More about PAIN

Last week I posted this blog introducing my recent studies regarding pain science starting with a few basics I learned from Explain Pain, by David Butler and Lorimer Moseley.  I also recently finished reading their 2017 edition, Explain Pain Supercharged, an awesome book, particularly in its use of easily understood metaphors and stories to help illustrate the concepts, but those underlying concepts are more complex than anything else I've ever read.  It made me think of first grade when the librarian was teaching us how to determine if  books were appropriate for us to read. She instructed us to select a book that might be interesting, ( I wanted to read the Boxcar Children), sit down in a quiet corner, open the book to any page, and read that page holding up one finger for every word we didn't know. If we didn't know five words when we finished the page, it was a little too tough for right now, but maybe next time back at the library it wouldn't be.  I still love the library and quiet corners.

This timing of my focus on pain science is intentional. I've mentioned that I've been working with more patients who are experiencing chronic pain - both at Seattle Children's and when I'm with the adult population.  The patient with chronic pain is interesting because they continue to experience pain long beyond the normal tissue healing time expected with injury and often to a degree that is not proportional to the injury that was originally sustained. Picture stubbing your toe on the corner of a table.  It hurts, but you keep going about your day, maybe hobbling a little bit, but then days later you're still hobbling and it still hurts, and then a month has gone by and now you're avoiding weight bearing at all. This progresses until you reach a point where you stop putting your foot on the floor entirely, switch to crutches or a wheel chair, become fearful of any possible touch to your leg, and consistently report high levels of pain.

For these patients, the nervous system has found a way to overprotect their body. It has gone from working a 9-5 job to becoming a workaholic where every increased responsibility at work just makes them more and more irritable - only we're talking about how the body works from the inside!  In the end, the principles to working with these patients are largely the same as any other patient - if you can understand the mindset of needing to unload the stresses on the nervous system and then progressively load that - rather than focusing on unloading other body tissues of the musculoskeletal system which we so typically target.  AKA - take a vacation, break the overwork cycle, read a book by the pool, have a pina colada, and then when you return, maybe take an extended lunch break or two to slowly get back into the swing of the job without it taking over life.

In addition to the clinical utility of learning about pain, Lorimer Moseley was in Seattle this past week and I went to hear him speak at the University of Washington. I attended the event with a crew of fellow PTs who have been learning and teaching me about pain science, using the framework of the biopsychosocial model with patients. Who better to help me understand the impact of my words on the patients I work with?  Dr. Moseley's presentation was entitled "Seven Amazing Pain Facts that Could Change Your Life."  Here they are, with a few thoughts on each:

1) All pain is real, regardless of cause.
Just because there is nothing on an XRAY or an MRI showing that there is something wrong, does not mean there is no pain or that nothing is wrong. Pain does not correlate with tissue damage.  Sometimes people have major injuries without pain.  And doesn't a paper cut hurt like the dickens?  (I typed that - then had to look up the origin of that phrase - the dickens is used to represent the devil because some people don't believe in talking about the devil.  Fun fact.)

2) Your brain is like a jungle.
Everything is connected in a complicated ecosystem with interdependence between creatures.  A little bit of Darwinian survival of the fittest with regard to the more you use certain brain pathways - including a pain pathway - the more intensified that pattern becomes.

3) Your brain is looking out for you in sneaky ways.
Pain is normal as a protective mechanism for your body.  But like my above example of a stubbed toe taking over, sometimes the protective mechanism is overactive and needs to be re-trained.

4) Your brain uses all incoming data.
This is consideration for that biopsychosocial model I've previously talked about here. Pain is influenced by numerous factors - including the tissues of the body, relationships with other people, stresses at work, diet, nutrition, exercise - the list continues.  It is also influenced by the words we use with our patients to describe their pathologies.

5) Your brain uses all the data already stored. 
If you've previously stubbed your toe and recovered with a typical pattern of recovery, you're more likely to have a similar recovery pattern.  If this is the first time you're stubbing your toe and the brain goes into it's overprotective mode, it's learning this pain pattern.  The brain remembers what it has done for similar events in the past and uses prior experience to guide responses to recurrence of similar activities.

6) Our nervous system learns pain.
Just like I said above.  We're like elephants... we don't forget.  And the more the pain cycle continues, the more re-inforced it gets into your brain until you can break the cycle.

7) Understanding contemporary pain biology may be the missing link.
For some patients, educating them about how pain works makes it less scary and helps them to break their pain cycle to start the road to recovery.  I'm thrilled to report that my first attempt to use my new knowledge appears to have had positive impact on the specific patient I chose to use it with, and that my colleagues are also having positive outcomes using this framework.  But I'm currently operating with an n=1, so I need a lot more practice on educating patients about their pain, and I'm working on further organizing my learning on this subject so that I can better choose when to focus on this treatment pathway rather than what I've always done in the past.

This is the link to the video clip I've started using for kids dealing with chronic pain. The video isn't actually targeting children, but it's the best one I've found, and, at the very least it is entertaining and parents can help their kids to better understand.  Check it out.  Notice the resemblance between cartoon Lorimer Moseley and real-life Lorimer Moseley, and let me know what you think!  I actually asked Professor Moseley about using the video for children and he said it's on his list to make a new, updated version, that's more kid-friendly.  But for now, this version seems like a good place to start. I hope I'm not boring anyone with my repeated topic of pain - especially because I anticipate one more upcoming post on the subject in the near future!

Me with Professor Lorimer Moseley