“That’s the thing about pain. It demands to be felt”
John Greene
Touching a hot cup of coffee or spraining an ankle. All of us have experienced pain at some point in our lives. Pain is a protective mechanism which signals us about potential damage to the body. However, while some may seem to cope well with pain, others may develop chronic pain syndromes where the pain sensation doesn’t seem to stop. Much of what we know about pain has been from recent discoveries and even now, pain, as compared to other bodily experiences still remains an enigma. Whether it’s just a sensation that we feel when we are injured or whether there are deeper connotations to pain, lets dig deeper to find out because as they say ‘No gain without pain’.
What is pain?
The word pain comes from the Latin word ‘poena’ meaning punishment or penalty. The current operational definition for pain laid down by the ‘International Association for the Study of Pain’ is that “pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of that damage”1. This landmark definition takes into account years of research and work devoted to decoding pain. Thus pain is not merely a sensation but an experience. From beliefs during Antiquity that pain is rooted in grief and sorrow, the medieval ages when the Church considered pain as a retribution for ones deeds, Descartes dualist theory that physical and psychological injury do not interact and are separate, the ‘Specificity theory’ that proposed specific pathways for specific sensations including pain ,the Pain Gate and Neuromatrix theory by Melzack that identified spinal and supra-spinal influences over pain relayed to the brain along with their complex interactions and now the current widely accepted ‘Biopsychosocial model’, our understanding of this complex puzzle has come a long way. As the name suggests this model explains pain considering biological (individual characteristics like personality, pain tolerance), psychological (mental and emotional quotient) and sociological factors (environmental). Although this model is widely used in the context of health and disease, John.D.Loeser was the first to apply it to the pain experience. He suggested that the pain experience consists of four variables- nociception (which is the input), pain (how the brain analyses the input), suffering (the emotional response to pain) and pain behavior (the individuals actions towards pain felt) 2, 3. Thus, simply put, these variables affect pain so much that no two individuals can have the same pain experience and even people with the same injury may report different levels of pain.
How is pain measured?
Nothing in this world is more subjective than pain. You may have visited the doctor and when asked about pain and how you feel, felt completely at sea. The most common way of gauging pain are self-reported scales such as the numerical rating scale (NRS) where pain is scored numerically on a scale of 1 to 10 or using Visual analog scales (VAS) where the patient is asked to mark his pain on a 100mm line where 0 denotes no pain and 10 stands for maximum pain one can bear. There are other scales like the Faces scales used in children which measure pain as what your face might look like when you are experiencing the pain such as a smiling face, regular face or sad face. Then there are categorical scales which measure pain as categories of mild, moderate or severe and the categories in between4. Other ways of measuring pain were the use of ‘dolometers’ that inflicted pain stimuli and measured the pain threshold and most recently the use of Brain scans which is by far the most advanced and modern way. However now that pain has been touted as the fifth vital sign by the American Pain Society5, just quantifying pain isn’t enough to treat it and doctors have to delve deeper by also enquiring about the nature of the pain, what causes it, past experiences, where is the pain, the consequences of the pain on quality of life and so on.
How can pain be managed?
Just as no two individuals can feel the same pain and as seen earlier that pain has sensory, affective and cognitive aspects to it, the management of pain also has to be individualized. From using drugs to nerve blocks, the management of pain has evolved over the ages. Rooted in the pain gate theory, hot or cold packs, massage and electrotherapy block pain at the spinal Gate level. Counter-irritants help reduce pain by initiating the supra-spinal influences which are also at play when an athlete who is severely injured refuses to back down from the game so as to win while exercises and graded activity inhibit pain because of the release of chemicals such as endorphins. Since pain has a cognitive quotient, operant conditioning and cognitive behavioral therapy has also been used to treat pain especially chronic in nature6. Thus, a multi-disciplinary system has to be employed to solve the pain conundrum because accept it or not, pain is entwined with the very fabric of human life.
From a physiotherapist’s point of view, here is a video on 3 exercises for mitigating back pain.
References
- Pain, S. (1967). THE CONCEPT, 11, 59–67.
- Germossa, G. N. (2018). History Pain and Pain Management. Research in Medical & Engineering Sciences, 3(4), 247–249. https://doi.org/10.31031/rmes.2018.03.000567
- Trachsel LA, Cascella M. Pain Theory. [Updated 2019 Aug 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.
- Younger J., McCue, R., & Mackey, S. (2009). Pain outcomes: A brief review of instruments and techniques. Current Pain and Headache Reports, 13(1), 39–43. https://doi.org/10.1007/s11916-009-0009-x.
- Levy, N., Sturgess, J., & Mills, P. (n.d.). “Pain as the fifth vital sign” and dependence on the “numerical pain scale” is being abandoned in the US: Why? British Journal of Anaesthesia, 120(3), 435–438. https://doi.org/10.1016/j.bja.2017.11.098
- Meldrum, M. L. (2003). A Capsule History of Pain Management. Journal of the American Medical Association, 290(18), 2470–2475. https://doi.org/10.1001/jama.290.18.2470
