“The main message is: Don’t be afraid of the pain.” The New York Times quote Anneleen Malfliet, lead author of “Effect of Pain Neuroscience Education Combined With Cognition-Targeted Motor Control Training on Chronic Spinal Pain – A Randomized Clinical Trial“, published recently in JAMA. Their really good research showed that “pain neuroscience education combined with cognition-targeted motor control training is superior to usual care at reducing pain and improving function and pain cognitions.”
Song for today’s blog: Hurt So Good (Susan Cadogan)
“Don’t be afraid of the pain.” This quote struck me, and made me think of a ‘hypothesis’ that’s been roaming my mind for some years. Let me tell you the story…
Almost 11 years ago my life changed in two ways: our first child was born and I gradually started experimenting with what we now call ‘natural movement’. Both these made me think about pain in a particular way:
Firstly, children, in their development and play, fall quite a lot. Ours luckily never got injured seriously, but they had their portions of bruises, scratches and pains (and still have). While these events surely contributed to learning how to move and behave in the world, the experienced pain did NOT stop them moving and playing.
Secondly, while running, jumping, climbing, crawling in natural environments, barefoot, I also had my portion of scratches from thorns, abrasions from tree bark, toes hitting hidden roots, stepping on stones, … People also noticed these souvenir scars from playing and commented on them. Adults apparently are not supposed to have them…
I concluded that minor/moderate pains are part of normal life. That is, normal life being defined as biologically normal and thus a life full of varied movement in nature. And many adults (and probably more and more children and youngsters) do not experience these pains (or at least to a much lesser degree).
Could this have consequences? Yes, would be my hypothesis. The absence of minor/moderate pain (or the reduced occurrence), could be a contributing factor to the development of (chronic) pain-states.
Let us consider some arguments:
Leslie Orgels second rule: “Evolution is cleverer than you are.” This is a very general evolutionary medicine argument. Changing a natural thing could be both beneficial or detrimental, but since products of evolution are bloody ingenious, this change often is for the worse.
There’s something called the ‘hygiene-hypothesis’, which states that “a lack of early childhood exposure to infectious agents, symbiotic microorganisms (such as the gut flora or probiotics), and parasites increases susceptibility to allergic diseases by suppressing the natural development of the immune system. In particular, the lack of exposure is thought to lead to defects in the establishment of immune tolerance.” (quote from Wikipedia). So, a lack of early childhood exposure to a microorganisms (stressor) has a bad effect on the immune system (defense system). In our case, the analogue story could be: lack of early childhood exposure to minor/moderate pain (stressor) has a bad effect on the pain systems (defense system). By the way, this is a specific version of the first argument…
And then there is the hormesis principle, where exposure to a certain dose of a stressor causes beneficial effects for the organism. The most known hormetic example probably is physical exercise, others being: fasting, temperature stress. The link with our story is pretty obvious. And by the way, this could also be seen as a version of the first argument, as you see that the stressors mentioned were part of normal ancestral life…
Next argument is a very cool and important one. In animal studies there’s a link between childhood play and the capacity to handle stress later in life, and this both physically and emotionally. Spinka et al (2001 Mammalian Play: Training for the Unexpected. Quarterly Review of Biology) state that: “The amount of play experience obtained affects the ability to physically and emotionally handle unexpected events and temporary handicaps.” And since mammalian play behaviour probably always causes minor/moderate painful situations (rough-and-tumble play: “sudden ‘gravitational’, ‘kinematic’, or ‘positional’ shocks such as losing groundunderfoot, falling over, being knocked over, being pinned down, or being shaken vigorously.”), this research is not only a strong stimulus for play in human animals, but also, possibly, in favour of our current hypothesis.
Since play is the mammalian learning mode, we can reframe the last argument in terms of learning. Pain does not equal damage, is the one of the important lessons from modern neurophysiology of pain. My kids know this, because they experience ‘some pain’ quite often, and they know that they can keep on playing, moving, functioning. They may not even know this consciously, but their protective systems know, because they have experienced it and learned from it. Essentially, your systems learns what pain is through experience, learns how to handle it better and better. And the best lessons are the ones you found out by yourself! *
Another Lee Scratch Perry production: Chase The Devil (Max Romeo)
Ok, in summary: minor/moderate pains are normal and natural. Changing this is probably not a good idea, as we already know from very similar and more substantiated topics such as the hygiene hypothesis and hormesis. Also, play, especially the rough-and-tumble kind, besides causing minor/moderate pains, helps mammals to cope with stressors, both physically and emotionally.
So, don’t be afraid of pain?
Actually, although I understand the need for positive messages for people in pain, I think we should be careful not being too positive. Sometimes it really is good to be afraid of pain, sometimes it is useful to be a little cautious with pain, while some pain can be ignored. And at all times, it is logical and understandable that people are afraid of pain. I’ll cover the ‘why-questions’ in the second part of this blog.
Let’s use the hygiene-hypothesis as an analogue story. We know that too much hygiene is detrimental, but surely some microbes are really bad for our health, sometimes even fatal! Some microbes are ‘neutral’, and many are necessary for human life and health. So, no microbiologist would say: “Don’t be afraid of microbes.”, without nuance. He would probably say something more like: “Don’t be afraid of the normal ‘house-and-garden-varieties’ of microbes, some of them good for you, most of them are no problem for your immune system, on the contrary, it keeps the immune system strong. But be careful with, or try to avoid, some microbes, they can cause disease, even death.”
Now let me translate this back to the pain story, and nuance the opening quote:
Don’t be afraid of most painful situations in real life. Don’t neglect them, try to learn what these pains try to tell you, but don’t be scared. Maybe they need some attention and you being careful, but often you can just go on with your life. Maybe these ones can even optimise and strengthen your protective systems (our hypthesis!). On the other hand, it is useful to be afraid of some painful situations, at least for a certain time, and these may warrant help from others, maybe professionals.
So, it there is some truth to this hypthesis, what are the consequences?
First, little pains could be preventive for chronic pain. The best way to get these little pains would be to move and play in a natural environment.
There’s another way, which leads to a second hypothesis. Could painful (but not damaging) treatment techniques help in alleviating pain through this hypothesised mechanism? Could triggerpoint massage, dry-needling, painful stretching, scraping, … be beneficial because they fulfil the role of our little pains? (I’m aware of the limited evidence of the effect of these treatment techniques…)
So, maybe, frequent little pains are necessary for an optimal function of the pain-and-protection systems. And probably our western, comfortable lives do not offer these pains in sufficient amount and variety…
Any thoughts, remarks or criticism? I’d love to hear them. In my next blog, I’ll discuss a few interesting ideas regarding the ‘why’ question. Stay tuned!
* A more literary sixth argument, from the book ‘From Here to Eternity’ by James Jones: “But then pain was a thing he knew about. Pain was like an old friend he had not seen for a long time. He knew how to handle pain. You had to lie down with pain, not draw back away from it. You let yourself sort of move around the outside edge of pain like with cold water until you finally got up your nerve enough to take yourself in hand. Then you took a deep breath and dove in and let yourself sink down in it clear to the bottom. And after you had been down inside pain a while you found that like with cold water it was not nearly as cold as you had thought it was when your muscles were cringing themselves away from the outside edge of it as you moved around it trying to get up your nerve. He knew pain. Pain was like ring-fighting; if you kept going back in there long enough you finally got an instinct for it, you never knew just when it came, or where it came from, but suddenly you discovered you had it and had had it a long time without knowing it. That was the way it was with pain.”