Me: "What started your pain?"
Patient: "I do not know."
Me: "What makes your pain worse?"
Patient: "Nothing specific that I can think of."
This interaction occurs often in the healthcare world. To no fault of the patient it is difficult to understand how pain started and more importantly what triggers it. At the same time however this is vital information that can help guide treatment. Recently I finished "The Power of Habit" which was a great read on how habits form, often without our control or knowing, and how they can be changed if we follow simple steps. This started me thinking on how this could this be applied to Pain and Physical Therapy?
Through habit and behavioral research there seems to be a simple yet complex pattern on how habits form: It starts with a Cue --> Leading to a Routine --> and Ending with a Reward. Otherwise known as the Habit Loop. Our brains receive a Cue, perhaps it is a time of day, which triggers us to get a coffee, that ends with us feeling more alert. However, if we expand this equation and think specifically in the framework of Physical Therapy and Pain we might come to this: Cue --> Pain --> Avoidance. Or more simply put our brain receives a certain stimulus which in turn triggers pain and therefore results in the avoidance of an activity or movement. This eventually leads to behaviors and thought processes that certain things are "bad" or that these activities have to be avoided completely. But what if we target behavior and habits with our Physical Therapy (or insert your profession here) interventions? Could we actually get patients to buy in and understand pain and it's framework better, thus resulting in empowerment rather then fear avoidance?
Through pain science we are aware that pain is an output (comes from brain not tissue), it is not dependent on tissue damage or nociception (hence why we have pain with negative MRIs), and it is a pattern that can be learned/remembered/recalled by the brain at any moment. A popular example is the brain being compared to an orchestra. When working properly and with all members in unison our brains can do amazing things including adapting movement, protecting us when needed, and by constantly changing the "tune". If our brain gets stuck on the same "tune" (as in pain) it becomes better and better at playing that tune and like our habits and behaviors it can occur without our control or us knowing.
One of the biggest frustrations I hear from fellow healthcare professionals is lack of compliance with a home exercise program. Where as one of the biggest complaints I hear from patients is that their home exercise program is not working or they do not have time for it let alone know when to perform it. Perhaps this can be linked to forming habits. It is commonly said if we listen to patients long enough they will not only tell you where to treat them, but how to treat them. With that being said if a patient has a good understanding of the "cue" that causes their pain this should serve as performing the "routine" of a home exercise program with the "reward" to be in less pain. If a patient has no idea what pattern or cues cause there pain this can serve as a great learning opportunity for them. Here is the formula:
1. Write down the time of day you had pain
2. Write down what you just finished doing and/or are currently doing
3. Write down your mood at the moment (the first one or two words that come to mind)
As an example if a patient is able to perform this for several days they may realize they always get pain in the middle of the day, while at work, after they just spoke to their boss and they felt stressed or frustrated. Therefore knowing these cues patient can practice their "routine" to better cope with these issues before they arise. Once we can identify a pattern we can build a new routine and turn it into a habit with practice.
This leads us down a further road of pain "context." It is well reported that cancer patients who associate pain with returning cancer have an INCREASE in pain perception, while those who are recovering from surgery may typically view it as a positive that they are healing and have a DECREASE in pain perception. It is the same feeling! This also connects the fact that a violinist who hurts his hand (or in our case a physical therapist) will have more pain then a runner who sustains the same injury. Why is this? Well think of the implications for the violinist or healthcare provider. Our hands are our tools, if we cannot use our tools we cannot work, if we cannot work we cannot support our family....Can you begin to see how complicated "pain" can become? Now what would happen if you change the perception of pain altogether (as in the case with the "healing" post op patient)? A recent study by Benedetti et al in 2012 attempted to answer this question. 45 people were randomly assigned to a control, positive pain perception, or negative pain perception group. Pain was elicited in the study via a compression through a blood pressure cuff around the arm. In the study patients in the positive pain perception group were given the following instructions:
"You will undergo the blockade of blood flow to the arm in order to stop oxygen supply and to decrease temperature in different tissues such as muscles. It has been shown that if repeated many times the procedure may be beneficial to muscle cells...This procedure can be painful and we ask you to resist as long as you can (before stopping)....The longer you resist the larger the beneficial effects will be"
As opposed to the negative pain perception group who was told the following:
"You will undergo a blockade of blood flow in your arm in order to induce pain. The purpose of this test is to study the emotional component of pain...You can give up and stop the test whenever you like but what we ask is that you resist as long as possible because we want to study the part when the pain becomes unbearable."
I am sure you can guess the results. The patients who had a positive meaning of pain were able to withstand the pressure given by the blood pressure cuff for much longer then their counterparts - yet they were given the same stimulus and "felt" the same thing. The common thing that unites all of our patients is sometimes the hardest to understand - but it would appear if we could help patients understand it, even a little better, we may be able to help people cope better and empower themselves to take action against it.
Until next time, Happy Rehabbing!
What is your opinion of pain science? Do you incorporate it enough into your practice? What have been some successful or unsuccessful strategies that you have tried?
Butler, David S., and G. Lorimer. Moseley. Explain Pain. Adelaide: Noigroup Publications, 2003. Print.
Duhigg, Charles. The Power of Habit: Why We Do What We Do in Life and Business. New York: Random House, 2012. Print.
Benedetti, Fabrizio. "Pain as a Reward: Changing the Meaning of Pain from Negative to Positive Co-activates Opioid and Cannabinoid Systems." PAIN 154 (2012): 361-67. Web.