How to know when something counts as pain?
Recently someone posed this question:
“how to know when something counts as “pain”, “significant discomfort” etc. (this is from my Dad who was seriously ill but busy being stoical, with the result that he was misdiagnosed. “If you had that you’d be in a lot more pain than you are,” said the doc. He did have that.)
This question is important, so I may come back to it in another blog as well.
Pain is very, very subjective, a very personal experience.
No two-people having the same procedure, or the same health problem, will report the same pain experience. Some people may report that they feel very high levels of pain, severe pain, with a simple surgical procedure, require a high degree of analgesia and the opposite can also apply.
In part this is because there are so many different factors that come into play. The feeling we call pain, is a ‘thing’ a feeling, produced by the brain. Previous experiences, negative or positive psychological state, emotions, fears, traumas, all impact whether we ramp up, make it more unpleasant, bigger and nasty or ramp down, ease, relax, calm, our brain and output.
This mainly happens at an unconscious level, but people can also learn to consciously ramp down, or up, reduce or magnify and then translate this, with practice, into an unconscious habit
In pain management we use this ability. We teach people to have more control over their feelings of pain by distraction, mirrors, imagination, mindfulness, focusing on other activities, changing their language, building resilience, group activity, creativity, moving, singing, dancing, talking to others, this is all brain skill training.
Plus, some people are good at producing their own natural pain relieving endorphins. Simple social dancing, spending time with others bonding has been shown to raise pain thresholds.
Others are just great at psychobiological effects, what we call placebo.
Ironically, many of these actions are the behaviour of a ‘stoic’. Someone who ‘grits their teeth’ and ‘puts the pain out of mind’. Someone who ‘stays busy’, uses mild language to describe their pain and ‘under plays’ their own state.
I’ve worked with people with cancer, who can literally put pain out of their mind. I’ve worked with athletes who, in the height of a competition, despite an obvious fracture, report no pain. Equally I’ve worked with elite performers who have been in tears, reporting severe pain from a simple strained finger after losing a competition.
Plus, the feeling of pain is relative, when we describe pain we quite often compare it to another episode of pain we’ve had before, or that we watched someone experience.
A person who has experienced a new severe toothache, acute nerve pain, a broken limb, recent severe burns, which is likely a high intensity of feeling albeit for a short time. If someone has experienced such a high intensity, when they experience another kind of ‘feeling’ with a very different character, then they may not report it as a ‘big pain’ because it wasn’t as bad as the ‘really intense’ episode they had before.
On top of this many times people are simply asked ‘Do you have pain?’. But how we describe pain can vary. People can use words like deep, sharp, gnawing, squeezing, crushing, wringing, stabbing, knife, grinding, moving, pulsating, hot, grating, dull. Some studies have shown that there are sometimes clues in the very descriptors people use to provide more understanding about location and severity. But this is a very poorly researched area and with language being so person specific could be difficult to validate.
So, when the Doctor said “If you had that you’d be in a lot more pain than you are”. This is tricky, because no clinician simply uses the person’s report of severity of pain as an accurate representation of their underlying health state & tissue pathology.
Reports of pain are invariably part of the complexity description of every presenting patient’s narrative. Medical professionals always ask about pain, position, nature, but they always ask about dozens of other things as well.
Doctors want to build a strong, multi-dimensional picture of presenting signs/clues to decide what care path to start down. They want details on history and often ask all manner of seemingly random questions, most questioning is directed to open or close possible clinical pathway directions. Medical diagnostics is complicated, good doctors make it seem easy.
In my Physiotherapist/coach consultations, when pain is the primary presenting sign, no matter how much the individual perceives that there is little wrong, I always ask about general health state, recent and decades of history, whether someone has recently been checked by their doctor or attended routine screening appointments. Plus, everyone is run through a barrage of checks to exclude what we term ‘flag’ signs. In clinic, this leads on to all manner of questions about life events, work, financial, relationships, stress, illness in other family members, familial history. To the client this may seem unimportant, but we treat the whole person, not the presenting sign.
In addition, there are strong boundaries between medical diagnostic tests arranged by a doctor and those carried out in clinic when someone presents having booked direct access for a Physiotherapist consultation or coaching. Sometimes answers raise questions that need medical diagnostics and a letter to the clients Doctor is required.
Coming back to the original question:
Q: “How to know when something counts as “pain”, “significant discomfort” etc.
A: Well its complicated, BUT, it’s not the best idea to pick and mix which symptoms to choose to share . Make sure you offer everyone in your medical team as much and as full information about your medical and life state, as you feel happy to reveal. The information you share will be confidential. Although you may not consider something is relevant, tell your doctors & medical team everything, or risk withholding a useful diagnostic clue.
Make notes to take to consultations is a great idea, especially if things have been going on for a while. Maybe ask a family member to remind you if there is anything you forgot. I often ask people to bring a written history and sometimes that can cover two or three pages of A4 paper. That can form the start point for the consultation and then my questions can bring out more of what I need to know. Medical consultants like this as well, having a list of key questions you want answered means you get the outcome you want.
Finally, this question is quite complex. There may be more to add in another blog, but for now I hope I have given a simple answer.