Last week I strained a muscle in my upper back and neck, likely my trapezius. For several days I had pain and stiffness that restricted turning my head and made sleeping difficult to say the least. I’ve had acute back and neck injuries before, as will roughly 80% of humans thanks to walking upright with spinal bones better suited for our arboreal ancestors, but this was one of the worst ones I’ve experienced yet.
Pain is one of the more complex health problems we face. There is currently no reliable means of measuring pain objectively. No blood test or imaging modality exists that might help me know if a patient is in pain or how much pain they are in. Instead I must rely on observing behavioral cues or, when a patient is old enough and capable of answering questions, I can ask them how bad their pain is using a variety of tools, none of which are very helpful.
The experience of pain is fairly unique to each individual. As they say, one person’s 5 out of 10 pain is another’s 10 out of 10. The specific factors that influenced my personal experience of pain over the past week or so aren’t easily quantifiable and largely exist in my brain, even though acute tissue injury was clearly the inciting event. Previous experiences with pain, cultural beliefs, and personal attitudes played a role, as did any subconscious fear of prolonged suffering or anxiety over the potential for loss of function. But this is just the beginning when it comes to biopsychosocial factors that might have influenced not only my experience of pain but also how I might describe that experience if asked.
This is not to say that the degree of tissue injury doesn’t correlate with the amount of pain someone might experience. A gunshot wound to the abdomen will naturally hurt more than a paper cut. There are clearly instances where I can reliably assume that there will be severe pain, and even pain that might last for an extended amount of time, and tailor my medical management accordingly. But it is often not clear.
How much should a generic unit of pneumonia hurt? How about a migraine, a broken arm, or an ear infection? There are a seemingly infinite number of injuries and medical maladies that result in a spectrum of pain severity such that it is challenging if not impossible, or just plain wrong, to make assumptions. And chronic or functional pain, which often lasts long after any potential tissue injury has resolved, ratchets up the complexity by orders of magnitude.
Another important factor in an individual’s perception of pain is their susceptibility to distraction. Our brains, through myriad subconscious processes, raise or lower the intensity of our pain based on numerous variables. For clarification (I hope), imagine the following two scenarios:
Scenario 1
A 40-year-old woman develops anterior chest pain soon after turning in for the night. Her father had died last year from a sudden and unexpected heart attack which initially presented with chest pain. The woman had similar chest pain a month ago and felt ignored by the emergency department physician who told her that it was just heartburn and to take an antacid. She had recently read an article online that discussed heart attacks in women and how there can be delays in diagnosis and appropriate medical care. In the emergency department, she rates her pain as 10 out of 10 and expresses that it is unbearable.
Scenario 2
A 40-year-old woman develops anterior chest pain soon after turning in for the night. Her family history is benign, and she has always been healthy except for occasional episodes of heartburn that she treats with an antacid. She recently read an article online that discussed common benign conditions that can mimic a heart attack. She spoke with her mother, a retired cardiologist, about the pain and rated her pain as 3-4 out of 10. She takes an antacid and watches an episode of her favorite television program. After an hour, she feels much better and goes to bed.
As I stated earlier, there is no objective means of quantifying pain. But what if I told you that in this thought experiment there was, and that each of these women with heartburn had the same amount of pain as determined by measuring some fictional serum biomarker? What would explain the difference in how they experienced and expressed their pain when asked?
The woman in the first scenario was, understandably, more worried about her chest pain. She was afraid of the repercussions of missing a life-threatening condition and her previous experience left her feeling as if her concerns were dismissed by the medical system. Her brain likely perceived the situation as more of a threat and responded by turning up the volume on her pain, so to speak, without any conscious awareness or control.
The woman in the second scenario had a very different background. There was no recent loss of a loved one and she had a history of heartburn so was likely able to reassure herself that this wasn’t any different than all those other times when an antacid did the trick. She was even able to bounce her pain off an expert that she trusted and who likely provided additional reassurance. Because her brain hadn’t assigned a high threat level to her pain, distraction was an easy and helpful intervention. Before she knew it, the pain was gone and she was able to avoid a trip to the emergency department.
These scenarios are necessarily simplistic. There are countless biopsychosocial factors at play when it comes to pain, and I could never come up with two short stories that cover all or even a quarter of them. My goal was simply to highlight how the potential psychosocial variables can be just as important as the biological ones, if not more so.
Distraction, such as when the woman in scenario 2 watched a television program that she enjoys, can be a very effective means of reducing acute and chronic pain in many people. This is particularly true during brief episodes of procedural pain, like a vaccination or a finger stick. And there are countless ways to achieve distraction, though not all approaches will work for all people. Some people won’t respond to any non-pharmaceutical interventions, while others react like it’s legit magic, which is of course based on yet more complex psychosocial influences.
In March, Archives of Physiotherapy published a “Viewpoint” by physical therapist Nicholas Washmuth and psychologist Richard Stephens that discusses the potential for harnessing the pain relieving, and performance enhancing, powers of swearing. It’s just another form of distraction and unlikely to work via any unique mechanism, but it’s still a quick and interesting read. It is available in full online, which is nice for a change, but I’ll briefly break it down.
In the introduction, the authors point out the power of words to change how we think, feel, and perform, comparing them to drugs. That’s true in the general sense, though words do have limits. They won’t replace insulin, after all. Still it’s a good point. They endorse a biopsychosocial approach to physical therapy, which is great. Failure to recognize the importance of how we think, and the role of environment, fails the patient every time.
They give a brief historical perspective on swearing and set the scene for why it might serve as a powerful distraction because of its shocking nature. As evidence of potential downsides to swearing, they mention the risk of social isolation and cite a study which found an association between swearing and depression in women with rheumatoid arthritis or breast cancer, but only when swearing around other people. I didn’t read that study, but I would be curious to know if it addressed the possibility that depressed people are just more likely to start swearing in public rather than the other way around.
The authors then switch gears and list positive attributes associated with swearing. They claim that swearing has been found to be a sign of intelligence, honesty on a personal and societal level, and perhaps even creativity? Yeah, no shit.
The most important point made in their introduction is that the power of swearing, as well as the potential for negative repercussions, is largely dependent on the context of the situation and on an individual’s prior experience. Someone will likely find swearing to be more emotionally arousing if they have learned, through negative feedback from people around them, that swearing is “bad” and should be avoided or at least used sparingly. Of course, according to the authors, this is only about 10% of the adult human population. The rest of us apparently curse like sailors.
The authors caution that swearing shouldn’t be incorporated into a treatment plan without a specific goal in mind, such as reducing pain or relieving stress. They further warn that swearing might be less helpful a tool if used in a formal or public setting, though they admit that swearing can help to bring people closer together in certain situations by engendering a more relaxed social environment. Swearing could, by extension, help to foster a better therapeutic alliance between physical therapist and patient, which might help to address psychosocial factors related to the perception of pain.
You’re probably wondering if anyone has actually designed a study looking into the potential pain reducing benefits of swearing. The Viewpoint authors surely wouldn’t waste our time with mere conjecture! They discuss a study where subjects placed their hands into ice water while repeating either a swear word or a more socially acceptable word. Subjects in the swearing group kept their hand in the ice water for 40 seconds longer on average and also waited longer before admitting that they felt any pain while their hand was submerged. Not surprisingly, subjects who used swear words more frequently experienced less of an effect.
All of this is consistent with simple distraction, which the authors admit is the most likely mechanism behind any apparent reduction in pain associated with swearing. They give some helpful tips for readers:
- Use a swear word that you would use if you banged your head accidentally.
- When in doubt, just use “shit” or “fuck”.
- Use an actual swear word rather than one that is made up to merely sound naughty.
- Don’t direct your swear at your physical therapist or any present individual.
- Limit non-therapeutic swearing in order to preserve any potential benefit for reducing pain.
The authors point out that swearing might not be for everyone because there are some potential negative consequences. They also recommend that patients should work with a trained clinician to determine if they might be a good candidate. Finally, they remind the reader that it’s probably best to keep the swearing private or at least to a group of trusted friends.
If it sounds like I’m giving this paper a hard time, I am…a little. Swearing to help reduce pain is a bit of a silly concept, but it is a potential distraction and might help alleviate some kinds of pain in certain circumstances. But it is a cumbersome means to achieve that end, and there are better and perhaps more productive approaches.
Even if we assume some benefit, the biggest weakness with swearing is the loss of effect with repeated use. Once the novelty has worn off, then the patient is just saying a word that has no power. Other distraction techniques don’t have this issue. But if you think swearing helps, whether to reduce pain, alleviate stress, or just to impress your friends, family, and co-workers, go for it.