Your Brain is Trying to Protect You, Part Three: More Tools

1. Knowledge: Understanding what is happening inside the body

One important way to begin to address fear avoidance is with knowledge. Some people with pain spend a lot of time learning about their condition through books, the internet, and other sources. The information they find may or may not be accurate, and this should be considered. Other people in pain may avoid the topic, wanting to spend as little time thinking and focusing on it as possible. Whatever the case, we believe that the person in pain is the “expert” on their own experience. Health care providers can be “experts” in current evidence, theory, and knowledge around pain, and sharing this information with clients can be extremely helpful.

The knowledge that is provided can take many different forms:

-What is happening inside the body?

-Which movements are good versus which ones could be harmful?

-Which activities are safe and which are unsafe?

-What does pain mean? Is it causing damage, or not?

-Coping strategies, techniques, and resources that are available.

Using knowledge and education to address fear avoidance sounds obvious, but there are many factors that affect the the outcome of education. For instance, a 2003 study on using education to address fear avoidance suggested that, as expected, people who were avoiding tasks because of fear of pain benefited from fear avoidance based physical therapy. What the authors didn’t expect was that the same education could actually lower clinical outcomes in people who they considered “confronters”, meaning people who tended not to try to avoid pain (George, Fritz, Bialosky & Donald, 2003). We interpret this to mean that it is essential for the clinician to understand the client’s current beliefs about their pain in order to determine what kind of information might be helpful to the client.

2. Self-Efficacy: Believing that you can do something about the pain 

Another essential tool is self-efficacy, a term that came from Bandura, a prominent psychologist in the 1990s. Some people may wonder - why talk about psychology when the problem is physical pain? The answer is that human beings are complex, and our minds and bodies impact each other.  To put it succinctly, “chronic pain is inherently both a medical and a psychological condition – what healthcare providers call a biopsychosocial condition” (McCallister, 2013). 

So what is self-efficacy? The textbook definition of self-efficacy is: “one’s belief about one’s ability to perform behaviors that should lead to expected outcomes” (Weiten, 2004). Basically, when it comes to pain, self-efficacy is the belief that you can manage the pain and continue living your life. Self-efficacy is essential to overcoming the effects that pain can have on everyday life. When people truly believe that they can do the things that are important to them and enjoy activities despite pain, they are well on their way to reclaiming their lives.

The great news is that health care providers can help people develop self-efficacy. One way is through information, as we described above. As Sandy Hilton explained, “when a person isn't afraid they are going to hurt themselves it allows them to act with more self-efficacy” (Hilton & Blickenstaff, 2015). So health care providers can encourage people to build self-efficacy by providing information about what movements and activities are safe to try. Once the person begins to try things and have success with them, the feeling of “I can do this” is reinforced.

Health care providers can also enhance self-efficacy simply by choosing their language and focus carefully. Sandy Hilton described this as “looking for opportunities instead of dysfunction in the way we describe things with patients.” By keeping our language ability-focused rather than impairment-focused, we emphasize people’s strengths, and reinforce that they can use these strengths to their advantage in managing pain (Hilton & Blickenstaff, 2015).

If you are a person in pain, look for health care providers who encourage and support you to develop your own strengths and abilities in managing your condition. Also, keep an eye out for ways to foster this empowerment in your own life. 

3. Re-introduce movements and activities: Gradually taking activities back from the thief 

Re-introducing movements that have become worrisome is basically hypothesis testing and rewiring the connections in the brain. In a way it is creating that sense of safety for the body to progress. It is saying “You know that big, bad thing you're afraid of? Well maybe it just isn’t so scary as you think. Maybe you can deal with it.”  There are different ways to create that sense of safety so there is room to increase activities, but today we are specifically going to look at graded exposure. This part of our post will be geared more toward clinicians, as it will be detailed about the specific therapy approaches. Through graded exposure the hypothesis of “If I do this movement, then I will cause pain or harm” is being tested. 

It’s important to note that graded exposure is different from graded activity. Both have a role in pain management, but graded exposure specifically has a role in looking at fear avoidance behaviour. Graded activity is where you choose one specific action, and gradually increase the difficulty level (intensity, duration, speed, etc) to increase your ability (strength, coordination, and skill). Graded exposure is where you look at the activities you’ve avoided because of fear of pain, and work from the “least scary” task to the “most scary”, to increase your confidence. 

For example, if you’ve been avoiding carrying groceries in from the car, graded activity would be starting with a box of cereal, then gradually building up to heavier grocery items. The goal would be to build up muscle strength so you can physically carry all the necessary groceries. Graded exposure addresses the emotional and psychological side more than the physical side. For example, if your specific fear is that carrying the groceries will result in injuring yourself further, being in excruciating pain, or not being able to go to work the next day, etc, then graded exposure addresses this fear. In graded exposure, you are not necessarily grading the specific activity, but grading which activities you’ll try, in what order. You would grade the exposure by starting with tasks that cause less anxiety and working up to tasks that have more fear attached to them. 

You might ask - what if my fear is a worsening of pain, and the fear comes true? Prior to beginning graded exposure, the clinician would help the client develop strategies for addressing these situations. Then, even if the hypothesis is proven true, the client is able to cope, and confidence still builds. We would also anticipate that often the consequence may not be as severe as the client fears (for example, if the client fears they will “break their back” lifting the groceries, the reality is they may find their pain increases temporarily, but they are extremely unlikely to actually fracture a vertebra).

When we first starting learning about graded exposure, we both wondered “why would anyone ever want to do this? It sounds awful and hard”. We’ve learned that the motivation for this particular method of re-introducing movements and activities often comes when people recognize that fear is affecting what they’re able to do, and they want to take back the control. This approach is also different from “flooding”, which is what some people associate with exposure therapy. In flooding, people do things no normal person would do - like climbing in dumpsters if they are afraid of germs. Instead, this approach focuses on realistic everyday activities. 

When deciding what activities to start with and what order to try activities it is critical to choose an activity that is both physically doable and emotionally achievable, and this is where the health care provider’s expertise and encouragement come in. The first consideration is the safety of the task, and whether the person believes it is safe. The second consideration is how realistic the task is - it has to be a task that the client can achieve. By starting with something that is achievable it creates that confidence and momentum to continue forward. Together both of these mean start small. Start with something that is just a tiny bit scary. Don’t give a grade one kid the New York Times and expect them to love reading. Instead you start with books that are at their reading level and gradually build up, and one day they just might grow up to be someone who loves the New York Times. 

All these tools work together 

To summarize, we will return to the example of the gentleman with back pain from our previous two posts. He was able to find success in regaining activities because of the combination of tools that met his individual needs. His doctor began by establishing trust and a working relationship. Then the doctor provided education on back pain and how “hurt does not always equal harm”, and movement can actually help improve symptoms. Next the doctor focused on building his self-efficacy by empowering him to realize that the tools he needed were within his reach. Then they discussed specific movements and activities that he had become hesitant about, even though they were important in his life. The doctor helped him understand how to start small in approaching these activities, and how to build on each success. The doctor encouraged him when needed and celebrated with him as he regained these activities. These tools together acted as a shield, protecting the man’s daily activities from the impact of pain. 

Each person’s story is different, and in real life it may not be as simple as a person approaching their doctor and finding straightforward answers about how to implement these tools. It may be a different kind of health care provider, or a whole team of providers who do this. It may not be a linear process, and these are only a few of the many tools that can be used. The pain fear avoidance model does not address all possible factors that might be involved in a person’s pain experience. We’ve simplified it for the purposes of this post. But even though each person’s journey and tools will be different, we hope you have found this overview helpful in beginning to understand how health care providers can support people in reclaiming their lives. 

Acknowledgment:

Diagram by Ashley and Colleen at Reclaiming Life. Graphics used are from Vector Characters.

References

George, S.Z., Fritz, J.M., Bialosky, J.E., & Donald, D.A. (2003). The effect of a fear-avoidance-based physical therapy intervention for patients with acute low back pain: results of a randomized clinical trial. SPINE, Volume 28 (23), 2551-2560.

Hilton, S., Blickenstaff, C. (Physical Therapists). (2015, June 9). Pain science and sensibility Episode 1: Self-efficacy and fear of movement in chronic back pain. [Audio podcast]. Retrieved from http://ptpodcast.com/pain-science-and-sensibility-episode-1-self-efficacy-and-fear-of-movement-in-chronic-back-pain/

McCallister, M.J. (2013). Institute for Chronic Pain Blog: Fear-Avoidance of Pain. Retrieved from http://www.instituteforchronicpain.org/blog/fear-avoidance-pain/ on August 31, 2015.

Weiten, W. (2004). Psychology themes & variations. California: Thomson Wadsworth.

Your Brain is Just Trying to Protect You, Part Two: What Can You Do?

Today we are going to learn about the shield built by our fictional gentleman and his doctor. The tools they used to build this shield consisted of: respecting his body, therapeutic relationship, knowledge, self-efficacy and re-introducing activities. Some of the tools were focused on mitigating the effect of pain and fear on current and future behaviours. They also had tools that were more designed to help them deal with the thief and reclaim the activities that he had already taken. Their goal wasn’t to relieve all the pain, but instead to reclaim his life by putting him back in charge.

It’s important to note that none of these tools work as well in isolation as they do together. And that not every person will benefit from every tool. Rainville et al. (2011) talked about how there are multiple factors behind fear avoidance behaviour. There is misinformation (e.g. I will do harm because someone said so), learned behaviour (e.g. this hurt, so I avoid it), and emotional behaviour (e.g. fear driven). Recognizing these factors can give a good starting point to identify which tools may be most helpful.

The Tools

1.)  Respecting your body: Permission to not be okay

So often it is easy to fall into the “I shouldn’t feel like this” mentality. A good first step is to allow yourself the courtesy to respect whatever you are feeling. Part of this is simply acknowledging these concerns and fears. It’s respecting the fact that pain avoidance is a logical reaction and that it’s not a sign of weakness. Recently we both attended Bronnie Lennox-Thompson’s course on Graded Exposure for Pain Avoidance. One of the things she said during the course that really resonated with us was the idea of creating space for the fear around the task and doing it anyways. The goal isn’t to logic away the fear or ignore it but rather to acknowledge it and respect that it is there. It’s something that happened with the injury that you have to treat just as you do the physical symptoms.

2.) Therapeutic Relationship: Meet people where they are

The creation of a relationship between the practitioner and client is one of the first things that happens when a person seeks treatment. This relationship can have a huge impact on the outcome. Because it is so important we think it is worth it to step back and examine this relationship for a moment. If you’re reading this as a health care provider hopefully the explanation of this tool will give you a basis for understanding the importance of how you interact with clients. If you’re reading this as a person in pain or a family member, this can help you understand why it’s beneficial for you to find health care providers who really connect with you.

There are many factors that go into creating a strong therapeutic relationship. The way these factors interact may depend on the two people involved. One if the key factors that is common across situations is the idea of validating the person’s experience; allowing the client to have a voice and be heard and to feel safe expressing their experience, questions and concerns.   Pain is often a sensitive issue and like any “invisible illness” people can often feel judged. People in pain may be bombarded with societal messages such as “your pain is not real” or “suck it up and deal with it.” They might come feeling like they have to defend the pain or justify their behaviour.  They really need to know that their health care provider believes them and is on their side. They need to be able to trust that their concerns are valued, and that their questions won’t be minimized. A supportive health care provider will look for the reason behind the concerns a patient decides to voice.

The person in pain also needs to know and trust that the health care provider knows what they’re talking about. A client once told a therapist “you’re like a friend who comes, but is full of knowledge.” Having this type of therapeutic relationship can be the starting point that all the other tools build on. A study on therapeutic alliance  in the context of treating lower back pain suggested that “factors related to the therapist seemed to be as important as the therapy in pain modulation, and their interaction may produce substantive clinical benefits”. The authors of the study went further to say” The effect of accepted interventions can be improved when clinicians interact positively with their patients” (Fuentes et al). A good relationship is key to allowing any of the next tools to be effective.

Up Next

The two tools discussed in this post (respecting the body and therapeutic relationship) are the foundation for the other tools we will discuss. Next post, we’ll go into detail about knowledge, self-efficacy, and re-introducing movements. We hope this overview will be helpful to you as you begin to build a shield with your own tools.

Acknowledgements

Diagram by Ashley and Colleen at Reclaiming Life. Graphics from Freepik.com (man, grocery basket, doctor, shield).

References

Fuentes, J., Armijo-Olivo, S., Funabashi, M., Miciak, M., Dick, B., Warren, S….Gross, D.P., (2014). Enhanced Therapeutic Alliance Modulates Pain Intensity and Muscle Pain Sensitivity in Patients With Chronic Low Back Pain: An Experimental Controlled Study. Physical Therapy, 94(4), 477-489.

Rainville, J., Smetts, R.J.E.M., Bendix, T., Tveito, T.H., Poiraudeau, S., & Indahl, A.J., (2011). Fear-avoidance beliefs and pain avoidance in low back pain. The Spine Journal, 11, 895-903.

Your Brain is Trying to Protect You: Part One

Did you ever touch a hot stove as a kid? It hurt, right? Hopefully you were leery about touching a hot stove after that, and learned that touching the stove when it's on leads to pain and should be avoided. 

The fact that you learned to avoid a hot stove is your brain at work protecting you. Likely you got the message after only one time, and didn't have to repeat that lesson over and over to learn not to touch that hot stove. Rick Hanson, a psychologist, talks about how we are wired to register negative experiences more quickly than pleasurable ones. He explains that for our survival it is more important for us to register that a certain insect bite can be fatal to a person than that the flowers beside us smell nice (Hanson, 2013).

So when your brain learns (very quickly) that a certain movement or situation causes pain, it becomes cautious. Avoiding things that are painful helps us survive and helps us know what parts need rest so they can heal. 

This is great.....until it becomes a problem.

The problem comes in when this "what is harmful" map becomes outdated or overgeneralized and begins to steal activities from us. Sometimes injuries can heal, but when you move that part of your body, your brain still says "Bad news, Bad news! What are you doing?" Your brain can become hypersensitive to that part of your body, so any message from that area becomes an alarm.

Your brain can also begin to generalize and gradually become sensitive to more and more movements and situations over time. That insect that was dangerous, so maybe all insects that look similar are dangerous too, and your brain learns to avoid those. If your brain takes this even further, then maybe the field you were in when you encountered that insect is dangerous. Maybe all fields are dangerous. Maybe simply going outside is dangerous. 

We're not saying the pain isn't real or the fear isn't justified. However, sometimes this protective mechanism can began to limit activities. An example of this process could be a person with chronic back pain that began after an injury from helping a friend move. The injury began by lifting very large objects in a way that caused tissue damage. Later it turned into chronic pain. The person could become reluctant to help anyone move after that. This probably won’t have a huge impact on the person’s day to day functioning, because this situation doesn’t occur frequently, and there are usually other options. The disruption to daily life comes if the same emotional reaction gets applied to similar situations that do occur frequently. For example, maybe the person notices that even lifting smaller objects like groceries now increases his pain. Or lifting his children or grandchildren. Or maybe he has a job that involves lifting and carrying, and he is now afraid of how his work will impact his pain (and vice versa). 

There are other valid reasons he may feel afraid to move. He may have been told by a well-meaning health care provider to avoid certain movements. He may have heard the idea that bed rest is the best thing for a back injury (an old way of thinking, but still believed by many people) (National Institute of Neurological Disorders and Stroke, 2014). He may have been told over and over that pain always equals harm, so he may be afraid of doing more damage to his body. 

As his brain tries to protect him, this can translate into an emotional reaction. Where at first he was cautious, he may become anxious or fearful. Frustration occurs when pain and the fear of pain limits movements. If it is limiting activities that aren’t important to him, it’s not a problem. The problem comes when it affects movements that ARE important.  

In healthcare talk it’s about the pain related fear and avoidance model. At its root this is where the fear of creating or worsening pain causes a person to avoid certain activities or situations. Pain avoidance has received a bit of a negative reputation, but if you look a little deeper it is just one of your body’s ways of trying to keep you safe; it has its roots in protective behaviour. It’s a totally normal and logical process.  It is not a character flaw or a weakness. So instead of feeling like pain avoidance is a “negative” give yourself (or your client) a pat on the back, your brain is just doing its job.

If the way your brain does that job is becoming problematic for your life, then it’s time to make a decision about whether you want to change it.  As a physiotherapist we know would love to say “acknowledgement is 50% of the solution”. In order to reclaim parts of your life, it can be helpful to examine the reasons and thoughts behind avoiding certain movements and activities. As you examine those, you can learn the difference between avoidance that is helpful to healing and fear that is disruptive for your life. If you are a health care provider, it’s essential to talk with your clients and find out their perspective on how avoidance is affecting them. Then you can empower them by tailoring your approach and utilizing individualized strategies that will help them live the life they want to live. “If you can learn about [avoidance], and acknowledge it when it occurs, then you can begin to challenge it and change it. It’s not an exaggeration to say that overcoming fear-avoidance is essential if you want to self-manage pain successfully. It’s really that important” (McAllister, 2103).

Please join us next time as we look at some of the ways we can begin to challenge and change these behaviours.

Acknowledgment:

Diagram by Ashley and Colleen at Reclaiming Life. Graphics used are from Freepik.com (background, man lifting boxes, hurt and anxious man, thief, superhero, light bulb and shield).  

References:

Hanson, Rick. [The Rush on Shaw TV].  (2013). Interview with Neuropsychologist - Dr Rick Hanson.

[Video file]. Retrieved from https://www.youtube.com/watch?v=9gK9DyvWuGA&feature=youtu.be on September 5, 2015.

McCallister, M.J. (2013). Institute for Chronic Pain Blog: Fear-Avoidance of Pain. Retrieved from http://www.instituteforchronicpain.org/blog/fear-avoidance-pain/ on August 31, 2015.

National Institute of Neurological Disorders and Stroke. (2014). Low Back Pain [Brochure]. Bethesda, Maryland: National Institutes of Health Department of Health and Human Services. Retrieved from http://www.ninds.nih.gov/disorders/backpain/low-back-pain-brochure.pdf on September 5, 2105. 

Spoon Theory

No online discussion of a chronic condition would be complete without including the spoon theory. The spoon theory is widely shared on the internet, probably because so many people can relate to it. It was written by Christine Miserandino of butyoudontlooksick.com. She is a woman with Lupus, but her words apply to many chronic conditions. From our perspective, this explanation applies very well to chronic pain and the associated fatigue.

We may not do it justice if we try to summarize it, so before you read any further, please read the original spoon theory explanation here or have a listen to the author here.  This theory creates a common language for people in pain and their supporters to understand the impact of pain and fatigue on everyday life. Please take a moment to review it, then don't forget to come back and read our perspective.

Basically spoon theory is about having a limited amount of energy and endurance, and having to make hard choices every day about how to use it. Think back to the last time you felt under the weather, things like getting dressed and cooking seemed extra hard.  With a chronic condition everything takes more energy. On top of this pain takes energy, so it’s a double hit. Things you didn't even have to think about before having a chronic condition, become very effortful. Even “simple” things like having a shower or visiting with a friend can take up a huge percentage of your daily energy.  Before having a chronic condition, you may have been able to go about your day knowing that even if you were tired, you would have enough energy to get through everything. With a chronic condition, life becomes a giant balancing act. You have to juggle your basic needs and responsibilities with others’ expectations and activities you would like to do. This juggling act often includes multiple days at the same time. Questions such as: “If I go out today with a friend, while I be able to go grocery shopping tomorrow?” or “if I shower now, will I have enough energy to get ready after?” become a constant thought.

Spoon theory is a way of taking an abstract thought (such as "I need to decide wisely where I spend my energy”) and making it concrete so people can understand. It helps explain the concept to people who have never had to make hard decisions about daily tasks. Activities cost “spoons” and one has to decide how their going to spend their spoons for the day. If loved ones read and understand this, it can help simplify communication. Instead of having to say "I can't do that right now" (which might feel like you're letting them down), you can simply say "I don't have enough spoons for that."

To put spoon theory into occupational therapy terms, it's all about pacing and energy conservation. It's about respecting yourself and your body enough to realize you don't have an endless supply of "spoons," and that's okay. You can plan your activities throughout the day to maximize your use of the "spoons" you have (pacing). You can also think about the way you do tasks, to reduce the amount of "spoons" they take (energy conservation).

The ideas behind this spoon theory has helped both of us begin to reclaim our lives. The great thing about spoon theory is it helps you understand that you are not completely powerless. By understanding how much energy things cost, you can use it to help stop the cycle of pushing and crashing. You can learn ways to lower the cost of activities and develop strategies that will give you more spoons. Choices can be made about how to spend your resources. You can learn to recognize how many spoons you have available on a given day and how the cost of activities changes from day to day. You can borrow spoons from following days or save spoons from previous days. You can decide what tasks are the most important and what tasks would be a bonus. 

For example, consider a man with fibromyalgia, who wanted to spend a day at the zoo with his wife and young children. He knew the zoo could be an exhausting and over-stimulating place to be with children, even for someone without a chronic condition. For him, the zoo could be a near impossible venture because of his pain and fatigue. But because of his understanding of pacing and energy conservation (spoon theory), he was able to not only go, but enjoy the day. He and his wife used every strategy they had to plan this day to be successful. They planned the zoo trip for a Monday, but kept Tuesday as a back-up plan in case of unforeseen circumstances like weather changes or a flare-up of symptoms. They also planned for the next day to be a rest day, so he could recover. That Sunday, he rested and saved his spoons. When Monday came, he (fortunately) felt up to the trip. He rented a scooter at the zoo to reduce the number of spoons he would need. He and his wife had no expectation of seeing every exhibit, and just decided they would enjoy the day and see what they could. When he needed a break, his wife took the kids on a ride and he rested. After the trip, he and his wife both knew he had used his spoons, and respected his body’s need for recovery. She took over the childcare and supported him in getting the rest he needed. 

Understanding spoon theory doesn’t 100% guarantee success. Both the man and his wife were aware of the risk of a flare up. But by using the strategies they’ve developed they were able to set the stage for an enjoyable day. They had learned not to take the simple pleasures of life for granted, and they were both grateful that they were able to experience a memorable family outing.

One common feeling that can come with pain or any chronic condition is a sense of powerlessness. By using strategies to maximize your spoons and being patient with what you have, you regain some sense of control. Through this process, you can respect your body’s needs without letting pain make all the decisions. We hope this helps you create the freedom needed to do what matters most. 

Acknowledgements:

Graphic designed using Tagxedo at http://www.tagxedo.com/

References:

Miserandino, C. (2003). The Spoon Theory. Retrieved from http://www.butyoudontlooksick.com on August 21, 2015.

What is Pain? Part Two: The Pain Alarm

Believe it or not, pain is very useful.  It is a wonderful thing that our bodies are capable of feeling pain. Acute pain is protective, needed, and serves a purpose. Imagine a toddler exploring the world without pain - that child would sustain an unbelievable number of injuries while experimenting with different ways of moving, with no indication that any of these movements could be dangerous. The protective nature of pain can also be seen with conditions that affect sensation, such as leprosy, diabetes, and quadriplegia. In these conditions there is a loss of protective sensation that can result in serious injuries and wounds. The following diagram is a simplified version of what happens in the body and brain when pain is experienced. The painful stimulus is recognized and our body reacts in order to protect itself.

However, there can come a point where pain stops being useful,and it turns into something far less helpful, and even insidious. Chronic pain is pain that is no longer protective. Sometimes chronic pain may be linked to actual damage in the body, such as in conditions like arthritis or cancer. Other times, there may be no obvious physical reason for the pain to persist “If acute pain is Dr. Jekyll, then chronic pain is Mr. Hyde. It is the body’s alarm system gone amok.” (Richeimer, 2014, p.2)

Another way to think of it is that acute pain is like a fire alarm, loudly informing you that there is a problem that needs to be addressed immediately. Chronic pain is like the fire alarm is malfunctioning - sounding regardless of whether there is a fire, or continuing to alarm long after the fire has been put out (Thernstrom, 2010). Even though this alarm is not signaling immediate danger, it is very real and can be so loud and overwhelming that it leaves you unable to function or focus on anything else. It can be undeniably disruptive to everyday life. There are many theories to explain why the alarm may become dysfunctional. This diagram demonstrates a few of them.

Unfortunately, chronic pain isn’t as easy to “fix” as a broken alarm would be. For a broken fire alarm, you would simply unplug it, or call a repair technician.  If chronic pain is telling us our system is out of whack, we need to figure out why and then work to solve it, which is no easy task! To fix the misfiring alarm you may need a team of “repair technicians” - a physician, pharmacist, physiotherapist, occupational therapist, psychologist, and other team members. Even with all these people on your side it is still possible that there will be no way to silence the alarm. Managing chronic pain is like reducing the volume on the alarm and learning how to function while it’s still sounding.

We firmly believe this is possible and achievable. Chronic pain changes life, but it doesn’t have to define it. There are no overnight solutions, but there are a variety of strategies that can lessen pain symptoms and improve the ability of an individual and their family to function. What are your strategies? What has worked (or not worked) for you? Please feel free to share your thoughts with us through the comments below or email us. We look forward to discussing these in future posts.

Thank-you for. coming along on our journey as we work on fixing the broken alarms in our own lives. We hope this blog can create a community where we can inspire each other to live the best possible versions of our lives. 

Acknowledgements

Diagrams by Reclaiming Life. Brain graphic from Freepik.com

References

Richeimer, S. (2014) Confronting Chronic Pain. Baltimore, Maryland: John Hopkins Press.

Thernstrom, M. (2010) The Pain Chronicles: Cures, Myths, Mysteries, Prayers, Diaries, Brain Scans, Healing, and the Science of Suffering. New York: Farrar, Straus, and Giroux.

What is Pain? Part One: Defining Pain

What is pain? It sounds like a simple question, but we challenge you to take a moment to try and define it before continuing to read.  

It’s difficult to do without simply using synonyms (eg. “something that hurts”). It’s also difficult to come up with a definition that includes all types of pain, from the annoying sensation of a paper cut to the overwhelming pain of childbirth, from the sudden, sharp pain of a needle to the dull, aching pain of a strained muscle. There are countless sensations and experiences that can all be described as pain. None of us has any way of truly understanding what another person is feeling when they say they have pain. Perhaps this is one of the reasons there are so many stereotypes and misconceptions about pain. We think it’s very important to define pain, for two reasons: First, for a person experiencing pain, defining it can be the first step in understanding and managing it. Second, for friends and family, a basic comprehension may enable them to be more empathetic and supportive.

We asked for your help in defining pain, and here are some of the comments we received:

• Pain is discomfort that can occur at infinite levels of intensity (not just a scale of 1-10 like your doctor says).
• Burning, stabbing, achy. Exhausting, draining, overwhelming.
• Chronic pain is tiresome; it doesn't leave you alone despite all your efforts to make it go away.
• Pain is a feeling that interrupts something you may want to do. As it intensifies, it becomes all you can think about and you become obsessed with finding ways to relieve it so you can get back to your regular life routine.
• Pain can be dull or sharp. It can feel like a knife, like being bludgeoned with a club, or being burned anywhere and everywhere. As shallow as your skin or as deep as your bones; it can debilitate your body, distract your mind, detract you from your goals/dreams, and overwhelm your senses.
• All of us experience pain in one form or another every day of our lives. Pain varies from the insignificant and fleeting experience of stubbing a toe to the gnawing and persistent pain of an abscessed tooth and the intolerable, totally absorbing, and endless type accompanying chronic diseases. We know the pain from a stubbed toe will pass and soon be forgotten. The toothache, too, is usually quickly remedied with penicillin or sulfur based drugs and a dental procedure. The pain of chronic diseases is the tiger let loose. It is only marginally controllable and its lifespan, completely undeterminable.
• Pain hurts and affects everything. If I don't react how you think I should, please blame the pain, not me, or you.

You can see how there are many different ways to define pain and the impact it has on life. Each of these comments adds more clarity and a more complete understanding of the experience of pain. There are a few more definitions of pain that we’d like to share with you. These definitions seem to be very widely used and accepted. Like your comments, each of these definitions adds an essential piece to the puzzle:

• “an unpleasant sensory and emotional experience associated with actual or potential damage” (Merskey & Bogduk 1994).
• “pain is produced by the brain when it perceives that danger to body tissue exists and that action is required” (Moseley 2003)
• “Pain is whatever the experiencing person says it is, existing whenever the experiencing person say it does” (McCaffrey and Beebe, 1989)

However, even with all these definitions together, there are still parts of the pain experience that remain unexplained. One reason it is so difficult to understand another person’s pain experience is because there are so many individual factors affecting it. One factor is our mood, as “pain viewed with stress, depression or anxiety is felt more strongly than pain experienced when you are hopeful, upbeat or encouraged” (Richeimer, 2014, p.16). Social factors also affect the pain experience. For example, boys may grow up believing it is unacceptable to cry in front of others (or at all). Even though boys and girls can have the same injuries, they may experience that injury differently because of the messages society has given them. Pain is also affected by previous experiences. For example, Ashley had a family member who had two herniated discs, who was is in excruciating pain and had emergency surgery. Less than 24 hours later,the nurse caring for him was astonished that he didn’t want any pain medication. She asked “Doesn’t your incision hurt?” and he responded “A little, I guess. But it just feels so good not to have the herniated discs anymore.” His experience clearly affected his perception of post-operative pain.There are many other factors at play in our bodies and environment. This graphic demonstrates some of them.

Adding to the complexity of pain is the fact that something so unpleasant is actually very much needed. Our next post will explain why and address the differences between acute and chronic pain. For now, we hope this post has brought some clarity and understanding. If you are experiencing pain, you are not alone. Pain is part of the human condition that we will all experience in some form or another throughout our lives. Understanding it is just the beginning.

Acknowledgements

A special thank you to everyone who provided their definition of pain.
Pain Experience graphic by Reclaiming Life. Brain graphic (center) from Freepik.com

References

McCaffery, M., Beebe, A., 1989. Pain : clinical manual for nursing practice. C.V. Mosby, St. Louis.

Merskey H, Bogduk N. 1994. Classification of chronic pain. IASP Press, Seattle

Moseley, G.L. 2003. A pain neuromatrix approach to patients with chronic pain. Manual Therapy, 8(3), 130-140.

Richeimer, S. (2014). Confronting Chronic Pain. Baltimore, Maryland: John Hopkins Press.