Because pain is relative to the individual it does not lend itself to easy or accurate measurement. This may lead to a misinterpretation of the pain an individual is experiencing, particularly when others cannot relate the experience to themselves. During a typical medical consultation, the patient is asked to describe their own symptoms, which in turn acts as the most accurate measure for the physician to work with. The judgement as to the nature and type of pain relief to be used is guided by the adjectives the patient uses to describe its intensity (stabbing, dull, crushing, etc). The patient may also be questioned regarding its duration, location and what, if anything, they are doing to relieve the symptoms and its effectiveness. Of course if pain is then associated with a clinical condition then treatment of the condition will help to reduce or stop pain.

Once treatment is administered, the healthcare worker relies on feedback from the patient. This feedback comes directly (nurse I’m still in pain), and indirectly, e.g. from relatives or from an observation of body language. Developing a full appreciation of pain experience can be a time consuming issue. For example, Karoly (1985) states that six key elements contribute to how we perceive pain. These are:

1. Sensory (intensity, duration, location, etc)
2. Neurophysiological (heart-rate, blood pressure, EEG, etc)
3. Emotional / Motivational (anxiety, depression, anger, etc)
4. Lifestyle (relationships, sexual behaviour, marriage etc)
5. Behavioural (exercise, work, previous history)
6. Information Processing (coping style, health beliefs and knowledge, etc)

More commonly, questionnaires or scales are used. One of the simplest measures is the use of the Visual Analogue Scale (VAS) The VAS is a small plastic ruler about 12 cm long, along which the patient can slide a marker. At each end of the ruler a statement is printed. The patient is asked to slide the marker to a point that represents their level of pain. Once done, the healthcare worker simply turns the ruler over and can obtain a rough numerical guide as to how the patient feels. VAS scales, despite their simplicity, are quite accurate forms of self-reporting. Over time, the healthcare worker can establish whether or not pain is diminishing, remaining stable, or getting worse.

Pain relief then, can come from a variety of sources. Drugs, such as opiates in the form of morphine, or salicylates like aspirin or ibuprofen, are standard and effective methods. Surgery is reluctantly used as pain often re-occurs after neural pathways have been severed. Physical methods such as massage, heat or cold packs, ultra-sound or TENS machines, serve to disrupt the pain in a manner similar to changing the wavelength on a radio. Psychologists encourage new ways of thinking, particularly with chronic pain, where dwelling on pain serves to make it feel worse. Relaxation and more focused ways of thinking are acknowledged to increase effective coping skills.

Our interpretation of pain seems to vary over time and across cultures. Pain, it seems, is a very personal experience and does not always need to relate to physical or pathological factors. In a previous article (”The Nature of Pain”) it was pointed out that even when physical trauma occurs it may not equate with the sense of pain and in some cases may not even appear at all.

Because of its variable nature attempts to explain pain from a theoretical perspective have not always met with success. Descartes (1664) likened pain to the ringing of a bell at the end of a rope. As the rope is pulled, so at the almost the same instant, the bell rings (prick your finger, you feel the pain). The idea of specific pathways for pain was to remain for a further 300 years. Theories became more elaborate as ideas about pain ‘spots’ over the skin (von Frey, 1894) were superseded by ideas involving different types of pain fibre and pain receptors. Whilst the specificity model has illuminated information about neural pathways, its main weakness is the fact that it cannot explain how or why sensations of pain varies so much according to individuals and circumstances. In such a model we should all perceive pain the same.

As a result of Beecher’s research with wounded servicemen (1959) it appears that psychological aspects play a crucial role in how we perceive pain. Severely wounded men will often complain of very little pain. One idea is that the relief that follows removal from a combat zone acts as analgesia, but it is also possible that the bodies own natural opiods may also have such an effect.

One of the most influential alternatives to specificity theory is a model of pattern theory developed by Melzack and Wall (1965). The ‘Gate Control’ Theory as it is known, is also a prime example of the biopsychosocial model in that it attempts to encompasses biological, psychological and social aspects into our understanding of pain:

According to the model, a system exists within the spinal cord in which messages to and from the brain serve to open or close the ‘gate’. So, if I bang my knee, a neural message is passed to transmission cells in the spinal cord which in turn alert the brain to my discomfort. The physical injury has opened the gate via small & large diameter nerves. My psychological state also has an effect on opening the gate. If I’m anxious for example, or if I dwell on the injury, the longer the chance I will perceive discomfort. The gating system is a two way process however. Conditions that help to close the gate are counter-stimulation (rubbing it better), or taking an aspirin, or being distracted by something more important than the injury.

Does this mean we understand how pain works? Well, not quite. Even though the Gate Control Theory provides an elegant way in which to conceptualise the pain / analgesia process, there are one or two issues still to be addressed. The first is that, to date, no gating mechanism has actually been found. Secondly, the theory still assumes an organic basis for pain and although an attempt has been made to link mind and body it is still the case that physical states are seen to influence psychological states and vice versa. Therefore the theory provides a mind-body overlap, rather than a truly integrated model.

Wouldn’t it be great if we couldn’t feel pain?

Well, no it wouldn’t. Our ability to perceive pain has evolved as a sophisticated response to our environment. Pain warns us that physiological damage is happening or has happened. It helps us to learn about situations and events likely to cause damage and even if we are injured pain serves to identify limit our activities until we have recovered. We do however have an insight into what our worl would be like without pain. In rare cases of congenital universal insensitivity to pain (CUIP), people are born with an inability to feel pain. Miss C, a Canadian and sufferer of CUIP, helped with experiments to try and understand the condition. Despite exhaustive investigations no cause could be found. Miss C died at the age of 29, after developing infections due to joint injuries which she could not feel. Even after death her post-mortem revealed no physiological abnormalities. CUIP remains a mystery to this day.

The case of Miss C is actually only one of several puzzles about pain. The sudden loss of a limb may result in a state known as episodic analgesia. Here the victim is perfectly aware of what has happened, but feels no pain at the site of the injury. The onset of analgesia (pain relief) is instant but only lasts for a limited time. This can result in the curious effect of the victim whincing at the minor pain of a tetanus injection whilst being unaffected, at least for a time, by the severity of limb loss.

Sometimes pain occurs after injury to the body has repaired itself. Neuralgia, for example, is a sudden intense pain that follows the track of a nerve. It is associated with nerve damaging diseases like shingles although, curiously, the pain starts after the disease has ended.

The vast majority, if not all people, suffer at some time with headaches. Headaches are a familiar if unwelcome feature of life and can often be traced to stressful events, over indulgence of alcohol, staring at this screen for too long and so on. Yet relatively little is known about the mechanism of headaches such as migraine which were originally thought to be due to dilation of blood vessels. However, it is now known that blood vessel changes are a result, not a cause of migraine. Headaches however stand as the prime example of how we experience pain without injury.

Whilst we tend to associate pain with the severity of injury this is not always the case. Certain cancers cause profound injury to the body but produce little pain until quite advanced. Yet, a paper cut on the finger can cause immediate discomfort. Likewise a damaged dental nerve can produce agonising levels of pain.

So-called phantom pains occur after the loss of a limb. People may try to walk on a phantom leg for example because it still feels so real. Phantom arms may feel as if they are hanging by the persons side. People with spinal injuries may also experience phantoms and may report the fatiguing sensation of cycling movements with their legs. Phantom limbs can appear to get stuck in awkward position and around 70 per cent of phantoms have a wide range of sensations such as heat, cold, itchiness and pain. An explanation for this is that the brain contains a kind of neural map of the body. When a limb is lost, the brain still regards it as being in place and tries to accommodate messages from nerves in way it can make sense of. This results in the sensation of limbs being intact.

Whilst a lot is known about pain it is clear that a great deal remains unknown. In the second of the articles on pain we explore psychological models that have been constructed to help explain the pain process. The third article looks at options in the treatment of pain.

The good news is you can strengthen your gluteus maximus fairly easily. And many people will find the exercises for this part of the body more interesting and enjoyable than abdominal exercises. You still need to continue your ab exercises such as crunches and sit ups, but doing gluteal exercises will protect you from all ends!

One exercise you can do to keep your gluteus strong is walk up and down stairs. If you do not have stairs the leg press is just as good or better. The leg press can be done in the gym on the machine or you can make your own version at home.

Here is how

Get a small bench or stepping stool to start with, about six to eight inches off the ground. Put your right foot firmly in the middle of the step, now lift and quickly tap your left toe up to the bench and next to your right. Quickly lower the left foot to the ground and then repeat. Use your buttocks muscles to do the lifting and lowering. To do this you will be bending the knee that is on top of the bench. Keep your movements slow and controlled, especially on the way down. Do about 12 to 15 repetitions on each foot.

Eventually you will want to work up to a higher bench that is about 12 to 18 inches off of the ground and do more repetitions. You can also increase the resistance by adding five to 10 pound weights rested on your shoulders.

Even if you are not having back pains now, gluteal exercises are essential for everyone wishing to protect themselves from future back pains and injuries. So … keep that rear in gear!

Just let the subject of lower back ache come up in a group and what started out a tidy conversation develops into a free-for-all, with men and women, old and young, fighting to share their woes.

Nine of every 10 of them are their own lower back’s worst enemy. The tenth really needs a physician’s attention. So just in case your number is ten, take this friendly advice. If your lower back hurts all the time, don’t rely on the price of this net to cure it. Go at once to your doctor. If he recommends medical treatment, take it. If he suggests consultation with an orthopedist, obey him. If he merely says, “You need exercise”, be thankful.

Pain in the lower back may indicate problems other than poor posture, lazy muscles or even sacro-iliac sprain. Certain diseases of the abdominal viscera give warning lights with lower back pain. If you’ve ever experienced kidney inflammation, for example, you know it was introduced by lower back pain. Some visceral ailments may be helped by exercise, but that should be your doctor’s decision, not yours. Certain doctors believe that even after sacro-iliac sprain, gentle exercise should be done.

A man repairing a stone wall on his property lifted a huge rock. Suddenly there was a snap and an agonizing pain in his lower back. His doctor diagnosed it as sacro-iliac strain, kept him in bed for a week, then strapped him securely and began putting him through mild exercises. In a few weeks he was his old self - with one notable exception, he has never stopped exercising his back muscles in the ten years since.

All exercises for such backs must be planned to avoid twisting the muscles. They should be done slowly and for a few moments only, both morning and night.

For the other nine of you, here’s how you abuse your lower back. First off, you don’t do a thing to strengthen it. Over and over again when back achers are asked if they do any exercise they reply brightly, “Oh, yes! Every night and morning I bend forward and touch the floor with my hands at least ten times.” This “exercise” strengthens the lower back muscles just about as much as drinking a cup of tea. Never in all my years of teaching have I given it in a back routine. Gravity carries the body forward and there is not sufficient counteracting muscle action to make it worth doing. The best that can be said for it is that it stretches the thigh muscles slightly. But there are far better exercises for even that.

No, you do not exercise your lower back properly. You do not stand properly, either. You stand with your weight on one foot and out juts the pelvic girdle. The pelvic girdle articulates with the sacral vertebrae, right where you hurt.

You stand with knees thrust back, calf muscles tense. Out go the buttocks and in goes the curve of the lower back. All the muscles there must brace themselves to adjust to this unnatural posture. But do you care? No. You just go on using hot water bottles when the ache becomes too severe. Take a tip from a doctor, a specialist in arthritis. He’ll tell you that the constant straining of muscles and ligaments due to hollow backs and rounded shoulders are the fore-runners of many cases of upper and lower back arthritis.

Then you mistreat your feet - a case where distance lends disenchantment. Closely linked roads lie between unhappy feet and the lower back. Visiting aches can travel over them quickly.

Are your arches weak? You’ll regret it in your lower back. Do your shoes pinch? Your lower back can tell you all about it. Are your heels so high that your weight pitches forward or so run over that it cants to the side? Look forward to an ache in your lower back.

You lash at your lower back muscles every time you lift and carry something heavy. There is no more vicious injunction than that oft repeated “Put your back into it” when we are being urged on to some extra task. Put your legs into it, yes. Your shoulders, too. But not those poor over-worked lower back muscles. They have enough work supporting the back and the viscera.

Did it ever occur to you that your bed mattress can fall into bad posture habits? It develops exaggerated curves, too, and they tease your back all the time you are sleeping. Give that mattress some corrective exercise along with your own. That can be done easier and at less cost than providing yourself with a new back.

By the way, have you weighed yourself recently? You’d be surprised how ten extra pounds and three inches around the abdominal region will drag at your lower back muscles. They’re probably weak anyway, for overweight indicates lack of muscle exercise. If you exercised your muscles you’d burn up that excess fat. With it hanging down in from the lower back muscles stretch and stretch till they’re so exhausted they can’t relax.

Do you really want to cure your back aches? Practice the posture we preach. Read the site and do the exercises that apply to your specific daily activities; study yourself to learn what you are doing wrong; then right that wrong. Do the exercises every day.

This first exercise is one of the easiest to do and an excellent one for beginners. It can be done without the slightest strain on even the weakest of lower backs. It can also be done standing. It is more beneficial if done twice a day, even if it is repeated fewer times on each occasion.

Exercise for the Lower Back

1. Lie on your face, arms in comfortable position, legs out straight.

2. Squeeze the buttocks muscles together as tight as possible.

3. Relax.

4. Repeat five times. Rest. Do this 10 to 15 times in all.

You can blame most physically induced back aches on faulty habits… in basic posture or in the attitudes we assume in daily occupations. We overuse our back muscles or we pamper them. Almost never do we use them just enough. Some overuse can’t be helped; it’s part of the weekly pay envelope. Knowing that the latissimus dorsi and trapezius must work with the upper arm and shoulder in addition to covering the back, you can see why any job requiring constant use of upper arm and shoulder may pay off in back pains.

Generally back aches strike in one or more of three places:

1. At the base of the skull, extending along the neck about two inches each side of the spine.

2. Between the shoulder blades.

3. Across the lower back.

Skullduggery

Sometimes the base-of-skull ache shoots clear to the shoulder joint. Sometimes it penetrates to the seventh cervical vertebra. If it does, you’ll know it when you angle your head forward sharply. Place your fingers on these spots and press. Did you say “Ouch?” Lots of people say worse than that.

Aches in this area are mean. They are red-hot needles that pierce deeper and deeper into your hide… an electric current probing among your bones. Lying flat on your back helps … until you get up again.

Nothing will permanently poultice your aches except perfecting your posture. You might lessen them by a change of occupation or by learning to relax your nerves. But what you want is to get rid of them, isn’t it? So pull in that head that protrudes like a turtle’s, it’s wrenching and straining at the muscles. And get those shoulders away from your ears. Take your elbows off the table or desk and your chin out of your hands; let your arms hang straight down for a change. Your muscles get awfully sick and tired of holding your shoulders up in the air that way.

Not-So-Gay Blades

If you suffer from a shoulder blade ache, perhaps you find it odd that it so often hits you at the right of the spine and just at the edge of the right scapula. It’s not odd, if you are right-handed. Were you left-handed, you’d point to the left of the spine to locate this ache. But southpaws suffer less from this ache than the right-hander. Ordinarily, the left handed person makes more use of his right hand and arm than a right-hander do with his left. And there’s one of the clues to that ache: overuse of the arm. When the arm works overtime, so do the trapezius and other muscles that are connected with your shoulder and shoulder blades.

A woman lawyer complained constantly of this ache. She worked at a desk all day handling heavy law books and eternally wielding a pen or pencil. Usually she labored under extreme pressure and tension. She was given exercises to strengthen muscles in that area, taught to maintain a correct sitting position and instructed in relaxation methods. In a month’s time her aches vanished. But later, under extreme pressure, she allowed herself to slump into her old occupational posture habits. The aches returned. There was noting more to be done for her. She knew what to do. But only she herself could make her do it.

Has this ache ever accompanied you on a weekend or vacation road trip? You packed your suit case too heavily for your unused muscles. Lugging any heavy objects by hand may have the same effect. And what about that blustery winter day you spent before the open fire, nose in a book all day? Didn’t you have a shoulder blade ache that night? Next time, hold the book up to your nose instead of your nose down to the book. Which of course brings us right back again to the matter of posture and holding head up and shoulders back. There’s a limit to what the trapezius can stand.

Shoulder blade aches have a particular affinity for men and women who sit most of the day. They dote on the typist, the switchboard operator and anyone else who constantly sits and uses arms and shoulders.

To be continued…

Anyone who is new to cycling is at risk of developing an aggravated neck sprain if they ride for a long time. Although neck pain normally disappears after a few days of not riding a bike, some cyclists experience pain any time they participate in cycling. If this applies to you, you must understand what causes the neck pain that occurs after biking, as well as ways in which it can be prevented and treated.

Neck pain that occurs as a result of cycling is frequently caused by neck strain due to poor posture when riding. When you buy your bicycle, try to have the sales clerk advise you as to the correct positioning of your body; also, make sure that the seat is positioned correctly for your height and weight. In many cases, the neck pain will be relieved when the posture and the seat are corrected.

Take generic Ibuprofen or other types of anti-inflammatory medication prior to cycling. This will help reduce any muscle swelling that occurs after your bike ride. Also remember to stay hydrated, because some people’s neck pain is associated with dehydration and headache pain. Upon your return from your cycling expedition, take more ibuprofen if necessary. You can also take a warm shower or place a warm compress on your neck muscles. If you do this, your neck pain should be relieved and you can get back to bike riding very soon.

Neck pain commonly occurs for many who are just starting cycling; as your body becomes used to the bike riding position, the pain will dissipate. Remember to use correct posture when bike riding and take frequent breaks. If you keep this in mind and use the correct anti-inflammatory medications, it is possible to continue to enjoy bike riding without suffering from complex neck pain in the future.

Paracetamol, together with an anti-inflammatory medication, is recommended for pain that is associated with inflammation, such as that of a back strain or headache.

If it is damaged or sensitive nerves causing the pain, as with conditions like sciatica or shingles, the pain is usually treated with tablets that are prescribed contrarily for epilepsy and depressive disorders. This medicine acts on the central nervous system.

Medicine is meant to increase our well being. You should carefully weigh the risks and benefits, as all painkillers can potentially cause unwanted side effects.

Aspirin, Paracetamol, Codeine, anti-inflammatory

Aspirin — Aspirin can have the same side effects as other anti-inflammatory medications, but it does not offer particularly good pain relief. Aspirin is usually not prescribed for pain, and has potentially grave consequences for children younger than 12.

Paracetamol — Two pills can be used for a maximum of four times daily and this is verified to be a good adult dosage. Side effects are rare and this amount can be used regularly for a long time. Overdosing on paracetamol can lead to grave side effects. It is typically taken as a headache treatment and many non-nerve aches. If your pain becomes worse, you shouldn’t take a higher dose, as this might make the condition even worse than it is.

You need to see your doctor if the pain continues for more than three days.

Anti-inflammatory Ibuprofen — Ibuprofen seems to work better when there is a definitive diagnosis of an inflammatory disease like having arthritis or being injured. It should not be taken for an extended time if you don’t have bad inflammation. If it is used for an extended time, there is a higher chance for stomach problems as well as hemorrhaging, kidney and heart trouble. Don’t take more than the suggested dosage since this will cause bad side effects to happen.

Codeine — Codeine is not very effective when taken alone. It is more effective when used in conjunction with paracetamol, and these paracetamol and low-dose codeine or co-cocadmol medications are available over the counter. Codeine has to be a prescription for higher amounts and also moderate amounts of pain medicine include Zydol and dihydrocodeine have to be prescribed.

Addiction can result with all of these painkillers, and this leads to unwanted side effects if you stop taking them, much the same as when someone tries to quit smoking. If addiction becomes a problem for you with these drugs, please seek out help by talking to someone you trust or a health care adviser, as overdosing on painkillers can be fatal.

Actually, though, adverse reactions to medications don’t always happen instantly. It may be weeks or even months before the symptoms of certain adverse medication reactions are noticed. For example, many people develop muscle soreness after they begin taking a statin medication for their cholesterol. Yes, it’s possible that someone could not display symptoms for a long time, without having heavy muscles and feeling discomforted, but typically the majority of bad reactions to drugs will happen after the first four to six weeks of staring the new medication.

Allergic reactions to drugs are one example of an adverse medication reaction that often occurs very soon after taking the drug. If you develop an allergic reaction to the medicine, the reaction will occur within a few hours to a couple of days after you begin the new regimen. A skin rash is often a mild symptom of an allergic drug reaction, while more serious symptoms include shortness of breath, fever, or dizziness. Even in those situations where a rash is the only symptom you develop, any symptom of an adverse drug should be evaluated and treated as soon as possible. After a person has been treated for a reaction, he or she should not take that medication again, because more severe symptoms could occur with the next dose.

What is the most effective way to avoid having an adverse medication reaction? So that it will be less likely you experience a drug interaction, keep your doctor up-to-date about every medication, herb, vitamin, and supplement you take. It is important that he or she also be told of any adverse drug reaction you have previously had. You should give your pharmacist information about all the medications you’re taking when he gives your prescription in order to ensure that there are no conflicts with your medications. If you start having any symptoms after you start taking a new medication, contact a doctor. Research your new prescriptions at trustworthy websites to learn what side effects are most commonly experienced.

An adverse drug reaction isn’t unusual, and in some cases, it can become a threat to your life. You may not notice the symptoms immediately; sometimes they happen weeks or months down the road, so be on the lookout for any new symptoms.

So what are some steps you can take?

Educate yourself. Find out everything you can regarding the kind of pain that you are afflicted with and what can be done about it. One of the big problems faced by chronic pain sufferers is that there are a myriad of “complications” that can occur. For instance, consider stress. Stress hampers the body’s healing efforts. Stress levels can rise when one experiences pain each and every day. Thus begins a downward spiral — the more you have to deal with pain, the more stress you may have. Your pain tolerance as well as your patience with daily irritations decrease as a result of the stress. This could be why many people with chronic pain do not find relief when they use traditional treatments. Plus, only 18% of those in pain try to find alternative methods to deal with their pain.

Look for other methods of treating your condition. There are many non-standard options available. Possibly massage, acupuncture or chiropractic manipulations would be helpful. Just because an option sounds unusual, do not discount it.

Become a member of chronic pain groups that deal with your condition. You may be astonished to find that many others suffer from conditions similar to yours. People who have gone through similar experiences may be able to provide some helpful pointers.

Remain active. Exercising regularly helps beat stress as well as decreases the perception of pain. Are you unable to perform your regular exercise routine? Modify your workout so that it does not cause pain or try an alternative such as Tai Chi, which is a gentler exercise plan. Don’t let pain stop you from remaining active. Doing so will only make you feel worse on a physical level as well as a psychological level.

Write it down. Write down your episodes of pain as well as those things that make the symptoms worse. What are some of the things that are helpful in decreasing your pain or helping you manage it? Perhaps a certain food or activity helps, or perhaps an increase in stress is a contributing factor. If you write it down, you may be able to avoid things or behaviors that bring the pain about.

Don’t fool yourself. Pain should not be thought of a weakness. It can be just a minor bother or it can be completely debilitating, or it can fall somewhere in between. You must be aware of and accept that there are things that you cannot do. Possibly you must learn to deal with the pain and carry out your daily activities despite it.

Pain is a real problem that many of us must deal with — it is not just a fleeting issue. Pain can be chronic or occur once in awhile and it can be physical or psychological in nature. However, one thing is obvious: pain indicates that something is wrong.

Although pain will never disappear from the world, one thing is certain — we are not the only ones who suffer.