Pain, Pain Perception, and Healing: A Primer For Writers

Page 1 of 38 Cohen/Pain, Pain Perception, and Healing
Pain, Pain Perception, and Healing
A Primer for Writers
Lisa Janice Cohen, MS, PT
links active and verified as of 3/08
contact the author :

ljcblue@gmail.com
http://www.ljcohen.net
http://ljcbluemuse.blogspot.com
Contents:
I. Introduction
II. The anatomy of pain
III. Factors affecting pain perception
IV. Wounds and healing
V. Fractures and healing
VI. The language of pain
VII.Summary
VIII.Example
I. Introduction
One of the challenges a writer faces is how to introduce the right amount of
detail to make a story feel real and engaging. Too much detail and the story risks
becoming encyclopedic. Too little or poorly researched detail, and the reader may not
be willing to suspend the necessary disbelief to engage in the story. Perhaps as a
consequence of working as a physical therapist for more than twenty years, I find the
literary treatment of pain, injury, and healing problematic in this regard. In the
fantasy genre, for example, the hero who singlehandedly defeats a horde of enemy
soldiers without breaking a sweat is almost as much of a cliche´as the horse that can
gallop twelve hours straight and not tire and the never-emptying elf quiver. A
perfect character is a boring characters and using injury or pain to complicate your
character's progress can make for a richer story.
This primer was originally written as an on-line class for Forward Motion for
Writers (http://www.fmwriters.com) as part of their series "Back to School for Busy
Writers.” The information presented can be helpful when writing about a character
who sustains an injury and is relevant to many genres, from literary fiction to
mysteries, to science fiction and fantasy and anything in between.

II. The Anatomy of Pain
Pain--we've all experienced it, we try to avoid it, and spend money, time, and
effort to battle it. It's not something we generally think about when we aren't
experiencing it, and in the grip of pain, we just want it to stop. But pain is an
extremely complex phenomena, encompassing both physiological and psychological
elements. This lesson will focus on pain from a scientific perspective in order to help
the writer gain insight into how individuals experience pain.
A. Historical Beliefs About Pain
In order to have a context for how people respond to pain and injury or illness,
it might be useful to examine how past cultures conceptualized these states. For the
writer working in the fantasy or science fiction genres, this historical perspective can
act as a jumping off point for world building around issues of how fantasy races or
alien cultures manage pain.
Malicious spirits/punishment for evil deeds
Ancient civilizations linked pain to malicious spirits or understood it as
punishment for evil deeds. Treatment revolved around making sacrifices to appease
the spirits or to atone for past deeds. Pain was not seen as something that came from
within the body, but from outside forces acting on the body. The individual that had
the power to mediate pain was the shaman or priest.
Imbalance of the four humors
Hippocratic medicine believed that pain was an expression of the imbalance
between the four humors: blood, phlegm, yellow bile, and black bile. This
conceptualization of medicine was developed in ancient Greece in the 6th century BCE
and was carried forward until the 17th century. It was the first 'scientific' advance,
moving the study of illness from a magical construct to something that could be
analyzed and treated. In the Hippocratic system, the humors were related to
seasons, elements, and personalities, and qualities according to the following chart:
HUMOR SEASON ELEMENT PERSONALITY QUALITY

Blood Spring Air Sanguine Hot/Moist
Phlegm Winter Water Phlegmatic Cold/Moist
Black Bile Autumn Earth Melancholy Cold/Dry
Yellow Bile Summer Fire Choleric Hot/Dry
Bleeding, leaching, and cupping were appropriate treatments for these
imbalances. A wonderful depiction of this in movies is the ending of the 1988 film
with Glenn Close and John Malkovitch, “Dangerous Liaisons.”

Imbalance of hot and cold influences
Aristotle (4th century BCE) believed in a physiological system centered on the
heart and the lungs/brain. In the heart burned a life-giving vital flame maintained
by a spirit named pneuma or spirito vitale (vital spirit). The heart was responsible for
heating the body. The primary function of the lungs and the brain were to cool the
overly hot influences of the heart. Aristotle had a great influence on the medicine of
his time and beyond with his focus on the observation of natural phenomena,
including the practice of animal vivisection. (For an excellent overview of the shift in
medicine between the ancient world of magical beliefs to the Hipporcatic Corpus, to
Aristotle's medicine, refer to: http://www.disf.org/en/Voci/84.asp
Decartes' delicate thread
(From: René Descartes. L'homme de Rene Descartes. Paris: Charles Angot, 1664)
In the 17th century, Descartes proposed that pain followed a pathway from the
injured part to the brain by means of a delicate thread or pain channel. The brain was
understood by Descartes to be the organ that became aware of the pain, but it had no
control over the experience of pain. He illustrated how particles of fire traveled from,
for example, the foot to the brain and he compared pain sensation to the ringing of a
bell.
Descartes' view was a mechanistic view of pain which became the dominant
pain paradigm for the next several hundred years. In this theory of pain, the brain
was simply the signal device. In order to treat the pain, the pathway needed to be
disrupted in some way: either at the sense organ end (remove the foot from the fire)
or by severing the path to the brain (amputate the damaged part, or cut the nerve).
Several observations made during the Civil War by battlefield surgeons began to
challenge the simplistic, mechanistic model Decartes had developed. Because of
primitive conditions, many battlefield amputations had to be performed to save the
lives of injured soldiers. Surgeons began to see soldiers who continued to experience
the pain of their injured limbs even when those limbs were no longer present. This
indicated a nervous system far more dynamic and complex than was explained in
Decartes' model and led to a system's approach to understanding pain and pain
modulation.
B. Pain Anatomy
The nervous system is a complex interaction of multiple subsystems balancing
sensory input, nerve impulse transmission, cognitive interpretation, and motor
output.
Sensory input happens via specialized organs in the body that are
specific for kinds of stimuli. In the skin, for example, we have hot/cold receptors,
pressure receptors, pain receptors, and position sense receptors.
Transmission: The nerve impulses are transmitted via electrical impulses
that travel along nerve fibers. Where one nerve ends and another begins, there is a
space between them called a synapse. The nerve impulse jumps across the synapse
aided by chemical messengers (neurotransmitters). The synapse acts like a relay
station, moving the impulse along and strengthening it. The spinal cord is a
specialized structure that acts both as the 'freeway' of the nervous system as well as
the 'on' and 'off' ramps. The spinal cord carries the nerves that communicate between
the brain and the body.
Interpretation: The human brain is a marvel. Its convoluted folds
contain ancient structures, essentially not much different from primitive reptilian
brains, contained within a more 'modern' cerebral cortex in which things like language
and logic are processed. But there are rich links between our 'old' brain and our 'new'
brain and it's those links that bring powerful associative memories and feelings
forward in response to sensory stimuli. It's the old brain that tells us how miserable
we feel, while the new brain localizes exactly where the pain is.
Motor Output: A system of motor nerves exists to take the modulated
and interpreted sensory input and make something happen, eg, run away.
The Reflex Arc
The most simple example of the nervous system in action is a reflex arc, such
as you might have experienced if you've ever jerked your hand back from a hot stove.
In fact, your body reacts to prevent a serious burn before you have any
conscious awareness of the pain. (http://www.free-
ed.net/sweethaven/MedTech/NurseCare/NeuroNurse01.asp?iNum=9
There are 5 elements in a simple reflex arc:
● the sensory receptor
● the sensory nerve
● the spinal cord interneuron
● the motor nerve
● the muscle
In the case of the hand on the stove, the sensory nerve in the hand responsible
for thermal stimuli, sends its alert through the sensory nerve to the spinal cord.
Special nerves (the interneurons) act to relay the alert directly to the nerve
responsible for action and triggers a muscle contraction in the arm that jerks the
hand from the potential danger. All of this happens at extremely fast speeds,
approximately 50-60 meters per second. and without any processing at the brain
level. That would take time--time in which the hand in contact with the stove would
sustain damage.
(Nerve transmission speed depends on many factors, including diameter of the
neuron and whether or not the neuron is sheathed with myelin or not. A good
explanation of nerve conduction and how to measure it can be found here:
http://www.stjohnsmercy.org/healthinfo/test/neuro/TP013.asp)
Now, we do experience pain along with the tissue damage, but the pain is
experienced after the hand is jerked away. Why? It is a simple matter of physics. It
takes additional time for the nerve impulses that describe the problem to reach the
brain centers responsible for interpretation.
What about phantom pain?
If there is no sensory organ and sensory nerve to communicate with the spinal
cord (and through the spinal cord, the brain), then how do we explain phantom pain?
That will be the starting point for the next section: Pain Perception.
Links:
http://www.library.ucla.edu/biomed/his/painexhibit/index.html
(The Relief of Pain and Suffering : a virtual exhibit)
http://www.wellcome.ac.uk/en/pain/microsite/history.html (Pain History)
http://neurosurgery.mgh.harvard.edu/History/ether1.htm (150 years of anaesthesia)
III. Factors Affecting Pain Perception
The character who shrugs off a hail of bullets risks coming off campy, but the
character who falls apart from a papercut is a whiner few readers will want to follow.
The key is balance: add only the level of detail in the character's experience of pain
that supports the story and is consistent with the story's world. Pain experience
varies greatly from person to person as well as situation to situation. Knowing how
both internal and external factors affect pain will help the writer deal with the
aftermath of his or her character's injuries.
A. The Gate Theory of Pain
If there is no sensory organ and sensory nerve to communicate with the spinal
cord (and through the spinal cord, the brain), then how do we explain phantom pain?
Actually this is a specialized case of a larger, more general question. If pain is a
mechanical transmission of stimuli along the nerve pathways, than how come
individuals vary in their experience of pain?
A possible answer to this question is found in the work of Melzak and Wall. In
1965, they published a paper putting forth 'the gate theory of pain' which explored a
complex feed forward/feed back loop that allowed for modulation of pain perception
at multiple levels of the nervous system.

(http://en.wikipedia.org/wiki/Gate_control_theory_of_pain)
The gate theory of pain helped scientists see how 'plastic' the nervous system
was and how complex. New models of pain incorporated many interconnected
systems that could modify pain perception and experience. This was a huge shift
away from the mechanical model of Decartes' theory which influenced medical
thought until the 20th century. In that mechanical model, sensory nerves (afferents)
brought information from the body to the central nervous system. Motor nerves
(efferents) carried out the brain's orders, taking information from the central nervous
system back to the body. This created a simple input/output chain.
The gate theory changed everything. In effect, there are several ascending
sensory pathways that bring information to the spinal cord and multiple descending
pathways that take information back to the body. Both kinds of pathways can alter
pain experience. In addition to ascending and descending pathways, the body also has
the ability to produce its own natural pain killers: endorphins and enkephalons.
They also have the ability to influence pain perception at the level of the brain.
Afferent (ascending) Pathways:
There are three kinds of afferent nerves involved in pain transmission: a beta,
a delta and c fibers. The a delta and c fibers are 'nociceptors,' i.e., they respond to
painful stimuli. The a delta fibers respond to mechanical and thermal stimuli and fire
for a short duration. They elicit the initial, localized response to pain (e.g., a
pinprick) The c fibers respond to chemical, thermal, and mechanical stimuli, fire for
a long duration, and transmit the sensation of burning or aching pain. The a beta
fibers are large diameter non-nociceptive fibers; that is, they transmit non-painful
stimuli. If stimulation from the a beta fibers get to the spinal cord before the a delta
or c fibers, it 'closes the gate' to the painful stimuli and thus modulates the pain
experience. An example of the gate theory: You stub your toe. If you rub it, it stops
hurting as much. This is because you flood the spinal cord with non-nociceptive input
and the new sensory input has inhibited the pain pathways from sending their
messages to the brain.
The Brain and Descending Pathways:
Within the brain are connections between the pain pathways and the old
'reptilian' brain, including the thalamus, hypothalamus, and the limbic system. These
old systems regulate core autonomic body systems including our fight/flight/fright
response, and integrates our thoughts (the new brain) with memory and emotion (the
old brain). If we are frightened, our sympathetic nervous system (responsible for
increased emotional arousal) is more highly reactive. Pain experienced under these
conditions is perceived as more distressful. Furthermore, research on memory his
shown that memories processed under conditions of heightened emotional states
persist longer than memories experienced in emotionally neutral states.
Scientists now know that our thoughts, feelings, and perceptions alter pain due
to these deep brain connections, which may be why practices such as meditation can
decrease the experience of pain. It may also explain the phenomena of a child in the
playground who falls off a swing. If the child's mother is calm, it is likely the child
will be calm as well. If the mother panics, the child will show outward signs of
distress.
Endorphins:
Endorphins are named for 'endogenous morphine.' Our brains actually produce
morphine-like substances that act to inhibit pain at the brain level. Many people are
familiar with the 'runner's high' which is attributed to the release of endorphins in
response to high exertion. Accupuncture may also release endorphins, as does any
kind of counter-irritation.
B. Taxonomy of Pain
Building on the work of Melzak and Wall, researchers have developed a way of
talking about pain that separates the biological pain signaling system from the
cognitive/emotional interpretation of the sensations. These concepts include
nociception, pain, suffering, and pain behavior.

Nociception The stimulation of pain sensitive nerve fibers. A
purely mechanical process.

Pain The labeling of nerve impulses as 'painful'.
Suffering The interpretation of pain as a negative emotional
experience.
Pain Behavior The actions of an individual to communicate that
they are experiencing pain or suffering.
While these distinctions may appear to be artificial, they are quite useful in
understanding the question that opened this lesson: How come individuals vary in
their experience of pain?
At the nociception level, individuals can have different thresholds to the firing
of nociceptors. Some individuals find the sensation of tickling to be intensely painful,
while others find it a strong, but not painful sensation. Tickling is actually carried by
nociceptors, so one could say that tickling was, in fact, a low grade type of pain.
Even if two individuals had similar thresholds and responses to a given
nociceptive stimulus, they may vary on whether or not that signal will be interpreted
by the brain as pain. Someone may describe a given sensation as intense, strong, or
prickly, for example, but not as 'painful.' This may depend on the degree of
modulation from the descending pathways, which in turn may depend on state of
mind, mood, and circumstances. For example, a soldier experiencing the sensations
of a gunshot may interpret that sensation as positive if it means that the soldier is
going home from the battlefield. If you burn your finger ironing clothes, the
experience of that burn (definite nociception) will be different depending on whether
you are about to attend your best friend's wedding or your best friend's funeral.
Suffering is a construct that incorporates thoughts, emotions, memory, context,
and expectations. Suffering can occur in the absence of nociception or even pain or it
can be the consequence of nociception and pain. In general, the nociception of
childbirth is interpreted as painful, but not categorized as suffering. Some pain is
more likely to be interpreted as suffering: more longstanding and generalized painful
stimuli versus localized stimuli of short duration. For example, contrast a migraine
headache with the sensations that follow hitting your head. Migrainers more often
suffer with their headaches. The localized head pain following a bump can be
intensely painful, but is less often seen as 'horrible' and 'awful', words usually
attached to the experience of suffering.
Behavior is something we've all experienced. Pain behavior can include any and
all actions of a person that communicates he or she is having pain. For example,
limping, moaning, complaining, lying down with an ice pack, yelling, and crying. Pain
behavior is neither positive nor negative, although many professionals view it as
manipulative. Because pain is a completely subjective experience, pain behavior is
the only way we can communicate its impact. Pain behavior often happens in a social
context. For example, imagine you are hanging a picture and you strike your thumb
with a hammer. Will you say the same things or do the same things if you are alone in
the house versus having your spouse is in the room? In both cases, you experience
nociception, pain, and perhaps suffering. Pain behavior may be accentuated in one
social condition and inhibited in another.
Genetics may play a role in pain perception. In studies on genetics and pain
perception, one of the findings is that red heads have lower pain thresholds than non
red-heads. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1692342
There are also studies about early life experiences and later pain perception. In this
study: http://www.cirp.org/library/pain/taddio/, the authors concluded that
circumcision on baby boys without anasthesia can lead to altered pain perception
months later. Because the infant brain is at its most plastic, researchers believe that
early exposure to pain can change pain biochemistry permanently.
There are multiple factors that alter our experience of pain, from the purely
physiological to the cognitive/emotional, to the environmental. If you are writing
about a character who experiences pain, it may be useful to identify the factors that
might increase or decrease that experience.
Links:
http://www.bsdh.org.uk/reports/TheScienceOfChronicPainManagement.ppt
http://en.wikipedia.org/wiki/Gate_control_theory_of_pain
IV. Wounds and Healing
The skin is our first line of defense against infection. When the skin is broken,
the bacteria that are ubiquitous in our environment have a chance to colonize within
the body and cause infection or sepsis. Until the advent of routine sanitation and the
discovery of antibiotics, a wound, even a relatively shallow one, could easily cause
death. In fact, we have come almost full circle in our vulnerability to infection from
a wound: after profligate use of antibiotics, we now have 'superbugs' that are
resistant to multiple antibiotics and can be fatal. (See information about MRSA at
http://en.wikipedia.org/wiki/Methicillin-resistant_Staphylococcus_aureus, or
necrotizing fasciitis at http://www.nnff.org/nnff_what.htm
“Laudable Pus”
Hippocrates closely observed wound healing and believed that suppuration (a
sign of an infected wound) was something to be avoided. He advocated cleansing a
wound with alcohol, bandaging the wound, and soaking the bandages in alcohol to
prevent pus and speed healing. Galen, a physician of ancient Greece disagreed with
Hippocrates and believed the formation of pus was essential for wound healing.
Galen's beliefs about 'laudable pus' continued to influence medical care well into the
late 19th century. It was not until the 19th century that the germ theory of medicine
began to achieve any acceptance at all. In fact, in the 18th and 19th centuries,
hospitals were horrific places in which patients were more likely to die if they went to
have their illnesses treated. It was common practice, at that time, for a doctor to
move from completing an autopsy to delivering a child without stopping to wash his
hands. As a result, many women died from puerperal or childbed fever. Surgical
operations (carried out before the development of modern anesthesia!) had a more
than 50% death rate, most deaths occurring from post operative infections.
The Civil War Experience
Much of our understanding of wound healing came as a result of medical
observations after battlefield amputations in the Civil War. There is a famous case of
a soldier who survived a compound femur fracture after being left for dead on the
battlefield. When he was found, his wounds were filled with maggots. Beneath the
maggots, healthy tissue was growing in and there was no sign of infection. Maggots
actually only eat dead tissue and do, in fact, sterilize a wound and are still used for
some specialized wound care. Today, with antibiotics, simple hand washing, and
sterile technique, fatal infections are far less of a concern than a hundred years ago,
yet each year, people still die of wound related infections.
Variability in Wound Healing
Wound healing is a slow and complex process and it is influenced by (among

other variables) age, overall health, nutrition, and activity level. Young people heal
faster than old, healthier individuals faster than those with chronic health conditions,
the well nourished faster than the poorly nourished, and the physically active better
then sedentary individuals. One of the worst combinations for healing: a sedentary,
elderly smoker. One of the leading causes of hospitalizations and death in an elderly
population is pressure ulcers (sores). Someone who is bed ridden and inactive will
develop pressure sores when the skin breaks down from constant friction and pressure
beneath the weight of the body. Those wounds, invariably on the buttocks or hips,
are exposed to urine and feces and become infected. Even using intravenous
antibiotics may not cause these kinds of wounds to heal.
Under ideal circumstances, the phases of wound healing progress predictably
from wound to healing over the course of weeks to months, depending on the wound.
In the body, these phases overlap in a kind of recursive process, although for ease of
illustration, they are discussed as separate entities. (A thorough treatment of the
cellular processes involved in wound healing is beyond the scope of this course, but
more specific information can be found in the links following this lesson.)
A. Stages of Wound Healing
Inflammatory Phase (days 1-4)
The body initially acts to stop blood loss by clotting. The clot is formed when
blood comes in contact with collagen fibers, triggering the start of the inflammatory
process. The inflammatory process is vital to healing, particularly in the early phases.
It is the inflammatory process that triggers the body's immune system to start the
process of digesting the bacteria and clearing away dead tissue. However, if
inflammation lasts too long, it can actually delay healing and lead to a chronic
wound.
Proliferative Phase (starting days 2-3)
The body starts to form new blood vessels, which will be essential to the tissue
repair. The body also starts to lay down a matrix that granulation tissue will grow
across to bridge the wound. This starts 2-5 days after injury and continues until the
open wound is filled in. This is not normal tissue, but a 'stand in' as the healing
process slowly replaces the damaged tissue with normal healthy tissue. One of the
final aspects of the proliferative phase is wound contraction--the healing tissue begins
to pull the wound edges closer together. Like many other aspects of the body's
healing process, contraction optimally exists in balance with other factors. If
contraction is overly prolonged, it can cause permanent tissue alterations and long
term loss of function.
Remodeling Phase
Remodeling or maturation begins when the rate of collagen production equals
the rate of collagen degradation as the damaged tissue is finally cleared away and the
new tissue is fully laid down. Weaker collagen is replaced by stronger collagen and
the disorganized tissue is reorganized along tension lines. By three months post
injury, the healing tissue has approximately 50% of the strength of the original tissue.
After full healing takes place, the new tissue may regain up to 80% of its original
strength.
B. Scarring
Scarring is actually part of the healing process. A scar is essentially a
disorganized mass of tissue. In the process of healing, the tissue becomes organized
and able to replicate its prior function. If the healing process does not proceed
normally, scarring can become permanent, causing dysfunction. There are several
kinds of scars relevant to this discussion of the healing process: keloid, contracture,
and hypertrophic.
Keloid scars:
These scars result from an overly aggressive healing process. Keloids most
often occur in individuals with highly pigmented skin (people of African, Hispanic, and
Asian decent) versus those with light skin. Keloids extend beyond the margins of the
original wound and can cause significant loss of function, for example, if they cross a
joint. Treatment includes cryotherapy, surgical removal, or injection with steroids.

Contracture scars:
The tightening of the skin over a wound that may even effect the tissues
beneath them. These are most common after burns and may require surgical
correction and skin grafting along with aggressive rehabilitation to allow normal
movement. Burns are a severe kind of wound and depending on the degree of the
body affected and the depth of the burns, often fatal. Even with modern medicine,
artificial skin, and surgical skin grafting, infection is a leading cause of death from
burns.
Hypertrophic Scars:
Similar to keloids, but raised and red. These scars do not extend beyond the
margins of the original injury. Steroid injections can calm the inflammatory response
and stimulate healing of these scars.
Wound healing is a complex, multi-faceted process that can take more than a
year to complete. Wounds leave us vulnerable to introduction of infective agents and
infection is often deadlier than the wound itself. The health of the wounded
individual as well as the sanitary conditions and available medical care are crucial
variables in the healing process.

Links:
http://en.wikipedia.org/wiki/Maggot_therapy
http://www.medscape.com/viewarticle/503947
http://www.medicaledu.com/phases.htm
http://en.wikipedia.org/wiki/Wound_healing
http://www.emedicine.com/ent/topic37.htm (keloid scars)
http://www.bmj.com/cgi/content/full/326/7380/88 (scarring)
V. Fractures and Healing
Your intrepid hero falls from his horse or from the second story of a burning
building. Does he roll dramatically, spring up to his feet with a flourish, dust off his
leather coat and continue on with his quest? If so, you don't need to read this lesson.
However, if in the fall, your hero fractures his ankle, there are a few things you are
going to need to know about how he will function, the degree of pain he will be in,
and how long it will take for the bone to heal.
A. Bone
Bone is a living tissue. It has three critical functions: Bone provides the
structural framework for the body to maintain itself against gravity, bone provides the
attachment point for muscles (via tendon) that allow us to move, and bone is the
living factory in which our blood is created (in the bone marrow).
An adult human skeleton consists of 206 bones, roughly divided into five types:
long bones, short bones, flat bones, irregular bones, and sesamoid bones.
Long bones:
The femur (thigh bone) and humerus (upper arm bone) are examples of long
bones. Long bones are longer than they are wide and contain two articular surfaces;
that is, they have two places where they form an intersection (joint) with another
bone. In the case of the femur, it articulates at the proximal end with the pelvis and
the distal end with the tibia.
Short bones:
The carpals and metacarpals (wrist and ankle bones) are examples of short
bones--basically cube shaped with a thin layer of cortical (compact, hard) bone over a
thick layer of trabecular (spongy or cancellous) bone.
Flat bones:
The bones of the skull and the sternum (breast bone) are flat bones, consisting
of two parallel layers of cortical bone with a layer of trabecular bone in between.
Irregular bones:
These bones don't easily fit into any other category. Examples of irregular
bones are the bones of the spine and the pelvis.
Sesamoid bones
are a subset of short bones and are small bones inset into tendons that act to
increase leverage in motion. The patella (kneecap) is a sesamoid bone.

Our bones remodel throughout our entire lives. In fact, bone is the only tissue
that doesn't heal with scar tissue. Rather the action of osteoclasts (bone eating cells)
and osteoblasts (bone creating cells) continually repair and change bone. In general,
osteoblastic activity outstrips octeoclastic activity in childhood when we are growing
the most. That is why it is rare for children to fracture bones and when they do, they
tend to heal much more rapidly than adults. In adults, osteoclastic activity tends to
overcome osteoblastic activity. This increasingly becomes the case in old age.
Fracture (particularly hip fracture) is a leading cause of death amongst the elderly.
B. Types of Fractures
There are many types of fractures. This section will discuss several basic
classifications.
Closed or Simple The bone is broken, but the skin over the fracture
Fractures is intact.
Open or compound The skin is pierced either by the bone or by the
Fracture mechanism of injury. This kind of fracture poses a
large risk of infection.
Transverse Fracture The fracture is at right angles to the long axis of
the bone.
Greenstick Fracture This is a common fracture in young children, so
named because the injured bone acts like a piece of
green (young) wood and fractured longitudinally,
usually on one side of the bone. This is a stable
fracture and healing generally happens quickly if the
bone is kept immobilized.
Comminuted Fracture A fracture where there are three or more bone
fragments.
Fractures can be described as displaced or non-displaced. Displaced fractures
are those in which the bone ends do not sit together like pieces of a puzzle. These
fractures must be 'set'; that is, the bones ends must be aligned in order for optimal
healing. Non-displaced, simple fractures are the quickest to heal, all other factors
being equal. A stress fracture is a kind of non-displaced, simple fracture.
C. Phases of Fracture Healing
Basic fracture healing is similar to wound healing. It consists of the same three
stages: inflammatory, reparative, and remodeling phases.
Inflammatory:
Bleeding from the fractured bone (remember, bone marrow is where the blood
is produced) brings the materials needed for healing to the fracture site. Skin
discoloration (black and blue marks or ecchymosis) is a hallmark of a fracture and
can last for several weeks. It also brings pain and swelling. This phase lasts from
days to weeks, depending on the fracture and is absolutely necessary to healing.
Reparative:
Here is where the bone ends begin to knit together. The body begins to lay
down new bone in a soft callus. This occurs two to three weeks post injury. This soft
callus cannot be seen on x-ray and is not strong enough to support weight bearing on
the injury site. Between four and twelve weeks after injury, bone has bridged the
fracture and can be seen on an x-ray. This callus will be thicker and larger than the
bone that it replaces because it is not as strong as the original bone.
Remodeling:
This stage begins at eight to twelve weeks post fracture and can last for years.
Here the body works to strengthen the bone at the fracture site and recreate it as it
was prior to the fracture.
D. Problems That Can Occur
There are many variables that impact fracture healing. Age, general health,
nutrition, severity of the fracture, and the care post fracture, to name a few.
Cigarette smokers and alcoholics tend to heal more slowly and with a higher rate of
complications than non-smokers and non-drinkers. While most fractures do heal,
there are several problems that can occur that may cause long term disability or
significantly delay healing.
Compartment Syndrome:
If post fracture swelling is severe enough, it can put pressure on the tissues
around the fracture and cut off the blood supply to muscles and other soft tissue.
Those tissues become necrotic (die) without continuous blood supply. This is an
extremely serious complication and can lead to the need to amputate the limb if not
treated.
Neurovascular injury:
Nerves and blood vessels can be torn along with the original injury that caused
the fracture. This can cause long term weakness or even local paralysis. For
example, a crush injury of the lower leg can cause foot drop (an inability to actively
move the ankle up) due to damage to the nerves that serve the foot.
Infection:
This is especially a risk for compound fractures--fractures that pierce the skin.
Arthritis:
It is more than an 'old wives' tale' that injuries to bone can lead to joint pain
and an ability to foretell the weather. Fractures that extend into a joint can lead to
accelerated development of arthritis (chronic and/or intermittent swelling) in that
joint. A joint is essentially a fluid filled enclosed space and as such is sensitive to
barometric pressure changes. An arthritic joint is more sensitive to these changes.
Growth abnormalities:
This can be a problem in childhood fractures. The bones of a child contain a

growth plate (physis); the place where the bone grows from. If the fracture is in the
growth plate, than one of two problems can occur: either the bone will stop growing
prematurely, or the bone will grow unevenly causing severe biomechanical problems.
Delayed, Mal or Non-union:
When a bone doesn't heal in a reasonable timeframe, it is said to be a delayed
union. A mal-union is a bone that has healed with some alignment problem (as in a
growth plate injury). A non-union is a fracture that has not healed; that is, the bone
ends are not aligned.
E. Management of Fracture
The vast majority of uncomplicated fractures in healthy people will heal within
eight to twelve weeks' time using a combination of RICE: Rest, Immobilization,
Compression, and Elevation. In the case of a weight bearing bone, this will likely
include non or significantly reduced weight bearing. Crutches and walkers will reduce
weight bearing. A single cane will assist balance, but not sufficiently decrease weight
on a healing fracture.
Surgical repair:
ORIF is 'open reduction, internal fixation' and represents a surgical technique
for treating displaced fractures. The area around the fracture site is opened, the
bone ends oriented together, and the fracture spanned by bone graft and/or artificial
fixation (screws, plates, etc.)
External Fixator: In some kinds of fractures, particularly comminuted
fractures, an external device is used with screw ends into the fracture(s) to bridge
the fragments. (see photo here: http://en.wikipedia.org/wiki/External_fixation)
Joint Replacement is beyond the scope of this lesson and is generally
performed for reasons of joint degeneration or serious fractures that span the joints.
Other Treatments:
Electrical stimulation is often used for delayed and non-unions. There is some
debate as to why this works.
Supported Weight Bearing--because some weight bearing can speed healing, the
rehabilitation of fracture often includes early walking with crutches or walkers as well
as walking in the water, using the buoyancy of water to de-weight the fracture.
Bones are a specialized form of tissue that follow the same basic healing as was
outlined in the wound healing material. Because one of bone's primary function is
skeletal support, healing from a fracture requires rest and immobilization until the
bone is fully healed and is as strong as the original bone. This process can take weeks
to months, depending on the severity of the fracture and the overall health and
activity status of the individual.

Links:
http://en.wikipedia.org/wiki/Bone
http://pain.health-info.org/Pain%20Pages/fractures.htm (types of fractures)
http://orthoinfo.aaos.org/topic.cfm?topic=A00139 (types of fractures)
http://www.davidlnelson.md/Fractures_in_general.htm
http://www.fortunecity.com/bennyhills/mayall/3/path2603.htm
http://www.fda.gov/fdac/features/396_bone.html (new ways to heal broken bones)
http://www.hughston.com/hha/a.fracture.htm (problems in the healing process)
VI. The language of pain
Background research aside, where the information in this primer becomes
valuable to the writer is in the writing. Words like pain, hurt, and agony have
become practically meaningless other than to tell the reader your character is in
distress. To show the reader, the writer must dig for more unusual and vivid
descriptors, both in the adjectives used to describe a painful experience and the
verbs used to show character actions.
For an excellent resource list of words to describe pain, look at the descriptors
on the McGill Melzak pain questionnaire (pdf of the pain measurement tool available
here: http://www.cebp.nl/vault_public/filesystem/?ID=1400) While the pain
measurement tool is widely used in the clinic and in research, it's primary use to
writers is in the adjective lists used to ask patients about their pain.
VII. Summary
Somewhere between the television action hero who gets shot, run over by a
car, and pummeled by the bad guys before shaking off his injuries in time to save the
heroine/the world/the day and a character whose nosebleed is lovingly described in
full Technicolor detail over the course of a dozen pages is the right level of realism
and detail for your story. The information and resources included in this primer offer
the writer a starting place in understanding the historical, psychological, anatomical
and physiological underpinnings of pain.

VIII. Example
This is a partial scene from my current 'wip' (work in progress) called “Heal
Thyself," a multi-cultural fantasy. The male protagonist, Zev, is recovering from
serious injuries he sustained at the story's opening, including head trauma and a
fractured right arm. In this scene, his injuries interfere with his ability to defend
himself in a fight. He is certainly not a “Teflon” superhero and finishes the scene
bloodied and bruised, surviving primarily by luck and his opponent's arrogance.
***
The buyer turned, a dagger in his right hand. Zev grabbed the second blade,
and whirled away from the man's strike. His opponent was big, nearly a head taller
than Zev with a body the size and shape of a barrel. He charged, bellowing like an
ox. Zev slashed at his chest but he moved with surprising speed for a man so large
and Zev’s knife glanced off his flank.
“No one steals from Hal Markesset.” He advanced, backing Zev toward the
wall. Markesset’s reach was a good dagger’s length longer than his. Without two
functional arms, he was going to get cut. He brought his right arm up and across his
body, trying to tangle Markesset’s blade in his sleeve. The man’s knife slipped
through the fabric of Zev’s shirt and sliced the arm beneath, jarring the break. Zev’s
hiss was drowned out by the man’s laughter.

“Well, really, you’ve done me a favor. I can take the girls and keep my
money.”
He charged again and Zev shifted, slamming his left shoulder into the outside
of Markesset’s right arm, hoping to dislodge the knife. Zev’s momentum kept him
turning, his left side slipping past his opponent’s knife-arm when Markesset slashed up
in an arc, bludgeoning Zev on his left hip.
He stumbled and lurched out of Markesset's reach. His right arm dripped blood
and his hip blazed with fire. This had to end and quickly before he was outmatched
by Markesset’s size and strength. Lunging, Zev stabbed the point of his blade into
Markesset’s exposed left side and nearly lost the knife as it stuck in thick leather. Zev
yanked the knife free, panting. It’s tip was red.
Markesset howled and shoved Zev hard. He fell backwards, his bruised hip
slamming into the ground and his knife skittered across the floor. His breath burning,
he scrambled to his feet, praying his leg would hold him. The big man laughed,
closing in to finish Zev off.
“The last man who tried to cheat me--I put his head on a pike.”
Zev didn’t bother answering. He was tiring too quickly and Markesset could
sense it. Limping backwards, Zev tried to put some distance between them. He
glanced at his blade and Markesset grinned, showing a mouthful of stained and
chipped teeth. They both knew he could never reach it in time.
Markesset closed on him and knocked him against a jumbled stack of crates.
Zev’s head cracked against the wood and the impact jarred his arm and jaw,
awakening fresh bursts of pain. Unsteady on his feet, he shook his head trying to
clear it. The crates were swaying, the one on top cantilevered over the rest of the
stack.
“You’re dead, my friend,” Markesset said, hefting his knife.
Zev pressed himself flat against the bottom crates as the top one slid, cutting
off Markesset’s taunts with the crunch of breaking ribs.
“I am not your friend,” Zev said. His legs trembled and he slid to the floor.
“I’ll see you in hell.” Struggling for breath and pinned beneath the crate,
Markesset wheezed, his voice was a faint whisper. He coughed and blood bubbled in a
thin stream from his lips.
Zev smiled. He felt the embrace of the Divine in every joint in his abused
body. “I very much doubt that.”
***
If you want to read more about Zev and the world of "Heal Thyself,” other snippets
are available on my blog: http://www.ljcbluemuse.blogspot.com

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Page 1 of 38 Cohen/Pain, Pain Perception, and Healing

Pain, Pain Perception, and Healing

A Primer for Writers

Lisa Janice Cohen, MS, PT

links active and verified as of 3/08

contact the author :

II. The anatomy of pain

III. Factors affecting pain perception

IV. Wounds and healing

V. Fractures and healing

VI. The language of pain

be willing to suspend the necessary disbelief to engage in the story. Perhaps as a

character's progress can make for a richer story.

Writers (http://www.fmwriters.com) as part of their series "Back to School for Busy

mysteries, to science fiction and fantasy and anything in between.

II. The Anatomy of Pain

extremely complex phenomena, encompassing both physiological and psychological

the writer gain insight into how individuals experience pain.

A. Historical Beliefs About Pain

alien cultures manage pain.

Malicious spirits/punishment for evil deeds

Ancient civilizations linked pain to malicious spirits or understood it as

the power to mediate pain was the shaman or priest.

Imbalance of the four humors

Hippocratic medicine believed that pain was an expression of the imbalance

HUMOR SEASON ELEMENT PERSONALITY QUALITY

Bleeding, leaching, and cupping were appropriate treatments for these

with Glenn Close and John Malkovitch, “Dangerous Liaisons.”

Imbalance of hot and cold influences

Aristotle (4th century BCE) believed in a physiological system centered on the

Aristotle's medicine, refer to: http://www.disf.org/en/Voci/84.asp

Decartes' delicate thread

challenge the simplistic, mechanistic model Decartes had developed. Because of

primitive conditions, many battlefield amputations had to be performed to save the

The nervous system is a complex interaction of multiple subsystems balancing

sensory input, nerve impulse transmission, cognitive interpretation, and motor

pressure receptors, pain receptors, and position sense receptors.

Transmission: The nerve impulses are transmitted via electrical impulses

aided by chemical messengers (neurotransmitters). The synapse acts like a relay

the brain and the body.

Interpretation: The human brain is a marvel. Its convoluted folds

Motor Output: A system of motor nerves exists to take the modulated

The Reflex Arc

conscious awareness of the pain. (http://www.free-

There are 5 elements in a simple reflex arc:

● the sensory receptor

● the sensory nerve

● the spinal cord interneuron

● the motor nerve

(Nerve transmission speed depends on many factors, including diameter of the

explanation of nerve conduction and how to measure it can be found here:

brain centers responsible for interpretation.

What about phantom pain?

III. Factors Affecting Pain Perception

aftermath of his or her character's injuries.

A. The Gate Theory of Pain

Actually this is a specialized case of a larger, more general question. If pain is a

individuals vary in their experience of pain?

at multiple levels of the nervous system.

system back to the body. This created a simple input/output chain.

Afferent (ascending) Pathways:

messages to the brain.

The Brain and Descending Pathways: