The Pain Dilemma

No emotion shows itself more plainly on the face of the sufferer than pain – hence the health professional can, from afar, read the face of the patient

Pain evokes in most of us unwanted, disagreeable discomfort. It is ‘a strongly unpleasant sensation’ causing physical and mental distress and ‘widespread suffering, disability, social displacement, and expense. Whether the issue is viewed from a moral, political, or public health perspective, pain that can be relieved should be relieved.

Some religious faithfuls might even wonder as to why did God inflict us with such a plight, and of what purpose it is to us after all. How we wished we were pain free! But without pain, life would not have been what it is; we would not have reacted to extreme discomfort or disgust with tears. Such reaction might have diverted our species to a different destiny. And we may wonder what type of beings we would have been, possibly dull and zombie like.

But reality plus pain is quite a different story. No emotion shows itself more plainly on the face of the sufferer than pain – hence the health professional can, from afar, read the face of the patient and guess the agony through which he or she is going. Generally, a cultured person will tolerate pain less than his counterpart who, having been accustomed to a rugged hard life, will be stoic. Thus some people have a low threshold to pain, while others may walk into the doctor’s surgery with a knife stabbed in their back and nothing told.

Doctors have to know the physiology of pain, its origin and importance, so as to come to a diagnosis. They must know about all types of pain, whether it is burning, stabbing, dull, crushing, spasmodic, colicky, localized or referred; other pain indicators include moaning, clenched fists and verbal complaints. The degree of grimacing or wincing will tell. Such description may, on many occasions, pinpoint exactly what the ailment is.

Is there exception to pain? Some children with abnormal genetic mutation experience no pain. But it is no advantage, for the danger of injury is real. Walking on a painless foot with broken bones, for example, leads to irreversible damage. Suddenly we discover the real function of pain: it helps to protect us from hostile, injurious environmental factors. Some patients go on smoking their cigarettes up to the last butt without noticing that the lighted cigarette is burning through their fingers; their disease has deadened their nerves and no pain is experienced and so they paid no notice. Their fingers go on getting eroded and shorter due to injury and wear and tear — this happens in leprosy.

By now all of us would have inferred that pain, and its intensity, is quite a subjective experience, difficult to assess by health professionals. That’s why many scales had been invented to quantify that noxious feeling; in many centers the most used is a universal visual analogue scale, graduated from 0 to 10. The sufferer is asked to locate his own pain on it, 0 representing no pain and 10 agonizing, intolerable pain. Then treatment is provided accordingly.

Grading

Acute pain is said to be one which does not last more than a month; it may be sporadic, mild, moderate or severe. Sometimes it is so severe that it could lead to sickness, nausea and sweating. After one month or more, pain is described as subacute, while after three months we call it chronic. This causes not only misery, but gradual loss of function of part of the body, and perhaps a decreased expectancy and quality of life.

Recent research has pointed out that there is a difference between acute pain caused by trauma and chronic pain; each lights up different, or overlapping, parts of the brain on MRI investigation. Chronic pain, like back pain, is amenable to modulation by thoughts and emotions; hence depression lowers pain threshold and makes it worst. It involves a structure in the brain called the amygdala, which is concerned with emotions, and part of the forebrain also. In future we will capitalize on such differences on the MRI results of acute and chronic pain to tailor-make our treatment.

Pain and Touch

If we touch ourselves anywhere on our body we will feel the touch; and if we pinch ourselves at these spots we will definitely feel the pain also. And the wonder is, if we think deeply, how come we pinch our knee yet the painful sensations which travel up to our brain via nerves can be felt at the knee but not in the brain – the central interpretation station! In fact there is no return signal to the knee from the brain. This has led some experts to believe that in what is known as its sensorimotor area our brain has a neural map of our own body moulded and imprinted. So some of us, who might have lost a foot or hand, may still feel vividly the pain associated with that absent limb; physically it is no more, but the brain image and sensation are still intact. Recently, someone has even suggested that most probably we have not only an indelible body image in our brain, but also an image of our own self and mind – within that very brain!

So pain and touch, through the largest sense organ, the skin, have led to a further understanding of the human being. All these sensations will help in the building up of our internal and external world image as we age; pain-receptors in our skin get matured and organized, so pain becomes a reality of life. Of course, all along our audio and visual senses will also add enormous valuable inputs to build our body image.

Our skin with all its receptors for pain, touch and other sensations, serves as an electronic interface between our external world and our brain, relaying any physical stimuli it experiences via nerves to higher centers for complex interpretation. And if we are told that our skin, nerves and brain come from the same original layers of the embryo, we will understand the close link between them.

In a Cavadee procession we will notice that many of the pilgrims have their tongues or skin pierced by dozens of needles. The devotees do not seem to suffer. Is it possible that the fasting rituals, accompanied by the religious songs, the priest’s mantra, the sound of rhythmic percussion sound associated with the particular aroma of incense – all reinforced by cultural traditions and hearsay — send the mind into a different track, which will finally inhibit the pain pathways of the pilgrims? Or could it be another form of acupuncture, where the stimulation by needles releases body morphinic substances – the endorphins — which ultimately dull the pain? Or is it both?

There are many ways to treat pain; the aim is to prevent the nerves to transmit peripheral sensation to higher stations in the spinal cord or brain. In extreme cases of intolerable pain physical methods to deaden the nerve, by infiltration with phenol, or just plain sectioning is practised. One of the safest, efficient and cheap pharmacological molecules for mild to moderate pain remains the much maligned paracetamol, popularly known as panadol. Failure to take it regularly as instructed is part of the deception. Opium derivatives are potent treatment, but are beset by addiction problems. Nowadays, many big health institutions have a specialized the pain clinic to deal with all aspects of pain, offering a range of treatment modalities.

But the treatment of chronic pain, which affects nearly one fifth of the world’s ageing population, is another kettle of fish. Some governments have already set up a national plan and strategy to look into that complex problem.

 

*  Published in print edition on 6 October 2017

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