Chronic knee pain, stress fractures, muscle spasms—most cyclists have (or have had) a relationship with pain. Sometimes, as athletes, we tend to ignore aches and live with them, or we spend a lot of time and money finding ways to heal.
To get a better understanding of pain, Runner’s World spoke to Abdul-Ghaaliq Lalkhen, M.D., the author of An Anatomy of Pain: How the Body and the Mind Experience and Endure Physical Suffering about what pain is and how to deal with both the chronic and acute.
Lalkhen has been working in pain-related healthcare for more than two decades. He is a member of the Faculty of Pain Medicine affiliated with the Royal College of Anesthetists and a visiting professor at Manchester Metropolitan University in Manchester, England.
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Runner’s World: What is pain?
Abdul-Ghaaliq Lalkhen: Pain is the word we use to communicate and describe an unpleasant sensory and emotional experience. It comes from the Greek word, poena, which means punishment. We are designed for survival and when we are exposed to a physical or psychological injury, which threatens that survival, we experience pain.
Pain alerts us to a potential or actual threat and moves us to implementing a set of behaviors designed to protect us. The pain from a broken heart is no less real than the pain from mechanical trauma and lights up the same brain areas on a functional MRI scan.
Let’s say, for example, that you have a broken bone. That broken bone releases chemicals designed to facilitate healing, which we generally refer to as inflammation. These chemicals attach to a harm-sensing receptor, which converts the chemical signal into an electrical impulse that’s transmitted to your spinal cord.
The spinal cord is not passive and acts as a relay station between the injured area and the brain. It sends messages to your brain, which then calls on many different parts of itself, including previous injury experiences, arousal, sleep, mood, sense of danger—among other aspects of thought—in order to create the experience of pain.
The brain can either increase transmission of harm-sensing signals from the spinal cord or reduce the flow of signals, thereby modulating the experience of pain.
The brain makes an assessment: How bad is this injury or threat? So, you experience pain through your unique cognitive and emotional way of experiencing the world. Because our brains are all fundamentally different, so are our experiences of pain. That messiness is not imaginary.
RW: Is that why some of us seem to tolerate pain more easily than others?
Lalkhen: Yes. Pain is an experience, and we experience things in different ways because our brains have developed and formed as a consequence of our unique life experiences. Pain is akin to a car alarm going off. We hear the alarm and we go outside to investigate. Some of us will panic and some will look around and say, “oh, it’s nothing.” Sometimes we react in proportion to the event, and sometimes we don’t.
We do know that different people, when faced with adversity, will react differently and this is partially related to what’s called self-efficacy. That is, they will think, “oh, my foot is broken, but I will be alright in the end.” Individuals with high self-efficacy recover better from injury and are less likely to continue to experience pain over time.
Now, that’s not to say that we should ignore or push through pain. Pain is a message that alerts us to danger. If your knee gives out while you ride and you feel pain, then you need to figure out what’s causing the pain. But if, over time, you continue to feel pain after fixing the functional problem, then pain is likely to be due to the fact that the pain alarm system is malfunctioning.
RW: Can pain, therefore, be psychosomatic—that is, all in our heads?
Lalkhen: Well, pain is in our minds—it is an experience created by the brain—but that doesn’t mean it’s imaginary or psychologically-mediated. When people are anxious and depressed, then the pathways from the brain to the spinal cord, which turn down harm signals, are less effective and pain is more severe.
Take, for example, chronic back pain. We don’t really know why we get back pain. We try to link it to changes in discs, but it is often non-specific back pain unrelated to specific damage. That is, we can’t figure out the cause.
When a doctor can’t determine the cause of pain, it’s very distressing to patients (and to some doctors). Chronic back pain is a disease of a malfunctioning pain alarm system. Pain is, therefore, not a symptom in conditions such as chronic low back pain. The disease process is a broken or malfunctioning pain alarm system.
In chronic pain conditions, any stress will turn the volume of the alarm up. We know, for example, that bereavement produces a stress response which will exacerbate chronic pain. We know that when people feel stressed, anxious, or depressed, they are more likely to report pain and to be disabled by pain because they are less able to reduce the volume of the alarm.
So, we need to get to the bottom of the pain. Acute pain might occur because of a disease or injury. Chronic pain may be due to a malfunctioning pain alarm. In both acute and chronic pain, psychological reactions to pain inform distress, disability, and recovery.
RW: Why do some people seem to welcome pain, as in to “push through it” in order to reach a goal? How much should you push back against your body’s natural pain messages to achieve a result?
Lalkhen: Runners and cyclists need to train, and some of that training comes with a cost in terms of inflammation due to tissue damage. Look at American football players who bash themselves every weekend and, to an external observer, don’t seem to feel the pain. They pick themselves up and continue playing and training—the context of the injury modifies the pain experience.
Each of us has the ability to sublimate the information about damage we get from our bodies, but that doesn’t always mean we should.
Cyclists and runners shouldn’t ignore pain. Instead, they should get help to determine the cause of the mechanical inflammation precipitating the experience of pain—the wrong gear, not stretching enough, poor biomechanics—so that they can perform better and not experience pain. Optimizing nutrition and their overall health, as well as engaging in sports-specific conditioning, are an important aspect of being able to perform successfully long-term.
That said, both runners and cyclists, as they age, will likely find their physiological reserve and the ability to recover is compromised. They might need to change their goalposts over time and ask themselves if it’s perhaps more important to exercise to achieve better overall health outcomes, rather than to win a race. They need to ask themselves, “Is reaching this goal going to make my life better?” because sometimes pushing through what they call pain will come with a cost, just as it does with football players.
What’s also important to keep in mind is that pain, because it’s such an individual and unique experience, isn’t the best indicator of disease. Other disease-associated symptoms are better at sending us important messages, including fever, unexplained weight loss, and night sweats. Loss of function is a better indicator of pathology than pain.
RW: You discuss natural pain remedies, such as acupuncture and ayurveda in your book. Some runners and cyclists take natural supplements for pain relief. What do you think of those?
Lalkhen: I work in a pain clinic and people come to me with their medical traditions and the articles they’ve read. There is some truth in everything. However, I operate from the scientific method. Has this treatment been subjected to randomized, controlled trials with the removal of bias? If it has, and the treatment is appropriate for the patient’s condition, then it’s something you can try if the risks of the treatment outweigh the benefits for that individual.
Truthfully, we’re not that advanced when it comes to our pharmacological agents for pain management. We have medications like Tylenol that treat pain for the short-term, but most long-term pain agents, such as opiates, are problematic. We’re quite limited pharmacologically, even in 2023.
RW: Can someone train their mind/body to deal with pain?
Lalkhen: There are a number of psychological techniques to manage chronic pain including education about the stress response, relaxation training, diaphragmatic breathing, and the development of cognitive behavioral therapy skills, among other solutions. Some of my patients learn these techniques and are able to accept and become okay with unpleasant sensations they feel. Of course, we also see people who are not okay with what they’re feeling.
People with anxiety, PTSD, and depression interpret pain sensations in a more catastrophic way, and are less able to adopt psychological techniques to manage pain.
Rather than trying to fix the pain or train your brain, it’s more useful to consider taking better care of yourself as a whole person throughout your life and avoid chronic musculoskeletal pain altogether.
We live pro-inflammatory lives. We don’t sleep enough, we smoke, we don’t eat properly, and all of that contributes to a pro-inflammation state, which results in musculoskeletal chronic pain.
If you want to be well and want to function optimally from a musculoskeletal point of view, you need to optimize nutrition and body composition, reduce or stop consuming alcohol, avoid smoking, and take care of your mental health.
There is never going to be a drug solution for chronic musculoskeletal pain. Taking care of yourself to prevent chronic musculoskeletal pain is superior.
RW: You see a lot of patients who are experiencing unrelenting and often unexplained pain. How do you cope with that?
Lalkhen: People are very vulnerable when they’re in pain and they often want a passive solution to their problems. “Please fix me, doctor,” but that rarely works for chronic pain. Even acute injuries require the patient to cooperate with rehabilitation sometimes in the presence of pain.
Patients should always ask the doctor to define the problem as the doctor understands it and in a way that makes sense. If the patient can’t obtain a good understanding of their condition, then they should seek a second opinion.
Ultimately, though, a patient’s overall health is in their own hands. Adults have autonomy and should be collaborated with in a healthcare setting. The doctor should be patient-centered. The patient needs to be invited to consider all of the variables that are important and ask themselves what wellness looks like for them. Then they need to enlist the support and expertise to get themselves there.
Because I sometimes work with highly distressed patients who are in a lot of pain, I engage with psychological supervision at work. This means that I meet with a pain management psychologist to discuss how I felt during these situations so that I can maintain my own mental wellness and learn to be a more effective communicator.
My role, as espoused by Edward Livingston Trudeau, the American physician and public health pioneer, is to “to cure sometimes, to relieve often, to comfort always.”
Donna Raskin has had a long career as a health and fitness writer and editor of books and magazine articles. She bikes in a nearby county park, lifts weights, takes Zumba, and loves to walk/run with her dog, Dolly.