Half the pain, half the gain

The subject of pain features quite a lot in these blogposts (see here, or here, for example).  Not because the members of the CPN are particularly expert in matters pertaining to pain, or because its of any more clinical interest than, say, cerebral palsy.  Pain is interesting, I think, partly because it’s become such a popular subject in the profession, and members of the CPN are prone to asking questions like ‘why this, why now?’

In recent weeks a few social media feeds have explored, once again, how we might better understand pain, and improve on our assessment and treatment techniques.  I’ve been struck by how almost all of these conversations are prefaced on the idea that pain is something bad, something noxious, disruptive, aversive, and detrimental to people’s lives, and must be ameliorated.  Given this view, the role of the physiotherapist (as part of the wider pain team), is to accurately and objectively assess (read ‘measure’) the person’s pain, and find ways (to help them) to minimise pain’s impact on the person’s life, so that they can resume their normal activities.

I’m struck by how exclusive and limiting these definitions of pain are, and I’m drawn to wonder how much more influential, useful and interesting physiotherapy might be if we only embraced a fuller appreciation for full meaning and significance of pain.

Here are eight examples of pains that are central to people’s everyday experience that, for some reason, are almost entirely ignored by physiotherapists:

• The pain people search for to know when they’ve had a good workout
• The pain of a good weepy movie or a hot spicy meal?
• The pain we learn to tolerate that helps us to form our identity (period pain, for example)
• The pain that is worth it because it comes with protection (i.e. injections)
• The pain that people self-inflict when they feel disembodied (self harm, for example)
• The pain induced for psychosexual pleasure (i.e. sadomasochistic pain)
• The pain as visual statement or display (tattooing or piercing)
• The pain induced in the name of fashion (wearing high-heeled shoes, corsets, etc.)

In response to some of our recent discussions, Derek Griffin posted the paper from Leknes and Bastian titled The Benefits of Pain, which argues that;

Pain is most often an unpleasant experience that alerts us to actual or possible tissue damage. However, insisting that pain is always bad news may hinder understanding of pain’s many facets. Despite its unpleasantness – or perhaps because of it – pain is known to enhance the perceived value of certain activities, such as punishment or endurance sports…Here, we review evidence for a series of mechanisms involved in putative benefits of pain. A byproduct of pain’s attention-grabbing quality can be enhanced perception of concurrent pleasurable stimuli. This is thought to explain why pain may augment the pleasure of spicy foods. By providing an aversive contrast, pain can also improve the experience of events that follow pain’s offset and lead to pleasant relief. Other potential benefits of pain derive from its ability to inhibit other unpleasant experiences and to elicit empathy and social support. The experience of pain can benefit our defence systems, since pain can enhance motivation to accumulate resources such as social support and calorie-rich foods. It can also reduce the guilt we feel after self-indulgence or moral transgressions. In sum, we highlight a series of potentially positive effects linked to pain. This framework can aid the understanding of why people sometimes seek out, enjoy, and gain rewards from pain as well as pleasure.

Although situated far too closely within the now well-established psycho-neuro-biological model of pain (characterised by a pain as a stimulus=response formula), the paper does at least ask us to broaden our horizons from the rather simplistic notion that we need only be interested in the kinds of pain associated with noxious stimuli.

If physiotherapists are only really interested in the noxious half of the pain experience, we should be clear about this, and be careful when we talk about pain as if we are referring to it in its entirety.  Alternatively, we could start thinking about the full breadth and depth of the pain experience and begin to imagine how our knowledge and experience could be brought to bear on this most perplexing, subjective and complex phenomenon.

Reference

Leknes, S., & Bastian, B. (2014). The benefits of pain. Review of Philosophy and Psychology, 5(1), 57-70. doi:10.1007/s13164-014-0178-3.