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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 :


ljcblue@gmail.com
http://www.ljcohen.net
http://ljcbluemuse.blogspot.com
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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
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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.


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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
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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.”


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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
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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.
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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.
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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,
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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)
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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.


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(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
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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
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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.


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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
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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
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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
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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
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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


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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
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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
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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.


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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.


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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)
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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;
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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.


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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.
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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
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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
Page 30 of 38 Cohen/Pain, Pain Perception, and Healing

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


Page 31 of 38 Cohen/Pain, Pain Perception, and Healing

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
Page 32 of 38 Cohen/Pain, Pain Perception, and Healing

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.


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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)
Page 34 of 38 Cohen/Pain, Pain Perception, and Healing

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.
Page 35 of 38 Cohen/Pain, Pain Perception, and Healing

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.


Page 36 of 38 Cohen/Pain, Pain Perception, and Healing

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.


Page 37 of 38 Cohen/Pain, Pain Perception, and Healing

“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.
Page 38 of 38 Cohen/Pain, Pain Perception, and Healing

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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