Your Brain is Just Trying to Protect You, Part Two: What Can You Do?

Today we are going to learn about the shield built by our fictional gentleman and his doctor. The tools they used to build this shield consisted of: respecting his body, therapeutic relationship, knowledge, self-efficacy and re-introducing activities. Some of the tools were focused on mitigating the effect of pain and fear on current and future behaviours. They also had tools that were more designed to help them deal with the thief and reclaim the activities that he had already taken. Their goal wasn’t to relieve all the pain, but instead to reclaim his life by putting him back in charge.

It’s important to note that none of these tools work as well in isolation as they do together. And that not every person will benefit from every tool. Rainville et al. (2011) talked about how there are multiple factors behind fear avoidance behaviour. There is misinformation (e.g. I will do harm because someone said so), learned behaviour (e.g. this hurt, so I avoid it), and emotional behaviour (e.g. fear driven). Recognizing these factors can give a good starting point to identify which tools may be most helpful.

The Tools

1.)  Respecting your body: Permission to not be okay

So often it is easy to fall into the “I shouldn’t feel like this” mentality. A good first step is to allow yourself the courtesy to respect whatever you are feeling. Part of this is simply acknowledging these concerns and fears. It’s respecting the fact that pain avoidance is a logical reaction and that it’s not a sign of weakness. Recently we both attended Bronnie Lennox-Thompson’s course on Graded Exposure for Pain Avoidance. One of the things she said during the course that really resonated with us was the idea of creating space for the fear around the task and doing it anyways. The goal isn’t to logic away the fear or ignore it but rather to acknowledge it and respect that it is there. It’s something that happened with the injury that you have to treat just as you do the physical symptoms.

2.) Therapeutic Relationship: Meet people where they are

The creation of a relationship between the practitioner and client is one of the first things that happens when a person seeks treatment. This relationship can have a huge impact on the outcome. Because it is so important we think it is worth it to step back and examine this relationship for a moment. If you’re reading this as a health care provider hopefully the explanation of this tool will give you a basis for understanding the importance of how you interact with clients. If you’re reading this as a person in pain or a family member, this can help you understand why it’s beneficial for you to find health care providers who really connect with you.

There are many factors that go into creating a strong therapeutic relationship. The way these factors interact may depend on the two people involved. One if the key factors that is common across situations is the idea of validating the person’s experience; allowing the client to have a voice and be heard and to feel safe expressing their experience, questions and concerns.   Pain is often a sensitive issue and like any “invisible illness” people can often feel judged. People in pain may be bombarded with societal messages such as “your pain is not real” or “suck it up and deal with it.” They might come feeling like they have to defend the pain or justify their behaviour.  They really need to know that their health care provider believes them and is on their side. They need to be able to trust that their concerns are valued, and that their questions won’t be minimized. A supportive health care provider will look for the reason behind the concerns a patient decides to voice.

The person in pain also needs to know and trust that the health care provider knows what they’re talking about. A client once told a therapist “you’re like a friend who comes, but is full of knowledge.” Having this type of therapeutic relationship can be the starting point that all the other tools build on. A study on therapeutic alliance  in the context of treating lower back pain suggested that “factors related to the therapist seemed to be as important as the therapy in pain modulation, and their interaction may produce substantive clinical benefits”. The authors of the study went further to say” The effect of accepted interventions can be improved when clinicians interact positively with their patients” (Fuentes et al). A good relationship is key to allowing any of the next tools to be effective.

Up Next

The two tools discussed in this post (respecting the body and therapeutic relationship) are the foundation for the other tools we will discuss. Next post, we’ll go into detail about knowledge, self-efficacy, and re-introducing movements. We hope this overview will be helpful to you as you begin to build a shield with your own tools.

Acknowledgements

Diagram by Ashley and Colleen at Reclaiming Life. Graphics from Freepik.com (man, grocery basket, doctor, shield).

References

Fuentes, J., Armijo-Olivo, S., Funabashi, M., Miciak, M., Dick, B., Warren, S….Gross, D.P., (2014). Enhanced Therapeutic Alliance Modulates Pain Intensity and Muscle Pain Sensitivity in Patients With Chronic Low Back Pain: An Experimental Controlled Study. Physical Therapy, 94(4), 477-489.

Rainville, J., Smetts, R.J.E.M., Bendix, T., Tveito, T.H., Poiraudeau, S., & Indahl, A.J., (2011). Fear-avoidance beliefs and pain avoidance in low back pain. The Spine Journal, 11, 895-903.

Your Brain is Trying to Protect You: Part One

Did you ever touch a hot stove as a kid? It hurt, right? Hopefully you were leery about touching a hot stove after that, and learned that touching the stove when it's on leads to pain and should be avoided. 

The fact that you learned to avoid a hot stove is your brain at work protecting you. Likely you got the message after only one time, and didn't have to repeat that lesson over and over to learn not to touch that hot stove. Rick Hanson, a psychologist, talks about how we are wired to register negative experiences more quickly than pleasurable ones. He explains that for our survival it is more important for us to register that a certain insect bite can be fatal to a person than that the flowers beside us smell nice (Hanson, 2013).

So when your brain learns (very quickly) that a certain movement or situation causes pain, it becomes cautious. Avoiding things that are painful helps us survive and helps us know what parts need rest so they can heal. 

This is great.....until it becomes a problem.

The problem comes in when this "what is harmful" map becomes outdated or overgeneralized and begins to steal activities from us. Sometimes injuries can heal, but when you move that part of your body, your brain still says "Bad news, Bad news! What are you doing?" Your brain can become hypersensitive to that part of your body, so any message from that area becomes an alarm.

Your brain can also begin to generalize and gradually become sensitive to more and more movements and situations over time. That insect that was dangerous, so maybe all insects that look similar are dangerous too, and your brain learns to avoid those. If your brain takes this even further, then maybe the field you were in when you encountered that insect is dangerous. Maybe all fields are dangerous. Maybe simply going outside is dangerous. 

We're not saying the pain isn't real or the fear isn't justified. However, sometimes this protective mechanism can began to limit activities. An example of this process could be a person with chronic back pain that began after an injury from helping a friend move. The injury began by lifting very large objects in a way that caused tissue damage. Later it turned into chronic pain. The person could become reluctant to help anyone move after that. This probably won’t have a huge impact on the person’s day to day functioning, because this situation doesn’t occur frequently, and there are usually other options. The disruption to daily life comes if the same emotional reaction gets applied to similar situations that do occur frequently. For example, maybe the person notices that even lifting smaller objects like groceries now increases his pain. Or lifting his children or grandchildren. Or maybe he has a job that involves lifting and carrying, and he is now afraid of how his work will impact his pain (and vice versa). 

There are other valid reasons he may feel afraid to move. He may have been told by a well-meaning health care provider to avoid certain movements. He may have heard the idea that bed rest is the best thing for a back injury (an old way of thinking, but still believed by many people) (National Institute of Neurological Disorders and Stroke, 2014). He may have been told over and over that pain always equals harm, so he may be afraid of doing more damage to his body. 

As his brain tries to protect him, this can translate into an emotional reaction. Where at first he was cautious, he may become anxious or fearful. Frustration occurs when pain and the fear of pain limits movements. If it is limiting activities that aren’t important to him, it’s not a problem. The problem comes when it affects movements that ARE important.  

In healthcare talk it’s about the pain related fear and avoidance model. At its root this is where the fear of creating or worsening pain causes a person to avoid certain activities or situations. Pain avoidance has received a bit of a negative reputation, but if you look a little deeper it is just one of your body’s ways of trying to keep you safe; it has its roots in protective behaviour. It’s a totally normal and logical process.  It is not a character flaw or a weakness. So instead of feeling like pain avoidance is a “negative” give yourself (or your client) a pat on the back, your brain is just doing its job.

If the way your brain does that job is becoming problematic for your life, then it’s time to make a decision about whether you want to change it.  As a physiotherapist we know would love to say “acknowledgement is 50% of the solution”. In order to reclaim parts of your life, it can be helpful to examine the reasons and thoughts behind avoiding certain movements and activities. As you examine those, you can learn the difference between avoidance that is helpful to healing and fear that is disruptive for your life. If you are a health care provider, it’s essential to talk with your clients and find out their perspective on how avoidance is affecting them. Then you can empower them by tailoring your approach and utilizing individualized strategies that will help them live the life they want to live. “If you can learn about [avoidance], and acknowledge it when it occurs, then you can begin to challenge it and change it. It’s not an exaggeration to say that overcoming fear-avoidance is essential if you want to self-manage pain successfully. It’s really that important” (McAllister, 2103).

Please join us next time as we look at some of the ways we can begin to challenge and change these behaviours.

Acknowledgment:

Diagram by Ashley and Colleen at Reclaiming Life. Graphics used are from Freepik.com (background, man lifting boxes, hurt and anxious man, thief, superhero, light bulb and shield).  

References:

Hanson, Rick. [The Rush on Shaw TV].  (2013). Interview with Neuropsychologist - Dr Rick Hanson.

[Video file]. Retrieved from https://www.youtube.com/watch?v=9gK9DyvWuGA&feature=youtu.be on September 5, 2015.

McCallister, M.J. (2013). Institute for Chronic Pain Blog: Fear-Avoidance of Pain. Retrieved from http://www.instituteforchronicpain.org/blog/fear-avoidance-pain/ on August 31, 2015.

National Institute of Neurological Disorders and Stroke. (2014). Low Back Pain [Brochure]. Bethesda, Maryland: National Institutes of Health Department of Health and Human Services. Retrieved from http://www.ninds.nih.gov/disorders/backpain/low-back-pain-brochure.pdf on September 5, 2105.