Pain Theory Applied

This post will be a little different from our typical chronic pain post. This is a real-life story about a woman who was able to use strategies based on pain theories to minimize disability from her pain. This post will bring together points that have been made throughout our previous posts.

This woman, let’s call her Abigail, had a knee injury a couple of years ago. At that time, the knee pain got pretty bad. It definitely interfered with her function. She wanted to go jogging, but that caused the pain to flare up, so she stopped doing it. Sometimes she even had trouble walking. She had a really hard time getting up and down off the floor with her young children, and it interfered with her enjoyment of spending time with them. She went to her doctor, who diagnosed it and referred her to a physiotherapist (PT). The PT taught her how to strengthen her quadriceps to put less strain on her knee. She had custom shoe inserts made to support her flat feet (which can cause her knees to go inward, and was thought to be contributing to the pain). She iced her knee and took anti-inflammatories only when the pain got really bad, thinking that she should avoid taking too many meds. She wore a knee brace for a while, because she felt scared to do things without it on. All these things seemed to help, and she felt good that she had a few strategies, but it took months until the pain gradually went away.

Now fast forward a couple of years. Abigail is in better shape overall, and her knee hasn’t been bothering her, unless she does too many squats. She likes to go to a zumba class a couple of times per month. She wants to be able to go jogging, because she has enjoyed that in the past. She’s a little worried that her knee might bother her, but she wants to try it. She starts a running routine with some co-workers, taking it easy at first and gradually building up, with a goal of reaching 30 minutes. She registers for a 5km fun run, hoping she’ll actually be able to run it. The first few weeks of training, her knee feels fine. She’s pleasantly surprised, but still careful.

When she gets to a point where she’s running 20 minute intervals, the knee pain is suddenly back. It’s relatively mild at this point, but it’s got her attention. She knows she doesn’t want to go back to the moderate/severe pain that affected her so much two years ago.  

This time, she sees an occupational therapist and a physiotherapist who both specialize in pain.  Her health care team explains some theories and science around pain.

1. The “Pain Alarm” (see this post)

• The pain alarm can be useful, so it is probably telling her something.
• Since the pain clearly started when she began to run 20 minutes at a time, she thinks it’s probably telling her she’s pushing herself too hard, too fast.
• But if she blindly listens to that alarm, or misinterprets what it’s telling her, and she stops moving completely, it will likely get worse.

2. Pain related fear and avoidance (see the diagram on this post)

• If she stops doing activities that can hurt (like running, zumba, or playing with her kids), the decreased activity could actually make things more difficult and painful. This in turn could increase her avoidance of these tasks, creating a cycle that results in decreased functioning.  
• If she completely ignores what her body is saying, and continues trying to increase her running endurance by trying harder and harder to push through the pain, well, that could potentially cause serious pain. Which would lead to avoiding activities because her knee truly can’t tolerate them. This in turn could lead to more fear, and more avoidance, and more pain.

3. “Safety in Me” vs “Danger in me” (see this website)

• There is value in anything that helps build her confidence in her body’s ability to move without causing her pain to get worse.

So basically, Abigail knows she has to pay attention to the acute pain “alarm.” She needs to find the balance where she continues to do activities, but doesn’t overdo it. Understanding these concepts, she works with her health care team to explore how her new knowledge applies to her situation, and develops some strategies:

• She knows that she needs to keep moving, but aims to “fly under the radar” (see last post) of pain, meaning that she will do movements that bring her just to the point of discomfort, but not past it into pain. Basically, she wants to stay in the pushing-herself-but-safe zone.
• With that in mind, she scales back on running, but doesn’t stop. She knows that when she was running for 16 minutes, her knee pain didn’t flare up. So she decides to go back down from 20 minutes to 16, and stay there for a couple of weeks. She plans to increase her time only if she feels the pain is well under control.
• She decides to replace Zumba classes with water aerobics for a while, to give her the chance to focus on running. She realizes that both running and Zumba involve impact on her joints, and decides she needs to choose one to focus on. She wants to increase her running endurance, so that's the one she chooses.
• She learns different exercises from her physiotherapist. This time the exercises are more personalized to the specific reason for her knee pain.
• She ices her knee and takes anti-inflammatories any time she feels the pain and swelling coming, instead of trying to be “tough” and taking meds only when she can’t take the pain anymore. She knows she wants to keep the inflammation at bay so she can keep moving.

Abigail finds great success in this plan. She’s absolutely thrilled that she was able to do it, and is so glad that she didn’t stop running when the pain first started. She’s also glad she took the pain seriously and came up with a plan. She’s grateful for all of the pain theory that she was able to build into her plan. The best part - in another month, she’s able to run the 5 km fun run without experiencing knee pain! 

Acknowledgments:

Diagram by Reclaiming Life. Graphics from freepik.com

Back Pain: A Tale of Two ER Visits

Imagine this:

You are 25 years old. Your back has been hurting lately and it's been getting worse. You haven't seen your doctor about it yet. You've been pushing through it, popping over the counter painkillers, and hoping it'll get better. Then one day at work it suddenly gets a lot worse. The pain extends down your leg, and your leg gives out under you. You can't ignore this anymore. Your over the counter drugs aren't even touching the pain and you feel like you can't take it anymore. You call your partner, who drives you to the hospital. 

Now imagine you get into the emergency room and the nurse says "oh man, you must have a herniated disc" with a look of absolute pity. You wait a few hours to be seen by a resident doctor, who does an exam that you can only describe as excruciating. He says you need an MRI and tells the nurse to give you narcotics. The narcotics kick in and you finally fall asleep, leaving your partner to sit there wide awake wondering what's going on. A while later, another doctor comes in and does the same excruciating exam. Even with narcotics this one hurts. You try to tell them that the resident already did this, so please don't do it again, but the doctor proceeds anyway. You wait another few hours and get your MRI. Another doctor comes in and again examines you in the same, horribly painful way. This doctor says "it's definitely a severe herniated disc. This pain is never going to go away unless you have surgery. But the reality is there's way too many people with painful herniated discs. If a surgeon will even take you, it'll be at least a two year wait. If you had neurological symptoms, then you could get surgery right away. But since it's “only” pain, good luck. Here's a prescription for two days worth of narcotics. I can't give you any more because I don't know you, so I can't be sure you won't abuse or sell them. Follow up with your family doctor.” Later you call the family doctor, only to find out she's on vacation for three weeks, and the covering doctor does not prescribe narcotics. 

Can you imagine the feeling of absolute helplessness and frustration that you would feel? The key message you receive seems to be “your pain is here to stay, and we don't care.” 

Now imagine this version of the story:

When you get to the emergency room, the nurse reassures you. She tells you they have very good doctors here, and they'll be able to figure out a plan for how to deal with this. You wait a few hours to be seen by a resident doctor, who explains that he needs to do an exam to figure out whether there are any neurological symptoms accompanying your pain. The exam is painful for you, but he’s compassionate about it. After the exam, he tells you that the good news is he isn’t seeing any neurological deficits, and because of this he doesn't recommend advanced imaging, like an MRI. He explains that you could have a herniated disc. He also explains that research is now showing that a lot of people who have herniated discs don’t actually have any symptoms, and doing surgery on the people who are having pain is not necessarily helping them. Sometimes it even makes their pain worse. He does prescribe appropriate pain medication to help you get through this current bout of pain, but he also tells you that there are many strategies that can be used to better manage the pain, and medication is only a part of the answer. He tells you that the emergency room is great for dealing with medical emergencies, and it’s good you came here to rule out any neurological symptoms. But at this point, there are better places to further assess the cause of your pain and help you learn how to deal with it. He refers you to a pain specialist who can help you along the way and also advises you to follow up with your family doctor. He tells you to come back to the ER if you do develop neurological symptoms.

What do you think you might feel in this scenario, and what overall message would you receive this time?

Click to enlarge.

What are the differences?

In the first example the whole situation is the opposite of how we would like to see pain treated. There is no empathy or reassurance. The wording used only increases the threat value of the symptoms. (“Oh no, this is really bad!”) This can take a nervous system that’s already on high alert because of the sudden worsening pain and escalate the system’s response. It also does not provide any hope that things can change. (Which could be argued to add a whole new threat: this will NEVER go away!)

In our ideal situation the client is treated with caring, respect and compassion. Decisions are discussed with the client and education is provided. The overall approach hopefully made the client feel supported in a scary situation. 

Points to ponder:

We’ve packed a lot of concepts into these two short examples. These topics could be posts in themselves, but we just wanted to introduce the ideas here. We would love to hear your thoughts on them.

1.) Respecting the client - In the first example we saw three different doctors do the same painful exam three different times. We totally understand each doctor wanting to an assessment before they make decisions. But if a colleague just did the very same thing, you trust their judgement, and the assessment is very painful for the client...is it necessary? At this point what are you looking for with your assessment and is it a good reason/justification to put the client through the assessment? If it is necessary, explaining the benefits to to the client might put them at ease. 

2.) Language - As we mentioned above, the language clinicians use to describe the pain can either reassure or terrify the person in pain. Clinicians are often rushed, trying to see many people in a short time frame. However, in our example above, it really wouldn’t take any longer to communicate in the encouraging manner used in the second scenario.

3.) Imaging - Imaging for pain is a topic that is currently being researched and discussed. As Bronnie Thompson so succinctly stated “We know that most people with back pain are not going to benefit from having X-ray, CT or MRI because these images either don’t show anything useful (no image shows pain) or show something irrelevant that might look interesting but is actually unrelated to back pain. We know this, and there have been numerous treatment guidelines and algorithms and education indicating not to give imaging for low back pain without neurological changes” (Thompson, 2016).

4.) Surgery - Again this is a topic that is currently being researched and discussed. There are many articles on this topic, and some suggest that surgery has been “overprescribed” (Senelick, 2014).

5.) Pain Education -  Educating the client on their own condition can begin at any stage and with any health care provider. While there may not be time to address it in detail in the emergency room, it can be further explored with healthcare providers who specialize in pain. These could be physicians, occupational therapists, physical therapists, psychologists, physiatrists, pharmacists, or a team of providers working together.

And a parting thought:

The first scenario is based on a real story. We don’t share it as a criticism, but as a starting place for a discussion on how pain is approached in assessment and treatment. For health care providers, we hope to draw attention to the impact your information and language can have on clients and their outcomes. If you’ve happened to be the client or family in an ER visit that resembles the first one, please don’t give up. There are health care providers out there who are treating people with compassion, kindness, and care.  And there IS hope that your pain and your life can get better.


Acknowledgement: 
Diagram by Ashley and Colleen at Reclaiming Life. Graphics from Freepik.com.

References:

Senelick, 2 (2014). MRI Back Scans Do Not Predict if you Need Surgery. Retrieved from http://www.huffingtonpost.com/richard-c-senelick-md/sciatica-_b_4098475.html on January 16, 2016

Thompson, B. (2015). HealthSkills: How to Spend Money You Don’t Need To. Retrieved from https://healthskills.wordpress.com/2015/02/02/how-to-spend-money-you-dont-need-to/ on January 16, 2016

Your Brain is Trying to Protect You, Part Three: More Tools

1. Knowledge: Understanding what is happening inside the body

One important way to begin to address fear avoidance is with knowledge. Some people with pain spend a lot of time learning about their condition through books, the internet, and other sources. The information they find may or may not be accurate, and this should be considered. Other people in pain may avoid the topic, wanting to spend as little time thinking and focusing on it as possible. Whatever the case, we believe that the person in pain is the “expert” on their own experience. Health care providers can be “experts” in current evidence, theory, and knowledge around pain, and sharing this information with clients can be extremely helpful.

The knowledge that is provided can take many different forms:

-What is happening inside the body?

-Which movements are good versus which ones could be harmful?

-Which activities are safe and which are unsafe?

-What does pain mean? Is it causing damage, or not?

-Coping strategies, techniques, and resources that are available.

Using knowledge and education to address fear avoidance sounds obvious, but there are many factors that affect the the outcome of education. For instance, a 2003 study on using education to address fear avoidance suggested that, as expected, people who were avoiding tasks because of fear of pain benefited from fear avoidance based physical therapy. What the authors didn’t expect was that the same education could actually lower clinical outcomes in people who they considered “confronters”, meaning people who tended not to try to avoid pain (George, Fritz, Bialosky & Donald, 2003). We interpret this to mean that it is essential for the clinician to understand the client’s current beliefs about their pain in order to determine what kind of information might be helpful to the client.

2. Self-Efficacy: Believing that you can do something about the pain 

Another essential tool is self-efficacy, a term that came from Bandura, a prominent psychologist in the 1990s. Some people may wonder - why talk about psychology when the problem is physical pain? The answer is that human beings are complex, and our minds and bodies impact each other.  To put it succinctly, “chronic pain is inherently both a medical and a psychological condition – what healthcare providers call a biopsychosocial condition” (McCallister, 2013). 

So what is self-efficacy? The textbook definition of self-efficacy is: “one’s belief about one’s ability to perform behaviors that should lead to expected outcomes” (Weiten, 2004). Basically, when it comes to pain, self-efficacy is the belief that you can manage the pain and continue living your life. Self-efficacy is essential to overcoming the effects that pain can have on everyday life. When people truly believe that they can do the things that are important to them and enjoy activities despite pain, they are well on their way to reclaiming their lives.

The great news is that health care providers can help people develop self-efficacy. One way is through information, as we described above. As Sandy Hilton explained, “when a person isn't afraid they are going to hurt themselves it allows them to act with more self-efficacy” (Hilton & Blickenstaff, 2015). So health care providers can encourage people to build self-efficacy by providing information about what movements and activities are safe to try. Once the person begins to try things and have success with them, the feeling of “I can do this” is reinforced.

Health care providers can also enhance self-efficacy simply by choosing their language and focus carefully. Sandy Hilton described this as “looking for opportunities instead of dysfunction in the way we describe things with patients.” By keeping our language ability-focused rather than impairment-focused, we emphasize people’s strengths, and reinforce that they can use these strengths to their advantage in managing pain (Hilton & Blickenstaff, 2015).

If you are a person in pain, look for health care providers who encourage and support you to develop your own strengths and abilities in managing your condition. Also, keep an eye out for ways to foster this empowerment in your own life. 

3. Re-introduce movements and activities: Gradually taking activities back from the thief 

Re-introducing movements that have become worrisome is basically hypothesis testing and rewiring the connections in the brain. In a way it is creating that sense of safety for the body to progress. It is saying “You know that big, bad thing you're afraid of? Well maybe it just isn’t so scary as you think. Maybe you can deal with it.”  There are different ways to create that sense of safety so there is room to increase activities, but today we are specifically going to look at graded exposure. This part of our post will be geared more toward clinicians, as it will be detailed about the specific therapy approaches. Through graded exposure the hypothesis of “If I do this movement, then I will cause pain or harm” is being tested. 

It’s important to note that graded exposure is different from graded activity. Both have a role in pain management, but graded exposure specifically has a role in looking at fear avoidance behaviour. Graded activity is where you choose one specific action, and gradually increase the difficulty level (intensity, duration, speed, etc) to increase your ability (strength, coordination, and skill). Graded exposure is where you look at the activities you’ve avoided because of fear of pain, and work from the “least scary” task to the “most scary”, to increase your confidence. 

For example, if you’ve been avoiding carrying groceries in from the car, graded activity would be starting with a box of cereal, then gradually building up to heavier grocery items. The goal would be to build up muscle strength so you can physically carry all the necessary groceries. Graded exposure addresses the emotional and psychological side more than the physical side. For example, if your specific fear is that carrying the groceries will result in injuring yourself further, being in excruciating pain, or not being able to go to work the next day, etc, then graded exposure addresses this fear. In graded exposure, you are not necessarily grading the specific activity, but grading which activities you’ll try, in what order. You would grade the exposure by starting with tasks that cause less anxiety and working up to tasks that have more fear attached to them. 

You might ask - what if my fear is a worsening of pain, and the fear comes true? Prior to beginning graded exposure, the clinician would help the client develop strategies for addressing these situations. Then, even if the hypothesis is proven true, the client is able to cope, and confidence still builds. We would also anticipate that often the consequence may not be as severe as the client fears (for example, if the client fears they will “break their back” lifting the groceries, the reality is they may find their pain increases temporarily, but they are extremely unlikely to actually fracture a vertebra).

When we first starting learning about graded exposure, we both wondered “why would anyone ever want to do this? It sounds awful and hard”. We’ve learned that the motivation for this particular method of re-introducing movements and activities often comes when people recognize that fear is affecting what they’re able to do, and they want to take back the control. This approach is also different from “flooding”, which is what some people associate with exposure therapy. In flooding, people do things no normal person would do - like climbing in dumpsters if they are afraid of germs. Instead, this approach focuses on realistic everyday activities. 

When deciding what activities to start with and what order to try activities it is critical to choose an activity that is both physically doable and emotionally achievable, and this is where the health care provider’s expertise and encouragement come in. The first consideration is the safety of the task, and whether the person believes it is safe. The second consideration is how realistic the task is - it has to be a task that the client can achieve. By starting with something that is achievable it creates that confidence and momentum to continue forward. Together both of these mean start small. Start with something that is just a tiny bit scary. Don’t give a grade one kid the New York Times and expect them to love reading. Instead you start with books that are at their reading level and gradually build up, and one day they just might grow up to be someone who loves the New York Times. 

All these tools work together 

To summarize, we will return to the example of the gentleman with back pain from our previous two posts. He was able to find success in regaining activities because of the combination of tools that met his individual needs. His doctor began by establishing trust and a working relationship. Then the doctor provided education on back pain and how “hurt does not always equal harm”, and movement can actually help improve symptoms. Next the doctor focused on building his self-efficacy by empowering him to realize that the tools he needed were within his reach. Then they discussed specific movements and activities that he had become hesitant about, even though they were important in his life. The doctor helped him understand how to start small in approaching these activities, and how to build on each success. The doctor encouraged him when needed and celebrated with him as he regained these activities. These tools together acted as a shield, protecting the man’s daily activities from the impact of pain. 

Each person’s story is different, and in real life it may not be as simple as a person approaching their doctor and finding straightforward answers about how to implement these tools. It may be a different kind of health care provider, or a whole team of providers who do this. It may not be a linear process, and these are only a few of the many tools that can be used. The pain fear avoidance model does not address all possible factors that might be involved in a person’s pain experience. We’ve simplified it for the purposes of this post. But even though each person’s journey and tools will be different, we hope you have found this overview helpful in beginning to understand how health care providers can support people in reclaiming their lives. 

Acknowledgment:

Diagram by Ashley and Colleen at Reclaiming Life. Graphics used are from Vector Characters.

References

George, S.Z., Fritz, J.M., Bialosky, J.E., & Donald, D.A. (2003). The effect of a fear-avoidance-based physical therapy intervention for patients with acute low back pain: results of a randomized clinical trial. SPINE, Volume 28 (23), 2551-2560.

Hilton, S., Blickenstaff, C. (Physical Therapists). (2015, June 9). Pain science and sensibility Episode 1: Self-efficacy and fear of movement in chronic back pain. [Audio podcast]. Retrieved from http://ptpodcast.com/pain-science-and-sensibility-episode-1-self-efficacy-and-fear-of-movement-in-chronic-back-pain/

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.

Weiten, W. (2004). Psychology themes & variations. California: Thomson Wadsworth.