Explain Pain 3, Day 3

Day three – another glorious day in Melbourne, another magnificent day of pain science education goodness. Lorimer led the morning session, explaining that before getting into the the evidence for explaining pain, he wanted to address some great questions and discussions that had been raised during lunch and breaks in the previous days and clarify further some of the brain activity and changes associated with chronic pain.

Lorimer used the story of his son “Lord adorable squeaky pants” learning to say the word “isosceles” – as in the kind of triangle with two equal sides and angles. Lorimer explained that L.A.S.P. had been trying for a period of time to get isosceles out right- isockskalese, isososkalese and so on, until finally, one day “isosceles” came out just perfectly. What happened, was that L.A.S.P. had learnt to deactivate parts of his brain – to refine the “saying the word isosceles” neurotag through precise inhibition following practice and repetition.

While this refinement and precision is a hallmark of learning and skill acquisition, Lorimer pointed out that in chronic pain, neurotags can become both sensitised – easier to fire off with a wider variety of ignition cues at lower intensities, and disinhibited – imprecise and less refined.

If this disinhibition occurs in the primary somatosensory cortex (S1) the result can be a spread of pain. Lorimer explained that a non-dermatomal spread of pain can be a strong clinical indicator of disinhibition in S1, with the spread of pain from hand to face, commonly seen in CRPS an example of S1 inhibition. Thalamic disinhibition might lead to the spread of pain from hand to face to leg and also be accompanied by widespread alteration in sensory processing.

Lorimer explained that disinhibition in chronic pain states tends to effect areas of brain that are involved in looking after the body, with sensory representations held in S1 being only one example.  These clinical signs can be very useful indicators as to what might be going on in the brain of a person in chronic pain, and Lorimer pointed out that while it is not known if cortical reorganisation is a potent contributor to chronic pain states, retraining for precision- reinhibition, does seem to work well with some people. (There is a bunch of great information available on this stuff at www.bodyinmind.org, in particular this post by Flavia di Pietro and these preliminary findings in a research report containing a very detailed protocol and ideas for application and progression of sensory retraining for low back pain)

Lorimer begun his discussion on the evidence for explaining pain by discussing where an Explain Pain (EP) approach might fit in amongst other therapy approaches. Lorimer suggested that classical physiotherapy may influence nociceptive, psychosocial and functional modulators of pain, with drugs influencing primary secondary and cortical nociceptive modulators, neurostimulation influencing spinal cord and cortical modulation of nociception and CBT approaches influencing psychosocial and functional/behavioural modulators of pain.  EP fits into this mix by targeting the evaluation of pain. EP is about trying to influence the equation for pain that Lorimer has suggested, namely that pain=(credible evidence for danger) – (credible evidence for safety) with negative answers to this equation resulting in pain.

Explain Pain can be a powerful provider of credible evidence for safety, as well as reducing the magnitude of any credible evidence for danger.

Lorimer provided a compelling argument for the credibility of the EP approach, using the NHMRC levels of evidence and demonstrating evidence at each level including systematic reviews and Level 1a evidence for therapy that demonstrates that explaining pain, as part of recovery and rehabilitation reduces pain and disability at six and twelve months with the number needed to treat for 50% pain reduction at about 3.

Some important summary points for explaining pain:

• Broadly, the literature suggests that when people really understand pain, their quality of life improves, their sleep improves, the likelihood of return to work increases and pain related expenses decrease.
• Explaining pain is not ‘advice to be active’, but rather explaining the benefits of activity.
• Explaining pain is not advice that ‘hurt doesn’t equal harm’, but rather explaining why hurt does not equal harm
• Explaining pain is not saying that ‘pain is now in your nervous system so simply learn to cope with it’, but rather explaining that the nervous system can become over protective in chronic pain and that learning to cope can be useful while the nervous system is trained to be less protective.

Lorimer explained that one of the key purposes of BiM was to undertake research to work out what are the most important things to explain to patients and when so as to maximise the benefit of explaining pain – not just to manage pain, but to take it on and reduce it.

After morning tea, Mark Jensen was again in magnificent form as he discussed hypnosis. Starting out by busting some common myths about hypnosis, Mark explained that hypnosis was not an all-powerful panacea, but equally did have demonstrable benefits, especially for chronic pain. Further, hypnosis was not a ‘parlour trick’ and people being assisted into hypnotic states did not relinquish control and nor were they somehow weak minded.

Simple put, hypnosis is one person guiding another with suggestions about changes in subjective experience, feelings and emotions.

Mark discussed a growing body of literature with common findings that hypnosis has effects over and above placebo and is more effective than no treatment.  However, the response is very variable amongst people, both in regards to response to hypnosis itself and any benefits.

Mark demonstrated a very nice “safe place” hypnotic induction (no swinging watches, and he didn’t say even one “look into my eyes…. you are getting veeeeery sleepy”) and had all the participants practise on one another.

While it is out of the scope of this summary post to go into lots of details about hypnosis and types of induction, Mark stressed that ‘hypnotic language’ could be used outside of formal inductions to reduce resistance to new ideas and help ideas “stick”.  Some examples included:

• Avoid negative suggestions that use “don’t”
• Use positive permissive suggestions such as “you might like to… consider everything that I have explained about pain today and how it might apply to you”, “you may find that…. as you consider your knew understanding of pain, you notice that you feel safer and more comfortable within yourself and undertaking activity”, “you may be pleasantly surprised at how easy it is for you to carefully and gradually increases you activity every day”
• Use ‘truisms’ such as “sooner or later you tolerance to activity will increase as you keep exercising appropriately”
• Use language that suggests a positive future such as “you may find that you are pleasantly surprised day after day at how much easier moving and being active has become”

If there was one phrase that really stood out for me from Mark’s various presentations, it was the idea of “follow, follow lead”. I could probably write a whole post on this (I might even do that), but at it’s simplest the idea is summed up by the notion of meeting the patient at their own story – the follow, and more following, and even more following if necessary to really enter their world, and then in the deep rapport that arises out of this, leading the patient, with their permission, towards a more accurate and deeper understanding, as well as towards more choice.

All of that and we had only just reached lunch. Probably also a good time to finish of this post (before it gets interminably long)  and make Day 3 a two part-er as there was still heaps to follow with David talking about story telling and metaphor in the afternoon sessions.

Comments, questions and thoughts encouraged in the comments below; keep an eye out for Part 2 of day 3 coming soon.

Tim Cocks

www.noigroup.com