The threshold of pain or the tolerance of pain?
It’s incredible the number of people who are very quick to tell me at my Physiotherapy practice in Stoke on Trent, that they have a high threshold of pain but do they really? Do they know what the pain threshold is?
There are two problems with this statement, the first is that they often mean tolerance, not threshold and the second problem is that how could they know? So that’s why today we are going to go through what the threshold of pain is and what can make it go up and down and the BIG question of men versus women!
So what is the threshold of pain?
Mosby (2013) states the following:
“The point at which a stimulus, usually one associated with pressure or temperature, activates pain receptors and produces a sensation of pain. Individuals with low pain thresholds experience pain much sooner and faster than those with higher thresholds; individuals’ reactions to stimulation of pain receptors vary.”
Put simply, the pain threshold is when there is enough stimulus to make the pain nerve fire. So the ‘threshold’ required for an action potential at a synapse in a C fibre neurone (pain nerve).
So what patients are referring to instead is their pain tolerance.
What is pain tolerance?
The tolerance of pain is defined as:
“the highest intensity of painful stimulation that a tested subject is able to tolerate.” (Farlex 2020).
So this is effectively how much pain you can take and deal with. This is, 9 times out of 10, what people mean when they state that they have a good pain threshold.
What affects the threshold of pain and pain tolerance?
Pain threshold is a very changeable entity and can be sent higher and lower at any given point even in the absence of structural harm or damage and we can easily see the phenomenon in people who report pain reductions with warm dry weather in osteoarthritis, which we know structurally doesn’t really heal and repair so why does their pain go down? It is due to a raising of their pain threshold to a point at which they may become pain-free.
So I just gave a quick example of what can change pain threshold in temperature and weather but what else influences it?
Staffe et al (2019) found that a lack of sleep lowers the threshold of pain making it easier to feel pain and increasing the pain that you feel, all from missing just 1-night sleep. Here is a video explaining more about this study:
Yes, stress does affect pain negatively because it is part of the fight or flight response, which is regulated by the sympathetic nervous system.
What is fight or flight for?
It is for protection.
What is pain for?
Protection too, so when you are stressed your fight or flight and pain protection levels can be elevated leading to a lowering of pain threshold. It has been shown that the number 1 risk factor behind whether you have neck pain or not is due to stress!
(Smedley et al 2003).
Yes, exercise improves pain threshold levels and pain tolerance and it strangely differs depending on the type of exercise. So in a study by Assa et al (2019), they compared people who didn’t exercise to people who did exercise and found that both pain threshold and tolerance were higher in the exercise groups. They also had two types of athletes in the exercise groups to see if the exercise type made a difference and it did.
So they had endurance athletes and had strength athletes and this is what they found:
The endurance athletes had better pain tolerance than the strength athletes.
But the strength athletes had better pain thresholds than the endurance group.
Now we don’t know exactly why this is but it is likely that an endurance athlete has to push through the pain for longer periods and they condition themselves to tolerate pain better and therefore longer. Whereas the strength athletes don’t have to bear with pain for long but due to the higher intensity of the exercise they have to deal with more in a shorter period, making their thresholds rise.
So it would appear that as we age we get less sensitive to certain pain types, in particular, lower intensity pain (Lautenbacher et al 2017). So just like the athletes, it is likely that due to exposure to pain is more as we age then we get less sensitive towards it. I have seen this phenomenon in my Physio clinics in Stoke-on-Trent many times, where a young person is usually not great with pain but an elderly person doesn’t even quantify pain even when it exists.
Do men or women have a better pain threshold?
Now it is often said that because women have to go through childbirth that they have better pain thresholds than men but is this a myth or is it true? In a study by Chesterton et al (2003) they compared healthy males and healthy females to see if it took more to cause pain in one over the other and they found that females exhibited significantly lower mean pain pressure thresholds than the males. So certainly for pain pressure men beat the women for pain threshold.
Do men or women have a better pain tolerance?
So this is how much you can take and put up with and this is more debatable. That being said, there is strong evidence that females tolerate less thermal (heat, cold) and pressure pain than males but it is not the case for tolerance to ischemic pain, which is very similar between men and women (Racine et al 2012). In study buy Mogil (2012) it was found that some evidence was inconclusive in finding differences between the sexes but when differences were found it was almost unanimously showing that women have a higher sensitivity and lower tolerance to pain than men. In epidemiological studies, there are more cases of chronic pain in women than men but this is not as clear as it sounds. For example, there are more chronic pain syndromes that women can suffer than men such as endometriosis and even more significant is that culturally it may be more difficult for men to report and seek help for pain when compared to women.
Another reason that tolerance could be the same or maybe worse in men is due to men’s threshold being higher meaning that because they receive pain signals later they don’t have to tolerate pain for as long as women in the same test for tolerance. An interesting theory to mull over anyway.
So pain threshold and tolerance are different things and most people are describing tolerance when they say threshold. Pain tolerance and threshold can definitely be increased and decreased by many things and men and women look like they are different when it comes to pain threshold but the jury may be out on tolerance.
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The content in this blog article is provided for general information purposes only and is not meant to replace a physiotherapy or medical consultation.