Why It Matters How You Think About Pain

Pain psychologists explore the differences between those who finish ultra-endurance races and those who don’t

Endurance athletes love to talk about pain. That’s one of the lessons I learned from writing my book Endure, which includes a chapter on the role of pain in endurance performance. I’d say that chapter has provoked more response—and gasps of recognition—from readers than any other. The gist of the research it describes is that trained athletes feel pain just like everyone else (they have the same pain sensitivity), but are nonetheless willing to put up with more of it (they have higher pain tolerance).

The unanswered question, though, is why. What enables athletes to tolerate more pain? Is there some physiological adaptation that dulls their nerve endings? Or is it simply that hours and weeks and years of challenging training have taught them to develop better psychological pain coping strategies? It’s the latter explanation that most pain researchers seem to favor, but there hasn’t been much research into the question—so far.

At the American Pain Society’s annual meeting last month, a research team led by University of Washington pain psychologist Kevin Alschuler presented some preliminary results from a study of 204 participants in three of the events in the 4 Deserts Race Series, which takes place in the Sahara, Gobi, and Atacama deserts. Each event is a 155-mile multistage run; the researchers collected data on pain intensity and pain coping strategies for five consecutive days at each event.

Some fun details emerge from the data. On average, the participants reported spending about 30 percent of their racing time thinking about pain. (See? Endurance athletes are obsessed with pain!) Their average pain levels were about four on a scale of zero to ten, with highest pain level during the run averaging just over five.

But the most interesting data deals with the difference between “adaptive” and “maladaptive” pain coping strategies. Adaptive strategies are things like ignoring pain, deciding that you won’t let it bother you, or overriding it with the urge to keep going. Maladaptive strategies are things like catastrophizing (“I’m going to have to drop out!”), fear (“It’s going to keep getting worse!”), and despondence (“This is awful!”). Each athlete was assigned daily composite scores of zero to six for adaptive and maladaptive coping, with zero corresponding to “never” and six corresponding to “always,” Alschuler says, reflecting “the extent to which the person is having thoughts that exemplify being willing to coexist with their pain versus the extent to which they are viewing their pain as a barrier that is difficult to overcome.”

Overall, the ultrarunners were remarkably good at relying on adaptive coping (3.04 out of six, on average) rather than maladaptive coping (1.31 out of six). If that wasn’t the case, they probably would never have made it to one of these grueling races. Still, there were some interesting findings. For example, when runners used more than their usual level of maladaptive coping, they reported a greater perception that pain was interfering with their performance—even when the actual level of reported pain was held constant. They also spent more time thinking about their pain, which should be a reminder that sometimes it’s best not to dwell on it.

The other interesting finding was a link between the use the maladaptive coping and the probability that a runner would finish the race. For every one-point increase in the maladaptive score, a runner’s likelihood of finishing the race dropped by a factor of three. Crucially, this finding was calculated with the level of reported pain held constant, meaning that the athletes weren’t altering their pain coping strategy (and then dropping out) simply because they were in more pain.

So far, these are preliminary findings, which Alschuler and his colleagues plan to publish soon in more detailed peer-reviewed papers. That means we should take the conclusions with a grain of salt. But it’s great to see that pain psychologists are starting to do field research with endurance athletes to get a better handle on what works and what doesn’t. After all, as Brad Stulberg recently pointed out, “making friends with pain” is a crucial skill for athletes.

Still, Alschuler, who has also collected data on participants in the 3,080-mile Race Across USA, adds a key caveat: “It’s probably obvious, but it is not our intention to encourage people to do something unsafe, such as persist through an injury where further harm is risked.” There are many different flavors and degrees of pain, and one of the big challenges in endurance sports is learning to distinguish between the pain you can and should push through and the pain signaling that something serious is wrong. If you’re still trying to figure that out, try asking some of your training partners about it. If you bring up the topic of pain, chances are they’ll be eager to talk.

My new book, Endure: Mind, Body, and the Curiously Elastic Limits of Human Performance, with a foreword by Malcolm Gladwell, is now available! For more, join me on Twitter and Facebook, and sign up for the Sweat Science email newsletter.