The Chestnut Challenge!

[Luke Rickards]

What people need to know that I have learned about pain and therapy is....
that there is a difference between pain and the problem of pain.

We do our best to understand the causes and effects of pain, and that understanding has improved enormously. However the experience of pain and its manifestations are inherently unpredictable. This isn't going to change.

Pain is a part of life. Obviously it is more a part of some people's lives than other's, and for the very unfortunate it is a significant part of life. However responses to this experience are complex and hugely variable and this often has little correlation with the intensity of physical sensations. The problem of pain does not arise from the sensory aspects of pain, but the anxiety and distress and fear associated with these sensations, and this is predominantly psychosocial.


What people need to know that I have learned about pain and therapy is...
that the more we focus on the pain and therapy for the pain the more likely we are to fail, especially in chronic pain. People in pain need to be empowered. They need to learn that they are safe, even with the pain, and why. They need self-efficacy, that is, the confidence to respond instinctively and creatively to their own pain experience. And as for everyone, they might need to be reminded to choose behaviours that we know make for a healthy and fulfilling experience of life.


What people need to know that I have learned about pain and therapy is....
whether or not we approve of a particular method, both positive and negative responses can occur from a huge range of 'therapeutic' inputs, and predicting the relative response of individuals to a specific treatment isn't always easy. No matter what else we do in the name of therapy, people in pain must be approached with the understanding that there is a nervous system under threat in your hands.

[BB]

What people need to know that I have learned about pain and therapy is....

Whenever you interact with another, you cannot help but impact their thoughts and actions, their behavior. In other words, you are manipulative like it or not.

We are paid to interact and impact behavior. This is our job.

Our impact is indirect. We require the interpretation of another despite the medium of interaction, whether it be touch, talk, presence, or expectation.

In order to affect behavior purposefully we must create a space for interpretation that creates a path. This is our craft.

The ability to create paths to specific behavior, to manipulate, means that we must utilize the tools and information available to create paths which make people better by their own standards, as measured by our standards. This is our responsibility.

Science is the method that best informs this responsibility.

Story is the method in which it is best conveyed.

I’ve learned that pain is

1) unavoidable, while many of its consequences are avoidable
2) something that occurs with and without injury
3) a felt sense while nociception is a non-conscious sensation

I’ve learned to account for phantom limb and asymptomatics in my arguments for or against mechanism. I’ve learned that I’m often wrong and that isn’t the end of the world so long as I move forward.

I’ve learned that a sense of autonomy tends to correlate with a sense of coping ability and the manners in which we interact have profound impact on the others sense of autonomy. It is preferable for a person to sense that change came from them instead of being done to them.

[bernard]

What people need to know that I have learned about pain and therapy is...

That unfortunately (?) I forgot quite all the things I learned at PT school...
I started to lurk at NOI discussion lists in 2003 and thought it was some alien forum since neurology and neurophysiology was not a priority for me and the majority of colleagues! Really?
Then I studied I was wrong at both ends:

That complex nervous system, running everywhere in our body, was of major importance and like a bad boy it may be sometimes irritable and angry when our action is not well understood or accepted by its owner: the patient.

Some years later, the major lessons I apply each day are :

• The first one is Listen and Learn!
• The second one is Less is More!

[ian s]

not so brief.....

“Yup. It's complicated. In the end, whatever happens in any treatment encounter is an outcome of two unique nervous systems interacting with each other, not a set of protocols enacted by a zombie robot upon the anatomical body parts of a human in pain in an operative fashion.” Diane Jacobs

‘Pain the science of suffering’ contained an iconic paragraph on the stages of recovery (or not) This key paragraph continues to influence my daily life and work. Critically, for Physical therapists of all affiliations, Wall described the importance of motor acts and the universal human desire in seeking safety, relief and cure.
Models of pain, physiological understanding, the dissemination and integration of stress biology have all influenced my own approach and understanding. Neurogenesis may provide optimism or pessimistic ‘realism’ as behaviours stay ‘wired’ with repetition.
Quite rightly science guides health care practice and discussion on pain related subjects. It is assumed that pathophysiological knowledge and brain science will lead to enhanced understanding and hopefully better forms of intervention. In some situations this is certainly true but in many aspects of modern health care science cannot (I believe) provide all the answers to the problems of pain and suffering.
My own belief is that individual brains can be studied but the nuanced interaction of people, environments, values and cultural influences lead to infinitesimal variations in pain behaviour. There are limits in other words of how much science can contribute to the project of understanding people.
Other subjects may help the understanding of how people cope and how they make sense of the world without recourse to metaphysics.
Understanding ‘meaning responses’ and the cultural forces, which shape belief and values, are critical in understanding pain and inter-related placebo or negative nocebo reactions. ‘Iatroplacebogenesis’ or factors, which may contribute to it, could be a goal of all future therapists interacting with patients in pain!
One ‘simple’ thing I have learned in regards to pain is the importance of metaphor and how it shapes ones understanding. Pain, understood as a verb rather than a noun for example affects ones perception and the naïve objectivity placed on this complex topic.
I believe that the ‘verb’ of pain needs therapists who are aware and familiar with modern science but who are also aware of the need to understand the affect they themselves have on patients. Pain (particularly chronic pain) needs creative solutions and alternative explanations; reading, curiosity, cultural understanding and self-development may all be helpful things to cultivate.

[HeadStrongPT]

What people need to know that I have learned about pain and therapy is...

We couldn't survive without pain. It’s an essential element of any species that wants to stick around on this planet for any length of time.

Pain wasn't likely a "problem" to our ancestors. You either learned from it and survived, or you didn't. We are much smarter than they were yet somehow we’ve managed to develop a very maladaptive relationship with pain. Our pathological obsessions of embracing and/or avoiding pain have prevented us from understanding pain. Modern society has managed to suppress this very basic instinct, and now we have problem with pain.

Patients need the wisdom to see when pain has a purpose and when it doesn't. They need to understand that constructively coping with a painful problem is a strategy that allowed us to become the dominant species on this planet. Passive coping such as reliance upon polypharmacy, medical specialists (including PTs), devices, etc. is not a healthy or sustainable practice.

Any intervention targeting a painful problem should attempt to elicit the patient's own instinctive ability to recover. No matter what therapy tribe or association you belong, this process starts and ends with the brain and the patient's potential to use it.

Our ancestors responded to pain like they did many other life events - they moved. Physical therapists, presumably holding court in the fields of movement science, should be at the forefront of helping patients explore this relationship. There are plenty of ways we can help patients overcome painful problems. We are the best option for patients struggling with pain, but we are also part of the problem.

Exercise is necessary for a healthy life, but patients should be allowed to move comfortably before they are urged to move with effort. The nervous system learns every step of the way. We should always be asking ourselves what we are teaching it.

I’ve learned that even small shifts in our understanding can lead to significant improvements in patient care. These aren’t “soft” changes either. I’m seeing improved patient satisfaction, clinical outcomes, and more cost-efficient care. All this results from paying more attention to the patient’s chief complaint!

Acting on our understanding of pain will allow physical therapy to be the “sleeping giant” Patrick Wall envisioned.

[Milehigh]

What I have learned about pain and therapy is....

Starting with nociception, which forms the basic homeostatic warning system in the human organism, nociceptors are in all tissues. The human organism attempts to deal with changes in nociception input reflexively and instinctively first. When sufficient nociception is attended to by higher centers of the CNS we become aware of it. Like many things in human biology and perception, this warning system is imperfect and subject to all sorts of distortions and illusions due to these imperfections.

Pain is the expression of these sensations. Pain is expressed through language so therefore was created by culture. The meaning of the pain expression is learned through the individuals social and culture interactions. Thus it is culturally, socially and individually relativistic. Unlike nociception which is nonconscious and is not communicated in any meaningful way between beings. The attribution of pain to a sensorial experience is dependent on a convergent and multimodal sensorial experience and therefore is not exclusively dependent on nociception. Otherwise stated, a person learns to express pain based on their unique sensorial experience, nociception only being a part of, mediated by the persons culturally learned language.

Evolutionarily, the expression of pain, from person to person, patient to practitioner, is used to express danger but also to signal a need for help. It begins with acute pain. The transition from acute pain to chronic pain is mediated by pain being “lost in translation”. From the perspective of the patient, they are unrelieved from solely a biomechanical attribution of their pain and the subsequent interventions that follow. From the perspective of western medicine, the patient’s pain is not real because it does not fit the biomechanical model. The patient’s expression and experience is ALWAYS vivid, real and relevant. It is the perpetuation of this language barrier that permits chronic pain to persist in so many patients.

The language of pain is strongest tool therapists have. The tool is used implicitly when we help ascribe new meanings to the patient’s internal sensations that fit the new science of pain. It is used explicitly when we directly inform them on pain education.

When approaching the organism of another, they should be approached through empathy and understanding resisting any attempt to label them. The most effective interventions delivered are those that are interactive. Those interventions that interact with whole of the person’s organism have the largest chance of impacting the person’s perception and function.

[TribalPhysio]

What people need to know that I have learned about pain and therapy is…both are complex interactions occurring within and between living organisms. While we have improved in our understanding of pain, the mechanics of its expression much like consciousness, remain elusive. For all we have learned, pain remains perplexing. It is a perception that is produced in response to either perceived/actual damage in an effort to protect the organism. It’s expression pre-determined by genetics, but is shaped by our environment and experiences. The brain’s perception of threat is malleable, changing based on our perception of both our internal/external environment, as well as our history and past life experiences; it is strongly influenced by psycho-social concepts I once found frustrating, as “things” that distracted me from what I thought mattered..the BIO (strength, ROM, conditioning, joint mobility). In reality, each individual’s pain experience is largely influenced by an interaction between each component of their particular bio-psycho-social profile.

Much of my journey in therapy was related to finding the “right” system to address my patients concerns, which coincidentally reflected my own concerns. “What is wrong with me [you]? How is therapy going to help me [you]? Why do I [you] still hurt?” These questions have led to the development of complicated algorithms and contradictory systems of evaluation and treatment. All of these may have some effect, some of the time…or none whatsoever. Many of these treatment paradigms have their own belief systems, their own theories, as to what is happening when Q-R-S is observed or X-Y-Z is performed; none have served to clarify the patient’s experience sufficiently. As I’ve grown as a therapist and examined my own preconceptions and misunderstandings, I have begun to see therapy for what it is…an interaction between two organisms, that is influenced by the murky interaction between both specific and non-specific effects. This has allowed me to view each system for its strengths and weaknesses and allowed me to embrace uncertainty in my approach; I can focus on what matters to my patients without getting bogged down by the minutiae of different systems. I can provide them independence, get them moving without unsubstantiated rules set by creators of systems, and provide methods for self-management based on their presentation and lived experience.

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Zachary Huff, PT, DPT, OCS

[Chocco]

The one thing I know is that I don't know anything and that is OK.

I believe that we are not a complex combination of body systems and functions, but one system that funtions off of memories, lessons, beliefs and functions that we have learned since we were born. Neurology, pscyhology, etc. gives us a way to study and learn the human body and human experience, but they don't truly exist. You function as one unit. You don't call on one specific system, you call on your memories, your lessons, your experiences and your beliefs and we use the to respond to whatever we need to. If this is true, then everyone's experience is unique to them and every patient needs to be treated as the unique individual that they are.

I believe that science is the best weapon on learning how to treat patients effectively, but I dont think it does a good job of showing us why. In studies the conclusion derived from the experiment are tainted by bias and are limited by our lack of knowledge. I believe the data and the results of well designed scientific studies move us much more forward as a profession and a society than the assumptions that someone conveys to explain why. I am not saying that we should not ask why or try to answer why. I am saying that we shouldn't be foolish enough to think we know why, when over time we know we will most likely be proven wrong. This will allow us to be a more versatile profession and society and help prevent the spreading information that will be proven incorrect years from now.

i believe that pain is a personal experience created by someone else's brain. It is very likely that you don't/can't feel the same pain your patient feels.

I believe that PTs need to understand "psychology". Not specific models or theories but an understanding of the impact that their words and actions have on their patients

I believe a lot things but the one thing I know is that...
I don't know anything and I am ok with that and so are my patients.