Whose Pain is it Anyway?

The popular comedy game show “Whose Line is it Anyway?” invites comedians to make up small skits around random topics that are suggested by either the game show host or the audience. The show is a mix of impromptu lines, humour, spontaneity, and sometimes confusion. Listening and acknowledging each others’ lines is a necessary part of the show in order to act on what comes next.

I have had many conversations with clinicians about the use of the word “pain”. A majority tend to shy away from its use because they believe it maintains the patient’s focus on the word, and thus makes their pain worse. This idea seems to me to be a bit of a waste of conceptual time and potentially invalidating. When the patient walks out of the clinic they will engage with a society that recognises the word pain as something unpleasant, so is there really any getting away from the word? I entitled this blog post “Whose Pain is it Anyway?” because it is not our decision to deny a person’s experience of pain or their relationship with pain. More importantly, it is our role to validate it and help to reconceptualise a person’s belief and behaviours related to pain. In my honest opinion, one less mention of the word “pain” is unlikely to have a profound effect.

What’s wrong with using the word pain anyway? It provides a universal meaning to something that is unpleasant, but it is also one of the most important biological tools in the preservation of human existence.

Pain is many things: Multi-dimensional, contextual, subjective, individual, metaphorical, philosophical… I could go on… So one thing you can’t do (in a 20 minute appointment) is make it go away, permanently. Certainly, just mentioning the word pain can fire a pain neuromatrix (Louuw & Pedentura, 2013).

To use a personal experience, I don’t like the taste of mushrooms. I find them weird, dry and tasteless, and I’m sure the word “mushroom” fires off my mushroom neuromatrix and disgust response. However, me not talking about mushrooms won’t permanently turn that off. Why? Because I am a conscious human being who is able to make an opinion about mushrooms. Plus they are hidden in my food! (Thanks to the nakedphysioette…)

Pain, as Ramachandran puts it, is an opinion. It is an opinion on the organism’s state of health rather than a mere reflective response to an injury (Ramachandaran, 1999).

So we avoid the use of the word pain, but then we use a scale to score… pain. This gives us a subjective measure (not a very accurate one), an idea of how bad the person reports their pain to be (in their opinion). Perhaps a better way, (and this might appear obvious to some) is to change the perception of thoughts that make up a pain construct, facilitating a reframing of pain itself (Yelland 2011).

‘Change the way you look at things and the things you look at change’ – Wayne Dyer

People are surrounded by the word pain in their everyday lives. So getting away from it is really impossible. Is avoiding the use of the word pain addressing the real problem though? A recent meta-analysis identified that perceived level of disability was more significantly related to “care-seeking” than pain intensity (Ferreira et al. 2010). Therefore, is using the word pain something that should be avoided? Do patients really care? Reframing beliefs and behaviours that construct a pain experience would arguable be more effective. In order to do this, we need to identify a patient’s understanding of their diagnosis, and what their concerns are associated with the injury, threats and fears of the future, as well as what their expectations are (associated with the injury, threats and fears of the future) (Gifford, 2015).

What patients want regarding a pain problem is eloquently explained by Yelland (2011). Patients have simple needs. The needs for legitimisation (being believed and listened to) and having their pain acknowledged or validated (being empathic to the difficulty that people face with long term pain) are significantly important. Acquiring and understanding knowledge about pain also helps to provide perspective and internal locus of control.   As previously mentioned, pain itself is often not the priority, the disability associated with pain causes more concern (Ferreira et al, 2010).  Hence, if we can change people’s understanding of the associated fears and threats related to pain, and enhance a sense of safety, we can facilitate a reduction in disability and pain  (Yelland 2011; Moseley & Butler 2015).

Earlier I referred to the use of the numerical pain rating scale and how this too is an unreliable measure. As such, I like to use something I refer to as the alternative pain scale. The alternative pain scale asks the patient to work with pain, to “rattle the snake” or “poke the bear” as @greglehman puts it.

Pushing into the progress zone provides an opportunity to make gains. My experience has found that within the “progress zone” patients find the pain is bothersome but tolerable. The scale is dynamic; if a patient continues to rattle the snake they will end up being bitten (flare up), so it’s important that they move in and out of the progress zone. I don’t like to use the phrase “Pain is inevitable, suffering is optional” because it is not an empathic approach to management. Perhaps “Pain is probable, functional gain is fruitful” is more appropriate, as it highlights the potential for personal growth.

As we learn more about pain we pick up (what we might deem as) useful tools to facilitate a patient’s journey (like avoiding the word pain), thus making us educators. In order for our tools to be effective we require an understanding of practice-based education (PBE).  Discussing PBE is beyond the scope of this blog post, however an example of PBE would be critical appraisal of both new tools we adopt and current tools we practice. Use of an evolving evidence base and PBE are a fundamental means to facilitating the needs of our patients (Cross et al, 2006).

Thanks for reading

TNP

1. Cross, V. et al., 2006. The Practice-based Educator: A reflective tool for CPD and accreditation. Chichester, England: John Wiley & Sons Ltd
2. Ferreira, M.L. et al., 2010. Factors defining care-seeking in low back pain – A meta-analysis of population based surveys. European Journal of Pain, 14(7), pp.747.e1–747.e7. Available at: http://dx.doi.org/10.1016/j.ejpain.2009.11.005.
3. Gifford, L., 2014. Aches and Pains. Book Three: Graded Exposure. CNS Publishing.
4. Louw, A and Puentedura, E., 2013. Therapeutic Neuroscience Education: Teaching Patients about Pain. A Guide for Clinicians. Minneapolis, MN: Orthopaedic Physical Therapy Products.
5. Moseley, G.L and Butler, D.S., 2015. The Explain Pain Handbook: Protectometer. Adelaide, Australia: NOI Group Publications
6. Ramachandaran, V.S., 1999. Phantoms in the Brain. William Morrow Paperbacks.
7. Yelland, M., 2011. What do patients really want to know? International Musculoskeletal Medicine, 33(1), pp.1–2.