No Pain, No Gain or No Brain, No Pain?
No Pain, No Gain – that’s one adage I hear so much as a massage therapist and yoga instructor. And it can be an incredibly frustrating one. Pain is your bodies way of trying to communicate with you. When you feel pain, your body is trying to alert you of possible injury or tissue damage. However, pleasure and pain are intrinsically linked. While some pain is “good pain”, it’s hard to know how attuned the client is to their body. Some people can tell “good pain” from “bad pain” and know to pull back in their exercise so they enjoy stretch but don’t break a hamstring. Others don’t. There is a fine line between pleasure and pain. Sometimes a deep tissue massage can be “good pain” and release muscle knots and relieve tension. Other times, it’s simply exacerbating tissue damage.
Pain. It’s a simple thing, at least, so I thought. Everyone has experienced it, it’s one of those shared experiences that makes us human; it transcends culture, religion, race or gender. Everyone looks at a gory wound, and goes “bro, that must hurt”!
When I did my undergraduate degree, pain was indeed, believed to be a simple thing. Textbooks spoke confidently about pain pathways. About the amount of pain being directly proportional to the amount of tissue damage. About the nociceptors sensing pain when tissue damage occurs, and sending that message via the nerves and spinal cord to the brain, where the brain could then instruct the body what to do to reduce or stop the pain. And the wonderment of the simple spinal cord reflex, completely bypassing the brain altogether; this occurs when you touch a hot stove – the nerve impulse is sent from the hand to the spinal cord, where a spinal cord reflex causes you to instinctively pull the hand away from the hot object. Self-preservation at its finest (1).
But what these models fail to take into consideration is pain that occurs without tissue damage. Pain that continues on long after the tissue has healed. Pain that arises from limbs that are no longer attached to the body. Why some people who have had extensive tissue damage, such as entire limbs blown off, feel no pain. Why some people feel pain so much more acutely than others. And the number of patients being told that the pain is “all in their head” because no physical cause can be found. Indeed, these people have been accused of imagining their pain, being malingerers or hypochondriacs or having factitious disorder.
Indeed, I myself started to question the narrative of pain, when a simple cervical smear would leave me crying and hobbling around the house all day, yet the old battle axe smear nurse would inevitably tell me that the cervix has no pain receptors, so the procedure could not possibly hurt. Indeed, women are more sensitive to pain than men and are more likely to express it, so female pain is often seen as an exaggeration rather than a reality (2). I prefer the more modern approach; Pain is what the patient says it is (3). And from an expert in sex differences in pain “you treat the pain that the patient has, not the pain that you think the patient should have.”(4)
Pain is a mystery. I never thought that the study of pain would lead me into the study of illusion, psychology and existentialism. What is real? Do the senses we put so much stock in lie to us? And if we cannot even trust our own senses, what can we trust?
Our eyes lie to us all the time. The image we receive from our eyes is upside down, but by the time our brain, with the help of the vesibular system in the ear, processes the pattern of nerve signals, the image is reinterpreted and corrected into a useful image. Maybe one of the reasons newborn babies look so puzzled is that it is thought they see everything upside down until the brain develops enough for them to see the world as it really is. Or is it? Optical illusions work because the part of the brain that controls vision misinterprets signals the eyes send. Seeing is believing. But can you believe what you see? A star may have died hundreds of years ago, but because it takes so long for the light beams to reach the Earth, we still see the light from a dead star. An illusion is a perception that does not match the physical reality. When pain is disconnected from the physical reality, is pain an illusion too?
One of the traditional Hawaiian values of Huna is IKE - the world is what you think it is, which we will explore more in another blog post. However, one thing is true, what we actually see or hear or feel or taste or smell isn’t actually what’s out there, but what we think is out there.
No Brain, No Pain.
One thing that is certain is that pain lies in the brain. Pain is associated with the activation of many different parts of the brain. These parts of the brain are not specific to the processing of pain, but belong to different functional systems that temporarily deal with the existence of pain (5). None of these areas exclusively processes or singularly determines the pain experience, but instead it seems to be a highly dynamic, integrated and spontaneous brain-wide network or dynamic pain connectome that leads to the pain experience (6)
Distraction is another factor in the pain continuum. We spend over half our time thinking about things that are unrelated to our present sensory environment (6). If you are distracted you are less likely to notice pain, indeed there is some scientific evidence that distraction can be used as a form of pain reduction (7) – as an interesting aside, this includes shouting the expletive of your choice (8). So pain has physical, cognitive and emotional aspects.
Getting back to the adage of No Pain, No Gain, it is worth at this point noting, that many parts of the brain involved in processing pain also process pleasure (9). This may well account some of the pain pleasure cross over. For example, it feels extremely painful during romi romi (traditional Maori bodywork) when the practitioner presses deeply on a haemata (pressure point) but it also at the same time feels so extremely good! And it feels amazing afterwards!
There is a very common perception amongst clients that a deep tissue massage is infinitely superior to a relaxation or therapeutic massage – again, the No Pain No Gain adage creeping in. Is this necessarily a justified assumption? In assessing the efficacy of massage for lower back pain, there is a small amount of evidence that deep tissue massage is more effective at reducing pain than therapeutic massage (10), however other studies also point out that any massage is better than no massage for treating chronic lower back pain (11).
Therapeutic massage has proved to be effective for cancer pain, reducing procedural pain, nausea, anxiety and has a positive effect on biochemistry; increasing levels of dopamine, lymphocytes and natural killer cells (12).
Studies have also shown massage is effective for surgical pain, reducing pain intensity, pain severity and anxiety during both the short and long term surgical recovery period. Interestingly, session duration and type of massage had no effect on the positive benefits received by the patients (13).
Massage and bodywork and unique in that for that whole hour the practitioner works on a client, that client has the practitioners full attention. It’s not a rushed fifteen minute appointment with a busy, distracted professional. It’s a whole hour of connection, human connection that cannot be replicated with an electronic massage chair, a robot or an AI. Relaxation massage allows the client to fully relax, and enter that state of deep relaxation, when the stress hormones switch off and endorphins are released. This state of deep relaxation can temporally stop the feelings of anxiety and depression (that can be associated with all types of chronic pain) and allow the person to switch off and relax. As James Herriot found out (see the story of the dying ewe in the dark stable) removing the stress stimulus for even a short time, can help the client to heal (14).
Ultimately, in my opinion, the jury is still out for No Pain, No Gain. The client lives inside their own body and knows intimately how it feels, and what it needs. In some cases, a deep tissue massage or deep bodywork feels amazing and is very therapeutic. In other cases, relaxation is more important than pummelling. It really comes down to listening to the client and ascertaining what’s going on for them and how to best meet their unique and individual needs.
We are more often frightened than hurt; and we suffer more from imagination than from reality – Lucius Annaeus Seneca
References
Lecture notes Physiology of Mammalian Organ Systems, Massey University, 2002
Bigg, Marieke. This won’t hurt, how medicine fails women. February 16, 2023 Hodder and Stroughton.
Miller, L et al. Journal of hospital palliative care, December, 2017. Pain is what the patient says it is: nurse-patient communication, information seeking and pain management.
From Heart Disease to IUDs: How doctors dismiss women’s pain. 13 December, 2022. Vanessa Saba
Ploner M, Sorg, C and Gross, J. Brain Rhythms of Pain. Trends in cognitive sciences, 2017, Feb 21 (2) 100-110
Kucyi, A and Davis, K. The dynamic pain connectome. Trends in neuroscience, 38 (2). February 2015, 86-95
Distraction from pain: the role of selective attention and pain catastrophizing. Rischer, K; Roldan, A; Montoya, P, Gigi, S; Anton, F and Meulen, M. European Journal of Pain, Nov 2020 24 (10) 1880-1891
Stephens, R & Robertson, O. Swearing as a response to pain: assessing hypoalgesic effects of novel swear words. Frontiers in psychology, 2020, 11: 723
Pleasure, pain activate same part of brain. Cromie, William. The Harvard Gazette, 31 January, 2002
Romanowski, M et al, A comparison of the effects of deep tissue massage and therapeutic massage on chronic lower back pain. Studies in Health Technology and Informatics, June 2012, 176m 411-414
Ernst, E. Massage therapy for lower back pain. Journal of Pain and Symptom Management. January 1999, 17 (1), 65-69
Calenda, E. Massage for cancer pain. Current Pain and Headache Reports. August 2006, 10; 270-274
Liu, C; Chen, X & Wu, S. The effect of massage on pain after surgery. Complimentary Therapies in Medicine. December 2022, 71.
James Herriot. All creatures great and small
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