I also read a lot when I'm preparing to give a presentation. This week, I was invited to talk about Pain Neuroscience and the Pain Medicine Clinic to the Seattle Children's Regional Rehabilitation Team. I like presenting because it requires me to focus learning on a specific subject and makes me seek out new resources. Educating clinicians is very different than patient care and it helps me consider my own beliefs, biases, and treatment approach. I was fortunate to be partnered with Hematology/Oncology Physical Therapist Dr. Jacob Ross, who spoke about the intensive Pain Rehabilitation Program (PReP) where I sometimes refer patients when they need more care than 1 or 2 hours per week in my clinic will achieve. If you're seeing Jacob at PReP, you're undergoing rehab or mental health or some school work Monday through Friday from 8AM-4PM for anywhere between two and four weeks! Based on
website, there are 83 pediatric pain clinics around the world, mostly (65%) in the United States, existing in 25 states plus Washington, D.C. That means half of the states and the majority of the world doesn't have this available at all - and if you consider that the states who do offer these type of services only have it in a small number of places, tons of kids with chronic pain have no access to this care! In Seattle, I've worked with families from Alaska, Montana, Idaho, and Washington - and there are probably patients from many more places that my team members have worked with.
If you're interested in learning about pain, I recommend you start with the work of Lorimer Moseley. I've previously written about his books:
Explain Pain,
Explain Pain Supercharged and the
Graded Motor Imagery Handbook, and I wrote about hearing him lecture and meeting him at the University of Washington,
here. The
NOI Group, who published those books, announced a new one coming out in December, "Pain and Perception: A Closer Look at Why We Hurt" which will be my next pain-related read. From a different perspective, I also wrote about
The Gift of Pain, which describes what happens when people are without the ability to experience pain. You don't pull your hand away from a hot pan or stop walking on a broken leg if you can't experience pain - a very dangerous scenario. If you came upon this post looking to learn about pain management, any of those resources would be great places to start, but they're more about educating clinicians and, though they may be helpful for patients, I've now read a workbook more specifically intended for patients and think it's a great addition to this list.
In preparation for our presentation, Jacob asked if I had heard of
Dr. Rachel Zoffness. "Why yes, Jacob, I have. I follow her on all the social media and listen to her podcast episodes (OMG listen
here or
here or
here or definitely my favorite:
here), and I just finished reading one of her books."
The Chronic Pain &Illness Workbook for Teens was published in 2019 and was the first new resource I read for my presentation. Dr. Zoffness is a Pain Psychologist who teaches for multiple higher education institutions, she is the Co-President of the American Association for Pain Psychology, and she is on the Board of Directors for the Society of Pediatric Pain. Oh, and she treats patients experiencing chronic pain and has written two books. (She also wrote
The Pain Management Workbook which I'm currently reading.) She's also released an $80
Workshop "Foundations of Pain Psychology" and more from that series are coming soon! Hopefully I'm not starting to look like a creeper because I've been fan-girling and re-sharing all her posts, podcast episodes, and books, so writing a blog about her work is probably the icing on the cake. When you find someone who can directly impact your patient care and knowledge, with easily digestible tools and clear, consistent messaging, I think you have to tell everyone.
If this is your first time reading one of my blogs, you might not know that I write to organize and synthesize information I'm learning to refer back to or share with others. Today's post starts with a look at a few of my favorite points from Dr. Z's Teen Workbook paired with information from two of the research papers I read for my presentation and it wraps up with a look at another pain management workbook from Dr. Greg Lehman.
If you're a person living with chronic pain OR a clinician who works with patients experiencing chronic pain, in-person multidisciplinary care is the best treatment option, but that isn't available or affordable or feasible for so many people. The Teen Workbook could be a solution for patients who need something they can do independently. It doesn't replace physical therapy or mental health counseling (or the many other treatments that may be appropriate and necessary), but it can certainly help educate patents and initiate behavior change that may be life changing.
1) Let's start with my favorite quote from Dr. Zoffness:"
Pain is ALWAYS both physical AND emotional, 100% of the time." This is the biopsychosocial (BPS) model at its heart and connected well to this image from Jull 2017 that I spent a lot of time discussing in my presentation. The Jull paper is a commentary on the BPS model and shows the idea that 3 different patients may have different amounts of biological - psychological - and sociological needs. But also, the same patient at time 1, time 2, and time 3 has different amounts of these domain needs, too. Today, for example, I might have a mild headache and I'm hungry but my mental health is good and I got to spend some time with friends so my social bucket has been filled, but my biological bucket may need more attention (maybe a sandwich for my blood sugar). Tomorrow, I might have eaten enough for breakfast but be stressed about my pain presentation at work and spending a longer day at the office missing out on game night with friends - so my biological needs have been met, but not the social pieces that keep me going. You can't just look at your patient and think they only need biological care or mental health care at your evaluation and then assume it stays the same for all of their treatment. I
The Workbook is clear about the role of the mind-body connection with regard to pain and explains what parts of the brain are involved. It provides concrete examples, intentional questions for patients to consider, and a roadmap of strategies to try to better understand your own pain triggers from each of the three circles and identify solutions to try to reduce your pain volume. Some of the pain books I mentioned above were really complex but this one is, without question, the easiest to understand and most user-friendly option for the general population, particularly when considering teenagers. Too often the "Bio" portion is treated alone, with Physicians and PTs attributing pain to tissue damage or disease, but that (biomedical) approach ignores two major domains that impact the patient's presentation (Psych and Social circles). The unity of physical and emotional care is essential to patient success and Dr. Zoffness is screaming this message from the rooftops for everyone to hear. I'm happy to amplify her message as often as possible to whoever will listen. I actually ask my patients "How's your mental health today? Anything stressful going on? When are your exams? Have you done anything fun with your friends lately?" If it's OK to ask them how their ankle is after they've sprained it, it should certainly be OK to also ask these questions. Clinicians: please consider adding this to your day to day interactions with family, friends, and patients - and I don't just mean handing them the depression questionnaire and glancing at it. Look them in their eyes and ask them how they're doing. And mean it!
2)
Metaphors, Analogies, and Stories help teach pain. It's no surprise that Lorimer Moseley is a mentor to Rachel Zoffness (and Greg Lehman) because they all use many of these to get their points across. I presented a few in my talk, also, but have a few favorites I use with patients. One example that I liked from the Teen Handbook is about practice. Think about an activity you wanted to learn. She uses playing piano, but I'm using basketball. At first, your hands struggle to dribble without staring at the ball and using your palm instead of your fingertips and the ball might bounce off your foot or miss the rim when you take a shot. As a novice the task is more difficult and requires more effort and concentration. So you practice. And over time, you get better and better, until at some point, you've stopped looking at the ball and can run while handling it and can make shots from farther away and your form looks more consistent as it becomes automatic. Your brain has developed new patterns that have been repeated enough times that the task is now easy. With chronic pain, you're unintentionally practicing pain and your brain develops patterns that make it easier or more automatic to have pain. The beauty of this is that with the appropriate treatment, the pain and learning can change. Another example Dr. Z has written about, is "
The Tale of Two Nails" which tells two really great stories that can inform our understanding of pain - but you should read those directly from her - so check out the article or buy her other book, because it's in there!
When Dr. Z is talking about practicing pain, she's explaining central sensitization, a phenomenon that I previously was struggling SO MUCH to understand. Central sensitization is a common characteristic of chronic pain, where you have an increased response to sensory stimuli resulting in hyperalgesia (increased sensitivity/bigger pain response to the same sensory input) AND allodynia (painful response to something that is normally not perceived as painful like hurting when you're touched by a feather on your skin.) Your nervous system changes when you experience pain for a long time.
For my presentation, this 2011 Clifford Woolf paper depicts normal sensation compared to central sensitization.
 |
| Normal Sensation: On the left side there is an input - either something noxious (potentially dangerous - top) or a light touch (feather, bottom). Notice the black arrows for the top path (pain) and the bottom path (touch) don't converge and the brown blob (brain) is the same color as the rest of the nerves. |
 |
| Central Sensitization: Here, the same sensory stimulus occurs at the far left, but now the black arrows merge to the same destination (brain) and the color has changed because the system has adapted resulting in hyperalgesia and allodynia responses. |
3) It's a workbook: there are pages for you to do work. This isn't just a book of education about pain. This is a guide with explanation of a key pain-related concept followed by actionable items to help improve your experience. Sometimes I feel like patients who have had pain for a really long time are desperate for a physical therapist to DO whatever we can TO THEM hoping to dull the pain for just a few minutes. What we really need is to serve as a guide, showing patients what THEY can DO on their own to turn down the pain. They have to take control of their lives and do the work for any success to occur. Physical therapists in chronic pain management should be cheerleaders, rooting on our patients as they make 1% progress day after day. People don't need to be 100% to live their lives fully, and often a really small amount of progress gets the ball rolling for a lot more progress to occur. I don't think patients realize how much control they have over their pain until someone empowers them to trust the process and themselves to get moving.
So, let's say you like the idea of a workbook and want to have multiple options to choose from, or you're an adult and want something a little deeper into the science. As I mentioned, I haven't yet finished Dr. Zoffness's other book, but I expect it might target that audience a bit more. There's another workbook I really like and was using prior to reading Dr. Zoffness's book.
Dr. Greg Lehman's "Recovery Strategies" Pain Guidebook is available for patients or clinicians to access online. I've previously written about attending his "Reconciling Biomechanics with Pain Science" course
here and have appreciated learning from him both at the course and from his online presentations and social media.
The workbooks are similar in their intent and both include key focus on the BPS model, describe how pain works, and provide action items for you to follow. And both have many metaphors, analogies, and stories. In particular I liked his metaphor for what happens to the brain with chronic pain: Consider that our brain is like a map of our body, and that a good map would be really clear, showing all the roads and rivers, but that with pain, things get smudged, almost as if you've spilled coffee on the map and the details get a little fuzzy. The details of our body can get a little fuzzy with chronic pain, but with exercise and movement, we can clean up the coffee mess and the map gets clearer. Overall, though, they're really quite different. Dr. Lehman's book is written as a series of infographics, almost a choose your own adventure graphic novel, where you can take a single page out of it to educate your patient. It includes pages of mythbusters, examining common misconceptions about various topics like "bones out of place," or how tissue damage found on imaging like an MRI doesn't always correlate with pain. I think Greg's goes into more detail on how pain processes occur, looking deeper into the science of the nociceptive system, the spinal cord, and the brain, but he also acknowledges that it's meant to be used for patient and provider together because of its level of complexity.
Also, I think that because Greg is a biomechanist, chiropractor, and physiotherapist, his handbook comes through from a more musculoskeletal lens. Though he fully emphasizes the BPS model, he's more from a bio background and gives adequate attention to the other bubbles. Rachel is a pain psychologist who comes from a more psycho-social background, and thoguh she gives adequate attention to the bio, it's super interesting to look at their two workbooks and consider how they're trying to reach the same outcome for patients from different angles. I think that patients would absolutely benefit from both.
That's all for now. December's blog post is about grief. It's another long one and recommends several books on that topic, too. So if you're looking for holiday gifts that are books on pain, start with Dr. Zoffness's books - or if grief books might help one of your loved ones, there are several being reviewed next month. Stay tuned!
TL;DR:
1) "Pain is ALWAYS both physical AND emotional, 100% of the time."
2) Your nervous system changes when you experience pain for a long time. This is called central sensitization which is characterized by hyperalgesia and allodynia.
3) Teaching people about why we have pain and how the pain process works has been shown to help improve pain. Multiple resources are listed to learn more about pain, often using metaphors, analogies, and stories to demonstrate complex concepts and make them more easily understandable.
4) The biopsychosocial model indicates necessity in attention to the biological, psychological, and social domains in treatment of chronic pain.
