‘I’m a Pain-Management Specialist, and Here’s What Pain Tolerance Really Means’
Although much of the pain we feel is indeed “in our heads”—based on the interplay of the brain and the nervous system—that doesn’t mean we have full control over our tolerance to it, or that if we were all to exert the same amount of willpower, that we could all handle the same amount of pain, anyway. In fact, the experience of pain is highly subjective, says physician and pain-management specialist Reuben Chen, MD. And a true definition of pain tolerance takes that reality into account.
- Reuben Chen, MD, board-certified physician specializing in sports medicine and pain management
What does pain tolerance mean, and how is it measured?
Just as alcohol tolerance refers to how much alcohol you can comfortably drink, pain tolerance refers to the maximum level of pain you can endure, says Dr. Chen. But, different from alcohol tolerance, for which there is a clear test (that is, the number of alcoholic drinks you can consume before adverse effects kick in), pain tolerance is tricky to measure. Not only are there ethical questions around studying pain (and subjecting people to painful stimuli), but also, there’s the fundamental reality that we all experience pain differently. “Two people rating a pain level as a six on a scale of one to 10, for example, could have very different perceptions of what that pain feels like,” says Dr. Chen. As a result, it would be tough to gauge objectively whether either of their experiences of the pain at stake reflects a high, low, or average pain tolerance level.
To get around this subjectivity issue, researchers in the past have developed a couple of tests with an aim to “create a standardized way for us to evaluate how much pain someone could tolerate,” says Dr. Chen. Those include the dolorimeter (which applies heat, pressure, or electrical stimulation) and the cold pressor test (which involves dunking your hand in ice water and holding it there until you can’t take it any longer.)
But these metrics have since fallen out of favor among pain-management physicians, not just for the questionable ethics of testing and utilizing them, but also because they fail to account for the fact that, again, different people can experience the same physical pain stimulus differently. And since these tests rely on the person to self-report when the pain becomes intolerable, “who’s to say your pain is equal to my pain?” says Dr. Chen.
In other words, one person’s ability to hold their hand in ice water for longer than another, for example, might just be a product of the fact that they’re actually experiencing less pain (or are less sensitive to pain) than the second person—and not that they have a higher tolerance for the pain.
“Pain measurement has as much to do with the biological components of pain as it has to do with the subjective experience of pain.” —Reuben Chen, MD, pain-management specialist
“Based on recent advances in pain research, we now know that pain measurement has as much to do with the biological components of pain as it has to do with the subjective experience of pain,” says Dr. Chen. And in turn, there isn't much value in comparing pain among people in order to determine what a "typical" low, average, or high pain tolerance looks like. “Since pain is so subjective, most physicians do not use the concepts of high or low pain tolerance anymore because it can change drastically from one patient to another depending on a variety of factors,” says Dr. Chen (more on that below).
Instead, pain-management physicians now typically use the visual analog scale (i.e., “rate your pain on a scale of one to 10”) to measure pain in a single person over time. “The key values we review are the change in pain before and after treatment for the pain,” says Dr. Chen. “For example, prior to starting the treatment, a patient may experience an eight pain level out of 10, and if the treatment is successful, following it, there should be a decrease in the number of that pain level.”
This way, the two measurements in question are both reflective of how that one person experiences pain (comparing apples to apples), rather than looking at the tolerance levels of multiple people who may be experiencing pain differently (comparing apples to oranges.)
What factors play into a person’s pain tolerance level?
Though, again, it’s tough to compare multiple peoples’ subjective experiences of pain, studies on pain have found that people with certain characteristics tend to have a higher pain tolerance than people without these characteristics. “Some of these factors are genetic, whereas others fall within our control to change,” says Dr. Chen.
1. Biological sex
A couple of studies have found that people assigned female at birth may have a lower pain threshold (the point at which a stimulus first becomes painful), and as a result, may be more sensitive to pain and/or experience more severe pain than people assigned male at birth. These differences could also create differences in overall pain tolerance levels between biological females and males.
But these results aren’t conclusive, nor are their origins fully understood. It’s also possible that gender norms and expectations around who "should" experience pain are playing a role here; if people assigned male at birth feel the need to “tough it out” and not complain of pain, they may be less likely to report their pain —or do so honestly—on subjective pain-assessment tests, after all.
2. Genetics
A whole variety of genetic variations can affect a person’s sensitivity to pain and pain tolerance; in fact, one study found that anywhere from 26 to 60 percent of thermally induced pain (that is, from heat- or cold-based pain tests) can be tied to genetics.
Most recently, the genetic variant responsible for red hair, an inactive melanocortin-1 receptor (MC1R), has been tied to the experience of pain. Specifically, an April 2021 study found that the lack of MC1R function in redheads results in less secretion of certain hormones that activate pain perception, leading to a higher pain threshold among redheads and potentially a higher pain tolerance, too.
3. Physical fitness
A 2012 meta-analysis of studies on athletes and pain found that athletes have a higher pain tolerance level than non-athletes, which suggests that coping skills for pain can be learned. In other words, “it’s possible to get better at pushing through the pain,” says Dr. Chen, even if you’re still feeling the pain to the same degree.
Additionally, it may also be possible to train yourself to experience less pain—not to just get better at tolerating it. A 2020 study analyzing pain in elite and high-level athletes compared to non-athletes found that the athletes actually reported lower pain intensity when exposed to heat than their non-athletic counterparts, and had higher pain thresholds—meaning they could stand the heat for longer before reporting that they experienced pain. This is all to say, becoming physically active may have the power, over time, to desensitize you to pain, too.
4. Sleep habits
If you feel like everything hurts more after a night of poor sleep, you’re not wrong, says Dr. Chen. A 2019 study found that sleep deprivation can increase pain sensitivity and also decrease the body’s analgesic response to pain in a painful double whammy. Specifically, the researchers used imaging to analyze different brain regions in participants who were exposed to an increasingly hot pad, first after a night of sleep and then after an all-nighter. During this exercise, the region of the brain responsible for pain perception was more active after the all-nighter, whereas the regions that help manage pain were less active.
5. Depression, anxiety, and other mood disorders
People who have mental health conditions like depression and anxiety have been shown to have lower thresholds for pain and to experience more severe pain than folks without mood disorders, likely for a variety of psychological and biological reasons. And it’s likely that the physical experience of pain among people with mental-health conditions can worsen their mental distress, and vice versa.
In this case, mental-health-focused interventions like meditation, mindfulness exercises, and relaxation techniques alongside cognitive behavioral therapy may help not only the mental symptoms but also the physical pain symptoms, too, “by changing the person’s relationship with pain,” says Dr. Chen.
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