The World Shall Know Pain – Part 2

Today we’re picking back up where we last left in our journey to better understand the experience of pain.

If you haven’t, I strongly recommend you go and read part 1 so you have a good understanding where we are in this analysis and how we got here. I’ve also been made aware that there are some good memes there and you don’t want to miss out on memes, right?

Briefly summarising, in the first part we finished by understanding that the build up of evidence has showed that the brain and certain areas of it are necessary for the processes responsible for the pain experience, but not enough for it. We also looked at the reasonable argument put forward by Manzotti (2016) that in all known cases of pain, together with a brain, a body, stimuli, environment, past and future behaviour and social interactions were also present.

As they are always present, perhaps the environment, social interactions, past and future behaviours together with our perceptions of them, as well as the different stimuli arising from these different factors also have role to play in pain.

This same hypothesis crossed the mind of pain scientists from the 1980s onwards, who started describing the first psychologically and sociologically-informed pain theories and models (Stilwell and Harman, 2018). Among these, one of the most influential as the Mature Organism Model, proposed by the absolute mad lad Louis Gifford (1998). I guarantee it is out of respect that I attribute such a prefix to Gifford, so revolutionary that he was. Gifford started his career as a zoologist, later coming to physiotherapy (Hunt, 2014) but bringing his previously acquired knowledge with him – I’ll explore the relevance of this below.

This model basically states that there are stimuli from the environment or the bodily tissues that are received by neurons and sent into the brain. However, in contrast to previous models the brain is now more that a passive spectator. It will scrutinise the stimulus and then send a response or output based on said scrutiny having our body change something in the environment or something in itself, or if it feels a certain level of threat to its existence, the output will be pain.

So now we have signals going up as well as signals down, but where does the environment, past experiences, social interactions and all that come into this?

The scrutiny I mentioned before will be made taking into consideration a lot of information. Our brain, through conscious and unconscious thought processes, will consider other stimuli being received from the environment and the tissues, telling where we are right now, what’s happening around us and what the current state of our body is. It will consider our past experiences with similar stimuli, similar environment and what were the outcomes at that time. It will consider the beliefs we have about our body, how it works, our personal and social identity and what meanings we attribute to all of these. And of course it will try to make predictions about how the stimuli will affect us in the near and distant future, based on all the information it just processed. Depending on all this information, the level of threat to not just the body and its tissues, but also to our identity, social position and beliefs, will be calculated and if there is enough evidence towards threat our body will sound the alarm – pain.

With this conceptualization we begin looking at pain as a biopsychosocial phenomenon, which was a follow up from the push for a biopsychosocial healthcare model, created by Engel throughout his works from 1960 and 1977 (Stilwell and Harman, 2018). This model tried to progress the biomedical model of the time through the incorporation of the all the biological, psychological and social aspects of health, considering the relationship of the patient with their social and healthcare contexts (Stilwell and Harman, 2018).

You might by now be feeling some scepticism towards what I’m saying. “Thoughts and meanings and beliefs and consciousness. Mate, if I bang my toe, I’ve injured my body and that’s why it hurts.”True, but that’s an incomplete picture as we explored in Part 1. Just be patient and it will all make sense.

We, both as a society and healthcare systems, are still greatly under the influence of the Cartesian dualistic conceptualization of body and pain, and the biomedical model of healthcare. Considering this, I need to make a very important point clear: what I’m saying does not in any way mean that your pain is in your head. It does not have to be a binary phenomena and it isn’t.

Just to show how weird we humans are, there is research that showed that when people were made to experience pain when opening a small, rectangular blue box in a video game by moving a joystick to the left their body started associating opening a box with pain. This resulted in the subjects of that study started to present with the same fear responses and bodily preparation to pain – avoidance, protective and guarding behaviours and even changes in the responses of the brain and nervous system – with the right  joystick movement that involved opening a different boxes in the video game (Meulders, Vandael and Vlaeyen, 2016). You might say that this was a result of those people being trained to expect pain whenever they moved the joystick. However they did not present those fear responses when moving the joystick to close similar boxes in the video game – indicating that the physiological response was dependent on the meaning of the task being performed, even if physically the same movements are being performed.

We still don’t fully understand why this happens, but one of the hypothesis is that the main biological function of pain is to warn organisms of impending or actual body threat and motivate them to act towards stopping or avoiding that threat at present, as well as learning to avoid it in the future(Meulders, Vandael and Vlaeyen, 2016; Meulders, 2019). Thus we can see the link between our thoughts, beliefs and attributed meanings to the more physical functions – our thoughts and beliefs will shape our actions. If we think/believe a part of our body is damaged we will start acting in ways that try to protect that body part, consciously and unconsciously, usually through behaviours such as bracing or guarding. The issue is that these behaviours can actually increase tissue loading, perpetuating pain, in turn making you more worried because your pain is still there or is getting worse, which in turn makes you brace and guard more (Caneiro, Bunzli, O’Sullivan 2021). A lovely snowball of pain and worry.

The body and the mind are so inseparable that some studies have found that in people without musculoskeletal pain (pain relating to the muscles, bones, ligaments and cartilage) negative beliefs about pain predict the incidence of future disabling pain while in people with acute musculoskeletal pain, negative beliefs about their pain predicts how it will disable them over time much better than any assessment of their body tissues or structures (Caneiro, Bunzli, O’Sullivan 2021).

If you think your body is threatened due to damage or potential damage – you tell your body a threat exists and it responds to that potential threat. If constantly you feel stressed, sad or anxious – you tell your body a threat exists and it responds to that potential threat. If you feel like your current work, family situation or circle of friends is going to be threatened or you’ll lose them in some way – you tell your body a threat exists and it responds to that potential threat. In a way, it almost becomes a self-fulfilling prophecy: you think you’re not well – physically, mentally and socially – and due to this belief you will not feel well. Weird, I know.

By recognising the interplay between all these biological, psychological and social factors, we reach the current definition of pain used by the International association of pain: An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage (IASP, 2020; Raja et al, 2020). I point your attention mainly to that last part – “…or resembling that associated with, actual or potential tissue damage.” By definition, tissue damage is not a necessary part of the experience of pain.

So, now we have a definition and we understand it is quite complex. What does that mean to you?

If you are member of the general public and developed or are experiencing pain, even if it is quite intense and has been lasting for a long time, it doesn’t meant it is because you have a serious injury or damage to your body. If your pain didn’t start with physical trauma, it is most likely that the opposite is the case – no relevant changes are present in your tissues (Lewis and O’Sullivan, 2018). Even in the cases of trauma, you can still have pain long after your tissues have completely healed – your body is just being over protective.

All of this means that if you go to see a physiotherapist or any healthcare professional for your pain, they still need to rule out a serious pathology or injury, which mostly can be done through you telling them the story of your pain and how it presents. However together with this also expect them to ask you:

• What you think is happening?
• What you think is causing this pain?
• How do you respond to this pain?
• Have you started avoiding doing things because of your pain?
• What do you want to achieve?
• What are your expectations for this pain?

These might seem like weird questions for a healthcare professional to ask a service user but you now know, through reading this far, that these beliefs will affect both what you feel and how you will progress. Together with these, you will also be asked about other biopsychosocial factors that we know can influence pain, such as your activity levels, sleep, psychological health and your lifestyle in general (Caneiro et al, 2020; Caneiro et al, 2019)  . This is the sign of a health professional that has kept up with the evidence and current guidelines, and cares about you as a person, not a body part (Caneiro et al, 2019; Lin et al, 2020; Lewis and O’Sullivan, 2018).

For clinicians, this means that when addressing non-traumatic pain, after ruling out serious pathology, you need to have an individualized patient centred approached, taking into consideration their needs and valued activities, educating about their pathology and prognosis, overcoming unhelpful beliefs and myths, participating in joint decision making, planning and guiding towards management strategies and improving lifestyle factors such as sleep, stress management and social interactions. And please, don’t treat them as machines with damaged parts, they’re not cars.

I hope you feel you’ve learned something by now and hopefully I’ve changed your perspective about pain and that it is not simply a signal coming from tissue injury. As I repeatedly mentioned, in our society is still mostly dominated by a mechanical view of pain which as lead to mistreating and failing people with pain. I can only apologise if this has happened to you. I can assure we are trying to learn more about this complex phenomenon and how to manage it.

I also suggest we might need to change our perspective of pain as a society. This is purely a personal opinion and I would love for you to challenge, as it is prone to change through being shown perspective and facts I’m not aware of at the present. I think that in the future, the understanding and management of pain will need to take into account individual’s perceptions of suffering-related experiences and its role in day to day live and society. Is it a realistic expectation to wish for a suffering, and therefore pain-free life? Or should this experience and all its cognitive and physical expressions be better integrated into our day to day? Pain developed as survival mechanism. Considering this, is there value in suffering?

Do you agree with me? Are you still confused about any of this? Please let me know through a comment in any of the social media platforms I use!

References:

Caneiro, J. P., Bunzli, S. and O’Sullivan, P. 2021. Beliefs about the body and pain: the critical role in musculoskeletal pain management. Brazilian Journal of Physical Therapy. Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia, 25(1), pp. 17–29. doi: 10.1016/j.bjpt.2020.06.003.

Caneiro, J. P., Roos, E. M., Barton, C. J., et al. 2020. Infographic. Roadmap to managing a person with musculoskeletal pain irrespective of body region’, British Journal of Sports Medicine, 54(9), pp. 554–555. doi: 10.1136/bjsports-2019-101681.

Caneiro, J. P., Roos, R. M., Barton, C. J., et al. 2019. It is time to move beyond a ‘body region silos’ to manage musculoskeletal pain: Five actions to change clinical practice, British Journal of Sports Medicine, 54(8), pp. 438–439. doi: 10.1136/bjsports-2018-100488.

Gifford, L. 1998. Pain, the tissues and the nervous system: A conceptual model. Physiotherapy, 84(1), 27–36. https://doi.org/10.1016/S0031-9406(05)65900-7.

Hunt, L. 2014. Pain pioneer Louis Gifford dies from cancer. Chartered Society of Physiotherapy : Frontline – The Physiotherapy Magazine for the CSP members. [online] Available at: < https://www.csp.org.uk/frontline/article/pain-pioneer-louis-gifford-dies-cancer#:~:text=It%20is%20with%20great%20sadness,he%20died%20on%209%20February >

International Association for the Study of Pain, 2020. IASP Announces Revised Definition of Pain. Washington. [Online] Available at: < https://www.iasp-pain.org/PublicationsNews/NewsDetail.aspx?ItemNumber=10475 >

Lewis, J. and Sullivan, P. O. 2018. Is it time to reframe how we care for people with non-traumatic musculoskeletal pain ? Br J Sports Med , pp. 1–2. doi: 10.1136/bjsports-2018-099198.

Lin, I., Wiles, L., Waller, R., et al. 2020. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: Systematic review’, British Journal of Sports Medicine, 54(2), pp. 79–86. doi: 10.1136/bjsports-2018-099878.

Manzotti, R. 2016. No evidence that pain is painful neural process. Animal Sentience, 3(11).

Meulders, A. 2019. From fear of movement-related pain and avoidance to chronic pain disability: a state-of-the-art review’, Current Opinion in Behavioral Sciences. Elsevier Ltd, 26, pp. 130–136. doi: 10.1016/j.cobeha.2018.12.007.

Meulders, A., Vandael, K. and Vlaeyen, J. W. S. 2016. Generalization of Pain-Related Fear Based on Conceptual Knowledge, Behavior Therapy. Elsevier B.V., 48(3), pp. 295–310. doi: 10.1016/j.beth.2016.11.014.

Raja, S. N. et al. 2020. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain, 161(9), pp. 1976–1982. doi: 10.1097/j.pain.0000000000001939.

Stilwell, P., Harman, K. 2018. An enactive approach to pain: beyond the biopsychosocial model. Phenomenology and the Cognitive Siences,[e-journal] 18, pp.637-655. Available through: https://doi.org/10.1007/s11097-019-09624-7