No brain, no pain: it is in the mind, so test results can make it worse

This post was first published on TheConversation. Here it is in a slightly longer format.

NPS Medicinewise has just launched its Choosing Wisely Australia, tagged with the line ‘An important conversation about unnecessary tests, treatments and procedures’. They have gathered an impressive collection of collaborators <http://www.choosingwisely.org.au/recommendations> and a substantial list of recommendations. I am in no place to comment on most of them, but I am in a place to comment on perhaps one of the most relevant to the wider community – imaging for acute low back pain. It is a common recommended “don’t” of the Choosing Wisely campaign in the United States, Canada and now also Australia is getting imaging for non-specific back pain. The initiative, which identifies tests, treatment and procedures that have little benefit but may lead to harm, is indeed wise in highlighting the dangers of such scanning.

The recommendation is based on several major studies – from 2007, 2008, 2009, 2010, 2011 and 2013. But while not imaging might be based on solid advice, it’s old advice. The recommendation has been around for years – ever since it was discovered that the state of your back MRI doesn’t relate very well to whether or not you have back pain. (Note to self – that paper is 20 years old!) – see this great blog post by Dr Neil O’Connell.

Still, they come…

Nonetheless, the vast majority of people who turn up to participate in our research, two or three weeks into an episode of back pain, bring with them a bundle of MRIs tucked under their arm and a somewhat worried look on their face.

When we ask referrers about their almost ubiquitous MRI use, the most common answers tend to be “the pain was just so severe and the patient really wanted it”, “better to be safe than sorry”, “no harm in just excluding the nasty stuff”, and, the clanger – “lucky we did – there are some pretty major problems in there”.

And here is the rub. There’s no doubt that MRI is a really powerful tool. I am one of those who is gobsmacked by the detail these things provide and the magic of being able to see inside ourselves. I’m also pretty convinced that MRIs don’t carry physical risks. (aside from those associated with having metallic objects inside massive magnets). So what’s my problem with it? If people can afford it, or if the pain is really severe, it can’t do any harm right?

So what’s problem? If people can afford it, or if the pain is really severe, it can’t do any harm, right?

Pain is always created by your brain in an attempt to make you do something to protect your body. J E Theriot/Flickr, CC BY-SA

One of my favourite phrases when it comes to the biological processes involved in pain is that we are “fearfully and wonderfully complex”. The key to understanding why an MRI might actually make your back pain worse is to understand first how back pain works. Indeed, how all pain works.

Pain is always – 100% of the time – no exceptions – created by your brain and it makes you do something to protect your body. People right in the middle of an acute episode of back pain know this better than most – it’s a brutal, distressing and, at times, terrifying feeling that possesses you to desperately want to be rid of it.

It’s so compelling and so clearly “in your body”, that it can be difficult to believe that you don’t actually need a body part to have pain in it.

But you do need a brain. No brain – no pain.

Don’t believe me?

For people reading this, the BiM version of this post, that won’t be a tough concept to swallow. Nor will this, although many ‘outside the ‘hood’ might struggle at first bite –  any credible evidence of danger to your body will make pain worse and any credible evidence of safety to your body will make it better.

Because we haven’t yet identified everything that carries credible evidence of safety and danger, we lump those we don’t know about together and call them placebo (safety) and nocebo (danger) effects.

Imaging will pick up the ‘kisses of time’ that have morphed your vertebrae and joints to better withstand the forces on them. Katie Cowden/Flickr, CC BY-NC-ND

The idea that the “placebo effect” or the “nocebo effect” are actual “things” is, in my view, a bit daft because they’re really just umbrella terms for all the effects we haven’t identified yet.

As we discover that, for example, a clinician’s belief in the treatment they’re administering affects its pain-relieving capacity, or that the pain-relieving effect of acupuncture depends more on whether you think you had acupuncture than it does on whether you actually had it, the placebo “effect” seems to get smaller. It’s not the effect that’s getting smaller, we’re just understanding things better. But that’s a bit by-the-by for now.

The stakes in this idea of “credible evidence of danger” are very high when it comes to pain because of neuroplasticity – the wonderful adaptability of our brain and nervous system. Neuroplasticity is ‘hot’, thanks to books such as ‘The brain that changes itself’ by Norman Doidge, and the explosion of ‘brain training’ products and websites. Of course, it’s not just your brain that changes by itself, it’s your whole body, which is why I prefer to think of it as “bioplasticity”. As Dear Dr Thacker repeatedly tells me – ‘the time for neurocentricity is over!’

The point is that the more you play the piano, or football, the better you get at playing the piano, or football. So it follows that the more your whole system produces something like pain, the better it gets at producing pain.

Try it out

With this model of pain in mind, and a healthy respect for bioplasticity, let’s revisit that MRI you got after a week of brutal back pain. If you’re over 25 and half normal, then your MRI will show “stuff”.

It will pick up the “kisses of time” that have morphed your vertebrae and joints to better withstand the forces on them; it will pick up old minor injuries – perhaps you never knew you had – that have healed but left their trace just like a scar on your skin; it will pick up evidence that you’re no longer fresh out of the womb; and it will pick up many of your own idiosyncratic anatomical characteristics. Just like a photo of your face clearly shows you’re not the same as anyone else.

Unfortunately, when it comes to MRIs, these usual things are then given rather scary names, such as “broad-based disc bulge”, “degenerative changes” and spondylolysis.

Credible evidence of danger? Sure sounds like it. And, because of your own fearfully and wonderfully complex system, your brain will store this information and quite possibly turn up the “need to protect” meter, just a bit.

The pain-relieving effect of acupuncture depends more on whether you think you had acupuncture than on whether you actually had it. Victoria Garcia/Flickr, CC BY

So you dive into the challenge of finding the best strategy to “fix the MRI”, until eventually you come across someone with the apparent audacity to tell you, actually, those MRIs are pretty normal. Now you are livid, right? Are they telling me my pain is all in my head?!?!

Clearly, it is not – it is in your back. But, like it or not, if you are a human, your pain is in fact produced in your head and it will produce it more readily and more intensely if you have what you think is clear MRI evidence that something is wrong.

Getting wise

I have deliberately taken a provocative line here, but it is by no means outrageous. There are experimental data that clearly predict this scenario and big studies that suggest getting an MRI early on is associated with poor outcome later.

So choose wisely when your back hurts; remember that even brutal back pain is rarely a sign of serious pathology and that it’s really, really common.

Remember that it will pass and it’s best to gradually increase your activity – respect your pain but don’t fear it. You should see a physiotherapist or a doctor because they know the important questions to ask and can coach you on the best road to recovery.

And remember – whether you think you are a tough nut or a bit of a softie – your brain considers all credible evidence of danger when it’s producing pain. If you do end up getting an MRI, expect to see the “kisses of time” and remember that they’re normal, even if they have scary names. Know that there’s no way of finding out when old injuries occurred, and the imaging will probably look just the same when your back no longer hurts.The Conversation

This article was originally published on The Conversation.
Read the original article.

About Lorimer Moseley

Professor Lorimer Moseley is a clinical scientist investigating pain in humans. After posts at The University of Oxford, UK, and the University of Sydney, Lorimer was appointed Foundation Professor of Neuroscience and Chair in Physiotherapy, The Sansom Institute for Health Research at the University of South Australia. He is also Senior Principal Research Fellow at NeuRA and an NHMRC Principal Research Fellow.

He has published 160 papers, four books and numerous book chapters. He has given over 120 keynote or invited presentations at interdisciplinary meetings in 26 countries and has provided professional education in pain sciences to over 7000 medical and health practitioners. He consults to governmental and industry bodies in Europe and North America on pain-related issues. He was awarded the inaugural Ulf Lindblom Award for the outstanding mid-career clinical scientist working in a pain-related field by the International Association for the Study of Pain, was shortlisted for the 2011 and 2012 Australian Science Minister’s Prize for Life Sciences, and won the 2013 Marshall & Warren Award from the NHMRC, for the Best Innovative and Potentially Transformative Project.

Link to Lorimer’s published research hereDownloadable PDFs here.

Comments

  1. Gerry Daly says:

    Just some thoughts on the ‘frameworks’ we employ when we attempt to define pain.

    When we try to consciously rationalise the threat detection nervous and immune systems, we can’t help but be in awe of the almost perfect functionalities involved. Both systems seem to fulfil a role in maintaining the living status of the body organism, perhaps to the point where they are both obvious candidates to sit on top the protective hierarchy of defence mechanisms which the body employs. However, there is one protective function which seems beyond the capabilities of both systems….and that is the detection of, and protection against, external threats which have not yet been actualised on the body. There would seem to be a need for another ‘intelligent’ protective system to fulfil that role.

    Thus, perhaps, has consciousness evolved from the autonomic systems, as a means of detecting and responding to external threats before they have been actualised on the body. As such, consciousness might seem to be a ‘secondary’ autonomic system, but its autonomic (instinctive) responses are configured to deal with threat configurations which exist outside the body. Consciousness must have a capacity, a risk vulnerable capacity, to engage with external threats in a manner which would be too compromising or too risky for our primary autonomic systems. So, consciousness may well be a protective ‘buffer zone’ against unactualised external threats.

    Because of its possible compromised vulnerability, consciousness might well sit below the primary autonomic systems in the hierarchical protective structure. There would need to be a means for ‘crossover’ exchange of information between the systems, which doesn’t compromise the primary system functionality in any way. The conscious perception we know as ‘pain’ may well be one type of ‘crossover’ event….perhaps informing consciousness of the actualisation of a threatened status, and perhaps, as a ‘reminder’ to consciousness that the primary systems have assumed the main defensive duties. Thus pain might signify a prompted restraint on possible conscious reactions, rather than signify an indication of threat, as it is most commonly perceived. After all, once a threat has been announced, why would there be a need for a continuance of threat warning, once the healing processes have been instigated on an autonomic level.

    If all this were so, speculative though it might be, and consciousness were to be a ‘secondary buffer zone’, and pain were to be a ‘system crossover event’, then we might be obliged to perceive consciousness as an intelligent protective system, totally predicated on external threat protection and defence. Considering what we already know about our conscious sensory capabilities, and their obvious prioritised protective functions, I think it is rational to assume such a single purpose for the functionality of consciousness as a whole. Put another way….all conscious thought, including imaginary abstract thought, might well simply be predicated on external threat detection and response purposes.

    However, our conscious capabilities to rationalise events are limited, and limited for specific protective reasons. We struggle continuously to rationalise and define consciousness itself, same with the primary autonomic systems, same with the pain event, and same with the non-conscious. What we may be failing to see is that consciousness is ‘restrained’ from rationalising these matters, because doing so would compromise the overall purpose of the protective systems. Consciousness has a vulnerability to external threats, or to becoming a threat itself, and so it is safe-guarded against by means of a separation from the systems which must maintain protective integrity. I think the obvious clue to that separation is the manner in which the primary systems continue to function when consciousness is ‘switched off’…..when asleep, or when unconscious, or even at a young age before we become consciously aware.

    As a speculative overview, admittedly in a pretty raw form, this approach to defining consciousness and pain might offer up interesting options for understanding the relationships between separated systems, all functioning in the interests of a protective hierarchy. Our seeming inability to rationalise consciousness and pain as being parts of a comprehensive protective system, might well be a ‘purposeful’ inability to rationalise, predicated on protection against a vulnerability to compromising the purposeful functionalities of our primary protective systems.

    Hope this fits in with the ‘no brain…no pain’ theme of this thread, perhaps as an alternative approach to questioning the framework before assuming solutions.

    Gerry Daly

  2. Gerry Daly says:

    Here’s a teaser…..

    We have developed biochemical means for suppressing the autonomic response systems. Does that mean that we have inadvertently increased the threat potential of consciousness ? It would seem so.

    Also, what means have we developed to assist the autonomic systems to respond more vigorously, if required ?. It would seem that the methods we employ, surgery or medications, are actually threat increasing methods which encourage a pre-gauged boosted autonomic response. It’s that autonomic response which actually does the healing, in all circumstances. If we were capable of switching off the autonomic response systems, which we are now capable of doing, most of our interventions would be deemed too risky.

    So, it might seem that our best methods for interacting with, or assisting, the autonomic systems might well be aggressive interventions with a potential for increasing threat. What does that tell us about the role of consciousness in an integrated protective system ? Begs the question…’Is consciousness a threat to the autonomic systems, right from the moment of its inception ?’. If that were to be a possibility, it might help explain why consciousness has not been enabled to explore the controlling functions of the autonomic systems…..and the relationship dilemmas we struggle with are really unsolvable because we don’t have, and perhaps never will have, the conscious tools.

  3. Gerry Daly says:

    Just assuming that query is directed at me, rather than at the thread originator. My answer would probably be….We observe functionality in the events we witness by means of our senses, and their consciously limited capabilities. The resulting conscious perceptions are then speculated upon in order to help define any controlling features which we perceive might be driving the functionality. Unfortunately, the only tool we have to enable the speculations, consciousness, seems to be limited in its ability to speculate beyond its own ‘known’ environment. And, so, we stick to the observed functionality as a guide to speculations, and that can be enough for determining the possible relationships between the different systems we assume might be creating the functionalities. If we perceive the functionalities (nervous system and immune system activities), whose origins are unknown to us on a conscious level, as being the ‘purpose’ of any assumed system, then I think it is rational and reasonable to build speculations based upon comparable systems which we already consciously understand. So, what matters is the observed functionality, rather than speculative assumptions.

    But, I also am inclined towards an inherent ‘restraint on consciousness’ element which restricts conscious speculation, particularly any speculative attempts to unravel the protective autonomic systems, because of the risk of compromising those systems. As I see it, it would make sense for any all-encompassing protective system to first assume that anything encountered has the potential to be a threat…including what we understand to be our own consciousness. And if autonomic responses on a purely tissue level are anything to go by, then I see no reason for excluding autonomic responses on a conscious perceptive level as well. All threats must be protected against, otherwise there arises the potential for compromise.

    The issue of pain as a possible system cross-over event, reflecting a particular ‘restraining’ functionality of the autonomic systems, would require a lot of space to explore speculatively.

  4. Austin Gallaher says:

    Does your definition of the brain include the nervous system? Would you be willing to say that pain is created by the nervous system or do yu restrict pain creation to the brain inside the skull.

  5. Gerry Daly says:

    Here’s some questions……..Will future treatments for chronic pain be governed by anecdotal theories ?. Will patients be required to display complicity when entering treatment programmes for chronic pain ? Will a patient’s failure to display a complicit nature lead to possible exclusion from offered treatments ? And, what other options might be available to a patient ‘excluded’ because of their possible rejection of treatments based on anecdotes ?

  6. Gerry Daly says:

    Just mulling over the much talked about operator/patient dissonance which tends to invade engagements with chronic pain patients. How does an operator, whose own mindset has a default expectation of healing, get to grasp the complexities of the default chronic pain mindset which seems set to a ‘no healing expectation’ ?……not forgetting that the chronic patient still always retains a healing expectation for other issues besides the actual chronic condition. So, I’ve imagined a little test that might be appropriate, and might help to bridge the dissonance……..

    Imagine nine dentists are put on stage and asked the same question….’What are the important relevant factors, and appropriate treatments when a patient presents with a rotted tooth which requires extraction ?’. I’m pretty sure all would reply more or less with the same answer….’Assess the damage to confirm extraction option, obtain patient consent, assess the required anaesthetic, assume confidence in required skill levels, proceed with extraction and advise patient of any after-care required’. How re-assuring is such a process. ?

    Now, put 3 GPs, 3 Physiotherapists, and 3 Neurosurgeons on the same stage and ask them…..’What are the important relevant factors, and appropriate treatments, when a patient presents with a possible threatened nerve at C3-C4 due to degeneration ?’ I don’t think I could list all the possible answers that might emanate from that question, and that usually amounts to re-assurance exiting the equation at the first hurdle. There’s really not much difference between the the two presented conditions. A rotted tooth could easily become chronic if unattended, unless, of course it self-resolved eventually. The accompanying nerve issues and pain perceptions belong more or less in the same order. The differences really only occur in the treatment options, where one is re-assuring, and the other perhaps confusing. All due to the state of the science, and the limitations imposed. Seemingly.

    Now, I would ask any operator, attempting to try and understand what goes on in a chronic patient’s mind, to try and imagine themselves as the patient in the ‘rotted tooth’ scenario posted above, except they are faced with the unlikely event of the nine dentists each giving a different answer. That, usually unsupported, internal dilemma about prospects, is what maybe lies at the heart of the much questioned chronic pain mindset.

    I tend to see the chronic pain patient having to continually juggle two opposing mindsets at the same time…one mindset that retains healing expectations for most future issues, and one mindset which has to come to terms with a ‘no healing expectation’ for the one ongoing diagnosed condition which is ‘chronic’. That internal dilemma can cause an internal mindset chaos with repercussions for rational choosing of available treatment options.
    I just don’t think it’s wise to add to that possible mindset chaos with pain theories which might further question the relevance of the subjective chronic pain experience. It is what it is, having evolved in tandem with the perceived experience, and probably best left alone unquestioned. Better to focus on that which might have caused it…..the uncertainty surrounding future prospects. Tackle that ‘uncertain’ element, and the mindset might just adjust itself naturally.

  7. Gerry Daly says:

    PS…..
    I might prefer the suggested ‘dysfunction dis-inhibitor’ overview if it were described as an ‘inherent coded confuser’ aspect to our protective system, which perhaps has the duty to protect against any conscious over-rationalisation of the protective systems which might compromise, or render defunct, the entire protective system. For that to work, we would have to change our normal perception to one of ‘consciousness, itself, being perceived as a threat’. That’s an overview which addresses a lot of unexplainable issues, for me anyway. At least, it maybe offers a new approach perspective.

  8. Gerry Daly says:

    Hi Connie

    I think the manner you describe what we’re discussing here, is what the word ‘Professionalism’ is all about. Professionalism, to me, means acquiring an ability to rise above one’s own trained perspectives, allowing a ‘credence’ to the presented narrative, and dealing with that within the context of the patient’s understanding, even at the expense of suppressing ‘trained’ perspectives. I agree with what you suggest. It’s all about the ‘operator approach options’ which tend to question the patient narrative, suggest enthusiastic programmes, and perhaps even shut the doors to exploring coping mechanisms which might be the only thing that is actually working.

    Re the Gifford ‘dysfunctional dis-inhibition system’ and ‘annoying tune’ description of chronic pain perceptions, unfortunately, I would tend to disagree with that ‘assumed’ overview. Makes it even harder to disagree knowing the high regard his opinions are held in. I see chronic pain more as a re-curring acute condition, which requires nervous system responses and resulting pain perceptions on a daily basis. I don’t see it as a habitualised event which can be manipulated by altering a patient’s mindset habits. Of course, there are patients who are susceptible to such habitualisations, but they’re probably few in number, and they unknowingly give the rest of the chronic pain demographic a ‘bad press’. By all means, treat those patients for mindset issues, but maybe not at the expense of assuming same for diagnosed chronic pain conditions with ‘no healing expectation’ attached. The ‘annoying tune’ tends to come with the repetitious nature of the condition, rather than as some ’embedded’ or ‘implanted’ overview perspective.

    Also, on the Gifford reference to ‘dysfunctional dis-inhibition’…….my argument against accepting that overview would be….’If we can’t define what proper functioning ought to be, then we are not entitled to assume a dysfunction of any nature’ . Same for the many references to ‘nerve misbehaviour’ when we simply don’t yet have the science to define proper nerve behaviour. In a way, it’s a means to excuse our lack of understanding, and it discourages deeper explorations all too conveniently. Basic rule here…..’dysfunction’ and ‘misbehaviour’ only exist by virtue of the primary existence of their positive counterparts. Does that make sense ?

  9. Connie Posigian says:

    Gerry Daly,
    I’m very encouraged by this theory you have presented, that a person’s perception of available treatment options could help or hinder their future prospects. I believe as you do that when options are adequately explained within the framework of what a person knows about themselves already, without trying to change their mind or emotions, the person can decide. And isn’t this a definition of self efficacy?

    A key part of finding out how to live to live with yourself, how to heal, is to be empowered with some good, helpful knowledge about the physiology of pain. But first us practitioners need to LISTEN & BELIEVE in what this person is telling you. How can we know how to tailor the delivery of new information into this person’s schema, if we don’t first get a glimpse of how this person gets through each day? What I think this person should do is irrelevant. I want to help a person find out what it is that THEY think they should do.

    Science has not yet found the switch that causes pain to stay on. According to Louis Gifford, there is a dysfunctional dis-inhibition system in our physiology, which allows an “annoying tune” to constantly play in our consciousness (p. 191, Aches and Pains , 2014).

  10. Gerry Daly says:

    Just wondering what opinions might be on this chronic pain puzzle…..What is it about chronic pain mindsets, where there seems to be a conscious ‘switch’ which flips the default mindset towards a negative momentum ?

    First response might be that pain perceptions might be responsible for the ‘switching’. Personally, I’m not inclined towards that reason because I think all of us, including, and perhaps particularly, chronic pain patients, are highly resilient to pain perceptions, and to accommodating them as required. Maybe the modern medications dependency culture has not helped that natural resilience, but that’s a different issue. I think that the chronic negative momentum mindset evolves more from a patient’s perception of an almost arbitrary, perhaps even unreasonable, disenfranchisement of their future potential. Any uncertain overviews of future prospects can open the conscious gateways to a ‘catastrophizing’ element, which in turn plays itself out on pain perceptions, whether current or future imagined.

    If that default switching had more to do with perceptions of future prospects, rather than current pain perceptions, then I think what’s really needed to settle the negative momentum, is to offer up future planning options which might utilise best potential within the limited framework expected. And, perhaps, most importantly of all, would be to offer up ‘comfort zones’, or ‘safe zones’, that might be achievable whilst the patient explores their own potential. Considering there may not be any available accepted treatments which guarantee an improvement, I think that it would be advantageous to allow the patient to consider their own options in the most relaxed climate possible (that’s where the best thinking is done ), without any imposed insistence on any requirement for mindset changing, or on any therapies which maybe don’t resonate with a patient’s intuitive instincts. It would be a shame , considering all the good intentions to improve treatments, if patients were to develop a reluctance to present themselves because they don’t fully understand the theory behind the treatments being offered, or the treatments themselves seem to lack resonance to the subjective experience.

  11. Gerry Daly says:

    Hi Stu

    Perhaps a little misunderstanding, or ‘lost in translation’ moment. You say “When the operator was reassuring and accepting of your previously ignored narrative, I assumed that the narrative was ‘there is something wrong with my neck’ and that the ‘pain is not in my brain.’ Perhaps my assumptions were wrong. “. That’s not really what I was trying to describe.
    I always knew I had issues with the neck. I’d had several xrays and tests over the years, and of course, there was always the ‘associated’ symptoms. In fact, with the arrival of the new symptoms leading to the MRI, there was actually a subjective clarification of the symptoms to a ‘well-documented’ variety of typical ‘trapped nerve’ referred symptoms. Previously, for 25 years, I had a range of difficult to define symptoms (cervicogenic headaches, frozen shoulder etc etc) which confused both me and my advisers. I read those symptom changes, due to nerve becoming more compromised, as the previous ‘associated’ symptoms no longer being a protective requirement, because the threat of compromising had become a reality. Generally, the new symptoms (numb hand/ arm pain/ pins and needles etc ) are easier to rationalize, and cause me less confusion. Maybe a case of a manifestation of expected degenerative changes, which actually improve my overall condition, including my mindset. That was an unexpected outcome, and very welcome indeed. The real problem was the confusingly (un)recognised pre-trapped nerve issues which defied any treatment plan, over the previous 25 years. Hope that helps create a clearer picture.

    Regarding the ‘ the pain is not in my brain’ issue you refer to……I don’t think I ever had trouble with that. I recognise that pain, once consciously perceived, is a manufactured conscious perception. I also recognise that pain perceptions, once created, can be influenced by mindset variations…no doubt there. But, I don’t think that mindset variations create the initial perception. So, ‘no brain…no pain’ looks a bit incomplete to me…it works on one level, but doesn’t address possible origin. And if we talk about pain being an ‘event’, it must be comprehensive enough to include possible origin. Thus my construct above on pain being a ‘crossover’ event, possibly linking protective systems to consciousness. Basically I think that because consciousness only seems to function by means of perceptions, and because pain may have a purpose to its emergence in consciousness, that instigating a conscious perception would be the only means of fulfilling that purpose. Consequently, a ‘purpose’ to restrain conscious reactions might seem to fit.

    I’m also semi-inclined towards an overview which includes an inherent ‘confuser’ aspect, to both pain and consciousness, which protects our protective systems from any compromise that might occur as a result of our attempts to rationalize both. That would make sense to me if I were to conceptualize a perfectly defended system.

    And, just to say. Operators are entitled to explore their preferences…..all part of the quest. My issues only concern the neutral treatments which emanate, and the theories which help evolve them.

  12. Gerry, thanks for your response. What I found disconcerting (but insightful) was when you mentioned that ‘currently, the most aggressive theories suggest that pain is a psychological ’emergent’ perception. This confused me. When the operator was reassuring and accepting of your previously ignored narrative, I assumed that the narrative was ‘there is something wrong with my neck’ and that the ‘pain is not in my brain.’ Perhaps my assumptions were wrong. I believe that there is no separation – we are an integrated system – the concept of adaptation tries to encompass the whole person. We all have thresholds of tolerance – we all have vulnerabilities. I try not to be sympathetic – I don’t perceive it is helpful. I try, clumsily at times, to seek further understanding. Perhaps I am still failing – I agree with you on that. Any help?

  13. Gerry Daly says:

    Hi Stu

    Yes, you really describe the background ‘default’ chronic survival mindset well. All those things, with ‘unwelcome’ social and work issues thrown in for good measure. We develop coping mechanisms, quite often in direct conflict with our desires, and we manage best we can. Doesn’t look pretty from the outside, but gradually we adapt to the limitations imposed. I read a blog recently by Michael, which referred to the whole chronic baggage as a ‘giant tangled hairball’ we drag behind us. Excellent description, got me thinking, and I can do no better.

    Regarding treatments, and particularly about an imposed characteristic of vulnerability to negative entrenchments being imposed on the chronic patient, I obviously have some issues, probably shared by many patients (my assumption). On the understanding that we are all of equal status, patients and operators alike, if it were put to me that I had a mindset vulnerability, I think my well-honed defenses would go into over-drive. Most likely, the same for any operator who was similarly challenged….something that most patients wouldn’t dare do because of the possible gateway-closing effect it might encourage. So there’s a possible imbalance being suggested, a required acceptance of a hierarchy, and IMO, even less chance of a good investigation of the presented patient narrative, especially where doubt exists about appropriate treatments. There’s that locus of control issue at outset.

    Another issue which flags up to me, is the tendency towards an overview of ‘the perpetuation of the persistence of pain’ . I get the thinking behind that, but I have to question it. ‘Persistence’ , to me, describes something which has had a resolution expectancy attached, but has ‘persisted’ beyond that. Is that really a suitable substitute for ‘chronic’, which I’ve always understood to mean ‘no expected resolution over time’ ? I understand the positive intention of wanting to soften the negative undertones of ‘chronic’, but at the same time, I worry it might have some impact on treatment approaches. From some online discussions I’ve had, I got the impression that some of the younger operators didn’t seem to be capable of tuning in to the chronic mindset, perhaps because they wished to avoid the undertones and retain a positive mindset themselves. Probably a natural inclination, and much evidenced in normal society anyway. But, I don’t think that chronic patients, generally, have a problem with their familiar term of reference.

    The ‘MRI moment’, I mentioned above, had a positive effect because the operator had reason to be reassuring and accepting of my previously much ignored narrative. But I remain concerned about others with doubtful conditions who maybe never get that mindset resolution offered, and have to jump through the hoops anyway without that reassurance focusing. As an ‘ex-avoider’ myself, that’s where my sympathies tend to lie.

  14. Gerry, what I find reassuring is that you found a ‘reason’ for your pain and justification for your years of suffering and used it to try to enhance your knowledge and move towards meaningful purpose. What I find disconcerting is that it seemed, more than anything, you wanted someone to agree with you. I sit in the same boat. Many people want a ‘reason’ for their pain and turn to imaging in the periphery (or centrally) for the whys. It has been shown in studies of non-specific back pain (whatever that means) that early imaging of the periphery perpetuates the persistence of pain. Over the 30 years that you were ‘whinging’ I am sure that you developed some strategies to help yourself – putting yourself in the driver’s seat. Not just avoidance. Perhaps the imaging gave you a reason for further exploration – a purpose. Perhaps it ‘quieted the noise’ long enough for you to re-evaluate with clearer thinking. Or perhaps, like Dr. Adahan’s work on treating the DRG with phantom limb pain, it resulted in a ‘clearer signal’. ‘Windows of opportunity, catalysts for change’ are statements I hear from interventionists – many are aware that they are doing things with patients and not just to them and that in many circumstances, expectation is aetiology. I need to embrace the contradictions perhaps and appreciate that people are just trying to help. Even by listening. Thanks for this post Lorimer.

  15. Gerry Daly says:

    Just a little rectifying post, to return this thread to its original intention….a discussion on MRI effects and how scan results can transfer onto the chronic mindset with a subtext of negative entrenchment about ‘persistence’ being willingly adopted into the default chronic mindset. Firstly, my apologies for my little attempted diversion towards alternative Pain Theory….I think it’s relevant, but perhaps too ‘lateral’ for this thread.
    I fully understand the perspective which suggests that MRI scan results can register in the chronic mindset as a re-inforcement of a patient’s negative self-confirmations. It can seemingly add validity to an already established overview, which might, in turn, create further barriers to inclusion in more positively oriented mindset therapies. Accepted. But, it is only one perspective, and it only applies where a chronic patient is vulnerable to such entrenchments, probably due to having been subjected to difficult to understand encounters with the ‘white coats’ over many years. So, here’s something I hate doing, because of the obvious confirmation bias involved……here’s a little narrative of my own experience of MRI repercussions which might support an almost opposite appraisal.

    I’ve had cervical spondylosis for over 30 years. 25 of those years were spent in daily contention with a ‘sub-text of disbelief’, on all levels, which ingrained itself on me to the point where I willfully avoided the encounters I reckoned might add to that negative context. About 5 years ago, some new symptoms appeared (numb hand/arm pain etc) and I was fast tracked to MRI and EMG etc. At my first interview with the PT to discuss MRI results, she confirmed the degeneration etc. So I said, couldn’t stop myself really, ‘Does that mean that all my whingeing over the years was valid ?’. She replied, without a flicker of condescension,…. ‘Absolutely’. And that was a moment for me that I could describe….but I won’t do it publicly. The MRI made that moment possible.

    Since then, I have turned my mind towards an exploration of the debatable dynamics of the C/S condition, which has been an interesting quest. Might never have happened without that MRI moment. There has been no negative entrenchment, or further ingraining. Much the opposite. The ‘sub-text of disbelief’ was relieved on the professional level, at least, and it’s resulted in a release of my own desire to explore the condition, in a fashion similar to those in the profession who feel a desire to improve treatments.

    So, just saying that we shouldn’t just assume that the chronic patient is vulnerable to negative overviews because of their experiences tending them towards that perceived image. There’s really no differences….we think the same as the investigative scientists, at least some of us who don’t accept, probably well-intentioned, imposed characteristics, do. The idea of assuming a chronic pain patient’s vulnerabilites, sometimes needs reversing in order to expose a different kind of vulnerability which might be affecting treatment approaches.

    Again, apologies for the personal narrative,,,,but sometimes, it’s the only way to get to the core of what is essentially a highly sensitised subjective issue…..chronic pain.

  16. Gerry Daly says:

    Thanks Michael

    A little encouragement always helps to advance the thinking processes. I could go a lot deeper into the conceptualising pain rationale, but probably not appropriate on someone else’s thread. My area of interest is reasoning and rationalising the referred and radiated symptoms associated with Radiculopathy, usually defined as ‘nerve misbehaviour’, but actually quite revealing about general nerve behaviour, as I see it. When a nerve is , itself, threatened or compromised, a whole set of peculiar responses, based on seemingly ‘odd’ nerve protection behavioual rules, are typically manifested. Getting to grips with the possible rationale behind those responses can be revealing, and has helped with the ‘pain as a restraint’ overview which I’m exploring conceptually.

  17. Michael Negraeff says:

    Gerry, interesting construct. Thanks for sharing it.

    I have not always been comfortable describing pain as all in the brain, although intuitively I get it as a phenomenon of consciousness. I like the integrative thinking that Connie above also proposed of the intelligence of all the systems working together. This dovetails, to me anyway, with what Gerry just said.

  18. Gerry Daly says:

    Just some comments on a Pain Theory overview which doesn’t usually get an airing.

    So, what is ‘Pain’ , exactly ?

    It’s really quite remarkable that we don’t as yet have a clearly organised definition of the pain event. There are many theories, from Cartesian to emergent, but, perhaps not too unstrangely, these theories seem to remain unchallenged within the small pockets of thinking fraternities which created them. There is an obvious lack of resonance between the theories and the subjective narrative of pain experience. Currently, the most aggressive theories suggest that pain is a psychological ‘emergent’ perception, which doesn’t require a direct link, nor correlation, to an actual threat of injury or disease. In other words, the ‘emergent’ perceptions can instigate themselves, and perpetuate themselves, with no known recognisable cause, and with no known predictive certainty about perpetuity. I am inclined to dispute such an overview because it would seem to relegate pain perceptions into relative insignificance when assessing any patient….’if the pain perceptions have no known origin, and if their fluctuations depend upon patient mindset variations, then there is obviously no pressing requirement for any interference other than attempting to alter a patient’s mindset ’ ! And so, I must ask again….’What is pain, exactly ?’, because I have an intuitive sense that conflicts with that theorised approach.

    So, what is the most obvious attribute of a pain event/perception/sensation, besides the more obvious discomfort it causes ? For me, top of the list has to be the manner by which our normally clear and responsive thinking seems to lose its clarity. A confusion is imposed on conscious thought, which highlights the distress, but discourages reaction which might be inappropriate. This may well be the ‘purpose’ of the pain perception, especially if we consider that a hasty reaction might further threaten an already vulnerable situation. If we think of a ‘purposefully’ created pain perception, perhaps originating in the autonomic protective systems, and then manifested in the conscious mind, as a means of restraining conscious reactions, it would seem to tick a lot of boxes about pain perceptions which aren’t normally considered. Generally, we only tend to see pain perceptions as threat warnings, or as signals requiring reactions. So, if we tinker with our overview a little, it’s not too difficult to come up with an almost opposite explanation i.e. that pain is meant to restrain reactions. I don’t think there could be much of an argument against the possible beneficial effects of a restraining ‘purpose’ , thus feeding into the overview perception of pain being a ‘for the good’ essential tool of the autonomic protective systems. We already know that our autonomic systems, the nervous system and the immune system, operate for our benefit, almost perfectly, and without any conscious control or interference, so why not assume that pain perceptions are an integral feature of that same protectively organised structure.

    My own understating of pain perceptions, intuitively observed, incline me towards seeing pain perceptions as some ‘crossover’ event, where, because consciousness requires perceptions to function, and where we have no conscious perceptions of nervous system/immune system operations, there has somehow evolved a need for a restraining element to discourage any inappropriate reactions. Seeing pain perceptions in that light, I think it gives a ‘purpose’ to the pain event which can be rationalised, and would have a beneficial effect on the way patients currently understand and respond to their pain experiences. On the other hand, if we define pain as a variable event, lacking any particular purpose, are we not really just assuming that pain treatments might be irrelevant to the bigger picture of treating recognisable threats. For instance, with neurological painful conditions, where no obvious source has been detected, are we to assume that the patient’s pain narrative should be ignored as ‘possibly consciously invented’ ? The ethics involved in such assumptions flag themselves up automatically, and should be a pointer to re-thinking the entire ‘pain question’.

    Gerry Daly

  19. Mike, thanks for your input. I don’t know if it helps as a starting point to identify that the pain is 100 % real and then start there. I would be interested in your viewpoint.
    I wonder if it would be helpful for clinicians who do things to patients (needling, injections, surgeries) to recognize and let the patient know that they are doing things with them (not just to them)? I realize that pain education can be helpful (if done well) prior to interventions however getting under the radar is tough. We all have blind spots. I have lots to learn and am interested in any insights. Thanks.

  20. Mike Castle says:

    Do you have Chronic Pain Ken ?
    Have you ever been a passenger in a Head On car accident ?
    I went to ADAPT – Royal North Shore !
    Even had a GP tell us about her Chronic Pain !
    I am now Hypersensitive to PAIN ! Now most of my body !
    If you want some reading material , read VS Ramachandran – The Tell Tale Brain and Phantoms in the Brain ! This is where Lorimer gets most of his info from ?

    KW Reply:

    Mike,
    I was in an auto accident back in 1987….T-boned. I had neck pain, weakness in my right arm with numbness in the index and middle finger of my right hand lasting over a year. Pain resolved but just a little numbness still left in the fingers. I had a return of pain in the right neck a few years ago and it took almost a year to resolve.

    I also had chronic right shoulder pain (I was a baseball pitcher) from 1983 until 2006….resolved.

    in 1994 I developed chronic sinus headaches after moving to a new city for a job. Lasted about 12 years.

    Went through sciatica for a few months back in 2007. Right leg pain resolved but now have left leg numbness (no pain).

    So I guess I have had my share of aches and pains but never really understood the mechanism until I read Dr Moseley/Butler along with a host of others. Also it’s interesting to see (and read about) what usually doesn’t work (and even will result in less function and harm) yet is almost “standard care” these days….eg opioids, shots, surgery etc.

    The way I look at pain now is: If it isn’t something “dangerous”, a cancer, a fracture, an infection, a blood clot, an immune disorder attacking my own cells, then I downplay it, minimize it, treat it with the least invasive least side effect producing modality and above all do no harm.

    I will read Ramachandran…I have his book on Kindle, but have yet to get to it.

    Thanks

  21. Ken Wenz says:

    I love this stuff! Great article and another excellent reference I can give to my patients. Keep on writing Dr Moseley!

    After reading Explain Pain, Painful Yarns, other books by Butler and Louw, and anything with L Moseley attached to it I have to say I’m getting the hang of this. It is almost comical (yet truly sad) to see the reactions of patients, peers, and even family members when I try and explain what is happening when they experience pain. It’s such a foreign concept to them. In fact I’m surprised Dr. Moseley is burnt out by now. Having the knowledge of pain and then seeing how difficult it is to “convince” others of it when they have been misinformed for years is a tough battle. It’s almost like there needs to be a huge “propaganda” campaign to convince folks of the truth. Then again people need to read, learn, persist, be patient, and take an active role……not easy, not a quick fix.

    Maybe chronic pain would better be treated by those who have the ability to “persuade,” rather than medicate, poke, cut, push, pull rub, etc. It’s a battle because patients often will listen but doubt….and then they run into their other health care provider who reinforces the usual gibberish, Then they are back to square one.

    Anyway, I just bought and read “The Explain Pain Handbook Protectometer.” All I can say is “another great book!!” I’m giving it as a reference to my patients. I think it should be required reading in medical school for goodness sake (along with the other books). In fact if we could get younger folks/children to read and understand it before they are polluted by misinformation then maybe this chronic pain thing can be changed. My kids picked up on it fast. Their favorite line is “All pain is made by the brain.”

    Dr. Moseley,
    Keep up the good work!!

  22. I don’t think it is the investigations that make people worse.
    It is the manner in which the ‘information’ is conveyed to patients that is the problem.
    A very typical comment on worker’s compensation claim forms re back pain after an investigation:
    “I didn’t realise my back was so bad!!”
    Interventional treatment is then commonly implemented with overall results that largely produce ‘placebo’ equivalent rates of benefit for patients in persistent pain but those who aren’t lucky enough to improve, for many emergent reasons, develop increasingly entrenched ‘protective’ pain constructs.
    “Why can’t anyone fix me?”
    Interestingly many have normal scans yet suffer the same outcome:
    “Why can’t anyone figure out what is wrong with me?”
    In my opinion, the fundamental problem is that the bio-model on its own is poorly predictive of outcomes; yet the significantly more predictive biopsychosocial model is rarely considered until ‘conservative’ (minimal if any pain education) and surgical management has completely failed and been exhausted; too late for many / most.
    I recall a comment from Prof Herbert Benson (author of the “The Relaxation Response” and much other research) – patient management should be considered a 3 legged stool with equal weight and reliance on each leg: pharmacy, surgery and mind/body. At present the stool is balancing on 2 legs only which it why it keeps falling over.

  23. Mike, keep looking for someone that can help you find out how to close your gates. There is hope, but it takes a lot of work and patience.

  24. Excellent discussion here! Sally, I agree the treatments you mention have clinical effectiveness in alleviating the suffering of pain. Chronic, persistent pain needs a diagnostic label to make it easier for health care workers to help people find treatments that work for them. It could also help streamline insurance payment by providing cost effective treatment for such a diagnosis.

    Pain is a physiological process that is experienced. Pain is a physiological process affected by chemical, thermal, and pressure changes in all of our systems. Our bodies have endocrine, digestive, reproductive, urinary, lymphatic, respiratory, cardiovascular, integumentary (skin), immune, nervous, muscular and skeletal systems. Changes in these systems can become “loud” enough for us to experience pain consciously: “this hurts.” All of these systems contribute to our homeostasis (the current state of the body).

    Let’s take running as an example. How do you “know” you are running? What is involved? We “make” our muscles carry our bones quickly, our heart begins to beat faster, we breath more deeply, our skin sweats, the lymphatic system works to drain wastes from between tissues, etc. If done over long periods, it is known to affect women’s menses. All the systems are working to maintain homeostasis.

    If one system is out of whack, it affects the other systems. The current state of the body is changed. If we have a flu, we can have digestive problems, a fever, the “chills,” muscles shake, breathing is labored, our skin may be pale.

    Pain is a result of our systems being out of whack, too. Doesn’t it make sense that all of our systems may be affected? Some of our body’s systems are known to have changes when pain persists; cardiovascular, immune, respiratory, and our nervous systems are adjusting to try to fix the situation. Science is just starting to find out (but it seems logical) that such physiological changes may happen to muscles as a reaction from these systems as well… which could give us “trigger points.”

    As an aside, I think it’s helpful to describe the brain as just another organ. The brain’s central nervous system processes are separate from “ourselves” or our thinking and knowing. We know we have pain, but just thinking about it is not going to change the pain. We have to decide what to do about it and make changes in our systems.
    I don’t think Psychophysiologic Disorder is appropriate, because it puts too much emphasis on the “psycho,” which has negative connotations.

  25. Maybe try the Feldenkrais Method. some awareness through movement classes and individual functional integration sessions…

  26. It’s so interesting looking at the words we use when describing something as emotive as pain. The effect words have on our physiology is huge, and it’s difficult to express what we want to say without labelling the patient and therefore boxing them into a condition or state of disease. Psychophysiologic Disorder (PPD) is gaining support in the USA and UK with growing evidence of success treating patients with Awareness /Mindfulness, meditation, breathwork, and psychology/psychotherapy. SIRPA have just had their first conference in the UK led by Georgie Oldfield, and the potential for treating patients who have been in pain for years is exciting. Doctors would do well to learn how to communicate more effectively with patients and to understand the effects of Adverse Childhood Events (ACE) later in life.

  27. Mike Castle says:

    What about injuries to neck and spine , spondylitis – spinal stenosis – internal disc disruption – degenerative disc disease – ptsd ! I have met Professor Nik Bogduk of Newcastle University ! Professor Michael Cousins of Royal North Shore Hospital ( ADAPT program ) ! What about trigger points , why are they so painful ? I think these act like mini brains , I think the brain acts as the main processor , but I think the gate is left open , as in the Gate Theory ! I am now Hypersensitive to pain ! My whole body is in PAIN !

  28. Lorimer Moseley says:

    Such excellent comments here – thanks. Fabrizio Benedetti’s work is really superb in my view and, as you say, he and others – e.g. Irene Tracy’s group at Oxford, Tor Wager’s group, Donald Price’s work from some time back – have all enlightened us as to what physiological mechanisms might be involved when someone has pain relief from a supposedly inert intervention. Those mechanisms are often called ‘placebo mechanisms’, but I don’t think that is correct in the same way that I don’t think the placebo effect is an effect. All of those researchers would, I am quite sure, agree that things like expectation, conditioning and subtle cues are triggers for these effects. That was the point I made about placebo – that it captures all those effects unless they are labelled as such. I did not mean to imply that those findings are wrong – just that we use the term placebo as though it is a thing itself, whereas I think it means ‘the rest of the cues/triggers/mediators we haven’t identified yet’.
    WRT the curative properties of the MRI – I agree that this happens. I think it happens less often than the deleterious effects, although I am unlikely to come across people who were helped substantially because they would no longer be seeking care, so your observations Heather might be much more common than my experience tells me they are.
    Bec – you touch on such an important and perplexing situation that is really common and has had me scratching my head for some time. I think your experience is a good example of the fearful and wonderful complexity of our biology. I know of many people who, like you, firmly believe that their pain is not indicative of damage, but they still hurt. The only way I can make sense of this, based on my understanding of the biology of perception, and pain in particular, is that the entire bio-system, almost all of which is evaluating, predicting, inferring things at an unconscious level, still concludes that protective action is required. We are working hard to understand this better – it is certainly not a unique example – what we consciously are convinced of does not align with the deeper processes of our system in other examples too (e.g. hunger when you are convinced you don’t need more calories), but it is a particularly frustrating example – particularly for those who are suffering. We are working hard on this to be able to bring better ways to get at the deeper processes.
    One way to modulate these unconscious processes is to decrease as much as we can the danger messages that are coming from the body, which touches on a common misunderstanding of posts like this – that the author is trying to convey something like ‘it is all in your mind so only consider changing your mind’. This is a really unfortunate breakdown in my communication, because I absolutely think that that statement is illogical. It is a bit like saying hunger is all in your mind (which i believe it is, although I am nervous about even using ‘the mind’ (it was not my title….) and prefer to use ‘experience’ or ‘consciousness’), so you don’t need to eat. Clearly hunger is an excellent conscious feeling that keeps us eating. So too, I believe that pain is a compelling conscious feeling that makes us look after our body. I will write another post on this kind of stuff because the current post is a great example of messages being morphed by journalistic flair and scientists (i.e. me) not being sufficiently vigilant to prevent that from happening. From some of the Facebook response to the post, it is clear to me that I have come up short in at least one of my own intentional objectives as a scientist who is very keen to ‘take the science to the people’: the objective of communicating in a manner that is both accurate and understanding of the situation of the observer, or learner. This is actually a fundamental component of good knowledge transfer and for me to have come up short here is disappointing for me.
    More of that in a future post, but of particular relevance here is your story BarleySinger. I clearly need to better articulate that pinning to the brain the job of making pain does not mean the rest is irrelevant. Not at all – I return to the hunger example here. My firm belief, based on my understanding of the science, is that every cue that implies danger to body tissue has the potential to increase our system’s choices about protection and pain is, in my view, a protective experience. I am disappointed (although not altogether surprised) by the responses to my post that clearly show people have taken it to mean there is no need to protect and there is no point in looking for danger cues that might be generated in the body. I do not hold that view and can not see any justification for that view anywhere in the scientific literature.
    Finally, I reiterate that which i have conceded before – I pin the final ‘decision to use consciousness to protect’ on the brain, but this relies on an assumption that is probably wrong – that if we removed every bit of the human except the brain we could still have consciousness and therefore pain. Roald Dahl wrote a great story on this and it is a common philosophical ponder. I expect consciousness would be lost somewhere along that process of removing body material but I don’t know where. We would be less vulnerable theoretically to say ‘biology’ than ‘brain’ although it does remain true that one can have intense pain in a body part that does not exist, and has not ever existed, or in fact if they have no nervous system connections below their neck.
    Anyway, thanks again for your comments and for those few Facebook followers who were dismayed, I apologise for my clumsy articulation. I apologise for the title – it was not mine and I was in a lovely performance of Summer of the 17th Doll during the time available for my final check and missed the deadline – I was as dismayed on seeing it as some of you were – but I take responsibility for it because I could have been more vigilant to that and a couple of other journalistic touches en route to publication.
    I will write more on these things anon. A great learning process for me and, although I have for the first time (to my knowledge) been reduced to ‘Show Pony’, I am really pleased for the reminders to be vigilant and empathic and respectful.

  29. Yeah, that’s all well and good, but if I firmly believe that the pain is coming from my brain, and that my body is perfectly healthy, why am I still getting this fibromyalgia pain?

    balto Reply:

    Because you Fear it.
    Negative events/emotions triggered pain symptoms. Fear keep it alive. No fear – no pain.

  30. Heather says:

    I am a Registered Massage Therapist in Canada, with 12 years experience, and I have also heard of the opposite effect of MRIs to what you cite in your article. I have clients who experience significant back pain for extended periods, who finally go for an MRI, and shortly afterward (a few days to a week), the pain diminishes and goes away! We call it the magical curative properties of MRI! Curious to hear how you think that fits your scenario?

  31. BarleySinger says:

    I know the brain is powerful. I also know I’ve never had any luck with the placebo effect at all, or any capacity to be hypnotized, or to do biofeedback. I also do not make assumptions about my internal physical problems without first having evidence. A test being DONE is not evidence of anything. The results might be evidence.

    Oddly enough I am in pain…several kinds… and from things that really are wrong my my actual body (other than in my brain) which tests can show to exist (if one can convince a doctor to USE those tests, which means explaining to them that the test exist – and has for a few decades).

    In me, treating the bodily problems makes the pain decrease a lot. Not doing so has very bad consequences on immunity and autoinflammatory issues and ongoing damage to the body.

    About 9 years ago I blew a branch of the hepatic artery due to a gall stone attack. That hurt an amazing amount. I had no idea what was happening but it did hurt ( could barely move or breath), and I had no MRI or other tests telling me I OUGHT to feel pain. The same has been true for every other type of pain I have had. The pain came before (way too long before) any doctor took me seriously. This is in part because in my experience doctors do not listen. The bones in the inner ear get removed when they get their licenses.

    Also to most doctors “pain is not a symptom” and “you can’t prove it is there (they claim)” – except – except that a crock because you CAN prove PAIN is really there using today’s brain imaging. It can (and out to) be done. Also all patients should have full cytochrome P540 testing done to see what medications they can use (and which could kill them).

    Anyway, advanced brain imaging can show the areas of the brain involved in pain, and it can show them lighting up like a Christmas tree. Yet this is NOT being done with people in pain. NO matter how bad the pain is, there are never any of the (many) test, actually used to find out what is going on.

    As far as I can tell the reason is not ignorance over what the technology can do. It is a lack of desire to look. If you look, you have evidence, and evidence requires action (it makes you legally liable for doing nothing) so the doctor must act – and in many cases they cannot act with “McDonalds Medicine – in and out in 15 minutes). It takes longer and the doc has to READ and LEARN…because there is so much new science out there – and that is another big issue. Do they understand actual science? Most doctors do not.

    In the last 3 decades I have met 2 doctors who knew much about actual science. I loved them. They treated me with respect, and found causal relationships in my health (many that nobody had bothered to look for). They loved a challenge, and kept up on everything they could, and had a love for knowledge. Note that I have seen a LOT more than 2 doctors.

    The issue here is that when a doctor is faced with a patient who has something REAL (with proof) then they have to do something. They can’t shove you out the door as an “unrewarding patient” (no fun to treat due to not magically getting better). This does mean the doctor must learn new things in many cases… something that wasn’t taught in medical school 35 years go.

    Worse (for most doctors) that “something else” probably has something got do with HARD SCIENCE… and most doctors don’t do science. They do “tradition”. The practice according to a “tradition” of care.

    I’m not a biochemist or a physician, yet for some reason I know more about the pain system in the human body than any of my doctors I get to see (except for one pain doctor to date) – and the truth is I know SQUAT by comparison to what is available right now that doctors MUST know to do the job right (and they don’t). I mention areas of the brain and get blank looks with explanations – statements that they don’t know about that. None of them (except for one pain doc) knows what the cytochrome P450 system is…. and they are allowed to treat patients.

  32. angie fearon says:

    Hi Lorimer,
    would you like to comment on the research by Benedetti on the placebo affect apparently being the activation of the endogenous opioid pathways? or have I completely misunderstood his work?