Why You Should Choose Conservative Health Care

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You can’t cut out pain. – every *good* orthopaedic surgeon ever

Despite what we know about pain, many people are subjected to poor medical management for their pain on a daily basis.

From the recommendations of medications that don’t work for certain conditions (ahem, anti-inflammatory drugs and low back pain), to expensive courses of passive therapies that have extremely low effect sizes.

Not only do these treatments not work very well, they are is an enormous waste of everyone’s resources. To make matters worse, many of these management strategies are not benign, meaning they have the potential for negative side effects.

When it comes to poor medical management, over the counter medications and ineffective passive therapies are the (very small) tip of the iceberg. Many costly, and potentially dangerous drugs, invasive therapies like injections, nerve blocks and the “grand-daddy” of them all, surgery all carry high risk profiles and for very small benefit, especially over the long term.

It’s right about now that I should add some moderation to this post:

I’m not saying these treatments are completely worthless all the time. In fact, I have had many patients who have benefited from the right prescription or surgery over the years.

What I’m saying, is that these treatments often come with big costs and risks that are not fully disclosed when they are recommended (although nearly every surgeon does a better job at explaining the risks of their treatments to patients, many still overplay the benefits or don’t fully explain the alternatives).

With this in mind, the sleeping giant in the treatment of most painful problems, especially those involving the musculoskeletal system is good conservative health care.

I emphasise the good, because there is so much bad out there.

No, I’m not trying to be negative and put down other health professionals. I am simply stating, that based on my experiences with patients (and supported by research), many have not had adequate conservative care to begin with, which is how they’ve ended up with chronic conditions in the first place.

What Is Conservative Health Care?

Conservative health care is based around interventions designed to avoid radical medical therapeutic measures or operative procedures. 

They are typically lower in cost than more aggressive treatments, which a much safer risk profile.

The downside is that some conservative treatments don’t have a large effect size, and many work in general, not specific ways.

Some examples of conservative health care include:

  • Education, advice and reassurance
  • Lifestyle changes
  • Dietary changes, including supplementation
  • Exercise based interventions
  • Physical/manual therapy
  • Certain medications

When Should You Seek Out Conservative Health Care?

Conservative health care is not appropriate for all health problems.

Serious and life threatening conditions typically need more aggressive and/or invasive treatments. Examples of such conditions include major infections, cancer, organ diseases and major trauma (though there are many more).

When conservative health care is most optimal, is when a condition is chronic and stable, or progresses slowly, when the condition is self-limiting (i.e. it will resolve with time, and symptomatic management is all that is required) and when the condition is non-specific (it can’t be attributed to a single cause), like many low back pain presentations.

Usually, a general practitioner will be able to advise you when conservative options are suitable, so that’s often a good place to start.

Conservative Treatment For Pain

Pain is the number one reason people consult their GPs, however, a lot of pain is very poorly managed from the begining, leading to the progression towards chronic and more debilitating pain.

This is where I feel that conservative management can really shine.

Almost every chronic condition will improve to some degree from improving your health generally.

Additionally, many chronic pain presentations will benefit just as much, if not more in the long run, from good conservative management.

Unfortunately, many people miss out on receiving good conservative care when they need it most, leading to them needing/wanting more aggressive treatment options when their condition has progressed.

The Benefits of Conservative Health Care

Conservative health care has a number of benefits for all parties involved: patients, practitioners and 3rd party payers (insurance companies, governments etc).

One of the biggest benefits is economic.

Let’s take chronic low back pain as an example, because it is so prevalent, and so widely researched.

The cost of these conditions to the Australian economy in 2012 was more than $A55 billion. Back pain and osteoarthritis, the most common of musculoskeletal conditions, accounted for 52% and 41% of cost respectively.

When we look at the costs, most people intuitively think of the cost of treatment (consultations, investigations like imaging, medication etc), however, the bigger cost is the indriect cost, that is the cost to society and the individual of lost income, productivity and quality of life as a result of their condition.

While the direct costs of chronic conditions is around A$9 billion annually, the indirect costs are a staggering A$54 billion annually!

With such high costs, you’d think that prioritising excellent conservative care from the outset would be high on the agenda for all involved.

Unfortunately, many clinicians do not follow the clinical care guidelines which are developed by compiling the best evidence from researchers around the world. In fact, only 20% of low back pain patients received care inline with the guidelines.

These guidelines are designed to ensure the best possible management of each condition, yet with only one in five people getting treatment based around them, many are missing out and going on to develop chronic pain, which ends up costing them in time, money and quality of life.

Other benefits of conservative health care include:

  • Safety – by definition, most conservative health care is low risk.
  • Availability – there are typically many more health professionals able to deliver conservative health care than specialists who deliver more invasive treatments.
  • Sustainability – conservative approaches can typically be maintained over the long term, which can help manage chronic conditions.

What stops people getting good conservative treatment?

I believe that most of the time, most people are doing the best they can. As a result, the lack of implementation of clinical guidelines for conservative care is not down to any one factor, but here are a few:

  • Market forces – funding for public health services is always stretched, so GPs cannot spend adequate time educating patients. Private practice clinicians are often limited in the number of times they can see someone due to a patient’s ability to afford treatment.
  • Expectations – patients often want to be “fixed”, not understanding, or wanting to participate in more active management for their conditions.
  • Practitioner knowledge and skill – most health practitioners are skilled in diagnosis and treatment, not in facilitating behavioural change. This makes it hard to create long term, empowered change.

With this in mind, we can see the challenges that need to be overcome to offer the best available conservative care.

What is needed to improve conservative treatment?

  1. Government and insurance companies need to appreciate the long term cost savings conservative care offers, and fund it accordingly. If a surgery costs $20,000 spread across direct and indirect costs, and that surgery could have been prevented by 2 years of physical/exercise therapy, then even at $100 per session, twice per week, you are coming out at break even. However once you add in the rehabilitation costs of surgery, and the costs of the increased risk, the physical therapy option is actually cheaper.
  2. Patients need to take responsibility for their thoughts and actions. Yes, circumstances can affect everyone, which can make life harder and less fair for some, however, taking 100% responsibility for how you respond and act will mean that you are in the best frame of mind to improve your situation and your condition.
  3. Educational institutions need to adapt to the changing demands on healthcare and focus more on communication and behaviour change. Simply increasing the awareness of this important skill will lead to those interested healthcare practitioners pursuing further education.
  4. Health practitioners must accept that they can always improve, and seek out ways to develop their skills to better serve their patients. This includes seeking out appropriate continuing education, but it also means enhancing their networks and their ability to utilise these networks to benefit their patients.

The Big Two

Of all these factors, the two most important are economic and cultural forces.

Money is always an influence on how we make decisions, and many people simply don’t have the financial freedom required to pursue optimal conservative care, especially privately.

While there are always those who are living on the edge, and literally have no room in their household budgets for anything about the essentials of living (housing, food, transport and utilities), there are many more who claim that health care is too expensive. Yet these people walk around with the latest iPhone on a high monthly plan, or drink/smoke/gamble regularly. For these people, who may be on average incomes, it is simply a matter of choice and priorities*.

This is where culture becomes important.

Our culture in Australian is heavily influenced by commercial interests.

Unfortunately, there is a lot of money to be made in selling treatments for conditions that offer a simple solution to a person’s health problem.

Whilst they appeal to our emotions, simple solutions are usually inadequate for complex problems.

So when you propose a long term course of conservative care, which involves active participation by patients, it is often a tough sell.

It is made even tougher by the massive marketing budgets pharmaceutical companies and medical device companies have. They use these to influence our culture.  Every night on TV there are commercials for different types of pain medications. Ironically, if most people spent just 30 minutes less watching TV, and decided to go for a walk instead, they probably wouldn’t need them anywhere near as much.

A Different Perspective

If instead of thinking in terms of expense (cost and time/energy), you changed focus to investment, then immediately you have changed your perspective on health.

When you invest in a term deposit, at the end of the term you have more money than when you started.

Conservative health care, done properly, is an investment.

Yes, you are spending time, money and energy to change your health, which has an initial up front cost. But, by the end of the treatment program, you should have improved health, reduced pain, better function and an overall better quality of life.

Get more years out of your life, and get more life out of your years.

These improvements can be thought of as your return on investment. Like a term deposit, conservative treatment is mostly safe, offers fairly predictable outcomes and is overall, low risk.

Once you have restored your health, the idea is to maintain it (just like you would with wealth). Usually this means you need to continue your healthy habits which you established during treatment.

A final word on perspective; if you are in debt, you must pay back your debt before you can invest. The bigger your debt, the more work and time it takes to repay. The same school of thought applies to health. While things can change quickly, true healing from chronic conditions, or even severe acute conditions, takes time.

If that puts you off, think about it like this: time will pass, regardless of what you do or don’t do. If you do nothing, you will be in the same, if not worse situation in a year or ten.

Conclusions

Conservative care is extremely important from both a public health and individual perspective. Delivered optimally, it saves money, improves outcomes and reduces the need for interventions with higher side effect or risk profiles.

There are some barriers to delivering good conservative health care at the population level. On an individual level, the two most important variables can usually be overcome.

If you are a patient: when you are seeking out a health care provider, discuss long term strategies and look for providers who will incorporate an active management plan.

If you are a practitioner, you should look to improve your communication and behavioural change skills. Telling someone what to do isn’t good healthcare. Guiding them through the process of how to do it is.

 

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.

 

 



 

 

 

Notes

*For those who are truly struggling, most universities with allied health programs have student teaching clinics. These allow students to provide supervised care at reduced costs. In special circumstances, the fees can even be waived. Bottom line, no matter your circumstances, if you are really set on helping yourself, you can find a way.

References

(1) Medibank: Chronic pain costs economy more than $22bn a year

(2) Pain drain: the economic and social costs of chronic pain

(3) The burden of musculoskeletal conditions in Australia: a detailed analysis of the Australian Burden of Disease Study 2011

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 and Personal Responsibility

The Mind Is Key

When it comes to persistent/chronic pain, taking responsibility for your thoughts, emotions and actions is paramount to achieving any semblance of a normal life.

If you’ve ever experienced any intense or lasting pain, there’s a big chance you’ve said to yourself at least once “I don’t deserve this”.

Unfortunately, the world is not a fair place, and bad things happen to good people, but, viewing yourself as a victim of pain helps no one, least of all yourself.

This post isn’t about blaming your (or anyone for your pain), but rather to encourage you to take responsibility for the things you can control, in order to give yourself the best possible chance of living a fulfilling and meaningful life.

Is It Your Fault You Are In Pain?

The most commonly accepted model of pain is Melzack’s “neuromatrix model” (1). This model says that pain is an output of the brain, based on multiple sensory inputs, including:

  • Cognitive: memories, attention, meaning and anxiety
  • Sensory: inputs from skin, musculoskeletal tissues and the viscera (organs)
  • Emotive: inputs from the limb system

With this in mind, it is fair to say that any time you experience pain, you probably aren’t at fault based on anything you were consciously aware you were doing, because so much of the pain experience is generated unconsciously.

It is also fair to say that you can influence your pain based on what you think and do when you experience it.

So, to answer the question, in general, the answer is no, it’s not your fault you’re in pain.

However, as always, there are a few exceptions:

  • Acute pain is your fault if it stems from an injury that occurred because you did something stupid – think alcohol related injuries or playing a game of pick-up football knowing you haven’t been active in years.
  • Gradual onset pain stemming from overuse type injury (work, exercise etc) is very preventable with appropriate workload management.
  • Acute, non-specific pain is often the result of psycho-emotional components, more so than any tissue trauma, thus if you constantly put yourself in stressful situations and don’t know how to manage your thoughts and emotions, then you are probably playing a big role in your pain.

No One Can “Fix” You

One of the biggest examples of not taking personal responsibility for your pain, is the misguided notion that someone, or something, will fix you.

There is a growing body of research demonstrating that people with the highest expectations about making a recovery from pain do so. (2)

Combined with the large (and growing) body of research that suggests passive approaches to managing chronic pain aren’t very effective, it is obvious to see that there is a big role for you to play in your own recovery.

This doesn’t mean more passive therapies are useless. It just means the appropriate context has to be set.

What we can boil this down to is as follows: if you can find a knowledgeable practitioner that your like and connect with on some level, who inspires confidence in your ability to recover and gets you involved in the process, then you probably will.

Now, before you think that you have found and done all of that and you’re still in pain, it’s important to define “recovery”.

Defining Recovery

Most of the data on chronic pain comes from specialist chronic pain clinics. These are often public funded and run in, or in association with hospitals. They are typically “end of the line” treatments for people who have not responded to any other form of pain management.

The results these clinics achieve are “fair” when taken objectively, often decreasing a persons self-rated pain by a couple of points on a 10 point scale.

But, when we take into account that nothing has worked before, this improvement is quite impressive.

Additionally, when people are asked to rate their quality of life, measuring things like anxiety, depression and fear of the future, things are generally even more positive.

This gives us good insight into what is realistic for chronic pain sufferers.

If “end of the line” sufferers can improve this much, then good management earlier in the timeline can theoretically achieve even better results.

One of the biggest differences between those who succeed in managing their pain and those who don’t, is that they take action despite their pain.

Don’t Wait For Your Pain to Get Better to Start Living Well

In personal finance circles, there is a lot of talk about developing the habit of saving money, no matter your income.

That is, if you are on the minimum wage, and can only afford to save a few dollars each week, it is still important to do so, even though the amount across a year might not be very much, the habit developed carries on with you throughout life, as you (hopefully) increase your income.

A similar approach can be taken when you are in pain.

Instead of thinking “when I feel better, I can finally do x”, try shifting your mindset to “how can I find a way to do x, despite my pain”.

Now this is often easier said than done, but a good practitioner will be able to guide you through the process. Many times the limitations are self imposed, and a graded exposure approach can work wonders.

What Can You Do About Your Pain?

  • Accept your circumstances, rather than looking for someone or something to blame.
  • Seek out an excellent health practitioner to work alongside you and help build a team around you.
    • Don’t be afraid of medications. Used appropriately, they can be life changing. It goes without saying that you should talk to your doctor before starting or stopping any medications for your pain.
    • Consider working with a psychologist who specialises in chronic pain, in Australia there is an excellent Medicare rebate for psychology – discuss it with your doctor.
  • Outline functional based goals, rather than pain based goals. For example, saying “I’d like to walk my dog for 45 minutes” as opposed to saying “I’d like to walk completely pain free”.
  • Focus on processes, rather than outcomes. Processes are the things you do, outcomes happen based on what you do, but they are always variable (because of factors beyond your control).
  • Start small and build up slowly. 
  • Don’t “let pain be your guide”. Chronic pain is an unreliable guide of what to do or not do. Some days or weeks are worse than others. The challenge is to persist through the bad weeks as much as you can, and enjoy the good weeks without being fearful.
  • Stay positive. I know this can sound like throaway type advice, but there is evidence to suggest that if you can get through your pain, your brain returns to normal – the changes associated with pain are not permanent! (3)

Conclusions

It can seem like an impossible journey at times, and a completely isolating one, but you are definitely not alone.

People have gone before you and conquered pain. Others going on to live full lives despite their pain. Both, in no small part, due to their determination to make their lives better.

This doesn’t mean that you can will yourself better, but it does mean that there is hope.

There are dedicate professionals out there who study hard and work even harder to help people in pain live better lives.

Sometimes you have to work to find them. Sometimes you have to travel to reach them.

But you must, you owe it to yourself, because, the right advice, the right words at the right time, the right actions in the right amount, can change your life.

 

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) Melzack and Katz, Pain

(2) Expectation and low back pain recovery

(3) Brain structure during and after pain

 

A Simple Mind Hack To Reduce Pain

Neurons

Neurons

Pain is the conscious correlate of perceived threat. – Lorimer Moseley, Professor of Clinical Neurosciences and Chair in Physiotherapy, Uni SA

Pain is only pain if we are consciously aware of it, if you aren’t aware of pain, you don’t have pain!

Knowing this, if we can shift our awareness away from pain, we can reduce it.

In medical terminology, this is described as distraction therapy.

Distraction therapy is an effective pain management strategy, and it’s something you’re likely to be familiar with.

If you’ve ever spent any time with children, you’ll have seen them hurt themselves. Sometimes, after a minor fall/scratch/scrape children make a bigger fuss than warranted (tears and tantrums), mostly for attention. Many clever parents use simple distraction techniques to take a child’s mind off the pain they are experiencing. It usually works a treat.

This is distraction therapy.

How Does It Work

There are 2 inter-related but separate mechanisms that are at play.

The first, and probably the coolest, is that distraction therapy leads to the secretion of pain relieving opoids by the brain (1).

These opioids, termed endogenous, as opposed to exogenous opioids that you consume (codeine, oxycodone etc) act within the central nervous system to reduce pain.

The second involves competition for attention between an important sensation and consciously directed focus (2).

This is because the conscious mind can only focus on one thing at a time.

Sure, we can rapidly alternate our attention between two or more things, but at any given moment our attention can only be on one thing.

And going back to the opening quote, “pain is the conscious correlate of perceived threat”, if our consciousness is focused elsewhere, then it cannot focus on pain.

How Do You Use It?

The great thing about this, just like with children, you can use this to help reduce your pain.

It’s important to understand that distraction therapy is not magical. It is simply a pain management technique that is free, easy to implement and accessible to all.

Distraction therapy can work with pain of all different causes, but you can’t ignore the underlying issue:

  • If your pain is caused by a medical condition, see a doctor!
  • If you are suffering pain due to injury, the injury must heal first before the pain goes away.
  • Likewise if you have pain related to movement issues, they must be resolved.
  • Finally, please understand, that persistent or chronic pain is considered a disease in its own right, it’s also not considered to be curable, instead, focus on finding effective management strategies.

 

So how do you do it? The beauty of distraction therapy is that there is no one way.

The most important thing is to use an activity that is interesting and meaningful to you. One that is comfortable and immersive.

You can’t think to yourself “I’m doing to distract myself from the pain by doing this” while you are doing it, because that means your attention is on your pain and not on the activity.

Doing this causes you to engage in a state of flow, and given that your brain will want to remain in this state, it will secrete opioids to modulate your pain.

That’s a win-win. You get to do something that is important to you and reduce your pain at the same time!

There is no limit to how long this will work for, it depends on how strong your concentration is.

Intention and Distraction: The Next Level?

Whilst the research on distraction therapy focuses on the immediacy of performing a task and the subsequent physiological response, here at Integrative Osteopathy we have used similar principles to help patients throughout their entire day.

This is not, strictly speaking, distraction therapy, but the principles are similar – namely that the conscious mind can only give attention to one thing at a time.

Not only does this technique help with pain management, but it can improve your mood and even your life.

The technique is called setting your intention.

It simply involves a short period of quiet contemplation in which you focus your attention on your intention.

What is your intention? It is another way of describing your focus.

If you look back through time, pretty much all cultures had periods of quiet contemplation built into their lives.

Whether it was prayer, meditation or spiritual rituals, these practices allowed people to process events that had happened and the associated thoughts and emotions, and find a place of comfort, if not clarity.

It is part of the reason mindfulness/meditation is gaining such traction in recent years – our attention is being attacked from every direction, distracting us – mindfulness helps with finding clarity again.

To add in quiet contemplation to your life, it need not be complex. In fact, it’s better if it’s not.

How To Set Your Intention

Setting your intention starts with quiet contemplation. A great time to implement it is in the morning, as it sets you up for the day ahead.

Pick something you habitually do, like taking a shower or brushing your teeth, and immediately before/after, close your eyes, slow your breathing and spend a few minutes alone with your thoughts and feelings.

Focus on the one thing, above all else, that you want for the day. This is your intention.

 

Your intention needs to be framed in a positive way. Your brain doesn’t recognise negative words. To illustrate, make sure you don’t think of dancing elephants while you’re reading this sentence.

Once you have the elephants out of your mind, get back to setting an intention.

This focus will govern all your actions for the day, both consciously and unconsciously.

After you have set your intention, you can create an intention card (3). Write your intention down on the front of small card, in one word. Then, on the back of that card, write out a prompt question.

Usually, you would frame it like this:

A. Statement of the intention
B. A question prompting the action which leads to the intention

Here’s an example:

Imagine someone who always feels stiff.

They might set their statement of intention as this: Fluid movement.

Then their question might read: what do I have to do to experience more fluid movement?

Instead of thinking about how stiff they feel, this question prompts somebody to get up and move, to stretch, to avoid prolonged positions and a whole heap of other things, all from a positive outlook. In essence, it’s distracting them from the problem whilst prompting a solution.

 

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) Attention Modulates Spinal Cord Response To Pain – http://www.sciencedirect.com/science/article/pii/S0960982212003934

(2) How Does Distraction Therapy Work – http://www.ncbi.nlm.nih.gov/pubmed/15745617

(3) Intention Cards – http://www.authenticeducation.com.au/intention-cards/