Title: Pain

Author: Stephanie de Montalk

In: Sport 33: Spring 2005

Publication details: Fergus Barrowman, 2005

Part of: Sport

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Sport 33: Spring 2005

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The sunlit uplands would not easily be found. The literature on pain was blocked by theory and principle, hedged like an inaccessible poem with hidden, internal workings and attempts to explain highly individual perceptions. All it could say with certainty was that, while significant progress had been made in the alleviation of physical distress, much remained individual, incomprehensible, beyond our control.

I was well aware of the consequences of this incomplete understanding of pain and its control. Twenty-seven years previously in Hong Kong, an anaesthetic for a Caesarean section had paralysed me, rendering me unable to move a finger or open an eye; but it had also left me fully conscious, pinned to the table as if beneath concrete, from a pre-operative palpation and discussion of the baby's position, through the gagging insertion of the endotracheal tube, page 6ripping midline incision, post-delivery ligation of the fallopian tubes and cries of constriction and pain reverberating in sound waves in my head.

The surgeon and anaesthetist had confirmed my distressed recovery-room account of their conversations in Cantonese and English, including the surgeon's remark prior to suturing that I seemed 'a bit light', and expressed horror that they had mistaken the twitching responses of my concealed consciousness for involuntary reflexes. 'Transient states of painless awakeness with incomplete recall are not uncommon,' they had said, 'especially during the light anaesthesia of Caesarean sections, but rarely at your sustained height of awareness and pain.'

In the years since, other patients have come forward, law suits for emotional trauma have been taken and compensations awarded.

More importantly, a Patient State Analyser and Bispectral Index, capable of detecting and measuring changes in brain waves during sedation, are in development and may soon enable anaesthetists to mix hypnotic and analgesic agents with greater accuracy.

Yet, for all this, the exact cause of the newly-named 'Anaesthetic Awareness with Explicit Recall'—or 'Silenced Screams', as a survivor entitled her book on the subject—outside obvious equipment failure or inadequate medication, continues to elude researchers, and the phenomenon—in my case forever reminiscent of Edvard Munch's work of anguish and alienation, The Scream, and a matter of inward panic each time I approach the doors of an operating theatre— remains a mystery.

The difficulties of diagnosis and treatment posed by the hidden process of pain seemed to be especially prevalent in the assessment of chronic pain: that mysterious landscape beyond the known impact of acute and obvious tissue damage; of childbirth's pain of purpose, surgery's pain of healing and prevention of harm, and injury's intention of warning. All too frequently chronic pain languished, not readily understood in the areas of medicine and surgery: a territory of disorders, syndromes and cycles; of past experience, unique personality and the interplay page 7of family, social and employment environments; of psychological and psychiatric attention.

It had little in common with the old Cartesian Theory of pain which likened the nervous system to a grid of electrical wires carrying signals from sites of injury to the brain, where sensations appropriate to the degree of tissue damage were recorded. It was closer to the newer Gate Control Theory of 'input modulation', which presumes that 'neural mechanisms in the dorsal horn of the spinal cord act like a gate', admitting, blocking, intensifying or reducing pain impulses before transmitting them to pain centres in the brain; that, during transmission, the signals are again modulated and pain is experienced when their arrival at the pain centres exceeds crucial levels.

Pain-gating further presumes that, if the pain gate changes or becomes damaged—as it might as a result of chronic or unrelieved pain—it stays open, even after the tissue has been treated or controlled. In such instances pain, often out of proportion to the original injury and level of harm detected by diagnostic means, and known as neuropathic pain, continues, at which stage the pain itself becomes the diagnosis or disease.

'As this long-term, unrelenting pain process continues,' a brochure on chronic pelvic pain concluded, 'as conventional treatments yield little relief, even the strongest person's defenses can break down.' The outlook was grim: limited physical and social activity, depression, displacement in the family and society.

I moved through the brochure's section on diagnostic testing (all that could be done, had been done) to 'Therapeutic Approaches': discussion of individual perception of pain in body and mind, the resultant rise of 'multiple interactive problems', the importance of patience, the assistance of mental and physical therapies, medication as 'a temporary supportive measure until other therapies kick in'.

But I was beyond patience and nebulous therapies, beyond breathing and relaxation. I needed conclusive solutions and unequivocal medications. The bio-feedback, distraction, imagery and other transmission modulating cognitive activities could come later. The pain was intractable, intense; surely this signalled significant physical injury, as the unfashionably simple Cartesian specificity theory proposed?