Explain Pain: Occam's Style
Occam’s Style. Not Gangnam Style. But if this post goes viral we’ll have helped a lot of people.
The following patient quote is actually an amalgam of what several patients have said to me over the years. They have helped me realize we can do more harm than good when we are trying to do what’s right.
I hope this blog post helps.
Disclosure: 100% possible I have been the “my last PT” Failure -> Learning
So what do I mean by Explain pain: Occam’s style?
As pain expert Louis Gifford said “Try and avoid brain-talk as long as you can.” Neuroscience facts can be interpreted as blame. We need to avoid making someone feel like their persisting pain is their fault.
How do you do that?
Eventually talking about the nervous system may be necessary but if done too early it potentially produces a nocebo (opposite of placebo) effect.
So I like to initiate this “intervention” with as much caring and normalizing as possible.
Here is how I proceed
START A CONVERSATION
“I think it would be helpful for you to understand your pain a bit more. Is it ok with you if I try and explain it?”
The most important message I want to deliver at first is: PAIN IS NORMAL. This initiates the process of decreasing threat.
What do I mean by NORMAL? Pain has a critical purpose. It serves to PROTECT you.
Stories and metaphors are the best way to foster a conversation that facilitates an understanding of pain. Science facts are not.
Stories allow for individualization and the evocation of emotions that ultimately nurtures a deeper understanding. Fundamentally what I want is to empower my patients to rewrite their narrative.
Here are my START UP stories and analogies
YOUR HOME ALARM SYSTEM
INTRO: Think of pain like your home alarm system.
The alarm system exists to protect you. Sometimes (for various reasons) it becomes super sensitive. Instead of the alarm only going off when someone enters a door, it goes of when someone taps on your window. A really sensitive system can go off when a car drives by.
One way you can think about this issue is the alarm system is working too well, too well at protecting you.
So before it normally took “X activity” to get you to feel pain. Now your protection system is more sensitive and you feel pain when you do “Y activity.”
It’s pretty common to feel a bit anxious when your alarm system starts buzzing.
PAIN THAT PERSISTS is somewhat NORMAL as well. 25% of people experience pain past normal tissue healing times. (I mention this because it helps to know you aren’t the only one.)
This conversation can get more complicated but it sets the stage that:
1) pain serves to protect
2) sometimes our protection system becomes over-protective
3) the goal is to make your alarm system less sensitive
I like this analogy because it introduces the concept of safety. Most people associate their homes as a safe place. The goal is for all of my patients to feel safe in their bodies. Even if folks don’t have home alarm systems they can imagine how one works.
A DINNER DATE
INTRO: Remember those dinner dates or even meals at home where everything seemed perfect?
There are so many factors that go into making a dinner date a great experience.
Was the food incredible? Did your dinner mate make you laugh or look really good that night? Maybe you were celebrating something special or the ambiance of the restaurant fit your mood. Perhaps your favorite song played in the background.
Multiple senses, emotions and even memories can contribute to how we feel in the moment or after an experience.
Just like a dinner date may be awesome for several reasons, pain is also a multi-factorial experience. Talk about your favorite meal experience or have them describe theirs. This is an opportunity to bring up a few key points.
Pain is like taste
Who doesn't like chatting about food? :)
The sensory input that contributes to the experience of taste doesn't only come from the receptors on our tongue. The way food looks (vision), smells (olfactory and feels (texture) all have a role.
Sometimes we have emotional attachments or aversions to certain foods and they usually relate to some association (memory) we have. I once got food poisoning from chicken salad. For a long time just the thought of chicken salad made me feel queasy. I didn't like looking at it and wouldn't eat it for several years.
The experience of pain is like this as well. It is very common that we associate a certain movement or experience with pain. Memories of that experience can be triggered by certain feelings, sights, sounds, etc. Just like the thought of chicken salad made me nauseous, memories of pain or associated sensory experiences can make you feel pain.
Flirting, aka Graded Exposure
Flirting is a great analogy for how we think about returning to activity and moving with less pain. On a first date you might smile a lot, maybe even hold hands. You start slowly with gestures that feel safe. You perceive how the flirting is being received and if it's going well you might make another move.
The same goes for exploring movement. We want to test out activities slowly and progress. But graded exposure is such a clinical term that I think the flirting analogy works better. The concept of moving can seem scary to those living with persistent pain but to a lot of people so is going on a first date.
Segue (not Segway) to other important factors
Many things can affect how great a dinner date goes and sometimes those circumstances are details you haven’t thought about.
This is my introduction to the importance of Exercise, Stress management and Sleep. Are you going to have a good date if you are tired or stressed? Unlikely.
These analogies above are a good starting point. How you proceed with more information, with possibly more neuroscience is very much dependent on you and your patient/client.
You can simply ask "Would you like to know more?”
If you're feeling like a rockstar and want to dive deeper check out the post I did on Pain Science Resources to learn more. My analogies and stories have been inspired from the folks mentioned there.
Remember, the delivery of any type of education is an art form. You are trying to communicate and express a concept, a feeling. The feeling I want my patients to come away with is TRUST. Then I know we can dive deeper.