There’s a particular part in the movie Wayne’s World where Wayne and Garth meet Alice Cooper. They both drop to their knees and proclaim “We’re not worthy” because of their admiration of Alice’s talent and fame.
This scene reminds me of some of what we see with current pain education practice. This post is a message to all clinicians that may have become single-minded in their approach to pain education, and would benefit from taking the blinkers off and embracing the contextual nature of actually understanding what pain is. There is no one panacea for educating and treating people with persistent pain. O’Keeffe et al (2015) highlights in her study that no one intervention has precedent over another when it comes to treating low back pain, just like there is no single approach to say manual therapy. There were many ways that manual therapy was and is applied – Maitland, Mckenzie, Mulligan, Cyriax all had their own way.
It is important to consider a number of points prior to discussing why we require a diverse understanding of ways to help people reconceptualise pain:
- Persistent (or chronic) pain has been recognised as a phenomenon that goes beyond traditional biomedical paradigms such as specificity theory, which sees pain as a sensation (Moayedi & Davis, 2013). It is important however not to ignore historical models, as they have set the foundation of our understanding and still play a part in educating people about the misconception between pain and tissue damage.
- Separating acute and persistent pain experiences is complicated. As Louis Gifford (2014) highlighted, every pain problem, acute or chronic, has a reasoning, thinking and emotional brain attached to it.
- A biopsychosocial paradigm has evolved. Originally proposed by George Engel (1980) interestingly it has taken years for the model to become recognised. The biopsychosocial model is not a revolutionary concept but it has failed to gain traction until more recent years.
- Moreover, a recent systematic review by Kamper et al (2015) has shown that, based on the largest collection of trials and participants reviewed to date, there are robust positive effects of multidisciplinary biopsychosocial rehabilitation programs. Patients participating in these programs are likely to gain small, long term benefits in improved pain and disability compared with usual care or physical treatments.
- We are embracing the biopsychosocial paradigm, yet the more we add to our assessment and treatment repertoire the more complex the issue becomes. We are no longer looking primarily at a structural pathology model, we are talking psychosocial factors that contribute to a pain experience.
- Due to the enormity of the biopsychosocial model and the complexity of pain there is a need for advanced communication and listening skills. This allows practitioners to identify medical language and metaphors that may be confusing or potentially threatening (Barker et al, 2009; Greville-Harris M & Dieppe P, 2015), and guide individuals to engage in a “safe” movement program or learn to live well with pain (Thompson, 2015).
I recently attended the San Diego Pain Summit, and after realising how many different disciplines there were in attendance (speakers and audience), it illustrated the necessity of a wider understanding of educational needs for people in pain. Furthermore, it supported my plea to clinicians who think there is only one way to educate people in pain – we need a diverse understanding of how to educate people to manage pain. There is no single correct approach, there is no mainstream.
The pain neuromatrix introduced by (Melzack 2001) has always maintained that pain is emergent – modulated by sensory inputs and cognitive events; that there are no specific brain maps devoted to pain. And yet it appears that this misconception has occurred. To say there is a brain map is an oversimplification and what I would ponder in an indirect and crude form, is an extension of specificity theory.
Recent publications (Butler & Moseley, 2015; Thacker, 2015) have highlighted the misunderstandings that have occurred from specific teachings such as ‘pain is in the brain’. It is important to recognise what Butler and Moseley originally endeavoured to illustrate. However, there are a number of current issues that should be brought to attention as identified by Butler and Moseley (2015) and Thacker (2015):
- That there is an ongoing inability of clinicians to be able to understand the complex neurobiology of pain.
- It seems apparent that clinicians are unable to separate the idea that nociception and pain are the same.
- That clinicians are unable to adopt a conceptual change model as coined by Butler & Moseley (2015)
- That clinical perspectives of being ‘brain bound’ can create obstacles in pain management programme engagement.
If this is the case then perhaps there is a need to provide a more nuanced approach to both helping people understand their pain, and then to actively engage in their own pain management. Clinicians are renowned for jumping onto bandwagons (read the sportsphysio’s post here), adopting a ‘one way fits all’ approach. We grab onto a single idea and run with it without learning to be flexible and working with a level of uncertainty. Flexibility and comfort with uncertainty would support our critical thinking skills and allow us to dig more deeply into the many factors that influence a pain experience. Pain isn’t just in the brain, it’s an experience that emerge from the interactions between the biological, psychological and social.
Therefore, it is pertinent to explore alternative educational approaches that complement our education repertoire and support clinicians and patients in the ongoing need to understand and explain pain.
If we are to embrace a better understanding of pain we need to broaden our theoretical, educational and practical skills, remove the blinkers and finally stop being like Wayne and Garth.
Thanks for reading,
Barker et al., (2009). Divided by a lack of common language? – a qualitative study exploring the use of language by health professionals treating back pain. BMC Musculoskeletal Disorders. 10:123
Engel, G.L., 1980. The clinical application of the biopsychosocial model. The American journal of psychiatry, 137(5), pp.535–544.
Greville-Harris, M & Dieppe, P. (2015). Bad is more powerful than good: The nocebo response in medical consultations. The American Journal of Medicine. 128, 126-129
Kamper, S.J. et al., 2015. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. BMJ (Clinical research ed.), 350(February), p.h444.
Melzack, R., 2001. Pain and the neuromatrix in the brain. Journal of dental education, 65(12), pp.1378–1382.
Moayedi, M. & Davis, K.D., 2012. Theories of pain: from Specificity to Gate Control. Journal of Neurophysiology, (Rey 1995), pp.5–12.
Moseley, G.L. & Butler, D.S., 2015. Fifteen Years of Explaining Pain: The Past, Present, and Future. The Journal of Pain, 16(9), pp.807–813.
O’Keeffe, M et al., 2015. Comparative effectiveness of active interventions for non-specific chronic spinal pain: Physical, behavioural or combined? A systematic review and meta-analysis. Physiotherapy (United Kingdom), 101, pp.eS1131–eS1132.
Thacker, M., 2015. Is Pain in the Brain? Journal of Physiotherapy Pain Association, 39, pp.3
Thompson, B.L., 2015. Living well with chronic pain : A classical grounded theory.