Pain. A view not so ordinary


As literature suggests there is more to pain, than what was previously thought of as merely a basic physiological reaction to a noxious stimulus. How pain is viewed, is shaped by a whole host of factors.

A function of pain is to demand attention and motivate behaviour to deal with an injury. (Eccleston & Crumbez 1999).

If pain is considered a threat, the greater the threat the more attention is given. Attention to pain may then be linked to fear and anxiety and the necessity to take action.
Vigilance, a term referring to an abnormal focus on possible signs of pain or injury (Leeuw et al 2007), provides an understanding of why a seemingly small injury can result in serious pain. This process highlights the close link between emotional and cognitive processes and attention.
Cognitive processes are used to interpret the information received. The cognitive process is closely linked with emotional processes as how we perceive a noxious stimulus is shaped by our past experiences. This would explain how it is difficult to “think about something else ” when pain is present and in contrast how when attempts to suppress pain are made the experience of pain can be heightened. Cognitive processes rationalise why sometimes an insignificant stimulus such as light touch can be experienced as severe pain or a serious injury as little or no pain.

We all posses some form of opinion on what pain is and what it would feel like to feel ‘pain’. The beliefs we hold about pain are useful as they can serve as a catalyst in the interpretation of stimuli. Accelerating the process our brain undertakes in making sense of the vast amount of stimuli that our brain needs to interpret, thus becoming a sort of automatic interpretation process. However, this natural tendency can lead to detrimental responses.
Main et al (2010) & Leeuw et al (2008) found there are a number of attitudes and beliefs related to the development of persistent pain and disability in patients with low back pain.These include the idea that “hurt is harm” that if it hurts then something serious is wrong and that “rest is the best cure” pain is a signal to rest and therefore any provoking activity should be avoided.
Buitenhuis et al (2008) supports such correlation between beliefs and pain persistence, their study found that there was a link between causal beliefs and prognostic value in patients experiencing neck pain post whiplash.

Normally when we feel pain we have some idea of its cause how it should be managed and how long we should expect before it is better. How our expectations are managed have also been proven to be good predictors of outcome by a number of studies both in patients with low back pain and neck pain.
We each make sense of incoming information differently. However, for a number of reasons some people fall into a cognitive trap where not intentionally but through error, their misinterpretation of actual or probable future events becomes reality (Linton, 2005 and Barlow 2004).
Pain catastrophising is an example of such a process. Typically catastrophic thoughts are assumptions. “The pain I have, if it continues will cause me not to walk again.”. Therefore, it is not surprising that pain catastrophising is associated with a variety of barriers that hinder recovery, thus making treatment more difficult and the chance of developing persistent pain and disability higher. In keeping with previous research into the development of chronic pain Buitenhuis et al (2008) also found that the severity of neck disability post whiplash event was related to pain catastrophising, however to what extent was unclear. Severeijns et al (2001) too concludes that pain catastrophising significantly contributes to pain related disability.

Anxiety, worry, and depression are all common emotional reactions to pain. It is well known within the literature, that emotions are powerful drivers of behaviour. Therefore, how these emotions are regulated by a person will impact on their experience of pain.
Fear, although short in duration is an emotion that prepares us for “fight or flight” a form of anxiety, that plays a huge part in our thought processes and behaviour.According to Salkovskasis and Warwick (2001) anxiety disorders are typically more prevalent in people with persistent pain than in those who aren’t.
Depression defined by Bair et al (2003) as a psychological problem characterised by negative mood, hopelessness, and despair is a common emotional state that has a powerful effect on the pain experience. There are a number of studies, that have found that patients who have depression pre treatment have poorer rehabilitation outcomes and that the incidence of developing chronic pain is a lot higher. Most research that I have found is in patients experiencing low back pain.

So… what does this all mean to us as clinicians? In my subsequent post this is something I hope to answer.

Reference List

Bair M, Robinson R, Katon W, Kroenke K Depression and pain comorbidity: A literature review Archives of Internal Medicine. 2003; 163: 10: 2433-2445

Barlow D Anxiety and it’s disorders: The Nature and Treatment of Anxiety and Panic; 2nd edition. New York, NY: Guildford Press 2004

Buitenhuis J, de Jong P, Jaspers J, Groothoff J Catastrophising and Causal beliefs in Whiplash. Spine. 2008; 33: 22: 2427-2433

Eccleston C, Crombez, G Pain demands attention: a cognitive-affective model of the interruptive function of pain. Psychological bulletin. 1999; 125: 356-366

Leeuw M, Goosens M, Linton, S The fear avoidance model of musculoskeletal pain: current state of scientific evidence. Journal of Behavioural Medicine. 2007; 30: 77-94

Leeuw M, Goosens M, Van Breukelen G Exposure in vivo versus operant graded activity in chronic low back pain patients: results of a randomised controlled trial Journal of Behavioural Medicine. 2008; 138: 192-207

Linton S, Understanding Pain for Clinical Practice. Edinborough, Scotland, elsevier, 2005

Main C, Foster N, Buchbider R How important are back pain beliefs and expectations for satisfactory recovery from back pain? Best Practice and Research Clinical Rheumatology. 2010; 24: 205-217

Severeijns R, Vlaeyen J, Van den Hout, Weber W Pain Catastrophising Predicts Pain intensity, Disability, and Psychological Distress Independent of the Level of Physical Impairment the Clinical Journal of Pain. 2001; 17: 165-172

Thompson D, Urmston M, Oldham J, Woby S The association between cognitive factors, pain and disability in patients with idiopathic chronic neck pain Disability and Rehabilitation. 2010; 32 (21): 1758-1767

Villemure C, Bushnell M Cognitive modulation of pain: how do attention and emotion influence pain processing. Journal of Pain. 2002; 95: 195-199