I’m looking at different pain scales right now and am surprised by some of the advancements in how pain doctors perceive pain patients and the need for the expression of pain. There are sociological and cultural components to the expression of pain that they’re starting to evaluate. One article, “Pain assessment in context: a state of the science review of the McGill pain questionnaire 40 years on” by Main is very interesting. A very tiny part of that article talks about the social context of pain behavior and the need for a science of pain expression, like “pain expressionology” – shout out to Alie Ward, although I’m sure she could find a Greek word to express it better.

Essentially there is a need to look at how pain is “coded,” communicated, and “decoded” by caregivers. Patients in pain “code” the experience in facial expression, physical motions, or verbally. The communication of that code is transmitted to a caregiver (or loved one), who then decodes it. For example, when a nurse asks you to rate your pain, he or she is then making a determination of how to judge that rating by also taking into account facial expression or body language. The problem is that the way people have been socialized affects the way they express pain.

I think of children who fall in the playground and scrape their knee. If there is a parent to run to them and brush them off and kiss their owie, does that reinforce the expression of pain? Will that child become an adult who easily expresses pain in the knowledge that he or she will get positive reinforcement of that pain? To go one step further, is that early positive reinforcement of pain a factor in the physiological changes that lead to actual chronic pain? Or is it chronic expression of pain? I’m not sure I’m making sense, but what if you compare that to the child who does not have immediate positive reinforcement of pain expression, who just stands up, brushes off his or her own knee and goes on to play? If both of these scenarios are repeated routinely throughout the two childhoods, is there a difference in the predictability of the development of chronic pain?

I know that childhood trauma is a factor in brain development and can be a predictor of chronic pain. But what if that trauma is the lack of positive reinforcement of pain expression? Am I tying myself into knots now?

There must be a connection between pain expression, how that expression is communicated, and how that expression is received and interpreted. Right? Stoic people who don’t express pain still have pain, but may be overlooked. “Hypervigilant” people who always express pain may “catastrophize” the level of pain, which may affect how other people with chronic pain are perceived by those trying to assess pain levels.

It may be true that there should be a science of pain expression. It should not only focus on how patients express pain but also how caregivers interpret that expression. Artificial, subjective pain rating systems should be the first thing explored.