Chronic Pain’s Mystery Cause Unveiled

The Pain Enigma: Why We All Feel It Differently

Have you ever cried out after bumping your toe? Could you compete in a major final with a fractured jaw, or keep working while internally bleeding? Our perception of suffering shapes everything. The science behind this sensation reveals a complex and deeply personal experience. This feeling is moulded not only by physical harm but also by our thoughts, past experiences, and our environment.

A Legend Forged in Agony

Some believe John Sattler was responsible for his own ordeal. There was a tense atmosphere leading up to the 1970 rugby league grand final. A year prior, the South Sydney Rabbitohs, captained by Sattler, had been defeated in the 1969 final. This was their opportunity for redemption. The team had no intention of letting the championship escape their grasp a second time. Shortly after the game commenced, Sattler initiated a tackle. As the players separated, he tapped John Bucknall of the Manly Sea Eagles on the ear, a gesture not unusual for the sport in that era.

An Agonising Retaliation

Just moments later, only three minutes into the match, the formidable second-rower retaliated forcefully. A powerful swing from Bucknall's right arm connected with Sattler, fracturing his jaw in three separate places. The impact also split his skin, an injury that would later need eight stitches. His teammate, Bob McCarthy, turned to see his captain bleeding profusely, his jaw visibly dislocated. Decades later, Sattler remembered the single, overwhelming thought that consumed him: a feeling of agony unlike anything he had ever known.

The Will to Continue

Yet, he remained in the game. He continued to tackle huge, muscular opponents as they charged. He withstood tackles himself, some impacting his head, as he tried to advance. Throughout it all, he was aware of his shattered jaw. At half-time, the Rabbitohs had the lead. Inside the locker room, Sattler instructed his fellow players not to remove him from the pivotal match. McCarthy urged him to leave the field, but Sattler firmly refused. He was staying.

An Iconic Victory

He stayed on for the entire match, playing the final 77 minutes. At the game’s conclusion, he delivered a speech and took a victory lap. The Rabbitohs were the champions. The next day’s Sunday Mirror featured a headline that declared, "BROKEN JAW HERO". A picture of Sattler—with his heavy green and red uniform sleeves rolled up, his neckline soiled with blood, and his mangled, swollen jaw—being carried on the shoulders of his teammates, has become one of Australia’s most recognisable sporting images. His championship performance is remembered as Australian sporting history’s most renowned display of enduring immense discomfort. Forever associated with the jaw that required surgical wiring, Sattler was praised for his bravery for years. He was hailed as one of the most resilient individuals to ever participate in the sport.

The Enigma of Discomfort

What allows someone who has been attacked by a shark to calmly paddle to shore, describing the bite as merely a 'shake'? How does a woman with a ruptured ovarian cyst manage to work for six hours as her abdomen fills with blood? What enables a soldier who has lost his legs to oversee his own first aid? Such questions point to the profound mystery of our body’s response to harm.

A Universal Yet Unique Experience

Every person experiences discomfort. We all have moments where we bump a toe, singe a finger, or bruise a knee. We also face far worse. The challenge of being confined to a single mind and body is the impossibility of ever knowing if our personal six-out-of-ten rating on a pain chart matches that of the person beside us. The capacity of certain individuals to endure significant harm while showing little sign of distress has long been a topic of stories and scientific inquiry. Tolerating such ordeals has been viewed as an act of heroism or an unusual anomaly.

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Lessons from the A&E

Such questions preoccupied Lorimer Moseley during his time as a physiotherapy undergraduate at Royal North Shore hospital in Sydney. He was intrigued by a comment from a neurology professor suggesting the most severe injuries can be the least painful. This prompted Moseley to observe patients arriving in the emergency department. He recorded their ailments and asked them about their level of discomfort. He remembers a particular man who arrived with a hammer embedded in his neck. Despite the gruesome sight and bleeding, the individual seemed calm. He simply strolled in, holding the tool, appearing completely composed.

An Unexpected Reaction

Then, the individual turned, bumped his knee on a low table, and immediately started hopping from the minor impact. This stark contrast made Moseley wonder what was occurring. After dismissing drugs, alcohol, or shock, the student understood. The man's lack of agony from the hammer was tied to pain's fundamental purpose. Moseley deduced that this sensation is what drives self-protection. It was most likely fear, not the hammer injury itself, that sent the man rushing to the hospital.

Pain's Protective Purpose

According to Professor Lorimer Moseley, who currently holds the chair in physiotherapy and is a professor of clinical neurosciences at the University of South Australia, this reaction is an evolutionary survival mechanism. Experiencing agony from the hammer would not have helped the man's chances of survival. Moseley points to soldiers on a battlefield who can lose a limb, retrieve it, and move to a secure location without feeling arm pain. He calls this a remarkably powerful and complex protective function. This mechanism can narrow its focus down to a very precise location, compelling us to shield the particular area at risk.

The Mind-Body Problem

Such accounts are familiar to Professor Michael Nicholas from the Pain Management Research Institute at the University of Sydney. He observes that in any hospital setting, you might overhear remarks about a patient having more discomfort than expected. This, he says, shows our common assumption that an injury's severity should directly correlate with the pain felt. Nicholas clarifies this is often incorrect, attributing our misunderstanding to a "mind-body issue."

A Shift in Thinking

For a long time, Eastern philosophies and early Western civilizations acknowledged the deep link between mind and body. The ancient Greeks, for example, had the Algea, deities of physical suffering who also represented emotional distress like grief. A shift occurred in the 17th century when René Descartes, a French philosopher, proposed that the mind and body are distinct. Nicholas explains that this has led many cultures to minimize psychological factors, insisting that pain is a purely physical matter. Only in recent times has this long-standing separation been questioned by modern medical science.

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The Bio-Psychosocial Revolution

For a long period, the biomedical viewpoint prevailed, seeing discomfort as a straightforward consequence of physical harm. Psychological factors were frequently regarded as secondary reactions or were only given primary consideration if no physical cause could be identified. Over the last 50 years, however, a more holistic perspective has come to the forefront: the bio-psychosocial model. This framework, advanced by thinkers like George Engel in the 1970s, views pain as a fluid interplay of biological, psychological, and social elements. It acknowledges that discomfort is never solely a physical sensation but a multifaceted personal experience.

A More Complete Picture

The bio-psychosocial approach offers a framework for comprehending the entire person. It combines physical training and patient education (the biological aspect), cognitive-behavioural therapy (the psychological side), and talks about work and social settings (the social component). This multidisciplinary method gives patients the tools to manage their own symptoms, which encourages autonomy and lessens the daily life impact of chronic pain. Despite its demonstrated effectiveness, the model is not consistently implemented in its entirety, with psychosocial elements sometimes still relegated to a secondary role in clinical settings.

A Faulty Compass

A personal account highlights this intricacy. A sudden, intense ache started in a woman's lower belly during a meeting one afternoon. She placed a hand on her stomach and took deep breaths, attributing the sensation to eating too many sugar-free candies. She took a walk, went back to her computer, and completed her day's work. The discomfort lingered, yet she walked to her sister's flat, sure it was nothing serious. It took a call to a health advice line for her to finally visit a hospital, almost ten hours after the initial feeling.

A Doctor's Insight

Later on, while getting onto an examination table, the agony suddenly stopped her. The concerned expression on the physician's face suggested her own judgment was flawed. Healthcare professionals use a patient's description of pain as just one indicator, also watching for changes in movement, expression, and protective postures. The real problem was found with an MRI scan: a ruptured ovarian cyst had caused internal bleeding. A surgeon later expressed his surprise, noting that such a condition is notoriously agonizing, making her pain score of six or seven seem remarkably low.

The Power of Judgment

What could explain the major disconnect between the physical injury and the reported discomfort? Melissa Day, an Associate Professor at the University of Queensland, clarifies that our appraisals are key. "The crucial factor isn't what happens to us, but our judgment of it." When we find a plausible and harmless reason for a sensation, such as blaming candy, our experience of that pain is likely to be less intense. The brain's interpretation of signals, not merely the signals, governs the feeling.

The Brain's Pain Matrix

When nociceptors, which are specialised nerve cells, sense harm, they transmit electrical signals to the brain. These signals travel to a number of important areas that make up the "pain matrix." The thalamus serves as a relay centre, passing the signals along. The somatosensory cortex deciphers the pain's location and intensity. The limbic system, which contains the amygdala, handles the emotional and affective dimensions of pain, like fear and anxiety. The prefrontal cortex is responsible for the cognitive aspect, including attention and expectation, which can greatly alter the pain's intensity.

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Our Genetic Blueprint

Our distinct genetic code is also a major factor. Researchers confirm that pain tolerance has a clear genetic component. As an example, Moseley points out that red-haired individuals, on average, have a varying point at which their nerves are activated by changes in temperature. More particular genes have been pinpointed as essential contributors. Variations in the SCN9A gene, which is responsible for a key sodium channel (NaV1.7) in pain signalling, can result in significant differences. Nonsense mutations can lead to a complete lack of pain sensation, whereas other versions are associated with disorders involving extreme pain.

The COMT Gene's Influence

Another gene of importance is COMT (Catechol-O-methyltransferase), which affects the levels of neurotransmitters such as dopamine. Differences in the COMT gene are linked to variations in pain sensitivity, with some forms connected to a lower tolerance for pain. These genetic elements are not absolute but indicate a predisposition. They combine with numerous environmental and psychological elements to form our unique experience of pain. Research into these genes sheds light on the wide spectrum of human pain perception.

The Burden of Chronic Pain

There is a distinction between acute and chronic pain. The acute form is a brief signal connected to a specific harm. Chronic pain, by contrast, continues for over three months, evolving into its own medical issue. In the UK, the magnitude of this issue is immense. It is estimated that 28 million adults, representing 43% of the population, live with some form of long-term pain. For approximately 8 million of them, the discomfort is moderately or severely incapacitating. It stands as a primary cause of disability, with lower back and neck pain consistently ranking at the top of international lists.

A System Under Strain

The frequency of chronic pain rises with age, impacting as many as 62% of people over 75. It also carries a significant economic toll. In 2022, musculoskeletal issues, a prevalent type of chronic pain, resulted in 23.4 million missed workdays in the UK. Many of these ailments are handled within primary care because they lack a known cure, which puts growing strain on the healthcare system. This ongoing pain is more than a physical hardship; it has a deep effect on mental health, employment, and social well-being.

When the Alarm Gets Stuck

How does a short-term pain become a long-term one? A primary mechanism is central sensitisation. This involves the central nervous system undergoing structural and chemical alterations, which leaves it in a lasting state of heightened responsiveness. The nervous system effectively learns to be overly protective, amplifying sensory information and interpreting normal, harmless signals as dangers. This can cause allodynia, where a stimulus that is not painful, like a gentle touch, results in pain, and hyperalgesia, which is an intensified reaction to a painful stimulus.

A Dysregulated System

In central sensitisation, the brain’s pathways for modulating pain can become dysfunctional. The descending routes that typically reduce pain signals may become less efficient, or the pathways that amplify pain can become overactive. This establishes a cycle that perpetuates itself, where the body experiences pain even without any new injury. This is not an imagined issue, but a tangible physiological shift in how the nervous system, along with the endocrine and immune systems, interprets information. Grasping this mechanism is essential for effectively treating many chronic pain disorders.

The Social Context of Suffering

Intricate social elements are also highly influential. A body of research shows individuals from lower socioeconomic backgrounds not only have more long-term pain but also have lower tolerances for acute pain in laboratory settings. Those residing in the UK's most deprived regions have a higher likelihood of reporting long-term pain (41%) compared to those in the wealthiest areas (30%). Factors such as healthcare access, stress levels, and work conditions all play a part in this difference. Our social environment has a profound effect on how we experience pain internally.

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The Gender Pain Gap

Studies also indicate that men typically have higher pain tolerance than women. A woman's pain levels can vary with hormonal cycles. Moseley attributes this partly to differences in immune sensitivity and hormonal reactions, but also to how they are treated from infancy. Day reinforces this, stating that nature and nurture are inseparable. Early learned responses to pain are closely tied to gender norms, such as how a parent may react differently to an injured son or daughter. This societal shaping affects how pain is felt and shown.

The Power of Expectation: Placebo

Perhaps no phenomenon illustrates the mind's control over pain better than the placebo effect. A placebo is a beneficial outcome that follows a treatment with no active components, such as a sugar pill. These results are propelled by positive expectations. When you anticipate a treatment will be effective, your brain can produce its own pain-relieving chemicals, like endogenous opioids and cannabinoids. This "internal pharmacy" is capable of creating real physiological changes, even diminishing the pain signals handled at the spinal cord level, the first stage of processing in the central nervous system.

The Dark Side of Expectation: Nocebo

The reverse is also a reality. The nocebo effect is when negative expectations lead to or aggravate symptoms. If a patient is informed that a treatment might have painful side effects, they have a greater chance of feeling them, even if the treatment is inactive. Similar to the placebo effect, nocebo reactions are propelled by expectations and can initiate observable changes in the brain. These occurrences show that our convictions and the details we get from medical professionals are not just minor factors; they are potent elements in any form of treatment.

Thinking Your Way Through Pain

Considering the mind's influence, it is logical that psychological approaches are vital for managing pain. A key insight is that perhaps the most powerful indicator of pain tolerance is a person's mindset about it. Individuals who are prone to catastrophising—with thoughts like "this is dreadful, it will cause me serious harm"—tend to have a lower tolerance. Cognitive Behavioural Therapy (CBT) works to change these unhelpful thoughts, feelings, and actions. Learning emotional self-control, practising meditation, and learning to soothe the body can also be beneficial.

Shifting the Focus

With short-term acute pain, suppression and distraction can be effective temporarily. Nicholas states that redirecting focus from the discomfort is something a person can manage. Managing these mental elements can lead to a better pain outcome. Top athletes frequently showcase this. They typically have higher pain tolerance from becoming accustomed to discomfort during training. A strong focus on an objective can enhance their capacity to overlook pain signals, a factor that was surely relevant for John Sattler.

New Frontiers: Virtual Reality

Modern technology provides fresh methods to leverage the power of attention. Virtual reality (VR) is gaining recognition as a significant aid in pain management. By placing a person in a captivating digital environment, VR can successfully divert the brain's attention from pain signals. This absorbing experience engages multiple senses and holds attention, which can be especially helpful for acute pain during medical procedures, like wound dressing or for children receiving injections. It offers a method to handle pain and anxiety without medication.

VR for Chronic Conditions

The use of VR is also demonstrating its value for long-term pain. It assists with ailments such as fibromyalgia, phantom limb sensations, and persistent back issues. VR can be incorporated into "exergaming" to make physical therapy more enjoyable and less painful, thereby increasing commitment to exercise routines. For certain individuals, VR therapy has been found to lessen long-term discomfort and sometimes offer a durable analgesic benefit after the therapy concludes. Although more extensive, high-quality studies are required, VR presents a promising, drug-free option for a challenging issue.

The Ultimate Mystery

Why did John Sattler continue playing? Since he passed away in 2023, we cannot be certain. However, we can observe that he possessed all the traits for enduring significant injury. As an athlete, he was accustomed to pain. In a critical situation, he was driven by reward and had been culturally conditioned to prize toughness. The impact likely triggered a release of his body's natural pain-relievers. His focus was diverted. He decided that winning the championship was more crucial than safeguarding his jaw. According to Moseley, we can never confirm if someone has a high pain tolerance because the same person both creates and endures the feeling.

A Mythological Power

The nature of acute pain is still steeped in myth and mystery. While we can grasp a great deal about the physical and some of the neurological processes, we can never be sure what another individual experiences. The Sattler legend continues with the story of him turning to his teammate Matthew Cleary after Bucknall's decisive blow. His legendary status grew because nobody, and maybe not even Sattler himself, realised the full extent of his injury. He is said to have uttered, “Prop me up, so they can’t see I’m hurt.”