Pain Is A Mystery, But How Do You Solve It?

Puzzle

It is easy to think of pain as a simple puzzle. Find the missing pieces, put it all together in the right order and then voila, you feel better.

Unfortunately, as much as we’d like things to be this simple, it’s not the case, and pain is more like a mystery.

Allow me to let Malcolm Gladwell explain (1):

The national-security expert Gregory Treverton has famously made a distinction between puzzles and mysteries. Osama bin Laden’s whereabouts are a puzzle. We can’t find him because we don’t have enough information. The key to the puzzle will probably come from someone close to bin Laden, and until we can find that source bin Laden will remain at large.

The problem of what would happen in Iraq after the toppling of Saddam Hussein was, by contrast, a mystery. It wasn’t a question that had a simple, factual answer. Mysteries require judgments and the assessment of uncertainty, and the hard part is not that we have too little information but that we have too much. – Malcolm Gladwell

Although it seems like there a new discoveries about pain being published almost monthly. So much about is still unknown.

And, because pain is invisible and has many unconscious components, we simply cannot know why you, or any individual is experiencing pain at a particular moment.

The Case Against Diagnostic Imaging

You would think that being able to visualise the structure of the body would be helpful to clinicians treating pain.

It turns out that this isn’t quite the case.

Firstly, there is a large, and growing, body of research that shows there is very poor correlation between the structure of our bodies and symptoms of pain.

From disc injuries (2) to degeneration (3)  and even partial or full thickness tendon tears (4), most of us are walking around with structural “damage” that would show up on diagnostic imaging (X-ray, CT, MRI etc).

Secondly, and most interesting to me, is due to the fact that the interpretation and reporting on diagnostic imaging varies wildly.

In a recent study on MRI reporting and interpretation (5), a woman with low back pain and neurological referral was sent for an MRI at 10 different locations. The results reported 49 total findings, with not one interpretive finding consistent across all 10, and only 1 finding consistent across 9 of the 10 reports.

This means:

  1. MRIs require skill to interpret, and not all radiologists are equally skilled, thus, it matters where you get an MRI done.
  2. Radiologists working in isolation from the patient, are assessing an image, not a person, and have to make a lot of assumptions, even with a comprehensive history.

What About Physical Assessments?

Physical assessments are a necessity for clinicians, but which assessments are valuable, and which just add confusion?

We can break physical assessment into 3 components:

  1. Vital signs like pulse, blood pressure and breathing
  2. Neuro-orthopaedic examinations that are designed to rule in or rule out specific pathology or conditions
  3. Functional assessment designed to determine an individual’s movement competency and capacity

It is the third area which is the most “grey”.

This is because human movement, being an emergent property, is not an easy thing to classify (6).

We can define good and poor movement, but again the definitions are somewhat arbitrary, and their are many exceptions who fall outside those defined ranges who do not have an consequences (injury, pain etc).

This isn’t to say their isn’t such thing as good movement, bad movement or better movement, but only that it is person specific.

So if we use a movement assessment to gain insight to a person’s movement at that moment in time, in those conditions (in the clinic for example)then we can look for a movements that can be better.

If we identify movement that could be better, we can challenge to brain to improve movement, with a variety of techniques.

Even Histories Can Be Misleading

A good clinician will help someone in pain by creating the right context, or environment for them to heal.

To do this, a good clinician will know what they need to know, and more importantly, what they don’t.

By focusing only on the important, relevant, information, a good clinician minimises the chance of nocebo, and maximises the chances for recovery.

What exactly then does a good clinician need to know?

Is this pain dangerous?

When consulting with a patient, first, we want to rule out risk – some musculoskeletal pain can be caused by serious pathological conditions that need medical intervention. We have to rule these out first, and when in doubt, err on the side of conservative.

As a caveat to the above section on imaging, an “unnecessary” X-ray is a small price to pay if the alternative is missing an early cancer diagnosis. This does not mean imaging should be routine!

Is this pain affected by movement or position?

Mechanical pain is characterised by changes related to movement or position. If the answer to this question is yes, this rules in mechanical pain as a diagnosis. This does not yet rule out other origins of pain.

We can follow this up with more exploratory questions around which movement or positions feel good and which don’t.

Combined with the assessment findings, this will give us some more insight into how to proceed with treatment.

What is your current autonomic state?

Your autonomic state says a lot about you.

If you are wound up tightly – in a sympathetic or stressed state, characterised by elevated heart rate and blood pressure, shallow breathing and decreased blood flow to the periphery of the body (including the skin) – then it will be hard to resolve your pain until you enter a more balanced autonomic tone.

What are the barriers to recovery?

These are often implied, and a good clinician will be able to identify these as much from what a patient doesn’t say, as what they do.

Factors that can affect recovery include:

  • Age
  • Disease
  • Nutrition
  • Thoughts
  • Comorbid conditions – anxiety, depression, high blood pressure etc
  • Medications
  • Family and friends
  • Employment, or lack thereof

As always, it’s not simple, and it’s definitely not linear.

We are, after all, dealing with people – you know, those confusing, irrational beings who like to “go out”, but not for too long, because then they have to “go home” (Seinfeld reference, video below).

The Downside of Irrationality

Human beings are irrational. This is a fact.

Being irrational has positives, the most obvious being love.

Love is a fantastic human emotion that is completely irrational. If we were completely rational beings, then we wouldn’t spend so many of our resources chasing love, or any feeling for that matter.

But, this is exactly why too much information does not help us treat pain.

Too much information can lead us to make false assumptions and draw erroneous conclusions.

This doesn’t help patients seeking help for pain at all.

Pain has very tenuous links to tissue damage, body structure, posture, strength, symmetry and stability. (8,9)

Investigating these to a high level, and then describing pain as a result of these findings is not only inaccurate, but also harmful. (9, 10)

Every time someone is told their pain is the result of the above findings, a link is made in their brain. This is called a neurotag. Think of it like a storage file in the brain. (11, 12)

If a clinician, family member or friend tells someone with low back pain they lack “core stability”, then this is added to the low back pain neurotag.

Then, because of the way our brains function, when we have existing knowledge, we look for examples to confirm this knowledge – this is called confirmation bias.

So the person with low back pain, who has been told their pain is caused by a lack of core stability, finds “evidence” to support this.

If their back hurts when they lift something, they blame their lack of core stability. If their back hurts after activity, it’s core stability’s fault.

They forget to focus on the times that they lifted something without pain, or that activity didn’t hurt.

This is just one simple example. There are many others like it.

Conclusions

Mysteries are interesting to us as humans – as long as we get closure and the mystery is solved in the end. This is the basis of the “open loop”*  TV shows, movies and books use to keep their audiences engaged.

Unfortunately life is not like a movie. We don’t always get a neat and tidy closure.**

The challenge facing any clinician, when we treat people in pain, is to focus only the important and relevant information, and to educate patients on why this is so.

The even bigger challenge, is helping patients face the reality that the mystery of pain can’t always be solved, no matter how much (or little) information you have.

 

*An open loop is used by writers whereby earlier in the story they introduce something, but don’t address it immediately, in order to keep your attention, because you want to find out what happens next.

**Except not all movies or TV shows have closure. One of the greatest TV shows of all time, The Sopranos, has a famous ending that didn’t give it’s audience the closer they were hoping for.

 

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 



 

 

 

References

(1) Enron’s Open Secrets

(2) MRI findings of lumbar spine in people without back pain

(3) Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation

(4) MRI findings in throwing shoulders: abnormalities in professional handball players

(5) Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period

(6) Metastability and emergent performance of dynamic interceptive actions

(7) The fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by lower back pain

(8) Different contexts, different pains, different experiences

(9) Nocebo hyperalgesia and the startle response

(10) Context as a drug: some consequences of placebo research for primary care

(11) Pain really is in the mind, but not in the way you think

(12) Reinstatement of pain-related brain activation during the recognition of neutral images previously paired with nociceptive stimuli

Chronic Pain Is Rooted In Fear

fear painChronic pain is rooted in fear.

Chronic pain is defined as pain persisting more than 3-6 months, this is the time it typically takes for injured tissue to heal.

However, both acute and chronic pain have a tenuous association with injury (tissue damage).

People can exhibit the signs and symptoms of chronic pain earlier than 3 months.

This is influenced by factors associated with developing chronic pain, including, but not limited to, a history of anxiety and/or depression, low education level, lower income and age.

In general, most treatment of chronic pain is unsuccessful.

This is related to poor expectations of patients (after many failures, who can blame them) (1), and treatments that are overly focused on the biomedical (tissue) factors of pain, that often don’t match up with patients’ goals (2).

There have been promising results achieved by combining physical therapies with cognitive based therapies to treat chronic pain. (3)

Why Do We Experience Pain?

Professor of neuroscience and world leading expert on pain, Lorimer Moseley, has previously described pain as:

…a conscious correlate of the implicit perception that tissue is in danger

For most, the perception of danger evokes feelings of fear, heightened sensory awareness and decreased cognition.

When we assess danger, there are two main forms:

  1. Actual danger – situations where our life or safety is at risk.
  2. Perceived danger – situations where we perceive our life or safety to be at risk, but it really isn’t.

Both actual and perceived danger activate the same neuro-networks in the brain and the same physiological responses in the body. (4)

Our perceptions of danger are shaped by numerous factors, including:

  • Our age
  • Our gender
  • Our social
  • Our cultural upbringing
  • Our experiences
  • Our current capabilities.

If pain is related to a perception of danger, and our perception is shaped by all those factors, it is fair to say that pain is shaped by those factors too.

Pain science has moved forward, and beyond simply being a perception of danger, pain is beginning to be defined as a “need to protect”. (5)

The perception of danger, or threat, is in part based on predictive processing. (6)

Predictive processing is what our brains do to make sense of the world we experience and take shortcuts to achieving a conclusion.

An optical illusion based on predictive processing.

An optical illusion based on predictive processing.

Because of predictive processing, and other neural processes, we tend to not see an objective reality, but rather a subjective reality.

This is especially true when it comes to pain.

When we are experiencing pain, our brain makes predictions about whether something is going to be “dangerous”, and produces pain preemptively, in order to protect us.

Pain is not the only time that our brains use predictive processing.

Take a look at the brick wall, and see if you can spot what is not quite right.

The Neurobiology of Pain

The big problem with pain, is that pain is perception that we perceive as a sensation.

It tricks us into thinking that it is coming from our body, when in actual fact, pain is always produced by the brain and localised to the body. (7)

It is complex, and emergent, not linear.

So just because you feel a certain way after doing something, or not doing something, does not mean that your actions, or lack thereof, caused that feeling.

In the diagram below, I’ve simplified the neurobiology of pain with injury (remember, pain can occur without injury, and injury without pain as well).

neurobiology-of-pain-injury

Injury here is used loosely to describe the inciting physical event that damages the body tissue – it could be physical trauma, it could be an immune response from an infection or an auto-immune condition, like rheumatoid arthritis.

This leads to nociception – “danger” signals that convey a change to the status of the cellular environment.

That could mean a change to the mechanical load, a change to the chemical environment or a change to the temperature (the three primary types of nociceptors).

Inflammation is an immune response, and we know the brain and nervous system has a large role to play in the immune response (these days, doctors are calling it the neuro-endocrine-immune system). (8, 9)

Inflammation can lead to increased nociception, and if nociception increases, then this is a mechanism for increased inflammation. (10)

This can lead to peripheral sensitisation – where the sensory nerves in the affected body region become more sensitive due to physiological changes that take place.

All of this takes place locally, but we do not experience pain as a result of this just yet.

The Brain Modulates Everything

Modulation is a process whereby signals (nociception) reaching either the brain or spinal cord are amplified or inhibited. (11, 12)

Modulation can be affected by our thoughts – conscious or unconscious.

Here is where it gets interesting: we often think that our thoughts are ours, but there is compelling evidence that this may not be the case, and that our culture and environment shapes our thoughts, feelings and actions more than many of us would care to admit. (13, 14)

“You can do what you decide to do — but you cannot decide what you will decide to do.”
― Sam HarrisFree Will

Using this line of thought – when it comes to pain, our ideas and understanding, especially at an unconscious level are already implanted by the culture we live in.

Currently our culture around pain is:

  • Pain is bad.
  • Pain is caused by damage, or degeneration (the dreaded “wear and tear”) or misalignment.
  • “I’m just getting old.”
  • Pain needs to be “fixed” – and can be done so by the right practitioner.
  • We need to find the cause of pain, and this can be done by physical assessment and diagnostic tests (MRIs, X-rays etc).
  • The weather causes pain to flare up.

If you live in Australia, or any other Western nation with a similar culture, all of these memes, plus many others, have been implanted into your thoughts.

You don’t even question them most of the time, because you don’t know you have them, until you experience pain.

Our thoughts shape our emotions, our emotions shape our actions and our actions reinforce both.

This is especially evident when we experience pain.

Changing The Unchangeable?

We discussed earlier that pain is a protective response, which is based on the perception of threat.

There is a greater evidence of danger to ourselves, than there is of safety for ourselves. (15)

Going back to the premise of this post: chronic pain is rooted in fear.

Fear changes our perceptions.

Fear makes us think or feel that we are in danger moreso than we actually are.

Fear makes us want to find safety.

But if fear is influenced by a host of factors, many that we don’t know, and most that are unconscious, can we change it, and as a result, change pain?

I say yes.

Cognitive Based Therapy

CBT

When we can identify our fears around pain, then we take away some, if not all of its power.

Yes, pain will still hurt, that’s the nature of pain, but our suffering is different.

We stop catostrophising.

We stop worrying.

We start focusing on what we can do.

We start focusing on who we are.

The challenge of identifying and treating unconscious fears is obvious.

Fortunately, over the years, psychologists have developed many ways to explore our unconscious.

One of which, is cognitive behavioural therapy.

Cognitive based therapy is based on the premise that each thought is related to a certain emotion and behaviour, and vice versa.

By exploring each aspect around our beliefs and understanding of pain, we can change what we think, feel and do, to decrease our pain and suffering and eventually, change our unconscious thoughts.

Cognitive behavioural therapy is not only effective for treating pain, but also something that can be performed by suitably trained manual and physical therapists*.

A Way Into The Neuromatrix

The most up to date, and most widely accepted model of pain, is the neuromatrix model, proposed by Melzack and Wall (pictured).neuromatrix

What you can see in this diagram, is that there are multiple inputs (on the left) to the “body-self neuromatrix” (the representation of ourselves, within our brain) from both the body and brain, which influence what our body does, how it feels and how it functions (outputs, on the right)

These include:

  • Cognitive related brain areas
  • Sensory signalling systems
  • Emotion related brain areas.

But, that’s not all, each of these inputs can affect each other, as can each output.

Everything affects everything when it comes to pain.

What any good clinician is trying to do when treating someone in pain, is provide enough context for the outputs of the neuromatrix to change.

We do this by influencing the inputs in a way that promotes increased descending inhibition (as discussed earlier).

In addition to CBT, we can use other interventions like touch (manual therapy from intelligent, responsive hands) and movement.

Basically, we are trying to tell your brain that it’s okay, things are safe and you don’t have to be on edge.

When your brain is no longer in “fear mode”, it can resume normal modulation duties and you start to feel better.

Conclusions

Most chronic pain occurs in post surgical patients. (16)

There is an obvious physical trauma that takes place.

Many others develop chronic pain conditions after intense and/or prolonged psychological and/or emotional distress.

Something occurs to shift the brain into “fear mode”, in which it wants to do nothing more than protect itself (and you), which it does by producing pain.

We know that pain is complex and multi-factorial, but too often we think we are the exception.

It can feel like we just need to “release” that tight muscle or “crack” that stiff joint.

It can feel like there is “wear and tear” or “damage”.

But at least 40% of people with widespread arthritis don’t experience pain.

Amputees with no limbs do experience pain, in the absent limb!

You have to be fully engaged in the process, and willing to confront a lot of home truths about what you think, feel and believe if you want to treat your chronic pain successfully.

Even when you do that, sometimes you’ll still be in pain.

But, if you don’t, you’ll definitely still be in pain.

 

 

Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 



 

 

 

*If your condition was too complex for the therapist alone, we would refer you to a psychologist. In Australia, there is a mental health plan, under which your GP can refer you for up to 10 consultations with a psychologist, partly subsidised by medicare.

References

(1) Expectations and chronic pain outcomes

(2) Patient goals and measuring treatment outcomes

(3) Cognitive functional therapy for low back pain 

(4) Activation of threat-reward neural networks

(5) What is pain?

(6) Predictive processing simplified

(7) Pain

(8) Nervous and immune system interactions

(9) Structure and function of nervous system lymphatic vessels

(10) Mechanisms of inflammatory pain

(11) Descending control of pain

(12) Continuous descending modulation revealed by FRMI

(13) Free Will

(14) Myth of free will

(15) DIM-SIMS

(16) Chronic pain and surgery

Pain Is A Verb, Not A Noun

Brain
When you seek treatment for pain, part of that process should be a thorough education about pain.

This education should cover the basics:

So that you understand the physiological process, at least at a basic level.

Many people think pain is only a marker of tissue damage. It’s not. It is a multi-factorial sensory and emotional experience.

To help people change their understanding of pain, I like to describe pain as a verb, not a noun.

For those of you who can’t remember primary school English (or never learnt it in the first place):

  • Verb = doing word
  • Noun = thing

Thinking about pain as something you experience, instead of something you have is empowering.

It gives you an active role in your pain experience. This means you can influence your experience, for better and worse

How? With your thoughts, feelings and actions.

Pain Is A Body and Brain Experience

All pain has three major components:

  1. Physical
  2. Cognitive (thoughts)
  3. Emotional

The relative contribution of each component varies.

Often we can determine which factor is likely to be the primary driver of each pain experience, but we can’t measure by how much.

Even though were aren’t always aware of each component, they are always there.

If the primary driver of your pain is physical, then physical treatment approaches tend to work best.

This is the same for psycho-emotional pain, which response best to psycho-emotional treatments.

Kind of obvious yeah?

Where it gets tricky, is that even physical approaches have cognitive and emotional aspects.

There is no separation.

Get Involved In Your Treatment

The best outcomes in pain treatment occur when you and your practitioner are working together.

This maximises the effects of treatment.

The more effective your treatment, the faster your resolution of pain. Again, kind of obvious yeah?

You are probably more involved in your treatment than you think.

First, you chose your practitioner (hopefully). The act of choosing is both psychological and emotional. You want to choose someone who is good at what they do, and who you like.

Second, you are probably already doing things to help your recovery. They may or may not be the best things, but you’re already changing your behaviour.

A good practitioner will point you in the right direction of what change is best, but you’ve made a start.

How To Change Your Pain Experience

Our mental and emotional state influences our perception.

Think about watching a movie. If you are on a first date, it’s a very different experience to watching the same movie with your long term partner after you’ve had a fight.

Same stimulus, different psycho-emotional status and thus different perception/response.

This principle can be applied to factors affecting pain:

  • Take control of your emotions. First, identify your thoughts and emotions around pain. Commonly these include fear, anxiety, overwhelm and frustration, among others. Then you can change them. A good practitioner will help you with this.
  • Improving your stress management. Stress is dictated by the way we frame an experience. Any event has the potential to be stressful. By learning to change your framing of stressful scenarios, you can minimise your stress load.
  • Change your environment. Our environments shape us, for better and worse. Sometimes, as hard as it is, the best thing you can do for your pain is change or leave aggravating environments.

Conclusions

It might be strange to consider pain as a verb, not a noun. But as I outlined, it can make a massive difference to both your pain and suffering.

Taking a different view on things is the first step to changing your outcomes.

And while different views can be quite confronting, it is the only way to grow.

Hopefully, this growth means improving or eliminating your pain.
Nick Efthimiou Osteopath

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.