Working With Pain & Injury

“Suck it up, the whole teams back hurts!” With my youthful pride and dedication being challenged, I obediently listened to my coach and jogged back to the huddle. I continued to go to football practice. I continued to lift heavy weights. I stopped complaining and took the pain like a man. But when I started asking my mom to tie my shoes before school because I couldn’t bend at the waist, the tough guy act had to end. I was only sixteen when I had my first spine surgery. Like many others, it was my pain that lead me to the path of mindfulness. Pain, whether physical, mental or emotional is a part of the human journey, but seems to be even more inevitable and frequent in high achievers.  Those who consistently take risks and stretch their edges in life, work or sport eventually go too far. The trial ends in error, and pain is a result. How we deal with pain is up to us.

The Mindful Ice Bucket Challenge

“Masochistic” is a word that’s been jokingly used by participants of the mPEAK program. What they’re referring to is an exercise we call the Ice Bucket Challenge. But in this experiment, rather than quickly dumping cold water on someone’s head, we have them slowly submerge a hand in a bucket of ice for as long as they can tolerate.

During the first round of this exercise, participants are instructed to distract themselves from sensations. “Try thinking about a Hawaiian vacation, count backwards, do math problems in your head-- just don’t think about your cold hand.”

In contrast, the instructions of the second round are to pay full attention to the hand in the bucket of ice, monitoring sensations of burning, stinging, or tingling. Participants are also told to notice what kind of story is in their mind while feeling these sensations. “Are you feeling particularly averse to this? Hoping it will end soon? Or maybe it feels refreshing or even soothing? Watch your thoughts, your physical sensations, and any emotional response you have to the experiment.”

Some report thoughts encouraging them to stick it out for a certain amount of time. “Wait until the person next to me pulls out…or maybe until after the ice melts”. Others conjure up images of black, frostbitten fingers and report feeling scared that they might damage their skin. But it’s not all that dramatic. One person was reminded of the previous winter where she’d been building snowmen and a memory of falling off her skis and being buried in a pile of snow. Most participants say that after awhile they can not only tolerate the pain easier, but even express curiosity in the way the sensations arise, change and fade away without any real thoughts or emotions attached to them. The point of the practice isn’t to think any certain way, or have any particular experience; it’s simply to notice what goes on in their mind when they feel unpleasant sensations.

When this same experiment was done in research settings, what was found was that in the early minutes of having your hand in the ice water, distraction techniques work better than mindfulness: You’re less aware of the discomfort because you’re telling yourself a story, or remembering something, or having a fantasy. But after the hand is in the cold water for a while, mindfulness becomes much more powerful than distraction for tolerating the pain. You can only run from the sensations for so long!

Pain & Suffering

According to Jon Kabat-Zinn, Physical pain is the response of the body and the nervous system to a huge range of stimuli that are perceived as noxious, damaging, or dangerous. But he looks at pain from three different dimensions: the physical, or sensory component; the emotional, or affective component— how we feel about the sensation; and the cognitive component—the meaning we attribute to our pain.

When I injured my back in 1992 there was real and intense physical discomfort. Lifting even small objects caused my back to go into spasm. Sitting for any length of time resulted in aching and compression and walking set my left leg on fire with searing nerve pain. This physical pain topped out at a 10 for a long period but it’s difficult to say if it was more intense than the emotional and mental components of the pain.

After my operation, I lost more than just muscle mass and physical function. Without my strength and the ability to compete, I had no idea who I was. Up until then, I was my body. I was my strength. It was this identity that won me the respect of my peers and the attention from girls. And at age sixteen, that was all that mattered to me. Now, I was nobody. Pretty sure I was doomed to be fat, friendless and lost, I watched the football games from the sidelines that season, depressed and embarrassed.

“When touched with a feeling of pain, the ordinary uninstructed person sorrows, grieves, and laments, beats his breast, becomes distraught. So he feels two pains, physical and mental. Just as if they were to shoot a man with an arrow and, right afterward, were to shoot him with another one, so that he would feel the pains of two arrows.”    –The Buddha

Pain and stress reinforce each other in a negative feedback loop. Chronic pain leads to emotional stress as it interferes with daily life, causing a person to worry about being able to do their job, play with their kids or participate in regular recreational activities. This emotional stress erodes the immune system over time, increases inflammation and magnifies the perception of pain. More pain equals even more fear-based rumination and it’s a down hill spiral from there.

“Pain is inevitable, suffering is optional.”

The habitual reaction to any stressor, including physical pain is to either fight or flee. We get angry at the doctor, pharmacist or insurance company. We feel betrayed by our body and mad that we hurt. Some people attempt to escape by overusing prescription drugs and numbing out with any combination of their favorite vices. It’s quite normal to want to get rid of the pain but according to Zen teacher Ezra Bayda, it’s actually this desperate desire to escape the pain that causes our suffering.

From the perspective of mindfulness, the goal isn’t to resist or try to get rid of pain. The practice is instead about changing your relationship to the pain by opening up to it and paying attention to it in a new way. You “put out the welcome mat,” as Jon Kabat-Zinn likes to say. We allow or accept the pain, because it’s already there.

Mindfulness of pain is the ability to observe the sensations of pain without identifying with the pain. When you realize you can rest in awareness, the pain may be just as severe, but you’re now cultivating equanimity and a degree of wisdom. There is a question that is often posed, “is awareness of pain, in pain?” After sitting in meditation, we see that the answer is “no”. You may begin seeing the pain as an impermanent, ever-changing dance of sensations. “It throbs over here, now it aches a little over there. Now it’s burning and sharp…oh, now it’s gone. Here it is again but not as bad.” There is an awareness that it is not pleasant. But the interpretation that “the pain is killing me, or ruining my career”, and all the emotions and dramas that go with it, are seen for what they are –just thoughts. In that seeing, they often lose their power over us.

The Science of Mindfulness & Pain

A Wake Forest University study conducted by Fadel Zeidan used MRI scans to show that just 4 days of meditation training lead to an approximately 40 percent reduction in acute pain intensity ratings during meditation when compared with non-meditation. But even when mindfulness meditation doesn’t work to decrease pain, such as in some chronic pain conditions, it often still works to improve quality of life along with improving our ability to cope with chronic pain. Take for example, a small research study with 63 rheumatoid arthritis patients. After two months of mindfulness training, the patients' physical symptoms did not disappear, but they reported feeling better. Scores of psychological distress dropped 30 percent.

So how does meditation work with acute pain? According to the study by Zeidan, four areas of the brain involved in pain processing or emotional and behavioral regulation have been shown to have differing activity levels during and after meditation. The primary somatosensory cortex, anterior insula, anterior cingulate cortex, and prefrontal cortex all experienced altered levels of activation due to meditation. The primary somatosensory cortex is the region of the brain directly involved in pain processing. If an athlete sprains her ankle, this area of the brain figures out where the pain is and registers the initial pain level. Then the anterior insula, the brain region involved in perceiving and regulating the body functions such as heart rate and blood pressure, appraises the pain in the body. After the athlete’s ankle has been sprained, the insula judges how painful the resulting injury is.

Then the anterior cingulate cortex comes in to regulate the athletes emotional response to the injury, making them feel angry, scared, or frustrated. Finally, the prefrontal cortex, the executive command center of the brain, takes all the information and guides thoughts and actions, including the inhibition of inappropriate thoughts, distractions, and feelings. After beginning to feel angry, the athlete responds or reacts in some way.

The research by Zeidan showed that meditation alters these four areas of the brain associated with the perception of pain. By decreasing activity in the primary somatosensory cortex, the pain processing area, and increasing activity in the three other regions, pain is reduced. Assuming the athlete who sprained her ankle meditates, she would have a reduction in activity in the pain processing area of the brain, meaning the sprain won’t hurt as much from the beginning. She would also have increased activity in the pain and emotion regulating areas of the brain. She won’t judge the pain to be as strong, and she will regulate her emotional response to the pain as well as her behaviors.

The Benefits of Practicing with Chronic Pain

It’s hard to say if meditation has directly decreased the chronic pain I still have resulting from my back injuries years ago. But there’s no doubt in my mind it’s had indirect benefits on the way I respond to pain. By learning to observe and let go of limiting stories about my pain, I’ve been able to suffer less and work with pain in more beneficial ways. I can acknowledge my fear of re-injuring myself as just a fear –and not the truth, which has helped me build the confidence to start physically moving in a wider range of motion, improving function and decrease pain. On the other hand there have also been times I’ve noticed my habitual tendency to ignore limitations and instead of pushing through the pain, I can offer myself the rest and treatment I need. And finally, I’ve been able to find meaning in my experience of pain and tell a new story about my injury. I’m not a victim of pain; instead I can see how pain has been a powerful teacher and sent me on a healing journey. Through it all I’ve leaned wisdom and compassion and am grateful for the path I’m on because of it.