Inappropriate Pain
Any person who has had pain issues, may have had a run-in with a medical professional who uses the phrase “inappropriate pain.” What does that mean? When a medical professional calls pain “inappropriate,” what she means is that the amount of pain you are reporting is not matching the objective data that the doctor has. In other words, if you have mild compression (in other words, part of the bones in your vertebral column are pushing on the spinal cord), a doctor may tell you that this is not an “appropriate” cause for debilitating back pain. They may also tell you that you are having pain in an area that should not be affected, given those imaging or test results.
From reading the posts on this blog, most of you are probably well aware that while there are myths about pain, none are as appalling as the idea of “inappropriate pain.” Pain is inherently subjective - it is defined by the person experiencing it. There is no objective way to examine a person’a pain, and the exact same injury may rate as a 3 out of 10 to one person, but an 8 out of 10 for another. Examining X-rays, CT scans, or MRI’s can tell a doctor where they might expect a person to have pain, but they are not “proof” of exist pain, or the lack thereof.
This is true for most senses - what one person calls dark blue another may respond is a true black. The difference is that with vision, we can examine the wavelength of the light to objectively determine what the color actually is. With pain, even an assessment of the activity of the nerves that carry pain in a person cannot really tell us what a person is actually perceiving. Many psychological variables modify the pain that reaches cognitive perceptual levels - including attention, past experiences, environmental factors, and the persons who are present at the time of the experience that is perceived as painful. This does not even address the potential physiological factors that can impact what a person perceives. Objective measures do not allow a doctor to determine what, or how much, pain a person should be expected to experience.
If a medical professional labels your pain as “inappropriate,” you should clearly examine trying to find another health professional to work with. In my experience, pain management physicians who have done fellowship training in pain are much less likely to make these kinds of judgments, as they have more explicit training about what pain actually is, and what happens when a person feels pain. If you know what pain is, and how it is physiologically generated a sensation, you will understand why the term “inappropriate pain” is clearly an oxymoron, a concept that contradicts itself. If an experience is pain, then it cannot be inappropriate, because pain is defined wholly by the person experiencing in. That is how pain is defined, even by the International Association for the Study of Pain.
IASP proposed definition of pain:
An aversive sensory and emotional experience typically caused by, or resembling that caused by, actual or potential tissue injury.
Proposed Accompanying Notes Section:
Pain is always a subjective experience that is influenced to varying degrees by biological, psychological, and social factors. Pain and nociception are different phenomena: the experience of pain cannot be reduced to activity in sensory pathways. Through their life experiences, individuals learn the concept of pain and its applications. A person’s report of an experience as pain should be accepted as such and respected. Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being. Verbal description is only one of several behaviors to express pain; inability to communicate does not negate the possibility that a human or a non-human animal experiences pain.
As you can see from this definition, pain is subjective by definition. How a person perceives a “nociceptive” (potentially tissue damaging) stimulus is defined by who they are, and what they have experienced in their past. A high level athlete will rate a painful stimulus very differently than a non-athlete, because they have experience with pain almost every day. Also, when most people are growing up, their parents tell them explicitly, “if something hurts, then don’t do it again.” The explanations that we receive as children about what pain is tend to focus on the fact that pain is telling us that something is wrong, and that we should stop doing whatever we are doing. The classic joke story about orthopedists is the one that goes, the patient comes into the office, and lifts his arm over his head. He says, “It hurts when I do that.” And the orthopedist responds, “Then don’t do that anymore.”
When you are visiting a medical professional, it is important to remember that your ratings of a pain experience cannot be compared to the rating of a similar experience with someone else. If you rate a broken arm as a 4, and your child rates her broken arm at an 8, that does not mean that your child’s pain is twice as bad as yours. Pain rating scales are inherently biased, and because they are based on a person’s past experiences, you cannot compare the ratings of one person to another, despite the fact that physicians and nurses do this all the time.
In conclusion, if you are confronted by a medical professional who tells you that your pain is “inappropriate,” it may be in your best interest to run, not walk, to find another healthcare provider. This kind of bias indicates a basic lack of understanding of what pain is, how the pain system works, and how pain becomes a conscious perceptual response. It can be very hard to adequately treat pain when one does not have at least this basic understanding of what pain really is.
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