Slide Notes
Pain of OA is such a complex issue. And fear is a big part of that.
A lot of our own learning around interacting with chronic pain patients is to try to explain to them that there is no longer tissue damage occurring but that ongoing pain is more about sensitivity in the nervous tissues.
We now know that all pain is 100% of the time produced by the brain. Acute pain is commonly associated with tissue damage.
By contrast in chronic pain, we know that tissue damage is generally not the main issue. But yes the soft tissues are continually remodeling, with osteophyte formation and cartilage destruction.
So it's in overcoming the fear, the perceived dangers of exercising - reassuring that the brain is also remodeling and can change and adapt to cope with these changes. And that pain does not come from the tissues but is the brains response to nociceptive input that associates the movement of that body part with fear and danger.
So what’s best to do about it?
Once anything ‘dangerous’ is excluded we can explain that most things in the body are usually healed as well as they can be within 3-6 months, so ongoing pain produced by the brain is less about structural changes in the body and more about the sensitivity in the nervous system. In other words, it’s more complex.
At what stage do we say, “well there’s nothing else that we can do for you.” Of course we can only take the horse to the water - we can’t make it drink!
Do we end up turning to surgery because the patient has reached end-stage or because we are unable to find the pool of water? Is that the patient’s fault or can we take some responsibility for not presenting the information in the way that they can understand?
But if we don’t address the fact that many of our patients think, as they usually do, that there must be 'something wrong’ - there must be ongoing tissue damage when doing there exercises (which is unlikely given the low intensity and specificity and focus on balance), then we are likely to have patients who are unable to buy into treatment and the self-management required to rehabilitate with conviction and change the neural networks that associate movement with pain.
We need to look at the language that we use when
Remember that pain is produced by the brain when our peripheral nociceptors fire danger messages to the somatosensory cortex and thalamus via the spinal cord. So much of failure to respond to rehabilitation comes from fear of tissue damage and lack of understanding that the brain has created all sorts of associations with the knee pain that is increasing its sensitivity.
We’ve grown up with the thinking that pain is something that lasts for a few days and then goes away. It gets very confusing when you develop a pain that becomes persistent and doesn’t go away. "I’ve taken the tablets, done a procedure, why hasn’t it gone away?" A lot of people feel that they haven’t had a clear diagnosis at the beginning.
Animation, you are driving a bus, someone jumps on who is unruly and causes chaos (an unwanted passenger). However irritated you are you can’t get this person off the bus. So you need to find out where you can put this passenger so you can carry on with the journey but stop being irritated so much. You have to accept that pain is going to be an unwanted passenger in your life. A lot of people become doctor shoppers or therapy shoppers. It’s important to get help and support but it’s also about what you can do to help yourself. Many people don’t understand what self-management mean. Ask someone what they would do if they developed back pain. Many people would say, well I’d go and see my doctor.
Ask someone if they brush their own teeth or if their mum still does it for them. That’s self-management. No-one’s going to do your pacing for you. No-one’s going to do your stretching and exercises for you. Even your TKR only gives you new ball bearings - it doesn’t give you a motor that will propel you up and down the stairs! Pain self-management is a confidence-builder. When your confidence starts to come back you get back to activities that you stopped doing because of your pain - you turn from a can’t do into a can do person again.
How long can this take? Some people are quick and some are slow learners. People say that the penny dropped for them perhaps after 6-9 months after a self-management course. Starting doing exercise on a regular basis, they often describe how they feared exercise would give them more problems, so wouldn’t do it every day. Once they started doing exercise on a regular basis, the pain levels just dropped off a cliff. With pain management there’s no finishing line that you can sprint towards, it’s more like running a marathon. The frustration for health professionals is that we think, well I’ve given them this info why aren’t they engaging with it? The Q we need to ask ourselves is, am I giving them the info that they need in a formula that they will understand? Think about the content of a leaflet before you give them. Understanding pain inhttps://www.youtube.com/watch?v=C_3phB93rvI
The best thing to ask someone is how do they learn? by watching, reading, practice or a combination of all 3. Many of us are visual learners. We learn in chunks of information, like pacing. Keep it visual, keep it simple. Give them information in a way that they can absorb and they’ll be able to embody it and take control to self-manage.
It’s unrealistic for people in pain to wait until they’re free of pain before returning to work.
Is my pain going to get worse if I go back to work? D you enjoy your job? People with back pain often don’t like their job, but often haven’t considered changing it.
Will I always have to live with pain?Learning to live with it, pacing adequately, exercising, learning how to live with it. This keeps the pain level down. You can live life to the full in spite of pain.
If you’ve only got a hammer, everything looks like a nail. Every condition can be treated with the pain cycle. Don’t get fixated on trying to reduce the level of pain - look at the other stressors in the cycle.
I’ve tried all the clinicians and no-one can help. Hang around with the people who can be supportive of you, who can help you with self-management. If you hang around the barber you’re going to get a haircut! If you hang around an ortho you’re going to get an operation. If you hang around a Pain clinic, you’re going to get injections and medications. You need a support team around you, practice nurse, physio, supportive family and friends. www.paintoolkit.org
Pain is an output of the brain. It does not exist until it exists. It doesn’t exist in your body - never does, it’s a production of your brain. It’s all about meaning. So what happens? Pain exists with activation of a neuro tag, which is a group or network of neurons. Each neuro tag shares individual component brain cells with other networks such that they are interlinked. The networks are different in all of us, and is different for different pains, like a signature. Related tags share neurones. The networks may be linked with the representation in your brain that involve beliefs about your anatomy (your body part). If you believe that your body part is fragile, easily breakable, degenerative, inflamed structure, then that brain cell will increase excitability of the pain. Thoughts and feelings are linked in the same way. Thinking errors can have catastrophic effects. Any credible evidence of danger to your body will modulate pain. The difference between pain and tissue damage. What happens when pain persists? Lorimer Moseley says that when pain persists we have increased sensitivity. We also get decreased precision. we have pain for a long time
When we have pain for a long time, the effect of reduced precision is that pain starts to spread. So there are more and more brain cells that are activated whenever that initial neurotic is activated. And if those brain cells are in a part of your brain that represents your body, for example the primary sensory cortex, that pain is now spreading, it’s moving or changing. If we don’t understand the complexity of pain and the plasticity, the changeability of the brain, then we would have to conclude that the body is becoming more damaged. And that is an erroneous conclusion. So we need to reconceptualise what we understand chronic or persistent pain to be.
What do we do about it? People need to understand that their pain is 100% real, it’s unpleasant, it’s horrible, it’s debilitating. But it is no longer an accurate estimation of the state of the body. Because the system has changed. People need to learn how to get under the radar of a sensitive nervous system that’s on the lookout to protect them. We can use tricks to help convince the brain that things are different. We can retrain the brain to regain precision. We don’t solve the problem but we’re starting to make gains that we couldn’t before.
Lock in with the patient - mirror them, stand beside them like a friend.
A lot of our own learning around interacting with chronic pain patients is to try to explain to them that there is no longer tissue damage occurring but that ongoing pain is more about sensitivity in the nervous tissues.
We now know that all pain is 100% of the time produced by the brain. Acute pain is commonly associated with tissue damage.
By contrast in chronic pain, we know that tissue damage is generally not the main issue. But yes the soft tissues are continually remodeling, with osteophyte formation and cartilage destruction.
So it's in overcoming the fear, the perceived dangers of exercising - reassuring that the brain is also remodeling and can change and adapt to cope with these changes. And that pain does not come from the tissues but is the brains response to nociceptive input that associates the movement of that body part with fear and danger.
So what’s best to do about it?
Once anything ‘dangerous’ is excluded we can explain that most things in the body are usually healed as well as they can be within 3-6 months, so ongoing pain produced by the brain is less about structural changes in the body and more about the sensitivity in the nervous system. In other words, it’s more complex.
At what stage do we say, “well there’s nothing else that we can do for you.” Of course we can only take the horse to the water - we can’t make it drink!
Do we end up turning to surgery because the patient has reached end-stage or because we are unable to find the pool of water? Is that the patient’s fault or can we take some responsibility for not presenting the information in the way that they can understand?
But if we don’t address the fact that many of our patients think, as they usually do, that there must be 'something wrong’ - there must be ongoing tissue damage when doing there exercises (which is unlikely given the low intensity and specificity and focus on balance), then we are likely to have patients who are unable to buy into treatment and the self-management required to rehabilitate with conviction and change the neural networks that associate movement with pain.
We need to look at the language that we use when
Remember that pain is produced by the brain when our peripheral nociceptors fire danger messages to the somatosensory cortex and thalamus via the spinal cord. So much of failure to respond to rehabilitation comes from fear of tissue damage and lack of understanding that the brain has created all sorts of associations with the knee pain that is increasing its sensitivity.
We’ve grown up with the thinking that pain is something that lasts for a few days and then goes away. It gets very confusing when you develop a pain that becomes persistent and doesn’t go away. "I’ve taken the tablets, done a procedure, why hasn’t it gone away?" A lot of people feel that they haven’t had a clear diagnosis at the beginning.
Animation, you are driving a bus, someone jumps on who is unruly and causes chaos (an unwanted passenger). However irritated you are you can’t get this person off the bus. So you need to find out where you can put this passenger so you can carry on with the journey but stop being irritated so much. You have to accept that pain is going to be an unwanted passenger in your life. A lot of people become doctor shoppers or therapy shoppers. It’s important to get help and support but it’s also about what you can do to help yourself. Many people don’t understand what self-management mean. Ask someone what they would do if they developed back pain. Many people would say, well I’d go and see my doctor.
Ask someone if they brush their own teeth or if their mum still does it for them. That’s self-management. No-one’s going to do your pacing for you. No-one’s going to do your stretching and exercises for you. Even your TKR only gives you new ball bearings - it doesn’t give you a motor that will propel you up and down the stairs! Pain self-management is a confidence-builder. When your confidence starts to come back you get back to activities that you stopped doing because of your pain - you turn from a can’t do into a can do person again.
How long can this take? Some people are quick and some are slow learners. People say that the penny dropped for them perhaps after 6-9 months after a self-management course. Starting doing exercise on a regular basis, they often describe how they feared exercise would give them more problems, so wouldn’t do it every day. Once they started doing exercise on a regular basis, the pain levels just dropped off a cliff. With pain management there’s no finishing line that you can sprint towards, it’s more like running a marathon. The frustration for health professionals is that we think, well I’ve given them this info why aren’t they engaging with it? The Q we need to ask ourselves is, am I giving them the info that they need in a formula that they will understand? Think about the content of a leaflet before you give them. Understanding pain in
The best thing to ask someone is how do they learn? by watching, reading, practice or a combination of all 3. Many of us are visual learners. We learn in chunks of information, like pacing. Keep it visual, keep it simple. Give them information in a way that they can absorb and they’ll be able to embody it and take control to self-manage.
It’s unrealistic for people in pain to wait until they’re free of pain before returning to work.
Is my pain going to get worse if I go back to work? D you enjoy your job? People with back pain often don’t like their job, but often haven’t considered changing it.
Will I always have to live with pain?Learning to live with it, pacing adequately, exercising, learning how to live with it. This keeps the pain level down. You can live life to the full in spite of pain.
If you’ve only got a hammer, everything looks like a nail. Every condition can be treated with the pain cycle. Don’t get fixated on trying to reduce the level of pain - look at the other stressors in the cycle.
I’ve tried all the clinicians and no-one can help. Hang around with the people who can be supportive of you, who can help you with self-management. If you hang around the barber you’re going to get a haircut! If you hang around an ortho you’re going to get an operation. If you hang around a Pain clinic, you’re going to get injections and medications. You need a support team around you, practice nurse, physio, supportive family and friends. www.paintoolkit.org
Pain is an output of the brain. It does not exist until it exists. It doesn’t exist in your body - never does, it’s a production of your brain. It’s all about meaning. So what happens? Pain exists with activation of a neuro tag, which is a group or network of neurons. Each neuro tag shares individual component brain cells with other networks such that they are interlinked. The networks are different in all of us, and is different for different pains, like a signature. Related tags share neurones. The networks may be linked with the representation in your brain that involve beliefs about your anatomy (your body part). If you believe that your body part is fragile, easily breakable, degenerative, inflamed structure, then that brain cell will increase excitability of the pain. Thoughts and feelings are linked in the same way. Thinking errors can have catastrophic effects. Any credible evidence of danger to your body will modulate pain. The difference between pain and tissue damage. What happens when pain persists? Lorimer Moseley says that when pain persists we have increased sensitivity. We also get decreased precision. we have pain for a long time
When we have pain for a long time, the effect of reduced precision is that pain starts to spread. So there are more and more brain cells that are activated whenever that initial neurotic is activated. And if those brain cells are in a part of your brain that represents your body, for example the primary sensory cortex, that pain is now spreading, it’s moving or changing. If we don’t understand the complexity of pain and the plasticity, the changeability of the brain, then we would have to conclude that the body is becoming more damaged. And that is an erroneous conclusion. So we need to reconceptualise what we understand chronic or persistent pain to be.
What do we do about it? People need to understand that their pain is 100% real, it’s unpleasant, it’s horrible, it’s debilitating. But it is no longer an accurate estimation of the state of the body. Because the system has changed. People need to learn how to get under the radar of a sensitive nervous system that’s on the lookout to protect them. We can use tricks to help convince the brain that things are different. We can retrain the brain to regain precision. We don’t solve the problem but we’re starting to make gains that we couldn’t before.
Lock in with the patient - mirror them, stand beside them like a friend.
