Teaching people about pain – why do we keep beating around the bush pt 2

Continued from previous post

… All is not lost, however. There is an emerging body of literature that suggests that we can change the way people understand their pain. We can reconceptualize pain in a way that makes clear the distinction between tissue damage, nociception and pain. The bulk of the work in this area is guided by a model that suggests three phases of intervention:

  • Provide evidence against the current (and inaccurate) conceptualization;
  • Provide evidence for a new (and accurate) conceptualization;
  • ƒTest, confirm and finally embed this new conceptualization, such that it can guide behavior.

Each phase has its challenges. For example, the first phase needs to avoid being retarded by the cognitive defenses we all possess in order to guard our own views. That is, key conceptual challenges need to be ‘snuck in under the radar’, as it were. We also need to exploit methods to make our interventions memorable – to maximize the likelihood that they will ‘stick’. For this, we need to engage emotional systems and use multiple media styles. Our group has recently tested the utility of using metaphors to induce a conceptual shift in the understanding of pain [14]. Metaphors can be described as understanding and experiencing one kind of thing in terms of another and are thought to provoke contemplation and increase the potential for reorganization of previous meanings. In short, simply giving people a book of short stories that are used as metaphors for key concepts in pain biology [15] led to measurable shifts in the knowledge of pain biology and in pain-related catastrophizing [14].

Much of the research into reconceptualization of pain has focused on the second phase of the above list – the provision of evidence for a new conceptualization. These experiments and randomized controlled trials show that ‘explaining pain’ (see [3] for coverage of material) as a therapeutic strategy leads to rapid changes in pain-related beliefs and attitudes [16,17] and increased pain threshold during movement [18,19]. When integrated into a behavioral or functional upgrading approach, explaining pain is associated with better pain- and function-related gains than upgrading alone [19–22], and when intensive cognitive–behavioral pain management is preceded by explaining pain, the long-term outcomes seem substantially better [23].

Of course, the loftier goal here is to reconceptualize pain before people have chronic pain (i.e., when they have acute pain or, better still, before they have any pain at all). This will clearly require a team effort. I argue that we can start by truly taking notice of Patrick Wall’s advice from 25 years ago and stop calling nociceptors ‘pain receptors’, nociceptive pathways ‘pain pathways’ and noxious stimuli ‘pain stimuli’. These are erroneous terms. That is, let us not fool ourselves that the mislabeling of nociceptors as ‘pain fibers’ is an elegant simplification – we need only sit with a patient in chronic pain to see that this mislabeling is indeed a most unfortunate trivialization.

Previously published in: Moseley, G. (2012). Teaching people about pain: why do we keep beating around the bush? Pain Management, 2 (1), 1-3 DOI: 10.2217/pmt.11.73

About Lorimer Moseley

Lorimer is NHMRC Senior Research Fellow with twenty years clinical experience working with people in pain. After spending some time as a Nuffield Medical Research Fellow at Oxford University he returned to Australia in 2009 to take up an NHMRC Senior Research Fellowship at Neuroscience Research Australia (NeuRA). In 2011, he was appointed Professor of Clinical Neurosciences & the Inaugural Chair in Physiotherapy at the University of South Australia, Adelaide. He runs the Body in Mind research groups. He is the only Clinical Scientist to have knocked over a water tank tower in Outback Australia.

Link to Lorimer’s published research hereDownloadable PDFs here.

References

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[2] Wall PD, McMahon SB. Microneuronography and its relation to perceived sensation. A critical review. Pain 21(3), 209–229 (1985).

[3] Butler D, Moseley GL. Explain Pain. NOI Group Publishing, Australia (2003).

[4] Beecher H. Relationship of the significance of the wound to the pain experience. JAMA 161(17), 1609–1613 (1956).

[5] Banzett RB, Gracely RH, Lansing RW. When it’s hard to breathe, maybe pain doesn’t matter. Focus on “Dyspnea as a noxious sensation: inspiratory threshold loading may trigger diffuse noxious inhibitory controls in humans”. J. Neurophysiol. 97(2), 959–960 (2007).

[6] Meagher MW, Rhudy JL. Noise stress and human pain thresholds: divergent effects in men and women. J. Pain 2(1), 57–64 (2001).

[7] Arntz A, Claassens L. The meaning of pain influences its experienced intensity. Pain 109, 20–25 (2004).

[8] Moseley GL, Arntz A. The context of a noxious stimulus affects the pain it evokes. Pain 133, 64–71 (2007).

[9] Keltner JR, Furst A, Fan C, Redfern R, Inglis B, Fields HL. Isolating the modulatory effect of expectation on pain transmission: a functional magnetic resonance imaging study. J. Neurosci. 26(16), 4437–4443 (2006).

[10] Ren K, Dubner R. Enhanced descending modulation of nociception in rats with persistent hindpaw inflammation. 18 J. Neurophysiol. 76(5), 3025–3037 (1996).

[11] van Tulder MW, Assendelft WJ, Koes BW, Bouter LM. Spinal radiographic findings and nonspecific low back pain. A systematic review of observational studies. Spine 22(4), 19 427–434 (1997).

[12] Peterson C, Bolton J, Wood AR, Humphreys BK. A cross-sectional study correlating degeneration of the cervical spine with disability and pain in United Kingdom patients. Spine 28(2), 129–133 (2003). 20

[13] Link TM, Steinbach LS, Ghosh S et al. Osteoarthritis: MR imaging findings in different stages of disease and correlation with clinical findings. Radiology 226(2), 373–381 21 (2003).

[14] Gallagher L, McAuley J, Moseley GL. A randomised controlled trial of using a book of metaphors to reconceptualise pain and decrease catastrophising in people with chronic pain. Clin. J. Pain (2011) (In Press). 22

[15] Moseley GL. Painful Yarns. Metaphors and Stories to Help Understand the Biology of Pain. Dancing Giraffe Press, Australia (2007).

[16] Moseley GL, Nicholas MK, Hodges PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clin. J. Pain 20(5), 324–330 (2004).

[17] Meeus M, Nijs J, Van Oosterwijck J, Van Alsenoy V, Truijen S. Pain physiology education improves pain beliefs in patients with chronic fatigue syndrome compared with pacing and self-management education: a double-blind randomized controlled trial. Arch. Phys. Med. Rehabil. 91(8), 1153–1159 (2010).

[18] Moseley GL. Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. Eur. J. Pain 8(1), 39–45 (2004).

[19] Nijs J, Van Oosterwijck J, Meeus M et al. Pain neurophysiology education improves cognitions, pain thresholds, and movement performance in people with chronic whiplash: a pilot study. J. Rehabil. Res. Dev. 48(1), 43–57 (2011).

[20] Moseley GL. Combined physiotherapy and education is effective for chronic low back pain. A randomised controlled trial. Aust. J. Physiother. 48, 297–302 (2002).

[21] Moseley GL. Joining forces – combining cognition-targeted motor control training with group or individual pain physiology education: a successful treatment for chronic low back pain. J. Man. Manip. Ther. 11, 88–94 (2003).

[22] Ryan CG, Gray HG, Newton M, Granat MH. Pain biology education and exercise classes compared to pain biology education alone for individuals with chronic low back pain: a pilot randomised controlled trial. Man. Ther. 15(4), 382–387 (2010).

[23] Clarke CL, Ryan CG, Martin DJ. Pain neurophysiology education for the management of individuals with chronic low back pain: a systematic review and meta-analysis. Man. Ther. 16(6), 544–549 (2011).

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