Windows into pain

I have a painful shoulder. It has been hurting since mid-December. I can recall no incident – just woke up one morning with severe pain on pretty much any movement. Now, I am not looking for diagnoses, nor in fact sympathy. What I would like to do instead is to run you through some interesting reflections I have had.

i) I wake up in the night a lot. I have tried very hard to decipher whether I had any pain before I woke. I conclude here that I have had pain the nanosecond I was awake, but not a nanosecond before. Is it possible to have pain in your sleep? Sleep is an altered state of consciousness, rather than a state of unconsciousness, but even then I reckon it is rare to have pain in your sleep and I would predict that the pain one might have in one’s sleep is rather more vague than the pain we have awake.

ii) Not sleeping as well as normal becomes a real drag after a while. What is more, it has become more of a drag now that I have realised that it has been 2.5 months of broken sleep – that is, the knowing seems to increase the impact. On some mornings I find myself saying, even if just to myself, that I had a bad night’s sleep when actually, I didn’t. I am going to bed earlier and rising later than normal so the actual hours of sleep are probably not that different to usual. Does whatever is driving my pain reduce the restfulness of my sleep without necessarily waking me?

iii) Having a persistent pain state makes one a good subject for one’s own experiments and I have had some fun trying out assessments and treatments. Not much, I must say, seems to have helped.

iv) I had an ultrasound six weeks ago and a couple of injections. I wanted the ultrasound doctor fellow to do a double blind placebo controlled injection of the bursa, but he said they did not have the resources for that. I said well how do you know if you have modulated the pain by an effect on nociception. He said ‘you just do’. So, injection of anaesthetic into the bursa did nothing.  I then had an intra-articular injection (I always thought it was along those lines) and I got immediate relief. The consensus in the room was that if i got immediate relief with the intraarticular and nothing with the bursa, it can’t be placebo. Anaesthetic and steroids – a few days I will be right as rain. Well my pain returned a few days later. Sounds pretty placebo to me – could have untangled that with double-blind injections.

v) I had an x-ray. I am not sure why really when we were always heading for an MRI. Still, my response to the x-ray was really interesting. In the course of my work, I have had reason to do a few catastrophising scales, fear avoidance beliefs questionnaires, somatic perceptions questionnaires etc etc, and I always score pretty low. However, I can honestly say that when I looked at the x-ray I was looking for cancer. I knew my pain was worse at night. It strikes me as remarkable that it was only then that I realised that I was not totally convinced that it was not something uber sinister. For the record, it is not.

vi) I had an MRI. Now, my shoulder is pretty mangled, BUT the interesting thing is this – my pain has increased a couple of points on a 10 point scale since I read the report that outlined, in detail, all the bits that are damaged. How amazing is that? Here I am – studying all this stuff – wise to a large extent to the power of descending modulation and upregulation of protective systems, and the knowledge of how much is damaged in there has absolutely, positively, increased my pain. I know for sure that I could not have done all that damage, in fact almost any of it, on the day before my pain started. So I really have no idea how much that damage is related to my pain. Even still – my pain is now officially brutal. I am both very annoyed at this development and very impressed in all that happens inside us without us making it happen. I shall now embark on the tricky process of deciphering what are the main contributors to my shoulder pain and how I should best address them. Here comes a journey.

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.

Comments

  1. Sorry to hear Lorimer – “Perastika”,… did you treat patients with shoulder pain 2 months before your pain “appeared” ?
    On Articulations – 9, Hippocrates

  2. Goodness, i’m so confused after reading most of the comments and more so because you have pain Lorimer and you can’t explain it… yet?! Brain, if you’re that intelligent and that plastic, please put us all (and those with clients) out of our miseries! Just go AWAY.
    All the best Lorimer

  3. Doménique says

    I am a person who is ‘lucky’ enough to experience pain in many different ways. I can answer your first question from my own experience. Because of my pain in my lower back (a result of a double hernia (operation)) I also wake up in the night a lot. I know for sure that I wake up because of the pain, but I experience de pain only when I’m awake. In your words: a nanosecond when I am awake. This is the same with my nerve pain. Here comes the rare part: This is different when I have a migraine. Sometimes it starts when I am sleeping. Although I’m still sleeping I know in my sleep that I have a migraine and that it really hurts. When the pain gets worse and really really hurts, I wake up and stay awake for almost the next 72 hours. When I do fall asleep during my migraine I am still aware of the pain. So in my experience it is possible to have pain in your sleep, but it depends on the kind of pain.

  4. Alex Chisholm says

    Hi, as an avid reader of your work, I am sorry to hear about your shoulder. It might be of interest to explore the use of hypnosis for your shoulder pain.
    Hypnosis is typically discounted, as few professionals are aware of the research behind it. Most associate it with stage shows and such, and the myths perpetuated by these performers. It is therefore often discounted, without looking at the link between neuroplasticity and hypnosis, and the research to support its use.
    I am a physio, and I am a member of the canadian society for clinical hypnosis and the international society for clinical and experimental hypnosis, and I use hypnosis in a major acute hospital. I prefer to call hypnosis synaptic synergy techniques, as I think this more accurately reflects what it can accomplish, without the other myths associated with hypnosis. Hypnosis is neuroplasticity on fast forward. The use of hypnosis can alter your brains ability to prioritize danger signals, as you like to call them.
    The research of Elvira Lang, Guy Montgomery, and David Patterson to name just a few, may interest you. Their work has shown hypnosis can be effective, as well as cost effective. Both in acute and chronic pain.
    I have used these techiques with large burn patients and trauma patients, who clearly have significant reasons for their pain in their ‘brain.’
    In no way do I suggest this will change the mechanics of your shoulder, but it can alter the way you experience those ‘danger signals.’
    I started out as a cynic in this field, and now cannot learn enough. The ability of the brain fascinates me. A good clinical hypnotist teaches the patient more control of their brain, just as a good physio does of the body. The hypnotist does NOT control the patient. The research is still in its infancy, still debating what kind, how often, which type of hypnosis. But I think you will find many parallels between your work, and that of a good clinical medical hypnotist. It transforms the cognition of how your brain processes danger signals to creating processing change.
    And yes, I became a convert when it worked on my chronic pain.

  5. Jenny Goodrick says

    There’s a knife in my shoulder
    it should be clear to see
    I try to ignore it
    by smiling happily

    I can’t say that I like it
    and it may yet be my demise
    but imaging’s not an option
    I may catastrophise

    How many of there like us?
    physios in pain
    we’re stuck in a no-man’s land
    by fighting with our brain

  6. Well I am most chuffed at the very many people who have responded to this and also to the very large number of responses that we didn’t put up – your offers of treatment and of moving to Adelaide to work your magic are most appreciated. I particularly appreciate those comments (posted here) that talk to and extend some of the observations I mentioned. It really is an interesting time for me and I have one further reflection to float: I can remember several occasions over the last 10 years in which I have fallen heavily playing sport and felt a clunk in my shoulder. On no occasion was this associated with excessive pain – perhaps a bit tender for a couple of days. I wonder now if these situations reflect an underprotective system – I wonder if my brain erroneously concluded that things were not that dangerous and therefore I had less pain than would have been ideal. We had a little get-together last night with Dave Butler and a bunch of physio’s who are participating in a project. Over pizza and wine, Richard made the astute observation that ‘it is all about context’. On reflection, I reckon I experience much less pain if I injure playing sport than if I injure doing something else, or, as is the case here, doing apparently nothing at all. This is not that surprising in light of the fact that I am, as far as I can tell, convinced in the belly of my nervous system that sport is good for you. Intriguing. Anyway – thanks for your astute observations and, Danny, for letting us in on your secret regarding MRI and super powers.

  7. Hi Lorimer

    Having had a sneak peak at an article you and Mick have written, this seems like a unique opportunity to practice the experiential approach and method to studying pain!

    I learn heaps from injuring myself playing sport (people that tell you exercise is good for you really should distinguish between the CV and MS systems), and hadn’t realised my dogged pursuit of footballing Nirvana was really a series of elaborate tests conceived by my unconscious mind.

    On the plus side, it’s a little known fact that MRIs rearrange your molecules and leave you with hidden super powers. It might be obvious like the ability to fly, but more often is quite subtle like the ability to fit 6 Jaffa cakes in your mouth all in one go. Have fun finding it, and remember, tell no one!

    Kate Reply:

    Gold.

  8. Mike Caruso says

    Lorimer, Sorry to learn of your troubles with persistent pain in your shoulder.
    First, thank you for the wiliness to share your experience and your journey.
    Secondly, the clinician in me is curious to know what is your external rotation?
    Thirdly, I am currently rereading Nortin Hadler’s Worried Sick and am fascinated with his concept of ‘treatment acts’ and ‘therapeutic envelope’ which a part of the journey you describe.
    It is his notion that seeking care in this type of predicament begins a process we should not take likely.
    He writes “Modalities are the particulars of what is done for us, to us, or with us by any purveyor of therapy to whom we turn…. The treat act is the whole process of intervention by the provider on behalf of the patient. The therapeutic envelope speaks to the fashion in which we are changed by the treatment act. The therapeutic envelope is our new being, the sum of our altered self-perception and our idioms of distress, and our narratives of illness and our peer affinities, as well as our expectations from our healthfulness in our communities…..No one should enter a therapeutic envelope without awareness of the passage and acceptance of the outcome.”
    This leaves me to wonder how do we as clinicians ‘help’.
    It seem to me that Nortin Hadler and you are often saying the same thing from different corners of science.
    Best of luck with your journey.
    Mike

  9. Lorimer
    What I find hard to understand is that by definition you have chronic pain or almost. When does the nervous system really become sensitized to a degree that it is hard to reverse. Which chronic pains can we expect to reverse and which are not going away? there is no way for us to know with the average person with “chronic pain” other than you try all the conventional and nothing works, but I always wonder if it is just not properly diagnosed with what we know. Also when you have been living with a chronic pain such as a neuropathic pain are you likely to experience chronic pain in the back if you have some back problems? that is when you have one chronic pain are you predisposed to others?

    Tanya Reply:

    Hi Lesley, I’d love to comment on that purely from a chronic pain person’s point of view. I had crps for years (I’d say it’s 95% gone now). I am now more predisposed to pain, definitely. I have a disc bulge and facet joint degeneration in my lower back which may or may not be causing or contributing to my chronic pain there. Also (and quite randomly) I can get ongoing pain from minor injuries, eg a superficial cut on a finger led to over a month’s pain through my wrist and forearm. But at the same time I can burn myself on my arms and not feel the pain of it for anything from minutes to an hour and a half later. When I sprained my ankle (the injury that set off my crps) I had grade 2 tears to two ligaments and yet no pain, swelling, bruising etc and the pain started 6 weeks later. All I can say is thank goodness I had a physio that could explain to me what was going on in my body!

  10. I’m sorry to hear you’ve entered what always feels like a teeter-totter in the orthopaedic world. I battle in my brain what I learn from your research AND the orthopaedic findings. I’m always wondering how much of the pain experience is due to psychosocial factors and how much is due to an actual physical/anatomical problem, especially when diagnostic findings confirm a problem. For me, the lumbar spine is the easiest and I have less waffling in my thoughts… but the extremities, oh, my, I have mental battles going on all the time.

    Most people I treat who had complaints similar to yours had no history of a substantial mechanism of injury either… they woke up with the pain. So, I wonder if there is a tipping point? Some level of deterioration or “mangledness” has to occur before the brain notices it?

    As a physical therapist in the orthopaedic world, another very real aspect in treating patients who present like you… when is surgery an appropriate recommendation? Your research messes with my brain quite frequently… how do I know that it’s the right time to recommend surgery as an option? This messes with my cognitive ability because your research can be reduced down to a single statement, “pain is in the brain.” It is, yes… but what drives the brain to interpret pain? I refuse to believe surgery is a placebo 100% of the time. How can it be determined that the anatomical structures need repair and the brain alarm is going off because of that as the problem?

    I’m chuckling at Brence’s question. Your pain WILL resolve. It’ll just be a memory and a story in 1-2 years. The real question is: “What is your expectation that your pain will resolve with conservative care?” You have entered a different realm of thinking once you have diagnostic testing. You are in a stage that many of your colleagues treat on a daily basis. We have patients walking in our doors having gone through all sorts of testing and able to share with us the sordid details of what’s wrong. And, as physical therapists, we can’t “fix” the anatomical mangledness. By the way, that is a really, really bad term to use. Think of what it does to your brain and your thoughts associated with it (just sayin’). Seriously, I sometimes feel as though my role is immediately set up for failure when someone like you walks in my doors for services. From a conservative perspective, it’s always an uphill battle that focuses on obviously the brain, and patient perceptions and expectations along with educating about the condition along with sharing the game plan and just how things may change and why they will change in what amount of time AND the backup plan if the anticipated results don’t happen.

    By the way… have fun next weekend on the Ride for Pain!

  11. Lorimer,
    What is your expectation that this pain will resolve? How have your expectations of recovery changed since mid-December until now?

  12. Diane Jacobs says

    I experienced about a week of bad nasty shoulder pain/pain perceived in the shoulder/frozen shoulder, last summer. I wrote a series of blogposts about it, here: http://humanantigravitysuit.blogspot.com/2011/08/killing-pain-part-ii.html
    It resolved completely, I’m happy to say. Good luck figuring out a way to deal, Lorimer. It takes a bit of focused determination, I found.

  13. Terry Wesselink says

    I too have had the experience of wonderment that all with all my professional knowledge about pain, my mind persists in experiencing pain in seemingly random proportion to the damage (or lack thereof) to my tissues. You are already an amazing researcher, I’m sure this experience, while unpleasant, will only drive you to look for more questions to answer. I look forward to following you journey into unravelling your own brain. And good luck with taming the pain.

  14. Lorimer
    therein lies the tale….pre-conception of the educated mind and the ensuing (nociceptive) extrapolation versus the naieve subject with a less sophisticated neuromatrix construction!!
    If only we clinicians could differentiate before we handle and discuss with our patients. It’s Russian roulette!!
    David

  15. Lorimer—so sorry to hear about your saga. Would probably be more enjoyable if you, too, were reading about rather than experiencing it…. My curiosity has to do with whether there’s a parallel to Fiona’s experiences of…having done a fairly good job of ignoring pain.

    Since the assessments revealed that your shoulder’s a mess [technical term, there], I can only wonder at the number of events which brought about said mess. Surely there was pain associated with those events, but I’m wondering what was missing in your reaction to that pain then. We humans, particularly in our younger years, can be quite blithe about pain. In sport-, musical-, and dance-athletes there’s an assumption that pain goes with the territory. [I suppose if those athletes really listened to their bodies they’d be off the field or out of the studio in a flash….]

    So, what was taking place in your body over the period of time in which your shoulder became messed? What takes place as one’s entire system habituates to pain? On how many physiological levels are there alterations? What’s occurring in the brain? And how is the psychological/philosophical Self altering?

    Also, what occurs in the whole system to cause a Sudden Experiencing of Pain? What could have been the tipping point for you? My own guess is that there was a likely ‘straw that broke the camel’s back’–a straw perhaps so seemingly trivial that you weren’t aware of it. Not aware because of…..those years of habituation which numbed your ability to sense accurately?

    Your observations about sleep disturbances are also interesting. I agree with Andy about sleep deprivation’s contribution to the amplification of pain. But I’m also wondering about the energy-depleting effects of ongoing pain and their relationship to your experiences of not-well-rested. How is it possible to measure, or assess, this aspect?

    Lastly, I’m guessing that there is something about one’s training and experiences which can interfere with one’s relationship with pain. B/c I don’t know how cancer presents, it wouldn’t occur to me that a structural pain could be a tumor. There’s a category of fear that wouldn’t come to me. However, whether I did or didn’t know about malignant presentation, I would want to be able to shift how I engage with my pain and my fears.

    Gendlin’s philosophy of the implicit has brought us a methodology for coming into “right relationship” with pain, distress, blocks, etc. It has more to do, I believe, with understanding rather then managing. Implicit in ‘understanding’ is a means of turning towards that which afflicts—more like aikido than Western boxing, more compassion than “war on”. The shifts in relationship with pain and fear and grief and helplessness alter one’s experiences of Self. And in the category of structural pain, can bring about a gentler, more accurate and functional way of moving—depending on the sensing abilities of the teacher or physio who is doing the guiding/re-training.

    Thanks for sharing your Excellent Adventures. Wishing you all the best in recovering and exploring.
    All the best from Santa Fe, New Mexico, USA
    Lynn Rosen

  16. The thing I find the most fascinating is as you say “I know for sure that I could not have done all that damage, in fact almost any of it, on the day before my pain started.” This is something that I find very difficult to explain to patients when I am trying to reassure them that the changes on their XRAY/CT etc are common and may not be the source of their pain. Why does pain suddenly start when it does? Is it all just psychosocial inputs? Or could there be a decrease of inhibition of nociception coming from the tissues?

  17. Lorimer- Have you read Tim Park’s book yet, Teach us to sit still? Fascinating narrative regarding the journey of pain and self awareness of the mysterious dichotomy of our wanting / needing to know the “why” of our pain experiences and how even knowing pain is a construct of our mind/brain doesn’t really change the fact that it is still uncomfortable . That is why we call it pain, not sensation. It is the emotion of it that is the issue, not the perception/nociception/sensory input. The Body Spesks is another book I recommend – James and Melissa Griffith. I hope if you have an epiphany that changes your current pain experience you will share the secret with us.

  18. Evert Jan Das says

    First of all I wish you all the best in youre recovery!

    I saw you had a medical assessment (ultrasound, x-ray & MRI) and injections into the bursa and intra-articular space. I also read you had some fun trying out assessments and treatments before this. Without any succes (unfortunately).

    I’m curious though as to what sort of assessments and treatments you tried….can you elaborate on that?

    I ‘d like to know because in you’re clinical reasoning I read mainly thoughts about central processing mechanisms and modulating influences. But what about any inputbased mechanisms like e.g. myofascial trigger points? (I’m not saying inputmechanisms are more relevant, but they could play a role in maintaining pain)

    I’d like to hear youre thoughts on potential input mechanisms. Especially the impairments (not the documented tissue damage).

    Greetings from the netherlands,

    Evert Jan Das

  19. Lorimer I am sorry to hear about your shoulder. I can relate 100% to what you are saying. I’ve had chronic pain for almost 5 years now and thanks to my physio and others (including Explain Pain) have actively learnt all about pain to better understand it. It really does help (think how much worse your pain could be if you didn’t already understand it) but it doesn’t stop the pain. It helps you better manage it and maybe lessen it.
    I’ve been through all the tests in the past too. These days each time a new pain comes or an old pain re-flares I have to ‘prove’ to myself there is no new underlying cause of it. Amazing how the brain just leaps to the conclusion there is something wrong. It’s so ingrained.
    I will be very interested to hear more about your journey. I feel like you are writing down all the thoughts I’ve had at some point in time. Please keep sharing your journey.
    All the best
    Tanya

  20. Hi Lorimer
    Sorry to hear of your rather nasty experience. Very interesting (although I am sure you would rather forego the opportunity). It is startling at times how even when we “know” what is happening in terms of the process of pain we seem to be unable to intervene or are limited in our conscious ability to intervene with great effect. WHile we can engage in reassuring self talk and recite the data and information on the nature of the beast still thoughts of catastrophe still arise unbidden from the murkier depths of our unconscious. Not sleeping seems to act as an amplifier of all that is negative – no wonder it is used as a form of torture.
    Do you think that knowing what you do about pain is helping or hindering you at this time? Or not making any difference?

    regards
    ANdy

  21. Frédéric Wellens,pht says

    I really appreciate your personnal input and reflexion about your pain, I’ve had pretty much the same about mine. I would really appreaciate you give us a periodical update.

  22. I am a physio who was distressed to wake 3/12 ago with what felt like a TENS machine turned up full blast in the C5/6 dermatome,. It had been preceded by several months of superficial numbness around the elbow which I had done a good job of ignoring.
    No immediate precipitating event but 8 months earlier I had felt lucky to get out of a major stack from my surfboard into a sandbank, tucked neck in and took it on upper Tx spine…..lots of self talk to say it will be fine , did settle quickly but never quite felt the same whole spine- again I ignored , continued work , gym and surfing. I do have a Hx of whiplash many years ago and regularly get “wry” necks which settle with NSAIDS and some Rx from a colleague when time permits ( typical physio).
    Interestingly for me – when the symptoms started I did catastrophise big time , assuming cancerous growth on spinal cord , brain tumour or similar! Once I had the MRI ( not a fun experience for Cx when you are claustrophobic) and got result of disc protrusion C7 I was much better . We are managing conservatively with possibility of injection if necessary but with Voltarin and adjustments to the way I do things it is settling very gradually. I am fascinated by the mismatch of symptoms to the textbooks…this has been an interesting journey for a physio – frustrating but interesting ! I also have no pain – all neuro , AND my Cx ROM is the best it has been for years ??! I have new empathy with patients – even though I deal with the other end of the body 🙂
    good luck with your recovery Lorimer !

  23. Thanks for your comments and interest in Lorimer’s shoulder pain. We have been absolutely inundated with comments, which is great. Those of you who have offered advice on treatment I have sent your comment onto Lorimer to look at via email, rather than detract from the real point of his post, which is to reflect upon some of the experiences he is having.
    Thanks all!

  24. Well, having a persistent pain state assists me enormously in conveying to my patients all of your work with regard to Explain Pain but your presentation and the way in which it has been dealt with thus far is a situation l encounter in the clinic on a weekly basis so l look forward very much to the journey that is looming for you because l know the result of it is likely to be to enable me to help my patients more in the future! All the best to you 🙂

  25. Neil O'Connell says

    Bad luck Lorimer, but if you’re going to do this study properly you’re going to need a control. One of your PhD students will have to volunteer to have their shoulder wrenched. Any takers?

  26. welcome to the journey, lorimer. it is not a fun or satisfying one… more like a dizzy ride on a merry go round…