Chronic pain

…and now what we’ve all been waiting for: What do to about central sensitisation in the clinic

For the last couple of weeks I’ve posted about central sensitisation; what it is, and how to assess for it. Today I’m going to turn to the “so what” question, and talk about what this might mean when we’re in the clinic.  Remember that most of this material comes from Jo Nijs’ recent talks at the New Zealand Pain Society.
Firstly, remember that pain is an experience that people have, underpinned by neurobiology, but also, depending on the level of analysis, on interactions with others, on systems and how they work, on culture, on individual experiences, and of course, on interacting within a body within an environment or context. Everything I say from here on is based on these assumptions.

The first point Jo Nijs makes is that when we know a bit more about the neurobiology of persistent pain associated with central sensitisation, we can use this knowledge wisely when we help someone make sense of their pain. This doesn’t mean wholesale and broadcast “I-will-tell-you-all-I-know-about-pain-neurobiology-because-I-know-you-need-to-know-it-because-I-know-it-and-think-it’s-important” which is, truth to tell, a lot more about the know-it-all than the person in front of them! We need to earn the right to give information – that means establishing that we’ve heard the other person’s story and the current meanings they’ve made from their experience. It also means asking permission to share new information. It means thinking about WHY we want to share new information.

So what if the person doesn’t use the same groovy language we use to describe his or her understanding?! So what if they’ve got some of the newer ideas slightly skewed. In the end, what’s important is that the person understands these things:

  • Pain isn’t a direct reflection of what’s happening in the tissues.
  • Pain can be influenced by many things, some of which are physical forces (heat, pressure and so forth), some of which are ideas, and some are emotions. And there are a bunch of other variables that can influence the experience, including what else is going on around the person.
  • The brain is intimately involved with our experience of pain, and it’s a two-way street from body to brain and brain to body.
  • Persistent pain is more about neurobiology than tissue damage per se (but not exclusively about neurobiology).

Our job is to make sure the person understands these things, rather than our job being about “educating” people. The end result matters, rather than any particular process.

If we look at the evidence for helping people reconceptualise their pain, there’s plenty to show that this approach is useful – it’s been a key tenet of a self-management cognitive behavioural approach to pain management since at least the late 1970’s. The later research (from Butler, Moseley and Louw et al) is simply looking at this approach within a slightly different cohort and in a different context. Rather than being integrated with an interdisciplinary pain management programme, research from these guys shows that physiotherapists (in particular) can deliver this kind of information very effectively – and that it helps reduce the fear and subsequent efforts to avoid pain (such as not moving, seeking healthcare, and being worried about pain). Yay!

It’s true that there are many different ways to influence the descending modulatory system, and release endorphins. One of them is to help people understand their pain and be more confident about moving. Another is to place hands on the person – hence massage therapy, manual therapies, manipulations and so on. Nijs believes hands on therapy has best effect after you’ve gone through some of the reconceptualisation that’s often needed (Bishop, Torres-Cueco, Gay, Lluch-Girbes, Beneciuk, & Bialosky, 2015).

Similar arguments can be made for considering sleep management and stress management as an integral part of pain management. (To be perfectly honest, I always thought this was part of what we did…). So here’s the argument: we know most people with persistent pain experience rotten sleep. We also know that people are stressed by their experience of pain. Because poor sleep is associated with increased activation of glia in the prefrontal cortex, amygdala and hippocampus, and therefore are pro-inflammatory, pain is often increased after a poor night’s sleep. Sleep medications interfere with the sleep architecture, so it’s useful to consider nonpharmacological approaches to sleep management.

Three strategies to consider:

  • CBT for insomnia – here’s one resource to use
  • ACT or acceptance and commitment therapy – I’ve written a great deal about ACT, just use the search function on this blog for more
  • Exercise – OMG yes, exercise is effective! (just not right before bedtime, kthx)

Stress management is tougher. We can’t avoid experiencing stress – and neither can we live in a bubble where we don’t ever get exposed to stress. Instead, we probably all could do with learning multiple ways of managing stress. Things like realistic evaluations of the situation, increasing our capabilities for regulating our response to stress via biofeedback if need be, and using mindfulness as a strategy for being with stress instead of fighting against it, or folding beneath it.

I haven’t cited many references in this post – not because there aren’t many, but because there are SO many! And I’ll post more next week when I start looking at the rather sexy neurobiological examinations of processes used in pain management for years (yes, we’ve been doing it for a long time, we now have great explanations for how these things might work – though effect sizes are still small.)


Bishop, M. D., Torres-Cueco, R., Gay, C. W., Lluch-Girbés, E., Beneciuk, J. M., & Bialosky, J. E. (2015). What effect can manual therapy have on a patient’s pain experience?. Pain, 5(6), 455-464.


Does central sensitisation matter?

In my last post I discussed some of the mechanisms thought to be involved in central sensitisation, and while many of the details remain pretty unknown, I think the general conclusion is that yes, it really is a thing. What do I mean by central sensitisation? Well, it’s curious, it can refer to the processes at spinal and brain levels that seem to reduce the usual descending inhibitory mechanisms, expand the areas in which neural activity takes place, and allows increased information flow to eventually reach conscious awareness. At the same time it can refer to the experience in which a person feels greater pain than anticipated, given the degree of input; pain that is distributed more widely than anticipated, given the degree of input; and/or pain that lasts longer than we’d expect, given the degree of input (Woolf, 2011). BTW most of this post is derived from talks given by Pro Jo Nijs at the recent New Zealand Pain Society Conference.

The question now is whether this really matters. After all, nociceptor inputs can trigger a prolonged but reversible increase in central nociceptive pathways – if they’re reversible, just eliminate the original nociceptive input, and voila! The sensitisation is gone. What we know, however, is that in many cases the tendency towards having long-term increased sensitivity remains, or was perhaps always present.

Well, unfortunately if someone does tend to have greater activity in the central nervous system, then it has the potential to add enormously to poor outcomes if he or she decides to have surgery. For example, individuals with this tendency experience poorer outcomes after total knee replacement; and after shoulder surgery; but not after hip-joint replacement surgery. Testing in these cases was conducted using conditioned pain modulation which involves people undergoing painful testing – when they’re already in pain! Brave souls. You can see why it’s not a popular testing procedure in mainstream surgical situations.

Adding to the view that central sensitisation matters clinically, Ferrandiz and colleagues (2016) found that central sensitisation mediates the treatment effects in people with low back pain; Jull and colleagues (2007) found the same for neck pain after whiplash; Coombes and colleagues (2015) found the same for people with chronic tennis elbow.  It seems that central sensitisation is associated with greater pain catastrophising, slower movements, higher pain reporting, poorer functioning, increased perception of pain, and fear of moving.

The question now is how best to assess for the presence of this phenomenon. Given that most people won’t want to undergo conditioned pain modulation (not to mention the need for testing equipment and skilled technicians to administer the test!), what’s needed is a reasonably simple way to identify those who have the characteristics of central sensitisation so we can plan for, and manage it, more effectively.

Nijs and the Pain in Motion Research Group published the first set of criteria in 2014, from an epidemiological perspective. This classification approach involves first excluding neuropathic pain – and the group propose using IASP diagnostic criteria for neuropathic pain (see Haanpaa & Treede, 2010). If the problem is neuropathic pain (where there is a clear lesion of the nerve), then it’s managed accordingly (although we really don’t have great treatments for this kind of pain, either!).

Then they propose an algorithm which helps to clarify whether the problem is central sensitisation or “something else”.

The first question is whether the person identifies they have “disproportionate pain experience” – now this I have a problem with, because what is a “proportionate” pain experience? Given how fluid our experience of pain can be, and how poorly the experience correlates with what’s going on in the tissues, I find this a bit tough to use as a clear-cut indicator. Nevertheless, it’s the first question asked in this algorithm…

The next question relates to the person experiencing diffuse pain distribution (or, perhaps, wider spread than expected). If this is the case, eg someone has a grazed knee, but pain is experienced all over the entire leg, then it’s identified as central sensitisation. If the result is more like pain just above the knee to just below, then it’s somewhat equivocal, so the authors suggest the person completes the Central Sensitisation Inventory. This is a questionnaire I’ve discussed in the past. I’m no nearer to establishing whether it really is a useful measure than when I wrote that blog, but the measure continues to be used, and research is ongoing. Certainly, Jo Nijs and group seem to think the measure holds promise and might help to classify those at greater risk of developing problems with pain if they proceed to surgery.

So, to summarise, while the mechanisms involved in central sensitisation are still being discovered, and it’s challenging to know where normal processes end and abnormal ones begin, it definitely seems to be a clinical phenomenon affecting not only those without peripheral nociception (eg migraine), but also those with clearcut peripheral problems like osteoarthritis. Central sensitisation processes seem to underpin some of the most problematic pain problems we know of, and can get in the way of recovery even when peripheral nociceptive input has been removed – 18% of total knee-joint replacements are revised because of ongoing pain, and this pain doesn’t seem to improve after subsequent surgery (NZ National Joint Registry). There’s confusion about language – does the term refer to the mechanisms thought to be involved, or does it refer to the experience described by people? And assessing it is challenging – either go through complex and painful testing, or complete a questionnaire that may confound distress about health (and subsequent hypervigilance about body symptoms) with pain and other responses that might represent the presence of central sensitisation processes being invoked.

More challenging still is what do we do once central sensitisation is identified? Are our treatments any good? That, folks, will be explored in the next enthralling episode on Healthskills!


Baert, I., Lluch, E., Mulder, T., Nijs, J., Noten, S., & Meeus, M. (2016). Does pre-surgical central modulation of pain influence outcome after total knee replacement? A systematic review. Osteoarthritis and Cartilage, 24(2), 213-223.

Haanpää M, Treede RD. Diagnosis and classification of neuropathic pain. Pain Clinical Updates 2010; XVII.

Nijs, J., Torres-Cueco, R., van Wilgen, P., Lluch Girbés, E., Struyf, F., Roussel, N., . . . Vanderweeën, L. (2014). Applying modern pain neuroscience in clinical practice: Criteria for the classification of central sensitization pain. Pain Physician, 17(5), 447-457.

Valencia, C., Fillingim, R. B., Bishop, M., Wu, S. S., Wright, T. W., Moser, M., . . . George, S. Z. (2014). Investigation of central pain processing in post-operative shoulder pain and disability. The Clinical Journal of Pain, 30(9), 775.

Woolf, C. J. (2011). Central sensitization: Implications for the diagnosis and treatment of pain. Pain, 152(3 Suppl), S2-15.

Wylde, V., Sayers, A., Odutola, A., Gooberman‐Hill, R., Dieppe, P., & Blom, A. (2017). Central sensitization as a determinant of patients’ benefit from total hip and knee replacement. European Journal of Pain, 21(2), 357-365.

Is central sensitisation really a thing?

It seems odd to me that there’s much argument about central sensitisation in pain circles. I thought the idea of central sensitisation was well-established based on research from some years ago – but apparently there are still arguments about its relevance, and lots of debate about how to identify it clinically. This post is based mainly on a presentation by Jo Nijs from Pain in Motion, at the recent NZ Pain Society meeting in Nelson. In this post I want to briefly review the material presented by Jo suggesting that central sensitisation is a thing. I’ll write more about assessment in a future blog, or this post will be the longest ever!

Firstly, what is it and why should it matter? Researchers have long been aware that when a nerve is repeatedly stimulated, in future stimulation it will respond for longer and with more intensity – this is called long-term potentiation. Recently, the contribution of glial cells to this situation has been identified (remember glia? Those little cells whose purpose no-one really knew? Turns out they release gliotransmitters that circulate throughout the spinal cord and allow information to be transmitted widely, far from the original source of stimulation – see Kronschlager, Drdla-Schutting, Gassner, Honsek et al, (2016). Glial cells occur widely throughout the central nervous system, and while LTP is a process we’ve known about in the CNS for some time – we’ve known because this is how “memories” are formed (remember “nerves that fire together wire together”? Pathways that frequently activate develop the tendency to continue to activate together) – we’ve perhaps not been aware that this occurs in the spinal cord as well. So, LTP occurs in both the spinal cord and the brain, and there is more than one way this process is facilitated. Glial cells are one. Central sensitisation involves this process of long-term potentiation across and amongst pathways within our nervous system – it means information from peripheral regions like your big toe are more likely to be transmitted to areas in the brain responsible for attending and responding to threatening information.

Why does this matter? Well, if we think of ourselves as a finely tuned homeostatic machine, one that wants to remain in a stable state, we can think of two systems balanced with one another. One system works to facilitate information transmission (nociceptive facilitation), while the other works to reduce or modulate this transmission (endogenous hypoalgesia). If we continue with the machine analogy, we want to know about “trouble” as soon as possible – so our nociceptive facilitatory system is like an accelerator, working promptly to make sure we know about the state of play very quickly. If you’ve ever driven a race car, you’ll know how twitchy the accelerators are! The brakes on this system is our endogenous opioid system which reduces the influence of the nociceptive system so we can keep moving forward. If the brakes fail, for whatever reason, in a race car we’ll burst forward! Similarly, if the endogenous modulatory system fails, for whatever reason, far more information ascends to relevant regions in the brain for interpretation – and ouch.

What sorts of things enhance connectivity between areas of the brain that deal with nociceptive information? Well, this is where things get all woolly and psychosocial for a while (sorry guys!). From many fMRI studies, it’s possible to establish that “pain catastrophising” or the tendency to brood on pain, feel helpless about it, and regard the pain as seriously intense activates brain areas like the dorsolateral prefrontal cortex, the anterior cingulate cortex, and the insula, which in term reduces the efficiency of the opioid analgesic system (that endogenous opioid system), makes it harder to distract attention from the pain, and increases facilitation (ie the transmission of nociceptive information from lower CNS to higher). In other words, this very psychological construct has a biological component to it.

Central sensitisation has been identified in many different pain problems, ranging from osteoarthritis in the knee (Akinci, Al Shaker, Chang, et al, 2016), post-cancer pain (Lam, 2016), shoulder pain (Sanchis, lluch, Nijs, Struyf & Kangasperko, 2015), and yes, those messy complicated ones like whiplash (Coppieters, Ickmans, Cagnie, Nijs, et al, 2015), low back pain (Sanzarello, Merlini, Rosa, Perrone et al, 2016) and fibromyalgia (Walitt, Ceko, Gracely & Gracely, 2016). Rates of central sensitisation vary from 10% in shoulder pain to 100% in fibromyalgia. For some good reading on central sensitisation in these disorders, take a look at the references I’ve cited.

So yes, central sensitisation is a thing, and it results in increased pain experiences that last longer and spread. Why do some people experience while others don’t? Now we’re venturing into rather more speculative areas, but some findings seem clinically useful. People who have, in their early years, experienced physical and/or psychological trauma, those who tend to catastrophise or have unhelpful beliefs (often inaccurate beliefs) about their pain,  those who have poor sleep, and those who have an elevated stress response seem more likely to have pain that fits with what we’d expect with central sensitisation (See Nijs & Ickmans, 2014).

Why does this occur? Well, stress increases release of glutamate and this in turn increases CNS excitability (makes sense – let’s react faster to everything, at least for a short time). At the same time, stress reduces GABA and serotonin, and as a result inhibition is reduced (the brakes come off). If we add microglial activity to the mix (remember that’s going to increase the connectivity between neurones), and if we add ongoing release of adrenaline in because the stress has been continuing for a while, we’re going to end up with activated glial activity in the prefrontal cortex, amygdala and hippocampus, all important areas for detecting salience and making decisions to act. These glial cells release chemicals known to increase neuroinflammation, reducing hippocampal activity (ultimately reducing volume of neurones in this area), increasing the size of the amygdala (which means it’s more capable of responding to threat), and reducing the prefrontal cortex size, reducing the capacity to make considered decisions (Kregel, Meeus, Malfliet et al, 2015). Ew… nasty! In longterm stressful situations, it seems our brains adapt – and not in a helpful way when it comes to experiencing pain. Whatever you do DON’T say to your patients  “Oh and by the way, your back pain means your brain is inflamed and parts of your brain are shrinking” – this is NOT helpful!

Next post I’ll discuss assessing for central sensitisation – but before I do, remember that central sensitisation is not the only factor at play in ongoing pain. In fact, some people don’t seem to develop central sensitisation even with ongoing nociception from either disease processes, or inflammation. We don’t really know why. What we do know is that simply treating peripheral nociceptive input when central sensitisation is present may fail to help the person – so keeping an eye out for it is important.


Akinci, A., Al Shaker, M., Chang, M. H., Cheung, C. W., Danilov, A., Jose Duenas, H., . . . Wang, Y. (2016). Predictive factors and clinical biomarkers for treatment in patients with chronic pain caused by osteoarthritis with a central sensitisation component. International Journal of Clinical Practice, 70(1), 31-44.

Coppieters, I., Ickmans, K., Cagnie, B., Nijs, J., De Pauw, R., Noten, S., & Meeus, M. (2015). Cognitive performance is related to central sensitization and health-related quality of life in patients with chronic whiplash-associated disorders and fibromyalgia. Pain Physician, 18(3), E389-401.

Kregel, J., Meeus, M., Malfliet, A., Dolphens, M., Danneels, L., Nijs, J., & Cagnie, B. (2015). Structural and functional brain abnormalities in chronic low back pain: A systematic review☆. Paper presented at the Seminars in arthritis and rheumatism.

Kronschläger, M. T., Drdla-Schutting, R., Gassner, M., Honsek, S. D., Teuchmann, H. L., & Sandkühler, J. (2016). Gliogenic ltp spreads widely in nociceptive pathways. Science, 354(6316), 1144-1148. doi:10.1126/science.aah5715

Lam, D. K. (2016). Emerging factors in the progression of cancer-related pain. Pain Management, 6(5), 487-496.

Nijs, J., & Ickmans, K. (2014). Chronic whiplash-associated disorders: To exercise or not? The Lancet, 384(9938), 109-111.

Sanchis, M. N., Lluch, E., Nijs, J., Struyf, F., & Kangasperko, M. (2015). The role of central sensitization in shoulder pain: A systematic literature review. Seminars in Arthritis & Rheumatism, 44(6), 710-716.

Sanzarello, I., Merlini, L., Rosa, M. A., Perrone, M., Frugiuele, J., Borghi, R., & Faldini, C. (2016). Central sensitization in chronic low back pain: A narrative review. Journal of Back & Musculoskeletal Rehabilitation, 29(4), 625-633.
Walitt, B., Ceko, M., Gracely, J. L., & Gracely, R. H. (2016). Neuroimaging of central sensitivity syndromes: Key insights from the scientific literature. Current Rheumatology Reviews, 12(1), 55-87.

… a little more about Pain Catastrophising subscales

I’ve been writing about the Pain Catastrophising Scale and how to use this instrument in clinical practice these last two posts here and here because the construct of catastrophising (thinking the worst) has become one of the most useful to help identify people who may have more distress and disability when dealing with pain. Today I want to continue with this discussion, but looking this time at a large new study where the subscales magnification, rumination and hopelessness have been examined separately to understand their individual impact on pain severity and disability.

Craner, Gilliam and Sperry looked at the results of 844 patients with chronic pain prior to taking part in a group programme (a heterogeous sample, rather than a single diagnosis, so this group probably look at lot like those admitted to high intensity tertiary chronic pain management services such as Burwood Pain Management Centre here in Christchurch).  Most of the participants were female, European/white and married, and had chronic pain for an average of 10.7 years. Just over half were using opioid medication to manage their pain.

Along with the PCS, participants also completed some very common measures of disability (Westhaven-Yale Multidimensional Pain Inventory – MPI) and quality of life (SF-36), and the CES-D which is a measure of depression.

Now here comes some statistical analysis: multiple hierarchical regression! Age, sex, duration of pain and use of opioids were entered into the equation and found to account for only 2.0% variance of the pain severity subscale of the MPI – but once the PCS was added in (subscales entered separately) an additional 14% of the variance was accounted for, but the helplessness subscale was the only one to contribute significantly to the overall variance.

When Pain Interference was  entered as the dependent variable, all the same demographic variables as above contributed a meagre 1.2% of the variance, but when the Pain Severity subscale scores were added, 25.5% of the variance was explained – while the combined PCS subscales contributed 6.5% of the variance. Again, helplessness was the only subscale to contribute to Pain Interference.

Moving to quality of life – the physical subscale of the SF-36 was used as the dependent variable, and once again the demographic variables accounted for only 1.5% variance in physical QOL, with Pain Severity accounting for 23%. PCS subscales contributed only 2.6% of the variance, with only the magnification subscale being identified as a unique contributor. When the mental health subscale was used, again demographics only accounted for 1.2% of variance, with pain severity accounting for 12.4% of the variance. This time, however, the PCS subscales contributed 19.5% of the variance with both Magnification and Helplessness contributing to the variance.

Finally, examining depression, demographics contributed a small amount of variance (3.3%), with pain severity additing 9.8% of variance. The PCS subscales were then entered and contributed a total of 21% to the prediction of depression with both Magnification and Helplessness contributing to the overall depression variance.

The so what factor

What does this actually mean in clinical practice? Well first of all this is a large group of patients, so we can draw some conclusions from the calculations – but we need to be a little cautious because these participants are a group who have managed to get into a tertiary pain management facility. They’re also a group with a large percentage using opioids, and they were pretty much all European – and from North America, not New Zealand. I’m not sure they look like the people who might commonly come into a community-based facility, or one where they’d be referred directly from a GP or primary care centre.

At the same time, while this group may not look like the people most commonly seen for pain management, they share some similar characteristics – they tend to magnify the “awfulness” of pain, and then feel helpless when their pain is bothering them. Surprisingly, I thought, ruminating or brooding on pain wasn’t a unique contributor and instead the helplessness scale contributed the most to pain severity, pain-related interference (disability associated with pain), poor mental health quality of life, and low mood, while magnification scale contributed to poorer physical health quality of life, mental health quality of life and low mood.

What this means for practice

The authors suggest that the construct measured by the helplessness subscale might be a factor underlying poor adaptation to life’s difficulties in general, leading to passivity and negative emotions. They also suggest that magnification might be a unique contributor to perceiving obstacles to doing the things we need to do every day, while hopelessness might mean people are less likely to participate in enjoyable activities and then in turn contribute to feeling low.

Importantly, the authors state: “We offer that simply collapsing the 3 dimensions of this phenomenon (ie, rumination, magnification, helplessness) may actually conceal nuanced relationships between specific dimensions of catastrophizing and outcomes that would might inform treatment approaches.” Looking at the overall scores without thinking about the subscales is going to give you less information to use for individualising your treatment.

In a clinical setting I’d be reviewing the individual subscales of the PCS alongside both disability and mood measures to see if the suggested relationships exist in the scores this person has given.

I’d be taking a look at the repertoire of coping strategies the person can identify – and more, I’d be looking at how flexibly they apply these strategies. Extending the range of strategies a person can use, and problem-solving ways to use these strategies in different activities and contexts is an important part of therapy, particularly occupational therapy and physiotherapy. Another approach you might consider is helping people return to enjoyable activities that are within their tolerance right here, right now. By building confidence that it’s possible to return to things that are fun we might counter the effects of helplessness, and help put pain back where it belongs – an experience that we can choose to respond to, or not.

I’d also be taking a look at their tendency to avoid feeling what their pain feels like, in other words I’d like to see if the person can mindfully and without judging, complete a body scan that includes the areas that are painful. This approach is intended to help people notice that alongside the painful areas are other nonpainful ones, and that they can successfully be with their pain and make room for their pain rather than attempting to block it out, or over-attend to it. The way mindfulness might work is by allowing people to experience the sensations without the judgement that the experience is bad, or indicates some terrible catastrophe. It allows people to step back from the immediate reaction “OMG that’s BAD” and to instead take time to view it as it actually is, without the emotional halo around it.

Pain catastrophising is a useful construct – but I think we need to become more nuanced in how we use the scores from the questionnaire.

Craner, J. R., Gilliam, W. P., & Sperry, J. A. (2016). Rumination, magnification, and helplessness: How do different aspects of pain catastrophizing relate to pain severity and functioning? Clinical Journal of Pain, 32(12), 1028-1035.

What do we do with those questionnaires (ii)

In my last post I wrote about the Pain Catastrophising Scale and a little about what the results might mean. I discussed the overall score suggesting a general tendency to “think the worst”, with the three subscales of magnifying or over-estimating the risk; ruminating or brooding on the experience; and helplessness or feeling overwhelmed and that there’s nothing to be done.  At the end of the post I briefly talked about how difficult it is to find a clinical reasoning model in physiotherapy or occupational therapy where this construct is integrated – making it difficult for us to know what to do differently in a clinical setting when a person presents with elevated scores.

In this post I want to show how I might use this questionnaire in my clinical reasoning.

Alison is a woman with low back pain, she’s been getting this niggling ache for some months, but last week she was weeding her garden and when she stood up she felt a sharp pain in her lower back that hasn’t settled since. She’s a busy schoolteacher with her own two children aged 8 and 10, and doesn’t have much time for exercise after teaching a full day, and bringing children’s work home to grade at night. She’s completed the PCS and obtained an overall score of 33, with her elevated scores on the magnifying subscale contributing the most to her total score.

Her twin sister Belinda has coincidentally developed low back pain at the same time, only hers started after she had to change the tyre on her car over the weekend. She’s a busy retail manager preparing for the upcoming Christmas season, and also has two children just a bit younger than her sister’s two. She’s completed the PCS and obtained an overall score of 34, but her score on ruminating is much higher than her scores on the other two scales, and this is the main reason her overall score is high.

What difference does Belinda’s elevated score on ruminating mean for us as clinicians? What do we do when we see Alison’s overall elevated score?

Common themes

Both Alison and Belinda live busy lives, and have lots of stressors within their lives. While they both have similar presentations, we might go about helping them regain confidence in their bodies slightly differently. I’ll begin with Belinda who might, because of the elevated ruminating score, have trouble getting off to sleep and might spend more time attending to her back pain than her sister. Ruminating is that endless brainworm that keeps on dragging our attention back to the thing we’re worried about (or perhaps the problem we’re trying to solve).  Alison, on the other hand, might be more inclined to monitor her back pain and imagine all sorts of dire outcomes – perhaps that the pain will never go away, that it’s going to “cripple” her, and that it’s going to be a major problem while she’s at work.

While both sisters would benefit from learning to move with more confidence, to relax the muscle tension that occurs when back pain is present, and to return to their usual daily activities, we probably need to help Alison learn more about her back pain (for example, explain that most back pain settles down quite quickly, that it’s helped by moving again in a graduated way, and that we’ve ruled out any sinister reason for her developing her pain). During treatment sessions where we help her learn to move more normally, we might spend more time giving neutral messages about fluctuations in her pain (for example, we might let her know that it’s normal to have a temporary increase in pain when we start moving again, and that this is a good sign that she’s beginning to use her body normally). If we notice her looking anxious during a new movement or exercise we might take a moment to ask her about her concerns and provide her with neutral and clear information about what’s going on so she becomes more realistic in her judgements about what her pain means.

For Belinda I might be inclined to help her deal with her thoughts in a mindful way, so she can notice her thoughts and her body sensations without judging them, bringing her mind back to breathing, or to noticing the equally present but less “alerting” body sensations she may be experiencing. For example I might ask her to do a mindfulness of breath exercise where, as she notices her mind wandering off to worries or concerns, I would ask her to gently notice that this has happened, acknowledge her mind for trying to help solve an insoluble problem, and bring her attention back to her breathing. I might ask her to notice body sensations including those that are uncomfortable and around the area of her most intense pain, taking care to be aware not only of the painful sensations she’s experiencing, but also associated body responses such as breath holding, or muscle tension. I might guide her to also be aware of a neutral but generally unloved area like her left earlobe (when did you last attend to what your left earlobe felt like?), or her navel. Because at the same time as she’s noticing the painful areas of her body, she’s likely to be trying hard to avoid “going there” with the result that her mind (trying really hard to help her protect herself) actually goes there more often! (don’t believe me? Don’t think of a big fat spider crawling down your shoulder – betcha did!!). Belinda can use the same approach when she’s trying to get off to sleep – by non-judgmentally noticing her body and what’s going on, she can be aware of what it feels like – but not get hooked up in alarming appraisals of what “might” happen. In a clinic setting I might ask her to use this same mindfulness approach when we’re doing a new exercise, or returning to a new activity. She could take time to really feel the movements, to be “in” her body rather than her head, and in doing so gradually reduce the tendency for her mind to take off in new and frightening directions.

Using the PCS is not about becoming psychologists: it’s about being aware of what the person in front of us is telling us about their experience, and then tuning into that and responding appropriately while we do what we do. Our job isn’t to replace a psychologist’s contribution – but to use the results of psychometric questionnaires to augment and support the work we do in a setting where people are actively engaged in learning about their bodies. I think that’s a priceless opportunity.

Schutze, R., Slater, H., O’Sullivan, P., Thornton, J., Finlay-Jones, A., & Rees, C. S. (2014). Mindfulness-based functional therapy: A preliminary open trial of an integrated model of care for people with persistent low back pain. Frontiers in Psychology Vol 5 Aug 2014, ArtID 839, 5.

Tsui, P., Day, M., Thorn, B., Rubin, N., Alexander, C., & Jones, R. (2012). The communal coping model of catastrophizing: Patient-health provider interactions. Pain Medicine, 13(1), 66-79.

What do we do with those questionnaires?

Courtesy of many influences in pain management practice, you’d have to have been hiding under a rock or maybe be some sort of dinosaur not to have noticed the increasing emphasis on using questionnaires to measure factors such as pain catastrophising, depression or avoidance. The problem is I’m not sure we’ve all been certain about what to do with the results. It’s not uncommon for me to hear people saying “Oh but once I see psychosocial factors there, I just refer on”, or “they’re useful when the person’s not responding to my treatment, but otherwise…”, “we use them for outcome measures, but they’re not much use for my treatment planning”.

I think many clinicians think psychosocial questionnaires are all very well – but “intuition”  will do “…and what difference would it make to my treatment anyway?”

Today I thought I’d deconstruct the Pain Catastrophising Scale and show what it really means in clinical practice.

The Pain Catastrophising Scale is a well-known and very useful measure of an individual’s tendency to “think the worst” when they’re considering their pain. Catastrophising is defined as “an exaggerated negative mental set brought to bear during actual or anticipated painful experience” (Sullivan et al., 2001). The questionnaire was first developed by Sullivan, Bishop and Pivik in 1995, and the full copy including an extensive manual is available here. Keep returning to that page because updates are made frequently, providing more information about the utility of the measure.

The questionnaire itself is a 13-item measure using a 0 – 4 Likert-type scale from 0 = “not at all” to 4 = “all the time”. Respondents are instructed to “indicate the degree to which you have these thoughts and feelings when you are experiencing pain”.

There are three subscales measuring three major dimensions of catastrophising: rumination “I can’t stop thinking about how much it hurts”; magnification “I worry that something serious may happen”; and helplessness “It’s awful and I feel that it overwhelms me”.

To score the instrument, simply sum all the responses to all 13 items, but to get a better idea of how to help a person, the subscale calculations involve the following:

Rumination: sum items 8,9,10, and 11

Magnification: sum items 6,7, and 13

Helplessness: sum items 1,2,3,4,5, and 12

There’s not a lot of point in having numbers without knowing what they mean, so the manual provides means and standard deviations relating to a population individuals with injury leading to lost time from work in Nova Scotia, Canada.

thingClinicians are typically interested in whether the person sitting in front of them is likely to have trouble managing their pain, so the manual also provides “cut off”scores for what could be described as “clinically relevant” levels of catastrophising. A total score of 30 or more is thought to represent the 75th percentile of scores obtained by individuals with chronic pain.

The “so what” question

Cutting to the chase, the question is “so what”? What difference will getting this information from someone make to my clinical reasoning?

Leaving aside the enormous body of literature showing a relationship between high levels of catastrophising and generally poor responses to traditional treatments that address pain alone (including surgery for major joint replacement, recovery from multiple orthopaedic trauma, low back pain, shoulder pain etc), I think it’s helpful to dig down into what the three subscales tell us about the person we’re working with. It’s once we understand these tendencies that we can begin to work out how our approach with someone who has high levels of rumination might differ from what we’ll do when working with someone who has high levels of helplessness.

As an aside and being upfront, I think it’s important to remember that a questionnaire score will only tell you what a person wants you to know. Questionnaires are NOT X-rays of the mind! They’re just convenient ways to ask the same questions more than once, to collect the answers and compare what this person says with the responses from a whole lot of other people, and they allow us to organise information in a way that we might not think to do otherwise.  I also think it’s really important NOT to label a person as “a catastrophiser” as if this is a choice the person has made. People will have all sorts of reasons for tending to think the way they do, and judging someone is unprofessional and unethical.


Rumination is that thing we do when a thought just won’t get out of our mind. You know the one – the ear worm, the endless round and round, especially at night, when we can’t get our mind off the things we’re worrying about. If a person has trouble with being able to drag his or her attention away, there are some useful things we can suggest. One theory about rumination is that it’s there as a sort of problem solving strategy, but one that has gone haywire.

Mindfulness can help so that people can notice their thoughts but not get hooked up into them. I like to use this both as a thought strategy, but also as a way of scanning the body and just noticing not only where the pain is experienced, but also where it is not.

“Fifteen minutes of worry” can also help – setting aside one specific time of the day (I like 7.00pm – 7.15pm) where you have to write down everything you’re worried about for a whole fifteen minutes without stopping. By also telling yourself throughout the day “I’m not worrying about this until tonight” and afterwards saying “I’ve already worried about this so I don’t need to right now”, worrying and ruminating can be contained. By being present with the thoughts during that 15 minutes, the threat value of the thought content is also reduced.


This is the tendency to think of the worst possible thing rather than the most likely outcome, and it’s common! Magnification can really increase the distress and “freeze” response to a situation. If a person is thinking of all the worst possible outcomes it’s really hard for them to focus on what is actually happening in the here and now. There’s some adaptive features to magnification – if I’ve prepared for the worst, and it doesn’t happen, then I’m in a good situation to go on, but in some people this process becomes so overwhelming that their ability to plan is stopped in its tracks.

Once again, mindfulness can be really useful here, particularly paying attention to what is actually happening in the here and now, rather than what might happen or what has happened. Mindful attention to breathing, body and thoughts can help reduce the “freeze” response, and allow some space for problem solving.

Of course, accurate information presented in nonthreatening terms and in ways the person can process is important to de-threaten the experience of pain. This is at the heart of “explain pain” approaches – and it’s useful. What’s important, however, is to directly address the main concern of the person – and it may not be the pain itself, but the beliefs about what pain will mean in terms of being a good parent, holding down a job, maintaining intimacy, being responsible and reliable. It’s crucial to find out what the person is really concerned about – and then ensure your “reassurance” is really reassuring.


Helplessness is that feeling of “there’s nothing I can do to avoid this awful outcome so I won’t do anything”. It’s a precursor to feelings of depression and certainly part of feeling overwhelmed and out of control.

When a person is feeling helpless it’s important to help them regain a sense of self efficacy, or confidence that they CAN do something to help themselves, to exert some sort of control over their situation. It might be tempting to aim for focusing on pain intensity and helping them gain control over pain intensity, but because it’s often so variable and influenced by numerous factors, it might be more useful to help the person achieve some small goals that are definitely achievable. I often begin with breathing because it’s a foundation for mindfulness, relaxation and has a direct influence over physiological arousal.

You might also begin with some exercise or daily activities that are well within the capabilities of the person you’re seeing. I like walking as a first step (no pun intended) because it doesn’t require any equipment, it’s something we all do, and it can be readily titrated to add difficulty. It’s also something that can be generalised into so many different environments. In a physiotherapy situation I’d like to see PTs consider exercises as their medium for helping a person experience a sense of achievement, of control, rather than a means to an end (ie to “fix” some sort of deficit).

To conclude
Questionnaires don’t add value until they’re USED. I think it’s unethical to administer a questionnaire without knowing what it means, without using the results, and without integrating the results into clinical reasoning. The problem is that so many questionnaires are based on psychological models and these haven’t been integrated into physiotherapy or occupational therapy clinical reasoning models. Maybe it’s time to work out how do this?

Sullivan M J L, Bishop S, Pivik J. The Pain Catastrophizing Scale: Development and validation. Psychol Assess 1995, 7: 524-532.

Main, C. J., Foster, N., & Buchbinder, R. (2010). How important are back pain beliefs and expectations for satisfactory recovery from back pain? Best Practice & Research Clinical Rheumatology, 24(2), 205-217. doi:doi:10.1016/j.berh.2009.12.012

Sturgeon, J. A., Zautra, A. J., & Arewasikporn, A. (2014). A multilevel structural equation modeling analysis of vulnerabilities and resilience resources influencing affective adaptation to chronic pain. PAIN®, 155(2), 292-298. doi:

Ups and downs and rocking and rolling

What a week it has been! Not only an unexpected result in the US elections, but also a very large earthquake north of Christchurch, along with a tsunami alert for the entire eastern coastline of New Zealand. Luckily I live far enough away from the shoreline that I didn’t have to evacuate, but the sirens certainly work!

As a result of these events, which I firmly believe are NOT associated except in time, the post I was going to make seems a bit redundant, so I’m going to talk about resilience and what it really means.

For someone who has lived through thousands of earthquakes since September 2010, resilience is almost a dirty word. People living in Christchurch are a bit tired of being called resilient.  You see, it’s not the quakes that are the problem – it’s the aftermath. The “new normal” that we’ve been living through these past years. The thousands of road cones lining almost every street. The constant detours as bits of road are dug up and sewerage, storm water and water pipes relaid. The delays. The ongoing processing needed to work out “where am I?” in the streets we used to know so well.

Resilience is intended to refer to “bounce back”. The thing is, I don’t think we bounce back to exactly the way we were before – we’re irrevocably changed by all experiences, but especially ones as significant as the earthquakes, or even political changes. That we don’t “return to normal” is one of the main reasons I don’t believe reports of people “going back to normal” if pain is completely removed. Why? Because people actively process and make meaning from everything that happens to them – and the meanings that are given to experiences don’t ever completely go.  We know, for example, that we can’t “unwire” nerves that have fired together, so what actually happens is that alternative paths or connections between nerves are formed. This means that under the right circumstances, those original paths will fire again… And people who have experienced chronic pain will, even if their pain eventually goes, know exactly what that pain meant, how it affected them, and I’m certain will be very aware of any new pain that seems to be similar to the one that was just there.

Resilience to me is therefore not so much about “bouncing back” as it is about being able to take stock of what actually IS, determine the paths that lead on in the direction of important values, and then choosing to take those paths. And this can often mean taking detours because old paths aren’t negotiable any more. That can be, and is, disturbing. It can be frustrating, fatiguing and far more demanding than the idea usually invoked by the word “resilience”.

So, in the next days and weeks, let’s think less about being resilient, and more about being flexible – flexibly persisting, if you will. We need to persist to get anywhere, do anything. We need to be flexible about how we get there and how we do what we value. We’ll need passion, but more than passion, we’ll need commitment.


When do we need to say we’ve done enough?

This post is food for thought for both clinicians and people living with pain. It has come about because of a conversation on Facebook where some clinicians felt that people with pain are only being offered the option to “learn to live with pain” when their pain intensity could either be reduced or go completely.  And this conversation is one repeated countless times around the world when those living with persistent pain seek help for their disability and distress.

I’m going to declare my hand right now: I think a the problem in chronic pain management isn’t that people get offered “pain management” or “learning to live with pain” or “accepting pain” too often – I think it’s not happening often enough, nor soon enough. But let me unpack this a little more…

We know that in New Zealand at least one person in every six lives with chronic pain that has gone on for more than six months (Dominick, Blyth & Nicholas, 2011). We also know the seven day prevalence of low back pain in New Zealand is 35% (men) and 48% (women) (Petrie, Faasse, Crichton & Grey, 2014).

Treatments for painful conditions abound. From the simple over-the-counter approach (medication, anti-inflammatory creams, hot packs, cold packs) to hands-on therapies (massage, osteopathy, chiropractic, physiotherapy), to exercise therapies (Pilates, core strengthening, gym programmes, spin classes, walking, exercise in water), and finally to the multitude of invasive therapies (injections, neurotomies, decompression surgery, fusion). There is no shortage of treatments that aim to get rid of pain, fix the problem and get life back to normal. And for the most part these treatments provide modest improvement in both pain intensity and functional gains. For low back pain it seems there is no single wonderful treatment that works for everyone – hence the proliferation of treatments! (cos if there was a single treatment that worked, we’d all be offering it – like we do with a broken bone or appendicitis).

Here’s a question: if pain “management” (ie helping people learn to live with their pain) was the main offering to people living with pain, wouldn’t there be a heap of places to get this kind of treatment? At least in New Zealand there are relatively few pain management centres although there are many, many places to go for pain reduction.

I’ve tried to find studies looking at how people are told they have persistent pain that won’t be cured. Strangely, I have had incredible difficulty finding such studies. They may be there in the research literature – but they’re fairly uncommon and hard to find. And given how poorly low back pain guidelines are followed despite being promulgated since at least 1997, even if there were studies examining the best way to convey this news, I’d be surprised if anything was routinely incorporated into clinical practice.

So, in my opinion there are many more clinicians offering to help reduce pain than there are those offering to help people “learn how to live with pain”.

I was asked recently “when you do decide to stop pursuing pain reduction?” I think I said “it’s ultimately the decision of the person living with pain” – but it’s complicated by the way we as a culture perceive this option. I think most people would be horrified to think “I’m going to have a lifetime of living like this” when our beliefs about pain are influenced by and attitude that “pain = suffering”, “pain is unnatural”, “pain is a sign of something badly wrong”, “pain is something to get rid of”. I know when I was told “I’m sorry but there’s nothing more we can do for your pain” I was terribly upset thinking I had a lifetime of feeling awful to look forward to! I was 22 and had low back pain that would not go away after 18 months. I’m now 52 and I still have pain – but I can tell you that I have done almost everything I’ve wanted to including SCUBA diving, tramping, fishing, dancing, working full time (overtime), and parenting.

When do we begin to think about living with pain rather than curing it? I think we need to take a hard look at what this sentence means.

Firstly it means living. Life continues whether we’re feeling like we’re moving forward, or we’re putting things on hold to pursue a particular goal. Life doesn’t actually stop – but the things we want to experience, the things we want to do change over time. Our focus at the age of 22 is quite different from our focus at age 52 – and I hope it will change again at age 82! We don’t get to hit the replay button and live life all over again. We get one shot at it. This could feel quite awful if we’re contemplating a life where looking for pain relief is our primary goal – especially when that process involves an endless round of hope then despair as treatments are tried – and then don’t quite work out. Even the process of looking for treatments is slow, fraught with anxiety, and it eats up time in a week. For me, taking time out from living to pursue a treatment that may work means a process of weighing up the costs against the benefits. The costs include time, energy, emotional investment in the result, and the discomfort of the treatment itself. The benefits? Well, that depends.

The second part of that sentence is “with”. Living with pain. To me this means establishing my willingness to experience something I don’t enjoy – and believe me, I’m not a fan of pain! If all I have to look forward to is pain, pain, pain I’m not keen on doing it. BUT I am keen on living and bringing pain along with me (because frankly, my pain is coming along for the ride anyway). Living with pain to me means making room to experience pain fluctuations while doing things that bring value and meaning to my life. It means I ache – but I have a beautiful garden. I have sore legs – but I’ve been dancing. I have an aching back and neck and arms – but my house is clean. Here’s the thing: even if I didn’t work in my garden, dance or clean my house I’d STILL be sore! And I’d be bored, feel like I hadn’t achieved anything, and would have had to ask other people to help because many of those things still need doing.

The thing is, pain ≠ suffering.

When do we make a decision to stop pursuing pain reduction? Well, if I’m honest I’m still on the lookout for something that will help reduce my pain. And I think anyone who does live with persistent pain would agree that we don’t really want to have this experience, just like people who have cancer don’t want it, or diabetes or stroke or any of the myriad other chronic conditions humans are prone to getting, especially as we age. When asked, I’m sure most people with chronic pain would say “Yes” to pain reduction as a goal. BUT, and this is important, living life as fully and richly as we can is just as important.  I would bet that anyone with any of those chronic conditions would also just love to have them cured too.

But pain is a funny thing, there are myths and unhelpful beliefs coming from clinicians and our cultural norms about pain being a bad thing that must go. Compared with the beliefs and attitudes about other chronic conditions, this is unhelpful. We don’t find health professionals constantly pursuing treatments to “get rid of” diabetes, the focus is on management. And we accept that people who have cancer may choose to no longer accept treatment – and we support them by providing good hospice care. How often do people with chronic pain get (a) support to make a decision to live with their pain and (b) support to learn to do this well without feeling like second class citizens who have failed. We even have a group of clinicians calling people who haven’t responded to their treatments “failed back syndrome” as if the person’s back has failed rather than the treatment failing.

What makes me decide to pursue a new treatment that promises to reduce my pain? Well, it has to fit into my life. It can’t interfere with what’s important to me in terms of time, energy or discomfort. The odds need to be pretty good for me to even look at it – I want to see more than a single research paper showing its effectiveness. I would have to trust the clinician, and they’d have to respect me and my lifestyle and priorities. I’d want to make sure that clinician was going to stick with me and help me decide whether it’s worth doing. I’d want to see that the treatment would help me achieve my goals and priorities – otherwise I’m not really interested.

Is this because I’m weird (say yes!)? Or that I have less intense pain than other people? (nope, because you can’t compare my pain with anyone else’s, and because pain intensity ratings are strongly influenced by distress, mood, anxiety, how much pain interferes with life, attention, culture yada yada yada (Linton & Shaw, 2011). I think it’s because right now I’m too busy living, I get more joy and satisfaction from doing things that make me feel like myself. But remember I’ve been doing this since I was 22. And it’s a process. And I’m weird. I am a pain geek.

The thing is, unless clinicians promote living well with pain as an equally valid option to trying to get rid of it, people will continue to think that it’s impossible to have a really good life unless their pain is gone. And that, to me, is a tragedy, because we only have one life to live.


Dominick, C., Blyth, F., & Nicholas, M. (2011). Patterns of chronic pain in the New Zealand population. New Zealand Medical Journal, 124(1337), 63-76.

Linton, S. J., & Shaw, W. S. (2011). Impact of psychological factors in the experience of pain. Physical Therapy, 91(5), 700-711. doi:10.2522/ptj.20100330

Petrie KJ, Faasse K, Crichton F, Grey A. How Common Are Symptoms? Evidence from a New Zealand National Telephone Survey. BMJ Open. 2014;4(6). doi: 10.1136/bmjopen-2014-005374.

Of cabbages and kings…

Well, cabbages for knee osteoarthritis, anyway! In this interesting study, three approaches to managing knee pain from moderate osteoarthritis were put to the test. To be truthful, actually only two active treatments were compared – the third was “usual care”.

In a carefully conducted trial, where participants were randomly allocated to one of three groups, and the study organiser remained blinded to which group people were allocated, topical diclofenac gel, usual care or a cabbage leaf compress were applied over the course of four weeks.  Key outcomes were pain intensity and scores on the WOMAC, a common measure of the impact of osteoarthritis on daily life.

Participants were asked to rate their expectations on whether cabbage leaf or the gel would be successful in improving knee pain prior to the study commencing. Each person in the cabbage leaf group was asked to take one or two cabbage leaves, remove the hard stem, bruise the leaves, then wrap them around the knee with a bandage and leave for at least two hours, preferably overnight. In the gel group, participants were asked to rub the gel over the knee up to 4 times a day. In the treatment as usual group, participants were asked to continue with their usual routine and care, but not to begin any new treatments over the period of time.

What did they find?

Well, as a breastfeeding mother I well remember the pain of engorged breasts – and the relief I got from cabbage leaves (although I will never forgive the man who brought two half cabbages home, held them up in front of me and said “I think they’ll just about fit”!). I wondered if the same effect might have been experienced by participants in this study – and to a certain extent, yes! While the effect sizes were not large, a significant group difference was found between cabbage leaf wrap and usual care (difference, -12.1; 95% CI, -23.1,-1.0; P=0.033) after 4 weeks. No group difference was found between cabbage leaf wrap and gel (difference, -8.6; 95% CI, -21.5, 4.4; P=0.190).

A small but consistent decline in pain intensity was found in the cabbage leaf wrap and gel groups, but not in the usual care group over the four weeks of the study.

This trial found that a 4-week application of cabbage leaf wraps was more effective than usual with respect to pain, functional disability, and quality of life. It was, however, not superior to a 4-week application of topical medication. Patients were satisfied with both interventions, and except for 2 adverse events in both groups the applications were well accepted and tolerated.

What does this mean?

Well, for me this study shows that a simple, home remedy may provide some help for people who either can’t afford the cost of gel, or who don’t want to take a medication. This treatment truly is “natural”! The study design doesn’t allow us to conclude that cabbage leaf wraps are better than gel, or that it was the cabbage leaf itself that made a difference (participants and physicians had to know what was being administered because it’s fairly hard to hide a cabbage leaf!), so the results could be due to “meaning response” or placebo. And the pain reduction was very small – but nonetheless important to the participants.

What’s cool for me is that this is something people can choose to do for themselves. It doesn’t seem to have adverse effects (those reported in the study could be unrelated to the cabbage), and people find it relatively easy to use. Given the cost of pharmaceuticals, and the need to attend a doctor to get a prescription, to know there is a reasonable alternative (or even adjunct) seems useful.

Lauche, Romy, Romeikat, Nadine, Cramer, Holger, Al-Abtah, Jallal, Dobos, Gustav, & Saha, Felix J. (2016). Efficacy of Cabbage Leaf Wraps in the Treatment of Symptomatic Osteoarthritis of the Knee: A Randomized Controlled Trial. The Clinical journal of pain. (in press)

Making sense of pain

Humans have an incredible desire for things to make sense. We want things to fit a story or what’s expected – and we get right discombobulated (it’s a word) if we encounter a situation where things don’t make sense. To a certain extent we can blame our use of language for this, because it’s the way we’ve learned to pair words with concepts, and to associate multiple concepts together. For example, we learn “ouch” is associated with that unpleasant sensory and emotional experience that we’ve learned goes along with scrapes or bumps or cuts. We’ve also learned that “ouch” goes along with “it will go soon” and “don’t use that bit too much or it will hurt for longer” as well as “big boys don’t cry” and “you’re just being lazy if you don’t suck it up” and “whiners talk about their back pain all the time” and other similar notions. This is how humans connect visible objects (nouns) with words and other invisible concepts to create a network of meaning that, among others who share similar language and culture, means we can communicate with one another and go beyond the here and now and into the future and recall the past.

Even when events don’t make sense, we struggle to create a sense from it – we even say things like “this doesn’t make sense” as a way to classify the event along with a bunch of other “events that don’t make sense”. 

Why does this matter?

Well, because we want life to make sense, and to understand what we and others are up to, we create meaning and sense (coherence) even where there is no sense. Sometimes we grasp at straws (otherwise known as explanations from people who may not actually know what’s going on, but can spin a good tale). And at times, grasping at these straws means we ignore our own experience just so we can  hold on to what we think ought to be there. Here’s an example: some of us have back pain. We don’t know why it started, but we try to make sense of why we experience it by drawing on things we’ve been told by others – we might blame age, lifting “incorrectly”, weak “core” muscles, or differences in how long our legs are. Now the explanation itself doesn’t need to even be accurate – what’s important is that by accepting an explanation we become less sensitive to alternative explanations, and even more importantly, we begin to ignore what our own body feels like because we think we should believe what an expert tells us.

The problem with trying to make an explanation work for us, when it’s not necessarily so, is that in adopting that explanation we may find it a lot more difficult to respond flexibly to different situations. For example, if we’ve learned that back pain happens because of poor posture (where “poor posture” means not holding the spine a certain way), then we have more difficulty doing things when we’re in situations where being hunched over is the only way to get into an awkward situation, like when we have to lift a child into the back seat of a car, or put the pots back into the back of the bottom shelf of the cupboard.

Explanations for pain

Because pain is so common, and critical for human survival, we hold deep and powerful beliefs about what pain should mean, and how we should handle it. We probably all learned that pain is temporary and generally settles down once tissues have healed. We might have learned to hide our tears and not to ask for help when we’re sore. We probably grew up knowing that if tissues are really mangled, then it really hurts, and if it’s a paper cut it shouldn’t bother us. And we learned all the myriad concepts associated with pain – like being too withdrawn or tearful means we’re not really very brave, that if we get angry and hit out at someone who’s helping us with our pain, it’s very bad. We learned that it doesn’t hurt as much when someone “kisses it better”, and we learned that we should find out what’s wrong, get it fixed, and get over it.

But what happens when pain violates our past experience and all the explanations we’ve been given before?

What if we have pain that doesn’t disappear? What if the explanations we get given don’t fit with our own experience? What if the very things we’ve been told to do to “help” our pain actually make our lives worse? What if we’re clinicians who find that all the things we’ve been told should work – just don’t.

If we’ve been good learners, most of us will be unsettled by these inconsistencies. Things don’t add up. We probably keep on looking for “the answer” that will fix the problem. We’ll probably feel guilty and perhaps even a bit embarrassed that this pain is different. We might doubt our own experience and worry that we’re being just a bit pathetic or a really don’t want to get better. Or if we’re clinicians, we may wonder if the person wants to get better, or if they’re really doing the exercises the way they should…

And this isn’t helped by well-meaning people who might suggest that we should keep on looking for “the answer” – even when doing this gets in the way of important things we want to be able to do! So we might take the pills that make us feel groggy and constipated. We keep on doing the exercises that are boring and don’t seem to change anything. We do these things not because they work – but because we think they should work. And so we all get frustrated and irritated and just don’t live lives of richness and fulfillment. Perhaps we forget what we want our lives to stand for anyway.

Difficult conversations

It isn’t easy to talk about pain that doesn’t do what it ought to. Our very human nature makes the situation difficult. I’m hoping that by beginning to think more contextually, more about what works in the here and now, about having a range of options to try so we don’t get backed into an unworkable corner just because that’s what someone has suggested should work, that we the people (those living with chronic pain and those working with those who live with chronic pain) might gently and creatively develop some flexibility around what can be such a sticky  concept. Maybe that’s what resilience is?