Pain: The Most Poorly Treated Experience in Healthcare

Pain is both the most undertreated and overtreated experience in all of healthcare. This is mainly due to the fact that healthcare professionals/researchers are still trying to understand the mechanisms of pain, and that the pain experience can look vastly different from person to person. In fact, there are literally over 100 different factors that could potentially influence your pain, that we currently know of (1-10). I think another reason why pain is so poorly treated is in large part due to the public being told that pain is something that can be “cured” or “fixed,” instead of viewing it as a normal signal that our brain releases; in order to protect us and grab our attention towards an issue. There’s also a vast amount of information out on the internet and social media, of people claiming to have all of the answers with overly simplistic approaches. I’m hoping today’s article can make it easier for the public to understand their experiences with pain, what to look for, and how to respond with the given information we have today.

First, let’s look at the definition of pain. Pain can most accurately be defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage.” (2) So how can it be that pain might be an emotional experience, and that we can experience pain without actual physical harm? Let me explain.

Pain is processed throughout multiple regions of the brain, with the most intense response coming from the insular cortex (3). The insular cortex is one of the least understood regions of the brain, hence why pain is so poorly understood. However, from what we currently know, the insular cortex is responsible for processing unpleasant sensations, such as pain, emotional experiences, subjective feelings, hunger, thirst, and more (3, 4). Those that are most susceptible to experiencing pain as an emotional response, as well as chronic pain, are those that first experience childhood trauma, and then later in life experience adulthood anxiety (5). Childhood trauma can either be physical neglect, emotional neglect, physical abuse, emotional abuse, and sexual abuse (5).

Now it’s important to understand that pain is not all one in the same. There are different types of pain that can help explain what the problem is. The four types of pain are nociceptive, neuropathic, nociplastic, and referred pain.

Nociceptive pain: (6)

• This form of pain occurs when there is either musculoskeletal injury, inflammation, and/or mechanical irritation

• Examples: muscle strain/rupture, ligament sprain/rupture, rheumatoid arthritis, and osteoarthritis

• Signs you are experiencing nociceptive pain, are if your pain is localized to a particular area, if you have clear aggravating and easing factors of pain, and your pain is intermittent (episodic as opposed to continuous) (9)

Neuropathic pain: (6)

• This form of pain occurs when there is injury, irritation, or disease of the brain, spinal cord, and/or nerves

• Examples: Traumatic brain injury, carpal tunnel syndrome, cervical radiculopathy, lumbar radiculopathy, spinal cord injury, diabetic neuropathy, and complex regional pain syndrome

• Signs you are experiencing neuropathic pain are if you have a history of nerve injury, disruption/loss of sensation, muscular weakness, decreased/absent muscular contraction, weak/absent reflexes, and if you test positive during nerve sensitivity tests (ex. straight leg raise test) (8)

Nociplastic pain: (6)

• This form of pain occurs when there is a disturbance in pain processing of the central nervous system (brain and spinal cord)

• Examples: non-specific low back pain, non-specific neck pain, chronic pain syndrome, and fibromyalgia

• Signs you are experiencing nociplastic pain are disproportionate aggravating and easing factors, diffuse (widespread) painful palpation, pain disproportionate to injury, and psychosocial symptoms (depression, anxiety, etc.) (7)

Referred pain: (10)

• This form of pain occurs when there is a convergence of pain signals from internal organs to other regions of the body, such as skin, joints, and muscles.

• Examples: Chest and left arm pain while experiencing a heart attack, low back pain while experiencing a kidney infection, and upper abdominal pain while experiencing a stomach ulcer.

• There are too many signs of referred pain for me to list in this article, but just be sure to understand that you will need medical treatment from a medical doctor to treat the conditions that cause referred pain.

So there you have it. Yes, pain is an incredibly complex human experience, and even this short article cannot hide that reality. If there is one thing I want you to remember, it is that pain that is gradually worsening, disabling, or causes you to experience a significant decrease in physical function, is not something that should be ignored. However, pain is also not something that should be feared. Just respect that it is your body telling you that something is wrong, and that seeking professional help may be necessary.

References:

1. Cholewicki J, Breen A, Popovich JM Jr, Reeves NP, Sahrmann SA, van Dillen LR, Vleeming A, Hodges PW. Can Biomechanics Research Lead to More Effective Treatment of Low Back Pain? A Point-Counterpoint Debate. J Orthop Sports Phys Ther. 2019 Jun;49(6): 425-436. doi: 10.2519/jospt.2019.8825. PMID: 31092123.

2. Raja SN, Carr DB, Cohen M, Finnerup NB, Flor H, Gibson S, Keefe FJ, Mogil JS, Ringkamp M, Sluka KA, Song XJ, Stevens B, Sullivan MD, Tutelman PR, Ushida T, Vader K. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain. 2020 Sep 1;161(9):1976-1982. doi: 10.1097/j.pain.0000000000001939. PMID: 32694387; PMCID: PMC7680716.

3. Bastuji, H., Frot, M., Perchet, C. et al. Convergence of sensory and limbic noxious input into the anterior insula and the emergence of pain from nociception. Sci Rep 8, 13360 (2018). https://doi.org/10.1038/s41598-018-31781-z

4. Uddin LQ, Nomi JS, Hébert-Seropian B, Ghaziri J, Boucher O. Structure and Function of the Human Insula. J Clin Neurophysiol. 2017;34(4):300-306. doi:10.1097/WNP.0000000000000377

5. Kascakova N, Furstova J, Hasto J, Madarasova Geckova A, Tavel P. The Unholy Trinity: Childhood Trauma, Adulthood Anxiety, and Long-Term Pain. Int J Environ Res Public Health. 2020;17(2):414. Published 2020 Jan 8. doi:10.3390/ijerph17020414

6. Chimenti RL, Frey-Law LA, Sluka KA. A Mechanism-Based Approach to Physical Therapist Management of Pain. Phys Ther. 2018;98(5):302-314.

7. Smart KM, Blake C, Staines A, Thacker M, Doody C. Mechanisms-based classifications of musculoskeletal pain: part 1 of 3: symptoms and signs of central sensitisation in patients with low back (± leg) pain. Man Ther. 2012 Aug;17(4):336-44. doi: 10.1016/j.math.2012.03.013. Epub 2012 Apr 23. PMID: 22534654.

8. Smart KM, Blake C, Staines A, Thacker M, Doody C. Mechanisms-based classifications of musculoskeletal pain: part 2 of 3: symptoms and signs of peripheral neuropathic pain in patients with low back (± leg) pain. Man Ther. 2012 Aug;17(4):345-51. doi: 10.1016/j.math.2012.03.003. Epub 2012 Mar 31. PMID: 22465002.

9. Smart KM, Blake C, Staines A, Thacker M, Doody C. Mechanisms-based classifications of musculoskeletal pain: part 3 of 3: symptoms and signs of nociceptive pain in patients with low back (± leg) pain. Man Ther. 2012 Aug;17(4):352-7. doi: 10.1016/j.math.2012.03.002. Epub 2012 Mar 30. PMID: 22464885.

10. Sluka KA. Mechanisms and Management of Pain for the Physical Therapist. In: Seattle, WA: IASP Press; 2009.