How pain can be like school

TheKettleBellPhysioBlog, Pain, Uncategorized0 Comments

In 1993-96 I was at University for the first time. My best mate Simon was in a room down the corridor in our halls of residence, then we shared two different homes together in our second and third years.

I don’t recall how it came up in conversation, but during our final year at Uni Simon shared with me some of his harrowing experience at school. Simon was close like a brother and he had a look on his face that I’d never seen before. More than 2 decades later I can still remember it, which is saying something because I often have a memory like a goldfish.
He had grown up in Cumbria in the Northwest of England. His dad was a lawyer and both parents were grey and very ‘proper’. They were horrified when he told them her was buying a motorbike, which I had encouraged because I needed someone to ride with. Simon was studying fire-safety at Uni and some other form of engineering-type Degree, I don’t recall what. He wasn’t an academic and was pretty average in the classroom. He didn’t care about that stuff though; he was more of the ‘P = Degree’ kinda guy, interested in a social life and going to the gym with me and our buddy Rob. He didn’t do sports, he was crap at that, but he was someone full of self-confidence and bravado. He spent money on nice clothes and enjoyed being the flamboyant snappy dresser and the centre of attention when we went out together. He wasn’t a physically big buy, but he certainly wasn’t the small weedy one either. We lifted weights together every day and I was forever envious of his pecs which were annoyingly always much bigger than mine. He wore glasses, but so did plenty of others; his were in fancy prescription lenses by Oakley though. He occasionally grew a goatee whereas I still can’t at 41, and he did reasonably well with the ladies. A few years after Uni I got him a job as a consultant in central London where I was working. He was my tenant for a while, then we bought a unit together before we finally went our separate ways.

That was Simon.

It turned out that throughout his school life Simon had been bullied. A lot. I never heard much about the details, but whatever he’d been through had clearly been traumatic for him; it was written all over his face. Even as a self-absorbed 20-yr old male I had noticed it like a smack in the face, and I recall feeling a little uncomfortable with his uncomfortableness in sharing. He was the kid who got hung up on the change room coat hooks by his underwear – really. He “hated” everything about his time at school. He couldn’t wait to leave and the tormenting memories he’d been left with, clearly haunted him, and will no doubt be etched in his brain for the rest of his life.

Everyone has unpleasant things happen at school one way or another – school dinners, being reprimanded by a teacher, made fun of, getting a lower mark than expected, being picked last, someone stealing your lunch money – there’s an endless list! But that’s just part of being at school, learning and growing up. Some, kids like Simon however, have a much harder time than others.

In a similar vein, everyone experiences pain; a paper cut, strains, bruises, broken bones, sun burn, or even the emotional ‘pain’ from a broken heart or losing a loved one. It’s part of life and being human. We *need* pain. It’s an important biological mechanism which alerts us to potentially harmful situations and triggers responses which are protective and helpful. For most people, pain is not more of a stressor than life at school; we all have our ups and down, but for some it can go pear-shaped, get out of control and become much more of a challenge than an initial trigger. For some people like Simon, ‘pain’ becomes amplified, unpleasant, unwanted and persistent. School isn’t ‘bad’, but it can become a really shit experience for some people, turning into emotional and psychological baggage being dragged along with life indefinitely. Pain isn’t bad either, but it can become a really shit experience for people that hangs around like a bad smell.

Our relationship and experience of pain as a child and adolescent determines how we see it as adults. Children can develop emotional and psychological scars from their pain that can taint future choices concerning their lives and health care.

Pain is truly both a physical and an emotional experience perceived and processed by the brain. It has meaning and if it becomes chronic can profoundly affect the nervous system. How we handle pain as an adult likely reflects our experience and perception of what happened to us when we were learning to place meaning to it. That can and does change though because the brain has an amazing capacity to adapt. We learn.

All pain is neurogenic, which means that we need a functioning nervous system to experience it – all 90-100,000 km of nerves including the brain.

The brain gives sensory information meaning and it’s the brain where the ‘sensation’ of pain comes from. A knee may feel sore, but a knee doesn’t “cause pain”; the brain creates an experience pain and makes us feel like it’s in a knee. The brain may well be receiving noxious sensory information from the knee of tissue damage or inflammation, but it could equally be perfectly normal. There could be sensory information going to the brain from somewhere other than the brain, but we ‘feel’ it in the knee. Clinicians are still trying to understand pain and work out effective ways to treat it! It’s confusing for us to understand! Imagine how challenging it is explain to someone that pain isn’t a ‘sensation’ like pressure, heat and cold. We feel in love, but we do not ‘feel’ love, yet the experience of love has profound changes on our physiology, like pain.

Signals reaching the brain are processed in parts of our brain involved with mood, emotion, learning and memory. This is where we worry about the pain and feel exhausted by it, so you may naturally anticipate pain and avoid the things that trigger it.

An area of the brain called the sensory cortex is where we ‘feel’ the pain, which we interpret and respond to. We decide how we ‘feel’ about the pain and may develop protective mechanisms in response to it. Pain is influenced by our cultural environment, social network and previous experience plus potential history of trauma, abuse or losses.

Imagine being in Simon’s shoes – terrified of going to school every day, not knowing what emotional and physical torment lay ahead, being excluded, made fun of, ostracised, beaten. Consider the emotional scars that would create in him and the thought of returning to that same place, or even another place of ‘schooling’ as an adult. What Simon carried with him into adulthood was and is a very real experience however, the effects of it would unlikely serve him well now that school is behind him. Imagine trying to unravel and understand Simon’s experience and make it ‘okay’ to continuing living a normal life. Where do you start? How do you do that? What matters and what doesn’t? Would you ever really understand how Simon’s experienced has fundamentally shaped him and potentially his relationships with his own family and children going forward?

Some people experience terrible trauma and pain in life. Jobs, careers, relationships, income and identity can be significantly affected by pain, sometimes lost altogether because of pain and disability. Imaging trying to unravel and understand that in someone else and make it ‘okay’ to continuing living a normal life. As Physiotherapists, understanding pain is a challenge in and of itself – it’s complex beyond explanation; really, we don’t understand it very well. Add to that the infinite complexity of a real human in front of us, and helping that individual in pain is so much more than what we can be lead to believe. Whether through ignorance or deception, clinicians can (and do) take advantage of people in pain. Nothing is easier to sell to people in pain than hope – they are the most motivated group of potential customers imaginable. If I tell you that your pain is due to your muscles being tight or weak, or because your back is too stiff, or your foot rolls in too much, it’s very easy to sell you an easy-to-understand solution for that. I can sell you $100 of products too so you can self-treat your trigger points, stiffness, and fascia at home. I would still need to see you regularly over a few weeks though for in-room treatment because I care (about my business) and it’s important that you feel like a health professional is taking care of you and you’re not on this difficult journey to a better life all on your own. I can help.
It feels empowering and most people fall for it. It’s clinical garbage.

Understanding and seeing pain in someone has been compared to looking at a photograph of them; often people with persistent pain ‘look’ to be happy and comfortable, but how someone ‘looks’ is not an accurate reflection of how they may feel. There may be no outwards signs of harm, but they may feel like a train wreck on the inside – broken, fragile, degenerated, torn, strained, weak, out of alignment; you know, all those phrases we Physios like to label people with who have pain but no signs of trauma (nociceptive pain) or inflammation (inflammatory pain) – the absence of tissue damage or any likely pathophysiological cause. By definition, if it’s not one of those two it’s considered ‘pathological’ and if it’s not clearly as a result of true damage to a nerve (neuropathic pain), then it’s very much ‘neurogenic’ in the true sense of the word in that the alarm system if going off without good cause. Persistent pain is an imbalance in the way in which sensory information is being processed, primarily in the spinal cord and brain. The human body isn’t like a light switch or engine; we can’t just ‘switch it off’. And importantly, if there is no obvious injury and no ‘red flags’, there is no need to keep ordering tests in an effort to ‘find’ the source because a) we won’t find it and b) that approach is more likely to make the pain worse.

Could we effectively help Simon get on with his life with manual therapy, taping, dry needling, ultrasound, TENS, exercise? The answer would of course be a resounding “no”. Some of those things don’t actually work at all, so that’s one good reason not to use them. They make him feel different, or even a little bit better if we sell it well, and the non-specifics effects of the professional therapeutic alliance we create is usually very helpful from a psychosocial perspective, but it’s not enough. Effectively helping someone who has been living with pain is not a one-size-fits-all approach. There is no single profession, tool, technique, medication or practice which affectively addresses all of the potential contributing factors.

As a Physiotherapist we have a few things up our sleeve which *could* be helpful, but persistent pain requires a team approach; a range of different treatments and a team of people to help. This is the very reason why PRIDE Physiotherapy is part of the Gold Coast Primary Health Network program for chronic pain; we are part of a team who work together to find the best way forward. If what we’re doing isn’t effective, we don’t keep flogging a dead horse; there are other strategies available with other professionals. Seeing a Physiotherapist could make someone feel worse!

Pain may not go away although, and often that’s not a meaningful or realistic goal for people living with pain, but you can change the way your brain perceives pain so that you *can* get on with daily living.

Sadly, there are still (arguably the majority it would seems) clinicians who still do not recognise that pain is not just about nociception and nociceptive pathways, and the important psychosocial factors get missed or ignored altogether.

The purpose of this post was simply to highlight the complexity of persistent pain as a complex psychosocial phenomena which may or may not have an important ‘bio’ component to it.

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