50 ways of thinking differently in pain science: Part 2

Welcome to part 2 of my 50 ways of thinking differently in pain science. I got the idea after reading an Auckland chamber of commerce article that applied the title to business.  I thought to myself there are a lot of similarities here in thinking in business and pain science. Nothing like a bit of healthy cross-fertilisation! So I decided to create my own. If you missed part 1 you can find that here.

So here’s my next 25:

1. What influences an individuals pain: I’ve blogged about this before here. Language, past experiences, beliefs, family, work, what people have read, what they see in the media, when their favourite rugby team wins or loses, what previous education they have had about their injury, particular aspects of their environment.
2. Think laterally not linear: Think outside the box, break down your defensive boundaries, be open to new ideas and share your ideas. We owe it to ourselves and the public to communicate openly, to share our experiences and knowledge amongst all professions and respect one another. Create a movement, be rebellious – think laterally.
3. Don’t forget the biological: The message ‘no brain no pain’ is important but brains do not get around without the means of a body. That body is prone to injury, has inflammatory, metabolic, immunological properties, and can have genetic mutations that have an influence on the pain experience. People have pain for a reason, they don’t choose to be in pain, we need to adapt how we work to understand that reason.
4. Turn the external locus placebo into an internal locus Placebo: Manual Therapy, tape, acupuncture, cupping (ugh, god forbid?) There’s low quality evidence to support these treatments. Yet patients still need them, that’s not to say you should give them but how about changing that dependency into independency? Can the patient take control by deep breathing, walking in the wilderness, meditation, listening to music, having a physical routine (10 face slaps before they start their day)
5. Load is the new buzz word: This is not a criticism. The application, variability, magnitude of load to tissue is highly influential for prevention, increases in self-efficacy, reduction in fear and for recovery. Tim Gabbett’s, Jill Cook’s, Greg Lehman’s knowledge in this area is excellent and worth a read, but it’s only one part of a very big pain picture.
6. Rattle the snake / Poke the bear: These are two metaphors that are personal favourites. I find them useful for graded exposure therapy. I use them to demonstrate ways of confronting fear by challenging beliefs as well as giving people more freedom to move. By teasing into pain reduces threat and desensitize’s.
7. “Pain is in the brain”: NO that’s not accurate! Saying ‘pain is in the brain’ gives the understanding that the pain is all in the head and that a person is not in control of the themselves.  It’s not that simple. There are many continuous subliminal brain functions and much information coming from the body that we can also be oblivious to. Our perception is what gives us the experience. Pain is a perception, it is an emergent phenomena based upon contextual factors.
8. Understand your pain terminology: Using words such as pain receptor, pain fiber or even pain centre in the brain are mereological fallacies. These things don’t exist, and this shows complacency in explaining and understanding pain. Don’t be lazy!
9. Respect the historical models but don’t get stuck behind the gate: Times change but it seems that historical models endure. An example is the pain gate theory, which has been misinterpreted and misunderstood. There was never an actual closing of a gate but more a balance of inhibitory and facilitatory inputs. Yes respect the models but it’s probably best to bring yourself into the 21st century if you find yourself still stuck in Cartesian times.
10. Pain is a perception: Pain is a perceptual experience by the person. It is an emergent experience made up of the individuals interaction with their environment, with contribution from memory, past, present and future, changes in nerve processing peripherally and centrally. It’s not the tissues that feel pain, it’s the person that feels pain.  Just like the ears don’t hear Jimi Hendrix it’s the person that hears Jimi Hendrix.
11. Drop either/or thinking: We all experience it, that feeling that you have when you have two or more conflicting beliefs or values, or when someone or the evidence says something that goes against your beliefs but actually makes sense. That’s cognitive dissonance. My point is THINK about what you are faced with, BE open-minded and work with a CRITICAL mind.
12. Get off the bandwagon, be curious: There are too many clinicians all doing the same thing. I encourage you to think more broadly towards a person’s lifestyle such as habits, sleep, diet, mindset and activity levels. What is influencing their ongoing pain, it can’t just be their poor posture!
13. What will you tell your friends or family: Most people want to know what’s wrong with them and to be told how they can explain that back to their family or friends. Kieran O’Sullivan asks a simple question, “what will you tell your friends and family about what you learnt today”
14. Don’t “hot potato” your patient off for a scan: One of the easiest options for us clinicians if we can’t figure out what is going on, is to “hot potato” people off for the scan. We should be up to speed now with understanding the discrepancies that exist with scan and persistent pain.
15. Don’t expect to change people straight away: They may even flare up! Remain calm, changes are more likely to occur when people begin to understand their pain and experience changes and reactions for themselves.
16. What impact does stress/depression/anxiety have on pain: The same chemicals that are released when we’re injured are also released when we’re stressed, depressed or anxious.  This can stimulate those nerves in the same way a new injury can.
17. Should back pain be seen more like sadness or fatigue: Back pain is common, so common it is almost always not about structure or posture (although they are just one part of the picture).  Comparing back pain to something like sadness or being run down is a way of understanding the frequency of it throughout our lifetime and that it is not as serious as is made out.
18. Leave fear behind: Don’t be an accomplice to an individuals fear. Telling people to stop when they say it hurts is helping to condition their understanding of what they can and can’t do.  Oh and has anyone ever thought that teaching someone to “brace their core” might actually be the reason they are getting back pain!
19. One size does not fit all: It really doesn’t, our patients are individuals.  Another blog I wrote here talks about this. Stop using the same approach for every patient (like core stability for example). Yes we should use an evidence based approach and respect the guidelines but this should be balanced with other dimensions. Using a uni-dimensional approach to a multi-dimensional experience just won’t cut the mustard! Funny that!
20. Patients are learners: A nice quote from Laurent Daloz ‘Like guides, we walk at times ahead of our students, at times beside them, and at times we follow their lead. In sensing where to walk lies our art.’
21. What are the relationships like with friends, family, work colleagues: Are you able to identify concerns, grievances, or feelings of uneasiness about an individuals relationship with friends or family. Does the person hate being asked about their pain? Do they distance themselves from family or social activities? Does the person have a concern about returning to work that needs to be addressed?
22. Give people strategies, don’t be condescending: Telling an individual to calm down and relax when they are stressed or to try harder when they feel they can’t do something is pretty unhelpful.  Developing strategies with the individual to overcome these obstacles is a more appropriate method.  This doesn’t have to be down to the clinician, discuss with the individual to help them come up with the strategies.  An easy way is to get them to identify what is good or bad for them.
23. What are the transferable benefits of movement/activity/exercise: Activity and exercise is important for strengthening muscles and tendons, but go the extra mile and explain that it will help their stress levels, their mental health, nourish their joints and discs, improve their immune system etc.
24. Can you get the person to be more engaged in their recovery: Don’t take on the responsibility of doing everything for the individual with pain. They have come to you to get better, so be their guide, encourage them to take control, that’s a helpful step forward in the journey of learning to live well with pain.
25. Sometimes you have to step back: You do want to help and support people with pain but you don’t want to be the crutch! Provide people with the strategies so they can go it alone. Use those newly discovered appraisal skills and reflect on those experiences to change your practice for the future.
26. Consider who the person is rather than what is wrong with them: (yes it’s 1 more) Pain science is not just about the technicalities it’s also about humanities. We can’t “fix” people, because people are not motorcars. If you want to know more check out the Know Pain NZ video presentation here

That’s my 50…51 ways of thinking differently in pain science! I don’t disagree there are probably hundreds more. I encourage you to share your ways on here or on social media.

Thanks again to those people who inspired me to write this blog, and to those that have a huge impact on my continuing desire to learn pain science. There’s some amazing work going on in this complex field.

Thanks for having a read

TMP