Pain was once believed to be very simple – the first theory of pain came from Louise Descartes, the man quoted for saying “I think, therefore I am”. Descartes’ theory was proposed in the 17th century and is still basically used today. If you put your big toe into the fire, the information goes up the spinal cord to the brain and we scream and withdraw the toe from the fire. It’s a direct line from here to there. So the thought was that if it were a direct line you could cut it and the pain would stop, similar to the old phones –  if you cut the cord the conversation was over. So early physicians cut here and there, and the pain did not usually go away. Then they figured out there was an emotional component to pain, so the neurosurgeons figured if you cut out the frontal lobe and remove it, the emotions and the pain will go away. Unfortunately that did not work either. Scientists and doctors are now figuring out that pain is very complex.

How many of you have experienced pain? Pain is a physical sensation that may or may not go along with tissue damage and pain can be an emotional sensation. Many of you are most likely feeling some sensation of pain right now. By looking at someone, can you tell if they are in pain? Can you estimate what level of pain that person is in… and on a scale of 1-10 (one being a sight sensation of pain and 10 being the worst pain you have ever had) determine what their pain is right now? If you asked the person what their pain level was on the same scale, would you believe them?

Pain is a very complex experience, you cannot see it and it’s different for everyone. We have no idea what another person is feeling right now. As a nurse, I was taught that pain is whatever the patient says it is. You can have two patients who have gone through identical procedures and one is have pain of 4 and the other one is a 10 on the pain scale.

What makes pain so complex and so individualized is our perception of pain.

Perception has everything to do with how much pain we have and how long it lasts. There are many factors effecting our perception:

Experience and expectations: At four years old you may see a candle lit for the first time, and your eyes light up and you wonder what the pretty red flickering light is. Oooohhhh, aaawwhh. You get closer, at this point you have no experience to tell you this is going to cause pain if I touch it. The brain does not perceive this as a threat, until you touch it. Receptors race information to the brain, sirens go off saying DANGER, Danger, retreat, get mommy. The next time you see it you know what to expect – you have experience, and your perception is totally different.

On the other side of this same scenario, have you seen firewalkers? I chose to partake in this experience, and while they are burning the wood to make the coals you will walk on, the participants are busy going through a process to show you that anything is possible. You’re breaking wood with your hands, bending rebar rods in the crease of your neck, and by the time the coals are ready most of the people in the group are so pumped up, it feels like there is nothing you cannot do. So by the time I walked over the coals, I could feel the coarseness of the coals under my feet, but I did not feel pain nor did I get burnt. However, the people in the group who hesitated and were sure they would get burnt, did. These really were hot burning wood coals, and an excellent demonstration of how perception, experience, and expectation can drive what we feel.

Motivation is another factor in perception. Athletes will perform through pain, to get the goal, finish a race and win. Remember the achievement motto: “No pain, no gain!”. And yes, there are even stories of amazing store sales, and women ignoring labor pains – solely driven by the goal to get their desired item on sale!

Reward and punishment: Have you ever seen a child do something that clearly should hurt –  but if the child is with the dad he may just shake it off, while if he was with the mom he may cry? That’s because the mom may reward the reaction to pain with kisses, a treat, or love. And dad may tell the child to suck it up and don’t be a baby – no reward in that.

Culture, religion, and sex are also factors in perceptions of pain. As a nurse, you need to know that in many cultures people will not tell you that they are having pain, and people carry their core cultural values with them even if they are in another country. Many religions believe that sacrifice and enduring pain bring you closer to God. Men are generally brought up to be demeaned for showing pain, as we saw in the scenario of reward and punishment above.

A huge part of perception is our mental and emotional status. How stressed out are you right now? Are you down to your last nerve? I use to say to my kids when I was really stressed out, “You’re on my last nerve!”, and they knew not to push me any further. So, if you are so stressed out and you’re on your last nerve and you stub your toe, doesn’t it hurt more then when you’re not stressed? Out come the expletives, and you might even cry because it hurts so badly. This is because the alarms have already been going off in your brain – Danger, Danger – and your brain intensifies the pain. When you’re not stressed, you may stub your toe and you simply say, “Oh darn it,” and you just go on with what you were doing.

Pain is very complicated, and it’s different for everyone because everyone’s perceptions of pain is different. If you expect it to hurt, chances are it’s going to hurt. If there’s motivation to get beyond the pain and finish, you probably will finish and then the pain will hit. If you generally get a cookie for a booboo, you may cry harder to get two cookies – but if there is parental disapproval from showing pain, you learn to suck it up. And if you’re on your last nerve, stop where you are, because chances are there’s a kid’s toy underfoot just waiting to take you down.

Tina Michaud-Gray, Integrative Pain and Rehabilitation Specialist, RN, LMT, SILC, CH
New England Rapid Recovery Center