“I know my pain doesn’t mean I’m damaging myself – but I still have pain”


In the excitement of helping people understand more about pain neuroscience, which I truly do support, I think it’s useful to reflect a little on the history of this approach, and how it can influence the experience people have of their pain.

If we go right back to the origins of pain self management, in the groovy 1960’s and 1970’s – the first truly significant work in chronic pain self management came from Wilbert Fordyce (Fordyce, Fowler & Delateur, 1968). Bill Fordyce was a clinical psychologist working in the Department of Physical Medicine and Rehabilitation, University of Washington, Seattle, Washington. He noticed that when people were given positive reinforcement (attention, and social interaction) for “well” behaviour, and ignored or given neutral responses to reports of pain, their “up-time” or activity levels increased. Interestingly for occupational therapists, in the paper I’ve cited, occupation was used as an integral part of the programme and occupational therapy was a part of the programme (somewhat different from most clinics nowadays!)  Thus the operant conditioning model of pain behaviour and disability was first developed.

As practice progressed, clinicians began discussing the gate control theory of pain to help people understand how incredibly powerful descending pain modulation could be. Included in those discussions was the distinction between “hurt” and “harm” – that simply because something hurt, did not mean it was a sign of harm in the tissues.

As the 1980’s wore on, interdisciplinary pain management programmes became popular, with much of the work involving helping people reappraise their pain as “noise in the system”, and encouraging participants to develop strategies to increase activity levels and at the same time employ approaches to “close the gate” and thus reduce pain intensity.  I started working in pain management in the mid-1980’s when not only did I develop a patter to explain gate control, chronic pain, the relationship between the brain and what was going on in the tissues, I also started using the case formulation approach I still use today.

The key effects of this approach were pretty profound: people said to me they had never realised their pain wasn’t a fixed thing. The commonplace examples I used to explain why the relationship between their pain and what was going on in the tissues was complicated and uncertain made sense – everyone had heard of phantom pain, everyone knew of people who played rugby and didn’t feel the pain until after the game, everyone had heard of hypnosis for pain, and people also recognised that when they felt bad, so their pain felt worse but when they were busy and happy doing things, their pain was less of a problem.

I’ve attached one of the original examples of “explaining pain” to this post.simple-explanation-of-biopsychosocial-model-of-chronic-pain

Now the interesting thing is that during the 1970’s, 80’s, and 90’s, there was still a lot of talk about ways to abolish chronic pain. Loads of nerve cutting and burning, lots of surgical fusing and metalwork, heaps of pharmacological strategies were all the rage. People felt sure there was a way to stop all this chronic pain from appearing – and the answer was to begin early, before pain behaviour was established, before people got the wrong idea that their pain was intractable.  As a result the “yellow flags” or psychosocial risk factors for chronicity were developed by Kendall, Linton & Main (at least in NZ). This created a great flurry of ideas about how to “get people moving”, and “assess and manage yellow flags” which have subsequently flourished and become a veritable rainbow of flags.

Sadly, I haven’t seen any significant reduction in the rates of chronic pain, or rates of disability associated with chronic pain – although there do seem to be fewer people having five or six or more surgeries for their lower back pain. Instead, there’s a far greater emphasis on “explaining pain” from the beginning – a good thing, you’d think! But hold on… a recent conversation on Facebook suggests that the purpose of explaining pain may have been misconstrued, perhaps even over-interpreted…

When we begin to untangle some of the elements involved in our experience of pain, we can see that at least part of the “yuk factor” of pain lies in our appraisal or judgement of what the pain signifies. Let me give you an example – say you were walking down a dark alley and someone approached you with a loaded syringe. They stab you with the needle! What do you do? Well – probably you’d run for the nearest Emergency Department, and my bet is that you’d be well aware of the sting of the needle as it went in. Now think about the last time you got your flu jab – same stimulus, but your response is likely to be quite different. You’ll notice the sting of the needle, but it will quickly fade, and you’ll generally be calm and matter-of-fact about it. Your appraisal of the sting is quite different from what I guess you’d be thinking if you’d been stuck by a needle in a dark alleyway.

When people are asked to rate their pain intensity, at least some of the “score” given on a visual analogue scale can be attributed to the “distress” portion of the pain experience. The part that we can attribute to “what this experience signifies to me”. And this is the part that an explanation about pain can influence – and thus pain intensity ratings can and do drop once a helpful explanation is given. BUT it does not change the biological elements, nor the “attention grabbing” aspects of pain (well, maybe the latter can be a little bit changed because if we don’t think of the experience as representing a threat, we can more readily put it aside and focus on other more important things).

Why is this important? Well, in the enthusiasm to explain pain to everyone, I think sometimes the application can be a bit blunt. Sometimes it becomes an info-dump, without really taking the time to listen to what the person is most concerned about. It may not be that they think their pain represents harm – instead it may be that they’re not sleeping well, or that they’re finding it hard to concentrate at work, that they’re worried about the effect of pain on their ability to drive safely. Because quite apart from the “yuckiness” of pain, pain intensity also has an effect on cortical processing space. And an explanation of the mechanics doesn’t take away the poor sleep, the worries about work, or make it easy to drive home. And there are times when the person remains unconvinced by an explanation – or has “head knowledge” but it makes no difference to what they’re doing. From our own experience in life, we know there’s a big difference between reading about something – and actually doing it. Experiential learning trumps “head knowledge”

Do I think it’s important to explain pain neurobiology? Most of the time, yes. But we need to do this with care, compassion and sensitivity.  We need to think about why we’re doing it. And we need to recognise that for some people, explanation doesn’t change their pain intensity, it just changes their judgement about the meaning of their pain – and if their concerns are about the effect of pain on their life, then an explanation may not be the most useful thing. And most of all, we need to remember that reducing pain intensity is not really the most important outcome: doing more is probably more important.

 

Fordyce, Wilbert E., Fowler, Roy S., & Delateur, Barbara. (1968). An Application of Behavior Modification Technique to a Problem of Chronic Pain. Behaviour Research and Therapy, 6(1), 105-107. doi: dx.doi.org/10.1016/0005-7967(68)90048-X

Okifuji, Akiko, & Turk, Dennis C. (2015). Behavioral and Cognitive–Behavioral Approaches to Treating Patients with Chronic Pain: Thinking Outside the Pill Box. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 33(3), 218-238. doi: 10.1007/s10942-015-0215-x

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10 comments

  1. Right on Bronnie! info dump, poor facilitation, inability to communicate with the patient beyond the info dump (not witnessing body language, or even worse not interpreting questions and comments well), and being invested in changing the person’s paradigm, or a bunch more reasons that this education doesn’t work
    I think I recently noticed you state that changing cognitions does not necessarily change behaviour. Right on again. This would suggest that the most powerful education for most is experiencing change in their body – being able to move with more ease, regain some function, feel as if they are becoming physically useful or competent again.
    So maybe this explain pain stuff should be focusing more on providing the person with an embodied experience of change. Many patients are excellent at kinaesthetic learning versus academic – at least in comparison to the typical PT or OT .
    I like an idea I heard recently – provide the individual with an embodied experience that is inconsistent with their previous determination of danger/safety of movement.
    That’s the whole point of explain pain – but maybe we should be focusing more on changing physical behaviour than cognitions …
    … just some thoughts a little afternoon rant here …

    1. Music to my ears Neil, I think some people are misinterpreting “explaining pain” as if it’s yet another technique, when it is intended to be a way to communicate. As you say, behaviour change is about doing not just thinking, like the difference between reading about centrifugal forces and friction and balance as compared to actually riding a bicycle.
      Experiencing something different and drawing your own conclusions seems to be a more creative and liberating enterprise than being told what to do and why!

      1. I think we can help people test out their expectation that pain = damage by setting up mini experiential exercises where the negative outcome isn’t obtained. We can also explore the many times when we experience pain without having damage – try not blinking for a while, or sitting still without moving for 5 – 10 minutes! I also use stretching the thumb down to the wrist as an example of the way acute pain acts as an “early warning system” rather than an indication of damage. Some ideas I’ve used in therapy anyway.

  2. I’m finding your blog very interesting. You seem like someone who might be able to contribute to a question that has been bothering me for some time. I can’t help wondering if the big focus in physiotherapy on getting people moving as soon as possible after an injury might be causing them to experience more pain than they would if they had done less, and that this could actually lead to a strengthening of the pain response, possibly encouraging it to become chronic. At the same time, clearly it is not a good idea to encourage patients keep the painful body part inactive. I wonder if we ought to be investigating a proper balance between the two, and emphasising the importance of using adequate pain relief in the early stages. I wonder if you have any views on this?

      1. I’ve been researching the transition from acute to chronic pain and it seems to me that current research suggests movement is only protective against chronic pain if the patient is able to do the exercises with little or no pain. The longer a patient experiences pain, or the more severe the pain, the more likely it is to become chronic (in addition to genetic and psychosocial factors). It seems to me, then, that it is crucial to ensure the patient is taking adequate medication (perhaps not opioids, as you say), and to avoid encouraging a patient to ‘grin and bear it’ in the acute stage. And of course with some conditions, such as tendinopathy, a reduction in movement and load may be required in the early stages, with gradual re-introduction later.

        Of course this is all a bit off-topic from this blog post (sorry!). I think you make a very good point when you say “It may not be that they think their pain represents harm – instead it may be that they’re not sleeping well, or that they’re finding it hard to concentrate at work, that they’re worried about the effect of pain on their ability to drive safely.” Definitely issues worth exploring with a patient/client. It’s so easy to make an assumption about why a patient is avoiding activity but to get that assumption wrong.

        I’m not entirely sure about the last line though, but certainly identifying the patient’s desired outcomes is key, and often not explored.

        Your blog is bringing to light may topics well worth discussing..

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