Tell me where it hurts
Pain is real, but it can also be in the mind and have far more to do with our perceptions than actual physical damage. By
“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 pain, titled “Predictive processing as a theory to understand pain”.
Thacker argues that rather than a strictly physiological sensation, pain is more a matter of perception. He uses several wellpublicised examples of situations in which we might experience pain without damage, or the opposite, damage without pain.
One such example was published in the British Medical Journal. A 29-year-old builder jumped off a scaffolding on to 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 that it went between his toes, and never caused any actual tissue damage. Yet, he experienced the pain as though the nail had gone through his foot.
Thacker argues that our existing understanding of previous pain is far more influential when it comes to predicting how we will perceive pain.
Biokineticist, and pain management consultant Jonathan Joshua concurs: “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, but what are the contributors to the experience of pain?
“Often when you go to a 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,” says Joshua.
That pain plays an important role in human life is arguably beyond debate. Take, for example, 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 can live a fairly normal life, they must constantly check for cuts, bruises, self-mutilations and other possible unfelt injuries.”
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. However, beyond acute pain, one of the least understood forms of pain is chronic pain, especially when it comes to joints.
“I think it’s very helpful to know that the joints – the ankles, knees, hips and spine – are designed to take a 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,” 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 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,” it reads.
“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 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.