Pain Reduction
I lived in Paris for three years in the 1980s. During two of those years, I spent a lot of time in a little neighborhood cafe, and almost every time I stopped by for my daily expresso, there was an old man at his usual corner table laughing with friends. He rarely went more than 10 minutes without laughing. I was amazed at this and asked him how he managed to stay in such a wonderful mood all the time. To my surprise, he said his laughter didn't always mean he was in a good mood. He laughed for two reasons. One was in order to get into a good mood. He lived alone and didn't like it. He knew that laughter would lift his spirits, so he forced himself to laugh until he really was feeling good.
The other reason was that he had arthritis and had a lot of aches and pains. One day (several years prior to my conversation with him) he and his friends were doubling up with laughter about pranks they had played when they were kids. He noticed that his arthritis pain had disappeared during the laughter and didn't show up again until an hour or so later. From that day on, he was a laugher. It was his way of managing pain. He took control of his pain in a way that also improved his mood and the quality of his life. About 40 studies completed since the early 1980s have supported the effectiveness of his approach to pain management. This pain-reduction effect of humor and laughter is now a well-established effect. Only a sample of this research is discussed here in order to give you a good sense of the breadth of the supporting data.
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Back pain, along with other areas of musculoskeletal pain, has become very common among adults - both in the USA and other countries.46 This is a common complaint among nurses, who are often in a position of having to help physically reposition patients. Research has made it clear that psychological factors make an important contribution to level of musculoskeletal pain experienced.47 In work environments, the level of this kind of pain is worsened by negative emotional states and reduced by positive ones.48
Pain, of course, is a totally subjective experience. You can only measure it by asking individuals how much pain they feel. Research has clearly shown that the level of pain experienced - both among individuals suffering from chronic pain and when it is experimentally induced in some way - is easily influenced by the emotional state you are in at the moment. There is an enormous body of research on patients with a broad range of medical conditions showing that pain is worsened by negative emotion.49 This is a long-established finding. But it is only in the past couple of decades that investigators have begun to study the impact of positive emotion on pain.
Norman Cousins drew the attention of the medical community to humor's power to reduce pain in his book Anatomy of an Illness. His spinal disease left him in almost constant pain. But he quickly discovered while watching comedy films that belly laughter eased his pain. Dr. James Walsh, an American physician, had noted decades earlier in his 1928 book Laughter and Health, that laughter often reduced the level of pain experienced following surgery and appeared to promote wound healing, but medical researchers seem to have been unaware of Walsh's observation until Cousins sparked new interest in humor and pain reduction.
Cousins built humor into his days whenever he could. To give you an idea of his sense of humor, one morning a nurse brought in a specimen bottle (to obtain a urine sample), and left it on his breakfast tray. There was also a bottle of apple juice on the tray, so Cousins poured some of it into the specimen bottle and finished his breakfast. When the nurse returned, she held the bottle up to the light and said, "Hmmm, it looks a little cloudy today." Cousins picked it up and said, "Well then, let's run it through again." And he drank it! Since this story is widely shared, other patients have been known to try the same trick. Perhaps it has been played on you.
On another occasion, Cousins was about to take a bath in a tub filled with an oily substance designed to ease some of his joint problems. He described it as "a cross between stale oatmeal and used crankcase oil." When the nurse left for a moment, leaving the bottle containing the oily stuff near the tub, Cousins poured most of it down the drain. When the nurse returned, he held up the bottle and said, "I'm terribly sorry, but I can't get the rest of this down."
Humor and Experimentally-Induced Pain
Most of the experimental studies of humor and pain have adopted either of two approaches to inducing pain. In one, subjects are asked to leave their hands in ice water (at one degree centigrade) for as long as possible before it becomes too uncomfortable/painful and then remove it. A baseline is established before having subjects watch either a comedy or some other kind of video. The ice water procedure is then repeated. The other involves the use of a standard blood pressure cuff on the arm. Pressure is steadily increased until the subject asks to have it stopped - because it becomes too uncomfortable/painful. The question tested is whether humor and laughter increase an individual's pain threshold (i.e., the length of time the hand is in water or the level of pressure reached with the blood pressure cuff).
Research using these approaches to induce pain has demonstrated humor's power to both increase the time individuals are able to leave their hand in the ice water50 and withstand higher levels of pressure on the arm using the blood pressure cuff.51 Similar findings have been obtained with children using the ice water approach.52 Although there is widespread support for these findings, it is still not clear whether humor just raises the threshold at which pain begins to be experienced or increases the capacity to withstand pain.
We also don't know just how long this pain reduction effect of humor and laughter lasts, but you will recall Norman Cousins' observation that 10 minutes of actual belly laughter would give him two hours of pain relief. The limited available experimental evidence suggests that the effect lasts at least as long as 20 minutes.53 And it may last longer.
Given the compelling evidence that humor does increase pain thresholds (or reduce pain), it makes sense that those who get greater enjoyment from the humor would show the greatest pain reduction effect. We have little evidence one way or the other about this, but it was recently found that pain reduction was greatest among individuals whose faces reflected greater levels of enjoyment.54 Surprisingly, increased laughter was not associated with greater pain reduction. So this supports the idea that it is the mental enjoyment of humor (perhaps due to humor's distraction power) that is the key, not the laughter itself. This issue is discussed below.
Although it was noted above that there is a great deal of evidence documenting the worsening effect of negative emotion on pain, there is also - amazingly - evidence that the specific negative emotions associated with both repulsion and tragedy (as experienced from watching a video) have an effect similar to that of humor. That is, they have both been found to increase the threshold for experiencing experimentally-induced pain.55 It is not clear how to make sense out of this, although researchers have concluded from these findings that anything that is physically and emotionally arousing may be effective in raising pain thresholds (making the experience of pain less likely).56 This is consistent with the frequent observation that individuals suffering terrible injuries in accidents often fail to notice pain if they are mainly concerned about doing something to insure the safety of a young child or other loved one also involved in the accident.
The apparent discrepancy between the statement (above) that there is a lot of evidence showing that negative emotion worsens pain and these studies showing comparable pain-reduction findings for humor and repulsion or tragedy may also be explained by the fact that most of the literature documenting a worsening of pain as a result of negative emotion concerns chronic sources of pain - not acute pain generated in a laboratory setting.
In a very different circumstance in which pain was induced by a hospital procedure for pain victims, the level of pain experienced during hydrotherapy by two young girls with burns was also found to be reduced by watching cartoons during the hydrotherapy (a very painful experience involving immersion of the burned skin in water).57
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If watching a comedy video in a research laboratory reduces pain thresholds, should we expect the same result for people who have a good sense of humor (as evidenced by higher scores on a sense of humor test)? There is some evidence that individuals who score higher on sense of humor tests show reduced pain sensitivity,58 but there are just as many studies showing the opposite. The reason for this inconsistency may lie in the fact that any pain reduction (or increase in threshold for experiencing pain) that results from humor presumably occurs for only a limited period of time. We have some evidence that it lasts up to 20 minutes (and Cousins' personal observation of a two-hour reduction in pain), but we still just don't know much about this issue. The duration of pain reduction may well depend on both the intensity and length of laughter, as well as the level of enjoyment or amusement associated with the funny event. Since some people who express great amusement in funny events laugh very little, this last factor could contribute independently to the pain reduction experienced.
Humor and Chronic Pain
Just as negative emotion tends to worsen pain among individuals suffering from chronic pain, positive emotion is associated with pain reduction in these individuals. Of course, when your patients suffering from a serious illness or injury are in a lot of pain, you don't expect them to show much positive emotion. Pain puts us all in a bad mood. But some people have an enduring trait of being more upbeat and positive than others, regardless of their circumstance at the moment. Some bring this quality with them to the hospital. Individuals who have this kind of "trait positive affect" have been found to report less pain in coping with such conditions as cancer,59 rheumatoid arthritis60 and fibromyalgia.61 This also holds for hospital inpatients suffering from a broad range of other pain-inducing conditions.62
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For people who don't have an enduring positive mood as a general personality trait to help manage their pain, humor offers an effective tool for putting oneself in a good mood. (And, as a nurse, you are in an excellent position to bring some humor into those patients' lives.) Several studies have shown that using a funny video to generate positive emotion is an effective means of reducing pain in connection with a broad range of medical conditions. For example, listening to an hour of traditional Japanese comic stories (Rakugo) reduced the level of pain experienced by Japanese rheumatoid arthritis patients.63 This is an especially important finding, since the symptoms experienced by these patients (as well as by patients with multiple sclerosis and numerous other medical conditions) generally worsen in the presence of negative emotional states. Laughing when you're in pain can help reduce the pain at the same time that it substitutes a more positive mood for a negative one and lifts your spirits. This may explain why rheumatoid arthritis patients who report more chronic pain also say they look for humor more often in everyday life.64 Like the old man in Paris who learned to laugh to ease his pain, they've learned that humor helps manage their pain.
Among patients in a rehabilitation hospital, 74% agreed with the statement, "Sometimes laughing works as well as a pain pill."65 The patients had such conditions as traumatic brain injury, spinal cord injury, arthritis, limb amputations, and a range of other neurological or musculoskeletal disorders. When elderly residents suffering pain in a long-term care facility watched funny movies, the level of pain they experienced was reduced.66
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Pain management is an important consideration for many patients following surgery. So it is worth noting that watching a funny video has been shown to reduce the level of minor pain medication requested by patients following surgery.67 Given the power of humor and laughter to reduce pain, it is not surprising that humor has been applied as a "treatment" in managing pain associated with burns and dental work68 and as a component of general nursing care.69
There is also widespread anecdotal evidence that laughter can help manage pain. Norman Cousins once described in a speech how he, Dr. Carl Simonton and Jose Jimenez (a comedian from the old Steve Allen Show in the 1950s) went to talk to a group of patients at a VA Hospital. Jimenez had them falling off their chairs laughing. The doctors later told Cousins that 85% of the patients had been experiencing pain when they entered the room. But the laughter reduced or eliminated the pain for most of them.
Nurses often tell me they know a patient who tried Cousins' idea of purposefully laughing a lot while watching funny videos and found that it also reduced their pain. But not all who try it experience pain reduction. The reason for this inconsistency remains unclear.
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If you (or your patients) are not very good at using your own sense of humor to help cope with pain or any other source of stress, is it possible to learn to use humor to manage pain? The answer appears to be "yes." A Swedish physician reported that six women suffering from painful muscle disorders got significant pain relief during a 13-week course on humor therapy.70 Throughout this period, they read funny books, listened to or watched funny tapes and worked at "giving higher priority to humor in their everyday lives." They also attended lectures on humor research. Those patients who laughed the most in group sessions showed the greatest symptom reduction.
The follow-up to this course (Humor and Nursing II) provides you with a ready-made humor skills training program, so that you can - over a period of two to four months - progressively build the skills you (and your patients) need to use humor as an ally in managing your daily pain, regardless of whether it is physical or emotional pain.
