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The Output Recipe for Coping with Pain

By Noigroup HQ Science and the world, Patient examples 12 Mar 2013

When we are injured or have a disease, a large number of biologically definable coping systems come into play to help us manage the state, repair and heal us and help us return to pre-trauma life. These output systems, essentially merging from the brain include the motor, autonomic, linguistic, cognitive, emotional, respiratory, endocrine and immune systems among others. They interact with each other, they feed back to the brain, their activation is often useful in the acute stages but these systems are not designed to be left “turned on”.

Clinicians confront this daily – you can be with a patient with a chronic state and wonder… “why in this person did the brain select an endocrine, autonomic and immune coping recipe to manage this but has called upon these systems for so long and hard that they have developed into a CRPS state”. Or in another person, the motor system has been called on as a prime defender and the patient has gone on to develop a severe imbalance state or, at worst “stiff man syndrome”.  In yet another person the immune system may have been preferentially called on and his/her problem has progressed to an immune based disease. Or in another, cognitions, once useful in the early stages have advanced to pathological catastrophisation.

Scientists rarely reflect on these things – many clinical scientists would.

I would love some thoughts on the things that might help construct the particular and individual output recipes that clinicians contend with daily. 

David Butler


  1. davenolan22

    The thing that seems the easiest to observe is the motor system. Some of my patients can really get unstuck with this one. There seems to be a belief built in the western world that abdominal muscles can only be to weak, always could do with being a bit more “toned”.

    Then once they have a back pain problem it must be because they are weak, not recruiting enough muscle. They then pre-tense for movement and brace there back when doing potentially threatening activities. This can become very maladaptive and potentially very provocative.

    I’m not sure as a profession we have dealt with the motor system well when dealing with persistent pain states. I still hear “Suck your tummy in” “be careful when you bend” “Work on that core””keep your back straight”. Are these phrases biologically defensible? I’m not so sure.

    I must admit, as a clinician I feel far more comfortable dealing with motor systems and cognitive states that have forgotten to “switch off” than I am dealing with immune and endocrine systems.

  2. Before clinicians can figure out why some patients respond to physical, emotional, or behavioral existential threats ( both real and perceived) using different productive or unproductive behaviors, clinicians have to be sensitized to a model of human complexity that is outside the reductionist tissue injury/healing models that all clinicians ( and patients) are conditioned to believe since the time we are children and reinforced during our years of professional training. When have a cut finger- the problem is one of the skin and vasculature; when we sprain an ankle, our focus in on the ligament; when we suffer an emotional loss, our focus is on the emotional coping mechanisms. In addition we impose upon these reductionist models the completely arbitrary classifications of acute and chronic. The acute sprained back; the chronic sprained back- one turns magically into another at 8wks, 12 weeks. Choose your time frame and one magically turns into a chronic pumpkin.

    What I find amazing is not the complexity of the human responses and how one protective system is integrated with another, but how often our reductionist thought and management processes work in spite of the complex interactions that we now know occur on multiple levels. Patients get better both because of what we may do and in spite of what we do. It is of no surprise to me that so few RCT’s come back with definitive answers. There are far too many systems to control and which interact within the what appear to be simplest of problems.

    Hopefully with time, as clinicians and the educational systems recognize and teach the complexity of the human response to real and perceived existential threats, there will be more eyes and ears observing and making correlations better explaining these complex interactions. With that information there is hope that researchers, theorists, and other reductionist visionaries will be able to better design those experiments and systems that will help patients and clinicians better handle the every day existential threats both within the short and long time frames.

  3. I suspect that one’s history of successes (and possibly tribulations) in dealing with prior insults and stressors would have significant influence on the nature of their response to subsequent threats.

    Though I have not researched the exact topic, I would reason that there is likely a genetic/hereditary link to one’s preferred “recipe”.

    Much is likely also learned from observing others and their responses to similar threats.

    Reasonably so, it must be the systems that are left “turned on” that are supplying the information that the brain desires at the time.

  4. Thanks for these thoughtful comments. Dave – we are going to try and develope a clinical literacy on this site to help incorporate output or homeostatic systems such as the immune, endocrine, language and cognitions, but I agree that there are many people out there left with motor-linguistic neurosignatures of “suck your tummy in” or “work on the core” and nothing more on their therapeutic journey. Wes – makes sense – if you called upon a certain response preferentially and successfully (say a sympathetic response) while young you will probably call upon it again later in life when threatened.

    John – I am not sure that “most people get better” – Chronic pain per year costs you guys in the US twice what it does to run the wars in Iraq and Afghanistan. But I take your point here. Of course brain outputs like cognitions, movement and pain are non linear emergent processess sort of like erosion, birds flying in a V formation, a musical festival, the weather, the economy, natural selection etc. By emergent I am referring to processes that belong to a system as a whole but not to any individual parts of the system. This contrasts to sequential linear processes such as the circulatory and digestive systems, stages of the moon, childbirth, mitosis .

    If you look at science teaching in schools, generations of students have stumbled when they come to studying emergent phenomena, despite extensive coaching. It seems that if they don’t have an exisiting emergent schema in their brains and try to explain emergent phenomena with a sequential linear schema they will be lost. How important is this likely to be in our “explain pain” work ? Critical I think. We can talk the tak about central sensitisation, cortisol , inflammation, ion channels etc, but if the action of these agents can’t be understood in term of the emergent processes such as pain that can arise from the interaction of the agents than I think lots of pain sufferers and clinicians won’t “get it”. We are certainly adding emergent schema identification work to our explain pain education now (with many thanks to education researchers such as Michelene Chi – Chi MTH et al 2012 Misconceived causal explanations for emergent processes. Cognitive Science Sci 36: 1-61)


  5. I agree, most clinicians let alone patients don’t get emergent schemas. I work as a counsellor and have a compressed nerve at L3 with neurogical deficits and pain. My colleagues who are psychologists in the chronic pain field and who use the theories from the Explain pain book and have attended NOI workshops insist that I don’t need surgical intervention, that my injury and neurological problems are all in my brain, that my injury must be one of chronic pain, that I am either to blame or just need to do more work on myself to get over my pain or my problem exists because of a thought I had or something lacking in my environment – obviously they don’t have an understanding of emergent schemas. I too, read the Explain pain book and found the info fascinating with many similar theories relating to anxiety phenomenas. I was and remain most concerned that I found one sentence in the second half of the whole book stating that if there is a medical reason for the pain then the injury needs to be fixed, this sentence could easily be overlooked by health professionals and patients and obviously by the responses I received from well respected professionals in the chronic pain field this sentence was either dismissed or overlooked. I implore the NOI group to include this critical sentence at the beginning of any revised book and at the beginning and throughout any training workshops and blogs, so that those who really require surgical intervention won’t be categorised under the ‘chronic pain schema’.

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