I couldn’t feel the pain

One of our readers alerted us to this story from the recent National Rugby League Grand Final

Burgess couldn’t feel pain from fractured face

Sam Burgess

Source: The Daily Telegraph, Picture: Gregg Porteous

Speaking after the 30-6 win over the Bulldogs that broke a 43-year premiership drought with the right half of his face swollen and purple, Burgess said he couldn’t really feel any pain from his fractured face whilst on the field but knew it was broken straight away.

“To be honest I couldn’t feel the pain, my head was a little bit dizzy, a bit of blurred vision in the right eye… a few of the boys recognised early on I’d damaged my face,” Burgess said.

Asked if he contemplated leaving the field, he said: “We worked for this day from the first of November [last year] so there was no chance of me missing out.

Asked if the pain had now kicked in with the game over, Burgess simply said “yep”.

A 43 year premiership drought. 12 Months of preparation for 80 minutes.

Is it any wonder that a ‘decision’ was made that it wasn’t worth experiencing pain during the game?

Perhaps the danger associated with the injury was outweighed by the safety of playing on in the most important game of Burgess’ career? Those tears were not from pain.

– Tim Cocks

www.noigroup.com

 

Find a new level of thinking at a noigroup course, or immerse yourself in some brainy books with Explain Pain 2nd Ed and The Graded Motor Imagery Handbook

12 Responses to “I couldn’t feel the pain”

  1. davidbutler0noi

    Great story – all of Australia heard it and I am hoping it has been repeated again and again in clinics for people in chronic pain.

    Sam Burgess should know that what he did could help thousands

    David

    Reply
  2. betsancorkhill

    I tell patients the story about my husband. He fractured his cheekbone 10 minutes into the second half of a rugby match and continued playing until the end of the game. He recognised that he’d had a blow to his cheek and it felt a ‘bit bruised’ but he had no pain. It was a big cup final and he was the team’s star kicker. They went on to win. The extraordinary thing is that he felt no pain when the game finished either – the euphoria and enthusiasm of winning a major cup final continued for some time.
    He drove home and said “I’ve had a bump on my face and I’ve got a bit of a lump on it, can you take a look?” When I looked his cheek bone was actually depressed and he wasn’t able to open his mouth fully. Still no pain. So it was off to A & E still on a high from winning. Saturday night is not the night to visit A&E especially with a ‘self-inflicted’ injury so after many long hours of waiting he received the diagnosis of fracture and yes he’d need surgery. He was discharged and asked to return at 7.30am on Monday. It was then that his discomfort began to kick in. I’m sure this wasn’t just down to the euphoria wearing off. The long wait in A&E, being told his cheek bone was fractured and having the necessary surgery and risks described in vivid detail, THEN having to wait until Monday to undergo surgery (whilst mulling over those surgical details) considerably raised his perceived level of threat.

    Betsan

    Reply
  3. John Barbis

    This is a wonderful story of how the brain can control pain and even nociceptively produced pain. I understand how everyone is willing to applaud him, but let’s think about this in reality. This was a dangerous injury. Another shot to the head or face could have produced a catastrophic event, potentially life threatening or at the minimum threatening his vision. Controlling pain and even nociceptive pain when there is a particularly more dangerous source out there (a lion chasing you) is important. But nociception is there for a purpose. We avoid it at a risk. We need to make good informed risk/benefit assessments. We need to make sure when we manage our patient’s pain (either chemically, mechanically, or behaviorally), we know what the nociceptive risks are and how dangerous controlling danger messages can potentially be.

    We also need to be careful when we use examples like this. Generalizing examples like this to the majority of pain patients can be quite hurtful to the pain patient. Yes, it illustrates a point. Society, family, medical care provider, employer, etc, however, . can use this example to belittle the pain experience of those who are impaired by what appear to be a “lesser” problem. The back pain patient will not make hundreds of thousands or millions of dollars for working though the pain nor will they get the adulation on the TV or in the press for going back to work. Usually that return and experience will be very lonely and a real struggle before they find success. In addition, the nervous systems of those who go through the Darwinian process of making it to the professional sports level have to be different in their abilities to process adverse sensory inputs. That could be through training but if you have spent anytime around a professional athlete, there has to be a genetic component.

    As a former athlete and longtime coach, there is a part of me that revels in this type of story. As someone interested in pain and treating pain, it is one of those fascinating anecdotes that can be illustrative of a singular event but not necessarily containing the sufficient information to be generalized. When we use it to explain a point, we need to be careful in its use.

    Reply
  4. davidboltononoi

    I can draw on personal experience here remembering fracturing my right radius ( blocking a beautifully exicuted kick from my opponent ) in the early stages of a European karate tournament. I had trained for months to be in the team.
    I new I was “damaged” but fought well and pain free for the rest of the day. Sadly I got layed out with a broken jaw in the finals. Wasn’t my day really :-)
    DB
    London

    Reply
  5. David Colquhoun

    Hmm well, while it’s true that you may not feel fully the pain of an injury in rugby, or during a boxing match, my recollection is that you sure feel it the next day. On the field, or in the ring, you’re hyped up for something that you’ve been training for for months or years. It’s your moment in the limelight and the adrenaline is circulating. I can’t see that this has the slightest relevance to patients with chronic pain. There is no analogy whatsoever.

    Reply
    • timcocks0noi

      Hello Professor Colquhoun

      Thanks for taking the time to read our blog and for joining the conversation, which I would respectfully continue.

      I’m interested in your comment about not feeling “fully the pain of an injury”. If one does not feel “fully” the pain, does this suggests that one feels half of it, a quarter of it, 66% of it? There seems to be implicit in this thinking an erroneous reification of pain. What then is a “full” pain experience? How would we know if someone is “fully feeling the pain of an injury “- the error of assuming that we can, from a third person perspective, judge how much pain a person ‘should’ be experiencing based on the presence/extent of an injury has dug us into a very deep hole that many (sufferers, clinicians, therapists and researchers) are yet to extricate themselves from.

      On your point relating to relevance, I beg to differ. Earlier you suggest that being “hyped up” with adrenaline circulating will influence a person’s pain experience. I would agree that a person’s context and biological state will influence whether a pain experience is constructed by that person or not. However, why is it that this just occurs in ‘one direction’? Why wouldn’t being “hyped-down” (to extend your metaphor, possibly past it’s breaking point) influence a person’s pain experience? If an individual’s “moment in the limelight” can have such a powerful analgesic effect, is there not by extension, an argument that the very opposite is also true? By way of example, I could imagine an individual who has been diagnosed with “CNSLBP”, who has been told to give up their passion – playing rugby, who has experienced pain for months on end, who has undergone countless investigations, procedures and treatments to no avail, who is embroiled in arguments with an insurer and who reports that just the thought of returning to work next week causes his pain to double. Is this person’s moment of suffering in obscurity likely to influence his pain?

      In this situation I would argue, a thoughtful clinician could use the above story of Mr Burgess to carefully deconstruct the fallacies that pain is an indication, and accurate measure, of the presence, and extent, of tissue damage. This story, with its stark contrast (a well known educational tool) could well trigger the beginning of a conceptual change process that leads to changes in the meaning of pain, reduced threat and fear, and a reduction in the very pain experienced. Whether this story is analogous with chronic pain is neither here nor there, and in fact was never suggested, but is it relevant? Absolutely.

      Best
      Tim Cocks

      Reply
  6. David Colquhoun

    For a start, I doubt that one can talk meaningfully about 66% of the pain.

    By “relevant”, I meant “useful for helping people who suffer from chronic pain”. It’s common, if anecdotal, experience of people who like contact sports, like rugby and martial arts that you don’t notice the pain so much in the heat of battle as you would if someone punched you out of the blue.

    But how on earth does that help someone with chronic back pain? I’ve experienced both (50 years apart!) and I get rather cross with “pain specialists” who are apt to tell you that I should change my mental attitude with the implication that positive thinking will make the pain from by lumbar spine go away. It doesn’t. The fact of the matter is that specialists in chronic pain can do very little for patients. Perhaps that’s why they tend to clutch at straws.

    Reply
    • timcocks0noi

      But of course there’s nothing meaningful in talking about 66% of pain – just as there is nothing meaningful in talking about not “fully” feeling the pain of an injury. The description to Pat Wall’s wonderful book, Pain: The Science of Suffering, says this very nicely;
      “Many scientists, philosophers, and laypeople imagine pain to operate like a rigid, simple signaling system, as if a particular injury generates a fixed amount of pain that simply gets transmitted to the brain; yet this mechanistic model is woefully lacking in the face of the surprising facts about what people and animals do and experience when their bodies are damaged. ”

      As to relevance – how is it not relevant to explore just what it is that occurs when one is “hyped up” or during “the heat of battle”. The story is relevant because it can be used to demonstrate that tissue damage/injury (and by extension nociception) is neither sufficient nor necessary for an individual to construct a pain experience. This can lead to and support an explanation that chronic pain (once one has been cleared of serious pathology) is not an indication of ‘chronic injury’ as suggested by an out of date mechanistic model of pain. There is ample evidence now to support this idea, as well as the notion that teaching people about the biology of pain reduces pain and disability.

      Any examples of the absence of pain in the presence of serious injury, or conversely, the presence of pain in the absence of injury (the famous case reported in the BMJ of the builder with the nail through his boot admitted to hospital in great pain only to discover the nail had harmlessly slipped between his toes, is a great example) are relevant when teaching people about pain and trying to overcome the robust misconception that pain is a reliable indicator of injury.

      I’m not sure what a “pain specialist” is. If you are referring to medical specialists who purport to ‘treat’ chronic pain by only prescribing powerful opiates with no evidence of efficacy but overwhelming evidence of harm, then yes, I agree that they do very little for patients at all.

      In regards to “mental attitude” and “positive thinking”, those ideas have nothing to do with a modern and evidenced based approach to teaching people about pain. Further, nothing can make pain from your lumbar spine go away, because lumbar spines don’t hurt – only people hurt.

      Reply
  7. John Barbis

    I agree that this type of anecdote can be illustrative of how phenomenal the processes involved in perceiving real or potential threat and actual or perceived tissue damage can be in pain production or non production. As I stated in a previous post, anecdotes like this need to be used carefully. Although they illustrate a point, they can be as harmful ( especially by unhelpful family members) as insightful. There is a lot that goes on in the production of pain. The social environment, past experiences, ” the adrenaline rush of the moment”, the thought of a $100k payday, the type and location of tissue insult, etc can all influence that individual’s experience. Let’s also not forget that the Bio in biopsychosocial refers not just to tissue injury but the bio of the nervous system. The evidence is growing that, just like there are genetically based variabilities in strength, coordination, etc, there are genetically based variabilities in the nervous system that effects how sensory information is processed. The vast majority of professional athletes got to their high status of play due, in part, to those genetic differences that produce a more efficient or powerful musculoskeletal body. Given the continual physical stress and trauma that professional athletes had to experience to get to their level, there has to be some type of Darwinian process that helped to select those who genes allow them to process sensory input differently than we weekend warriors. As a result, I do believe that Dr. Colquhoun has a valid point. Comparing the professional athlete to the persistent pain patient may not be helpful and may be hurtful. JohnB

    Reply
    • timcocks0noi

      Hi John

      I agree that any pain story needs to be used with care, with the appropriate person and in an appropriate context. As I look back to my original post, I can still not find any reference to using this story to help a person experiencing chronic pain or whether Burgess should be lauded for his actions. Those suggestions came later (or in the case of applause, not at all as I read it), from others. I tend to agree with those suggestions, as I have tried to explain and I would still contend that in the right time, place and manner, this story could be instructive and helpful, even to a person with chronic pain.

      Would you consider that there is another side to potential harm that you mention? That there is also potential harm in any suggestion that a professional athlete is somehow ‘super-human’ – either through training or genetics – and through their superior biology and conditioning they are somehow able to avoid pain or are immune to it. What then for a “weekend warrior”? Might this (mis)intepretation lead to the ongoing promulgation of erroneous and harmful beliefs about pain?

      As to genetic differences, are we at a stage where we can even begin to talk meaningfully about how genetic differences in sensory processing (do we know what they might be, these differences?) might alter the lived experience of pain?
      The quest for a deeper understanding of the nervous system on a genetic basis will surely lead to some fantastic discoveries, but in relation to pain, is it really any different than the failed search for answers in the tissues? Why do you think natural selection might operate in relation to modern-day athletes? Is there any evidence at all that athletes do in fact have nervous systems that process sensory information differently – and if so how?

      Context, environment, meaning and past experiences affect us all – from professional athletes to the persistent pain patient. I think having a rich library of examples and stories involving athletes who ‘didn’t feel the pain’, surfers who didn’t know their leg had been amputated by a shark, or farmers who cut their hand off after it got stuck in a baler, can enhance our ability to engage a person experiencing pain in any necessary reconceptualisation.

      Best,
      Tim

      Reply
  8. Gerry Daly

    Prof Colquhoun is right, although he doesn’t need me to argue his point. An analogy was suggested in one post ( “Great story – all of Australia heard it and I am hoping it has been repeated again and again in clinics for people in chronic pain.
    Sam Burgess should know that what he did could help thousands” )
    which inferred that transposing a similar response mindset into a chronic pain treatment might elicit a similar denial of chronic pain effects. The problem with that is that the ‘natural frequencies’ ( viz Gerd Gigerenzer ‘Risk Assessment’) in such a comparison are not interchangeable, nor comparable, so the analogy doesn’t make sense. On one side of the equation we have an ‘acute’ incident….and on the other side is a chronic recurring incident. It might be ok to describe chronic pain as ‘recurring acute’ …..but certainly not as ‘acute’, or for that matter as ‘persistent’, or as ‘lingering’ as trends seem to be suggesting. So, the notion that the two incidents are in any meaningful way similar, so as to make such a comparison, is misleading, and sure to be picked up on by any chronic pain sufferer who intuitively senses the danger contained within the assumption of comparisons made by ignoring the frequency differences.

    I can understand the good intention of the assumed analogy, but at the same time, I see it as a ‘positive-spin veil’ being thrown over the limited understanding we already have of chronic pain mindsets and effects. What has been overlooked in that analogy is the fact that chronic pain patients are continually in a ‘fight or flight’ contest with their condition, and the only real way to deal with that recurring mindset, is to recognise the dangers and deal with them appropriately, rather than fantasising some scenario where a totally irrelevant one-off incident might have beneficial transposed repercussioins for a chronic pain patient. That vaguely hints at the service provider ignoring the actual presentation, for want of a better way of describing it. We can’t ‘de-chronic’ a chronic condition with wishful thinking….although I do see how anyone without a subjective chronic pain condition might like to think so. I would define any such attempt as ‘hoping for the best by altering, by suggestion, the chronic patient’s intuitive understanding of their own condition’. Sometimes, I suspect that there is some ‘wishful thinking by proxy’ at play in these mind-games being constructed around what is essentially a very real experience of chronic pain. And, I would expect any chronic patient to stand their ground on any insinuation that their inherent instinctive experience of their condition can be manipulated by words alone. No-one, i.e no-one, should be expected to allow such an intrusion into their subjective experience, on the off-chance that it might reflect beneficially on their recurring pain experience…..that might just be, despite the good intentions, an intrusion too far !

    Having said that, I don’t think it’s improper to explore these controversial areas of understanding, as long as it’s not at the expense of ignoring the patient feedback which might suggest that chronic pain sufferers, like everyone else, might not feel inclined towards having their intuitions meddled with in a manner which suggests they should accept meaningless analogies before they should expect any positive pain-easing outcomes. That just looks like an additional ‘barrier in understanding’ to me.

    Reply
  9. Gerry Daly

    Hi Tim,

    Thanks for the detailed response. The contended issues are not being ignored, and that’s important in any discussion on contentious issues. I understand your responses on most of the issues raised, expected same, I suppose, and that helps to steer the debate towards the ‘core issue’, which might well be responsible for my initial reactive responses to the original post. That ‘core issue’ is contained within the trending theories, which seem to imply a chronic pain patient’s possible complicity in the continuance of the chronicity of their condition. The ’emergent’ theory would seem to allow for such an overview, and I’d suggest that the other differences we discuss emanate from that core issue.

    I’m not, for a mere moment, suggesting that establishing a patient’s psychological complicity is a goal of the emergent theory, but it tends in that direction, by default….especially in instances where the cause of the chronicity might seem indefinable. That, in itself, allows a certain licence for certain types of chronic conditions to be overviewed as ‘patient driven chronicity’, and also it allows licence for relaxing more mainstream exploratory investigations of what’s being presented….i.e the ‘real’ work of defining causes and treatments for chronic conditions. This is perhaps particularly true of neurological chronic conditions which manifest in difficult to define ways. The ‘Wishful thinking by proxy’ comment was a reflection on how operators might apply themselves to such presentations, without feeling a sense of negative usefulness. In my opinion, as a long time cervical spondylosis patient, the ’emergent’ theory attempts to solve the confusions around the condition, by implanting a mystery (emergent theory) onto an existing enigma. That’s double confusion by anyone’s understanding. My intuition tells me I am not complicit in any continuance of my condition, and yet emergent theory suggests I might be. That, in itself, is an emergent theory side issue which may not be all that visible to the average operator. And there’s the inherent conflict in a nutshell ! I have no intention of altering my intuitions…I have complete faith in them. And yet, I cannot buy into emergent theory without discarding some of those instincts. Where does that leave me in terms of committing to future treatments ? Can I even trust treatments emanating from emergent theory ? In that respect, I view emergent theory as a barrier, almost a retro-step, to progress for my condition. Accepted, that’s a one-sided view, but, as a patient, that’s all I got.

    I do understand how emergent theory can be useful for maintaining a positive attitude towards more transient conditions, no problem there, but I think it falls short, and undersells the patient’s presentation, when it comes to chronic issues. Any doubting of a ‘real’ biophysical cause for chronic pain conditions must be challenged, and any analogies which suggest, no matter how small the inference, that the ‘complicity’ issue should in any way replace the ‘unknown biophysical cause’ issue must also be challenged. It seems to be one of those situations where the exceptions are determining the rule….i.e rubber hand experiments, mirror illusions etc are being analysed, and forthcoming conclusions are then being translated into an understanding of pain which, when all things are considered, doesn’t seem to mesh well with the chronic patient’s understanding of their own pain experience. Perhaps there’s a missing link to explain all, I don’t know, but I’m fairly sure that most chronic pain patients would say that the theory and the experience are lacking synchronicity. Whereas it may well be ok to dabble in altered perspectives in the world of transient pain experiences, when it comes to chronic issues, there is bound to be a questioning of the rationale behind any suggested treatments, if only because resentment at any failures is likely to last longer. The theory drives the treatments, and therefore we have a responsibility to be watchful. Personally, I’d rather see the effort put into establishing ‘real’ causes and treatments, rather than having to accept one mystery being excused with another, something which, it would seem, if emergent theory rules, would be a pre-requisite to any treatments being offered. That’s not a reasonable trade-off I would ever be inclined towards. I already come with a history of well intentioned, but ultimately failing treatments, so my sensitivities are already highly aroused to any imbalances in the operator/patient pact. I’d be much more in favour of tweaking that pact towards establishing real causes, rather than any assumptions which might imply a patient’s psychological complicity in the continuance of a chronic condition. I realise that hasn’t been implied directly, but it is implicit in emergent theory.

    Please view my comments as a ‘questioning’ rather than as something ‘opposing’.

    Regards

    Gerry

    Reply

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