Is pain damage or an indication of something being seriously wrong?
Or it’s just our bodies protecting us from further damage? Is everyone’s pain the same or does it vary from person to person?
The international association for the study of Pain (IASP) defines pain as, “ An unpleasant sensory and emotional experience associated with, or resembling that associated with actual or potential tissue damage.”
In simpler words, pain can occur with and without any tissue damage and sometimes can occur when our brain anticipates damage before it has occurred.
Pain is protective and usually results as a response to perceived threats by our brain.
For instance, ~90% of low back pain occurs in absence of any identifiable injury to the muscles, ligament, tendon, or disc.
A systematic review by Brinjkji et al (2015), conducted using studies done on 3110 individuals from 1946 to 2014, concluded that about 30% of 20-year-olds, 40% of 30-year-olds, 50% of 40-year-olds, 60% of 50-year-olds, 69% of 70-year-olds and 77% of 80-year-olds have a disc bulge with no pain.
Even in the presence of tissue damage, the presence of pain allows us to protect the area and take appropriate further action.
Well, isn’t it a sign of a great system, that anticipating damage resulting in pain protects us from actual damage i.e. pain before an injury is protecting us from the injury itself, or is allowing us to take measures in order to prevent further injury?
That’s an efficient system that is super vigilant and smart, because what will the point of pain if it occurs way after the injury when the damage would have already been taken place?
Plot twist!
There is a possibility of absence of pain at the time of injury. For instance, if someone sprains their ankle while crossing the road, do you think pain at that moment would be the right move ? or pain inhibition that would allow the person to cross the road and reach a safe place first would be a better survival (protective) strategy?
Therefore, pain is also contextual.
There is a better possibility of an ankle sprain hurting more terribly when you have to go to work the next day and not so much if you have to go on a long-awaited vacation.
(Note: even in a case of acute injury like an ankle sprain, the amount of pain experienced can vary according to the individual and the situation.)
For example; Even though tattoos and piercing damage the tissue extensively, the pain doesn’t persist beyond a few minutes or hours even though the damage in the form of stained and punctured skin is permanent? Why?
As humans, we hold an advantage of predicting the future and remembering our past which helps us to make better life decisions and navigate life. The same can occur in instances leading to pain where our body makes a decision of whether we need pain in the current moment or not and holds the possibility to influence the pain in some way, depending on our past life experiences and current life circumstances.
Context driving pain experiences.
This process sometimes can work inefficiently like in cases of chronic pain,
After all, it’s just decision-making, the brain’s best bet, based on all the available data.
For example, in cases of chronic low back pain where a person is fearful of bending forward since they correlate forward bending with further damage based on all the information they received from various sources (considering how much forward bending is demonized and our beliefs also impact our pain) and their own previous experiences like initially experiencing pain because of bending forward,
The person becomes conditioned to feel pain while or even before bending forward and even long after the tissues have healed, just like all of us get fearful of the buzzing of a bee around us, even though there is a high possibility that it might not sting us till we mess with it.
Simply said,
our brain is constantly trying to protect us at all times be it heightened senses as a result of a bee’s buzz which makes us more aware of our surroundings and move away or forward bending which allows us to believe that we are avoiding damage to our spine but in fact, both these instances can turn out to be counterproductive like panic in case of the buzz can lead to chaos and avoidance of bending can affect our daily activities and hence the quality of life.
Pain is a learned experience designed to help and safeguard.
Touching a hot stove hurts immediately and compels us to pull back our arm, the reaction is so quick that in most scenarios there is no evidence of any tissue damage but the pain might linger for a few minutes to divert our attention to that area to prevent any further damage to the site (like touching the hot stove again right away) and the pain is so sharp that the next time we remember not to touch a hot stove with bare hands, at least for the next few days.
Imagine if we didn’t feel any pain on touching the hot stove. We would keep touching it which would eventually lead to tissue damage in the form of some degree of a burn.
Therefore, it would be correct to say that pain is important and it protects us from further damage rather than solely being an indicator of damage.
Moreover, the response to a potentially painful stimulus can be learned by observing a parent’s reactions or people around us while growing up, as it happens for most things.
This paper discusses the etiology of chronic pain by using an example of two women Lydia and Caroline who suffer from low back pain and how multiple factors like their upbringing, work environment, behavior, beliefs, etc influence the pain and their recovery from it.
The authors explain, “Lydia’s problem has developed over considerable time, with many unsuccessful attempts to treat it, and it has gradually become worse. The repeated bouts have resulted in a pattern of responses such as worry and avoidance that continues to drive this progression. By comparison, Caroline has experienced a single episode. Caroline experiences her pain as a logical result of a situation at work, whereas Lydia’s onset was insidious and the bouts are unpredictable.
Because Lydia has experienced childhood with a “sickly” role model (her father), it can be foreseen that she will become worried and fearful; these responses promote behaviors that are counterproductive in the long run. In contrast, because Caroline has experienced a sense of control while growing up, she will more likely employ effective ways of managing the pain and its treatment.”
What if we felt no pain?
A condition known as Leprosy is an infection caused by a bacteria that causes damage to the peripheral nerves leading to no sensation in the hands and feet, therefore, no pain.
This leaves the extremities vulnerable to burns and injuries that can result in loss of fingers, toes, hands, and feet. People suffering from this condition struggle with safety during everyday tasks. For example, they don’t realize if the stove is hot and when to pull back leading to severe burns and damage and they even lose fingers and toes without any awareness of the incident!
Well here is damage and no pain!
Who said pain only indicates damage again?
Another more common condition that helps us realize the importance of pain in protecting us is diabetic neuropathy. Where damage to the peripheral nerves occurs secondary to high blood sugar levels, again leading to loss of sensation. People suffering from this condition are not able to identify minor cuts and ulcers on their feet as there is no pain to divert their attention to the compromised area and hence they take no further action. Progressively, the minor injuries advance into major insults as a result of not being taken care of, which when missed sometimes leads to a stage where amputation of the foot is the only solution.
Too intense! But not to worry, these days high blood sugar levels are better diagnosed and treated early along with the promotion of proper patient education regarding foot inspection and care.
Pain is also influenced by memory.
Phantom limb pain is the experience of pain in a body part that does not exist. Seventy percent of people who lose a limb experience a phantom limb.
The pain after amputation is usually more severe; when the pain before amputation was severe. This is a type of pain memory. Right here is an example of the persistence of pain despite the absence of the physical body part. There is no tissue, no existing injury, yet pain exists.
Likewise, a memory of a painful incident can be triggered by any pain or discomfort in the same area which can sometimes exaggerate the condition.
In this study, the frequency of pain severe enough to require a narcotic was studied in 150 male civilian patients and contrasted with similar data from a study of wartime casualties. The group of soldiers has very extensive wounds, were clear mentally, and were not in shock’ many had no morphine at all, yet less than one-fourth said, on being questioned, that they had enough pain to want anything done about it. The percentage of patients desiring narcotics was 32 and 83 for the military and the civilian groups respectively.
The authors of the study concluded, “There was no dependable relation between the extent of a pathological wound and the pain experienced. No significant difference was found between the pain of sudden injury and that of chronic illness. The intensity of suffering is largely determined by what the pain means to the patient.”
Here, then, are two groups of individuals, each with severe tissue trauma. In the one case, there was sudden relief from almost overwhelming anxiety, and the injury was viewed as good fortune; in the other case, the injury was viewed as a disaster and was fraught with anxiety.
“The soldier considers himself happy if he saves his life yet loses an extremity. And, as long he has assured security, he faces with courage, even joy from the scalpel of the surgeon. But look at the unfortunate laborer, the farmer, or the artisan, whose work is the only resource of a large family. He is obsessed with fear; misery awaits him. His is a profound sorrow, dark hopelessness. He accedes only with regret to the insistence of the surgeon. One should not be surprised by the difference in results.”
The above example explains how pain is very multifactorial, individual, and context-dependent. The pain we feel can be determined by everything from our nutrition, sleep, stress levels, and environment to our beliefs, past experiences, and current situation. Since pain can also be influenced by what it means to us and how we interpret it, it becomes important to understand what is it in the first place and the several things that can contribute to it.
Changing the narrative of pain from damage to protection along with focusing on its composite nature helps us to deal better with it by identifying contributory pain factors that can be modified in addition to helping decrease the anxiety and uncertainty surrounding it.
This blog doesn’t do justice to the intricacies of pain but I hope it provides an idea of what pain is rather than just something that is a result of a “damaged structure.”
In conclusion:
Pain is personal, subjective, and multifactorial.
Perception of danger doesn’t mean the presence of harm
Pain is not limited to tissue damage. Even though tissue damage can be one of the important factors for acute pain, it isn’t directly correlated to the amount of pain felt i.e. a minor injury can cause severe pain and vice versa.
Each individuals pain experience is unique and a person’s report of an experience as pain should be accepted as such and respected
Don’t fear movement, our bodies are strong, adaptive, and resilient. Keep moving as much as you can, whenever you can.
Comment down below to share instances where pain doesn’t occur as a result of damage/injury.
Disclaimer: In the presence of pain all the structures and context must be clinically assessed, this blog is in no way a substitute for a clinical assessment and all must consult a physiotherapist or a physician in such conditions.
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Cover photo by Pavel Danilyuk from Pexels
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