Thursday, October 18, 2007

Pain for Dummies – Part VI

Or: can you handle the truth? ;-)

Motivational Speaker

When taking the history of a patient one phrase comes up all too frequently: “I have tried everything”.
To be honest: no – you haven’t.

Here’s why:
We – and this concerns all of mankind – have a huge problem: there is so much information available that we have a hard time keeping up. Add to that that not only would you have to read all this new information – but also understand it and use it – while also working your usual 40 hour+ work weeks.

Change is hard – as explained here. Old patterns – be they motor patterns or other behaviors – are more efficient than new ones. That’s why - especially in times of stress - we use them over the new ones.

The treatments you as a health care professional provide are on the safe side – something you have established over the years. You think you know that they work and you apply them over and over again.
Problem is that they are mostly based on what I call the old paradigm – the purely body based approach (structural thinking).

You have to remember that the brain was out of reach of serious scientific study until 10-15 years ago. People in pain could describe their problem – you could look for clues what’s wrong with their body – but there was no way to have a look at their brain in pain. That’s why treatments for tinnitus, phantom limb pain, fibromyalgia, CRPS and other similar ailments focused on the changes that were visible to the naked eye so to speak.

That’s why – when you look at the studies done using those kinds of treatments you always end up with the “rule of thirds” as I call it – a third of the patients got better, another third stayed the same and the rest got worse.
It's like using a shotgun: some pellets hit the bad guy - the rest misses or injures an innocent bystander. In medicine you prefer the magic bullet that is able to hit the problem directly - nothing more - nothing less.

It’s no ones fault really: there simply was nothing better at the time.

This however has changed rapidly during the “Decade of the Brain” – now we have treatments that are able to address the cause of the problem. And here we encounter the second obstacle on our way forward: health care professionals have applied those old treatments for years – with moderate success (think shotgun). But since those illnesses were so hard to treat even 30% improvement seem like a good deal. Those old treatments are “hardware” based – flashing lights, infusions, pills, … - they all seem very thought out.

They are – there really is no other way of describing it – “sexy”. They are what you – the average Joe – came to expect from medical professionals (in a future posting I'll write at length about the link between expectancies and experience).

Along come the neurosciences and take away all the fun by having you use a mirror.
And even I have to admit: it just sounds too simple. Moving both hands while looking into a mirror? – you dare call that a treatment? Are you nuts?
Even worse – you – the health care professional – doesn’t have to do anything but explain what to do?
Remind me why I should pay you for just talking to me?
The next guy is even worse – telling me not to move anything but just think about it!
Has everybody gone crazy?

Now imagine having to explain this type of treatment to others in your field – can you imagine how a hands-on trained physiotherapist is going to react?
Asking someone to change their whole approach of thinking about a medical problem and changing his treatment methods accordingly isn't a step taken lightly.

And then there is the word “psychological”.
I treated a MD once who himself suffered from phantom limb pain. When I asked him about mirror training he said that he read an article about it once but never tried it because it was published in a Psychology journal.
If you can’t convince people like these – imagine how long it’ll take till a new generation of health care professionals is in the majority and the “new” treatments become universally accepted.

As for you – the patient: what can we learn from this.
a) Again: no - you haven’t tried everything because the people treating you aren’t aware of every option available.
b) the Internet comes to the rescue: information is free – you can read the articles yourself; the better educated you are about your problem the better you can help yourself
c) forget “the media” – they have the “empty space” problem, i.e. they have to fill 24 hours of programming and the pages of their magazines and are very unreliable sources of information. They are clutching at straws –producing huge amounts of "Fark" - hyping everything; pain is serious business – it doesn’t need the latest trend – but good science.

Sunday, October 7, 2007

Pain For Dummies - Part V

The social aspects of pain.

Humans are social animals through and through. Our brains are hardwired to enable us to live in groups of up to 150 people - what others sometimes call a tribe.
Nowadays with over 6 billion people around we have to be more open and willing to meet and interact with others - but our peer groups (those that are close to us) - remain relatively small.

How do children learn to speak a language? How do they learn how to eat with tools? Where do they get their behavioral norms from?
At first from their parents - since they are there 24/7. They observe behavior, speech patterns, motor patterns and simply try to do the same.
As they grow older other people come into their lives - and they adapt to those as well. As social animals we want to be able to fit in and communicate with others - so we have to find a way to connect with them.

That's why babies and children have no problems learning several different languages at once - the need to connect and their ability to learn is nearly limitless.

What about pain?
First we have to distinguish between the subjective experience of pain which isn't visible and the outward expression of someone in pain. It has been suggested that the basic pain threshold is pretty much the same in every person (apart from "redheads" who are more sensitive).

The most striking difference however occurs in how people of different cultures express their pain - how they show the world around them that they are in pain. Remember - this is also a learned response! But if you are from a different culture that has it's emphasis on let's call it "quiet suffering" - you might be overwhelmed when someone shows up who is very agitated although he has only a minor injury.

That's why it's so essential to have some kind of objective measurement. I had a patient once who - despite rapid improvement in function - still complained about the pain in the most exaggerated fashion. Even tests that are meant to provoke the pain were negative - but asking him about how he felt got me the same response every time. Since in his case there was only acute trauma and pain I felt very confident that his description was something cultural and no longer something physical.

We should also be aware that the behavior we see in people is sometimes a reflection of what the medical community has "done" to them. Imagine someone in chronic pain who keeps on going - someone with a positive and life-affirming attitude.
Now put that person through a medical journey from hell - no one takes him seriously, no one listens time to listen and so on and so forth.
One simple response to such treatment is to start to exaggerate the outwardly visible part of the pain experience!

If people don't pay attention - you have to do something to change that; small children are masters at this - they use their acting skills to the fullest and without holding back.
Just watch them when they feel they don't get the attention they deserve - suddenly they start limping, develop "stomach pain", .... - they learn that by faking symptoms they can get what they want!

I'm not saying that these responses are intentional - they are learned and become automated - like the rest of our behaviors. In principle they work like a simple reflex - if you get the desired outcome the behavior is reinforced.

But as we have seen before we have this thing called metacognition and can become aware of these behaviors and change them.

The lesson for therapists is this: if you see exaggerated illness behavior (that's the technical term) - listen, educate and be a honest health care practitioner. These people don't need another snake oil salesman.

Is there a message for patients as well?
To be honest - I don't know yet. As soon as I come up with something for you to work with I'll let you know.

Hollywood also uses exaggeration as a tool: ;-)


Wednesday, October 3, 2007

Pain For Dummies - Part IV

Metacognition - the coolest feature you have and didn't know about.

Let's face it - changing one's habits isn't easy.
Just watch smokers who unsuccessfully try to give it up.
Our brains are prediction machines - they use experience and other stored information (motor patterns) to get us through the day.
That's why we are able to identify people by the sound alone that they make when they walk - because they always walk that way (the same motor pattern is used over and over again).

Using established motor patterns and habits makes sense because it doesn't require any attention and is therefore a very efficient process - as long as things go according to plan.

It is also very quick - so that you are able to regain your balance very quickly after you slip. If you had to do something like that consciously you would start sending signals to your muscles only after you were already lying on the floor. It's incredible to see just how slow our brains get when the cognitive demand is even just upped a little: see these kind of tests/games for example.

The message is this: learning/re-learning requires time and a non-threatening/not-distracting environment. If you want to learn something new your brain has to be convinced not to use the fast and efficient old pattern - but the slow, inefficient new one.

Try this simple little experiment at home: brush your teeth with your other hand tonight. Sounds simple enough - right?
After you've done this think about people who have to learn to walk again after a stroke and maybe you'll be able to understand what they have to achieve.
I'd rather climb Mt. Everest than ever having to do that!

This far we have only talked about motor patterns - but what about habits?
Well - it's all just electric signals - so we can treat them the same - the brain does so too.

Thoughts - those that are automatic - are the same as motor patterns. They just aren't visible to an outsider. They are also stereotypical - based on experiences and memories. If you express them outwardly they are mostly called "prejudice".

Think about it: our brains form categories for everything around us - they have to in order to be fast enough. When you look at a picture like this your brain doesn't really "look" at it but simply calls up the appropriate categories (toys, Playmobil, bath, ...) and constructs the visual experience you have.
And it has no problem making huge mistakes doing this. That's why 99% of people fail to notice that the Playmobil figure has a frowny face!

And that's why we are prejudiced: experiences we have with only one person with a "special" characteristic are applied to the whole category that person belongs to!
"All Men are the same" is just one of those things we say and hear all the time.
But the same goes for skin colors, professions, weight, height - every observable difference to oneself really.

Where does chronic pain fit into all this?
Pain is in your brain - it has to be. And we know from research that people who suffer from chronic pain react automatically with a stress response when they just read words that are associated with pain! This alone can lead to an increase in their pain!
Do they know this - are they aware of it? No.
It's an automated learned response that is outside of conscious awareness.

But - and this is where the cool feature of Metacognition comes in - you can learn to become aware of this automatic reaction if you choose too.

Metacognition means "thinking about thinking" and is the same as watching yourself walk in front of a mirror. You observe an automated motor pattern/habit - thereby creating feedback that you can use to change the pattern.

Let's say you don't like dogs - your automatic thought is something like "He is jumping up and down because he is going to bite me in the leg."
Changing this reaction requires you to become aware of it - just "stand back" and watch what your brain and your body does when you see a dog. Heart rate? Pulse? Breathing? Muscle tension?, ... - just observe these reactions.

That's the first step you have to master: you have to notice all those little things - especially the rise in muscle tension in stressful situations. You have to become aware of the position of your shoulders in order to be able to change it later on.

And just to give you a rough idea of how long this first step takes: it'll be well into 2008 - still 3 months away at this point - before you are any good at it. Think weeks and months instead of days. That's why "old habits die hard".

The good point is that even a little experience is better than nothing and you can start improving the situation right away.

The second step is to actively stop the automated reaction. As soon as you start thinking "He is going to bite me!" - interfere.
Rationally observe the situation, look at the real facts - not the ones your brain is pumping out - and act on it. The best way to do this is to find someone who has a dog and explains their body language to you. Interact with one (a friendly one of course) and simply get to know them.
I did this myself a few years ago and am no longer afraid of them because I can tell from the way they move that they are mostly just curious about who you are and want some attention.

Again - when it comes to chronic pain - stop those automatic reactions.
Since the stress response is the easiest to feel and observe it's a good starting point - that's why relaxation techniques often bring fast relief. Like taking a bath:


The other things like thinking "This is going to hurt" when you perform a movement are a little harder to change - but it's not impossible.
Take your time doing them, don't do too much at once (pacing) and gradually expose yourself more and more in order to adapt. Sleep on it in order to establish new patterns.

By the way: in Psychology this form of therapy is called Cognitive behavioral therapy - and it is extremely effective.

Pain For Dummies - Part III

The Psychology of Pain.

This is a big one - probably the most important factor contributing to the development and treatment of chronic pain.

First let me get one thing out of the way: there is a link between chronic pain and psychological problems (depression, ...) - which means that yes - pain is (only) in your mind/brain.
But - and this is good news: we still can't tell for sure which comes first!

Imagine yourself having to live with chronic pain day in and day out. Going from doctor to doctor - spending a lot of time and money on treatments that don't work - loosing friends, social support, .... - who wouldn't get depressed? It's damn near impossible to stay happy when you hear the stories of people who went through hell for years on end. It's normal to become depressed when there simply is no end in sight to the suffering you have to endure.

What it comes down to is this: there are people who are just better at coping with difficult situations than others - copers vs. non-copers. Some people are just able to handle everything that life throws at them - no matter how horrible we think it is what they have to go through. Think imprisonment (concentration camps), torture, war, accidents where you have to cut of your own arm in order to survive.


Impossible? Definitely not - there are tens of thousands - hundreds of thousands (?) of people who are able to cope with such things. What happens is that just as we have a healing response when it comes to our tissue we also can heal psychologically. Our psyche receives "damage" and goes through the same stages that healing tissue does.

The basis for who is a coper or a non-coper are probably the same as for everything else: it's partly genetic - so choose your grandparents wisely ;-) - and the environment either activates those genes or it doesn't.
Nature and nurture instead of nature vs. nurture.

Let's say you are one of those who was unfortunate enough to have the wrong genetic code and is more likely to be a non-coper/pessimist.
What can you do to improve your situation?

- Distract yourself: attention is a limited resource; if you concentrate on the pain it gets worse - shutting out everything else. Focus your attention on something else and pain is reduced.

- Find an outlet: put a rat in a cage and give it random electric shocks; the rat has a chronic stress response leading to high blood pressure, osteoporosis and ulcers. Give the rat an outlet - something it can bite for example - and nothing happens. If you put a weaker rat in an adjacent cage the rat that gets the shocks runs over and bites the other rat that is just sitting there. Guess who gets the ulcers now?
I think everybody knows these two types of people: the ones who have to jog for miles every day and the others who take out their frustration on their subordinates. I recommend the first way of coping!
And while you are at it buy this book. Trust me. It doesn't get any better than this.

- Write about it. Pennebaker has done some amazing work on this. Expressing emotions helps enormously in dealing with them. I think that this has to do with the way our brains are built - we have two hemispheres that are organized differently. One hemisphere is the "human" part - emotional, creative, ... - the other is the more "robot" like part: pure rationality. There is a bridge between the hemispheres - the corpus callosum - but it can't transmit every bit of information - it's bandwith is limited.
If you use your eyes however - by reading something you just wrote down - the part of the brain that didn't have anything to do with the creation of those words and thoughts gains access to them through a different channel and is able to contribute too.
That's why it's also helpful to take out pen and paper and start drawing sketches when you are stuck working on a concept or a presentation.
Mind Maps also work by using this pathway; as soon as you are able to use all of your brain - and the differing points of view the hemispheres have to offer - the sky is the limit. ;-)

- Do something different. I can't stress this enough: keep learning - forever. Novelty is one of the best ways to distract yourself because learning a new skill - be it a new sport, a new language, a new way to move your body needs a lot of resources. It is estimated that we can only keep our focus for a maximum time of 15 minutes - after that our brains start to get tired.
Compare your sleep quality after a normal day with the quality you have when you solved a new type of puzzle before going to bed.
Our brains use the time we are asleep to consolidate memories and to add to the "experience database". If you give your brain something to do during the night it'll do so happily - leading to deeper and more refreshing sleep.
Yes - you can distract yourself even when you are unconscious!
Problems that seemed unsolvable the day before are often gone the next day; I had that experience a few years ago playing Panzer General: I just couldn't get past the Russian Defences at the battle of Kursk. After dreaming about it (!) I woke up and was easily able to smash a hole into their front line after which my tanks were able to pour through.
Imagine that: achieving victory through sleeping well - not by working harder. ;-)

If you want even more advice on how to become a better coper familiarize yourself with this very exiting branch of psychology: Positive Psychology - initiated mainly by Martin Seligman.

For those to take the test - don't despair - pessimists (like myself) are more prone to depression but at least we are able to see the world "as it really is" - and not through pink-colored glasses. That has it's advantages too.