One More About Pain

Homonculus

Sorry readers!  I know I promised a three-part series on pain... but I've been side-tracked by the excitement going on in the WNBA. In case you haven't been watching, the WNBA Finals begin tomorrow with the Seattle Storm hosting the Washington Mystics!  You should watch. Or come to the game and say hello!

Anyways, here's long-anticipated part three!  (I'm pretty sure the future will bring more pain posts because I'm working hard to learn more about it.)  I still don't feel like this is necessary for every patient, but with patients experiencing chronic pain - pain that has lasted more than three months - it has been essential.  The biggest takeaway from reading several resources and watching a Medbridge course about pain science while implementing it with my patient care is that this topic is super complicated but sometimes can be mind-blowing in its impact!  You can find part one of my series, which describes the book Explain Pain, here and part two discussing the "Seven Things About Pain That could Change Your Life" from Lorimer Moseley's visit to the University of Washington here.

How is this one different from the previous two?  There may be a little bit of review, but I'm also going to explore a few concepts from the Explain Pain Supercharged book as well as a few from watching "Teaching People About Pain" a Medbridge course presented by Adriaan Louw.  Along with those concepts, I'll go into a bit of a case study regarding how I observed the impact of some of these concepts and also used this information with a patient with positive outcomes.  Again - do I think that using this approach is necessary for all patients?  No.  Do I think clinicians (and I mean more than just physical therapists) can be more mindful of their word choice so that we aren't creating issues for patients in the future? Yes. 100%.  Do I think that Physical Therapists can, in general, do a better job of helping the general population understand pain and how the body works?  Yes.

The Explain Pain Supercharged book was like climbing a mountain... you start off walking at a fast pace, moving along quickly through the switchbacks, the air is good and you can breathe... then you hit a huge incline (chapter 3 - Pain Biology) where you slow down, have to be more careful of your steps, and consider each move with caution, before you reach the summit to enjoy the view.  In the case of this book, the journey is learning the science behind pain and the destination is learning how to treat it.  It was, without question, the most challenging book I've ever read - and I think, at some point, I'll have to read it again.

The Adriaan Louw presentation was quite the opposite, maybe because I had already read the book, but he describes the mechanisms of pain in his South African accent using excellent images that really helped me improve my understanding of pain.

Key things I learned:
1) When teaching a patient about pain, the use of metaphors and/or images is critical.  To try to describe how the body works is functional for some people, but creating a mental image really increases the understanding and helps increase communication about pain.

For example, a common metaphor used is that pain is like the body's alarm system.  Picture your house having an alarm.  You want the alarm to go off when a burglar breaks your window.  You don't want your alarm to go off when a bird sits on the roof.  Pain operates similarly - you want your body to experience a pain response if your hand is touching a burning flame, so that you can respond and pull the hand away.  You don't want your hand to hurt when you're petting your dog.  The house alarm - and the pain response - can both malfunction.  Chronic pain is that malfunction - when petting the dog starts to be painful.  Unfortunately, where the house alarm can be rebooted with a flip of a switch, the human brain doesn't work so easily.

I've used this description with patients, as well as others.  In the example of our case, a young girl tripped and fell on the playground and hurt her foot.  A few days later, her foot was still hurting and she started to limp.  Negative XRays, negative MRI.  There certainly may have been some inflammatory processes occurring... but no major tissue damage.  By the time she came in for physical therapy, she was on crutches and had not put her foot on the floor for several weeks.  I used the metaphor of a thermometer for her.  She drew me a thermometer and colored in the red tip where it would be very hot, the blue tip where it would be very cold, and in between, could be comfortable, but it would be a range of temperatures.  I asked her, because she liked giraffes, to picture that a giraffe started the day in the normal temperature zone, but then it got a little bit warm.  Could the giraffe go for a swim to try to cool down?  Sure! And it wouldn't be in danger, but it would be warmer.  Now, if the giraffe can't cool down, and keeps getting hotter and hotter, couldn't it reach a place where the temperature was dangerous?

She experienced pain when her foot was on the floor - and so she stopped putting it down entirely.  But, while picturing a giraffe in a bathing suit, she could recognize that just by putting her foot on the floor a tiny bit, her foot wasn't actually in danger.  And thus, recovery began.  Pain is meant to be an output in response to danger messages, so once she learned about the danger signals and could start to recognize that she could tolerate small amounts of the pain and work to increase that tolerance over time (progressive overload), we started to set small, realistic, achievable goals for her to achieve.

2) When a person experiences pain, they move differently.  They oftentimes start to associate movement with pain.  I hurt my back - it hurts when I move - if I stop moving, it won't hurt - so now I can't move.  You're still actually able to move - but it may be uncomfortable.  This concept may seem obvious, but it's actually a bigger problem than it seems.

You've seen someone stub their toe and limp.  Limping in general is meant to protect the foot from further injury because it had a momentary threat of danger - but as long as the limping does not persist long-term, it's really not an issue.  After a longer period of time, however, if they won't put their foot on the floor for several months, they're also not using their calf muscles, their thigh muscles, their glutes, etc in their normal fashion.  The control of their hip and ankle in space will adapt to the new stresses (or lack of stresses) applied to them.  Fortunately, in the case of the little girl, she didn't have any issue with lifting her leg - and so she could do hip strengthening exercises right from the start without any issues from her feet.  Getting her to move in ways that didn't affect her pain levels was essential in her willingness to participate in activities.  She started to trust that some activities we did would not hurt at all and that all of the activities chosen for her PT sessions were intended to keep her out of danger.

For an older, bigger, stronger, more athletic patient, such as a teenage football player I'm currently working with who also has not walked on one of his legs for several months, this battle is going to be a little more difficult because of the amount of muscle atrophy and disuse his leg has gone through.  But still, it surprises these patients, sometimes, when they can do several activities that don't hurt at all.  He could do sit ups no problem.  He could do a bench press without issue.  Muscle strengthening activities don't just target that specific muscle- they increase circulating hormones that can benefit the entire body.  Move the parts of the body that are able to be moved without issue - so that you can start increasing tolerance to activity in general.  Then focus on the specific body part that needs loading.  And you can build trust with the patient.

3) According to Adriaan Louw's presentation, certain types of people are more or less likely to experience chronic pain.  I actually didn't like learning this - but it was thought provoking.  People who participate in contact sports or who work in manual labor type jobs tend to experience less chronic pain. People with lower incomes or lower education levels tend to experience more pain.  Educating people about pain can decrease this.  People who have experienced pain and then recovered from it in the past tend to have overall less chronic pain.  This last thought, I think, is perhaps why I see more chronic pain now that I work in the pediatric population.  Most of the kids who I've worked with who experience chronic pain have never had an injury before the one that started this path.  They don't always fit the above criteria, such as working with a football player experiencing chronic pain, but these are considerations that cannot be ignored.  Generalizations can be dangerous because, as a clinician, I should not assume that every child I work with who comes from a low income house and has had pain for a little longer than normal is following a chronic pain pathway, but it needs to be considered, because often some of the stressors associated with family life may be contributing to the pain pattern.

4) Your brain makes a pain map that is specific to you, and the more you experience pain, the more distinct that map becomes.  Close your eyes and picture your pet.  What does it look like?  Feel like? Fluffy? Hairy? Spiky?  My friend has a chinchilla as a pet... so... what would that be like?  How about smell? Does your dog stink?  Does your cat meow?  Ok... you've just put an image in your head of your pet- and it will collectively activate multiple centers in your brain.  If I simplify it, the smell center and the vision center and the touch center of your brain all activate in a specific way when you think of your pet.  My pet is different than yours - but a smell center, and a vision center, and a touch center will all be activated in my brain, too.  The centers in the brain are similar, they activate as a group when processing a certain idea, but these differ between people.  Similarly, when you experience pain, centers in your brain are activated, and though the areas in my brain will also be activated, they're not describing the same pain.  Your pain is yours - mine is mine.  And the brain maps are similar... if we're both picturing dogs, they're likely to have similar characteristics, but they're still not the same.

As you can see from having written three posts on pain, I could keep on going.  For now, I'll just say that I think we're going to see changes in the future when it comes to chronic pain.  I already see it at Seattle Children's Hospital where we have specific groups of clinicians who work with kids experiencing chronic pain.  We're going to find that people having had pain for extended periods of time are going to seek out clinicians who have worked with this patient population.  This is challenging and I'm really enjoying learning about it so that I can better serve children who are struggling to get back to their lives.  The best advice I can give, though, is to prevent your pain from reaching this stage.  If you've had pain for a few weeks and think that leaving it alone will just make it better - or that pain medication is going to be the answer - I urge you to find someone who works with chronic pain and can help you get moving.  Movement, after all, is the ultimate answer.