Pain
What is pain? We know it when we feel it, but it’s not so easy to put into words. In 1979 the taxonomy committee of the International Association of the Study of Pain was able to come up with a definition, which still has relevance. “[Pain] is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage,” the committee stated. “Pain is always subjective.” With those last few words, the committee added a crucial element.
What makes telling anyone about the pain you feel so difficult is precisely its subjective nature. The philosopher Ludwig Wittgenstein said, “I cannot feel your pain.” Any pain the philosopher felt was his own. That’s the human condition. Nobody can feel your pain; you can’t feel anyone’s pain. All you can do is empathize. A physician like myself, looking at a patient’s MRI, may see a herniated disc of the sort that sometimes hurts terribly. Yet the patient may insist she feels nothing. Her truth must become mine. Of course, the opposite situation may also exist, when a patient feels tremendous pain for which I can find no apparent reason.
Symptoms and Signs
Symptoms are the unpleasant physical problems that usually bring patients to doctors, who then make a diagnosis and prescribe treatment. Anything you feel subjectively and must communicate to another person in words is a symptom. That means pain, heaviness, tingling, ache, or any one of a number of other types of discomfort. You are the only one who knows where and how much it hurts and the only one who can express all that in words. You’re the world’s expert on your own pain.
Signs are the external manifestations of illness and injury. A fever is a sign, but dizziness, blurry vision, cramps, earache, stiffness, a feeling of being “chilly” are symptoms. Swelling is a sign. Signs are the opposite of symptoms, because they’re objective. Nausea is a symptom; vomiting is a sign. A keen observer, your health-care worker may tap on your knees to check your reflexes, may press on a muscle to see how tight it is, may listen to your heartbeat. A sign is also the result of a diagnostic test performed with equipment—the number on a blood test, the contents of a spinal tap, what an imaging study like an X ray or an MRI tells the doctor.
The distinction between symptoms and signs is an important one for helping you understand your conversations with your doctor, and for communicating with your yoga teacher. The trained interpretation of symptoms and signs in the context of a medical history is what clinicians call a medical exam. This involves the Review of Systems: a checklist of symptoms and signs created by great Greek, Arabian, and Jewish physicians of the Middle Ages and earlier, which every contemporary medical student must memorize. The medical exam encapsulates wisdom gathered by many healers over the millennia, and some say it accounts for 90 percent of the conclusions that comprise a diagnosis.
Intensity
If your pain interrupts your concentration and daily activities or makes it difficult to work, enjoy your leisure time, or sleep, it’s time, or past time, to do something about it. If you would describe your pain as slight or moderate, you may not need to see a health-care worker, unless it persists for more than two weeks. A dull, persistent ache that goes on and on can exhaust and depress you. Get help if you have symptoms for more than fourteen days.
There are scales your doctor may use to help you gauge the severity of your pain. These scales have been used with some success to quantify pain, to make a reliable, objective correlate. These scales ask you to “grade” your pain on a scale of one to ten, or they present a drawing of a person, front and back, and ask the patient to use multiple-choice descriptions of where and how much it hurts.
A pain scale is useful in gauging the effectiveness of physical therapy, acupuncture, medicines, and exercise like yoga. You might find it an interesting exercise to assign your pain a number from one to ten and to make a note of the number several times a week to see if yoga is making a difference for you.
0—no pain at all
2—bearable pain anyone might experience from carrying a heavy bundle too far or standing on one’s feet too long
5—pain that often interferes with your concentration
7—intense pain that takes the pleasure out of daily activities and is the chief focus of your attention most of the time
9—pain that may make you feel like screaming
10—unbearable pain, a medical emergency
Some people find it difficult to locate pain with any certainty. It seems to move from place to place. Others have trouble finding the words to describe their pain. The McGill-Melzack Pain Questionnaire, popular with physicians, has more than seventy-five words to describe pain, including flickering, jumping, pricking, lacerating, pinching, gnawing, cramping, scalding, itchy, sore, heavy, taut, tiring, sickening, annoying, spreading, nagging, and dreadful.
Time spent finding the proper words to describe and locate your pain is not wasted. As Wittgenstein asked, “How could I get between a man and his pain?” Words are insubstantial enough to do just that.
Acute and Chronic Pain
The way you approach yoga is determined in some measure by whether your pain is chronic or acute and, of course, by your underlying physical condition. Assume for a minute that your pain is chronic. Let’s say it comes and goes, that it hampers you but doesn’t cripple you. You don’t play tennis the way you used to; you don’t jog. But you can go on with your life. If this describes the type of pain you have, then yoga is exactly the right thing for you. You should start slowly. Get a diagnosis, then find the poses that are appropriate and helpful for you, and go straight ahead.
If your pain is acute, yoga may also be for you but you are going to have to proceed a little differently. You will need to be mindful of the pain itself. It’s not the chronic condition that is your target here; it’s the pain you’re experiencing while you are actually doing the yoga poses. I’m making a distinction between doing the poses so you won’t feel pain (chronic) and doing the poses so you will relieve the pain you already feel (acute). In the second case the disadvantage is that the pain itself can keep you from doing too much yoga. But the advantage is that you can actually feel the effect of the pose as you do it. You have instant feedback on your pain. If doing a specific pose or a number of poses makes your pain worse, don’t continue. However, it is worth talking to someone with adequate experience and knowledge who can give you advice before ceasing all activity. There are many kinds of pain that we all know about that get worse before they get better.
You may be experiencing that type of pain. A tight hamstring has to stretch. That’s something that isn’t painful to start with, but when you make it hurt a little, you know very well what you’re doing. A hamstring that’s in spasm is extremely painful, and unfortunately the only way to relieve it is to stretch it. That often produces significantly more pain before you get the benefit of relief. That’s the type of additional pain that should not deter you. On the other side of the increased pain that comes with the stretch is the diminution of the discomfort.
If you feel a sharp, tingling, or stabbing pain while doing yoga, stop what you are doing immediately! This is especially true if you are pregnant. The type of pain that comes from slowly stretching muscles, ligaments, joint capsules, or fascia is the only type of pain that is acceptable.
Do not do the stretch or the pose that is to relieve a spasm unless you can identify the spasm. When you can feel that the muscle is tight, when pressing on it relieves pain, when you can see muscle contraction, then stretch can be a good thing. If you have a pinched nerve, that very same pose you found helped you with a muscle spasm can hurt you instead.
If you have sacroiliac joint derangement, you may need to stretch the muscles around the joint a little. A little pain may bring relief later if you have arthritis. To relieve the dull, aching pain of piriformis syndrome, you will need to cause yourself a little bit more pain, since this problem is usually associated with muscle spasm as well as a nerve compressed by the tightened muscle. If you have spinal stenosis, the acceptable stretch is in the muscles, nowhere else. The red stoplight goes on if you feel any stinging, numbing, or other neurological symptoms.
Muscular Pain
“Nonspecific backache” is the fifth most common reason patients visit doctors. Included in this diagnosis are muscle spasms, sprains, strains, sacroiliac joint pain, and backache caused by nonneurological conditions, stress, and other emotional problems.
If you feel a dull, manageable ache in the area of your lower back, you probably have musculoskeletal pain. It is possible to verify this by placing your thumbs a little above your waist, three or four inches to either side of your spine. If pressing on the muscles there—the quadratus lumborum and the serratus inferior posterior—produces pain, it may be that you have lifted something too heavy or worked too hard in the garden.
Try putting your hands on your hips and “walking” upward with your thumbs. When you can feel the curves of your ribs, you may feel pain. The problem could have come from twisting or moving from side to side while carrying something heavy, like a suitcase, from parking a van without power steering, or from an awkward repetitive movement.
Neurological Pain
Tip-offs:
• If your pain follows the pattern of nerves in your body, i.e., sciatica, where pain descends to the thigh, calf, and/or foot
• If your muscles don’t ache but do feel stiff
• If you have distinctive pain, for example feelings of electrical shock
People who have back problems often suffer from neuropathic pain. In a sense, all pain (and pleasure) is neurological since the nervous system participates in anything we feel. Neuropathic pain arises not only when the nervous system communicates and registers the pain, but also when the pain originates from damage or other causes that affect the nervous system itself.
Diabetes mellitus, for example, can cause unpleasant tightening of the shoulder capsule, the discomfort of which is communicated to the pain centers in the brain through the nervous system. This is not neuropathic pain. However, the elevated blood sugar seen in diabetes can also cause direct damage to neurons, giving rise to painful sensations of burning, tightness, and tingling, which would be classified as neuropathic pain. The injury to neurons caused by increased concentration of blood sugar can also cause numbness. That scenario gives rise to a strange possibility: The injured neurons might actually reduce the pain coming from a non-neurological cause—in this case, a painful shoulder. In other words, a person with a frozen shoulder and a neuropathy caused by diabetes might not feel the pain of the shoulder condition because pain-communicating neurons don’t function properly.
I have seen this situation. Generally it results in gross damage to the joint, since the patient is getting no feedback that draws attention to the orthopedic condition. This phenomenon—when you don’t feel what ought to hurt—also applies to low back pain.
The injury that causes pain in the low back can also reduce the ability of the spinal cord to carry signals up and back from the point of injury to the brain. In a sense this may muffle your body’s call for help, reducing awareness of the condition that is causing harm.
When reflexes are working normally, a tap on the knee activates the sensory nerve, bringing impulses up to your spinal cord, where they synapse with a motor neuron to make the muscle move. If you have an injury in your spinal cord, it’s quite possible that it will interfere with the nerve conduction and, finally, the reflex. The most serious injury of this sort occurs when there is an injury in the lower back, which can interfere with the sensory nerves that carry feelings of fullness from the bowel and bladder, affecting control. Also the sphincters of the bowel and bladder may not work properly because the motor neurons that actually keep them closed aren’t working, or because the brain isn’t functioning the way it should.
Neurological problems can also affect your locomotion. The way you walk, your gait, is a delicate process that depends on coordination of an extensive pattern of signals that go up from the bottom of your foot to your knee and hip when you move your leg forward. The nerve impulses direct the movement of your leg until you finally put your foot down in front of you to begin the next step. If your gait becomes abnormal, for example with “dropped” foot, you could have problems with the motor system or the sensory system or a combination of the two. If this happens, obviously the danger of falling is greatly increased.
Danger signals: Go to the emergency room immediately if you are actually weak, if numbness ascends your legs, or if you lose control of your bowels or bladder. These symptoms and signs could signal that the nerves ascending in the spinal cord are being compressed to the point where they may actually die, causing permanent disability. While neurological pain may be intense, all high-level pain is not neurological. Do not try to ignore any pain that approaches the unbearable or excruciating; it should be promptly diagnosed by a competent medical professional.
Sometimes symptoms and signs are localized, existing in a particular part of the body. For example, the feeling of tightness you get when you have sunburn is a symptom you can easily “place” in the skin. That is opposed to the redness the sun may produce, which is an objectively observable sign. But nerves are everywhere. Blushing, even though it may be due to something subjective, is, after all, objective and observable. If we consider the endocrine system, then if someone feels hot and has a rapid heart rate, the sensation of heat is a symptom and the heart rate is a sign of hyperthyroidism. The nervous system, however, is the largest system in the body to which symptoms and signs are ascribed. That’s natural. The nervous system is the foundation of behavior and feelings, and in any movement, it’s part of the act.
Pain with Specific Activities
With neurological pain there is a classical, structural approach to finding the cause. Damage to individual anatomical elements results in signs and symptoms. For example, the MRI may locate a specific spot where a nerve root is compressed by a herniated disc. The clinician knows that particular nerve root supplies the skin at the inner calf and the muscles that raise the foot at the ankle. If the patient slaps that foot on the floor and complains of tingling and numbness above the ankle when walking, the physician can make a diagnosis before a word is spoken.
In cases where there is neurological pain, however, there may also be problems with the integration and coordination of the anatomical elements. It may not be possible to isolate a particular pathology of any kind. Piece by piece, the anatomy is just fine but the situation as a whole may be like a dysfunctional family of four healthy, basically happy people who come together and make each other miserable. For instance, a somewhat overweight flight attendant with mildly narrowed nerve openings in the spine may arch his back just enough when leaning over to serve the person in the window seat to cause electric shocks along the femoral nerve in the leg.
But of course other problems may also cause pain. You can have another dysfunctional family consisting not of nerves, but of muscles, bones, and joints. The history teacher whose posture is somewhat hunched over but in the normal range who also has a slightly backward-tilted sacroiliac joint may have terrific back pain throughout the school day. And if you have two perfectly normal legs that just happen to be of slightly different lengths, you may have a different but also painful problem.
I have a vigorous patient, an older man who lives at the shore. In the summer he likes to exercise by walking through chest-high seawater. This gentleman came to me because of a puzzling situation. He had terrific pain when he walked east through the water and felt fine when he walked west. Finding that this man has a leg length discrepancy solved the problem. When he walked with the long leg closer to the shoreline, the slope of the beach added to the difference in the lengths of his legs. It was as if he were walking with one foot on the street and the other on a high curb. Walking in the opposite direction the slope of the ocean floor made up for the discrepancy in the length of his legs.
Actually, there are five ways that doing a specific activity can cause pain:
• You’re doing it incorrectly.
• Individual muscles or muscle groups aren’t equipped for the task.
• There’s an anatomical mismatch that causes damage or pain.
• Poor approach.
• You’re doing it for too long.
In the case of a mismatch, take the yoga pose called Marichyasana. If you have stubby arms and a prominent abdomen, trying to place your arms behind your back and then clasping your hands will be either impossible, or possible at the price of moving something farther than it ought to go. If you feel that your body parts are not meant to or can’t perform a certain activity, common sense and reason ought to come in and take the place of enthusiasm.
Poor approach is often linked with poor posture. At work your chair may be too low. Holding your elbow out while typing might have a negative effect anywhere along your back. If you lean forward squinting at a computer screen for too long, you may cause yourself pain. In my experience people who do physical work may overdo it, but those who have white-collar jobs are at risk for the same mistake.
Yoga may be a specific activity that causes pain. The BBC News has reported that doctors and physiotherapists have observed a surge in the number of inexperienced student yogis hurting themselves after doing difficult or unfamiliar asanas.1 According to this report, the most frequent injuries are those that come from repetitive strain or overstretching, and the wrists, shoulders, neck, spine, sacroiliac joint, hamstrings, and knees are the most vulnerable. Avoid injury by making sure your teacher has adequate training and realize that the cautions above apply.
Yoga may also be used as an analytical tool to diagnose pain caused by another activity. If you find that certain yoga poses or elements of them are hurting, you should discuss it with someone skilled at both yoga and diagnosis. Your doctor or teacher/therapist may be able to use the pose as a way of figuring out what’s wrong.
What you do away from work is, of course, easier to change and adjust than what you must do while you earn a living. However, to quote an old saying: “Don’t let your work interfere with your fishing.” For many, giving up beloved leisure activities is simply not an option. If that’s true for you, and if those out-of-work pastimes are causing physical discomfort, search for ways to make accommodations.
When Yoga Is Not Enough
Every therapy has its limitations. It may be difficult to identify when it is time to move on, with or without yoga, but definitely to take some additional measures to control pain and cure the problem that is causing it. Three such criteria are:
• When you get disabled from doing something such as driving, working, walking, or doing anything that is important for you to do.
• When it hurts or tingles enough to disturb your concentration, whether it’s working, cooking, shopping, watching a movie, talking, reading, etc.
• When compensation for it starts causing other things to happen that aren’t readily controlled: in order for the hip to behave, you start walking or sleeping a little differently, which makes the upper back hurt. If you change your posture ever so slightly, and then your neck ends up stiff, you might take one more Motrin, but the stomach wishes you hadn’t.
It’s All in Your Head
Some individuals spend years trudging from doctor to doctor, explaining their pain as well as they can. Although their pain is real, they may not find a physician clever enough to make a diagnosis and prescribe an effective treatment. In some cases it may seem impossible to find a viable diagnosis.
Usually, when a doctor looks at you and says, “It’s all in your head, dear,” it’s a condescending and disrespectful way to say that you don’t seem to have any of the five or six major causes of back pain, and therefore there is no cause at all. As far as I’m concerned, if this happens to you, you should thank that doctor and then walk out and look for a diagnostician capable of finding out what’s wrong. You may very well have one of the problems the doctor has dismissed, or any number of “composite” causes, such as the ones discussed above.
There’s no question that Freud was onto something real when he spoke of the “Conversion Syndrome,” meaning the transformation of a mental state or problem into a physical one. But in twenty-five years of medical practice, I have not seen this as the full explanation for any patient’s pain. Nevertheless, there are ways where pain is magnified or diminished quite consciously or not quite consciously.
• Identification
• Focus
• Feedback
If you are a kid sleeping out in a tent with your friends for the first time, and they start screaming about a spider infestation, you might identify the normal movement of your pajama leg caused by your own squirming as a spider coming to bite you. If you had a muscle spasm in your back a year ago, you might fear and even begin to believe a much less serious muscular problem is a new spasm. Identification may heighten anxiety, tighten muscles, and actually produce the thing you’re guarding against. This is particularly true with feared diseases. A patient once said to me, “Doctor, I only feel the pain when I start thinking I might have cancer.”
Then there is the incident that makes you focus on pain or the possibility of it. Say someone just coasting along in his car bumps into the back of your car, and for the rest of the day all you can think about is the pain you might get. After a while you begin to feel a little something in your neck, and then in your shoulder. Unconsciously you stiffen your neck and shoulder, tighten the muscles, and change the blood supply to those muscles, increasing the chances that your mental state may cause physical discomfort.
Or it’s feedback. When a car going three miles an hour bumps yours, you may focus on the possibility of pain. Your face takes on an expression of concern, of unhappy expectation. Several studies have documented that if you simply make a face, put on an expression of sadness or disgust, you may actually feel sadness or disgust. Or in the case of the small automobile accident, your facial expression afterwards as you think about what happened could suggest that your brain sent you a message that you are beginning to feel some pain.2
I’ve had a desperate patient say to me, “What can I do if it’s all in my head?” Having a backache makes some people feel guilty, especially if there’s no dramatic explanation, such as a fracture or a herniated disc. But now we know that a person’s low back pain may be related to stress, anxiety, or a number of other psychological factors. Dr. John Sarno, Professor of Rehabilitation at New York University’s School of Medicine and attending physician at the Howard A. Rusk Institute of Rehabilitation, has been a leading figure in helping patients work on stress, which results in low back pain, which results in more stress.3
Stress is a well-documented factor in low back pain. A recent study conducted in the Department of Environmental Health at the University of Cincinnati won the Volvo Award in Biomechanics. Investigators gave individual participants heavy boxes to lift and simple or complex decisions to make. The study concluded that mental stress could result in less controlled movements and increases in trunk muscle coactivation—physical adjustments that raise the risk of low back pain.4
Ernest Holmes, author of The Science of Mind, and Dr. Harold Koenig, author of The Healing Power of Faith and other books, Larry Dossey, author of Prayer Is Good Medicine, and many others have turned to religion for ways to deal with pain. These advocates assert that prayer can actually modulate pain and illness, possibly by reducing stress.5
Last, there is another type of focus—positive focus. Your back may hurt, but if you are able to put your focus elsewhere, you may be able to go on with your day more constructively. I think of the memorial monument of the American fighters raising the flag on Iwo Jima during World War II. Some had injuries; others had even been shot. They were smiling anyway. They weren’t paying attention to what was hurting, but were focusing on something that gave them pride and satisfaction. That all but made the pain seem as if it had been all in their heads.