1. Dr Suzanne Heywood-Everett
Explaining Pain
Dr Suzanne Heywood-Everett
Dr Rachel McEnery

2. Introductions
Hopes and expectations

3. Learning Objectives
Helping you to help patients reconceptualise their understanding of pain from that of a marker of tissue damage or pathology, to that of a marker of the perceived need to protect body tissue.
To increase the awareness of evidence based physical and psychological treatments for chronic pain 5

4. Plan for this evening Introduction Explain pain
How should we be managing chronic pain
Any questions?

5. Why are we discussing this today?
Chronic pain affects 20% of the population
In the top 10 most burdensome health issues of our time chronic pain problems occupy 1st, 4th and 8th positions
Costs more than Diabetes and Cancer combined
Chronic pain patients are being inappropriately managed

6. What's thoughts emotions arise for you when someone visits with chronic pain?
Brainstorm 6

7. Different Health Beliefs
Different behaviours / presentations…
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8. Knowing is not the whole story
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9. YELLOW FLAGS
Attitudes & Beliefs - towards the current problem. The most common worry is that the patient feels they have something serious causing their problem.
Behaviours - adopting disabled role, rest, use & abuse of medication
Compensation - Is the patient awaiting payment for an accident/ injury at work/ RTA?
Diagnosis - or more importantly Iatrogenesis. Inappropriate or confusing communication can lead to patients not being sure what the problem is, the most common examples being 'your disc has popped out' or 'your spine is crumbling'.
Emotions - Patients with other emotional difficulties such as ongoing depression and/or anxiety states are at a high risk of developing chronic pain.
Family - There can be two problems with families, either over protective or under supportive.
Work – If there are difficulties, people are more likely to develop chronic problems.

10. Explain pain role play

11. What is pain?
Pain is a conscious experience designed to evoke a protective response.
All pain no matter where it is felt is produced by the brain 100% of the time no exceptions
All pain is normal and physiological but the causes of it are not
Pain involves all of your body systems (motor, autonomic nervous system, immune, endocrine).
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12. What is chronic pain?
Chronic pain is a pain that’s persisted for greater than 3 months that is not amenable as a rule to treatment based upon specific remedies or to routine methods of pain control
Chronic pain is less likely to relate to changes in the state of your tissues and more likely to be due to other threats.

13. Where are the problems in chronic pain? - The sciencey bit
Nociception
modulation
Neurotags
Imprecision
Facilitation/sensitization
The body’s other protective systems
Autonomic nervous system
Endocrine system
Immune system
Brain maps
Phantom movement maps
Sense of ownership
Neglect
Maps of space

17. The body’s other protective systems
Autonomic nervous system
Sympathetic ‘fight or flight’, like a match easy to light goes out fast.
Parasympathetic ‘rest and digest’
Endocrine
response more like a fire – harder to get going but lasts longer
Immune system

24. Explain Pain : Lorimer Mosley
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25. Thought Viruses Thoughts are nerve signals too
Ever feel pain when thinking about the painful movement or watching someone else do it?
Anxiety about pain or disability can increase pain
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26. Unhelpful things we say
Lucky things are not worse
No wonder it’s sore looking at MRI
For you your pain is real (for everyone else it’s not!)
Battle metaphors – ‘war’ can be won with biomedical escalation
Using strong adjectives
Slipped/ruptured discs
Trapped nerves
Degeneration, crumbling
Using nonsense terms e.g. Pain receptor/pathway/fibres/message/signal/stimulus

27. What we should say I know your pain is real and horrible
Pain can improve with knowledge and the right support
Degeneration - Kisses of time
Trapped nerve - Can squeeze onto a nerve/pinched or release chemicals that irritate a nerve
Use friendly and accurate terms - Danger detector/transmitter/messenger nerves/message/(Potentially) dangerous stimulus
Avoiding the unhelpful terms e.g. Somatoform pain disorder, Myofascial syndrome, Repetitive strain injury
Medication – side effects, addressing patient expectation

28. Putting it all together!

29. How can we fix our pain?

30. Flat Tire video https://www.youtube.com/watch?v=5RIii6 OUK2A&t=7sqw230

31. Summary
Your body is sending signals to the brain all the time and when your brain receives them it decides what the signals mean.
Pain occurs when your brain believes the signals =DANGER
Pain great way to know there is a problem, but not a reliable way of knowing how bad that problem is.
When pain persist the link between pain and damage is weaker
Pain can occur without damage & not a good indicator of whether the damage is eg heart attack

32. In acute injuries pain is important to help protect and heal
As healing occurs so do the protective mechanisms- like limping even though we no longer need to be protective.
Pain just one protective mechanism: also movement, stress response, immune response, endocrine response, swelling= increases sensitivity which is designed to heal and protect the body.

33. Pain volume
Your brain controls how much it listens to the pain signals and how much pain depends on how sensitive to these signals eg car alarm
But pain can continue past healing = for some reason the brain and body still feel the need to be protected- so protective mechanisms stay
When pain persists the levels of pain threshold and tissue damage change- no longer have a close relationship.
People start to feel pain a lot sooner before tissue damage may occur

34. How we should be managing chronic pain
We need to respect it not fear it and plan a road to recovery.
Education about pain biology
Reducing the threats through active coping strategies. If you reduce threats you reduce activation in all of your protective systems
Treating as a long term condition
Avoiding the medical model (drugs, referrals, investigations)

35. Lady Gaga
When my body goes into a spasm one thing I find really helps is infrared sauna … I combine this treatment with marley silver emergency blankets … In order to not overheat my system and cause more inflammation i follow this with either a VERY cold bath, ice bath or … keep many reusable cold packs in the freezer ( or frozen peas’ n carrots’!) and pack them around the body in all areas of pain.”

36. Our Expert Patient Stories

38. Chronic pain
Physical therapies

40. Simplest/ good Rx is about two things...
Desensitising Pain
Reloading Stress and cause adaptation

41. Exercise

42. Goal setting Gives the Pt and active role in their rehab
Reduce anxiety
Pt centred
Short term goals increase motivation
Long term goals help keep Pt hopeful for future

44. Protectometer DIMs - Danger in me SIMs – Safety in me
Anything that’s dangerous to your body tissues, life, lifestyle, job, happiness, your day to day function. A threat to who you are as a person.
These need modifying and removing
They will switch your own drug cabinet off (reduce endorphins and serotonin)
BIN THE DIMs
Anything that makes you stronger, better, healthier, more confident, more sure and certain – within and about yourself
These need strengthening and gathering
They will switch your own drug cabinet on (increase endorphins and serotonin)
SING THE SIMs

45. DIMs and SIMs Can hide in hard to find places. Can switch teams
Everyone can learn how to switch off and turn down their protective systems
Identify them
Back pack – when you’re exploring new territory – pack plenty of SIMs and throw out the weighty DIMs

46. I WILL be in pain when the credible evidence of danger in me is greater than the credible evidence of safety in me
I WILL NOT be in pain when the credible evidence of safety in me outweighs the credible evidence of danger in me

48. Pacing and graded exposure
Twin peaks
Decide what you want to do more of
Find your baseline
Plan your progression
Don’t flare up but don’t freak out of you do
It’s a lifestyle thing
Always do more than you did yesterday

49. Graded motor imagery Accessing the virtual body
Retraining the orchestra to help it play a more harmonious tune
E.g. imagined movements, alter environment, add distractions
Designed to make the neurotag curious, make it wonder what’s next. You be the master.

50. Psychological therapies
Chronic pain
Psychological therapies

52. Key Processes Acceptance and Mindfulness: Values-based Action:
Involves decreasing the influence of problematic thoughts, feelings, and sensations on living.
Includes a willingness to experience pain/distress without attempts to control them.
A quality of action occurring while in contact with these experiences.
Values-based Action:
Actions directed towards personally meaningful purposes, rather than towards the elimination of unwanted experiences

53. Dahl et al., 2004; McCracken et al., 2005; 2007;
Treatment Outcomes
10 published studies
Improvements in:
Pain
Disability
Distress (i.e. Depression, Anxiety)
Healthcare Utilization
Physical Performance
Work & School Attendance
Acceptance
Mindfulness
Values-based action
In comparison to “treatment as usual” or waitlists.
Gains persist (i.e., 3-6 months)
Dahl et al., 2004; McCracken et al., 2005; 2007;
Vowles et al., 2007a; 2007b; 2008; 2009; Wicksell et al., 2007, 2008, 2009.

55. Meditation & Pain John Kabat - Zinn
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56. Tone down that nervous system
Active Relaxation
Deep breathing
Breathing with diaphragm
Heat, ice, TENS, anything else that works for you

57. The future Explain pain supercharged Spinal cord neurotags
Neuroimmunology
Development of transformative metaphor

58. Points to remember Chronic pain is REAL and horrible HURT ≠ HARM
Explain pain – don’t get despondent.
Get your colleagues, trainees on board
Encourage physical and psychological therapies

59. Recommended weblinks https://www.youtube.com/watch?v=5KrUL8tOaQs
-Brainman explains pain
Understanding pain – Brainman chooses
– Brainman stops his opioids
– A video explaining the problems with opiates
base_0813.pdf

60. Recommended reading