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A New Way to Explain Pain - The One by the Physiotherapist

Welcome to the first article in a series of three related to understanding and managing chronic pain. This article is written by guest writer and physiotherapist, Adrian Benson. Look for the second article in the Analyse This category, titled A New Way to Explain Pain - The One by the Psychologist, and the third in the Up Close & Personal category, titled Moving Into the Moment.

Adrian Benson grew up on a farm near Simpson with a mum who was a nurse and a hard working dad who always encouraged his kids to follow their passions and be persistent. It makes no wonder then that he chose a career in healthcare and really loves cheese. More than that, he is a husband, father of three girls, and a coffee connosier. Adrian's personal goal for this year is to teach himself how to surf; one $80 second hand board and a you tube 'how to' video later, he can stand up and is proud to say he is persisting!

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Pain; it's so complex, I'll get the kids to explain it for us!

If I was ever diagnosed with osteoporosis, diabetes, hypertension or congestive cardiac failure, I would expect the health professional making the diagnosis to explain to me what that meant. I don't think that would be asking too much? These are chronic conditions, with no known cure, and they could have a major impact on my life! I would want to know them, and I would want to understand how to manage them. Surely I am not alone in that? I would want to know what I can do to minimise the impact they have on my life. I would want to keep on living and enjoying my life!

So would it not also be reasonable to expect that if I was diagnosed with Chronic Pain, that that could be explained to me as well? Unfortunately this rarely happens to a level of satisfaction or in a way that leads to effective treatment pathways. Perhaps some doctors and health professionals have tried to explain the diagnosis, but I suspect Google does the heavy lifting when it comes to finding out "what it all means".

This is certainly the experience that Dr. Cristina Manu, Jodie Fleming (psychologist), Natalie Taylor (occupational therapist) and I (physiotherapist) have of patients attending the Pain Management Program at St John of God Hospital Warrnambool (Perhaps therein lies a clue as to why patients with chronic pain seldom have a good, accurate working knowledge of their condition. It takes a village to raise a child, and a team to manage chronic pain!)

To be fair, most patients have had some aspects or features of their chronic pain explained to them. People tell us things like they have 'nerve pain', 'sensitised nerves' and 'central sensitisation'. They often believe that the only management available is to try an almost endless variety of medications and "learn to deal with it" because the pain isn't real, or "is all in my head". This is far from true, and actually makes the problem worse!

In the past 10 years our knowledge of pain; from basic science to practical treatments; has expanded beyond belief from exciting new research and an ability to better understand how the brain works. Much of this research on understanding pain, and managing Chronic pain in particular, has been done here in Australia, and it is a really exciting time to be working in this field.

Pain, from the Latin poena "punishment, penalty, retribution, indemnification" is a negative experience. The World Health Organisation defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” So pain is the word we attach to this unpleasant experience. We all learn the application of pain from experiences early in life, and thinking about this, children can help us understand the complexity of pain.

Perhaps a lot of people reading this can relate to this story. My 5 year old daughter complained of a sore tummy. She looked pretty miserable and uncomfortable, she pleaded in a soft voice, close to tears, that she needed a bandaid! You could stand and argue until you're blue in the face, or just give her a bandaid.

How is that bandaids can fix things for kids that aren't bleeding? Even sore tummies! The educated and the sceptical would identify this a classic placebo response, and maintain that bandaids are ineffective in treating sore tummies. But we have just seen it work.

Let's look at placebo for a minute. Placebo is largely misunderstood and has a bad reputation, largely due to the nuisance factor in drug trials. To work out how effective a drug is, we randomly allocate people to one of two groups. One group gets the drug that is being studied (the active treatment group), the other group gets a sugar pill (the control group). With effective 'blinding', nobody knows which group they are in. We would expect that only the group getting the 'real' drug would improve, but up to 30% of people in the control group will show improvement. How is this so? The placebo effect is not isolated or unique to drug treatments. In fact, the more invasive and technical the treatment, the larger the potential for placebo. By this I mean the colour, shape and size of tablets and capsules contribute to the size of the placebo effect. Injections have a larger placebo response than tablets, and surgery has a larger placebo effect than injections. This has been proven in back surgery for crush fractures of the spine and knee arthroscopy.

It is important to understand at this point that I am not dismissing the effectiveness of medication or surgery. Quite the opposite. There are times when these are absolutely recommended and clearly indicated. Here is an interesting bit to think about. The control group, those receiving the sugar pill, actually get a powerful opioid medication, 50 to 100 times stronger than Morphine! The cool bit is, they are getting it free, with absolutely no negative side effects. They don't even need a script for it. They make it.

Think about it, the only reason any medications have an effect in our bodies, is because our bodies have receptors for them. Not exactly receptors for the medications, but receptors for the organic compounds that our own bodies make. The body uses hormones and signalling chemicals to pass messages around the body, to stop and start certain processes in the body. These compounds can be produced in the brain, liver, pancreas or any of our glands, and circulate through the body in the blood stream to have effects on tissues in places far away, not connected directly by nerves. It is these compounds that the drug companies try to replicate, and in doing so, they serve our desire to have pain relief when we want pain relief. So when my daughter gets a bandaid to put on her sore tummy, her brain makes all the natural pain killers that she needs. The 'drug cabinet in the brain' is open, to borrow a phrase from David Butler and Lorimer Moseley, founders of the Neuro Orthopaedic Institute - a research group in Adelaide whose work we base our pain management program on, because her brain is convinced that she will now be safe and does not need to worry or fear about the sore tummy.

I've got another story to tell, then we will look at a bit more of the how and why to get a deeper understanding. I'm sure that even people without kids will relate to this story as it is played out so often. Think for a moment, about the young child that has come off the bike/scooter/swing etc. and run over and grazed a finger, or a knee. There may be some initial crying, deep breaths, looking around for Mum or Dad. Perhaps they will grab and squeeze the knee or finger. The parent arrives on the scene, and comforts and supports until the initial fear and hysteria has settled down. When the injured little one has calmed down completely and stopped crying, the parent might say "let's have a look!" and the youngster will uncover the injured body part. As soon as the child sees the grazed and torn skin, the blood and bits of imbedded gravel, the pain is significant, and the child who was moments ago quiet, calm, with dried tears and a snotty nose, the child whose initial deep breathing had turned to shallow sniffing at the snotty nose, starts screaming hysterically again! In this scenario, the drug cabinet in the brain just snapped shut.

The physiology and biology of pain doesn't change during puberty. It is for all people, of all cultures and ages, that pain is a contextual experience. It has a meaning, and it is an output of the brain. To say that pain is all in your head is both incredibly accurate and misleading. Firstly, it is very accurate. The brain constructs pain. If you do not have a brain, I guarantee you will not have pain. If you have had a body part amputated, you may still feel heat, cold, itchiness, pain, and many other sensations in the body part that is no longer there! These are commonly referred to as phantom sensations. These 'live' in the brain, where all of sensation lives.

Secondly, to say that pain is all in your head, is incredibly misleading. Blood pressure and core temperature are also all in your head. So next time you have a fever, does knowing that it is all in your head help you to reduce it? If you needed help interpreting a map, and someone who could read the map denigrated you by saying that it is all in your head, would it help you reach your destination? Unlikely.

So do we have control over the drug cabinet in the brain? Probably not if you view it as a switch that is either on or off. But think of it for a moment as not being on or off, think of it as a set of scales. One side of the scales would have DIMs, the other SIMs.

Scales diagram

A DIM (Danger In Me) is anything that is dangerous to your body, your life, livelihood, health, happiness or day to day functions.

A SIM (Safety In Me) is anything that makes you stronger, healthier, happier or more confident.

The brain weighs up the world, and in doing so, will take into account everything it knows from past experience, the current environment or context that you are in, and regards what future significance might look like. In an instant, the brain works out the most likely advantageous response to the situation, and determines the appropriate output. If the credible evidence for Danger outweighs the credible evidence for safety, then pain will be included in the outputs of the brain. For a child, seeing torn and bleeding flesh is a VERY BIG DIM. If the credible evidence for Safety outweighs the credible evidence for Danger, then pain will not be part of the brains outputs, and band-aids, which have the power to cover up the 'torn and bleeding' flesh are a VERY BIG SIM for most children.

Is it the same for adults? Of course. We all have a unique experience of pain and response to painful things. We have all heard stories of people with significant injuries driving themselves to hospital and collapsing at the front door, or crawling great distances to make a phone call for help before collapsing. In these extreme scenarios, people are often in 'shock', and adrenaline and other hormones will be produced in large quantities. Pain is blocked by the drug cabinet in the brain, and our focus is entirely on survival - the most likely advantageous response to a situation. In less extreme scenarios, the same thing still happens.

Think of the soccer player who scores a goal and then has 1,2,3,4,5,6 teammates pile on top of him. The weight of half a ton perhaps! And he gets straight up with a big smile and keeps on playing, perhaps even better than before. The response to an identical pressure might be different if you were lying down reading a book or relaxing on the grass in a park and 6 people piled on top of you!

All sensations 'live' in the brain. Just because we experience the pain where the body part is, we think that the pain is 'in' the back, the leg or the finger. When we watch TV we actually think that we hear the presenter speak, or we hear Bart Simpson speak. Because they happen together and make sense to happen together, the brain associates them as being the same. This is how it happens for pain and other sensations that we feel in the body. A certain amount of conditioning takes place here, and this is how the brain learns, and adapts, to master skills and be able to do things efficiently.

Imagine for a moment if we couldn't adapt in this way. Just think of the first time you used a sewing machine, a power tool, a chainsaw, or drove a car. If the brain could not get used to integrating the multiple sensory experiences involved, the noise, the vibration, the movements that the machine makes etc., then every time would be like the first time, and you would always be a beginner. Your work would be slow and inefficient, you would make mistakes, and the outcome of your labour would not get better with practice. You would probably also be at higher risk of having an injury or accident with the powertool, chainsaw or sewing machine. Thankfully, the brain can and does adapt very well. Unfortunately, it also adapts to having pain, which becomes a conditioned response to movement or certain activity in chronic pain.

The drug cabinet in the brain isn't likely to be open, if big heavy DIM's like telling yourself that "I will pay for it later", or "I can't hang out that load of washing". Many DIMs though are not as obvious. When we talk about the brain weighing up the world, taking into account everything it knows; our memories, our expectations, our understanding of what is happening and why, all of the sensory information that is available to us - the things we hear, see, taste smell and touch - the places we go, people in our lives, our thoughts and beliefs, you can start to see and appreciate the complexity of all the processing our brain does, and so little of it is done in the conscious cortical areas of the brain.

The good news is, we can change this.

The process of neuroplasticity; where the brain changes in response to how it is used, is a never-ending, continuous process that happens from the cradle to the grave. Neuroplasticity is a competitive process, a true use or lose it. This is a good thing. It gives us the potential to 'lose' some of the unhelpful adaptations that we have developed. It gives us the potential to learn and develop new, helpful pathways and connections. But much like riding a bike which we all believe is "something you never forget" - if you haven't done it for 40 years you will need some practice and training. Just appreciate that we are learning new skills that will take time to develop. We are starting to change old habits that are hard to change, and we will never forget the pain - it will be imprinted in our memory and in our immune system forever. We just don't want to exercise it regularly.

Look out for part II of this article - A New Way to Explain Pain - The One by the Psychologist.

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2 comments

  • Comment Link Jodie @ The Psychology of it Thursday, 14 April 2016 17:18 posted by Jodie @ The Psychology of it

    Thanks for reading Kate. Adrian has such a knack for explaining chronic pain. We hope you enjoy the other articles as well!

  • Comment Link Katemorrissy Thursday, 14 April 2016 16:12 posted by Katemorrissy

    Thanks! Great read..

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