Why Won’t My Pain Go Away?
28th March 2018
Dr Stephen Humble, Consultant in Interventional Pain Medicine at London Spine Specialists at the Hospital of St John and St Elizabeth gives fascinating insight into the concept of pain, how it differs between men and women and how it can be managed effectively.
Dr Humble specializes in X-Ray and ultrasound guided injections such as epidurals and facet injections for spinal pain, joint pain and nerve pain.
1) What Physiological Processes Are Behind Pain: What’s Its Purpose Generally?
Almost everyone has an immediate understanding of the word Pain, however, everyone experiences pain in their own way and an injury that causes mild discomfort for one person may be excruciating for another. This can be due to differences in the way the brain works and also the way nerves in the rest of the body function.
The nervous system may be considered as a complex monitoring system to maintain body integrity. Nerves respond to changes in the body and may transmit painful signals to the brain via the spine. The perception of pain in response to a mechanical, thermal or chemical insult can be reduced or heightened at any given time. For example, inflammation may increase the pain associated with a standard painful insult by making the nerves themselves more sensitive. Functional changes associated with inflammation are usually temporary but can last for days, weeks or even longer in some cases.
There are different types of nerves and they facilitate the physiological process of sensory discrimination and the monitoring of the physical environment, which confer survival advantages for the lower back pain, individual.
2) What’s The Purpose Of Pain In The Context Of Exercise?
Acute pain has a highly important physiological role in that it alerts the individual to the presence of injury thus prompting the need for rest and recovery. In this way, pain may be considered to be beneficial in that it prevents us exacerbating injury. Indeed, people that are born insensitive to pain, due to rare a mutation (of Nav1.7) tend to develop chronic disabling injuries during childhood.
Occasionally, nerves themselves can become faulty and send pain signals to the brain even when there is no injury or other real cause for the pain. Faulty nerves may result in real pain that may be difficult to treat and often, normal painkillers don’t work sufficiently for nerve pain (also known as neuropathic pain). Neuropathic pain is often described as sharp, burning, electric shocks, squeezing or crushing and can last for months or years. Nerve injuries can cause increased sensitivity to pain or even pain when there is no injury or when a previous injury has healed completed.
We expect to suffer from pain during or after an injury, but, naturally, we expect it to go away after a few days. However, a minority of people can develop chronic pain, which may persist even when a previous injury has healed completed. Chronic pain is best treated aggressively as soon as it occurs (do not suffer in silence!). Some individuals are at higher risk of developing chronic pain due to the biological traits inherited from their parents while others may be at higher risk due to stressful childhood events such as physical or sexual abuse. Sometimes it can be helpful to reflect back on previous experiences and understand how they have helped to shape the present so that they can be processed and potentially resolved.
3) To What Extent Can We Teach Ourselves To Deal With It By Changing Our Mindset?
The experience of pain itself is highly variable between individuals and so too is the ability to deal with pain. As well as being inherited from our parents, our physiological response to pain can also be affected by our social environment and emotions such as stress and depression.
Pain may be managed in numerous ways including psychological coping strategies, relaxation/dissociative techniques, physiotherapy, drug treatments, TENS machines (electrical stimulation pads), acupuncture, steroid injections and stretching. The best approach is perhaps to combine multiple modalities and tailor the treatment according to the response of the individual. Mind and body are highly integrated and psychological factors can play a huge role in the response to tissue injury. People may complain of excruciating pain after trivial injuries, while in 1946 Beecher surprisingly recorded that many World War II soldiers with acute severe injuries reported no pain and declined painkillers.
In cases of increased sensitivity to pain it is still important to carry out daily gentle exercises and stretches, however, the exercises should only be for very short periods of time initially, until they start to increase the pain each time. They should be repeated each day so that the person becomes accustomed to them, and then they should be increased in duration and intensity. It is very easy to fall behind with exercises, but it is also very easy to overdo them as well. By taking this slow and steady approach, people will get the best result in the long-term, but only patience reaps true benefits. It is important to seek personalised professional advice in cases of injury.
The emotional response to an injury is based on cultural and family background, memories of previous personal experiences and from descriptions of injuries that we may have heard from other people. An acute back injury may be associated with emotional shock and anxiety that a serious injury has been sustained. The pathophysiological mechanisms by which acute back pain becomes chronic back pain are complex, but psychological factors also play a part. Pre-existing psychological characteristics can be affected by stressful events or traumatic injuries. Traits such as catastrophising are associated with worse outcomes and social issues can also have a significant impact on response to injury. Anxiety itself may increase muscle tension and even generate muscular spasm in a process of positive feedback. Pain of a potentially indefinite duration, coupled with loss of income, social status and hobbies is enough to precipitate depression. This can sap motivation, reducing one’s ability to cope with any given situation and magnify the impact of pain. The worse the pain is, the less likely someone is to socialise with family and friends and the process of progressive social isolation can affect mood and therefore pain perception. Patients with pre-existing depression may focus obsessively on back pain as a manifestation of their psychiatric illness.
It is therefore important to acknowledge these processes and pitfalls in order to build resilience. Individuals may enhance their resilience by have supportive family and friends and also by actively engaging with local running clubs. Humans are social creatures and typically need the interpersonal interaction. It is beneficial to set SMART goals. Write them down and share them with family and friends. Many people train more effectively in groups and this can enhance motivation and participation. There are many examples of athletes achieving much greater feats when being part of a team than on their own. Fellow runners can spur each other on and distract one another from the pain of running via distraction techniques such as interpersonal rivalry or even humour. Separately, many athletes are able to ‘zone out’ of their bodily discomfort via certain types of music or by entering a trance like state via self-hypnosis techniques.
4) Are Women Better At ‘Taking Pain’? If So, Why Is This The Case?
Chronic pain in general is more common in women than men, with women being more likely to suffer from conditions such as migraine and fibromyalgia. This may be due to both the relative concentration of the sex hormone and also to cultural factors i.e. women are more likely to open up about their feelings, while men are conditioned to be more stoical in general. In experimental conditions, women are generally more sensitive to a standardised painful stimulus. However, in the setting of endurance sports this difference may be dwarfed by other physical and psychological factors.
5) If True, Could This In Theory Make Us Better Endurance Athletes?
It is hard to determine conclusively whether women on average make better endurance athletes than men on average. It is worth noting that women tend to have proportionally greater fat reserves, which can be crucial for endurance sports. There are many other highly relevant factors to take into consideration such as personal motivation, focus and self-confidence that are not necessarily gender dependent. These other factors are perhaps more relevant than gender itself.
Although for the vast majority of sports male athletes have a physical advantage over female athletes, when it comes to extreme endurance events there appears to be little difference between the sexes. This is perhaps because in these events psychological resilience is disproportionately important and therefore physicality less so, providing appropriate training has been undertaken. One area where women may have the advantage is that men on average tend to be more reckless. This means that women in general may be more likely to keep a cool head and conserve their energy by pacing themselves rather than burning themselves out in the way that many over-competitive men can do when they desperately push themselves beyond their physiological limit. Interestingly, some scientists have predicted that women will ultimately predominate over men in ultra distance running, but that it may take another century for this to happen.
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