A perspective on pain

I just finished reading Hell on Two Wheels, by Amy Synder, which is a book that chronicles the 2009 Race Across America (RAAM). RAAM is a endurance race unlike any other. It starts in Oceanside, CA at the Pacific Ocean and ends in Annapolis, MD at the Atlantic Ocean. It covers 3,000 miles and time doesn't stop until you have finished the entire course. That means that any time you spend sleeping, eating or resting off the bike is time you are not racing. The winners finish in under 10 days (Christoph Strasser set a new record of 7 days 22 hours 11 mins in 2013), and the official time cutoff is 12 days.

If you want to read more about the perils of the race, the impact of sleep deprivation, the hallucinations, the physical ailments that the cyclists suffer through (including life-threatening respiratory emergencies, heat stroke, muscle failure, and nerve damage), the importance of the support teams, and the logistics of competing in the race, I would highly recommend the book.

One of the things that struck me most about the story was how the cyclists deal with pain for days on end. In order to complete the transcontinental crossing under the time limit, racers average 22 hours on the bike per day. Day after day after day. I know how tired I am after 10 hours of racing on the bike for one day. The thought of racing over twice that long for days on end sounds unbelievable.

The cyclists in RAAM have different strategies for dealing with the pain they experience. Some dissociate from it. One cyclist in the book says, "I try not to think about it. I just remind myself what my goal is." The ultracycling legend, Jure Robic, said, "I know it is there because I feel it, but I don't pay attention to it. I sometimes see myself from the other view, looking down at me riding the bike."

Others try to gain control over their pain. They use problem solving skills to reduce their suffering, such as focusing on relaxing when they have cramps in their shoulder blades or changing their seat angle to reduce saddle sores.

Some tackle their pain head on. "Pain is the goal," one cyclist in the book said. "I accept it. It's where I want to be. The key is not to get down on myself." Another cyclists reminds himself that, "Suffering is my choice, so I don't feel victimized by it. If I'm miserable, I've got to remember I've chosen to do the race, and I've got to accept the gift of being uncomfortable."

Strasser uses cognitive distraction to endure pain. During training rides before the 2009 RAAM, he would rub peppermint oil on his skin and think to himself how cold he felt, programming his mind to associate the smell of peppermint with cooling. When some part of his body hurt, he diverted his attention away from the pain by focusing on tapping his fingers on the handlebars or wiggling his little toe. He basically trained his mind to focus on sensations in his body other than the pain.

Finally, at some point in the race, all racers sought out social support for dealing with the pain. They depended on words of motivation from their support crews, phone calls from loved ones at home, or online posts of encouragement from fans.

All of these methods of coping with pain are called adaptive methods because they allow the athlete to reduce the stress caused by pain and to resume his/her previous level of functioning. In contrast, maladaptive methods of coping with pain are more avoidance oriented such as restricting activity or tensing up.

Most studies have found that athletes have a higher pain tolerance than non-athletes, although it is not known if individuals develop a higher pain tolerance from years of training or if individuals with an innately high pain tolerance to begin with are more likely to be involved in athletics.

I started looking for an explanation as to why athletes can tolerate higher levels of pain. Here is what I found:

1. Athletes have better coping strategies, including cognitive distraction and dissociation. In pain tolerance tests, those athletes who can endure the highest levels of pain use used some combination of those 2 techniques. They didn't catastrophize their situation.

2. An athlete's emotional state also influences pain perception. Positive emotions and reduced fear/anxiety about a given task are associated with reduced pain levels. Conversely, if someone is anxious or distressed, he or she will experience an increase in perceived pain. One theory is that athletes associate pain with positive emotions (ie pain is a sign of getting stronger or of getting to the finish line faster) and thus a painful stimulus is perceived by their brain at lower intensity compared to nonathletes.

3. Another theory to explain athletes' higher pain tolerance has to do with something called conditioned pain modulation. According to this theory, if an individual is exposed to a painful stimulus, there is a system in the brain that gets activated and inhibits pain signals coming from other body parts. For example, pretend a burning rod is touched to your arm. It will hurt a lot. However, if your other arm is exposed to pain first, say submerged in freezing cold water before 30 seconds before the hot rod is applied to your arm, the burning pain perceived will be less intense. This time, the same burning rod will only hurt a little. The idea behind conditioned pain modulation is that pain inhibits pain.

Athletes may have greater conditioned pain modulation capabilities compared to nonathletes. Because athletes are constantly working out, straining their muscles, and racing at their maximum, they are constantly triggering the structures in the brain responsible for pain inhibition. This may allow them to produce more powerful pain modulation and have higher pain tolerance levels compared to individuals who are not regularly exposed to pain.

4. Finally, one additional explanation for greater pain tolerance in athletes may be due to the "runners high." Several studies found increased levels of endogenous opioids (endorphins) in individuals after exercise that positively correlated with the level of euphoria athletes felt as well as their increased pain threshold.

So whether it's mind over matter or natural opioids being produced during exercise, one thing is for certain. The racers of RAAM can endure pain unlike anyone else. As Amy Synder writes in the book, "Suffering is a hallowed cultural value in the world of competitive cycling, probably more so than in any other sport. Cyclists equate suffering with excellence, and it's widely believed that those who can endure the most punishment will rise to the top of the heap. 'I won because I suffered the most' is a familiar bike racer refrain. Another is 'Once you learn how to suffer out there, you can do anything on a bike.'"