What is Pain?
With pain being the number one reason why people seek out the help of a physiotherapist, the answer to this question is something I would consider to be a fundamental concept that needs to be understood by both the physiotherapist and the person looking for help from a physiotherapist.
At first glance this many seem like a simple question, and yet, if you take a moment to think about it, you may be surprised at how long and complex the answer is.
HOLD UP! As everyone who has ever played Monopoly knows, before you pass begin, you must collect R200… so before we begin here is your R200: pain is personal, it’s individual, unique and specific to you! One of my favorite sayings is that: "my pain is what I say it is". This has many implications, the most important of which, is that the only way of knowing if someone is in pain, is to ask.
The other implication is that management of each person's pain needs to be tailored to them specifically. You and a friend may have received the exact same diagnosis for the pain that you have been experiencing, but your pain and your friends pain are not the same. No generic one size fits all, no magic bullet here!
Alright, so you’ve collected your R200… so, what is pain? It may be easier to first answer the question: “Why do we experience pain?” If your answer to this question included something like: “It’s the way my body tells, or informs me of danger or a potentially dangerous situation,” then you would be absolutely right! Imagine kicking your toe really hard on the edge of a table, or almost putting your hand on a hot stove top! Ouch!!! You would definitely want to know that your toe is O.K. before taking another step, or know that the stove is hot so you stop yourself from potentially burning yourself!!! Bingo! The answer to the question “what is pain” must therefore be that pain is a warning or an in built alarm system that tells you where and if something in our body has gone wrong, or is about to go wrong! Well, you would be right, BUT pain is also a lot more complex than that!
Think about people who have had an amputation but still experience pain in that part of the body that no longer exists (known as phantom limb pain). They experience pain without there being a physical stimulus like a hot stove, on the body part, so there is no alarm system to set off, and yet there is pain. What’s going on here?
To understand this, let’s take a step back and ask: normally, how does the danger message get from the area in danger to the brain? Unlike our ever smarter technology which is steadily becoming more and more wireless, our bodies still rely on our own kind of wiring (our nerves) to get the message from our bodies to the mother board (aka the brain). And it is in our amazingly complex brains that all the magic happens!
If you have read this up until now with a critical eye, you will have noticed that I have purposefully not used terms such as: “pain message”; “pain pathways” or “pain stimulus”. There is very good reason for this! The reason: pain is a produced by the brain not the periphery (i.e. tendons, muscles, bones, joints). This is important! It always has been, always will be, 100% of the time, no matter the kind of pain: sharp, dull, achy, acute, chronic, severe, or mild etc., be a product of your brain. Just like a computer with all its wiring would be useless without its motherboard, so our bodies, with all its nerves cannot interoperate anything without the brain. So… we talk about danger messages coming from our body, which the brain then uses in the process of making pain.
So is pain all in my head? There are many, many myths and misconceptions about pain, one of which is this idea that pain is made up and “in someone’s head”. This misconception is especially felt (and harmful) by those who experience chronic or persistent pain, whose health care professionals seem to have exhausted every avenue in trying to understand why their pain has not been resolved. Pain is always real, and the person feeling it should ALWAYS be believed. So… if pain is made by the brain, but not “all in my head”, what does your brain have to do with pain?
!SPOILER ALERT! Here comes the answer to our original question:
Your brain analyses all the different contributors to your current experience as either things that threaten you (things like: there is now a dent in the wood where I kicked my toe; and my neighbour ended up with a fractured toe when he hit his toe this hard); or things that bring you safety (things like: my husband is with me and he can look after me and take me to the hospital if needed; I can still move my toe; and I don’t see any blood when I look at my toe). Pain then occurs when your brain concludes that there is MORE credible evidence of something threatening your body than safety.
Another way to understand this is by imagining a seesaw, pain occurs when the kid sitting on the “threat” side outweighs the kid sitting on the “safety” side. Not yet convinced? Think about that bruise on your leg that you don’t remember getting, or that scrape on your arm that you only noticed when someone pointed out to you that you were bleeding. In both these cases the kid sitting on the “safety” side outweighed the kid on the “threat” side, so your brain concluded that there was more safety than threat and there was therefore no reason for it to produce pain.
If we understand pain in this way then we can also start to understand that the danger message coming in from the body is only one factor that sits down on the threat side… so when you scraped your arm a danger message from your arm was sent to your brain, but because there were so many other factors sitting on the safety side, your brain decided there was more credible evidence of safety than threat. This then explains why someone with an amputation can still experience pain: there may be other threat factors, other than just the danger message that would have come from the body, that outweigh the safety factors.
So… what is pain? Pain is a highly personal experience that is normal, always real, protective, and influenced by many different factors including but not exclusively, the danger message from the body. It motivates us to take action and seek help when needed!
