Pain and injury

Pain and injuryPain and injury are poorly related. Unfortunately most of society continues to believe in a stimulus-response relationship between these factors, but in reality it does not exist. This was raised by Pat Wall in his classic 1979 article entitled ‘On the relation of injury to pain’.

Since then we have learned an enormous amount about pain; what it is and the purpose it serves. Why should the relationship between pain and injury be so unreliable? The answer is because pain is contextual, motivating appropriate action for that moment depending upon a range of factors. These include the injury itself and what it means, prior experience, beliefs about pain, the environment, who is there, how one is feeling before and at the point of injury and what is going on at the time. Here are some examples:

* a carpenter hitting his thumb with a hammer — despite the fact it will hurt, this is not unexpected, an occupational hazard if you will, and soon dismissed.

* an electrician electrocuting himself — similar to the carpenter; the context is key

* spraining an ankle in a cup final — there are many reports of injuries being sustained whilst playing sport that are not painful at the time, because playing on is more important

* battle hospital reports — severe injuries but no pain initially; the same in many accident and emergency reports

* a concert violinist who cuts his left index finger the day before his most important gig — what do you think this experience could be like versus a chef?

These examples demonstrate the variability in lived experience despite the biology of healing being similar (effectiveness may vary depending upon existing and prior health) — the two lives, that of our biology and that of our lived experience. The clinician’s role is to marry the two for the person so that they understand the hows and whys before focusing on what needs to be done to get better.

When my knee hurts, or any other body area, the vast majority of the biology that is involved resides elsewhere. Pain is located to my knee, although I can’t possibly know from where exactly; where is the stimulus? Yet to feel pain in my knee I need the systems that protect me to detect certain sensory activity, predict that the causes are threatening and then translate this to a sensation that is pain; i.e./ the biology becomes ‘conscious’. Whilst there are signals from the knee to the spinal cord and onwards, this is not necessary for us to feel pain. Think about phantom limb pain.

There are many levels whereby signals and predictions are modulated until the most credible prediction emerges as a lived experience. This is why prior experience, beliefs, emotional state and our thinking play such a role in pain as all can modulate the meaning and level of perception of threat.

An analogy is watching a film at the cinema. The film is on the screen yet for this to happen and be experienced, there must be a projector, electricity into the projector, and this electricity comes from the grid. Most of the necessary elements are not where you watch the film. The same can be said of pain, when it is made up of many non-pain factors that come together to create that lived experience. The point there is that when we address these in a comprehensive treatment and training programme, we can change pain and get better. But to do this we must think beyond the structure (the cinema screen) and consider the person, their beliefs, their thinking, their lived experience, the phenomena of their life, in order to be successful, which we can.

Pain is not related well to injury, but instead to the level of predicted threat.

Pain Coach Programme for persistent pain | t. 07518 445493


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