Welcome back to the Healing Pain Podcast with Joe Tatta, PT, DPT, CNS
The words pain science and pain education are used so frequently nowadays in professional circles that we rarely take the time to explain the difference between the two or reflect on what clinical practice was like before these advancements came into our life. What was it like for people living with pain without this knowledge? Pain science is a part of a larger field of neuroscience, which investigates nociception and the lived experience of pain. It is most often taught in University Physical Therapy programs but over the years, it’s begun to show up in the training of many licensed healthcare professionals. Pain education is one component of an overall cognitive-behavioral intervention, which teaches people how to effectively self-manage chronic pain. It focuses on the components of each individual’s pain experience and how it affects their daily lives. Research shows that when people have a better understanding of how pain works in the body, it can ease fear, anxiety and create hope.
It also improves the skills of healthcare professionals so they can successfully assess, treat and understand the lived experience of pain. Pain at times is a normal part of living. Understanding both the science of pain and how to educate people about pain, alleviate suffering and improves the human experience. We take the time to honor the many voices and minds of those who have advanced the field of pain science, pain education and those who have joined me on this show. We begin at this time with integrated Pain Science Institute Instructor, Dr. Carey Rothschild. There’s a bit of a distinction between pain science and pain neuroscience education, some overlaps but some distinctions too. Can you tell us about the distinctions between them and then how you approach that within the context of the course you’ve created?
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The World’s Top Pain Science Innovators and Leaders
The course is called Pain Mechanisms and Treatment in Rehabilitation. It is a comprehensive look at pain from the basics of pain neurobiology. How do you best assess pain and inclusion of a lot of the outcome measures that have become popular? We then go into talking about those individual differences and pain variability that you see in different patients in different populations. We talk about the mechanism-based approach to pain management for the PT and then we do spend quite a bit of time talking about the therapeutic alliance and motivational interviewing. We do some role play with those two topics and we do talk about pain neuroscience education as an educational intervention. They explain the pain type of modeling again as a mechanism for educational intervention.
We get to review some of the key concepts of the modalities course, which was taught the semester prior and then we talk about some of the other interdisciplinary topics that are related to pain. Some things that you’ve highlighted on your show like sleep hygiene, nutrition and lifestyle factors. We talk about some of the psychological approaches that are used in pain management as well. Some of the things you’ve covered extensively on your show with regards to cognitive behavioral therapy and ACT and even basic relaxation, breathing, mindfulness-based stress reduction. They get all of this in the beginning then the very last two weeks we talk about all those concepts in the context of some of the common pain syndromes like fibromyalgia, chronic headaches, chronic low back pain. Even moving into chronic regional pain syndrome and osteoarthritis, rheumatoid arthritis, those kinds of things. To get back to your question, definitely quite a bit more and then pain neuroscience education, which encompasses about one module of the ten modules that we have.
Up next is Dr. Carolyn Berryman. What does the literature say about cognitive function as it relates to those with chronic pain?
That was a big part of my PhD and we did a couple of systematic reviews, which were quite large because a lot of people have investigated cognitive function and its effect on pain. The literature before we did this systematic review was quite disparate. There are some people that would say that it had an effect or the pain interfered with your cognitive function. Other people might say not part of their reason that that happened was when we were looking at the 24 studies but working memory deficits in people with chronic pain. We found that they tested working memory in at least 24 different ways.
People have decided to make their own or design their own ways of testing these cognitive functions and how bad is the ill definition or ill-defined concept that cognitive function is. Nonetheless, we found over the literature that in fact working memory is poorer, in general, in people with chronic pain states. We took it just as a very broad definition of chronic pain, meaning that they probably have a little bit more difficulty dealing with that interaction with the environment and day-to-day activities of daily living, calculating change, all sorts of things that are ongoing concentration and mental capacity. Also, it’s set-shifting. Set-shifting is otherwise known as mental flexibility. The ability to change your idea, change your concept of how you see a particular problem.
Professor Lorimer Moseley because we’re starting to talk about the interaction between the nervous system and the immune system and this balance between a pro-inflammatory state and anti-inflammatory state, which all of us are constantly going through. How does it explain pain the psychoeducational intervention influence this balance in our body?
The precise answer to that is we don’t know. However, if we were to predict on the basis of what we do know what would happen, there are several things that are relevant. For example, learning new data in animal studies is anti-inflammatory. The spatial data associated with learning also maintains a sustained anti-inflammatory effect. In the animal model, if the animal learns something cool in a certain location in the maze, that location in the maze potentially becomes an anti-inflammatory location. I imagine that’s about cues of different sorts, even that it’s an extrapolation of data. To extrapolate it to humans, that’s a big extrapolation. If I was to talk more maybe ideologically, if that makes sense, the theory ideologically, another term I made up, I would say that I think there’s very good evidence to say that explaining pain is anti-threat.
We could argue that anti threat is anti-inflammatory can explain the kind I would describe as a big seam in the language of the Protectometer. A big hit of safety cues when understanding and appreciating I can do something about this and I have some skills to do it makes sense why my pain is worse in this place or with these people, with these different cues. Anything that is anti-threat is not about feelings like pain. It’s about all of our protective mechanisms one of our protective strategies is to become inflamed. To go back to the precise answer, we don’t know. The predictions are it should be anti-inflammatory.
Dr. Greg Lehman, you also talk about being robust often that one of your goals is to help people to re-confront their thoughts and emotions or their beliefs about how they can be more robust in their life and in their health? Can you talk about that a little?
Robustness to me is tolerance. It’s meaning that you’re gonna have things that try to knock you down and you can cope with them when you have persistent pain. When you get out of that and you’ve recovered, you’re still gonna have flare-ups. The definition of stability means there’s a perturbation. You get knocked and you should come back to your original resting state. Robustness means that you can tolerate more and more perturbations to your life and come back to that resting state, that’s a stable system and a more robust system means it can tolerate more stressors. That’s what we’re trying to build. I think that it might be a synonym. That’s the idea of resiliency, the robustness and resiliency because we can’t avoid all of the stressors in our life. That’s what we do when something’s fragile. We put the stamp on the outside of the box, “Fragile. Handle with care.” Instead, we should be saying, “You’re not fragile. You don’t have to handle the care. You need to stress it to make it more robust, adaptable and tolerant.” That’s the cool thing. We’re not eggs. I don’t think an eggshell responds to load. That you don’t want to drop.
Pain researcher, Dr. Jeffrey Mogil. Everyone has always asked the question who is more sensitive to pain or who feels “feels pain” more intensely, men or women. Can you talk about that debate a little bit?
First, I’d like to point out that it’s a pretty odd question because most scientific questions, you go to people on the street and you say, “What is your opinion on this scientific question?” They look at you like you’re an idiot and say, “How would I know? I’m not a scientist.” If you ask them that question, everyone will guess. They will all guess 100% and mostly they guess wrong. The idea that people seem to have in their mind is because women undergo labor, they must be more tolerant of pain, less sensitive to pain. Here’s what we know. We know that women are greatly over-represented as pain patients. If you go and talk to pain doctors that have specialty practices in pain and you ask them, “What percentage of your patients are women?” You’ll get answers that are around 70%.
About 70% of the pain patients are women. That could mean that women are more sensitive to pain but there are other possible explanations there. It’s possible that women are more likely to go to the doctor. Maybe women go to the doctor more than men. They do. This is well-known and it’s not so much that women go to the doctor more than men. It’s that men refuse to go to the doctor. A better way of answering the question is not by looking at how many patients there are but by doing broad surveys.
Dr. Tim Salomons, can you explain what the pain neuromatrix is and what the best evidence of it? How it can affirm a clinicians’ practice? There’s a terrific controversy around that.
It’s a terrific question and it’s one that I’ve been spending a lot of time on. If you’re like me, you do neuroimaging, you’re interested in the brain and you believe that the brain plays a very fundamental role in pain, the first thing you’re looking for is can we recognize pain when we see it in the brain? I think what has driven a lot of this is that we struggle with whether we can trust subjective reports because sometimes people are looking for medications or they may have many reasons not to be forthright with their pain ratings. Everyone is always saying, “I wish we had objective measure.” We went about 10, 15 years running these pain studies and we got what we called the pain matrix.
It was a pattern of activation that no matter what pain imaging study you run, you see the same pattern of activation. Not to bore your readers with long lists of brain regions but reasons like the anterior cingulate cortex, the insula, the thalamus. If you don’t see these regions in the pain imaging study, you’re probably doing something wrong. People started to think, “Maybe this is the objective marker we’ve been looking for. We’ll have one of these things in every doctor’s office and companies started to offer legal. We can do this in legal settings.” As I’d like to say that neuroimaging has solved every problem because it would certainly benefit my work in terms of funding but what we’ve found is what we thought was the pain matrix or maybe a specific signature for pain turned out to not be as specific as we thought.
Physiotherapist and pain researcher, Dr. David Butler, what are the key principles that practitioners need to be successful at for explaining pain to patients?
First of all, that’s something my colleague Lorimer Moseley, some of your readers would have surely heard we worked together a lot. When we write, explain pain, we were telling the story of neuroscience in a language, patients, therapists and health professionals would get. We realized a little bit later that we needed to do more on how to translate that information over, which is essentially conceptual change theory. How do we change concepts in our patients as well? That’s merging the education element with neuroscience. There are a few things they had to be good at it.
First of all, I think you’ve got to have a biopsychosocial approach. That’s the first thing, the nice, wide, biopsychosocial approach but there are also competencies that help professionals need. I think you need to be, first of all, biologically literate. Biologically literate these days means there’s a little amount of understanding that neuroscience is changing at an incredible rate. Allow systems we learned about nociceptors and stuff is changing. We have to be neuroimmunologists, I think. If we don’t take on immunology and realize that at least 50% to 80% of the brain cells have gotten immune function then we’re missing something. The glial cells have an immune function like critically in learning, in health and sensitivity.
Dr. Cormac Ryan. What’s nice about your research is it begins to culminate with some principles that you share that can help practitioners with their application of PNA and potentially make it more effective for the clinician and the patient. Can you share a couple of those principles with the practitioners who are reading?
I go back to mixed methods, systematic reviews of the future. I think they’re extremely powerful because they don’t focus on the numbers. They focus on how to do the work well from the perspective of the condition of the patients. One of the key things which seem to be important for the patient was the ability to be able to tell their story. This idea of going in and delivering the education in a very bland way at leaving doesn’t seem to be the optimal way of delivering. Sitting down with the patient, asking them to tell you their story and giving them time to voice their concerns, I think it’s an integral part of PNE. It shouldn’t just be a one-way conversation.
In doing that and allowing them to tell their story, patients often identify inconsistencies in their own stories, which begin to hurt the medical model and the biomechanical model in their own mind, which could help you when you’re talking about delivering Pain Neuroscience Education to them. It will be a prerequisite to delivering PNE. If you’re delivering it in a cold planned way without listening to the patient’s story, you’re going to have less of an effect. I would say that’s probably number one. Also, in terms of that, I think probably the key thing of all of our work has been around the issue of relevance. Making the education relevant to the patient and having listened to their story first will allow you or help you when you’re delivering the education to make it bespoke to that individual.
Pain researcher, Peter Stilwell. I met this one of the things that I try to talk to practitioners about is kind of just maintaining a sense of this flexible out-of-the-box thinking. If you box yourself into any one theory or any one treatment approach as special, I think it’s most problematic. Maintaining this flexibility to think about the patient, what they’re experiencing and how that’s going to influence your evaluation, your treatment, your plan of care, your interaction with the patient. How does this model help with that flexible out-of-the-box thinking that people have maybe fallen into with regard to those biopsychosocial silos?
At least Sanneke de Haan’s work emphasizes that flexibility she uses examples of these like network models and she shows all the intertwined factors and how they change over time and how that shapes that individual’s experience. I think that’s important because that changes over time based on the person. Their body might change, their environment might change. Treatments may be that worked in the past might not work in the future. We have to be constantly attuned to that individual, their current perspectives and how things might be changing. Working with a philosopher now out of Germany to try to explore some of these ideas in relation to pain. I’m excited. I’m slowly learning and struggling. I have a crisis at least once a week where I’m just like, “Where am I going with this?” I get excited about all this different literature. I don’t know, at least some people might find it valuable so that might be worthwhile.
Neuroscientist and neuropsychologist, Lisa Feldman Barrett. If you look at The International Association for the Study of Pain’s definition of pain, it’s both physical as well as emotional experiences. Why we wanted to have you on to talk about emotions, you touched on it just briefly there in your theories and perspectives and constructs that you’ve helped build out with regard to emotion. Emotion is a perception and that perception happens ahead of time even before it comes to our consciousness.
There are so many things that are fascinating about how brains work. I was telling my husband, we were talking about prediction, in particular. I was saying, “If I wasn’t a neuroscientist and I can’t see the evidence with my own eyes, I’m not sure I believe it because it sounds preposterous.” Here’s an example that illustrates it nicely. I use this in Seven and a Half Lessons About the Brain. When we’re thirsty and we drink a glass of water or whatever, some cool, refreshing beverage, we drink the whole thing, we’re not thirsty anymore. It takes twenty minutes for the liquid that you’ve imbibed to reach your bloodstream and change the osmolarity of your bloodstream to tell your brain that there’s more hydration there.
Twenty minutes earlier than the biological signal is there, you stop feeling thirsty. Why is that? The answer is the same answer that I would give if you asked me what is so interesting about baseball. How does a bat or swing a bat at a ball that he can’t see where it’s going to be? He’s swinging where it’s going to be in a moment from them. The answer in both cases is your brain is predicting. For your whole life, you’ve had many occasions where you’ve drunk liquid and then at some point later, you stopped feeling thirsty. Your brain is preparing your experience before the sense data arrived. Now, in the case of drinking water, it’s twenty minutes. That’s a long time but in the case of most things, it’s very quick. There’s an example that I use when I’m demonstrating how the brain predicts.
I get people to imagine an apple and I would say 70% or 80% of the time people would say, “I’m salivating.” I’m like, “You’re salivating because I got you to predict that you were going to eat an apple.” You don’t believe that you’re going to eat an apple but for your brain to even understand what an apple is, it has to engage in the same neural pattern and part of that pattern is preparing you to digest it. That’s why you salivate in advance of eating food. In fact, Ivan Pavlov won a Nobel Prize for this at the turn of the century. His explanation for this phenomenon was completely wrong and it was wrong for about 100 years but in fact that’s what’s happening.
Your brain is a prediction organ. It’s predicting on the basis of how things are. If we were to stop time, your brain has some representation of what’s going on inside your body and what’s going on outside in the world. Your brain is predicting on the basis of past experience what is going to happen next. The prediction is your brain changing the firing of its own neurons to prepare, to receive the sense data and to act on it. Your brain starts to prepare your experience and your actions before it makes itself aware of that preparation.
Physical therapist, Major Timothy Benedict. First, is there some research supporting PNE, Pain Neuroscience Education, for PTSD? Tell us about your work specifically.
I had this idea that it does make perfect sense to me. I have a link between chronic pain and PTSD. To get a diagnosis of PTSD, there are a few clusters. Number one, after you’ve had a trauma, you start to re-experience this. Number two, you’re hypervigilant. Number three, you avoid things that remind you of that trauma. It’s very common that you have co-morbid negative cognition like depression, remorse, guilt. When I look at that cluster there, we will see a lot of things in chronic pain as well. We know people in chronic pain avoid. They re-experience pain after tissues have healed. They can be hypervigilant and have central sensitization. Definitely to me, there seemed like there was a close conceptual link between those two issues. I wanted to first make sure that as I talked about the neuroscience of stress, that veterans, that individuals with PTSD would be able to understand it, would be able to comprehend it.
There are lots of other studies that have looked at the same type of issue. Let’s make sure that the end-user, the patients can understand Pain Neuroscience. As what Moseley has found, like other practitioners have found, our patients do a much better job than what we as clinicians typically give them credit for. The first thing was making sure that these veterans could understand it. By using the military stories like when I talk about Pearl Harbor, what connects with these veterans and what helps them understand what’s going on with PTSD and what’s stress. That was the main aim. First of all, before going out and launching it in a clinical trial, can it be as veterans understand it? Does it connect with them? That’s what the first study, the pilot study with a sample of several individuals both with and without PTSD and found that they had good comprehension equal to a medical expert panel once we control years of education. We met our first goals and making sure that our end-user would be able to comprehend them.
Physical therapist and pain researcher, Adriaan Louw. Why is it still considered a radical idea that physical therapists can use the mind and cognitive-behavioral interventions in practice to help people?
There are multiple answers. It’s the models we follow. It’s a legacy to where they lay their cards. I think the biggest thing is when I hear from therapists like, “I don’t do that. I’m not going to go that way,” but I start laughing because you’re already doing it. You don’t know you’re doing it. I made many people better by what I tell them but not by the technique I did. I think I don’t push them, I leave them be. That’s fine. Do your thing. We’ll all get there but I think the reluctance is the models. We need to significantly update the models we’re teaching and understanding that there’s the stigma. It’s in my head. You think it’s not real. All pain is real.
I’m a neuroscientist. We scan brains and we’ve never scanned a brain and let’s call it fake pain. All pain is real and a message if your patients are reading, if a provider ever makes you feel like they didn’t believe you then fire them and go find somebody else because your pain is real. It’s leftover from the models we were told for years. It’s periphrastic , leftover from years ago. For the clinicians who think they’re not doing it, I have a message for you. You’re doing it. You just don’t know you’re doing it. That’s the fun part.
- Dr. Carey Rothschild
- Dr. Carolyn Berryman – past episode
- Professor Lorimer Moseley – past episode
- Dr. Greg Lehman – past episode
- Dr. Jeffrey Mogil – past episode
- Dr. Tim Salomons – past episode
- Dr. David Butler – past episode
- Dr. Cormac Ryan – past episode
- Peter Stilwell – past episode
- Lisa Feldman Barrett – past episode
- Seven and a Half Lessons About the Brain
- Major Timothy Benedict – past episode
- Adriaan Louw – past episode
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