Dental DIMs and Sedation SIMs

Our good friend Wouter is back with another great story – thankfully nothing burned down this time around.

Last week I had an appointment with the dentist to extract a wisdom tooth – left lower jaw. Everything went as planned; some sedation, a pair of pliers and off he went. A few cracks and pops and the culprit was out. The dentist advised that I not rinse too much – the blood clot that forms in the hole is important as it protects the bones and nerves, and off I went.

First day everything is ok. Second day a little more pain, but everything is still ok. Experiencing some pain is not bad – it keeps you alert and reminds you not to chew on anything that could potentially damage the tissues further – or loosen the blood clot.

Day three – the pain gets a lot worse.  I started thinking “I had an extraction that went “wrong” a couple of years ago – surely it’s not happening again?

It is. I lost the blood clot.

Now I’ve got a condition called alveolitis osteitis or “dry socket”. It’s an inflammation of the socket where the tooth once resided – even writing up this little story with those words makes my jawbone more sensitive.

So, two things happened to me yesterday:

Firstly, I went to work and forgot my pain killers. The pain got bad, really bad. When it radiated to the whole left side of my face I got desperate and phoned home. My partner, how lovely she is, jumps in the car and brings me my stash of ‘dope’. Opening my mouth, swallowing the pills brings even more pain, but 5 minutes in and the pain subsides completely. “Damn”, I thought to myself, “the stuff isn’t even in my bloodstream yet and the pain is gone… Is our system conditioned to respond with immediate relief to ‘popping pills’ for pain or illness? Perhaps it is – my system seems to have learned, ‘the pill is in, I’m safe now, no more pain is needed…'”

Secondly, a few of hours later and the ‘drugs’ are wearing off. Another thought – “if just swallowing pills is enough to stop the pain completely, why do they ‘wear off”?” Anyway, the pain starts to come back. But now it’s not only the bottom left of my jaw, but also the top right – where I had a dry socket a couple of years ago… Why is my ‘brain’ doing this to me? That place healed up completely! Why pain there? Why does my brain ‘think’ there is danger coming from that area, there isn’t any damage…

In both cases it is clear that beliefs, expectation and past experience all play a big role in determining the level of ‘credible evidence of danger and safety’ in me, and my experience of tooth (and lack-of-tooth!) pain.

– Wouter Ramboer

Physiotherapist, West Flanders, Belgium

 

Wouter is a very active Twitter user and can be found by his Twitter handle @neuromanter, where he will be regularly posting links to some of the latest and most interesting articles related to pain and neuroscience, and discussing the future of the physiotherapy profession with others from around the globe.

34 Responses to “Dental DIMs and Sedation SIMs”

  1. stevenawoor

    Excellent Wouts…!! I can relate to that with an experience I had at the age of 14 yrs old on a school trip to Brighton when I knocked out my front tooth on a bumper car leaving the nerve exposed. I have another cortical map route to a neuro tag that must be logged when I fractured my cheekbone in the Army at 17yrs old which freaks me out every time I go to get my hair cut :) Must write those up for next blog. Great stuff as always and catch up on Twitter #Duvel

    Reply
  2. timcocks0noi

    Hi Wouts
    Thanks again for sharing another thought provoking and illuminating story with us. So many DIMs and SIMs in you story that can be teased out.

    I think your missus missed an opportunity for experimentation though – if only she had swapped out your ‘dope’ for Naloxone we could’ve had a nice case study to write up ;)
    My very best
    Tim

    Reply
  3. Wouter

    Hi steve,

    Think these tooth ache stories are quite good to explain pain…. almost everybody experiences it, and i don’t know many people who like to go to the dentists office…. ;-)

    Hi tim,

    Always a pleasure for me to write something up…. I am a very lucky person that my house burnt down last year, and that i have had the opportunity to experience a ‘dry socket’ :-D

    A couple of thoughts in retrospect to the post:

    Knowing a little about pain, but nothing about dental stuff, the pain got
    me anxious, making me to consult doctor google…. Reading a couple of
    stories by people who had the same issue… Some positive, some negative,
    but in a weird sense my mind was atteacked and from time to time when the
    pain flared up, the thoughts about the negative stories popped up
    (infected jawbones, surgery….)

    This made me call my dentist (who made an appointment to see him)…. He
    explained me in a calm matter that everything looked good giving the
    circumstances…. And that it would take about 3 weeks to heal up….

    It still hurted like a bitch after the consultation, but it bothered me
    less, worrying thoughts were less in frequence…..

    Plus it got me acting instead of passively waiting…. With the
    toothbrush i went rubbing gently around the extraction wound, progressing
    over a couple of days (rubbing harder and over the extraction wound)….

    The pain in face and jawbones deminished fast other healed drysocket
    stopped aching…

    Interesting stuff…. Helps ya to better understand patients in pain, if
    you experience it yourself….

    Reply
  4. Gerry Daly

    Interesting. Not easy to deliberate publicly on the details of any dental experience, perhaps due to cultural expectations to not add to the phobias that exist privately…but should maybe never be allowed a public platform that might affect a general willingness to attend the dentist when in need. Dental stories require a delicate sensitivity to breach that cultural barrier, and well done with this story.
    I realise the point of the article was to illustrate the peripheral influences which might have affected the pain experience, but I was particularly taken with the following…… ” First day everything is ok. Second day a little more pain, but everything is still ok. Experiencing some pain is not bad – it keeps you alert and reminds you not to chew on anything that could potentially damage the tissues further – or loosen the blood clot. ”
    For me, that suggests a ‘restraining’ purpose to the experienced pain…..almost suggesting that any conscious interference is not to be ‘trusted’, and the pain is the only barrier to any possible inappropriate interference. If that were so, what would that say about ‘conscious reaction reliability’ and a need for a conscious perception of pain to counteract any desire to meddle where a full appreciation of the vulnerabilities might not be obvious to us. The pain event would seem to play a role in restraining reactions, perhaps to the point of giving a much sought after ‘purpose’ to the pain event. Maybe, the reason why pain seems to be so easily manipulated by peripheral influences might be due to the fact that we find it difficult to settle on a purpose for the pain in the first place, thus consciously creating the conditions for variable interpretations of the experience. It would be nice to think that anyone achieving a convincing understanding of their pain experience might also achieve a better tolerance……..just like a basic understanding of aerodynamics should help to reduce any exaggerated fear of flying.

    Reply
  5. EG Physio

    Wouter,

    A woman named Sharon Waxkirsh had her wisdom teeth extracted under self-hypnosis. She does this for dental patients also.

    Reply
  6. Henry Madison

    Wouter,
    Did the thought of returning to work increase your pain?
    IMO pain is useless and a “pain” unless is is indicating tissue threat or damage. We need to scoff at, laugh at, and ridicule pain and the brain (not the pain patient) that produces it when there is no impending doom.
    Great name by the way….Wouter Ramboer!

    Reply
  7. Gerry Daly

    “We need to scoff at, laugh at, and ridicule pain and the brain (not the pain patient) that produces it when there is no impending doom”

    That is something which is already in the culture…..and wrongly IMO. There seems to be a tendency for conceptualising the brain as an external operating system. when it is quite obviously integrated and inseparable from the body general. Default chronic pain mindsets evolve according to pain experiences, and no amount of ‘ridicule’ will alter that mindset, although it might help those without a similar misfortune to overcome their unrequited lack of appreciation of the chronic pain mindset. In fact, the patient narrative is the only reality in play, and it should be approached with the respect it deserves. Theories about altering that mindset sound, to me, like desperate attempts to shift the goalposts……perhaps to suit the mindset of those who still have unquestionable faith in a positive ‘healing expectation’ overview. Seems there will always be a dissonance between the two mindsets, apparent here. Strangely, those in chronic pain do not assume a fault in the mindsets of those who aren’t……it may well be time to restore some credibility to the patient narrative, and not stray too far into misunderstood assumptions.

    Surely, it’s the patient’s prerogative whether to laugh at their own narrative, or not. It would be a shame to see patients developing ‘chronic self-ridicule’ to add to their woes.

    Reply
    • Henry Madison

      Gerry,
      I mean no disrespect. I liken chronic pain to a phobia, a fear towards a situation that is not dangerous to the organism from a sense of actually tissue damage or threat of such. Dare I say an “irrational fear” that doesn’t reflect reality. So I may have a fear of the dark, or of heights, or a possible letter in my mailbox, but the chances of those events causing harm are small, yet I “fear.” If I minimize it, rebuke it, understand it, rationalize it,etc then maybe, just maybe there is a chance my brain will decrease the fear experience. Or perhaps I have to face that fear, not over medicalize it, don’t do treatments that show no benefit or even may harm. If chronic pain in most situations is not because of ongoing or impending tissue damage then the more we coddle to it the more it grips us. I look at the brain as a second entity that wants to guide my behavior and darn it I’m going to fight it, mock it, mess with it as much as I can and not give it the satisfaction of making me miserable. Irrational fear is not really real fear for there is nothing really to fear but fear itself. Irrational pain is not really real pain (tissue damage or threat there of) for there is nothing to be painful about except the pain experience itself, I think. It’s pretty inconvenient and irritating but if it’s a brain produced experience not reflective of tissue damage then screw it. I know, easier said then done. But why glorify it? Why make it such a big part of our world? It draws a lot of attention and doesn’t offer much (or any) good. In fact we should call chronic “pain” something different than pain as it is another “feeling” our brain produces that seems to get our attention an affect our behavior without reflecting tissue damage. We should call it chronic fru fru, or chronic fructoshire, or chronic irributsmacker or something. Sorry, just ranting.

      Reply
      • Gerry Daly

        Hi Henry

        Almost missed your response due to other events on the page. I’d agree with most of what you say about any ‘fear’ having a vulnerability to tend towards ‘irrational fear’, and all that might result from that. But I don’t see chronic pain as being irrational, in any sense. I’m also aware of the tendency to overview chronic pain as ‘persistent’ pain, as though it ought to have resolved at some stage, but somehow ‘persists’ beyond a point of possible resolution.
        For instance, a simple trapped nerve will repeat it’s referred symptoms day after day, almost like a new acute episode each day. It’s meant to happen, and it happens consistently with neurological conditions, perhaps as some kind of protective or restraining means for allowing reduced functionality……lesser of two evils maybe. It’s consistency dispels any irrationality, IMO, and I don’t think that developing a (respectful) dismissive approach to it, because it seems to some to be irrational, will achieve anything positive. In fact, that might have all the ingredients for backfiring in the chronic pain mindset. It might seem that the reality is being overlooked in favour of some imposed soothe-saying.

        Chronic pain patients may be vulnerable to fears, and desperate for remedies, but they are also capable of detecting any ‘operator outclauses’ presented as part of treatment. Thats usually a low point, where the patient realises that operator soft-talk may be the only thing on offer ! I know I sound quite cynical in that respect, but I also know that such cynicism is protective in those circumstances.

        Reply
  8. EG Physio

    Gerry,

    I tend to agree with Henry on his point about laughing at pain and making light of it. Seriousness is rooted in fear and we can’t be adding to the client’s burden with our serious professional seriousness…. seriously. Even though chronic pain is one hideous condition, we need to stay light about it. Light, but attentive and very focused.

    NLP has some great techniques where fear is laughed at. The patient is invited to consider a different perspective on his fear/pain. Maybe worth a look?

    The positive expectation approach is by far the most powerful and proven of all healing modalities available to us physios. It leaves everything else in its wake. But one has to know how to apply it. If there’s a clash between client and therapist expectations (as can happen), then the client has not been properly prepared. He needs to be taken back to ground zero where all expectations are temporarily void. Then the new expectation is delivered with great expectancy.

    Regards, EG

    Reply
    • Gerry Daly

      Hi

      Suppose it really depends on whether we’re discussing ill-defined palliative distractions or science-based treatments. Any crossovers will always consign the distractions into a secondary role in any comparison. I fully understand the cultural requirement for a bit of self-ridicule, and even some self-deprecation, when faced with difficult circumstances…..and laughter is a great medicine, perhaps on a similar scale to the placebo effect. And let’s not forget the need for operators to rise above the issues they encounter everyday, by any means possible.

      I guess, what I’m hinting at is the validity of the assumption of any transference of operator optimism which has evolved from a ‘healing expectation’ overview, onto a chronic pain patient with a mindset already skeptical of humour affecting any outcomes. Humour works fine for transient issues, only because there is an expectation of the pain being resolved. It falls a bit flat on chronic issues, unfortunately…..and, as a possible replacement for sought after science-based treatments, humour could be seen as a means of distracting from the real work of finding solutions.

      The usual cultural cliches, whether humourus or not, normally applied to transient conditions…..e.g. ‘Hope you feel better tomorrow’ , ‘Nevermind, you’ll soon be normal again’ etc etc, simply don’t resonate with the chronic pain patient who wakes in the morning savouring the bitter disappointment of the failure of the well-wishing. Similarly with any, probably well-intentioned, inappropriate attempts to ‘lighten’ the issue. Ultimately, I think the patient will see that as an avoidance of effort to tackle the real problem. If the professional is dismissing a real sense of engagement….what is the chronic patient supposed to think ??

      Gerry

      Reply
      • Gerry Daly

        Just an afterthought…….

        Perhaps one of the most reassuring things a professional can say to a chronic pain patient is, strangely,……’We currently don’t know how to fix this problem, but we’re working on it’. That honesty will reassure the patient that their difficulties are somewhat understood, rather than any attempts to alter their mindsets to be in tune with more normal expectations. We all have a right to be wary of any questioning of our default mindset, so why should we presume that chronic pain patients might need some mindset tinkering. There may well be more than just a little arrogance in such presumptions….no matter how well intentioned !

        Reply
      • EG Physio

        Gerry,

        –“We currently don’t know how to fix this problem, but we’re working on it”.

        That is probably one of the worst things you can say to a chronic pain sufferer, and you really should know this. It immediately shuts down any chance of improvement, and any practitioner who says such a thing doesn’t understand the first thing about pain or how to relieve it.

        The whole idea of “honesty” is a wrong concept. Pain responds to expectation, so we create either an aggravation or relief depending on where we put our expectation.

        — “We all have a right to be wary of any questioning of our default mindset, so why should we presume that chronic pain patients might need some mindset tinkering”.

        Yes. Pain-producing mindsets are hard to let go of, even though they hurt us. The skillful therapist sets the stage and allows the client changes his own mindset.

        Milton Erickson rightly pointed out: “Patients come to you for help. They may resist help, but they hope desperately you’ll win”. In other words, they want their mindset changed, but not in a way which threatens their self-esteem.

        Rgds, EG

        Reply
  9. Gerry Daly

    EG Physio

    Thanks for the response. You present an approach to treating chronic pain in a way which I am at odds with. No problem exploring the differences….but I am tempted to comment that you are resisting any alteration of your mindset. Perhaps that might help highlight the issue where mindset alteration is advised to those in chronic pain. We are conditioned to protect what is precious to us, and that applies across the board. Even if the most extreme form of mindset altering known to us i.e. Hypnosis, was applied, I still doubt that it would in any way affect tomorrow’s difficulties for the average chronic pain patient. And, I have no problem with experimentation, as long as the patient enters the contract willingly in full knowledge of past outcomes and possible future downsides. It’s one thing to dress up an optimistic overview for chronic conditions, quite another to ignore real research in favour of a sound-bite whose palliative effect might only last minutes. If the tendency towards mindset alteration, as a pre-condition to hoped for beneficial outcomes, gathers pace, as it seems to be doing, then I would be concerned about the real work of exploring these conditions being consigned to the ‘unopened file’ at the back of the pile.

    For sure, self esteem in a vulnerable population is a very important issue. And how do we enhance that self-esteem…….surely not by questioning the mindset which created it. The very assumption that one persons mindset is more stable, or more able, than another’s, I’m afraid, creates an unacceptable inequality of status in any process between two people. It needs a rethink !!

    Reply
    • EG Physio

      Yes I’m resisting from the viewpoint of ‘my mindset works for me’. It’s functional for me and it’s functional in a clinical setting. If my mindset was delusional, then you’d be able to deconstruct my arguments and make me look silly.

      If I was to switch into clinical mode here with you, I’d be identifying your central theme (which is doubt), and encouraging you to move in the direction you want to go. I’d have complete agreement with your doubt and let you express that as much as possible, reflecting it back to you. Then it would be up to you to exhaust that theme. If I provide the right environment, then you will exhaust your doubt because you want to. It feels good to. If it takes 10 sessions to express all that doubt then that’s how long it takes. Then we’re back to carte blanche and good things can happen from that state.

      EG

      Reply
  10. Gerry Daly

    I’m a bit concerned about where the locus of control exists in that arrangement. Seems to me there’s an inherent assumption, contained within the contract, that any ‘fault’ can only lie with one party….and, for reasons of clarity, let’s call that party ‘the victim’. From my perspective , I have a question niggling me, which supercedes all that might follow…” Are the operator’s assumptions only confirmed by their sense of self-righteousness ?”. Or, put another way….if self-righteousness is the only confirmation here, then I am absolutely obliged to stick with my own self-righteous belief in my otherwise questioned mindset. Again, the assumption of inequality of status undermines the prospect for a meaningful encounter. A return to the drawing board beckons on that issue also.

    I think, at the heart of these issues, lies an unresolved contradiction……people with no subjective experience of chronic pain are devising treatments for those in chronic pain….and then perhaps failing to understand the objections aroused in the mindset of the chronic patient. Chronic pain treatments should not fall into the realms of quasi-religious born again methods, because that would only drag the science back into medieval mystification. We can’t laugh off a toothache, it demands a non-humorous visit to the dentist……so, why should we assume that chronic pain is anything less serious ?

    Reply
    • EG Physio

      You sound like you are getting mileage out of being “the victim”. It’s a method of draining energy from anyone who engages you. Like a leach.

      The number of incorrect assumptions you make is astounding. For example: “people with no subjective experience of chronic pain are devising treatments”. So you know everyone involved in the field do you? Is that what you’re saying? You’ve met every practitioner and every scientist in the world and you know their personal health history, do you?

      And you’ve read all the research on expectation, so you’d know it’s as powerful as a clearly analgesic dose of morphine…right? You’d know that already. And you would have read the research on hypnosis and you would know that the significance of the findings are higher than pretty much any other method we currently have. You’d know that.

      Let me know if you want to continue the discussion. I can offer great value, and I think you can too. But if you persist with the ‘leaching’, I won’t reply.

      Reply
      • Gerry Daly

        Actually, what I’m doing, is questioning the tendency towards an assumption of a ‘fault’ in the default mindset of any chronic pain patient. Seems to me, the ‘fault’ most likely resides in the presumptive attitudes of those who have little subjective experience of chronic pain, and that is why I would tend to insist that the patient narrative must be respected as presented…because sometimes there is simply no other way to avoid second-party, or third-party, misinterpretations of presentations. The tendency to dispute the patient narrative seems to go against medical ethics as I understand them. Only the patient knows their own real experience……all else is assumption unless incontrovertibly supported by the science. Creating assumptive pre-conditions to treatments is merely adding to the exclusivity of treatments….and I suspect that it is being done to assist operators, rather than patients.
        What happens if the patient disagrees with having their mindset altered to suit the treatment. Are they then excluded ??

        Reply
  11. Gerry Daly

    And, just to lighten the tone….here’s a little humorous nugget I came across as I was sitting in the dentist’s wating room many years ago (in the Readers Digest of all places !)….
    Question: ” What’s the difference between a major surgical operation and a minor surgical operation ?”
    Answer: “Everyone else’s operation is minor !”

    I think that probably has good resonance with the chronic pain experience.

    Reply
  12. EG Physio

    You’re afraid that if you let go of your particular mindset that you won’t have any value or significance as a person. I understand that. You might even feel as if you don’t exist and that the therapist (with his ‘superior’ mindset) is ‘better than’ you. After all, he has taught you how to become a respectable, pain-free person. Surely that places him ‘above’ you?

    Obviously, a scenario such as this ^^ would be highly undesirable.

    A real therapist never tries to ‘treat’ anyone because he knows it’s not even possible. The only possibility for someone playing the role of therapist is to treat himself. In treating himself, he lets go of as many beliefs, attitudes, tensions and assumptions as possible. His mind becomes quiet and the silence fills the room. The silence is an invitation to the client to follow suit, nothing more. From this place of silence, harmful mindsets are seen as harmful (rather than things that will save and protect us).

    You’ve drawn out my best work Gerry. Well done.

    EG

    Reply
    • Gerry Daly

      Perhaps the patient should be billing the therapist ?? Re harmful mindsets….I don’t think a chronic pain patient sees their evolved mindset as harmful. They see it as ‘matter of fact’, evolved from experiences, and right for the circumstances. However, someone not used to, or not familiar with the inevitability of chronic pain re-occurrence, may well perceive a harm in such a mindset…but only because it conflicts with their own ingrained ‘healing expectations’ mindset.. The relevance appropriate to each mindset is not transferable because the premises differ. We shouldn’t really proxy our mindsets onto others whose experiences differ from ours…that’s merely favouring our own limitations above another’s unknown limitations.

      My soundbite for this issue would be….’Accept fully the patient narrative as presented, and only proceed to treatments which don’t conflict with the context of that narrative’. Alternatively, ‘Assume a ‘fault’ in the narrative, and spend the next 10 years attempting to research the reluctance for participation in treatments which come with that proviso’. Any suggestion of mindset manipulation may well be the potentially ‘harmful’ element in this equation. What if the patient willingly adopts the mindset change, and it fails to produce beneficial results…..is there a support group to help pick up the pieces ? Perhaps some post-brainwashing programme to help re-establish the mindset that existed before the re-education was imposed ?

      Reply
      • Gerry Daly

        PS…..

        Tinkering with mindsets is a tricky business. What it’s really about is undermining a person’s intuitive survival instincts, and replacing them with a fabricated mindset in order to hopefully open the door to a new perceptive ability. If all goes according to ‘ plan ‘, if there is a plan, …..that’s probably fine, because there would be no need to question a positive result. On the other hand, if results don’t match expectations, I’d like to know ….where are the safeguards against someone being dropped from the programme because of some assumed incompatibility ? Looks like a treatment method with the potential to create victims, to me.

        The only way to avoid hierarchical selectiveness in medical processes is to assume a democratic appreciation of equality of status, and that means giving as much credence to the patient narrative as one would give to one’s own narrative, even when there is total disagreement. That’s what the ‘professionalism’ is supposed to address, as it happens all the time. Most medical procedures are already governed by strict rules which dictate who gets to have the final say, who gets to sign on the line which is dotted. Unfortunately, it would seem, there are those who might choose to think that the same restraints might not apply to their experi’mental’ methods. Good news is, people are people, and they will resist any change which doesn’t tick ALL the boxes.

        Reply
  13. EG Physio

    Have you ever been to a physio (or doctor) who properly applies a confident expectation?

    Are you aware that the proper application of the placebo and expectation research is much more than mere words? It’s not just about saying to the client “you will fully recover” and sitting back! It’s an active process the therapist engages in, and it’s for your benefit. Words actually play much less part in it than you’d imagine. And of course you can shit all over that if you want – your choice. But I only uses processes and procedures which the research is VERY, VERY CLEAR ABOUT.

    You’re afraid to trust anyone. All I can say is that clients who totally let go and trust have huge reductions in their symptoms. And those who resist, do not. I’m not saying it’s easy to let go and trust (I struggle as much as the next guy). But this is where we’re at – you’re afraid. Fine. There’s a risk, but it’s not a great a risk as you imagine.

    It’s hard to find good examples of confident expectation that I can show you. I can point you to my blog post “How Powerful, Placebo?”. See how she can’t move comfortably, then suddenly she can? Now tell me what’s going on there?

    In Australia we have a minor celebrity neurosurgeon called Charlie Theo. He gets lambasted by the establishment for performing unproven surgeries on “hopeless cases” and in many cases curing them. I don’t know the first thing about surgery, but if the establishment is saying a technique is unproven or disproven, then it probably is…right? And yet he maintains this unbelievably tight positive expectation and his patients just surrender to it! And they benefit enormously. Even in those cases where the outcome is not good, I have heard reports that the patient was very appreciative of his attitude. No shattered pieces to pick up there.

    I must admit, I am a bit afraid your attitude will put therapists off applying such an approach. As it is, therapists are unwilling to apply research findings and you’re not helping anyone’s cause, particularly your own. You’re sticking with this “all take and no give” approach and it’s very off putting.

    Reply
    • Gerry Daly

      Let me put it this way. Chronic pain patients are not Lab Rats. They must be fully informed of all the implications of any new therapies, before they get to make a decision on whether they see that therapy as appropriate, or not. They must live with the outcomes, therefore they, not the operators, get to make the final decision regarding whether a suggested treatment is appropriate. Can you not see that any new treatment, which comes with a pre-condition that the patient may require mindset altering, conveniently sidesteps that patient control issue, and allows licence for whatever the operator sees fit. In an ideal world, where nothing is predicted to go wrong, that might be ok. In the real world, chronic pain patients are entitled to protect against any suggestions that arouse skepticism. To me, the suggestion that chronic pain can be somehow relieved by self-ridicule, just makes me think that the professionalism behind such a suggestion is laughable. Looks more like an admission of abject failure, dressed up to relieve operators of residual guilt from treatment failures. I am obliged, by my interest in the relevance of future therapies, to question a ‘laugh it off’ treatment approach. It’s not that I don’t get the mindset that might be capable of making such a ridiculous suggestion….it’s more that I wonder just exactly what goes on at Neuroscience Awareness Weekends that encourages such thinking.

      If future therapies are in the hands of those who seem to be so removed from the realities on the ground, then I have much to be concerned about. From my perspective, operators are not entitled to invent their own narrative and introduce it into treatments. Neither are they entitled to dislodge a patient’s narrative to achieve that. They are only entitled to treat according to the narrative presented. I think Hippocrates covered that issue 2000 years ago…..for good reason.

      Reply
      • Gerry Daly

        PS….

        The trouble with most research into chronic pain issues, I believe, stems from the fact that most research is clinic-based, or hospital based. That’s a rarified atmosphere which doesn’t really reflect the reality of the 99% of time where the chronic patient has to cope without qualified back-up. There’s little , if any, monitoring or research into the coping mechanisms adopted to fill those long intervals. And now there’s also the suggestion that the mindset which develops those coping mechanisms should be questioned, and possibly discarded in favour of a new mindset which may have had it’s origins at a PT soiree. If there’s any resonance to what I’m saying, can you not see that a reluctance might be relevant ?

        Reply
  14. EG Physio

    You’re bitter and suspicious because no one has helped you. I get it. I’d feel the same way.

    Reaching out for help to professionals for help with chronic pain, and getting a big fat zero in return is actually commonplace. Reaching out *repeatedly* and getting nothing is commonplace. That’s why you’re baiting me – to try and let me know what that feels like. News flash – I already know.

    Most physios don’t read the research. And of those who do, most don’t know how to apply it.

    Question to therapists reading – yes you. How would you use this research (below) and come up with YOUR OWN technique or approach to treatment that would actually benefit someone with chronic pain?

    Koyama T, McHaffie JG, Laurienti PJ, Coghill RC. The subjective experience of pain: where expectations become reality. Proc Natl Acad Sci U S A. 2005 Sep 6;102(36):12950-5.

    Reply
    • Gerry Daly

      Before I go in search of the article you mention (no link provided), I’d just like to say something. I don’t question the empathy, the sympathy, or even the intention where genuine research obviates itself both by method and by conclusions which reflect the reality of usefulness. Practically all research into chronic pain issues ends up inconclusive about applied therapies/treatments, otherwise chronicity might have become a thing of the past. What I do question is the approach perspectives employed when trying to conceptualise the real dynamics creating the chronic condition. Those dynamics are not created by a mindset fault, they are created by physiological responses to a particular condition, which are then manifested as a conscious perception of pain. That perception is secondary to the cause, as with any injury or disease. Why should it be perceived as being any different, seemingly just because an operator, with little or no familiarity with the subjective chronic experience, cannot get their thinking around what a chronic recurring condition really is.

      I’m sorry to say that the ‘fault’, which discourages proper investigations, might well be an inability to conceptualise the unfamiliar dynamics that render a condition chronic. As someone who is familiar wioth long term chronic issues, I can see the dissonance in approach perspectives, and I comment on that regularly. I can also see the efforts being made to try and bridge the chasm….it’s a bit like trying to build a bridge from one side only, without a full appreciation of the difficulties the other side might have completing their side, so both can meet in the middle. Simply insisting that any chronicity might only be a perceptive misbehaviour, looks like a rather blunt instrument to address the realities of the circumstances….perhaps adopted out of frustration at some shortcoming in conceptualisation ability. No need, in my mind, to transpose that on to the other side of the equation, and create more difficulties.

      Reply
      • Gerry Daly

        PS…..Just read some of article

        Quote….”These results confirm that a mental representation of an impending sensory event can significantly shape neural processes that underlie the formulation of the actual sensory experience and provide insight as to how positive expectations diminish the severity of chronic disease states.”

        Well, we all know that worrying, or anxiety, can increase the expected intensity of anything. But that doesn’t, in any way, define the chronic condition which created the allowance for such secondary interesting observations. Just seems to be a convenient overlooking of the real cause, and a tendency towards , again, an insinuation that the patients default mindset might be the originator of such exaggerations. Something has to be there, in the first place, for any exaggeration to occur. Looks like reverse analysis to me, trying to prove a point by only observing some unusual outcomes. Of course a positive outlook will increase transient tolerance, but I hope no-one is suggesting that’s some kind of end to the chronicity. That would be a quantum leap to a conclusion which begs questioning. Taking painkillers also offers transient relief, and I don’t think anyone would suggest that such a method is a cure of any description. Placebos and palliatives have their place in any regime, but they are usually incidental, temporary, and ill-defined.

        Reply
  15. EG Physio

    You say: “Just seems to be a convenient overlooking of the real cause [of chronic pain]”

    What is the *real* cause? [Personally, I don’t know the real cause, but I do know what helps and it points backwards towards thought patterns].

    You say: “Placebos and palliatives have their place in any regime, but they are usually incidental, temporary, and ill-defined”.

    So they do have a place now? They didn’t have ANY place a few posts ago. You were quite adamant about that point. And temporary…?!! (Read the comments section after my How Powerful Placebo post). Or this. http://www.nytimes.com/1997/04/16/us/placebo-effect-can-last-for-years.html

    And this continual reference you make to “self-ridicule” when no one mentioned such a thing in this ridiculously long thread!

    Gerry your posts are all over the shop!! And you don’t seem to properly digest any of the replies I post.

    What we’re doing here is a perfect example of the reason I never mention any topic related to thoughts/mindset in the rooms… even though I am using such concepts maximally.

    Reply
  16. Gerry Daly

    Ok. I’ll attempt a detailed response, despite the insulting ‘all over the shop’ slight.

    “What we’re doing here is a perfect example of the reason I never mention any topic related to thoughts/mindset in the rooms… even though I am using such concepts maximally.”

    So now, not informing the participants of your methods is proper, I presume ?

    “And this continual reference you make to “self-ridicule” when no one mentioned such a thing in this ridiculously long thread!”

    A chronic patient laughing at their own condition is a form of self-ridicule.

    “You say: “Placebos and palliatives have their place in any regime, but they are usually incidental, temporary, and ill-defined”.

    So they do have a place now? They didn’t have ANY place a few posts ago.”

    I don’t think you’re reading my posts correctly. You seem a bit overheated trying to defend a rational questioning of your support for a ‘laugh it off’ method of treatment for chronic pain.

    “What is the *real* cause? [Personally, I don’t know the real cause, but I do know what helps and it points backwards towards thought patterns].”

    Well, exactly. You don’t know the ‘real cause’. I would have thought that that’s an essential part of the equation which needs resolving before proceeding to treatment options. As for “it points backwards towards thought patterns”…..that’s exactly the kind of unsubstantiated reverse analysis that I argue against. It’s actually assuming a ’cause’ with no supporting evidence. If anyone can put forward an argument which proves that thought patterns are capable of creating chronic pain sensations/perceptions with no prime physiological cause involved….I’m listening. Probably best to be careful with that one, because any errors in judgement might have reputational implications, not to mention the implied implications for future treatment prospects for chronic pain patients. The current trend for defining chronic pain by means of illusion-based anecdotal evidence, might well be a bit of an illusion in itself.

    However, so as not to seem too one-sided, I will comment that thought processes, alone, can be responsible for a temporarilly perceived illusion of pain……which has absolutely no relationship whatsoever with the causes or experience of chronic pain. So I would say, discounting a physiological cause requires a certainty that hasn’t yet been substantiated…..might be more profitable to work off an assumption of ‘unknown’ real physiological cause. Then, at least, chronic patients might feel that nothing is being intentionally avoided.

    Reply
  17. EG Physio

    “So now, not informing the participants of your methods is proper, I presume ?”

    Not informing clients of certain aspects is what I’d call ‘expedient technique’. When you go to a restaurant, how would you feel about the waiter saying: “I’m going to smile now because it will make you feel more comfortable. And now I’m going to give you a small compliment on your choice of meal … is that ok? I’m trying to get some rapport with you”. You don’t explain the art of therapy…. or waiting tables.

    “A chronic patient laughing at their own condition is a form of self-ridicule”.

    This is the crux of our problem. You *are* your condition? There’s a huge identification issue here. And you can’t see it. I would also argue that your pain is not even a PART of you (let alone WHO you are). This is where philosophy becomes an essential component of therapy. It’s a bigger topic.

    “Laugh it off”.

    That sounds glib to me. One particular technique (which I rarely use) is to introduce humour and ridicule in order to re-frame fear. Earlier I said ‘fear/pain’, but really it’s about fear/expectation, which is the underlying cause of the pain.
    If you want to see it in action, here’s a doctor having treatment herself with a guy called Paul McKenna, NLP expert. It’s for a needle phobia.

    “If anyone can put forward an argument which proves that thought patterns are capable of creating chronic pain sensations/perceptions with no prime physiological cause involved….I’m listening. Probably best to be careful with that one, because any errors in judgement might have reputational implications”

    Reputational implications!! I promise I’ll be careful. I wouldn’t want you to think of me as a bad guy! : (( You’re WAY too serious.

    Pain ALWAYS involves physiology. Even in the case that you close your eyes and imagine pain, it involves physiology. I’m assuming what you meant to say was ‘pain without tissue threat or damage’.

    Nocebo studies – do I have to dig them up for you? Or if you want proof immediate pain resulting from thought without tissue damage, watch this video.
    I’ve posted it numerous times before. Yes, it’s real.

    Now I’m going to preempt your next rebuttal by saying i get inspiration from all manner of sources. But maybe you’d prefer having some ultrasound for your pain? 5 minutes of ultrasound 1 Mhz, pulsed, 2 watts/cm-2. Sound good?

    Reply
  18. timcocks0noi

    Hi gentleman
    It’s been quite the ride reading through the comments on this post, with some interesting ideas and evident passion on the topic of pain. I’ve been happy to let it run even though it’s very much gone off topic from the original post, but, I think it might be time to close off the comments on this post as things are starting to look circular with no end in sight.
    I look forward to contributions from you both relating to future posts.
    My best
    Tim

    Reply

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