Reflections on pain

The prevailing definition of pain is based upon a subjective and emotional experience of actual and or potential tissue damage (Merskey and Bogduk, 1994Merskey H, Bogduk N 1994Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. Seattle, IASP Press. [Google Scholar]). However, more recent research in pain physiology indicates the overlap between the brain’s representation of bodily versus emotionally conditioned pain experience and activation of the same neural circuits in the somatosensory cortex. This is one example of how pain perception also occurs independently from nociception (Kross et al., 2011Kross E, Berman MG, Mischel W, Smith EE, Wager TD 2011 Social rejection shares somatosensory representations with physical pain. Proceedings of the National Academy of Sciences in the USA 108: 6270–6275.[Crossref], [PubMed], [Web of Science ®],, [Google Scholar]). Besides, pain does not always have to have a negative connotation (Bastian, Jetten, Hornsey, and Leknes, 2014Bastian B, Jetten J, Hornsey MJ, Leknes S 2014 The positive consequences of pain: A biopsychosocial approach. Personality and Social Psychology Review 18: 256–279.[Crossref], [PubMed], [Web of Science ®],, [Google Scholar]). The experience of pain involves important learning, while also increasing the capacity for self-regulation with regard to cognitive control, coping, and achievement.

Modern neuroscientific research tells us much about how pain perception and pain behavior are reinforced through factors such as vulnerability, negative learning, maladaptation, and sensitization (Baliki and Apkarian, 2015Baliki MN, Apkarian AV 2015Nociception, pain, negative moods and behaviour selection. Neuron 87: 474–491.[Crossref], [PubMed], [Web of Science ®],, [Google Scholar]; Apkarian, Hashmi, and Baliki, 2011Apkarian AV, Hashmi JA, Baliki MN2011 Pain and the Brain: Specificity and plasticity of the brain in clinical chronic pain. Pain 152: S49–S64.[Crossref], [PubMed], [Web of Science ®],, [Google Scholar]). There are however fundamental questions connected to the origin of unexplained pain; in which context did it first appear; what were the early symptoms of an expression; and how could they be understood in a biological, psychological, and existential sense? Central to our contribution is the notion that unexplained pain has its reasons, a purpose, and a meaning, hidden in the patient’s mental and bodily history. This may seem obvious; however, it is rarely expressed explicitly in clinical practice.

Individual and cultural sensitivity of symptoms

In biomedical terminology, the term “symptom” is understood as patients’ subjective description of their ailments (Dorland, 2011Dorland WA 2011 Dorland’s Illustrated Medical Dictionary, 32nd edn, Philadelphia, PA, Elsevier Saunders. [Google Scholar]). Based on their description, the doctor or therapist will look for signs that may explain the cause of the symptom. This entails distinguishing between symptom and sign, whereby the sign, if it can be verified through technological examinations, laboratory tests, or clinical tests, provides an objective explanation or endorsement of the symptom. Despite the fact that signs that can be visualized and measured must also be interpreted, based on the interpreter’s knowledge and experience, the relevant context, and prevailing medical culture, the sign is considered to have greater credibility and legitimacy than the symptom (Staiano-Ross, 2012Staiano-Ross K 2012 The symptom. Biosemiotics 5: 33–45.[Crossref], [Web of Science ®],, [Google Scholar]). However, for the patient, the symptom will always be a sign; a sign that something is wrong, and one that generates worry and anxiety.

It is common to both patient and therapist that the symptom, as a bodily experience, can primarily be ascribed to a disruption or malfunction in the body. This may contribute to a fixed, narrow perception of the relationship between body and symptom. The fact that the existence and expression of symptoms has changed over various historical periods and cultural currents indicates that the symptom is a dynamic and mutable entity (Lian and Bondevik, 2015Lian OS, Bondevik H 2015 Medical constructions of long-term exhaustion, past and present. Socialogy of Health and Illness 37: 920–935.[Crossref], [PubMed], [Web of Science ®],, [Google Scholar]; Staiano-Ross, 2012Staiano-Ross K 2012 The symptom. Biosemiotics 5: 33–45.[Crossref], [Web of Science ®],, [Google Scholar]). Likewise, patients’ perception and description of the symptom will be characterized by their living conditions and life histories, psychological factors, and the prevailing cultural and social context (i.e., the patient’s life world). These factors form the basis for the patient’s meaning-making activity and are reflected in the patient’s way of understanding, relating to and communicating the symptom. This provides a basis for regarding the symptom as a biocultural phenomenon, and symptom debut, development, and changing expression as biocultural events (Staiano-Ross, 2012Staiano-Ross K 2012 The symptom. Biosemiotics 5: 33–45.[Crossref], [Web of Science ®],, [Google Scholar]).

Symptoms as signs that carry meaning

Instead of distinguishing between symptoms and signs, the doctor and psychoanalyst Irene Matthis (2007Matthis I 2007 Sykdommens historie er en fortelling. In: Bondevik H, Kveim Lie A (Eds). Tegn på Sykdom: Om Litterær Medisin og Medisinsk Litteratur, pp. 63–85, Oslo, Scandinavian Academic Press/Spartacus Forlag. [Google Scholar]) distinguishes between the significance of symptoms and their meaning. She describes the symptom’s significance as that which is actually present: pain or exhaustion, ascertainment of myocardial infarction or arthrosis of a joint, in other words, a what. The meaning aspect of a symptom alludes to questions of how and why. Biomedicine is very frequently able to answer questions of “what” and “how,” but “why” is another matter: Why me, precisely? Why now, exactly? Why precisely these symptoms? The actual and universal significance of a symptom will differ from the particular, experienced content of thoughts and emotions that the symptom entails for the individual. Even when verifiable signs are present, the question of why will usually remain unanswered. This implies that signs which explain the cause only exist at a particular level: even when the cause of the symptom is known, the basis for it is frequently unknown. It may therefore be appropriate to differentiate between causes and reasons.

Semiotics

Semiotics is the study of signs and the term used for a theory of signs developed by the scientist and philosopher Charles S. Peirce (1839–1914). The professor of literary studies, Drude von der Fehr, in whom we lean on in this presentation, is inspired by Peirce and his version of semiotics. In her work, she aims to understand specific and subjective experiences of illness, including unexplained symptoms. The human can only be understood as an “I” (von der Fehr, 2008von der Fehr D 2008 Når Kroppen Tenker. Oslo, Universitetsforlaget. [Google Scholar]).

Semiotics is interdisciplinary and anti-dualistic, based on the idea that humans in their endeavors to understand and relate to themselves and their reality will seek, communicate, and exchange meaning through signs. According to von der Fehr (2008von der Fehr D 2008 Når Kroppen Tenker. Oslo, Universitetsforlaget. [Google Scholar]), knowledge of the sign can form the theoretical basis of subjective experience.

A sign bears a message and must be interpreted, whether it is expressed in the external world (our surroundings) or the internal world (the body). The sign may be an expression of pain, a muscular or autonomic reaction, a fracture line in a bone, or loss of cartilage in a joint. Signs are produced and interpreted at all levels of human life, from cell to society. Blushing is both a reaction to something (i.e., another sign) in the autonomic nervous system, and a sign that is expressed in the external world. The sign tells of a biologically emotional state and will be observed and interpreted by individuals themselves as well as by their environment. Thus, signs are simultaneously natural and cultural.

A sign may be described as a phenomenon that represents another phenomenon (an object, state, or situation), and its characteristics can only be defined based on its relationship to this other phenomenon (von der Fehr, 2008von der Fehr D 2008 Når Kroppen Tenker. Oslo, Universitetsforlaget. [Google Scholar], 2010von der Fehr D 2010 Symptomer som ikke er årsaksforklarende et tegn teoretisk innspill [Symptoms that are not etiological – A sign theoretical input]. Michael Quarterly 2010(Suppl 9): 28–34. [Google Scholar]). In other words, pain as a primary sign represents the body’s current condition and can only be characterized on that basis. The simplest examples are those in which pain represents or is clearly related to the condition, as in the case of physical injury. The body has interpreted its situation and initiates its own self-healing measures. The process of repair is underway, and the interpretation has led to appropriate consequences. The interpretation occurs at all levels of consciousness in the patient’s body from physiological reactions to cognition and reflection at a high level of consciousness. The physiotherapist interprets the signs from the outside and subsequently this will of course influence the patient’s interpretation. Thus, during the process of interpretation, new signs constantly appear which must in turn be interpreted, and this entails an ongoing, dynamic process both within and outside the body.

Biosemiotics

Biosemiotics is a field of knowledge that has its roots in natural science and philosophy, as well as biology and semiotics, respectively (Hoffmeyer, 2005Hoffmeyer J 2005 Biosemiotikk: En Avhandling om Livets Tegn og Tegnenes Liv. Ries, Charlottenlund. [Google Scholar]). Biosemiotics seeks to describe the sign processes that control and form the basis for the development of biological interplay, between organisms in relation to each other, and physiologically and biochemically in the individual organism. The biologist Jesper Hoffmeyer (2005Hoffmeyer J 2005 Biosemiotikk: En Avhandling om Livets Tegn og Tegnenes Liv. Ries, Charlottenlund. [Google Scholar]) calls the myriad of signs that we relate to and that appear both within and outside of ourselves, “the semiosphere.” His manner of describing it is that at birth we are thrown out into this sphere of signs, significance, and meaning. Everything that we sense means something and entails communication of meaning, whether it is a matter of soundwaves, sensory impressions, touch, movement, electrical impulses, or chemical signals. All life forms must orientate themselves and act appropriately in this sphere in order to survive, and the prerequisite for managing and functioning in it consists of experiences in evolutionary terms and in our life histories.

The human body is understood to be a biological organism, at all times carrying with it its own history, that of the species and of the individual, and with a consciousness of self. Body consciousness seeks survival, self-fulfillment, and meaning. Like other living organisms, the human body will also seek to maintain homeostasis and fulfill its function. However, human behavior often runs counter to natural physiological and psychological needs, for various reasons—more or less voluntarily and more or less consciously. The individual neither thinks nor acts in all situations in his/her own best interests as a biological organism (Lilleås and von der Fehr, 2011Lilleås UB, von der Fehr D 2011Chronic pain syndrome explained as a bodily state of preparedness for others and why it is hard to cure. Nordisk Sykepleijeforskning 4: 257–269. [Google Scholar]; von der Fehr, 2008von der Fehr D 2008 Når Kroppen Tenker. Oslo, Universitetsforlaget. [Google Scholar]). Self-destructive behavior as in eating-disorders and self-loathing are obvious examples, but as we will see, there are also more subtle forms.

Irrespective of the situation in which individuals find themselves, they will produce, interpret, and relate to all types of signs, based on what gives meaning in a given moment. Interpretation involves biological, cognitive, and emotional factors, and results in physiological reactions and mental and emotional activity, at various levels of consciousness and in different parts of the brain. In this way, biology, experience, consciousness, and behavior are all integrated. At the same time, sign processes also encompass possibilities, creation, and change.

Indexical signs

In a semiotic model, medical symptoms are considered as indexical signs. An index indicates that something occurs or is, and points to a natural or existential connection between things and phenomena (von der Fehr, 2008von der Fehr D 2008 Når Kroppen Tenker. Oslo, Universitetsforlaget. [Google Scholar], 2010von der Fehr D 2010 Symptomer som ikke er årsaksforklarende et tegn teoretisk innspill [Symptoms that are not etiological – A sign theoretical input]. Michael Quarterly 2010(Suppl 9): 28–34. [Google Scholar]). The index will often point to a causal relation. A bone fracture manifests itself with visible signs, both clinical and radiological. The accompanying pain, which is expressed through other signs, has a clear causal relationship to the fracture. The pain points back to the injury, and the injury explains the pain. High blood pressure is another example; a measurable sign that may be accompanied by dizziness, which is also a sign in the way that we understand it here. The two signs can be placed etiologically; the measurable sign, blood pressure, can explain the sign that is experienced, dizziness.

As physiotherapists well know, dizziness can also occur without measurable, etiological signs. However, the physiotherapist will look for and often find other signs in the body; in musculature, posture, movement, and respiration. Tension and stiffness in the neck muscles are signs that are often accompanied by dizziness. Likewise, dizziness is one of several signs when patients tell of anxiety.

A relation based on association and proximity to the phenomenon exists here, rather than a direct causal relationship between the signs. The signs exist in the same body and appear to involve each other in different ways. When the sign is pain, and no other explanatory signs can be identified, it nevertheless tells us that something is wrong. These signs are also indexical signs, but of another kind. In the following, we will explain the important difference between indexes based on causal relations and the ones that are based on association and proximity. These signs make up the essence of the contribution of semiotic theory regarding MUPS. Something is, but there is no obvious relationship between the sign as it is expressed and its explanation. If a sign like this manifests as pain, it tells us of a body that is unwell and that the individual’s welfare is threatened, but in itself it does not indicate a cause nor an obvious solution. Nevertheless, the sign may be regarded as an announcement, first and foremost to the individual itself; it carries a message, a meaning. Apparently it communicates other aspects about the patient’s life and body than measurable realities, and generally the meaning will be hidden also for the patient.

Going beyond the measureable realities makes it possible to explore the signs and their meaning in a wider perspective and interpret them based on different, but equivalent sources of knowledge and experience, both on the part of the therapist and the patient. It becomes irrelevant to denote the knowledge as objective or subjective, as more or less valid. Knowledge and experience, be they medical or originating from a lived life, will always be characterized by the context to which they relate, the ‘zeitgeist’ and the previous history.

Self-referential signs represent the body speaking to itself

Based on biosemiotic and humanities-inspired research into disease, von der Fehr (2008von der Fehr D 2008 Når Kroppen Tenker. Oslo, Universitetsforlaget. [Google Scholar], 2010von der Fehr D 2010 Symptomer som ikke er årsaksforklarende et tegn teoretisk innspill [Symptoms that are not etiological – A sign theoretical input]. Michael Quarterly 2010(Suppl 9): 28–34. [Google Scholar]) describes this other type of indexical signs as self-referential. These are bodily signs that refer to the body itself, in the quality of a biological, experiencing organism. The signs may be expressed as pain or other MUPS and are part of the body’s internal communication. von der Fehr (2010von der Fehr D 2010 Symptomer som ikke er årsaksforklarende et tegn teoretisk innspill [Symptoms that are not etiological – A sign theoretical input]. Michael Quarterly 2010(Suppl 9): 28–34. [Google Scholar]) regards the self-referential signs as important reminders, originating from the body’s own knowledge regarding what is good for it. Just as the heart knows that it should beat, and will react to changes in working conditions and disruptions that affect its normal function, so the body as a whole will react when living conditions, thinking, and behavior pull in a negative direction. It may be possible that the individual is establishing mental or bodily (interpretive) habits that prevent the self-healing function of the body (Lilleås and von der Fehr, 2011Lilleås UB, von der Fehr D 2011Chronic pain syndrome explained as a bodily state of preparedness for others and why it is hard to cure. Nordisk Sykepleijeforskning 4: 257–269. [Google Scholar]). When chronic pain is a fact, the habit is entrenched both bodily and mentally.

Patients as well as health-care workers acknowledge the general need for nourishment, sleep and rest, physical activity, and fresh air as prerequisites for good health. Similarly, we know that psychological needs such as those for affirmation, affiliation, intimacy, and respect are fundamental to our experience of wellness. However, when these needs are insufficiently catered for, ignored, or counteracted, it can be difficult to assimilate how this can lead to specific bodily ailments and ill health. Despite a growing understanding of how body and brain communicate in monitoring and regulating the organism, it is easy to forget that the human body is also a living, purposeful biological organism that knows what is best for itself, and “wants” to function optimally and fulfill its function. When the body is prevented from doing this, it will have to speak out, to itself, in other words to the individual. As a body, it will naturally use its own language (i.e., bodily signs such as pain and fatigue). From a semiotic or biosemiotic perspective, we may say that the body expresses its wisdom and knowledge through bodily signs, as a message to the individual that “things are taking a wrong turn!”

The self-referential signs thus function as warnings and are triggered when the individual’s thinking and behavior run counter to the fundamental needs of the organism, such as when the individual relates inappropriately to his/her own welfare and integrity. This type of warning must be acknowledged and followed up by the individual him/herself (Lilleås and von der Fehr, 2011Lilleås UB, von der Fehr D 2011Chronic pain syndrome explained as a bodily state of preparedness for others and why it is hard to cure. Nordisk Sykepleijeforskning 4: 257–269. [Google Scholar]). Some aspect of life, thinking or action, has to change in order for the body, i.e., the person, to regain its balance, physiologically and mentally. Perhaps it is as a qualified partner in exploring what this “something” is, that we can best help the patient. However, one can also regard the experience of peace, relaxation, and well-being as self-referential signs, as a positive feedback from the body itself; I am in balance, I am well.

As mentioned, neurobiological research confirms not only how the brain’s various networks communicate in monitoring and adjusting the condition of the body, but also how the plasticity of brain cells renders them vulnerable to inexpedient learning and maladaptation (Apkarian, Hashmi, and Baliki, 2011Apkarian AV, Hashmi JA, Baliki MN2011 Pain and the Brain: Specificity and plasticity of the brain in clinical chronic pain. Pain 152: S49–S64.[Crossref], [PubMed], [Web of Science ®],, [Google Scholar]; Benedetti, 2011Benedetti F 2011 The Patient’s Brain. The Neuroscience behind the Doctor-Patient Relationship. Oxford, Oxford University Press. [Google Scholar]). The latter may be the origin of negative interpretive habits that entail a conflict between the organism’s search for balance and well-being, and the individual’s learned patterns of thought and behavior. Humans do not always act in their own best interests and are often driven by forces other than those of self-preservation. The precondition for learning, either positive or negative, is the interpretation of the meaning of a sensory impression or situation. What gives meaning is again based on the interpretation of signs: is the sensory impression interpreted as pleasant or unpleasant? Do the signs indicate that the situation is safe and positive, antagonistic or threatening? Since the interpretation is characterized by context and experience, motivation and expectation, it has its own innate logic, but its consequences will not necessarily appear rational or serve the individual as a biological organism and integrated self. According to von der Fehr (2008von der Fehr D 2008 Når Kroppen Tenker. Oslo, Universitetsforlaget. [Google Scholar]), MUPS constitute a progression from constructive warnings to negative bodily interpretive habits, from self-referential signs to prolonged, unexplained symptoms.

Clinical implications in a semiotic perspective

It is an obvious goal for physiotherapists to alleviate patients’ suffering, but equally important is to render them capable of self-help in the longer term. The latter is considered particularly urgent in the treatment of MUPS. Positive clinical encounters with this patient group require first and foremost that physiotherapists raise their awareness and deepen their own understanding of the body. According to Nicholls and Gibson (2010Nicholls DA, Gibson BE 2010 The body and physiotherapy. Physiotherapy Theory and Practice 26: 497–509.[Taylor & Francis Online],, [Google Scholar]), the body as a philosophical and theoretical construct has not been a topic for physiotherapists. They claim that “Physiotherapists have a paradoxical relationship to the body, which is ubiquitous in practice but absent in theory.” The challenges related to MUPS reflect this. Little attention is paid to the body as a self-conscious and self-preserving biological organism in an evolutionary perspective. In order to communicate knowledge about the body as a purposeful biological organism governed by its own experience and evolutionary knowledge, physiotherapists themselves must assimilate this insight. The need for revision is also now being expressed within the ranks of evidence-based medicine, with a new focus on context and individualism through meaningful dialogue (Greenhalgh, Howick, and Maskrey, 2014Greenhalgh T, Howick J, Maskrey N2014 Evidence based medicine: A movement in crisis? BMJ 348: g3725.[Crossref], [PubMed], [Web of Science ®],, [Google Scholar]).

A further element in a semiotic approach will be a conscious focus on the meaning aspect of symptoms. When the significance of a symptom has been examined as thoroughly as possible in a medical sense, an investigation of its meaning becomes important. This means that the physiotherapist must acquire an understanding of the patient’s experience, thoughts, notions, and expectations with regard to the symptom, as well as the feelings related to it. Insight into this enables an understanding of the symptom in light of the patient’s learning and life history and of the current situation as it stands. A dialogue that seeks to identify the meaning of the pain is based on the idea that the solution to the problem lies with the patient him/herself, not with the physiotherapist or doctor, and that the possible function of the signs will emerge through the conversation. In this context, we have referred to the function of self-referential signs as warnings and reminders, but what the warning actually implies will be specific to the individual. Using the physiotherapist’s knowledge and understanding of the experiencing body, the patient can be guided into an awareness-raising process in which negative interpretive habits can be revealed and broken.

Each and every symptom will have a meaning, irrespective of whether the signs are self-referential or point to a causal explanation, explained or unexplained symptoms. The meaning that pain has for the patient will color his/her experience of it and the way in which the patient relates to it. At the same time, the life situation of the patient and his/her roles in life will be decisive: active sportsperson, new employee, mother of small children, pensioner? Back pain, regardless of the cause, will have a different meaning for an active sportsperson than for a pensioner. In both cases, it is essential to gain an insight into this, providing a better opportunity to approach the patient where he/she is, mentally and emotionally. In this way, we can come to an understanding of what drives and motivates the patient, i.e., what is at stake for the individual.

In line with the distinction between the significance of the symptom and its meaning, there is a third point in the clinical approach we argue for here: the differentiation between causes and reasons. Various reasons may exist alongside well-defined, verifiable causes. Personality factors such as vulnerability and disposition may be both underlying and maintaining reasons, while disease or injury may be triggering and appear as causally related signs. Living conditions and serious life events can presumably be underlying, maintaining, and triggering. Thus in many cases, both types of indices appear in parallel; however, the self-referential signs, which perhaps reflect reasons to a greater degree, require a different insight and a different approach. In other words, various complex access points exist to a condition of MUPS, and the exit points are highly individual. Evidence-based medicine as we know it will fall short here, based as it is on the average person. It will be crucial for the physiotherapist, in liaison with the patient, to attempt to sort through this complex picture in order to see associations and understand the origin and development of the pain. It will then be possible to explain the unexplained, or at least make some progress, not only based on medical premises but also existentially.

A semiotic model can integrate various types of knowledge

Unexplained pain is rarely perceived as a meaningful sign in the service of the organism, in the way that we see it. The meaning aspect of signs runs the risk of being overlooked in the solution and action-oriented therapist’s focus on repair. But should pain, irrespective of what it may be an expression of, be alleviated in every situation? In contrast to etiological signs, self-referential signs do not call for an external solution, such as medication or surgery, or physiotherapy directed at symptoms. Relief of unexplained symptoms may undermine important premises for change, lead to overtreatment, and render the condition more entrenched.

Many physiotherapists are concerned with, and now receive training in, cognitive forms of treatment. They communicate knowledge of the associations between experience, interpretation, and perception of pain. A cognitive approach is highly relevant and is encompassed by a semiotic perspective, whereby the patient is guided toward raising his/her awareness of automatic patterns of thought and action and, as von der Fehr expresses it, “is helped towards a constructive doubt” (von der Fehr, 2008von der Fehr D 2008 Når Kroppen Tenker. Oslo, Universitetsforlaget. [Google Scholar]).

Also recent research in pain physiology forces us to reevaluate traditional understandings of the mechanisms and perception of pain. It appears that nociception occurs continually at unconscious, subconscious, and pre-conscious levels, as an ongoing bodily defense mechanism (Baliki and Apkarian, 2015Baliki MN, Apkarian AV 2015Nociception, pain, negative moods and behaviour selection. Neuron 87: 474–491.[Crossref], [PubMed], [Web of Science ®],, [Google Scholar]). Again, these mechanisms can be understood as the body’s sign-based internal communication. At the moment in which the pain is consciously experienced, it is a final product of interpretation, at both a peripheral and central level, and the result of the interaction and influence of various cerebral networks, based on learning and adaptation.

A survey of various factors, in accordance with the biopsychosocial model, will help to obtain an overview and an insight into the patient’s situation. However, unless attention is paid to interpretation as a crucial factor in learning and adaptation, a deeper understanding of the patient’s lived experience may be lost. Nor will the biopsychosocial model enable the physiotherapist to differentiate between different types of sign; the causally related and the self-referential. As we have seen, these occur in a complex interplay and will mutually affect each other. The former can, in the best case scenario, be alleviated by means of evidence-based knowledge and practice. The latter requires an approach that extends beyond, but may include, both the biopsychosocial model and evidence-based medicine.