Lunch times during Explain Pain 3 were pretty loud and riotous affairs. Lunchtime activities included Bollywood dancing on day 1, juggling on day 2 and practical mindfulness on day 3. There was also an opportunity to try out some Graded Motor Imagery at our GMI stand with the Recognise™ Apps, Recognise™ online and a few mirror boxes getting a good workout. It was very nice to be able to introduce some people to GMI for the first time and have a play with the various aspects, all within the context of explaining pain and understanding a bit more about the brain.
Dave, Lorimer and Mark were always kept very busy during the breaks, trying to balance getting a bit of food in while being deep in discussion with small groups that had gathered to question and clarify and probe further.
Lorimer was back for the first session after lunch on day 3 and took the group through a very practical session in understanding what a clients’ pain can tell us about what was going on in their body. Having covered a lot of fundamental science in relation to the nervous system and brain, this session aimed to link together the various biological changes that occur with chronic pain and the subjective experience of the person in whose nervous system the changes had occurred.
Lorimer explained that he liked to start off by asking a client what was happening in their lives in the week building up to the injury or onset of pain. This question aimed to give insight as to the environment that the nervous system, nociceptors in particular, may have been in at the time pain commenced – was it being bathed in adrenaline as a result of significant stressors? Had it adapted to an immune environment with increased pro-inflammatory cytokines? Were there stress related or immune related triggers to pain now that could be related back to the internal and external environment at the time of injury/pain onset?
In a really juicy example of research informing clinical practice and reasoning, Lorimer explained that he was also very keen to gauge just how precisely the client was able to recall the event that led to pain. Research underway was testing the hypothesis that the precision with which the brain represented the initial pain event may indicate to what degree the brain would encode for protection. By way of example, Lorimer suggested that after a person experience a dog bite, they might encode for protection against a specific, individual dog, a specific breed, size and colour of dog, or even dogs in general. The resultant protective behaviours would then differ markedly from avoiding the specific dog that had bitten, through to avoiding all dogs in general.
Similarly, if after an event that precipitates pain, a person encodes very precisely for protection against a specific movement in a specific context, lifting a tool box out of a truck at waist height, for example, their pain and behaviour may be less generally protective compared with a person that encodes for protection against any and all movement. The extent to which a person can recall precisely what occurred during the event, even down to the angle of their feet, the extent to which their knees were flexed etc, may provide a clue as to how precise the protective encoding is within their brain.
Next, eliciting an individuals understanding of what occurred in the past and what is occurring now will inform further about neurotags that represent the event and ongoing pain, as well as providing a sense of how the individual is conceptualising pain.
Lorimer explained that he was very interested in the answer to the question “where do you feel pain?” He suggested that while we can take the answer to this question for granted, it could provide very useful clues as to the biological processes underpinning the pain experience. Along with where the pain was experienced, the behaviour of the pain and response to external stimuli could further assist in reasoning biological processes.
Together, Lorimer and the audience built up the General guide to contributing mechanisms that is available at the Body in Mind site. Lorimer was careful to point out again that this is a general guide, but suggested that a careful assessment that elicited the information summarised in this guide could greatly enhance both the therapists and the clients’ understanding of the likely biological processes forming the substrate of the pain experience.
While the guide can be a bit overwhelming on first glance, working through each of the colour coded domains individually certainly helps and build stye complex end picture up in bite-size chunks. Definitely worth spending some time with the guide and having a copy nearby as clients are interviewed.
Dave started the final session of the day with a bit of an acknowledgement; explaining that between he, Lorimer and Mark, they had published well over 700 papers. This was met with deserving applause, followed by laughter as Dave explained that his contribution was to be the co-author on the grand total of four of them. But Dave was there to share stories and the power of storytelling within a neuromatrix paradigm and got stuck into this often under-appreciated aspect of therapy.
Story telling can be roughly divided into various categories by the length of the narrative – from quick little “neuroscience nuggets’, to metaphors, to longer stories and to classic stories and longer metaphors. The specific stories told can be guided by the clinical exam and the history taking, with Dave encouraging the use of “e flags” – aspects of the client’ story that you mark to return to with an explanation at some stage.
Each ‘e flag’ might represent a neurotag associated with the pain neurotag and addressing and ‘taking out’ these e tags might be enough to start disassembling or reinhibiting a disinhibited pain neurotag.
Getting in to some classic neuroscience nuggets Dave spoke about the ion channel, fundamental for the function of our nervous system, but constantly being renewed with ion channels turning over every 2 days, with subsequent links to changeability of sensitivity and neuroplasticity within the nervous system. The understanding that humans map and encode the space around them, the peri-personal space, and the notion of pain on approach to a protected body part – pain prior to any touching at all that can be explained with neuroscience so that the client’s experience is validated and acknowledged rather than dismissed. Further nuggets including the knowledge that distraction can quickly and momentarily disassemble a pain neurotag, some night pain is likely to be associated with sensitive peripheral nerves and that irritated peripheral nerves can lead to neurogenic inflammation and subsequently swelling and “soggy, boggy” tissues distal from the site of nerve injury.
Moving on to longer pain stories, the explanation of pain with a combination os stories about the brain, brain representations, changing, “smudging” body maps in the brain and some time spent on the “majesty of the master organ” helping people to fall in love with their brains and its various outputs. A lovely saying came from the audience; “The brain is the boss and is large and in charge”, with Dave quickly advising that he would be stealing that one to use again.
Finally, a story that Dave thought that everyone was entitled to, the classic “drug cabinet in the brain” a super powerful story to explain pain, help alleviate the fear of a person coming off opioid medications, or to reassure a client getting ready to commence a graded activity program. In all its glory below:
And then it was over.
Lorimer took to the stage to thank Mark Jensen for travelling a very long way to join us and share his work and ideas. A sentiment echoed by long and loud applause from everyone in attendance. Mark in turn thanked everyone for their enthusiasm and hospitality, “sending us home with thoughts of love” asking for some self reflection about what the audience members might do differently having completed the course and hoping that they would listen deeply and reflectively when they next met with their clients.
Finally, Dave explained that everyone had passed, “even those of you that were failing at the start of the day” and had the final words with “you are all rockstars, now, go forth…. and multiply”
– Tim Cocks
Nice video presentation.
With the education aspect, I like to do it when the patient is most receptive. This is where interferential is so useful. Whilst attaching the cups I might say: “Would you like something to read or just sleeeep”. The monotonous drone of the IFT helps her drift away. When I come back, if she has relaxed, then the critical faculty of her conscious mind can be bypassed. I make my suggestions and they are readily absorbed.
Many thanks for the summaries of the three day course.
We have had many people grateful for them including people on the course and those who wished they were.
If the injury happened in the middle of a negative psychosocial event then the chances are that the resulting pain experience and tissue response will be used to manifest the pain of the PS event rather than an expression of the physical injury……..until the PS event is resolved the response will continue…….it’s the old story of what came first the chicken or the egg…..or better said who comes first the physiotherapist or the psychotherapist ………?hence the importance of those initial questions and the need to listen to the answers……don’t be afraid to say ” Can I just stop you there a second. So what did you mean when you said………..”?