Updated: Sep 21, 2022
Pain is something we've all likely experienced at some point in our lives, whether it be from a "pulled muscle" or some other type of injury we've suffered. When we experience this pain we can all tell someone that we "hurt", but have you ever tried to define pain or describe what you mean when you say, "it hurts"?
If you're up for the challenge try giving it a shot right now. Take a moment to explain what your pain is without using the phrase, "it hurts". Go ahead, i'll wait. How was that little exercise? Challenging? Were you able to describe or define your pain? Was it difficult? What words or phrases came to your mind? Did you feel any emotions begin to surface when trying to describe your pain? Maybe frustration or irritation. Or maybe you felt a bit uncomfortable or even afraid?
If you had difficulty or even felt some sort of emotional response that is ok. Both are to be expected. Pain is an extremely difficult word or concept (maybe even somewhat elusive) to define using a single word or phrase. This is likely due to the lack of our collective understanding about how the systems of our bodies interrelate. In fact, for years we've been told that when we have pain it is the "side effect" of an injury that resulted in our "pain receptors" creating the sensation of pain. In line with this belief, as soon as the injury heals or you had a surgery you should no longer have pain, because everything broken was now "fixed" or "healed".
This more or less "medical model" of explaining pain made it extremely easy and convenient for medical practitioners in general to compartmentalize an individual's symptoms or clinical presentation. Not to mention helped to make interventional decisions (including treatment approvals/denials from insurance companies) much easier when it was based on a quantitative ("by the numbers) pain or symptom report, you know the drill..."describe your pain on a scale of 0 to 10." Unfortunately the more we've learned about pain the more we realize it doesn't always quite fit into this short and sweet "by the numbers" clinical reasoning process.
The good news for us is that as more research is being done the more our understanding of what pain is as well as what pain isn't is starting to unfold, painting a much more nuanced picture that appears to be uniquely specific to the individual. According to the International Association for the Study of Pain (IASP), pain is, "an an unpleasant sensory AND emotional experience associated with actual OR potential tissue damage, OR described in terms of such damage."
Let's take a moment and discuss this definition a bit. Pain is "an unpleasant sensory AND emotional experience". We all know that pain is an unpleasant feeling that promotes a significant emotional response, but did you know that this unpleasant sensory AND emotional response could also be present in light of a "potential" damage to tissue? That's right, a person DOESN'T even have to have an injury to experience pain!
Pain is "an unpleasant sensory AND emotional experience associated with actual OR potential tissue damage, OR described in terms of such damage." -International Association for the Study of Pain-
For decades, based on the medical model of patient care, medical providers have used various tests and measures to provide "by the numbers evidence" as to "why?" a patient presents with pain. The sad fact of the matter is that much of this "evidence" was significantly lacking in meaningfulness with respect to the "why?" a patient has pain. One of the most visible examples of this mismatch between the "evidence of why" and a patient's clinical presentation is that of low back pain.
Low back pain is the most common source of musculoskeletal pain seen across the globe with over 500 million people suffering from this condition at any given point in time. It's also the leading cause of activity limitation and days away from work in that same sphere. Yet interestingly the majority of folks with back pain (85-95%) have no identifiable source or "reason" for their pain. In other words, they feel pain and even have disability due to their pain, but no "true" pathological (disc herniations, fractures, etc..) cause to explain their pain. We'll discuss back pain in more detail in future posts, but for now keep in mind this is only one of the many persistent pain entities running rampant in our society today.
Something that may get lost in translation when looking at the IASP's definition of pain is that pain is an extremely personal experience that is a culmination of three broad factors: 1) biological, 2) psychological, and 3) social factors which are uniquely specific to the individual. This point of view is often described as the "Biopsychosocial Model" and is believed to better reflect the complexity of a individual's pain experience by looking through a wider and more holistic lens.
It's through a combination of these areas or domains that we can better understand "how" or "why" a patient's pain experience might manifest or more importantly why it may persist beyond the "normal" healing time associated with injury. We've known for centuries that structural, biomechanical, and functional tissue disturbances (biological factors) can indeed impact a person's pain experience, but unfortunately due to several factors such as a lack of technology and research as well as a considerable amount of bias, at some point it became the only lens (medical model of patient care) through which our society viewed the individual.
Thankfully we now know that social and psychological factors can also deeply impact a person's pain experience as much if not more, in some cases, than biological factors alone. Psychological factors include those factors an individual has learned or developed throughout their lifetime such as their beliefs, thoughts, knowledge, and or feelings about pain; whereas, social factors include those interactions or individual encounters that help to shape an individual throughout their lifetime. These include community or cultural influences as well as those influences derived from interactions with family, friends, and or colleagues.
Think for a moment about how you respond to stressful situations. Who taught you how to handle or respond to situations in this way? Maybe you've never thought about it like this, but many of the things you've always done without giving much thought to are actually things you learned by watching or observing others and then consciously or, more times than not, subconsciously applying to who you are and what you do. Was it your mom or dad or both? Maybe a grandparent or another caregiver? Once you land on that person (or persons) consider how they recieve, perceive and respond to situations, stressful or otherwise. Does your perception of how they behave in response to life remind you of anybody you know?
Throughout the experiences of your lifetime how have you come to understand pain? Do you consider pain a bad thing? Is pain something you fear? Does it make you feel broken or like there's no hope? You can answer truthfully, its ok. There are no wrong answers to these questions, which is something else that gets lost in translation. Your beliefs about your pain, how you see your pain, or how you feel about your pain should be respected. It's your pain experience and its valid. Even if you don't quite know how to communicate openly and verbally about your pain, it doesn't mean that your symptoms or your pain aren't real. No one medically trained or otherwise can define or describe how you experience pain.
Whether we realize it or not pain is a good thing for us to experience. Pain is one of your body's ways of protecting you from danger. In fact, we have receptors (called nociceptors) all over our bodies whose job it is to send specific messages to our brain that suggest whether or not a stimulus can cause tissue damage or if it persists long enough could also cause tissue damage. The brain then determines if any or all of these messages are a "credible" threat to your body. If so, the brain may produce pain. If not, pain is not present. Now another point of clarification is warranted at this point. Just because the brain determines whether you have pain or not, this DOES NOT mean that "it's all in your head" or that you're making it up. That couldn't be further from the truth! However, we know now that the brain is the major player when it comes to how much, how often and two what extent we experience pain.
Consider this example from my own life for a moment. Several years ago I was in the mountains of New Mexico riding 4-wheelers with my brother and his wife. We were on a trail (later we realized it was a motorcycle trail) that was just about too narrow for our 4-wheelers, yet it meandered along the side of a mountain with an incredible view. As I drove along the trail taking in the moment one of my tires hit a rock jutting out from the mountain side. This rock was imbedded in the mountain enough that it didn't budge. In fact, the next thing I knew my 4-wheeler and I were headed over the edge of the trail and down the mountain side. I instinctively jumped from the 4-wheeler taking my chances on my own two feet. As I jumped two of the 4-wheeler tires stuck in the dirt and immediately threw the machine into a seat over wheel roll down the mountain. As for me, the minute my feet hit the mountain's steep vertical face my left foot, being closer to the ground than my right, immediately rolled when it accepted the weight of my body causing my ankle to give. Next thing I knew I was rolling head over foot down the mountain as well. At some point myself and the 4-wheeler came to rest at least some 75 feet down the side of this mountain, thanks to a row of trees graciously stopping our decent.
So there I was lying on my back in the beautiful mountains of New Mexico taking in the gravity (pun intended) of the situation. As I shook off the disbelief and began to take a mental inventory I realized my body for the most part had come away unscathed, with the exception of several scrapes and cuts on my arms and legs from all the small trees doing their best to stand up against my rolling assault. Unfortunately the one thing that didn't fare so well - yep you probably already knew - was my left ankle. It was in fact looking extremely limp and discolored from the ordeal.
As I assessed my ankle's condition, my mental efforts were interrupted by my brother shouting "are you ok?" Then it hit me...the pain began to come on as fast as the realization that I was now no longer on the trail. We bantered back and forth for a few minutes thinking of the best course of action. My brother then came up with a plan to get the 4-wheeler as well as myself back on the trail using a 25 ft tow rope and the 50 ft winch cable from the 4-wheeler. Tying the 2 cables together we used the end of the tow rope to tie off to various trees above my position to ever so slowly winch the 4-wheeler back up the mountain side until finally reaching the flat surface of the trail. So where was I during this ascent back up the mountain? Well I was right next to the 4-wheeler standing on my own 2 feet, one busted and the other completely intact, guiding the 4-wheeler up the mountain.
You see it's not that my ankle wasn't injured or that I wasn't hurt, it's the fact that my brain decided the "danger" of staying on the side of the mountain was a more credible threat to my overall well being than that of using my busted ankle to get to safety. Even though using the limb might mean more damage to the ankle and surrounding soft-tissue my survival was more important.
This is how our brain works. Isn't it amazing?