Treating pain as a perceived expert means that there is a responsibility to understand it from all perspectives first.
We owe it to our patients and also to the fundamental 'first, do no harm' principle.
The standard method of simply telling someone in pain that whatever is seen on the scan is the cause of their pain has intrinsic harm potential.
Most patients in pain believe in their health professionals.
Words alone can alter their outcomes.
Interventions can harm them.
Just because successful results are perceived in a number of patients does not prove that the management is directly successful.
Common pain interventions are not supported robustly and consistently by proper trials and in systematic reviews. There is often a significant degree of bias and there are methodology concerns in many supportive studies. Varied techniques are then applied enthusiastically and liberally, hiding behind the guise of the 'art of medicine'.
New procedures are marketed aggressively and gain ground ahead of properly conducted trials.
Placebo responses exist in all therapies and clinical interactions.
There is a placebo hierarchy.
The colour and expense of fake pills affects the placebo rate of success. Injections are more powerful via a placebo construct than tablets. Recent research suggests that surgery for pain has the highest placebo response rate of all. Standard comparative, 'best available' research methods of assessing 'success' via reported outcomes are therefore highly questionable. These are the 'gold standards' in many studies.
But surgery is potentially harmful, and pain can persist not uncommonly even after successful surgery, and EVEN after surgery for accepted robust indications.
Have you never wondered WHY?
Have you never wondered why chronic pain has increased alarmingly in the same period as major advances in imaging and other technology and intervention expertise?
There is an excellent explanation in science, and even though aspects of it may be confronting, it should not be ignored.
The scientific method that has brought so many benefits to humanity relies on principles that theories and paradigms should be constantly re-examined and questioned. They should never be just accepted as 'gospel' truth based on expert opinion. This is especially the case when outcomes do not produce consistently reliable results.
Even the great Albert Einstein recognised this -
In pain and pain related disability there are many important, but often subtle, 'forks in the road' that can result in serious long term changes to the outcome. For example simply telling someone phrases so common as "your pain is because of that bulging / degenerate / ruptured (etc) disc", "your unstable back" or "that bone on bone arthritis" etc, etc ... can have extraordinary long term consequences.
If 'danger > safety' is perceived based on your comments then maladaptive and treatment-resistant pain is more likely.
This is not just time dependent (please read my blog and the 'tale of two nails') but becomes more of a problem when pain persists due to maladaptive plasticity processes.
There is a basic, safe and logical alternative management pathway.
I think it is VITALLY important to do the basic things as well as possible and not to be lured by seductive shortcuts.
As analogised on my first intro page, solid houses need solid foundations and it is very difficult to rectify faulty foundations afterwards.
The earlier patients are given full pain understanding, proper perspective and reassurance the better; it is much more difficult to alter long entrenched beliefs further down the track.
Standard rehabilitation methods have different outcomes if done with the confidence that 'no harm is being done'. Contrast this with a tentative approach with poor confidence because structure is perceived as faulty, flawed and worthy of surgery down the track 'if conservative management fails'. Comments as simple and innocently intentioned as this one are made commonly. In those who do not resist these messages they effectively sabotage benefits that would be obtained from non-interventional pathways.
Conservative management without appropriate pain literacy education and full perspective is NOT sufficient to be described as 'failed'.
It is worth considering adding pain literacy education and comprehensive consideration of the injury context to injury management. The focus should be on reassuring patients as to the positive adaptability potential of their minds and bodies as well as a good exercise rehabilitation program. All this contributes to 'optimal' and safe conservative management for a pain related condition.
To assist in this re-conceptualisation process I offer the more basic resources on another page and further more professionally oriented ones here.
Take a risk and take my test yourself and then explore the answers which are all science based and justifiable, but always open to discussion.
Finally, I offer my blogs for a more quirky view based mainly on my own rationale, perspective and experience. These are mainly influenced by the many detailed case reviews that I have done over many years where context has almost always trumped pathology, yet we mostly still obsessively prioritise pathology.
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 it should be considered compulsory reading for clinicians and patients!
I also highly recommend that you check out the following websites, subscribe to the blog or follow on twitter the following related to these authors:
The noiep➂ Explain Pain course over 3 days that I attended in / April 2014 was EXCELLENT! I highly recommend attending one of these courses that is run in different areas.
Details are available on the NOI website.
There is an excellent text by Adriaan Louw who has authored important research titled:
- The Effect of Neuroscience Education on Pain, Disability, Anxiety, and Stress in Chronic Musculoskeletal Pain. Systematic Review. Louw et al. Arch Phys Med Rehabil Vol 92, December 2011
Preoperative pain neuroscience education for lumbar radiculopathy: a multicenter randomized controlled trial with 1-year follow-up. Louw et al. Spine (Phila Pa 1976). 2014 Aug 15;39(18):1449-57
It is a guide for clinicians on how to understand and explain pain to patients effectively. This and other patient education texts, relevant to pain generally or various specific pain conditions, are available for purchase on AMAZON or directly through the OPTP website via the links to the right ----->
I recently completed reading a text which is written by Professor Ian Harris. He is an eminent academic and a NSW Orthopaedic Surgeon, who has published extensively including regarding the poor results of surgery in compensable pain conditions (ie: manifesting that 'context' defeats 'pathology').
I commend him for this work, its forthrightness, credibility and honesty.
It addresses the 'elephant in the room' with respect to surgeries and interventions that have not been proven to be effective, yet are being applied liberally with inherent harms. Importantly, Prof Harris calls for a 'science-based' rather than 'evidence-based' approach and I couldn't agree more.
There is published evidence to support just about any standpoint; that doesn't make it scientific. The quality and problems with current published 'evidence' is addressed in this text and also in a TED talk on the matter* (* refer to the link below this section).
I only have one issue with Prof Harris' book. He refers to placebo as having no real effect at all. The science would suggest that that comment is not entirelryaccurate.
Placebo responses are based on expectations. They are real and are both psychological and physiological. They are measurable.
- Placebo and Pain. From Bench to Bedside. Colloca, Flaten and Meissner. Elsevier Publishing 2014
- Medicine's inconvenient truth: the placebo and nocebo effect. Arnold, M., Finniss, D., Kerridge, I. (2014). Internal Medicine Journal, 44(4), 398-405
A relevant blog:
Prof Harris has illustrated the powerful placebo effect inherent with surgical procedures. Understandably, given the focus of the text, he didn't explore certain other important factors such as the coincidental nocebo influence of surgical pathways. Eg: simply being told that (ineffective and poorly science based) surgery is available and 'needed' to 'fix' structural changes in painful regions. It is concerning how many times I have seen patients concerned about this advice based largely on scan changes that were present a long time before their pain onset and equally present in people with no pain at all; ie: "I never knew how bad I was!!"
If the nocebo effect is understood properly (psychological and physiological) this is a powerful 'fork in the road' message in vulnerable patients. They understandably believe such common, expert, 'evidence' based, but not 'science' based, statements.
Another major perspective which merits exploration, related to this text and the science it is based on, is that the entire 'pain' diagnostic process, based on the current model, uses responses to interventions as the GOLD STANDARD (!!?) If these responses are spurious and largely placebo construct responses, then the back flow repercussions right back to the original pain diagnosis seem logically considerable.
Hmmm .... Houston, we may have a seriousproblem.
* TED talk on current problems with medical research referred to above --->
Resources related to my projects:
The first document to the right is an explanation of terminology and concepts that I use in report writing. It is mostly directed towards relevant health / other practitioners.
These are my conclusions based on personal observations over many years, wellover 2000 compensation related case reviews and examiner assessments over approximately 15 years, and my pile of researched evidence. Feel free to comment, qualify or contribute constructively.
A condensed version of the large number of references I have accumulated to support these comments in relation specifically to a project I have been involved in relating to spinal surgery pathways is also provided. Many full texts are available via an online search.
Explanation of terminology and concepts 10-03-16.pdf
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Type : pdf
References relevant to spinal pain diagnosis and interventions 10-03-16.pdf
Size : 441.071 Kb
Type : pdf
Here are some sub-pages to explore via the links to the right with various related topics --->
- "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.
- "Mud" - unsophisticated, commonly used diagnostic methodology that can and does lead to harm.
- "Blood" - an excellent article on needed paradigm change called "Stabbed in the back".
- "Knockout" - who wins in the title bout between the context of an injury and the pathology?
- The pain revolution.
There are videos that are worth seeing on the 'For Patients' page.
Here are some more videos freely available on the pain literacy message which are more directed towards health professionals:
The 2015 Koadlow Public Lecture, hosted by Arthritis and Osteoporosis Victoria, featured a presentation by renowned Director of Neuro Orthopaedic Institute and co-author of Explain Pain, Dr David Butler.
Over the past two decades there has been a revolution in our knowledge of how pain is made by the brain, but very little of this information has reached pain sufferers.
Much of the complex pain science can be reduced to a simple formula, “we will have pain when our brain has more credible evidence of danger to our body than credible evidence of safety to our body.”
This presentation explores the danger and safety balance via some novel take home assessment tools and then explores what you can do about it. Knowledge as pain-relief and therapy is powerful - no prescription is needed, you can use it 24/7, and there are no side effects.
This presentation contains many stories of the changeable brain, how thoughts can influence inflammation, how painful body parts can be ‘disowned’ by the brain and how they can be “taken back”, and how pains we once thought were ‘weird’ can now be explained.
David Butler also discussed how movement can be improved with pain knowledge and the vital importance of language, not only how the language of others can influence your pain but also your own use of language. We now know that saying things like “it’s like a knife in there” or “my leg doesn’t feel like mine” can alter your brain and influence the pain you experience. All of this is good science, backed by years of research demonstrating that understanding some of the science of pain is more effective than drugs for many pain states.
Professor Lorimer Moseley is a clinician and researcher with a special interest in pain and brain sciences. He is author of Painful Yarns. Metaphors & stories to help understand the biology of pain, and co-author of Explain Pain, which is a key text for pain sciences at universities throughout the world, Explain Pain Handbook: Protectometer, and the Graded Motor Imagery Handbook.
He completed his doctorate in medicine at the University of Sydney and post-doctorates at the University of Queensland and the University of Sydney. In 2004, he was appointed Nuffield Medical Research Fellow at Oxford University, UK.
He has over 190 scholarly works including articles in Lancet Neurology, JAMA Internal, and multiple papers in PNAS, Current Biology, Brain, PAIN and Neurology. He is Associate Editor of PAIN, the Journal of Pain, the British Journal of Sports Medicine, and the European Journal of Pain.
In 2007, he received the Ulf Lindblom Award, given by the International Association for the Study of Pain to the outstanding mid-career clinical scientist working in a pain-related field. He won the 2012 Marshall & Warren Award for Innovation and potential transformation from the NHMRC and has been recognised with awards for service from physiotherapy or pain societies on every continent. He is now NHMRC Principal Research Fellow, Professor of Clinical Neurosciences & the Foundation Chair in Physiotherapy at the University of South Australia, Adelaide, and Senior Principal Research Fellow at Neuroscience Research Australia.
Dr Silje Endersen Reme is a psychologist & scientist interested in pain, health, sick leave and coping and is based in Norway. She performed a relevant TEDx talk relevant to the manner in which injury context influences outcome most significantly and incorporated pain neuroscience in her discussion. Silje Endresen Reme's talks about the common phenomenon of back pain; why some people develop chronic pain and disability while others don't, and what psychology has to do with it. Silje is a PhD. from Uni Health, Uni Research, Bergen & Harvard School of Public Health, Boston.
THE EVIDENCE-BASED PERSPECTIVE OFFERED ON THIS WEBSITE IS NOT NEW!!
PLEASE WATCH THIS EXCELLENT SCIENTIFIC EXPLANATION OF THE MIND / BODY CONNECTION, UNBALANCED HEALTHCARE PROBLEMS AND PLACEBO / NOCEBO EFFECTS BY PROF HERBERT BENSON (HARVARD PHYSICIAN AND AUTHOR OF SEVERAL BOOKS INCLUDING 'THE RELAXATION RESPONSE'), WHICH WAS RECORDED IN 1997 ..... !!
The first and main obstacle to be overcome is the entrenched belief system based on a flawed model of care.
Beliefs readily become 'stuck'.
Change is difficult ...
A practical course for clinicians interested in 're-training' their thoughts and processes to best help patients in pain is available via the link to the right.
There is a 'free' section for patent education in the form of 15 x 1 minute slide presentations available in various languages that is worth working through first.