their condition as most of those in pain end up in the treatment room of a doctor or manual therapist. With both parties often expecting that medication or hands-on treatment should be the main component of the appointment. While that might be beneficial, it may not be the best solution if pain education is not also on offer.
There is so much more to say, but this is an already whopper of a post. So coming in part 2: Ways forward in pain management, pain education, and resources.