If PainAdelaide was the entree, providing a selection of tasty morsels to sample and savour, Explain Pain 3 is definitely the mains, with healthy servings of wholesome ideas served with heaps of sides of fun and laughter.
Even before the room filled there was a buzz of excited anticipation as over 150 people checked in. The noi team of Jules, Kat, Paula, Claudia and Martina worked like a magnificently functioning brain, with connections fizzing away to get everyone registered and off and going with their goodies bag.
With every seat filled, Dave kicked off the day with some big picture, scene setting stuff. Kondratieff Waves have been written about before by Dave in a noinotes and provide a wonderful context to set the notions of healthcare, Explain Pain and health literacy within. The idea of healthcare as an economic driver and a critical output of the economy in maintaining and improving our’s and the wider world’s way of life can provide and reinvigorate the meaning of the work of bringing comfort to others. Dave pointed out that when he and Lorimer first ran an Explain Pain course in Sydney many years ago, only 9 people turned up – with a course full to capacity and a waiting list besides, it seems that the 6th Kondratieff wave has arrived.
Dave reiterated that at the moment, explaining and reconceptualising pain is the best approach we have to treating chronic pain. However one of the barriers to doing this is health literacy. Health literacy is defined by the WHO as “the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health”
Health literacy is scored on a scale of 1 (low) to 6 (high) with 3 being considered a minimal skill level to successfully access and use health information – a majority of Australians are below 3. But, as clinicians and therapists and clinical scientists, we are able to improve health literacy in our patients with a good knowledge base, some conceptual change, communication, motivational and coaching skills.
We also need to be aware of the paradigms we, and out patients operate within. Dave explained that there was evidence that people hold two broad frameworks in regards to pain and health; namely a biomedical and biopsychosocial framework. While the biomedical framework has saved millions of lives, it fails for chronic pain and health conditions with its broad premise that illness is strictly a biological process that can be cured.
By contrast, a BPS paradigm recognises multiple causes from biological, psychological and social domains, focuses on illness as well as disease, strongly acknowledges interactions between brain and body and includes psychosocial contributing factors as precursors to injury/disease. Modern biopsychosocialism is all embracing and can be considered ‘neuroimmune refreshed biopsychosocialism’.
The ‘sub-paradigms’ that underpin BPS understand include the more traditional paradigms of anatomy, biomechanics and tissue pathology and repair and all have their place and can be useful, but Dave pointed out that “we treat processes, not anatomy”.
Modern paradigms that add to these traditional paradigms and power them up with neuroscience and clinical reasoning. These paradigms include the pain mechanisms model from people such as Louis Gifford and the neuromatrix model from Ron Melzack and notions of a distributed, representative brain Paradigms from psychology are of great help with the onion skin model from Loeser and the Fear Avoidance model from Vlaeyen and Linton. Evolutionary biology can provide a paradigm that helps explain why, and powerfully can reconceptualise pain and other protective outputs as highly evolved defences rather than ‘defects’.
Dave finished off the morning session with an introduction to some conceptual change science. Conceptual change, while a type of learning, can be differentiated from other types of learning as it requires a fundamental change in the content and organisation of existing knowledge as well as the development of new learning strategies. The outcomes of attempts at conceptual change can be highly variable and will be influenced by the deliverer, the learner, the message and the social environment.
Conceptual change will also be influenced by the ‘grain size’ of knowledge and ideas held by the learner. Ideas and misconceptions can be held “loosely” as single grains and might be easy to change, but they can also have more “coherence” and form flawed mental models – sandcastles, made up of a number of different ideas of smaller grain sizes. Finally, misconceptions might be held very tightly and formed tightly together – “sandstone” like and be very hard to change. Additionally, some learners may lack the mental framework (schema in the conceptual change language) to understand complex ideas and try to apply existing frameworks that lead to poor learning outcomes. We’ve written about the idea of emergent and linear mental frameworks quite a bit on noijam – here, here and here.
After morning tea, Lorimer cruised on up to the stage and hit the button for the first slide of his presentation which he had aptly named “Lozzie’s Bits”. Lozzie’s first bit was to ask the audience to define pain, to complete the statement “Pain is…”. These definitions were then passed through a number of tests, firstly- replace “Pain is…” with “Phantom limb pain in a person born without the limb is…”. Lorimer was adamant that an accurate, up to date definition of pain must be able to explain all pain, including the more complex pain states. The second test was to replace “Pain is..” with “Fear is…” and ensure that the ensuing words failed to define fear. The key factor here is that pain is felt somewhere in our body, while fear is not in Lorimer’s words – “pain hurts, fear frightens. They feel different. We allocate pain to a part of our body; because of this it can be seductive to think that pain occurs in our body or is from our body tissues – but it does not”.
Lorimer discussed a number of studies which demonstrated that nociception is “neither sufficient nor necessary” for pain and that the amount of nociception that may be produced by an event or stimulus is in no way associated with the degree of pain that may be felt.
The key question when it comes to pain is “how dangerous is this really”. Lorimer provided a formulation for pain, suggesting that pain is as simple and as complex as he equation:
Pain = (credible evidence for danger) – (credible evidence for safety).
If the answer is positive, that is, the credible evidence for danger to the body outweighs the credible evidence for safety, then pain will be experienced.
The classic snake bite story illustrates this beautifully:
[youtube http://www.youtube.com/watch?v=gwd-wLdIHjs?rel=0&w=853&h=480]
We are all potentially sources of credible evidence for danger or safety, as is the environment and an individual’s beliefs, values, past experiences and so on. Pain emerges from a human being after this very complex evaluative process, but this understanding can give hope as well as provide direction for therapy.
Lorimer was back again after lunch and got into some nitty gritty neuroscience. Some key ideas from this session were:
- There are numerous modulators of nociception – peripheral sensitisation, central sensitisation, cortical sensitisation of supra spinal networks and descending modulation.
- Primary nociceptors can become sensitive to adrenaline if exposed to increased adrenaline while firing – a fright during a period of nociceptive activity (such as an injury) can lead to the generation and implantation into the cell membrane of adrenoreceptive channels that can open and lead to nociceptive firing in response to another fright at a later time.
- Central sensitisation occurs when the secondary nociceptor becomes “wound up” and increases its firing rate in response to primary nociceptor activity in the dorsal horn.
- These changes and wind up occur in the cortical and sub-cortical (supraspinal) regions of the brain and can lead to pain neurotags that are disinhibited and more easily ignited – they are turned on more esialy and become harder to turn off.
- A neuroscience nugget for the clinic is that in central sensitisation patients are not heat sensitive (unlike in peripheral sensitisation – think sunburn and a hot shower) but can be cold sensitive.
- Humans have the hardware to construct central sensitisation without the precursor of peripheral sensitisation
A really nice take home quote from Lorimer’s second session was the fundamental idea that “pain is always equally real, regardless of any process of peripheral or central sensitisation”.
After a well deserved afternoon tea, Mark Jensen took to the stage for the first time. He lamented the fact that he was getting up to speak after two of the world’s best presenters! He explained that had he known and thought about it, he would have fought to have spoken first.
But any fears Mark had should have been dismissed as he proceeded to take the audience on an intriguing journey into the unknown (for most audience members) with an introduction to hypnosis.
Mark explained that we don’t really know how hypnosis works, but we do know that it increases responsivity to information and can greatly enhance other approaches such as CBT.
Mark ran a brilliant audience participation session demonstrating how the brain communicates locally with fast oscillating waves of neuronal activity, and how the brain can communicate over larger distances, across 100 billion neurons, with slower oscillating waves known as theta waves. Importantly, hypnosis is associated with increased theta activity, providing some clues as to why and how hypnosis has the effects that it does.
Mark explained that neurons that fire at a theta rate are inhibitory and speculated that theta waves facilitate brain wide coordination. Importantly, theta frequency activity in the amygdala and the hippocampus is essential for learning and memory which supports the notion that learning and response to information will be more powerful in hypnotic states.
Mark discussed the various impacts on theta waves in the brain including everything we see, hear, smell, touch and taste and other people.
As therapists falling into the ‘other people’ category Mark suggested a number of ways to enhance theta activity and thereby enhance readiness in patients to learn and take on new information, including:
- Taking time to build and maintain rapport
- Speaking slowly and rythmically
- Being mindful of what you say
- Be mindful of how you say it – use metaphor and stories
- Consider using positive future imagery.
Mark ran a demonstration of hypnosis with an audience member which had the rest of the attendees hushed and listening carefully as Mark used careful language patterns and delivery to induce a hypnotic state and then use that state to suggest increased feelings of relaxation and wellbeing.
This is really new territory for so many people and Mark was very keen to dispel myths around hypnosis. In closing, Mark made a very interesting point about relaxation training. Mark stated that relaxation training was basically hypnosis with only one suggestion – to relax. Hypnosis that is done well and purposely on the other hand has an unlimited number of possible suggestions and can therefore be a powerful adjunct to many other forms of treatment.
And that was Day 1. A bit of a quick and dirty post, but hopefully enough to give you a taste of the day.
I’ve been tweeting in real time all day and you can join me again tomorrow on twitter by following @altThinq, as well as @noigroup and @NOIExplainPain. You can also join the conversation (there’s a bit of buzz on twitter right now which is great) by searching and using the hashtag #ExplainPain3.
Until tomorrow.
– Tim Cocks
1. Fear is …. the expectation of pain.
2. Expectation drives outcome (as in the placebo effect).
3. (1 +2 syllogism) No fear means no pain.
Point 2. could be argued, maybe. The expectation of “no pain” would relate not so much to the physical symptoms but to the underlying psychological issue which is causing the pain.
I can assure you that fear can be very painful and expressed in the physical…….Heat can be very soothing for the persistent pain state and a hot bath is the only place were I feel relatively pain free…….We could now open many chapters of discussion based on my two experiences…….