Saturday, March 2, 2013

10 things I wish my Doctor had told me about pain!

Jake Tumber, PT asked me what things I know now about pain that I wish I was told in 2002 when I visited my Family Doctor after a minor car accident. I decided to get it down on a list here:

1) You are probably not damaged!
Despite all the impact demolition derby drivers sustain, they have ultra low incidence of chronic whiplash and persistent neck pain. It has nothing to do with the forces (they get blind sided too) but everything to do with the meaning and context of what happens. This study may not be the most robust (Retrospective). But it does pose a pretty challenging question to some base assumptions. Physical damage is a poor predictor of how much pain you will experience.

2) Move it or lose it!
If you treat your body like it is fragile and damaged, it will become more so. There is a something called Hebb's Rule after Donald Hebb which states "Cells that fire together wire together". What this means in this case is that if you move less, you will lose some of those capacities to move. That sounds kind of dire but of course this happens over time. And time is pernicious when it comes to chronic pain. If you allow yourself to act fragile and breakable you will slowly, physically and mentally, change to support that belief over time. You are much more robust then you realize and with a little creativity you can find something that you can do. This makes all the difference in the world.

3) Banish fear!
Being afraid of the pain getting worse makes you fearful of movement. Along with point 2) this kind of attitude can lead to catastrophising, depression, and more fear. All these may cause you to stop exercising or challenging yourself which creates self perpetuating loops that slowly paint you in a corner. This is why "letting pain be your guide" is not helpful to your recovery.

4) Pay attention!
Blasting past the pain and ignoring flare ups will piss off the nervous system. And nobody's happy if the NS isn't happy. Diane Jacob's talks about the "Critter Brain", Todd Hargrove mentions the "Wild Animal". They are talking about that older part of you that is constantly monitoring threat and mounting defensive responses if it deems it necessary. Treat your newly sensitized nervous system like a wild animal or ancient critter brain that you are attempting to tame and soothe by building trust.

5) Exercise and move for the general benefit!
You can't stretch out the pain. And strengthening only indirectly affects pain, most likely because exercise and movement are so helpful in general. So forget about weak muscles and asymmetry, if you walked in the room and didn't fall over your core strength is just fine. Paul Ingraham started me on a wild journey a few years ago with that first stretching article, his site is well worth a visit.

6) No therapist should increase your pain!
If you ever have any therapist that increases your pain during therapy and implies that it is somehow good for you. Punch them and get out of there. (I'm talking to ART people especially here.) Increasing your pain through therapy can heighten the sensitivity of your nervous system which is the exact opposite of what therapy should be going for. Sometimes the best thing a therapist can do is Do Nothing as Barret Dorko writes.

7) Looking inside isn't going to help!
Getting any imaging done should be an absolutely last resort. Unless there is a serious red flag, chances are any findings on MRI's, X-rays etc will just cause you to worry about something unnecessarily. Many people have no pain and would have plenty of abnormal imaging findings.

8) Your brain is king (or queen) of it all!
Your brain is in complete control of the pain experience. Pain is produced as a pain experience just like hunger and thirst. Only with pain it is similar to a car alarm that has been set on high sensitivity. Sometimes the alarm may go off because a strong wind has just blown or some car stereo bass shook the windows as it went by. With pain, there doesn't have to be anything wrong for the experience to occur, it can be simply because the sensitivity is up to high. This one is the most vexing because it feels so real. And it often feels like your pain has a distinct location. You would swear under oath that something is wrong "right there". But our brain can be tricked very easily, I mean very very easily. You can't trust your experience.

9) Your brain can get cranky!
Your brain extends throughout your entire body. 72kms. All nervous tissues have their own blood supply and can get very cranky if they are not well fed. This is where you may need the help of a competent therapist. And the earlier the better. A proper therapist will always help you regain your inner locus of control, they will never attempt to be the "healer" or the "guru" with special knowledge that only they understand leaving you dependent on them for recovery.

10) Quacks are after your money!
Finally, here is a quick list of money wasting therapies. Craniosacral Therapy (CST), Ultrasound, Myofascial Release (MFR) Acupuncture, Cupping, Moxibustion, Ayurveda, Homeopathy, Naturopathy, most Pathy's, reiki, Therapeutic Touch, energy work (of any kind), TENS, Chiropractors that believe in Subluxation Theory, traction devices, most anything that buzzes, whirs, bleeps, or rumbles, magnetic anything, copper bracelets, quite a lot of surgeries, any instruments that are used to scrape the skin in some way (especially aggressively), or any treatment that approaches the body as some dumb lump of meat that has no super sensitive tissue permeating every square millimetre of it.

Knowing this stuff 11 years ago would have put me on quite a different (and less money wasting) track than the one I ended up traveling so I hope it gives someone who is starting out now a leg up. I would love to hear from your experiences if you'd share them below.


Diane said...

Do you really think that all the practitioners you slam in #10 believe the body is a dumb lump of meat? Quite the opposite: it is because the body responds that we do the work we do. I'm sorry you've had bad experiences with those in the healing arts (I did not say healers), but to paint them all as inherently useless and a waste of money is a little silly.

Anonymous said...

Everyone's body reacts differently to different therapies. To slam any of them reveals your ignorance.

Anonymous said...

I agree, 10 is just plain ignorant. While some of these practices have continued to succeed hundreds of years of cynicism and scrutiny other have faded with the lack of results and reasoning over time. The one thing I learned at the NOI pain conference last year was not to discount anything, especially a working placebo. The lesson learned is to move and to have a better attitude. Finally, discounting energy as a healing power results in treatment that only approaches the body as some dumb lump of meat, example: allopathy.

B said...

Hi Diane,

Thank you for your comments.

When I was originally composing this post I had a Chiropractor slam me for lumping him in with others of his profession that believe in Subluxation Theory. He had adopted 1-9 on the above list and included it in his practice. That is highly commendable and I wish he wasn't in the minority. I added the distinction of the main "flawed' theory that Chiropractic is founded on.

I suppose I could have worded the end of #10 as "OR any other therapy that believes the body..." However I still stand by the list of therapies as being bunk.

Others who have credentials (eg. RMT) and actually do practice inline with the current pain science literature (I don't see how a Homeopath can do this though) and are able to provide valuable help the people in pain.

I will point out to you though that it is the Nervous System that responds and there are a whole host of considerations to take into account. I particularly love Diane Jacob's take on the Operator vs Interactor []. I really hope you will read her stuff.

So many of the reasons that "practitioners" in the listed fields are successful has nothing to do with the "theory" of the fields itself.

I read a Dan Gilbert quote recently that is apt. "Disbelieving is hard work"

I plan to write a bit more about that in the future (I hope)

B said...

Hi Anonymous (1). Is this Ted Danson? :)
If you have some counter points I would be happy to consider them.
Of course everyone's body reacts differently. Why does that make the theories I have been critical of valid?

B said...

Hi Anonymous (2). Now this must be Larry David.

David Butler and his group are doing some amazing things at NOI. One thing I don't think Mr Butler would agree with is the notion that "energy is a healing power". I am not sure he would say "don't discount anything" but perhaps you are right about that. But isn't it interesting that the placebo effect explains so much? And once we have that, why doesn't the placebo effect solve everything? And then what about the Nocebo effect? Where ideas/ treatments that lead to people having wrong beliefs about their body that recirculate an unhelpful pain story? An example of that being my discs are out, or my spine is that of a 70 year old man?

I believe many of these are imbedded in the therapies I listed above and are unhelpful (i.e. worthless)

Move and have a better attitute seem in line with what I have stated above.

Morten said...

Nice piece. I enjoyed reading it.


Anonymous said...

I wanted to share this so badly then I read #10. I can't slam other practitioners and won't bc I don't know/practice what they do. I may know alot about the beliefs of many of them but cannot lump all of them together. For example some accupuncturists I know place their needles based off knowledge of the cns, moseley, melzack, wall, butler etc. There are many different ways to treat pain. And some people need different stimulus. I don't know your background Byron but if you are a yoga person do you not agree that there are good and bad yoga teachers based off how and what tet teach? So again, we can't lump therapies together as useless. On the other hand I do agree that more often than not some are better.

B said...

Hi Morten,

Thanks for your comment. Looks like you have quite a website there. Keep up the awesome work!!

B said...

Ok, 3 Anonymous people? Now I have to make up a third name. How about Larry Danson.

To your point then. Notice that, other than Chiropractors that believe in Subluxations (which I could have just listed as Subluxation theory). I actually wasn't slamming practitioners. I was slamming theories. Apparently this is the hardest thing in the world to get people fully entrenched in a theory to read. This is not a personal attack at any one. This is an attack on belief systems. Sure I know some great Yoga teachers (I hope to be among that list someday). But there is a ton of crap in Yoga. I was pretty close to putting Yoga Therapy on that list but I am not sure yet what Yoga Therapy even is.

I am sure you will agree that the things that unite each of those therapies I listed is a flawed fundamental belief in how pain is created and how a practitioner would utilize that knowledge for healing. Once you strip all of that away, say in the case of Acupuncture like you list, why even use it anymore. Why stick the needles in anymore? If we are working to calm the nervous system down isn't it an odd thing to be stabbing at it with tiny little swords?

There are many therapists that are questioning what they have been taught. And it is a very hard world for them once they do that. Any help we can give them by focusing on the really good stuff is well worth the effort.

If you said yoga is full of BS, I would agree with you. It is. I am working to stay as far away from that end as possible.

Thanks for commenting though, I do appreciate that!

Ben said...

Nice list, Byron. It seems like you may have struck a few... nerves.

Personal experience: a few years ago I resolved a self-inflicted case of whiplash (I think that's what it was) by gently turning my head back and forth, repeatedly, over the course of a few days. That's all I did. No poking, scraping, "releasing" or manipulating.

This was before I had learned anything about current pain science, and these questions remained in my head: How did my neck heal so fast? And if it really wasn't that injured to begin with, then why did it hurt so much?

I never got any reasonable answers to questions like that until I found SomaSimple. "Money-wasting therapies" is right. Not because they can't produce any results, but they remove locus of control from the patient.

B said...

Hi Ben,
Thanks for your comments. I think we both joined Soma Simple around the same time. I know I can't recommend the place highly enough to people.

I like your work on ectodermalizing personal training! It is exactly the kind of thing that I am working on with Yoga, and just what we need the other professionals to start thinking about.

pete said...

Hi Byron, nice list..10 is obviously the contentious one. I completely agree that the theories for most alt med is spurious, including osteopathy (which I do). However I think we have to differentiate between those practitioners who hold tight to their theories.. often the newly qualified and those who have discovered that people heal when they are listened to, comforted and taken seriously. The modality in these cases becomes secondary...Many good alt med people I know.. use the modality to start the process of empowering the individual to heal.. they simply might like the idea of taking a homeopathic pill more than aspirin because it does no harm. I don't meet many greedy self aggrandising people in the alt world.. most are gentle and empathic. and if they are egotistical new age gurus I'd have as much distain for them as bankers :)

Unknown said...

This is a great list, Byron. I wouldn't change one word of it.

pete's comment made me chuckle. It's ok to be a quack as long as your " gentle and empathic"?

And who says a homeopathic pill does no harm? Someone's paying for that worthless pill. Since when is perpetrating a fraud not harmful?

But, as long you mean well...

B said...

Hi Pete,

Thanks for your thoughtful comments.

There is a challenge here and I think it falls into the distinction between Mis-Information and Dis-Information.

Mis-Information which is good people sharing false or even harmful information with the best intentions. This can happen from a lack of training, a lack of critical review of the information taught to them by a confident and believable senior, or a genuine misunderstanding of basic physiological principles.

The other, more insidious one is Dis-Information. Someone who purposely shares information that they know is false. They may do this because they have built and career that depends on this information being true and so they rationalize away the facts to suit their purposes. Cognitive Dissonance is the term for the point at which they become aware that they may be wrong, some choose to accept but others choose to ignore this unwlecome insight. These people are, unfortunately, usually in a position such as trainer, or expert in their field. To accept that their main foundational principles are false would mean complete disaster. At least for a while.

Regarding your example of the Homeopathic Pill vs Aspirin. You had to pick Homeopathic didn't you :). I think you a presenting a false dichotomy here. Perhaps you didn't mean that but I am going to use it. There are not just 2 options in that scenario. i.e. "Homeopathic Pill" or "Aspirin Pill". There is also the "Wave a dead fish overtop the area of complaint", "Take an MRI of the area", "Offer a section of the Yoga Sutra's to repeat as a Mantra", and "perform surgery to fuse the L4 and L5 vertebral discs" etc.

I do think it is important to remember that once a therapy has been proven thoroughly useless, it should be discarded, permanently. It holds back the species. It diverts research money (yes there is still money spent trying to prove that homeopathy works) from finding something that is useful biologically, physiologically, sociologically, or psychologically.

Caring attention has value, I don't think we have that completely figured yet, so let's take the research money from pseudoscience and move it there.

Caring attention can be provided by someone who is a (hopefully recovering) Homeopath. But let's stop pretending that a magic pill is the answer?

B said...


Thanks for you encouragement. I had my reply to Pete 90% finished 2 weeks ago but got caught up in other things. Your post reminded me to finish it off.

As you can see, your point is exactly what I had planned to make :)

Mark Hollis said...

Interestingly No 10 is the one i had the least umbrage in and was unsurprised by the 'to slam them is to reveal ignorance' quote of anonymous. You forgot to put in physiotherapists that do ultrasound. You're not slamming a profession, you're slamming health illiteracy and in some cases, of those that are health literate, laziness or greed or any number of other reasons we do things to other people even though we know they are not beneficial to them. Good blog

B said...

Thanks for your comments Mark. My roof still is on fire from your last comment :)

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