Pain Isn’t All In Your Head—But Some of It Is

Kevin Kling on the Marines, chronic pain, and laughter

A billboard ad depicts a young Marine recruit in the midst of an agonizing struggle. He’s got his chin nearly up and over a lower bar, and his left arm is gripping a second. From the look on his face, it’s a bridge too far. Alongside the picture: “Pain is weakness leaving the body.”

If that’s true, then there may be no stronger person in the world than Kevin Kling, one of Minnesota’s finest playwrights, performers, and storytellers. In 2001, a motorcycle accident severely damaged Kling’s brachial plexus—the nerves that course out of the neck to innervate the arm—leaving him with a painful and fairly inert right arm.

Kling was understandably demure about accepting the title of Most Powerful Human on Earth—or at Least the Twin Cities, but he did. “I’ll take it,” he says. “Just so I don’t have to prove it.”

There’s a story Kling likes to tell about how people perceive pain differently, about a kid he met in an elevator during rehab. “He was like eight years old, and said he had hit his head on a fence post and had to have eight stitches,” says Kling. “And he points to the back of his head. And I said, ‘Oh yeah? I had to have stitches from here-to-here,’ and I go from ear to ear, down one arm, down my chest, down one leg, and then down my foot. And then he looks at me and says, ‘Yeah, but mine really hurt.’”

What Kling learned from a motorcycle accident and what that eight-year-old learned from a fence post, I’ve learned from a career in medicine: Your pain is your pain. No one can tell you different—or prove otherwise. With relative precision, science allows doctors like me to measure someone’s blood pressure, sodium level, the dimension of their kidneys, or the density of their bones. But when it comes to pain, all I have is a woefully lame question: “On a scale of 1 to 10, how much does it hurt?”

The usefulness of that diagnostic tool diminishes the first time a young physician is called to the bedside of a patient who’s become over-sedated by narcotics. After a lot of verbal and physical prodding, the poor soul finally rouses, and when you ask them to rate their pain 1 to 10, they say “It’s a 20!” and fall right back to sleep. Or you see a tiny, elderly woman with a fractured wrist getting by on a little Tylenol, while the same injury causes a 31-year-old pipe fitter to shotgun Percocet out of a PEZ dispenser. Every physician quickly comes to understand that pain is as personal as a fingerprint.

If that’s the subjective side of pain—it is what it is—here is the objective side: Specialized nerve endings called nociceptors convert the energy of a painful stimulus—say, the heat from a stove top—into an electrical stimulus that is transmitted by two types of pain fibers. A-delta fibers carry the brief, sharp, initial pain that causes you to spasmodically toss a hot cookie sheet down on the stove top. C-fibers work a little slower, delivering the dull, achy, and unpleasant pain that comes a moment later, when you remove the moth-eaten oven mitt, shake the injured finger, and curse the oven mitt and all of its ill-begotten oven-mitt lineage.

Your brain is instantly aware that your finger has been burned. There are, in fact, a lot of areas of the brain that take a personal interest in whether you are going to pay dearly for some oatmeal-chocolate chip cookies, but a deep-brain structure called the thalamus seems to play a pivotal role. The thalamus interacts closely with a structure in the front of the brain called the cingulate gyrus, which regulates how we perceive the cognitive and emotional aspects of pain. It’s the stuff that a worm doesn’t feel when you put it on a hook.

But pain isn’t just a one-way street. A series of nerves running from the brain back down into the spinal cord allow the brain to either blunt or augment the pain signals coming in from the peripheral pain nerves. Opioids work by dampening the transmission of pain signals through the spinal cord.

In some patients with chronic pain, it appears that these spinal nerves become overactive, too eager to transmit every hiss and crack generated by pain nerves. Every stimulus, even a normal one, can feel painful. That’s what happened in Kling’s case: Severed and damaged nerves continued to misfire like a sparking wire, sending off painful impulses to his brain. The doctor who specialized in brachial-plexus injuries told him that the pain will be “both intermittent and ever-present.”

At first, Kling didn’t understand the oxymoronic description. In fact, it wasn’t until a year after the accident that he experienced any pain; his arm had been numb until that point. So when the pain did hit, Kling was surprised. “What I thought was, ‘This is going to be a fleeting thing.’” But the doctor’s description proved apt. “By him saying it’s intermittent and ever-present, it kind of came down to ‘It always hurts, unless it really hurts.’”

But if the transmission of pain is all in our nerves and spinal cord, the perception of pain—how bad it is, the emotion of it—is, in fact, in our heads. Hypnosis and active distraction have both been shown to slow the metabolic activity of the cingulate gyrus, thereby easing pain.

Kling has firsthand experience with the sensation. “Sometimes when people come up to me and say, ‘Are you in pain?’ I’ll say, ‘I am now, but I wasn’t until you brought it up!” he says. “But this is absolutely the truth: I have never been in pain while I’ve been performing. I’ll be waiting in the wings, waiting to go on, and I’ll be getting these amazing shooting pains, and then I’ll get on stage: nothing. And when I exit the stage, the pains are there again. And it’s because when you’re on stage, your distraction is so complete. You’re focused.”

So what does Kling think when he drives by the Marines billboard? “Well, here’s the thing: My relationship with pain is very different than if I was in my 20s,” he says. “Your passions are very different back then, and your mortality sits way further away. Now I would just go, ‘I’m still not joining the Marines.’ But back then I would have gone, ‘Oh yeah, take this!’ I would have attacked pain from a very different angle.”

While I, the internist, attack it with a prescription pad.

Craig Bowron is a Twin Cities internist.