How does it work? Pick your theory


I’m working with a man who has neuropathic pain in his right (dominant) hand.  He developed his pain some 8 years ago after he caught it in a woodworking machine and basically mashed it, damaging most of the carpal tunnel area.  After numerous orthopaedic, and plastic surgical procedures, he’s now left with nasty scarring, and even nastier neuropathic pain with some central sensitisation elements.  While he has almost full range of movement in his wrist and fingers, he rarely uses his hand and instead, cradles it or leaves it sitting half-curled, palm up.

We’ve been working together for a month or so, along with physiotherapy and psychology, and my parts of this programme have been to help him develop a personalised model of the factors that contribute to his pain; help him develop some self regulatory skills particularly to downregulate his very sensitive sympathetic drive; and to start the process of him being mindful of his hand rather than ignoring it or focusing on it.

I’m using a combination of approaches – Socratic questioning and guided discovery to help him develop a better understanding of his pain – particularly focusing on helping him recognise that trying to control his pain through either avoiding the use of his hand, or using distraction is counter-productive.  When he avoids using his hand, he’s either limiting the activities he can get through during the day and gets bored, frustrated and is probably contributing to the pain because his neuromatrix isn’t receiving normal movement patterns.  When he uses distraction, he can almost completely ignore the pain while pushing himself to ‘do everything’ – but then he gets an overwhelming increase in pain when he stops, which is distressing.

We’ve spent quite a while discussing the nature of control – is it pain we’re trying to control? Is it his activities we’re controlling? Is it is thoughts and emotions that we’re controlling?  I’ve been using mindfulness and some of the concepts from ACT and suggesting that try as hard as we might, pain is not something to control, and neither are thoughts or emotions.  In fact it seems the harder we try to control any of these things, the more they dominate and control us!

As a result, much of what I’m working on is helping this guy to non-judgementally regard his body sensations as simply sensations, allowing his attention to go to his hand without trying to ignore it (you can’t!) or to over-attend to it, but simply to notice it.

Taking this a little further, we’ve been working on breathing and mindfully attending to breathing as one way of introducing self regulation. This involves gently guiding his attention to his breath, and just as gently, noticing when his attention drifts away and bringing it back to his breathing.  Not as easy as you’d think!

I’ve been using biofeedback as part of this process because this guy is a practical man.  He’s not one to just accept doing something without having some feedback about what is actually going on.  I’ve used skin conductance, surface EMG, heart rate, respiration rate and skin temperature to monitor his overall arousal level.  He’s aware now that he can influence usually unconscious processes just by breathing or even thinking differently!

Yesterday I took it a little further.  I asked him to look at his painful hand, and simply describe the sensations without judging them.  What this means is he told me about the tingly, burning sensation over his palm, the throbbing aching in his fingers, he noticed where the pain started and stopped on his hand and fingers, the sensation of heat where his fingers touched each other, the sensation of pressure on his forearm where it rested against the arm of the chair, the sensation where the fabric of his T-shirt touched his skin – and so on.

It was interesting for him to notice that the painful area isn’t as big as he’d imagined.  When he really started to notice the quality of his pain, it wasn’t nauseating or particularly intense, it varied in sensation.  What I noticed was that initially his readings on biofeedback jumped – but they gradually settled down as he looked at his hand and really noticed it.

We then did some deep relaxation, really a kind of hypnosis.  In this we used an imagery device I’d discussed with him before the session.  I guided him in to using his attention to become aware of his hand and in particular, its position in space and the sensations over his whole hand and forearm.  I then guided him through an imagery process where he imagined holding his hand in warm water, allowing his hand to ‘thaw’ and open.  We then spent some time imagining his hand feeling normal, moving normally and imagined opening and closing his hand to lift a cup, pour milk, and flex and extend his wrist.  Throughout I was monitoring his biofeedback readings, and using words like ‘relax’ and ‘warm’ and ‘comfortable’ whenever the readings suggested he was becoming ‘stressed’.

When we completed the session, he had achieved sustained attention to his hand for about 35 minutes, completed a guided imagery of his hand doing normal activities, and had remained calm throughout.  He reported some increased discomfort around his wrist particularly after imagining wrist extension and flexion, but what really excited me was that he’d been able to increase the skin temperature on the finger of his right hand.

So, lots of choices in terms of theory to explain what I’d been doing.

  1. Graded motor imagery and sustained attention gives the neuromatrix normalised input, while not activating what Lorimer Moseley and David Butler call ‘neurotags’ or emotionally-laden pathways in the brain.
  2. Graded exposure using visual imagery as described by Johan Vlaeyen and following the exposure paradigm used in phobia reduction.
  3. Using a behavioural model, biofeedback providing immediate feedback on progress and arousal levels, influencing both my behaviour (guided imagery) and the clients responses
  4. Hypnosis allowing the ‘judgemental’ aspects of the mind to be quietened, thus allowing the client to experience sensations without distress
  5. Mindfulness where sensations are experienced but judgements are stilled.

Take your pick!  I’m not entirely sure myself, but whatever the mechanism, I’ll be continuing with this approach to the point where this client can carry the same process out with eyes open, then when actually moving.  Oh, and at the same time, the rest of the team will be working (along with me) on helping him set and achieve goals, manage difficult emotions and maintain a regulated activity pattern, as well as work on his relationship, look to the future of work, and help him communicate effectively with his case manager.  This is why pain is often not the main focus in pain management!

2 comments

  1. Great blog (again!) and a topic I seem to be discussing a lot with physio staff and students – when something helps do we know why? And then does it matter, providing it helps?
    Obvious examples of this are reactivation -v- exposure – totally different models and approaches yet we seem to end up addressing some of the anxiety issues through gradually getting someone to ‘do more’.

    the other impact is on outcome measures and assessment tools. what do you choose to measure if you aren’t even sure what you are influencing? Or just a little bit of everything?

    My sense is that it when it goes well and the patient improves / reaches goals etc it doesn’t really matter. when it is crucial is when they aren’t successful – if you haven’t produced a robust piece of case formulation (this is their situation, and this is why they are in it) and allowed your treatment plan to reflect that, then you won’t be any the wiser when it doesn’t work out. The use of walking programmes or Hydro programmes (with progression to land-based exercises!) that are slapped on everyone risk missing the point.
    Stretching makes you more flexible, strengthening makes you stronger and that is as far as the evidence goes. I’ve stopped been surprised now when I see chronic pain patients who are fitter than the team I work in, yet remain disabled – I just go back to their assessment and review the original hypothesis.

    Keep it up B, you are making me think!

    Px

    1. Darn, making you think means I have to think too! The truth is that disability is much more important and more complex to manage than fitness, pain intensity, or impairment. I wonder whether once we stop thinking about pain as the focus and look more deeply at disability, we might have a better chance of making significant differences in the lives of the people we want to work with.
      Hypothesis-testing is the approach I try to use – but of course I’m human too, and may not always identify the appropriate hypothesis, or even the best way to test that hypothesis. It does mean, though, that I can avoid the ‘blame the patient’ game that can sometimes go on🙂

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