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Old 17-04-2012, 12:21 PM   #1
Randy Dixon
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Default Can pain education cause harm?

I recently underwent an episode of atypical trigeminal neuralgia that lasted several months.
http://en.wikipedia.org/wiki/Atypica...inal_neuralgia

I have been on this list for several years now and I am reasonably well versed in the literature regarding pain science. I found that knowing about pain science and the biopsychosocial model of pain did not lead to any resolution or diminished fears about the pain I was experiencing, instead it lead to almost a type of guilt. There is an idea within this model that we can control our pain by being aware of the causes of pain, by not fearing the pain, and yet I hurt, and sometimes hurt badly. In some ways I felt like I had failed. It doesn't help that many practitioners feel that this type of pain is a type is Somatiform Pain Disorder, or psycosomatic using older terminology.

When I researched this condition I found that this was a common problem, with this and a similar condition Atypical Facial Pain, in fact, they decided to change the name of AFP to Persistent Idiopatic Facial Pain, because many of those who suffered from it had become deeply depressed because of this very thing, that they were given the impression that it was under their control. Most of these stories do not have happy endings. My own I believe will, mostly through luck.

It turns out that my conditon is associated with low dopamine levels or more specifically a problem with D2 dopamine receptors. I happened to be diagnosed with a pituitary tumor at the same time. I asked the doctor and he said the two conditions were completely unrelated but I started taking Dostinex (Cabergoline) which is a dopamine agonist and my ATN cleared up almost immediately. This is after trying other medications such as Neurontin which had no effect. Dostinex decreases prolactin and increases dopamine. I think this is what caused the ATN to resolve, and also the high prolactin is what caused it to manifest in the first place. I add these details in case anyone out there is involved in this type of medicine or research and might be interested. The real point of all this is to ask this:

Can you actually do more harm to the patient by telling them they are in control of their pain than if they believe it is something that happens to them? Is that what you are telling them, implicitly if not explicitly, when you explain pain, threat perception and modulation to them?
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Old 17-04-2012, 12:37 PM   #2
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I agree with you that when we tell patients they are in "control" of their pain, we are really screwing them up.

But that should not the focus of pain education.
Pain education relates to the "how" pain actually works, what the potential influences are and what the possible dampeners are. At worst, it should help reduce the risk of ramping up-and-up-and-up.

Even Moseley has trouble with his pain.
It is a deeply rooted protective experience that is not simply "turned off".
Especially not where there is pathology of the actual chemistry of the nervous system!
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Old 17-04-2012, 12:39 PM   #3
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Randy,

For 8 years I have dealt with cluster headaches. I feel I have a good handle on the basics of pain science giving me peace of mind when they hit (1.5 months of 2-3 clusters per day). The pain is 100% real and paralyzing. It also results in a continued hyperalgesia throughout my C1-C4, SCM, upper trapezius on the left side when the headaches cease.

My 'condition' is idiopathic and in my case, mostly genetics. I understand my 'unexplained' pain and it has resulted in my not searching for the cause or other interventions that have had and will continue to have little impact on my condition. Luckily, I have a medication that helps me, but in the event this medication is not available ($300 prescription) I know my pain is not harmful to me.

If I didn't have this understanding, I would still be getting MRI's, CT scans, multiple prescriptions thown at me (three neurologists and two PCP's; all prescribing a different cocktail) or lifestyle changes that don't need to be made for a condition that is not understood.


My pain, I can understand that. 100% real and a normal response to a perceived threat.
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Old 17-04-2012, 08:22 PM   #4
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Quote:
Can you actually do more harm to the patient by telling them they are in control of their pain than if they believe it is something that happens to them? Is that what you are telling them, implicitly if not explicitly, when you explain pain, threat perception and modulation to them?
I don't think you can do more harm (tissue damage), but they may hurt (pain) more. Often times after first explaining pain to a patient as they process the new information they can hurt. Just had a patient yesterday 3 months post MVA. As I explained these things to her, she was understanding everything very well. She understand how thoughts and thinking about the accident could increase her pain, she stated just us talking about it made her arm and neck sore. She was not fearful of the pain, but understanding that it is normal biological processes that make that happen.

Matthew, put it very well. Pain is always 100% real. While it may be in the brain it is just as biological as anything else we have going on in our body.
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Old 18-04-2012, 12:37 AM   #5
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Butler mentioned the emergence of a group with "explain pain pain" in their research. At that time they weren't sure what to make of it.
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Old 18-04-2012, 12:43 AM   #6
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I remember David talking briefly about trigeminal neuralgia and at the time there was no manual therapy solution available that he knew about.

Both cluster headaches and TN are a real problem for their owners. But any professional who suggests the latter is "psychosomatic" should be hauled over the coals; in this day and age, it is almost criminal to imply that.

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Old 18-04-2012, 02:35 AM   #7
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Quote:
Originally Posted by Randy Dixon View Post
Can you actually do more harm to the patient by telling them they are in control of their pain than if they believe it is something that happens to them? Is that what you are telling them, implicitly if not explicitly, when you explain pain, threat perception and modulation to them?
I think pain education....done wrong can certainly end up not being beneficial (this happens...a lot).

Generally, there really is no simple explanation as to why someone has pain but the mechanism is always the same.

If a patient leaves your office with the impression that they can simply control their pain like some kind of light switch ( ie it's their own fault if they don't flip it).....you've done a bad job and potentially a dis-service.

Along this line I have noted an interesting trend where I work. There is this acceptance of "pain theory" with Butlers posters recently purchased for the clinic. We have all the "explain pain" books all over the place and when general discussion occurs, it seems there is a certain understanding.

Yet on the floor of the clinic....I see PT's still believing a caudal glide of the sterno-clavicular joint actually "fixes" the faulty biomechanics...( when the patient gets up and suddenly moves the shoulder better no thought is given to what other factors influenced that outcome.)

Lot's of PT's out there throwing pain education at patients. They do it wrong for the most part I think.

Most of the time they whip it out when the patient has failed the magical approaches. In other words....it's the patients fault and at least now I can blame the patients stupid brain!

Wrong.

Last edited by proud; 18-04-2012 at 02:52 AM.
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Old 18-04-2012, 02:56 AM   #8
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Quote:
Originally Posted by proud View Post
I think pain education....done wrong can certainly end up not being beneficial (this happens...a lot).

Generally, there really is no simple explanation as to why someone has pain but the mechanism is always the same.

If a patient leaves your office with the impression that they can simply control their pain like some kind of light switch ( ie it's their own fault if they don't flip it).....you've done a bad job and potentially a dis-service.

Along this line I have noted an interesting trend where I work. There is this acceptance of "pain theory" with Butlers posters recently purchased for the clinic. We have all the "explain pain" books all over the place and when general discussion occurs, it seems there is a certain understanding.

Yet on the floor of the clinic....I see PT's still believing a caudal glide of the Sterno-clavicular joint actually "fixes" the faulty biomechanics...

Lot's of PT's out there throwing pain education at patients. They do it wrong for the most part I think.

Most of the time they whip it out when the patient has failed the magical approaches. In other words....it's the patients fault.

Wrong.
That's exactly the reason why I wrote my review editorial article. There are three problems :

1-PTs lack basic understanding of pain science in general.

2-PTs lack a proper basic understanding of connective tissues mechanics and physiology (that also probably still includes me to some extent) and the forces needed to change a tissue, how the tissue changes with repeated tensionning, force distribution, bla bla bla, this sort of things.

3-PTs also generaly seem to lack a basic understanding of the scientific process and of basic ways to think and reason philosophically whitout making important sophisms.

Trying to change things only by teaching 1-, is bound to fail. After doing just that, they simply use 1- as whip cream on Jello! (to paraphrase LMFAO (Gee! that even rimes!))
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Old 18-04-2012, 03:08 AM   #9
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As for the original interrogation of Randy, I will say yes. It's really different to teach that patients can stop their pain or «solve» their condition through pain education than to teach that their pain level, intensity, mere presence and character is profoundly complex and understandable through a complete BPS model where they are left with new ways through which they have the possibility to influence to some degree their conditions by understanding it, re-conceptualizing it thus leading them to take a new course of action that might end up diminishing their pain and also that will put them back in the driver seat of the treatment encounter.

They have to undertstand that it helps, it's empowering, it's up to date but by it's by no means THE solution to their problem. And that for most condition no one has THE solution just yet.
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