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Knowing what’s really going on — that pain is always an experience generated by the brain — should we change how we talk about pain? Should statements like “my ankle hurts” be rephrased like “I hurt in my ankle” or “my brain claims that my ankle hurts”?
No, I don’t think so — no more than we need to start saying, “My brain claims that I can see a bright, hot object in the sky.” The verb to see is a perfectly good shorthand for the dazzingly complex neurological phenomenon of vision: we don’t need to spell it all out.
There are “unfortunate trivializations” in the way we talk about pain:
The labeling of nociceptors as pain fibers was not an admirable simplification, but an unfortunate trivialization under the guise of simplification.
The relationship of perceived pain to afferent nerve impulses, by Patrick Wall and SB McMahon, 254–255
But simple references to the subjective experience of pain are mostly just fine as they are. Statements like “my ankle hurts” don’t express all the implications of pain science, of course…but no practical statement can. There is no good vocabulary for what’s really going on, but that’s par for the course with science and language. In the last three centuries, knowledge has raced far ahead of the ability of non-technical language to express it, and there’s no good solution to that.
Nevertheless, it’s a good idea — especially for patients with serious chronic pain, and the professionals who help them — to learn to think more literally about how pain works. Make no mistake: it may seem like your ankle hurts, but it doesn’t necessarily have much to do with your ankle, because Pain is Weird.
This is a suspenseful, evocative 30-second TV ad about pain from a fine organization in my own neighbourhood, PainBC.ca. And what a challenging job for this actor! Not sure I could stand still and expressionless through all that ripping…
“Some nerve pain makes makes your skin feel like this. It's just one of the chronic pain conditions one in five British Columbian's live with everyday. Learn more at PainBC.ca.”
So, what kind of nerve pain feels like that? The best match for “it feels like someone’s ripping duct tape off my skin” would be allodynia, which is a painful reaction to things that shouldn’t hurt at all, like being licked by a puppy, or a refreshing breeze. (Yes, the awfulness of that is right off the charts.) Allodynia is a symptom of several painful conditions, most commonly neuropathies, neuralagias, fibromylagia, and migraines. More rarely, and more severely, allodynia is the signature symptom of complex regional pain syndrome. These are topics that I haven’t covered well on PainScience.com to date, mainly because I’m not a neurologist and I’ve come to pain science via musculoskeletal medicine. But I do plan to slowly and carefully develop some content about these kinds of pain.
As I continue to tie up loose ends from the big bibliography upgrade, I realize that I’ve actually written quite a lot over the years about science, research, citing, and, yes, even statistics. Apparently I can’t resist writing super dorky, abstract articles! They’ve really piled up over the years. Here’s eight links to get you thinking deep thoughts about science…
I’m also happy to report that I’ve been exploiting my new bibliography super powers: science updates for the books have started to flow again after a fallow period, and I’m working on completely new content again for the first time in ages. Feels good!
Pulsford et al. is a good FUD-fighter: its results directly contradict the overhyped notion that a lot of sitting is just as dangerous as smoking, an idea that’s been around for a few years now, and it always reeked of premature fear-mongering speculation. There was never any good evidence for it, but this is good evidence that “sitting time was not associated with all-cause mortality risk” in over 5,000 subjects.
This doesn’t remotely get us off the exercise hook. It doesn’t mean that a sedentary lifestyle is safe or healthy, but it does strongly suggest that we aren’t doomed by it (that is, you likely can compensate for a lot of time in a chair by being as active as possible otherwise).
And it’s still possible that sedentariness is unhealthy independently of other exercise, and I’m sure we’re going to see more research about it. Regardless, the scary headlines over the last few years were not defensible, and this new evidence is definitely reassuring.
I’ve updated my main chair trouble article with a reference to Pulsford…
Interesting read on the idea of no pain, no gain in sport:
Japanese trainers have gone so far as to enshrine this marriage of pain and athletic discipline in the concept of taibatsu, which translates roughly as ‘corporal punishment’. In his piece on Japanese baseball for The Japan Times last year, Robert Whiting traces the concept to one Suishu Tobita, head coach of the fabled Waseda University team in the 1920s. Tobita advocated ‘a baseball of savage pain and a baseball practice of savage treatment’. Players nicknamed his practice sessions ‘death training’: ‘If the players do not try so hard as to vomit blood in practice,’ he said, ‘then they cannot hope to win games. One must suffer to be good.’
Oh, Japan: you’re so kooky! And probably right. There’s a part of me that howls in outrage at the idea that “one must suffer to be good,” but there’s another part of me that’s all, “Oh yeah, no, that is so true!”
Here’s a dramatic example of athletic toughness, and a nice demonstration of how “pain is an opinion”:Shoulder dislocations are notoriously painful, but this rugby player dislocates his shoulder and just pauses to calmly, competently pop it back in place. In other words, this player’s brain seems to be more concerned about getting back in the game than worrying about a shoulder dislocation! Of course there’s more to it than that. Chances are good this guy has dislocated his shoulder quite a few times, and it’s so hypermobile that it isn’t nearly as brutal for him as it looks. Still an interesting example though!
Ig Nobel prize goes to pain science, in the masochist category. For this Ig Nobel win…
Michael Smith, of Cornell University, subjected himself to several stings a day to his face, arms and genitals to map out what section of the body was most sensitive to the barbs.
After weeks of research Smith found that although stings to his penis and testicles were uncomfortable, the worst place for a bee to attack was the nostril. Being stung on the upper lip was also one of the most painful locations for a bee sting.
But an honourable mention for stings on the shaft of the penis specifically.
Now for the fun part: trying to figure out where to cite this research here on on PainScience.com!
(Aside: I’m a fan of CBC Radio One’s As It happens, and the easiest way to explain why I’ve been so dedicated to the show is that they always cover the Ig Nobels. In fact, they never stop: most of their science stories are about the kind of science that might win an Ig Nobel.)
The management of load represents a key component of what the physiotherapist or athletic trainer does. Once the clinician establishes the need for some form of physiological adaptation, the primary clinical question becomes one of dosage.
This is a dense but excellent and polished article for professionals (for some of the same concepts pitched to patients, see Progressive Training). Nice to see Scot go straight to Dr. Dye’s patellofemoral syndrome research, which has been a major influence for me for a decade.
Researchers found that mitochondria in mouse muscles not only produce energy, but can quickly distribute it across the muscle cell through a grid-like network. The findings reveal a major mechanism for energy distribution in skeletal muscle cells, and could provide new insights into diseases linked to energy use in muscle.
What a wonderful example of how much we still have to learn about muscle tissue (and others too, I’m sure, but muscle seems to be particularly full of surprising puzzles). It seems likely that we probably can’t understand muscle pain properly if we have only just now discovered something so fundamental about muscle biology. Imagine trying to troubleshoot an electrical problem if you weren’t aware of a major feature of how power is generated and transmitted!
The application of evidence-based medicine (EBM) has always involved a mixture of evidence, experience, and the particulars of each case. For instance, a physical therapist deciding whether or not to use dry needling might consider three things:
In other words, EBM isn’t exclusively about the evidence. It’s based on it, but not limited to it. And so I got this savvy question recently:
You are obviously keen on PainScience.com being known as an EBM-friendly website, so what do you do when the evidence is contradicted by the clinical experience of your readers? Or your own?
The artful merging of evidence and experience with the unique special-flowerness of the patient in front of you is a clinical challenge…not a writing challenge. Clinicians have to make decisions based on all three, every day. That’s their job. I left that challenge behind several years ago. These days, my new challenge is to provide clinicians (and patients) with as good a picture of the evidence as I can. I’m a specialist now — I focus on just one of the pillars of EBM, the science-y pillar.
You must be very cautious not to lean too hard on your experience, because “you are the easiest person to fool” (Feynman). It’s only a third of the equation. Not two thirds. Not half. Just a third
On the other hand, I was also clinician for ten years, and I have constant and deep correspondence with many extremely experienced clinicians today. So there are hat tips to clinical experience here there and everywhere on PainScience.com. Certainly I do talk about what clinicians believe. But, mostly, I stick to what the evidence can support.
But for you clinicians: when confronted with evidence that’s a bummer, at odds with your experience, remember that your experience is a fully legit third of that EBM equation. But! You must be very cautious not to lean too hard on your experience, because “you are the easiest person to fool” (Feynman). It’s only a third of the equation. Not two thirds. Not half. Just a third, roughly, give or take (probably always less than a third for younger professionals). And it’s never a very reliable third. Just like science, experience is difficult to interpret and often wrong.
EBM-First.com is a nicely done directory of reading recommendations and references for a couple dozen topics in alternative medicine. It’s surprisingly hard to find good reading lists…but not on EBM-First. The most relevant topics for pain and manual therapy are craniosacral therapy, energy therapies and reiki, homeopathy, magnetic therapy, reflexology, therapeutic “touch.”
As you can see, there’s a strong focus on alternative medicine’s goofier side: several topics I’ve barely touched on myself, because they’re just too remote from science and reason. For instance, I will probably never bother to write about magnets. I’m happy to be able to direct readers to EBM-First for that.