Whenever I think of the word “pain,” the first image that comes to mind, and I’m dating myself here, is that of Mr. T, who played Clubber Lane, the villain in Rocky III. When asked by a news reporter for a prediction of his upcoming fight with Rocky, Lane slowly turns toward the camera and simply growls, “PAIN!”. Obviously he was planning to harm Rocky. I suspect he also intended to teach him a lesson – Don’t mess with Clubber Lane again.
This vignette sums up most of our understanding of pain’s main purpose for humans. Pain is an unpleasant experience, alarming us that something is wrong and meant to teach us not to repeat its cause. But are those all of pain’s roles, and is pain always right in distinguishing the good from the bad?
I studied biology in college. I am a physician and have an interest in human behavior and psychology. So when I look at everyday human activities, I often like to look back in time – to early humans – to see why particular traits may have developed. What distinct survival advantage have they provided that has led to their adoption and persistence over thousands of years?
When it comes to pain, we can quickly see two characteristics that would explain pain’s persistence. Pain, viewed through the lens of being a warning, alerts us of a physical problem. When early woman stepped on a sharp rock and felt pain, she immediately knew that she had injured her foot. This allowed her to instantly protect herself – to look down and be more careful while walking over such rocks. Later on, as humans developed, it also notified her to stop the bleeding, care for her wound, and prevent infection.
The second benefit comes from experience. The lesson learned served to protect our victim from getting injured in the future. Pain experienced from walking on sharp rocks, taught her to not repeat that act, or at least to be more careful when doing so. It also protected future generations when the injured woman taught her offspring, family, and tribe about what she had learned. Finally, this simple mishap could spur innovation by stimulating someone to invent foot coverings or develop trails, and then later, sidewalks.
So clearly, pain has some evolutionary benefits. But is that the whole story? Does pain sometimes misinform us? Does it warn us when a warning is not needed? Can pain also signal a beneficial activity? Yes, yes, and yes!
Is pain always bad?
Most of us are taught from our earliest age that pain is always bad. We are taught that when pain is experienced, something must be wrong. That whatever is causing our pain must be stopped and not repeated. As an orthopedic surgeon, I see pain among my patients all the time. It’s often why they seek evaluation. For those needing surgery, it is usually the most significant source of anxiety before and after their operation. Like you and I, most of my patients have also been taught that pain is always bad. As you’ll see though that is not always the case.
Pain can occur during beneficial activities. “Deliberate Practice” is distinguished from more mindless practice by incorporating a systematic regimen with laser-focused attention. Anyone who has ever learned anything using this technique knows just how difficult and trying this process can be. In fact, because deliberate practice is so challenging for the learner, it can only be maintained for brief periods of time. It is extremely taxing and as a result can be mentally and physically painful. Yet it is very beneficial. Those who exercise are well aware just how painful that extra “push” at the end of a sprint or long run can be. Or how painful squeezing out an extra couple of pushups is. And for those who have ever tried to quit a bad habit, putting down that cigarette or forgoing that cupcake can also be very painful. Yet all of these behaviors are good. Here your sense of pain is misguiding you.
Pain’s ability to misdirect us can also occur when dealing with our health. In fact, this is the purpose of this post. Explaining to patients that pain is often part of the illness process and treatment, that it doesn’t always mean that there is something terribly wrong, and that succumbing to pain now can lead to more pain and problems later, is one of my most difficult professional challenges.
Nearly all of us have strained our back at one point. Whereas this can be very uncomfortable and disabling, back strains are almost always self-limiting. That is to say, they usually recover within a couple of days to weeks with or without treatment. Back strains are one of the ramifications of walking upright, and rarely does it ever indicate a more serious issue. Those who succumb to the pain, who limit their activity and are prescribed or choose to adhere to strict bed rest, often will develop more pain and have a longer recovery. Additionally, they will have more significant risks of developing blood clots, anxiety, and depression—of which the latter two can further impair one’s ability to ever fully recover.
Orthopedic injuries and surgery…
We see similar findings in those recovering from other orthopedic injuries or orthopedic surgeries. Specifically, it has been shown that those who have a lesser tolerance for pain or are unable to cope with their pain as others might, have worse surgical outcomes. Orthopedic surgery often involves procedures in our joints or to the long straight bones or tissues connecting our joints. When joints or the surrounding structures are injured, either by accident or the trauma of surgery, they have a tendency to stiffen and then weaken. Often this can be avoided, but there is a window of opportunity that narrows and closes over time.
I may be dating myself again, but I liken this “window” to playing a game of Tetris. For those unfamiliar, Tetris involved different shaped objects falling from the “sky.” The game’s goal was to position these shapes in a particular order. If done properly, they would disappear and free up more space on the “ground” for even more objects. If you failed to arrange the pieces correctly, they would stack up. Once there was no more space for new shapes to fall into, the game ended. If you moved early and continued to move quickly, you had a chance to win. If you waited too long or took a break during the game, you risked falling too far behind and being unable to catch up, and the game was over.
Frequently after orthopedic surgery, patients will have pain. If they choose to move early and continue to do so (assuming that this is permitted by their surgeon and appropriate for their procedure), they have a chance to have a good outcome. However, suppose they choose to wait for “a less painful time” to begin their prescribed rehabilitation. During this waiting time, they may get stiffer and weaker, often making later motion even more painful and difficult to overcome. Like delaying action while playing Tetris, waiting too long to begin rehab after surgery can sometimes mean “game over” as well.
Moreover, patients who catastrophize pain after injury or surgery and try to avoid pain at all costs run the risk of developing heightened pain syndromes such as Chronic Regional Pain Syndrome (CRPS) and Amplified Pain Syndrome. These ironically cause an exaggeration of pain, making progress much more challenging, if not impossible.
We all are aware of the phenomena of accommodation. If we step from a dark room into the sunlight or from a quiet room onto a noisy city street. The initial bright light or noise is bothersome. It can actually be painful. Shortly afterward, however, we get used to the stimuli. In fact, frequently, after our eyes and ears accommodate to these sights and sounds, they eventually go unnoticed. This same phenomenon can occur with pain as well. However, suppose we limit our activities or over-medicate to not feel the pain at all. In that case, the pain’s intensity can increase as our tolerance to it diminishes. Furthermore, for those who overmedicate, dependency on controlled substances, and all the problems that can arise from them, may follow, making a successful recovery even more challenging. Either way, this can be a very difficult, if not an impossible, spiral to extricate from.
Good and bad…
That is not to say that all pain is good and should be ignored, but instead, that pain is like most things. It can be either good or bad, depending on the degree and context. Our job as patients is to be open to this idea. And my job as a physician is to guide you through the painful process. To make sure the pain does not mean something more severe and help you accommodate to your pain, grow your pain threshold by reducing your narcotic usage, and keeping you moving in the right direction.
I’ll do my part. Will you do yours?