The following downloadable document is my personalised explanation of pain and persistent pain based on the neurobiology. It is updated every now and then as I think of better stuff.
It also attempts to explain how current health industry methods which prioritise body structure causes for pain, and most commonly offer no wider perspective, can unintentionally feed into persistent pain. This can be a very much greater problem in certain contexts eg: in compensation related pain conditions.
There is specific relevance to a project I in which I was involved in relating to spinal surgery pathways for back pain.
It is mainly intended for patients but there is likely relevance to all, including health professionals who are managing pain focussing mainly on injuries and changes in body structures as the cause.
It is split into two parts - a general part and the second part which uses the common problem of pain in the spine as an example.
I am not making this stuff up!!
Look how similar the information is in this booklet produced by the Department of Health in Tasmania that I just found online recently
PS: the only bit missing is how negative information and information that is over-focussed on structural things (which is unfortunately quitecommon these days) can actually harm you.
I am not making this stuff up!!
The link to the right is to a freely available collaboration which walks you through this information via 15 x 1 minute slide presentations and other material -
(it is available in a variety of different languages)
I collaborated recently on a publication with Dr Darren Beales, PhD, a musculoskeletal physiotherapist, who 'gets it'.
Please have a look at the resources on his site, especially if you have persistent pain from a compensation injury --> Pain Options.
This next downloadable document is for patient information purposes and follows on well from the example of back pain referred to in my patient education document above.
It was created by the American College of Physicians based on very solid research that the majority of scans in back pain result in obtaining information that is associated with WORSE outcomes.
The solid explanation for how this happens is in the science of pain and placebo / nocebo responses.
It is not the scan itself that somehow magically makes you worse, it is how the information on the scan is interpreted and advised to the patient that is the problem. This information feeds into the 'danger' side of the brain's pain equation (see below) unhelpfully.
Radiology Tests for Patients With Low Back Pain.pdf
Size : 32.537 Kb
Type : pdf
Hopefully the information makes some sense. What I am attempting to do is to connect the dots between:
- how pain actually works in everybody (not just you!) as an output of nervous system processing; not an input, and in every condition (yes - even cancer),
- how actual healing and recovery from pain and injuries doesn't just rely on the 'injury' or 'degeneration' alone but also on the very powerful 'mind / body' connection,
- how standard health systems can 'help' you, but how they can also unintentionally 'harm' you,
- how other life issues and influences are important in recovery and how this actually works.
So, the 3 summarised take home messages are:
Pain is not in reality aligned with 'damage'. Pain is in reality aligned closely with the perception of the need for PROTECTION.
What is said, perceived and believed about an injury is far more influential in the outcome than the injury itself.
EXPECTATIONS are very important. Best and safest results are obtained when expectations align between all involved in a RE-ADAPTIVE direction.
Here is some more detail:
- Pain is an important protective mechanism, BUT pain CAN and DOES exist or persist even when there is nothing that needs protection. All that is required is a perception that protection is required. And the longer this goes on, the more 'stuck' it becomes. The ultimate aim is to end up with the protective pain that is needed and nothing extra. This is reliably possible only once pain is properly understood.
- Pain is generated by the brain. It will be generated reliably when the brain's perception of 'danger' is greater than the perception of 'safety'. This is the 'brain's pain equation'. DANGER = electrical signalling input when present (but remembering this is NOT sufficient on its own or actually even necessary for pain), perception of harm, damage, injury, threat to person or security, including financial security, inconsistent information, need for something to be 'fixed', being told 'there is nothing wrong with you' when you are in pain, the pain itself via a negative feedback circuit etc, etc, etc. SAFETY = perspective, knowledge, reassurance, confidence etc. Unfortunately I can think of many more things that feed into the 'danger' than the 'safety' side of the equation.
- Please consider that your general health, psychological situation, fatigue levels, stress, poor sleep, the CONTEXT of your injury etc, are inseparably CONNECTED TO PAIN and, in particular, persistent pain. They are not secondary to the pain as many believe; they are part of it and need to be managed primarily to facilitate the best recovery. This is most effective if you understand your pain properly.
- Be very aware that unfortunately many in the health system have as yet not adequately realised that WORDS can be as powerful (if not a lot more powerful) than medications, syringes, interventions and surgeries in pain situations. This occurs via what is called the NOCEBO response, which is the opposite of the PLACEBO response. Both result in measurable body changes not just psychological effects. And this can happen to anyone, not just certain types of people.
- In life everyone is presented with challenges. At some stage in any challenge it is important to decide whether you are going to strive to be a SURVIVOR or give in and be a VICTIM. Pain struggles to persist if you are a survivor but thrives if you become a victim. Quite often, the system around you disempowers you and unintentionally contributes to convincing you that you are a victim. Don't let it ... Be as good as you can be. This may be difficult but don't settle for anything less! You owe it to yourself and your family (have I mentioned that chronic pain also affects your children ie: if you have it and don't get rid of it your children are more likely to have a similar problem!).
ASK MANY QUESTIONS!! Be an 'informed health consumer'. Don't just accept perceived expert opinions as facts. Many experts only provide you with an opinion based on what they have accepted as being true and their own personal opinions based on their experiences. You would be surprised how little solid evidence there is for many of the things you are being advised.You would be amazed at how little many health practitioners still understand about pain apart from simply blaming things seen on scans that also appear commonly in people with no pain as well. That is a bit like seeing the horizon as a line and then believing that the world is flat.
- NB: One of the very worrying things I have discovered is how little the great majority of people actually understand about their pain, and yet they are willing to undergo potentially hazardous and pain provoking procedures in a desperate effort to escape their pain. In my opinion, that is not proper 'informed consent' especially if the surgery is dangerous and unproven as being directly and truly effective.
There are many more resources out there that support this information!
Here are a fairly large selection.
I recommend you 'drip feed' them ie: one or two at a a time or it will all be a bit overwhelming (if it isn't already!)
The 'Explain Pain' text and related items by Dr David S. Butler and Prof G. Lorimer Moseley.
are available for purchase via the button link to the right.
In my opinion this text should be considered compulsory reading for patients and clinicians.
NB: Please watch this short video on pain 'thought viruses' and how 'explaining pain' works as the vaccine against them:
I have also discovered an excellent text available fully online via the button link on the left written by a credentialed Canadian Physiotherapist called Dr Barham Jam called:
"The Pain Truth … and Nothing But!
-An Easy to Understand Patient Education Handbook on Pain Management"
I think it is excellent and also recognises the role of inappropriate scan focussed diagnostics in the persistent pain process.
There are some excellent practical tips to achieve recovery.
It is available for purchase in hard back version via:
The button link here to the right below the graphic will take you to a site where I would highly recommend that you consider purchasing the DVD, or the download, for an excellent production by Shannon Harvey with the primary aim of understanding the remarkable link between your mind, your body and your health. I have had personal contact with Shannon as well as a few of the presenters interviewed in this film. I am convinced that her primary motivation, like mine, is to share our discoveries and the extraordinary research that strongly supports this relatively poorly prioritised aspect of healthcare.
Please also check out the extra information available including the longer interview with Prof Herbert Benson (Professor of Medicine at Harvard Medical School and the Director Emeritus of the Benson-Henry Institute for Mind Body Medicine)
The brain's role in pain
- It is worth spending about 10 minutes listening to this piece by an impressive neuroscientist and researcher Dr Tasha Stanton, who is working on non-drug treatments for people with chronic pain. This approach is quite similar to the aims of this website to empower recovery with 'knowledge'.
This was broadcast on Monday 15/08/16 on ABC Radio National's Health Report program hosted by Dr Norman Swan.
It is available via the button to the right --->
Here are some other freely available you tube video links to explore that are relevant to my messages:
The first video was created by the Hunter Integrated Pain Service (Details are available via: http://www.aci.health.nsw.gov.au/ie/projects/brainman).
It is a great, easy to follow and short introductory video about chronic pain. It helps you understand what current research has been saying about chronic pain - thats its not a joint or muscle problem, rather a 're-wiring' of the brain perception of itself. In other words, the brain has become more sensitive than before:
The video to the right is similar to the one above but is directed more towards a younger, adolescent age group:
And more from the 'BRAIN MAN' series:
Here's a great TED talk from Lorimer Moseley, a clinical neuroscientist who studies pain and the co-author of "Explain Pain". Lorimer is an internationally influential researcher who is based in Adelaide. He is also an engaging and humorous speaker.
Many of the science based principles are surprising, useful, non-intuitive and unfortunately unknown by many people who suffer from pain and even people who treat pain for a living.
The video is a typically short TED talk and so it is reasonably just another introduction to encourage people to re-conceptualise pain in the proper way based on the solid available science. He is NOT saying that pain is imagined!
We experience pain from the moment we are born until our dying breath. We spend our lives trying to escape it, yet it is essential for our very survival. This BBC documentary explores how genetics, the latest scanning techniques, virtual reality and hypnosis are helping us to unravel some of the mysteries behind pain. Find out why some feel more pain than others, meet the people who feel no pain at all and discover why our emotions and thoughts can influence our perception of pain:
The concept of NEUROPLASTICITY is almost certainly the key to understanding why pain can become chronic, resistant to treatment and get stuck!
NEUROPLASTICITY is the brain's ability to reorganize itself by forming new neural connections throughout life. Neuroplasticity allows the neurons (nerve cells) in the brain to compensate for injury and disease and to adjust their activities in response to new situations or to changes in their environment.
Neuroplasticity sometimes may contribute to impairment in the opposite way in a poor environment. It is becoming increasingly recognised as a major factor in the persistence of pain.
Here are some videos that will hopefully help in understanding neuroplasticity.
A good understanding of the way the mind processes external advice and information, perceptions of threat and 'harm' is vitally important. The 'mind / body' connection is REAL, POWERFUL and SCIENTIFIC.
In most research involving medication the fake 'sugar tablet' is effective in as many as 30-40% of people. There is evidence that injections have a higher placebo effect rate, and surgery for pain probably has the highest placebo success rate for many good reasons. Unfortunately, this is also potentially harmful if a complication occurs and as many know, pain can persist quite often even if the surgery is structurally successful based on the mind's priorities.
Wouldn't it be wonderful if we were able to harness the placebo effect 'naturally' by simply understanding what was actually happening in our minds and bodies and applying clever, confident strategies.
But then there is placebo's evil twin to consider - the 'NOCEBO' effect or as it is probably known in our Australian indigenous society as "pointing the bone".
Hopefully these discovered videos will help explain this further:
Here is a TED talk from Dr Elliot Krane, an American paediatric anaesthetist with an interest in pain.
At the severe end of the spectrum of pain sensitisation is an extraordinary condition which has been referred to as Reflex Sympathetic Dystrophy or more recently as Chronic Regional Pain Syndrome Type 1 (CRPS). This shows how severely impaired the neurological processing and production of pain can actually be in some cases and how this has very little to do with the severity of the injury.
We think of pain as a symptom, but there are cases where the nervous system develops feedback loops and pain becomes a terrifying disease in itself. Starting with the story of a girl whose sprained wrist turned into a nightmare, Elliot Krane talks about the complex mystery of chronic pain and reviews the facts we're just learning about how it works and how to treat it.
Here are a selection of presentations available from Doc Mike Evans relevant to pain, stress management and the health benefits of exercise.
Dr. Mike Evans is a physician based in Toronto, Canada, known worldwide for his work in innovative, evidence based health messaging to the public. He has built a media lab that brings together filmmakers, designers, patients, and social media mavens. More than 10 million people have seen his famous whiteboard lectures on YouTube.
He has other excellent presentations available via a simple searchon you-tube or via:
Dr. Daniel Levitin is a Montreal based neuroscientist. His research focuses on pattern processing in the brain.
He also gave a recent TED talk on the problem of not making the best decisions when you're stressed. He proposes that there's a way to avoid making critical mistakes in stressful situations, when your thinking becomes clouded — the pre-mortem. "We all are going to fail now and then," he says. "The idea is to think ahead to what those failures might be."
It is also worth visiting these links to other sections in this site to get a better understanding of how you can get caught up in a health system that may have lost its way ----->
Links 4 u:
- "Wasted" by Dr Norman Swan and Jaya Balendra. Four Corners episode aired 28/09/15
- "VOMIT" - Victims of Modern Imaging Technology
- "GRIT" - a road map metaphor for injury recovery and pain.
- "Chuck" - the role of perceived injustice in chronic pain.
- What do the common cold and persistent pain have in common?
- Making a mountain out of a 'pain' hill.
- "He (or she) done it!"
- Pain is SUCH a pain!
- Crime and punishment.
- 'I feel your pain'.
- Be careful what you believe in; it can become your reality (parts a & b).
- The problem with carrots
- "Save a life, save the whole world"
There are a fantastic series of texts by Adriaan Louw who has authored important research on pain. These are both general and specific to certain pain conditions. These are highly recommended and are available for purchase on AMAZON or directly through the OPTP website via the links to the right -->
The health benefits of meditation and/or mindfulness
If you would have told me several years ago that I would be supporting such management so strongly, I would have laughed.
It is a testimony to how little perspective was provided in my medical education that I had to find out for myself that there has been strong evidence for some time regarding the health benefits of simply taking time out regularly to 'calm the farm'.
There is in fact more impressive, wide-ranging and consistent scientific evidence for this than there is for just about any musculoskeletal / orthopaedic intervention that I can think of!
I recently attended a 4-5 week course that I can highly recommend.
It is run by excellent presenters including an enlightened rheumatologist who is doing excellent standard medical management in a holistic framework.
I can highly recommend this course as a valuable, potentially life changing and PAIN-REDUCING experience.
Please check it out via this link:
An excellent text on this is The Relaxation Response which is a book written in 1975 by Prof Herbert Benson, a Harvard physician, and Miriam Z. Klipper. The response is a simple version of Transcendental Meditation presented for people in the Western world. It is evidence based and I repeat that it was written originally in 1975; I did my medical training from 1978 to 1983 and not a word of it was mentioned in the unbalanced focus on trying to explain pain and illness by physical factors alone.