If we really broke down what we have learnt from the pain revolution in neuroscience over the last 20 years, it might come down to three key points;
1. The brain is very, very changeable
2. The brain plays a major role in how we, as humans, construct pain
3. The brain is a ‘neuroimmune’ organ and the science that we are really talking about is ‘neuroimmune science’
Although saying that pain is ‘constructed’ in the brain may upset some of our friends in the philosophies of mind and consciousness, it has become a shorthand way of talking about the amazing complexity of pain and the first step towards informing society that learning about the brain and pain can be beneficial.
At NOI, we have trialled, played with, and guessed at ways to tell people about their brain and pain. Like many clinicians out there, we have had some great wins –“Yes. I understand it now, of course that makes sense, thanks“… and some spectacular failures – “bloody physio thinks it’s all in my head”. Over time I think we are getting better and better at this complex intervention – future clinical studies will let us know. But for now, there is research from educational psychology and science that we can and should apply – there are ‘guidelines’ from evidence based multimedia to power up and improve our ‘made in the brain’ narratives. (We have written about these before.)
Talking about brains is an intimate thing
When you really think about it, talking about someone’s brain can be an intimate thing. It’s right up there in the league of chats about bladders, bowels and sex! Not only can it be intimate, it can be exhausting discussing a three dimensional, hidden structure with complex, everchanging, abstract and emergent workings. While many people have something of a mental picture of the external view of a brain, the internal workings are especially hard to imagine. Patients and other learners need something solid to grasp onto when trying to make sense of this very abstract idea.
A nail box (also called a pin box – see the video below) can be used to explain aspects of brain function and the therapeutic potential of interventions that target the brain. These boxes were popular in the 70s and 80s but can still be found online, or in toy and gift shops. In terms of evidence based multimedia, the box is an external, animated model which allows a reasonably accurate, metaphorical, three dimensional model of neuroplasticity. It is particularly powerful because it can demonstrate the ‘elasticity’ of the brain – it’s ability to change, and also change back.
The nailbox is also something you can touch, experience and ‘see’ changes in. Demonstration of the brain’s working via a nailbox requires minimal scientific language and, via this simple mechanism, it’s possible to show complex aspects of neuroplasticity. For those who find the brain story a bit too personal, the metaphorical nailbox also allows a bit of distance from the real thing and may help to, respectfully, get past cognitive defences.
Here is my version of telling a person about smudging in the brain and the changeability of the brain with a nailbox. Take a look and let me know your thoughts, how you might use the story, and how we can make it better in the comments below.
[youtube https://www.youtube.com/watch?v=3QVAY5stO3U?rel=0&w=853&h=480]
Supercharging Explain Pain and Explain Brain at EP3 2015
We owe a debt of gratitude to the pioneers in brain imaging here. The many blobs of activity on early fMRI scans proved that there was no ‘pain centre’ in the brain and that nociception triggered off a cascade of parallel, distributed activity in the brain that we now label as neurotags (as well as the fact that nociception wasn’t even required for brain activation and a pain output).
At the forefront of modern brain imaging is Robert Coghill, who will be travelling to Australia next year to present at EP3 2015. Robert and his team work to better understand the role of the brain in pain, combining psychophysical and functional magnetic resonance imaging to explore the relationship between regional brain activation and discrete aspects of the pain experience.
Joining Robert in Melbourne for EP3 in 2015 will be Kevin Vowles. Kevin is the world’s leading exponent of the application of Acceptance and Commitment Therapy (ACT) to chronic pain. Kevin’s work has established the validity of the ACT model for chronic pain and he has published widely on the notions of psychological flexibility, fear and anxiety in relation to pain.
Robert and Kevin will also be joining a stellar line up at PainAdelaide on 30 March 2015 for “Probably the best little pain meeting in the world” – definitely making March the best time to visit Australia next year. Both Robert and Kevin will add their unique perspectives and expertise to the growing multidisciplinary science, and evidence, behind Explaining Pain – I’m looking forward to powering up my brain narratives even further with the latest findings from brain imaging and the world of psychology. See the details below for more information and how to register for EP3 2015. website | flyer
– David Butler, Noigroup
Thanks David, always love hearing your thoughts! I am a bit over trying to explain pain to patients with neuroplasticity, neuroscience, etc. I am focussing more these days of getting patients to understand that their subconscious belief’s about healing are either helping them or holding them in a pattern of injury, pain, dysfunction. Bruce Lipton’s book “The biology of belief” to me is the CRUX of the issue. If patient’s believe they can heal themselves… then they will. If they don’t think they will get better, then guess what? doesn’t matter how good their physio is… they wont.
I have been focussing on this science and encouraging them to watch this documentary https://www.theconnection.tv/. I am conducting my own research with patients in private practice – two groups – one with the information and one without – very basic and highly flawed study design, but from where I am sitting the results have been stellar.
What is also relevant is my belief as their treating physio as to whether they can recover fully. If I don’t believe they can get there… then they probably wont – and that is where I have to CHANGE. Love your thinking, keep it coming.
Marion McRae – Art of motion movement studio – Margaret River WA
I often wonder why so much time and effort are put into attempts to explain pain in terms of indefinable emergent features which can never be truly charted or assessed with any purity of purpose. What a thankless task it must be if even the most thorough descriptions must end with….’after all our intense observation, we must admit, by virtue of our acquired definition, that we are unable to state a definitive structure for the progress of a pain event from beginning to end’. That’s not a direct quote from anything, just a guess at what any pain theorist might be thinking.
Maybe it’s time to give pain a better definition……perhaps something like ‘Pain is a tool, employed by the autonomic protective systems, to confuse conscious thought, and to restrain conscious reactions from responding inappropriately to any injury/threat.’ If that theory fails to convince on any level, then we can move on to the next best offering, and thus by a process of elimination we eventually arrive at a workable theory which ticks all the boxes. Adding mystique to something as important as a required understandable theory of pain, merely increases the options for misinterpretations….and that all trickles down eventually to a possible undermining of the patient’s belief in their own intuitive interpretations. Which comes first…the patient or the elevated theory ?
A beautiful line ” Which comes first…..the patient or the elevated theory” Bravo 👏👏👏
DB London
On location😎☀️🍗🎅🎄
Thanks. It might taste sweeter to me if it didn’t contain any self indictment ! But it does…perhaps a price to pay for attempting to rise above the easy answers.
Just following on from the ‘Which comes first….the patient or the
elevated theory ?’ comment, I’d have to express some concern about the current theory trend towards pain being an indefinable emergent conscious phenomenon, mostly because of how such a definition plays out in the intuitive understanding of the patient, and how it might contribute to an undermining of the subjective pain experience, particularly in instances of ‘hidden’ chronic (not persistent) pain conditions. By ‘hidden’, I mean conditions like Cervical Spondylosis etc, which although recognisable by means of MRI or Xray, or even by means of recognition of radiated symptoms, do not manifest their cause directly to patient or operator, and thus contain a confusion at their core which is vulnerable to biased and erroneous interpretation. Unfortunate, but true.
My concern is about the way in which a patient might ‘choose’ to intuitively come to some workable understanding of the mechanics and dynamics of the condition they are experiencing, only to have their overview undermined by an imposed theory which suggests that there might be no direct linear correlation between their referred pain experiences and a probable nerve threatened cause. The ’emergent’ theory, whilst offering up an option for ignoring a direct link, also relieves somewhat from the responsibility of having to further explore the ‘threatened nerve’ dynamics…..perhaps the theory is being constructed around a need to justify the little we seemingly understand about threatened nerve behaviour. As a patient myself, that’s how I tend to interpret the current trends….and I would need some convincing otherwise. What flags up, for me, is a possible conflict with the patient narrative, which favours the operator’s overview, and that in turn brings into question the ethical frameworks which would normally support the patient narrative as the driving force in any exchange between patient and the services. Of course, we expect the professionals to insist on something if they see it differently, but the ultimate choice to enter into that ‘trust’ is always the perogative of the patient. Where differences of opinion occur, the patient is faced with the further complication of perhaps choosing against their intuitive instincts….and that can be a confusing and distressing experience for someone already exposed to vulnerable influences. What seems to be happening in those circumstances, is the services are limited by their recommended options, and any flexibility for treatment options is being off-loaded back onto the patient. That’s a process which, if true to form, would seem to fall short in its advisory responsibilities.
Assuming that such encounters are not uncommon, and even just partially accepting the possible ensuing difficulties, is it really a wise move to introduce an extra factor of confusion about the acquired understanding of pain definition being in conflict with the intuitive understanding of pain experience. I suppose, if it could be proved that the acquired definition had beneficial implications for treatments, that would be justification by default. However, if outcomes aren’t improved, introducing the acquired theory might seem like an extra ‘spanner in the works’, only adding to the dilemmas a patient must negotiate in their attempts to manage a condition. The bottom line for me has to be that treatments are ‘patient driven’…I think Dr Patrick Wall referred to this caveat in one of his BBC interviews. That’s the only foundational approach which is justified from all angles, and it deserves its place at the top of the decision making hierarchy. Any theories which might be seen to ‘chip away’ at that foundation, need to be scrutinised closely.
Something which might be missing from the ‘elevated theory’ approach is qualified patient response, just to help ensure that the final product is ‘leak-proofed’ ! The first draft should always be scrutinised by the harshest critics.
I cannot find any “nail box / pin box” anywhere on the web… Does anybody know were to find one? Thanks.