“You and that bloody Explain Pain book. It made me completely rethink what I thought I knew, and question what I do as a clinician… your ears must’ve been burning at times with the things I said about you! I’ve read it twice and I think I’m starting to get it, BUT, where do I go now, what do I actually do?”
Explain Pain was Lorimer’s and my first attempt to take the complex pain biology that was exploding in the scientific literature and make it relevant, interesting and understandable. We hadn’t intended to write a step by step ‘how to’ treatment guide – but over the years, we’ve both heard from clinicians (like the one above) who were challenged by the material – and it’s practical application. We’ve never wanted to put forward a formula or a ‘method’ for Explaining Pain, but the idea of another book – a kind of clinician’s ‘manual’ – that went really deep on the neuroimmune biology of pain and how to deliver Explain Pain interventions based on educational psychology and science, has bubbled along in the background. The result of all that bubbling and brewing of course is Explain Pain Supercharged – a book that supercharges your pain biology while also providing chapters on conceptual change science, curriculum development, Explain Pain competencies and assessment, clinical metaphor, and a huge list of ready to use educational neuroscience nuggets and novellas.
A peek under the Explain Pain hood
For this NOInote, we thought it might be useful to provide an example of how it can all come together right at the coal face – as you sit with a person experiencing persistent pain in the clinic. What follows is a taste of Explain Pain in ‘real time’ – it is by no means meant to be a ‘recipe’ for Explaining Pain, but rather a glimpse into our thinking, clinical reasoning and integration of Explain Pain resources. Read on…
Cassidy (not her real name) is an 18-year-old in her final year at school. She previously loved to play soccer, volleyball and go to the gym and has dreams of being a gym trainer. For the last 3 years she has experienced widespread, bilateral pain (as per body chart below). She has seen multiple health professionals and has been told she has Scheuermann’s disease and ‘will always have pain’ and has been given ‘core stability’ exercises. Cassidy now abstains from soccer and volleyball, is worried about her future, gets down and depressed and has developed gut problems. Some of her family think she is being ‘dramatic’. A full medical work up revealed no red flags.
David Butler’s internal thinking and monologue, captured via advance brain scanning*: Lots of E flags (see definition below) here – long term, widespread pain is suggestive of some sensitisation processes and the depression and gut issues hint at multiple output system perturbation. The ‘Scheuermann’s Disease’ diagnosis is potentially a potent DIM driving worry and pain, and needs dethreatening and explanation – probably needs to be a Target Concept.
All spinal movements are a bit limited and shaky. Forward flexion to knees ‘pulls in my back’, and a gentle chin tuck increases this pull. Straight leg raise (SLR) is limited bilaterally to 30o and felt in the knees posteriorly. Bilaterally, slump test is restricted and shaky with thoracic pain on spinal flexion released with knee flexion. All neurological tests are normal except for an excessive knee jerk bilaterally. Lumbar two-point discrimination (TPD) is normal bilaterally. Recognise results of left/right= discrimination in the back and feet are normal.
DB: More E Flags here – the chin tuck increasing the pull in the back would benefit from a neurodynamic story, perhaps with a focus on how growth can affect the permissibility of neural movement. Nothing major objectively, but the increased knee reflex fits with a sensitive system and perturbed outputs. Restricted and shaky movement may indicate that ‘motor control’ and ‘core stability’ approaches are the opposite of what is required – motor freedom on a foundation of up to date knowledge
Explain Pain Assessment
Cassidy is keen to learn about pain and science and prefers to learn via talking, reading websites and watching video clips like YouTube. She gets good marks at school and is studying some science (psychology). Likes to think of herself as a ‘tech-savy millennial’ and has access to a smartphone and an iPad. Her health knowledge comes from teachers at school, talking with friends and family and Facebook ‘news’ articles. Sometimes she looks up conditions on Google. Cassidy doesn’t know a whole lot about pain (low level pain literacy) – ‘I always hurt but I don’t know which part of me is broken’.
DB: The level of misconception (a belief that pain is equal to damage in the body) is likely at the ‘sandcastle level’ – multiple bits or ‘grains’ of information loosely held together; opportunity for conceptual change here. This has likely been reinforced by notions of a ‘weak core’ that needs to be ‘strengthened’. Relevant Target Concepts include 2, 3, 4, 5, 6, 7, 8, 10 and additionally specially constructed Target Concepts ‘Growth spurts and the mobile nervous system’ and ‘The story of Scheuermann’s – it’s not a disease’.
Treatment Day 1
Education: Discussed overprotection using the Twin Peaks Model – exploration of how other symptoms may be overprotective (i.e. pain, gut problems, mood). Introduced the notion that pain and tissue damage aren’t always related. Discussed the bioplastic nature of the nervous system and potential for change.
Movement: Ceased previous core stability exercises. Education provided as to why – discussed outdated notions of ‘motor control’, ‘weakness’ and links to pain. Discussed how updated, dethreatening knowledge could provide new context for motor freedom. Introduced gentle slump/slider movements and graduated spinal flexion with breathing techniques. Discussed the goal of loose, free, easy, comfortable movement rather than being tight – ‘loose and long rather than tight and tense’.
Homework: Provided The Explain Pain Handbook: Protectometer as a guide throughout this journey and encouraged to read page 1-20 and fill in activities. Prefers to use iPad so will fill in ‘Protectometer’ on the App. Agreed to purchase the eBook version of Explain Pain and read ‘Amazing pain stories’ (page 8-17) on iPad.
Plan + Contract:
Discussed the importance of active treatment in both education and movement – agreed on a ‘treatment contract’ with the following objectives to be achieved over next three visits:
- Understand pain biology knowledge as it relates to Cassidy and use this knowledge to change thoughts and beliefs about pain and damage, and move differently with less fear and worry
- Set realistic short and long term goals
- Commence a graduated return to full function
- Use the knowledge and experiences as part of career development
This was covered in a 60 minute initial consult.
To be continued
In a first for NOInotes and noijam, we’re going to deliver a number of serialised posts so that you can follow Cassidy’s progress, and the clinical reasoning that goes with it, over subsequent consults.
Comments? Questions? Sound off in the comments below.
– David Butler & the NOI team
*Not really, he just wrote it down later.
E Flags – An E flag is a piece of information picked up during a routine assessment or a deeper DIM/SIM analysis (Protectometer) for which you want to provide education and explanation. We identify these in our notes and put a small flag with a ‘E’ on it as a reminder to come back and address it later during an Explain Pain intervention.