Unpalatable truths about pain

Recently I read a blog post about the way “Explain pain” had landed with a group of people in the general public. The point being made was that people found the ideas presented unpalatable. They didn’t agree with the points and they thought the ideas were dismissive of their experience.

Now I am a critic of any recipe-based approach to helping people. I am especially a critic of clinicians using something they’ve picked up on a weekend course, or out of a book, being applied holus bolus to an individual without nuance. There have been outrageous claims made about the effectiveness of giving someone information and reducing their pain – and absolutely no doubt that not experiencing pain reduction for people living with pain who have had this sort of message handed to them is more than a slap in the face.

But…. there are many unpalatable truths about pain that both clinicians and people living with pain find incredibly difficult to swallow. Here are a few I’ve learned over my 30 year career.

1. The amount of HURT experienced doesn’t correlate well with the degree of tissue damage. It’s true that there is a small and complex relationship between tissue damage and pain intensity, but it’s complex! This complexity begins with sex differences in the way humans process nociception, and goes on from there…(Presto et al., 2022)
2. There are two groups of pain disorders for which we have very little to offer for pain reduction. Dammit, we haven’t got good treatments for either neuropathic pain or nociplastic pain right now. We just don’t. No matter what therapy we offer – surgery, pharmcology, neuromodulation, exercise, mindfulness, self management, CBT or ACT – there are a substantial number of people for whom pain treatments are not very effective (Finnerup et al., 2021; Fitzcharles et al., 2021).
3. Women are more sensitive to nociceptive stimuli than men, are far more likely to have chronic pain (by 2:1), have poorer treatment even when presenting with acute pain, and have poorer quality of life than men with pain of the same type (Fitzcharles et al., 2021; Samulowitz et al., 2018; Zhang et al., 2021; Zhang et al., 2021).
4. Emotional state along with appraisals (ie what pain means to us including the diagnostic label given) do influence pain (Yarns et al., 2022; Muller et al., 2022; O’Keeffe et al., 2022). Yes, even in acute pain experimental settings! (Cimpean & David, 2019).
5. Some of our favourite strategies for living with/coping with pain don’t have a lot of evidence for them. Yep, even pacing (even though pacing is assumed to be integral to chronic pain management – Sharpe et al., 2020).
6. While medical practitioners might try to propose a biopsychosocial or multifactorial model of chronic pain, people with such pain don’t like or agree...(Allegretti et al., 2010). I’m not sure if it’s the message or the messenger but there is a huge amount of resistance in the community towards the idea that pain is complicated and a whole person experience.
7. Exercise, while well-studied and with an enormous evidence base, offers small reductions in pain intensity and small reductions in disability, and we still don’t know which form, frequency, intensity, or duration is the best, although there are some ideas (Ferro Moura Franco et al., 2021). It’s worth noting that despite the size of the review by Ferro Moura Franco and colleagues, they found “effect sizes found were generally below the minimal clinically important difference threshold of 20% or 10 mm.” More than this – for many people with pain, sticking to a long-term programme of movement practice is not even considered because the majority of studies ended before 32 weeks. My main criticisms of exercise studies for people living with chronic pain is the poor description of exactly what the exercises consist of, the assumption that because someone can ‘perform’ the exercises they can translate their movements into daily life activities, and the lack of consideration for how people might integrate movement practices into their long-term lifestyles. Seriously, if I was offered a treatment with an effect so small on pain and disability with the amount of effort needed to do it, I’d be pretty reluctant to go there. Except, of course, that I like to move!
8. The way you lift doesn’t really matter. Yep – move in the way that helps you do the job, all things considered, not just ‘biomechanics’ (Saraceni et al., 2020). Think about how you’re feeling (fatigue, concentration), the size and shape and form of the load and especially where you’re going to hold onto it, the reason you want to move it, the other people and things around you, the floor and your footwear, the lighting, distractions… all of these things will influence the way you move and your control over the load. Your back position is probably the least thing you need to think about!
9. Health professionals don’t get very much training in pain – and most of their training is about nociception and the spinal cord with not much dedicated to the brain (Shipton et al., 2018). There is little education given to what pain means to people, how people express that they’re in pain, our human biases in interpreting other peoples’ pain or illness behaviour, and pretty much nothing on contexts and how these influence what people do. Pain is almost exclusively associated with disease – forgetting that many normal everyday humans do things that hurt (just think about running or going to the gym! and then there’s kink and body modification and tattoo….).
10. Living well with pain is possible! (Lennox Thompson et al., 2019). Just don’t say that in an online support group or you may well be told that your pain is ‘not as bad’ as the other participants, even though they’ve just been criticising clinicians who estimate their pain intensity. The irony is real. And saying that medications don’t help (yep, I’ve tried them) only leads to ‘oh but your pain can’t be as bad as mine because I’m on the couch and taking medication X, Y and Z.’ Um…. if my pain doesn’t respond to medications, lying on the couch is only going to make me bored, cranky and STILL SORE!
    

I applaud efforts to be positive about future cures or strategies for reducing pain. I also applaud the idea that we should be positive about approaches such as exercise/movement, mindfulness, ACT, CBT, CFT, pain neuroscience education, pacing and all the other things we offer BUT can we please be honest and humble? People with pain don’t deserve to be disbelieved if they don’t respond to a treatment. Truth is, for so many of us with pain, nothing takes the pain away. This isn’t ‘removing hope’ – it’s about being open, honest and offering the person an opportunity to grieve. You know that ‘sense of closure’ that people talk about when a missing person is found – even if the missing person is dead? People with pain cannot begin to work through a sense of closure and begin to plan for a life alongside pain if clinicians can’t be honest and compassionate enough to let them know that maybe they’ve reached the end of our pain reduction treatment options. And you know what? You don’t need to be a psychologist to help someone grieve for their losses – we do it all the time with other disabilities (think brain injury, stroke, amputation, diabetes, COPD…) but somehow we think psychologists are the only clinicians able to help someone with chronic pain feel sadness and grief. Can we just be humans please?

Allegretti, A., Borkan, J., Reis, S., & Griffiths, F. (2010). Paired interviews of shared experiences around chronic low back pain: Classic mismatch between patients and their doctors. Family Practice, 27(6), 676-683. https://doi.org/http://dx.doi.org/10.1093/fampra/cmq063

Cimpean, A., & David, D. (2019). The mechanisms of pain tolerance and pain-related anxiety in acute pain. Health Psychol Open, 6(2), 2055102919865161. https://doi.org/10.1177/2055102919865161

Ferro Moura Franco, K., Lenoir, D., Dos Santos Franco, Y. R., Jandre Reis, F. J., Nunes Cabral, C. M., & Meeus, M. (2021). Prescription of exercises for the treatment of chronic pain along the continuum of nociplastic pain: A systematic review with meta-analysis. Eur J Pain, 25(1), 51-70. https://doi.org/10.1002/ejp.1666

Finnerup, N. B., Kuner, R., & Jensen, T. S. (2021). Neuropathic Pain: From Mechanisms to Treatment. Physiological Reviews, 101(1), 259-301. https://doi.org/10.1152/physrev.00045.2019

Fitzcharles, M.-A., Cohen, S. P., Clauw, D. J., Littlejohn, G., Usui, C., & Häuser, W. (2021). Nociplastic pain: towards an understanding of prevalent pain conditions. The Lancet, 397(10289), 2098-2110. https://doi.org/10.1016/s0140-6736(21)00392-5

Lennox Thompson, B., Gage, J., & Kirk, R. (2019). Living well with chronic pain: a classical grounded theory. Disability and Rehabilitation, 1-12. https://doi.org/10.1080/09638288.2018.1517195

Muller, R., Segerer, W., Ronca, E., Gemperli, A., Stirnimann, D., Scheel-Sailer, A., & Jensen, M. P. (2022). Inducing positive emotions to reduce chronic pain: a randomized controlled trial of positive psychology exercises. Disability and Rehabilitation, 44(12), 2691-2704. https://doi.org/10.1080/09638288.2020.1850888

O’Keeffe, M., Ferreira, G. E., Harris, I. A., Darlow, B., Buchbinder, R., Traeger, A. C., Zadro, J. R., Herbert, R. D., Thomas, R., Belton, J., & Maher, C. G. (2022). Effect of diagnostic labelling on management intentions for non-specific low back pain: A randomized scenario-based experiment. Eur J Pain. https://doi.org/10.1002/ejp.1981

Presto, P., Mazzitelli, M., Junell, R., Griffin, Z., & Neugebauer, V. (2022). Sex differences in pain along the neuraxis. Neuropharmacology, 210, 109030. https://doi.org/10.1016/j.neuropharm.2022.109030

Saraceni, N., Kent, P., Ng, L., Campbell, A., Straker, L., & O’Sullivan, P. (2020). To Flex or Not to Flex? Is There a Relationship Between Lumbar Spine Flexion During Lifting and Low Back Pain? A Systematic Review With Meta-analysis. J Orthop Sports Phys Ther, 50(3), 121-130. https://doi.org/10.2519/jospt.2020.9218

Sharpe, L., Jones, E., Ashton-James, C. E., Nicholas, M. K., & Refshauge, K. (2020). Necessary components of psychological treatment in pain management programs: A Delphi study. European Journal of Pain, 24(6), 1160-1168. https://doi.org/10.1002/ejp.1561

Shipton, E. E., Bate, F., Garrick, R., Steketee, C., & Visser, E. J. (2018). Pain medicine content, teaching and assessment in medical school curricula in Australia and New Zealand. BMC Medical Education, 18, 110. https://doi.org/10.1186/s12909-018-1204-4

Yarns, B. C., Cassidy, J. T., & Jimenez, A. M. (2022). At the intersection of anger, chronic pain, and the brain: A mini-review. Neurosci Biobehav Rev, 135, 104558. https://doi.org/10.1016/j.neubiorev.2022.104558

Zhang, M., Zhang, Y., Li, Z., Hu, L., Kong, Y., & Su, J. (2021). Sexism-Related Stigma Affects Pain Perception. Neural Plasticity, 2021, 1-11. https://doi.org/10.1155/2021/6612456

Zhang, M., Zhang, Y., Mu, Y., Wei, Z., & Kong, Y. (2021). Gender discrimination facilitates fMRI responses and connectivity to thermal pain. Neuroimage, 244, 118644. https://doi.org/10.1016/j.neuroimage.2021.118644