Episode 6: Understanding your pain can be key

Welcome to Episode 6 of the Flippin’ Pain Formula Podcast. The key message that we are going to cover in this session is that understanding your pain can be key.

This podcast aims to help you re-think the way you understand your pain. We want to help you to move away from the outdated understanding that pain is simply the result of tissue injury. Instead, we want you to understand your pain the way the scientists do: that the purpose of pain is to protect you, and that pain is a marker of the subconscious brain’s perceived need to protect the tissues. Also that pain is influenced by everything: not just biological things, but psychological and social things as well.

We believe that if you understand your pain better, this will help in two ways. Firstly, it will help you to manage your pain better, to be less worried about it, and in time, it may actually help your internal alarm system to dampen down and lead to reduced pain. Secondly, better understanding your pain will help you to make more informed, evidence-based choices about your future care.

Let’s take the first reason: understanding your persistent pain will help you to manage it better, to be less worried about it, and in time it may actually help to reduce the pain.

So how could understating pain potentially lead to less worry, and indeed, less pain? In the old, incorrect understanding of pain, pain means damage: so avoiding painful activities seems like the appropriate thing to do, and every time you feel pain you think you are doing more damage to your tissues. That perfectly reasonable logic can make people really worried about their persistent pain.

When we talk to people after learning about the science of pain, it is not uncommon to hear them say how reassuring it was to understand that pain does not mean tissue injury and that the pain does not mean they are damaging themselves. This helped them to worry less about their pain.

There is strong evidence to show that people who are less worried about their pain are more likely to have better clinical outcomes and manage their pain better. There are lots of reasons why this might be the case, I would like to talk about two reasons that are different but related.

The first is biological: let’s go back to Assumpta. When Assumpta asks the question, ‘how dangerous is this really?’, she will draw on a variety of factors: previous experiences, beliefs, attitudes, knowledge, and contextual factors like social circumstances and our surroundings. Being worried that the pain represents damaged tissue that is getting more damaged when our pain increases is a big ‘danger in me’ factor. This will unbalance Assumpta’s Scales in the direction of danger or threat. Thus, it is more likely that Assumpta will want to draw your attention to the problem and get something done about it, and the more likely she will give you pain. Don’t forget the purpose of pain is to protect you: the greater the worry, the greater the pain.

This can be worry that you are aware of, but it can also be subconscious worry that exists within your alarm system that you are not aware of, contributing to it becoming overprotective. By reducing the worry through changing your understanding of your pain, we can shift the balance of Assumpta’s scales. Not only is she less inclined to give pain, but this will also encourage her to unlock the drug cabinet in the brain and send inhibitory messages down your spinal cord. That will reduce the amount of danger messages coming up, further rebalancing the scales in the direction of safety and thus less need for pain.

The second reason is behavioural. We are still learning a lot about how persistent pain develops and is maintained. One of the leading explanations is the ‘fear avoidance model’ of persistent pain, which was developed in the 1980s, along with the Rubik's Cube and disposable cameras. In this model, pain and our worry about the pain increases the likelihood we will avoid activities that might increase the pain. In the short term, over the first few days when we get pain, this can be a useful strategy: a bit like putting a broken leg in a plaster cast to avoid too much movement whilst allowing the bones to heal. However, what if you never took the plaster off? In the longer term, this strategy would do more harm than good. In the long term, avoidance is a poor strategy.

This avoidance can sometimes be very obvious (like making the conscious decision not to do any more gardening), but more often it is quite subtle, and we are not even aware we are doing it. This could be gradually taking the car more often than walking to the shops or being more careful when picking something off the ground. Over time, this avoidance can lead to a gradual reduction in our activity levels and a gradual increase in disability, disuse, and deconditioning. This reduction in the things we enjoy can also be accompanied by a lowering of our mood, which can have a direct impact on both our pain levels and our motivation to be active. Does this sound familiar to you?

Whenever I think about this avoidance model, I am always reminded of the poem by Robert Frost, called ‘The Road Not Taken’. In this poem, Robert talks about how he came to a fork in the road and choose to take the path that was less used:

‘Two roads diverged in a wood, and I -

I took the one less travelled by,

And that has made all the difference.’

Pain makes us avoid things. It is designed to do this. To do the opposite is completely counterintuitive. It makes absolutely no sense, especially if your understanding of pain means that by avoiding it you are saving yourself from damage and more pain.

However, what if you knew that pain does not mean damage? What if you knew that doing your usually daily activities despite the pain was actually good for you and your tissues? That it would, in time, lead to less disuse, less disability, less deconditioning and a better mood. Then maybe, over time, gradually you would choose to ‘do’, rather than to avoid.

This would be hard initially, and it could lead to some increased pain in the short term, over the initial days and weeks. But in the longer term, over months and years, it would lead to better results in every way.

Pain wants us to take the road more travelled: it pushes us towards avoiding activities, and inadvertently towards all the longer-term negative consequences that come with it. The purpose of this podcast is to help you to take the road less travelled, because the science says that will make all the difference!

I’d like you to do another quick task. I would like you to identify if there are any activities that you have been avoiding because of your pain. Is there anything you used to do that you don’t anymore because of the pain? Can you list these?

Can you think of when you stopped doing these things: a week ago, a month ago, a year ago? Has your pain improved since you stopped, is it about the same, or is it even worse? If it is about the same or even worse, what might that tell you?

Finally, can you think of times when you considered avoiding something but didn’t, and it turned out OK? Please spend the next five to ten minutes thinking through these questions.

How did you get on with the task? If you have been avoiding certain activities because of your pain, then you are definitely a human being. So, try not to give yourself a hard time about it. But what should you do about it?

Well, the first step is to become aware of it: give yourself a tick in the box, first step done. The next step is to start doing something about it: one great way of doing that is through a thing called pacing. This is about starting to do those activities, but starting small (in way that you feel confident you could achieve them) and then working your way up. This does not mean gritting your teeth and going ‘hell for leather’ at the activity you have been avoiding: that road often leads to a short-term hike in pain levels that can be really incapacitating and lead to significantly reduced activity over the following period. It is known as the ‘boom-bust’ scenario.

The best way of explaining pacing that I have come across is in the book, ‘Explain Pain’, by Lorimer Moseley and David Butler.

Imagine two mountains side by side. Let’s look at the first mountain: this represents life before persistent pain. We all have a level of tolerance in our tissues: below that level we are safe, and above that level would mean severe tissue damage. Our tissues are strong, so it would take something pretty hefty, like a road traffic accident or a nasty fall to take us over that line into physical damage. So, the area above and beyond your tissue tolerance is the danger zone and is the very peak of the mountain.

When we come close to our tolerance level, pain kicks in to act as a buffer and protect us. So now, before we get anywhere near the tip of the mountain, we have a tissue damage barrier and before that, a protective pain barrier. The distance between the tissue tolerance line and the protective pain line on this first mountain (life before persistent pain) is not very big, allowing us to do all of our normal everyday activities pain-free in the rest of the mountain space, underneath the pain protection line. And we know that pain will kick in before we reach the ‘danger zone’.

When pain has become persistent, the lines shift a bit. Imagine the second mountain. Life with persistent pain. The tissue tolerance line is the same, your ‘danger zone’ is the same. The big change is the difference between the new tissue tolerance line and the new pain protection line. The new pain protection line is now much lower. This happens to protect you. It creates a much bigger buffer zone between pain onset and tissue damage, which is great in some ways, because the pain stops you from even getting close to the point where you could injure your tissues. Unfortunately, it goes so low that even everyday activities, that are in no way dangerous, can trigger pain. The space we can take up on the mountain without pain has become smaller. Our ‘danger zone’ is the same as before but it appears much bigger because of pain.

If you push on up through this new pain protection line, you may encounter a flare up. At this point, the pain really flares up and it can feel just like it did when you first hurt yourself. This can be a real ‘heart-sink’ moment: you can feel like you are right back at square one and have reinjured yourself, even though in reality you have not injured the tissues. This is why pushing on and completely ignoring the pain can be a bad strategy. When flare up pain gets so bad, you can become incapacitated for hours, days or even weeks. Instead of increasing overall activity, you decrease it.

This is where pacing can help. When pacing you aim to do an amount of activity, which sits above the new pain protection line but below a flare up line. This is called your baseline activity level. When you do this it hurts a little bit, but when you stop the pain settles quickly back to your pre-activity levels. This is a positive experience for your protective pain system, showing it that movement can be safe.

Repeating this over and over again can lead to a shifting of the lines, with the gap between the new tissue tolerance line and the new pain protection line narrowing, allowing you to do more and more of your usual daily activities with the same or less pain. Like they were before any injury occurred. That is the wonder of our plastic alarm system: it has such great capacity to mould and change.

Let’s talk through this for walking: if you have persistent knee pain and you want to do more walking, but currently you can’t even walk to the corner shop at the end of the street without flaring up and paying for it over the following 2-3 days, pacing could really help. To begin, identify an amount of walking you are confident you could do with some pain but without flaring up: that might be just to the end of your driveway and back. Then try it and see how you get on. If there is no flare up, try doing that daily for the next week. At the end of that week, take stock of how it has gone. If you have not flared up, ask yourself how confident you are that you could increase that by 10%. If the answer is yes, then give that a go for the next week.

Keep repeating this process until you reach that corner shop. If you do flare up, don’t beat yourself up about it. Remember, the journey to recovery is not easy and it is not quick, but it is worth it. In the case of a flare up, readjust your target back to where you feel confident and then start again from there. When it comes to pacing, you are in charge: set the level of activity and rate of progression to suit you, try to set goals you are confident about and stick to them. Broadly speaking, try to do a little more this week than you did last week.

Pacing always reminds me of a famous story about the famous Scottish king, Robert De Bruce. At one very low point for Robert, when all seemed lost and he was hiding from the English army in a cave, he watched a spider building a web. Time and time again, the web would break and the spider would have to start again. But he kept rebuilding and rebuilding until slowly, but surely, it was done. This inspired Robert to gather himself up and to keep on fighting. The rest as they say is history!

A good guide can really help you pace. A good health care professional might help, or there are lots of good resources online to help also. You can find resources on the Flippin’ Pain website: www.flippinpain.co.uk/resources.

Over time, gradually increasing your activities can help your alarm system to slowly become less overprotective by giving it evidence that doing these activities does not lead to a worsening of the condition in the long term. Assumpta becomes less concerned. Each successful activity experiment is evidence of ‘Safety In Me’ and shifts the balance scales back towards the middle, away from threat and the need to protect. These are steps towards reducing the sensitivity of the alarm system, allowing you to gradually do more and more with less pain.

If you believe that pain means tissue injury, pacing makes no sense: and so you might never try this very useful, scientifically supported pain management tool.

This brings me to the second reason why understanding your pain is important: better understanding your pain will help you to make more informed, evidence-based choices about your future care.

In Episode 5, we learnt that surgery and medication are usually not the answer for persistent pain. They are considered low value care in that they have little scientific evidence to support their use. We learned that all the evidence-based guidelines for persistent pain recommend more holistic interventions: advice, education and active physical and psychological therapies. These interventions include things like the pacing we just discussed, and things like relaxation, imagery and exercise. These fall within the category termed ‘high value care’, with a strong evidence base to support them.

Unfortunately, in clinical practice we are seeing an increase in ‘low value care’ (like surgery and medication use) with no sign of a similar increase for ‘high value care’. One big reason for this is that most people, and I include healthcare professionals in that, believe in the old, discredited model of pain: that pain is the direct result of tissue injury. With this understanding none of the more holistic, evidence-based interventions make any sense as they are completely counterintuitive: and so we don’t use them. It’s important to note that with the increase in ‘low value care’, there hasn’t been a global decrease in pain. In fact, it’s an increasing problem!

The best example of a treatment seeming to be ‘counter intuitive’ is physical activity. If you believe that more pain means more tissue damage and being physically active leads to an immediate increase in your pain, then it would make absolutely no sense to try to do more physical activity as a management strategy.

That is a great tragedy because we have strong evidence that exercise is beneficial for persistent pain.

In a recent study that I was involved in, we looked at all the raw data from all the clinical trials that have investigated the effectiveness of physical activity for people with persistent back pain, compared to a control group. This analysis included over 3,500 people. Those who did physical activity as a treatment, over time, reported 20% less pain and disability than those in the control group who did not undertake physical activity. Imagine that. Imagine if you could reduce your pain by 20% in the long term, just by being more active.

Unfortunately, many people with persistent pain are not getting enough physical activity. Why, I hear you ask? Well, to start with, about 25% of the population believe that physical activity is bad for your back when you have back pain. Not just ineffective, but actually bad for you. No wonder they are reluctant to engage in physical activity. But if we can change people’s understanding of their pain, help them to understand that pain does not mean tissue injury, then it is easier to believe that physical activity is not just safe but actually beneficial.

This does not just apply to physical activity, but also to lots of other evidence-based interventions such as active psychological therapies. If you believe that your pain is caused by the damage in your tissues, then why would you want to try active psychological approaches for your pain? It would make no sense. But if you know that everything matters when it comes to pain, if you know that our pain levels are influenced not just by the biological but the psychological and the social, then that puts a completely different perspective on it, and it makes these psychological therapies completely sensible to try.

As we come to the end of this episode, I want to mention one last way that understanding your pain can help. Over the course of my professional life as a pain scientist and health care professional, I have met thousands of people with pain. In my conversations with them, one issue keeps popping up again and again: that is the issue of being believed. Because persistent pain can’t be seen, many wonder if other people actually believe them when they say they have pain, or if they believe just how bad the pain is. This can be compounded by often well-meaning but ill-informed health care professionals, telling them that the pain ‘is all in their head’. This is then further reinforced when all the scans and tests show up negative.

This feeling of not being believed can be really demoralising. It can even lead to people questioning themselves. But understanding the science of pain can change all that. It allows us to understand how we can experience the most awful pain with little or no tissue damage, and that persistent pain (in the absence of significant tissue damage) is no less real than pain with significant tissue damage present.

Pain is separate to tissue damage, and it is always real. I will leave you with this quote from one of our participants that shows how understanding pain helped her to feel validated: a value which is commonly overlooked by those without pain and deeply valued by those with pain.

“I began to think, well, am I losing my mind? Honestly. And then when he was going through the science, I thought, ‘that’s me that, yeah, that’s me’… I thought, ‘God it’s not me going crazy’. You know, it was brilliant.”

‘Two roads diverged in a wood, and I -

I took the one less travelled by,

And that has made all the difference.’

By understanding your pain better, you are taking the road less travelled, and that can make all the difference!

Congratulations: you have made it to the end of Episode 6. I look forward to speaking to you again in our final episode. Thanks for listening.