Pain don’t hurt.

                                  – Dalton, Roadhouse

Steel is an incredible metal.  It is both tough and resilient.  A material’s ability to absorb energy when deformed elastically and then to return it when unloaded is called resilience.  Soldiers, particularly today’s elite warriors, also need steel-like resilience.  They must undergo grueling physical training to build strength and endurance as well as a tolerance to pain.  They must also undergo psychological training to learn to control their attention and to direct it to what is relevant for survival.  The training helps them to test their limits, and then to push through physical and mental barriers to accomplish real, not Hollywood, impossible missions, and to learn what Robin Rosenberg calls “emotional self-regulation,” or what he describes as “how to act in planned, intentional ways, not impulsively…how to regulate their emotions when their buttons get pushed.”
One of the key parts of the psychological training of elite soldiers is learning how to redirect their attention from pain.  “They are amazingly able to focus their attention to the problem at hand,” Rosenberg says, “momentarily diminishing the threat of the situation so that negative emotions don’t spiral out of control and interfere with the mission.”  They learn how to distract themselves from negative stimuli, or better yet, how to sort out relevant from irrelevant negative stimuli.
H.K. Beecher, a physician who served with the US Army during the Second World War, suspected that some individuals could manage pain more effectively than others.  He observed in “Pain In Men Wounded In Battle” that as many as three-quarters of badly wounded soldiers reported no-to-moderate pain, and that they refused pain relief medication. Beecher noted that these were not trivial injuries, but consisted of compound fractures and penetrating wounds.   Beecher concluded that some men seemingly had the ability to block pain.
What is Pain?

Today’s martial artists and combatives instructors could learn a thing or two from this knowledge.  Much of self defense training is built around two major principles:  (1)  Avoiding our own pain, while (2) generating pain in others. In fact many modern combat specialists train in specific “pain compliance” techniques.  Richard Nance, law enforcement defensive tactics instructor, defines these techniques as “either manipulating a person’s joints or activating certain pressure points to create sufficient pain to achieve compliance (to verbal commands).”  A more thorough knowledge about pain is important in pain management techniques as well as understanding an individual’s response to pain.


Pain is good because it’s bad,” says Dr. Anne Louise Oaklander, a pain specialist at Massachusetts General Hospital. “And it’s the badness, the unpleasantness, the horrible emotions that are evoked when we feel pain that make it work so well.”
One of the main problems that people experience when they feel pain,” says martial arts instructor John Moore, “is that they complain about it. They complain to others, and they complain internally to themselves. ‘Oh man this hurts, I can’t believe this.’ The issue with this is that we create this vicious cycle of emotion where we get more and more upset – to sustain this – the mind amplifies the pain experience. They also project the mind into the past (memory) and future (imagination) to add energy to their emotions. This can descend into a serious state of self-pity, a very low level form of grief that taints everything we experience.”
Moore may be right.  According to A. D. Craig, pain researchers now understand that there are specific pain centers in the brain, which have apparently evolved from a primitive system that controls physiology, or the health of the body.  “The overlap between these areas and emotion-processing regions of the brain could explain the peculiarly human subjective qualities of pain,” says Craig.  “There is evidence that different feelings of pain have their own specially adapted pathways to the brain.  (Thus) pain can then be seen as a specific homeostatic response consisting of a distinct ‘physical’ sensation and an ’emotional’ component.”
The experience of pain depends not only on sensory signals coming in, but on your emotional state and how you interpret those signals,” says researcher Tor Wager, who proposes that “pain is a psychologically constructed experience.”
Pain in Margaritaville

In Jimmy Buffett’s song, ‘Margaritaville,’ Jimmy sings, “I blew out my flip-flop, stepped on a pop-top, cut my heel had to cruise on back home.”  But what exactly happens when you’re walking along the beach and suddenly step on a pop top?  First, there are special pain receptors called nociceptors which spring into action whenever there has been an injury, or even a potential injury, such as breaking the skin.  “Pain,” according to Ossipov, Dussor, and Porreca, “results from activation of sensory receptors specialized to detect actual or impending tissue damage.”  So even if the skin is not broken, explains Erica Jacques, “the tissues in the foot become compressed enough to cause the nociceptors to fire off a response.  Now, an impulse is heading through the nerve into the spinal cord, and eventually all the way to your brain. This happens within fractions of a second.”  The spinal cord, a complex bundle of nerves, is a superhighway for nerve signals traveling seemingly at almost light speed to and from the brain.  “But your spinal cord, Jacques says, “does more than act as a message center:  It can make some basic decisions on its own. These ‘decisions’ are called ‘reflexes.'”  The foot moves quickly, without a lot of thinking involved, from the immediate source of pain.

Jacques describes an area of the spinal cord, called the dorsal horn, which acts as an information clearing house, directing impulses to the brain and back down the spinal cord to the specific area of injury.  “The brain does not have to tell your foot to move away from the rock, because the dorsal horn has already sent that message. If your brain is the body’s CEO, then the spinal cord is middle management.”But taking your foot off the pop top is not all there is to it, because pain is more than simply stimulus and response.  The spinal reflex may take place at the dorsal horn causing the quick reaction of moving the foot, but the pain signal continues to travel on to the brain.  Jacques says that several things happen.  “No matter how mild the damage, the tissues in your foot still need to be healed. In addition, your brain needs to make sense of what has happened.  Pain gets cataloged in the brain’s library, and emotions become associated with stepping on that rock.”  Different parts of the brain are involved with this process…the thalamus gets involved so that the pain is more completely interpreted.  The cortex is engaged to learn where the pain came from and to compare and contrast it to other sensations already stored in the pain catalog.
What Does Pain Look Like?
In an incredible NY Times article, “My Pain, My Brain,” Melanie Thernstrom looks at some new breakthrough pain management techniques at Standford University, called “real-time functional neuro-imaging,”  that actually allows subjects to see computer enhanced images of their own brain activity while feeling pain for the purpose of trying to change brain activity and thus control their pain.
This real-time process shows colorful images of brain activation of the parts of the brain which are involved in pain perception.  Subjects, over a matter of weeks and several sessions, can learn how to increase or decrease their pain while watching this activation.  The process is similar to early, indirect biofeedback exercises, but is more specific.  According to Dr. Sean Mackey, the study’s senior investigator, this new approach allows subjects to interact with the brain itself.  “We are doing something that people have wanted to do for thousands of years. Descartes said, ‘I think, therefore I am.’ Now we’re watching that process as it unfolds.”
The study has begun to show that there is not just one, single pain center in the brain.  Instead it appears that pain is a complex, adaptive network which may involve as many as 5-10 areas of the brain.  This ‘pain matrix’ has been described as “a collection of brain regions that are involved in neurological functions, including cognition, emotion, motivation, and sensation as well as pain.” (Ossipov, Dussor, and Porreca)

Turn it Up, Turn It Off

Soldiers, athletes, martyrs and pilgrims engage in battles, athletic feats or acts of devotion, Thernstrom says, “without being distracted by the pain of injuries.”  This is due to the mind/body’s pain-modulatory system.  The sensation of pain is highly variable between individuals.  Sensory input to the body’s central nervous system can be modulated or inhibited.  One’s “emotional state, degree of anxiety, attention and distraction, past experiences, memories, and many other factors can either enhance or diminish the pain experience.” (Ossipov, Dussor, and Porreca)
Thernstrom recounts the story of when the teenage surfer Bethany Hamilton’s arm was bitten off by a shark:  She felt pressure, but she didn’t feel any pain.  Hamilton later described the terrible incident, saying, “I’m really lucky, because if I felt pain, things might not have gone as well.”  Perhaps this is why the modulatory system evolved, Thernstrom surmises, “if she had thrashed about in pain, she would have bled until she drowned.”
There is an interesting irony to pain,” comments Christopher deCharms, who, Thernstrom says, worked with Mackey in designing and carrying out the Stanford study.  “Everyone is born with a system designed to turn off pain. There isn’t an obvious mechanism to turn off other diseases…with pain, the system is there, but we don’t have control over the dial.”
A “system designed to turn off pain”–what a great description of the pain-modulatory system. This system uses endogenous endorphins, opiate-like substances, to shut down pain.  The system even sometimes works when placebos are administered.  When the brain believes that pain relief has been provided, even when it hasn’t, (i.e., the placebo effect–what the Skeptic’s Dictionary defines as “the measurable, observable, or felt improvement in health or behavior not attributable to a medication or invasive treatment that has been administered“), the pain-modulatory system is activated and endorphins are released.  “Activity in some pain-sensitive regions did not drop when placebos relieved pain,” observes researcher Daniel Kane. “This result strengthens the idea that placebos do not block the body’s sensory features that transmit pain from the skin to the brain. Instead, the brain modulates its interpretation of those signals.”
However, you can also turn up the pain.  Just as there is a placebo effect, there is also a “nocebo effect” which is just the opposite..  When patients expect a treatment that they are led to believe will enhance pain; i.e., “when subjects were told verbally or nonverbally through the application of conditioning stimuli, or both ways that enhanced pain was to be expected, it was found that expectation of pain resulted in pain to non-painful stimuli as well as enhanced pain in response to noxious stimuli, suggesting that increased pain expectancy activates the pain network.”   (Ossipov, Dussor, and Porreca)
How to Turn It Off
A 2006 study at Wright State University found that deep-breathing relaxation exercises may contribute to one’s ability to manage pain.  Combining deep-breathing, especially abdominal or diaphragmatic/’belly breathing,’ with PMR (Progressive Muscle Relaxation) exercises is recommended as a pain management tool.
Jon Kabat-Zinn, professor emeritus of medicine at the University of Massachusetts, stripped down certain Buddhist meditation practices in the late 70’s and developed a ‘mindfulness’ approach to pain management.  His book Full Catastrophe Living remains one of my favorites and offers some much needed advice to those who lead stressful lives and go on to experience severe body pain.
There are really three dimensions to pain,” Zinn explains, “the physical or sensory component; the emotional, or affective component, how we feel about the sensation; and the cognitive component, the meaning we attribute to our pain.”  Expectations, projections, and fears about the pain compound the stress and exacerbate the pain.
As weird as it sounds, he recommends that we change our relationship to the pain by opening up to it and paying attention to it.  “If you distinguish between pain and suffering, change is possible. As the saying goes, ‘Pain is inevitable; suffering is optional.'”
As an experiment dip your arm in ice water, and at first you can distract yourself, (a story, mental imagery, a mental puzzle), and you can stand the pain.  But eventually the pain becomes too intense.  Mindfulness however might allow you to handle the pain longer.
This may seem a little bit new-agey, and skeptical radars are probably going off all around.  However pain management clinics and doctors specializing in treating pain have been using Zinn’s formula for decades with good results.
Expecting pain to occur or believing that pain will get worse is a self-fulfilling prophecy.  On the other hand distraction and reappraising the pain while focusing on the mission at hand seem to help downplay the pain.  John Moore recommends that we should not mentally judge or put labels on the pain we experience.  “Do not go into a memory or project anything into the future. Slow down your breath…don’t label the feeling, don’t judge it as good or bad.”
Guest Author Ron Goin, P.U.M.A.
[Original post, Feb. 6, 2012. website]

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