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by Jennifer Bennett Ziegler

    A person’s experience of pain is influenced by a complex matrix of physical, social and psychological factors. This paper does not encompass a complete review of the many types of pain, or the many varying factors involved in pain and pain management. In general, this paper does not address the chronic pain population, but rather, those with acute pain that has an identifiable physical cause unrelated to a chronic disease process, such as cancer or colitis, or pain that is complicated by severe psychological factors, such as PTSD. For the most part, the pain and associated factors addressed herein pertain to the average person who has no chronic physical or clinical psychological circumstances.

    Any kind of physical training – be it running, weight-lifting, rowing, boxing, gymnastics, or martial arts – involves pain. The human body is a remarkable and wondrous thing. From devastating war wounds, the ravages of disease, any number of horrific accidents, childbirth, bombings, violent assaults, to stunts gone wrong, the human body has the capability of enduring and recovering. More important, the human brain has the ability to deal with the resulting pain. Sometimes, this ability seems impossible, mysterious, or magical. This paper generates the hypothesis that a person’s experience of pain is a determining factor in who quits and who continues.
    Pain is a necessary sense and vital to survival. Pain alerts us that something is wrong. Pain can be a warning signal (Don’t touch that stove!), an indicator of disease (That tender abdomen could be a sign of appendicitis.), or tissue damage (Get that knee checked!). So, what makes people willingly undertake and continue with training that hurts? Do these individuals have a higher pain tolerance than others? What makes roughly 70% of the people who come into a dojo and begin training quit in less than six months (Rates of Attrition ¹)? Do these people have a lower pain threshold? Is pain tolerance the best indicator of performance?
    Medical pain is defined by the Merriam-Webster Online dictionary as
           a : a state of physical, emotional, or mental lack of well-being or physical, emotional, or mental uneasiness that ranges from mild discomfort or dull distress to acute often unbearable agony, may be generalized or localized, and is the consequence of being injured or hurt physically or mentally or of some derangement of or lack of equilibrium in the physical or mental functions (as through disease), and that usually produces a reaction of wanting to avoid, escape, or destroy the causative factor and its effects
            b : a basic bodily sensation that is induced by a noxious stimulus, is received by naked nerve endings, is characterized by physical discomfort (as pricking, throbbing, or aching), and typically leads to evasive action
    Pain can be categorized in a number of ways. One way is to classify pain by acute pain or chronic pain. Acute pain generally has a quick onset and is sharp in nature. The pain may be slight and short-lived, or it may be severe and last days, weeks, or a few months. Acute pain usually indicates an injury or threat to the body and is resolved with an escape from a painful stimulus, or a successful treatment of the underlying cause, as in the healing of a broken bone. Chronic pain, however, is pain (sharp or dull) that lasts longer than three months and is present even after an injury has healed, or without any indication of a past injury or evidence of damage (Brannon 161). There also are ways to classify pain by cause: tissue damage (nociception), nerve damage (neuropathic pain), and psychogenic pain (pain affected by psychological factors) ("Pain Classifications"). The type of tissue affected can also be used to classify pain, i.e., back pain, joint pain, myofascial pain ("Pain Classifications").
    No matter how you identify it, pain is a very subjective experience (Tracey 377). There are many factors that influence how an individual interprets and reacts to pain. Several studies have indicated that negative emotions (anger, anxiety, and depression) correlate to increased perception of pain and the likelihood that an individual’s acute pain will transition into chronic pain (Robinson 77). Coping strategies also greatly affect an individual’s perception, and therefore tolerance, of pain. Catastrophizing ("This is the worst thing that’s ever happened to me"), hoping ("I have faith that someday doctors will find a cure for my pain."), and invalidation of pain ("This isn’t really pain; it’s just a dull ache.") generally have a negative effect (Boothby 349 – 353). Ignoring the pain or diverting attention with passive activities like reading a book have little influence or inconsistent results in the perception and tolerance of pain. However, people who received instruction on distraction or sensation monitoring, those who used positive coping self-statements and those who exercised regularly exhibited a higher pain tolerance and generally recovered from their pain condition (Boothby 349 – 353). However, one of the most interesting findings, especially for the scope of this paper, is regarding appraisal properties.
    Primary appraisals…are those relating to judgments about whether a potential [pain] stressor is irrelevant, benign-positive, or stressful… stressful appraisals [are] those that suggest the event poses a threat, those that suggest the event poses a challenge, or those that suggest the event will result in possible harm or loss. Appraisals regarding potential harm produce negative emotions, such a fear and anxiety, whereas those focusing on the challenging aspects of the event(s) might produce feelings of eagerness or excitement, particularly when the person believes that positive coping skills are possible…Finally, coping responses…ultimately influence important adaptational outcomes, such as social functioning, morale and somatic health (Boothby 344).
    Those undertaking a physical activity with any seriousness are likely to suffer intense acute pain at the onset – muscle soreness and joint pain. As training continues and intensity increases, tendon, ligament or joint damage can (and sometimes do) occur, even among the most careful athletes. As a result, pain can be a powerful deterrent. Many do not continue with any activity that results in pain. Though every one of the world’s greatest athletes started out as everyone else does – at the beginning, as amateurs.
Interest, desire, time, financial resources, and natural ability can account for the success of many, as does an ability to control and manage pain. Olympians are some of the best trained athletes on the planet. All of them are in amazing physical condition. But, being so doesn’t necessarily immunize them against a painful injury that keeps them from performing. Most athletes at this level have had multiple injuries, some very severe and which required, sometimes, a year or more of recovery. Yet, once they heal, they continue to pursue their training. How do they do this? It’s not merely the fact that they are in good physical condition or that they possess a magical and unattainable pain threshold. Those things certainly help, but when you are in the sphere of Olympians and career sportswomen and men, body type, natural ability, drive and a tolerance for the rigors of training far exceed the average.
    What about the average, but dedicated, runner, swimmer, or martial artist? What about female college student Bobbi Gibb who trained for and completed the Boston Marathon, despite being raised with the belief that running more than a mile-and-a-half was deadly to women (Binkowski)? What about regular kid, Bill Kirby, who endured glandular fever and numerous failings to become the fourth fastest swimmer in his home continent of Australia (Townsend)? What about the people who actually stick it out in dojos, dojangs, and kwoons? What makes them come back time and again after sustaining multiple contusions, broken fingers and toes, torn muscles, sprained limbs, and even major knee and shoulder surgeries? It’s not just pain tolerance.
    In the 1968 Summer Olympics in Mexico City, world-record-holding American runner Jim Ryun was favored to win the 1500-meter race. Kipchoge Keino, a police officer from Kenya, was one of his opponents. A few days before this race, Keino collapsed during another race, was rushed to the hospital and diagnosed with a gall bladder infection, which is extremely painful, especially when taking the deep breaths needed for running. He also was told by the doctor that if he ran the 1500 he could die ("How One Kenyan Tribe…"). Keino ran it anyway.
    At the start of the Olympic 1500, Keino was dead last. After the first lap, he was third and after the third lap, he was first ("Keino v. Ryun"). This didn’t bother Jim Ryun, because he was famous for his "kick," adding a burst of speed at the very end of the race ("How One Kenyan Tribe…"). In the last lap, Ryun employs his kick. Kip Keino is in the lead and must have been in pain due to his gall bladder infection diagnosis a few days prior. But he did not slow down. Despite Ryun’s best efforts, Keino wins gold ("How One Kenyan Tribe…"). Not only did he win the gold, he set the Olympic world record and won by 20 meters, "the widest margin of victory in that event in Olympic history" (Rhoden).
    Since the 1968 Summer Olympics, Americans have associated Kenyans with being good runners. However, it is not Kenyans, in general, but a specific tribe in Kenya – the Kalenjin – that excel in running ("How One Kenyan Tribe…"). The Kalenjin number approximately five million, which makes them a minority even in Kenya, out of a total population of around 44 million. This makes them a significant minority on a global scale – yet they dominate the world’s long-distance marathons. For example, Wilson Kipsang won the 2013 Berlin Marathon with a time of 2 hours, 3 minutes, and 23 seconds, the fastest marathon time ever recorded ("How One Kenyan Tribe…"). A few weeks later at a race in Chicago, Dennis Kimetto broke the course record there, even though he had only been training for four years. Consider this: seventeen American men in history have run marathons in under 2:10. In a single month, October 2011, 32 Kalenjin runners clocked marathon times of under 2:10 ("How One Kenyan Tribe…").
    In his book, The Sports Gene, David Epstein attempts to explain this phenomenon. The Kalenjin live at high altitude, have a high-starch diet and run to school. Additionally, the annual salary of a runner is attractive for rural Kenyans – ten to twenty thousand dollars. Epstein points out, however, that these factors are not unique to the Kalenjin tribe. Lots of people all over the world live at altitude, eat high-starch foods, run to school and could use some extra money – yet they don’t come close to the dominance of the Kalenjins in long-distance running ("How One Kenyan Tribe…"). The Kalenjin also possess certain physical characteristics that give them an advantage when running, such as long, slender limbs with very thin ankles and wrists ("How One Kenyan Tribe…"). Even taking into account these biological advantages, Epstein asserts that "there is not a single sports gene that ensures success." There is something to performance and ability that "scientists haven’t found a gene for – a mental ability to persevere through unimaginable pain" ("How One Kenyan Tribe…").
    There is, however, one thing that is unique to the Kalenjin experience that highlights how they approach pain. They have an initiation ceremony, a rite of passage that all Kalenjin teens – girls and boys – must go through. The successful completion of this ritual means that the teen is accepted as a full member of the community. As such, the teens become adults and are able to date, select a partner, marry and begin a family. Failure to complete this ceremony earns one the label of "coward" and essentially results in being ostracized by the entire tribe. The ceremony is one that tests the limits of the human body to endure terrible pain ("How One Kenyan Tribe…").
    The first part of the ceremony involves crawling, mostly naked, through a tunnel of African stinging nettles. Next, the teens are beaten on the bony parts of the ankle and their knuckles are squeezed together. Acid from the nettles are wiped onto the genitals of the teens and, early one morning, the girls undergo genital mutilation and the boys are circumcised with a sharpened stick. After this, they are taken away from the village to separate huts to heal for, at most, a day or two. They are told when they leave the hut, they may no longer walk. They must run everywhere. The most significant requirement of the entire ritual is that at no point may the teens show any signs of pain. They may not grimace, clench their teeth, twitch a muscle or utter a sound. In some cases, mud is caked onto the faces of the girls and boys and if a crack appears in the mud, the teen may not become a full woman or man ("How One Kenyan Tribe…"). This ritual is just a ceremony, but it is reflective of a communal attitude toward pain.
    It is this ability, Epstein believes, to endure extreme pain with stoicism that gives the Kalenjin an edge in the distance-running department ("How One Kenyan Tribe…"). While this ritual certainly gives a forum for the Kalenjin to learn how to endure, this ability is not magic. It also is not reserved only for the Kalenjin tribe, elite athletes, or Zen masters. Regular people can develop this ability and learn ways to mitigate and manage pain. These regular people are the Bobbi Gibbs and Bill Kirbys of the world. These people are the ones who don’t quit their practice within six months, not because it doesn’t hurt them, but because they can or have learned to deal with pain in productive ways. And they do so even if they don’t realize they are doing it.
    Angela L. Duckworth, Ph.D. studies "grit psychology." Her term, grit, is defined as "perseverance and passion for long-term goals" (Duckworth 1087 – 1088). She further details that grit entails working strenuously toward challenges, maintaining effort and interest over years despite failure, adversity, and plateaus in progress. The gritty individual approaches achievement as a marathon; his or her advantage is stamina. Whereas disappointment or boredom signals to others that it is time to change trajectory and cut losses, the gritty individual stays the course (Duckworth 1088).
    Dr. Duckworth and her colleagues developed the Grit Scale (Duckworth 1089). Their research found that academic performance is influenced more by grit than by IQ; and those with a lower IQ, but more grit, performed better than those with a higher IQ, but less grit (Duckworth 1093). The team wanted to further test their findings on people who undertake an extremely rigorous and challenging path. So, they applied the Grit Scale to freshman cadets entering West Point Military Training Academy (Duckworth 1094).
Acceptance into West Point is extremely competitive and the military already has extremely high standards for applicants, such as high SAT scores, leadership ability, past performance and physical ability (Duckworth 1094). Even so, one out of twenty cadets quits during the first few months of training (Duckworth 1094). Dr. Duckworth and her colleagues wanted to see if their Grit Scale would be a better predictor of retention than other factors (Duckworth 1094). Her team found that "grittier candidates were more likely to complete their first summer of training at West Point" (Duckworth 1096). Further, "grit predicted completion of the rigorous summer training program better than any other predictor (Duckworth 1095).
    As mentioned previously, coping strategies and primary appraisals are important factors in how one interprets pain. A person who associates pain with negative feelings ("Not again!" or "This is just like last time.") will be more likely to succumb to pain than a person who associates pain (like the Kalenjin) with positive feelings ("This will make me a woman/man!")
    Those whose primary appraisal of pain is irrelevant or benign-positive were better at managing pain than those who appraised pain as a stressor. For example, a woman going through labor who views her pain as a means to deliver a healthy child will interpret her pain as more manageable than a woman who views the pain as pain, without a thought to the necessity of it. Additionally, those who view pain as a potential for harm rather than a challenge will interpret their pain as less manageable and will be more likely to avoid painful activities (Boothby 344).
    Hypnosis² has been used (at least in Western medicine) to control pain since WWII (Syrjala 189). "Hypnosis and imagery are generally agreed to be states of highly focused attention during which alteration of awareness, sensations, and the affective response to perceptions occur" (Syrjala 187). Hypotheses vary as to why hypnosis is effective in pain control, but it is generally thought "to reduce pain by mechanisms including attention control and dissociation…" (Syrjala 187). Changes in blood flow and electrical activity along spinal pathways have been observed during hypnosis, which support the hypothesis that hypnosis is associated with altered consciousness (Syrjala 187). Through hypnosis, someone in pain can try several strategies to mitigate or eliminate pain. The most common are to imagine walking down a path away from the pain, focusing on acknowledging and exploring the pain, and imagining the pain as a bright color then fades, or a high temperature, which cools (Syrjala 199). Each individual has different images or suggestions that are most effective with her or his individual practice of hypnosis and finding the right ones increase the effectiveness of pain control (Femhi 68 – 73). Hypnosis spectrum activities provide an example of how our actions can mold our experience of pain.
    Consider the Kalenjin tribe. All of its members expect an extremely painful coming-of-age ceremony. They view the ceremony as an important and necessary test. They are highly motivated to successfully complete the ritual to avoid public shame. They have witnessed many of their fellow tribe members go through the ceremony and so learn that it is within their control to complete. And perhaps most important, the Kalenjin are able to see past the short-term pain to the long-term benefit – becoming full women and men. These mental strategies carry over into their performance in running. They have developed, consciously or not, positive primary appraisals of pain, as well as effective coping strategies to deal with it.
In light of the information presented thus far, we can assert that pain tolerance is not just a physical characteristic or a genetic anomaly, but rather a mental skill that appears mysterious and magical, yet is explainable and attainable. It can be acquired by experiences imposed on us, as with the Kalenjin ritual, or it can be acquired by simply seeking out a hypnotherapist.
    Also, pain tolerance in and of itself is not the only factor that predicts a person’s willingness and ability to continue along a path of resistance. "Grit," too, appears to be an extremely helpful characteristic needed to endure in the face of extremely challenging conditions. In the example of the West Point cadets, something more than physical and intellectual ability (or even pain tolerance) is required. Duckworth believes that "grit" can be taught, and is currently working on ways to develop a systematic way to do that, especially among children (Winerman 31).
    It is these characteristics, the mental ability to effectively deal with pain -- the mindset -- and the "grit," -- the fortitude -- that high performers have in common. It is these traits that give the average person the ability to keep training, even if and when it hurts. It is the lack thereof that determines who will quit at the first aching muscle. This mindset is learned in our own dojo and is taught to every beginner if she or he has the capability to see past the pain to an attainable goal. It is taught and learned whether the student realizes it, or not. The act of coming to the dojo, checking ego at the door, bowing in to a sacred space, changing out of street clothes and then taking chudan-gamae are the first steps to developing this mindset. And developing this mindset is the first step to being able to give the blood, sweat and tears required for the job of becoming more.
    It’s not magic. It’s not a mystery. It’s just mindset.

Notes
    ¹ Rates of Attrition for Itten Dojo for the time period of 2008 – April 2014. Analysis received by this author on 13 April 2014 via email. Statistics compiled by Robert E. Wolfe, II show that 38% of new members quit within three months and 68% quit within six months.
    ² In this paper, hypnosis refers to hypnosis with or without imagery, as well as self-hypnosis or hypnosis that is guided by a trained clinician.

Works Cited
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