I have often been told that the pain science message makes sense and resonates with what is observed so well.
BUT then I am asked questions like these by patients in pain, clinicians treating them and many others involved:
- "What do I do now?"
- "How can I practically change the situation in a meaningful way?"
- "What procedures are there to help?"
- etc ...
Therefore, I am offering the first draft of my 'plan' as a work in progress and welcome any feedback.
I am playfully calling it 'KALS' plan. It is a 4 point plan using the key parts of what I have found to be most necessary for a safe pain re-adaptation program to be successful.
Here it is, firstly in point form:
Hopefully, after reading other material on this website, this makes enough sense on its own, but to make sure here is some elaboration:
- KONSTRUKT A FOUNDATION OF PAIN LITERACY -
Building a foundation is essential for a solid structure to be built over the top. Undergoing a rehabilitation or treatment program alone without understanding pain properly can work, but this result is very sensitive to the surrounding CONTEXT which is commonly overwhelming. This is likely to be the reason why so many are failing to improve and chronic musculoskeletal pain has been increasing alarmingly. Pain literacy includes understanding pain science basics including the key message that pain is an output of the brain with many inputs into the 'brain's danger versus safety pain equation'.
It is my firm opinion that optimal pain literacy should also include an honest appraisal of the low level of scientific validity associated with what is done currently to manage pain ie: being very careful in viewing the 'carrots' that incentivise behaviour in an unreliable and often hazardous direction and convince you that you are damaged (unhelpful). The human body is an amazingly adaptable healing unit and it can be trusted unless rare circumstances apply. However, for recovery to occur optimally, both the brain and the body have to be going in the same direction (helpful).
ANALYSE WHAT IS HELPFUL AND WHAT IS UNHELPFUL -
It is not the injury severity that generally predicts the overall outcome. Severe injuries can result in excellent outcomes and minor injuries (and even no visible injuries at all) can result in horrific pain outcomes. It is the CONTEXT of an injury or pain event that is observed and researched to be a major determinant of the overall outcome. Context is very wide and includes sociological variables, past experiences, perceptions of blame / injustice, and both primary and secondary psychological factors etc, etc. It prominently includes the context that is introduced by others - perceived experts, family and friends, media, case managers, rehabilitation providers etc, etc, etc. Once it is understood how important the inputs to a pain response can be, and how many sources can provide such inputs, it is absolutely vital to be able to differentiate between what is helpful and what is unhelpful.
Unfortunately, there seem to be many more unhelpful / 'danger' messages than there are helpful / 'safety' messages. And more unfortunately, many of these come in the disguise of 'expert' opinion that in chronic pain is at best poorly evidenced, mostly speculative, and at worst utterly inaccurate. And here is the most startling thing - EVEN if it the information is correct from a technical view, it may NOT BE HELPFUL from a pain science perspective. ALL injuries are capable of healing and re-adaptation to excellent levels. So, consider what may be the 'pain' result if you are given comments like these after an injury (they are commonly stated) and you are scared by them - "Oh dear, that is one of the worst breaks I have ever seen!", "You are likely to get really bad arthritis after this injury", "You have degeneration and one day you are likely to need a joint replacement!" etc, etc ...
It is of vital importance to construct a metaphorical 'force shield' to repel all unhelpful messages. Fear is a powerful feeder of pain and in many the problem is made worse because an abundance of helpful safety messages can be trumped by a single unhelpful danger message. There is much building to be done - erect a force shield above the konstrukted foundation of pain literacy.
Conversely, HELPFUL input includes understanding pain properly, being aware that ALL structural changes seen on scans are seen COMMONLY in people with no pain at all, trusting your body to heal / re-adapt, and similar.
LEARN THAT PERCEIVED HARM IS NOT ACTUAL HARM -
The next part of the process is to take your new ability to understand your pain via the best science available and start to think about all the things people have likely told you not to do to 'protect' yourself from harm. While these may have been relevant early in an injury process, the longer the pain lasts, the more thinking that protection is required becomes unhelpful. These thoughts can perpetuate your pain simply because they convince your brain that ongoing protection is required. This is known as a 'catch 22' effect where the very thing being advised to help you is making you worse. This belief that protection is required becomes an entrenched reality that can result in prolonged and severe pain and pain related disability. The longer pain lasts for any reason, the less input signalling is required for the same (or a greater) pain response.
So here it is - simply perceiving that harm is a possibility is PAINFUL. If the great majority of activities that we do on a day to day basis are examined critically they produce NO HARM; yes, even lifting reasonable weights and bending when you have back pain puts structures at minimal REAL mechanical risk. People with advanced 'arthritis' generally do BETTER and avoid joint replacement surgery if they do vigorous exercises ... even without understanding their pain properly!
The sooner and the more activity is NORMALISED, the better the overall outcomes are statistically. Don't believe me or the available research? Spend some time at a football club and observe what the players are able to play and get away with, especially around Finals time ... (remember, my background is in sports medicine). Now that's not to say that you should throw yourself out on a football field, but compared to what goes on out there, standard day to day activity and general exercises are certainly NOT harmful.
- START TO MOVE AGAIN CONFIDENTLY -
Exercise is well researched for its hugely beneficial effect. Comparing to many other 'fixing' interventions and medication effects, the health benefits of exercise tower in reliable effectiveness. This research has been confirmed for a long time in 'arthritis' but is now extending to many other areas of health, including EVEN CANCER. There are many theories as to how this works and most focus on structural benefits and immune / anti-inflammatory benefits. What is becoming increasingly appreciated is that there is positive effect through adaptive neuroplasticity processes ie: a direct effect on the nervous system that is responsible for pain in the first place!
As I have stated, exercise has such a positive effect on pain and inflammation that it even benefits many who still think that their 'degenerative arthritis' is the direct cause for their pain and 'may need to be fixed one day' (both unhelpful). As also stated, unfortunately when exercise doesn't work, people resort to potentially hazardous 'fixes' still not understanding their pain or the limitations of those 'fixes'. There is little general knowledge that knee arthroscopy surgery has the same effect as fake surgery ie: people just thinking that they have had the surgery. There is little general knowledge about the official statistics on hip and knee joint replacement surgery. These show that 1 in 4 people have significant persistent pain independent of surgical complications! That is a staggering figure if you think that you could go through such a big, potentially harmful and irreversible operation and that statistic applies. Evidence is now showing that optimal pain literacy as part of a good rehab program can even improve the success rates of surgery, if not increasing the chance of avoiding it altogether.
So it stands to reason that the BEST form of exercise rehabilitation, and normalisation of all activity including return to work, is one that is Konstrukted on a foundation of pain literacy, the ability to Analyse helpful from unhelpful inputs, Learning that perceived harm is not actual harm and that there is a hill that needs to be crossed to achieve the best recovery. Now is the time to Start travelling that pathway confidently.