What can a patient’s pain tell us about contributing mechanisms?

Ever put down a copy of Explain Pain, or some other highly valuable text, and asked ‘So how do I integrate all this stuff when I assess a patient and plan treatment?’ You might have felt exasperated after reading yet another article on pain mechanisms, or central sensitisation, or cortical reorganisation, and said to yourself ‘yes but how do I know what is driving what?’ If my conversations at conferences and courses is anything to go by, then a whole lot of you will be nodding.

This post is really just to introduce a general guide that we use to interpret how a patient describes their pain. One might go through the different sections (in different colours on this slide) and place a tick next to the relevant mechanism. I hope it is fairly self explanatory – feel free to download General guide to contributing mechanisms and modify it as you see fit. If you do take it into the clinic and use it in a more formal way, then we would love to know about it. Good luck folks!

grey What can a patients pain tell us about contributing mechanisms?

Some general guides for interpretation of a comprehensive assessment, with regard to identifying contributions to a pain state from nociceptive and non‐nociceptive domains. Patterns are consistent with contribution of biological mechanisms (primary nociceptive, nerve root (also dorsal root ganglion‐evoked nociceptive discharge), peripheral neuropathic and central nervous system, immune, autonomic and endocrine contributions). Psychosocial contributions clearly have their effect on the CNS but are not biological contributions. PCS = Pain catastrophising scale; PKQr = Revised pain knowledge questionnaire; FABQ = Fear avoidance beliefs questionnaire.

Download high resolution General guide to contributing mechanisms here

About Lorimer Moseley

grey What can a patients pain tell us about contributing mechanisms?Lorimer is NHMRC Senior Research Fellow with twenty years clinical experience working with people in pain. After spending some time as a Nuffield Medical Research Fellow at Oxford University he returned to Australia in 2009 to take up an NHMRC Senior Research Fellowship at Neuroscience Research Australia (NeuRA). In 2011, he was appointed Professor of Clinical Neurosciences & the Inaugural Chair in Physiotherapy at the University of South Australia, Adelaide. He runs the Body in Mind research groups. He is the only Clinical Scientist to have knocked over a water tank tower in Outback Australia.

Link to Lorimer’s published research hereDownloadable PDFs here.

Comments

  1. Thank you Lorimer,

    very interesting I look forward to trying to integrate it if not directly at least indirectly. I note the duration element at >3 months do you think that may be somewhat arbitrary? Or is that a hard enough figure given that other mechanisms input to the CNS are largely accounted for elsewhere in the schema?

    regards

    Andy

    Lorimer Reply:

    Hi Andy -
    Yes somewhat arbitrary – but thought it prudent to put it in – really it should read “the longer the more likely…..”
    nice work,
    Lorimer

    Karen Kowal, RN, LMT, NCTMB, NCBTMB CE Provider Reply:

    3 months is the designated time frame for categorizing pain as ‘chronic’. This is a known criteria within the medical field so we need to be in sync with this criteria if we communicate with patients and other medical profession. Good you added this!

    Annonymous Reply:

    Thank you this is very interesting. I am currently working with a client who is experiencing chronic lower back pain from a soft tissue injury. I am wondering if there is a link between hormones and pain experience? And if so, what is the nature of the relationship? Thank you

  2. Harry Eeman says:

    Nice framework though I’m still perplexed as to why you dichotomize the psychological vs the biological. The substrate of psychology is biology. One doesn’t cause the other, they are expresions of the other. One isn’t more ‘real’ than the other. If you change the brain (eg. Stroke, ABI, MS, etc) the psychology changes.

    I don’t have a problem with the ‘social’ being distinct from the ‘biological’ in that there is a causal relationship between the two – ie the social impacts on the biological/psychological; your environment changes and shapes your biology. Likewise, each individual influences the society they live in; each biological/psychological being contributes to the societal or the culture.

    I propose we get rid of the umbrella term ‘psychosocial’ as an entity as it implies that the ‘psychological’ and ‘social’ are more closely related to each other than the ‘biological’ and ‘psychological’. In fact, the lumping of psychosocial as a singular entity perpetuates Cartesian dualism which has led medicine into classifying disease into having either ‘organic’ (biological) and ‘non-organic’ (psychological) aetiologies. I’m sure I don’t need to convince anyone that this paradigm is hopeless at explaining and helping people who live with chronic pain.

  3. Thanks Lorimer, this is definitely helpful as I am challenged by this everyday!
    Thanks for your work & I look forward to seeing you in Portland in October !

  4. lorimer says:

    Thanks folks – Harry – great comment! The presentation is not meant to imply against your conviction, which I completely share, that the psycho is biological. It is to group a class of measures and mechanisms that involve neural networks (or ‘neurotags’ – see Explain Pain) that are not in the nociceptive chain. They are the substrate of thoughts, beliefs, mood, contextual cues etc. I think your suggestion to stop coupling psycho and social is very interesting – I can see real merit in that, although the manner in which we interpret, process and interact with our social (and physical) environment is also biological i think – do you? If so, then are we compelled to reengage with the wider biopsychosocial semantic? Regardless, I appreciate your comments.

    Harry Eeman Reply:

    I’m not sure about ‘biopsychosocialism’. It means so many different things to different people (a bit like ‘central sensitisation’). If we agree that the substrate of psychology is biology then can we not get rid of the concept of ‘mind’ as being distinct from ‘brain’? This of course runs us into dangerous philosophical territory – if we are just the product of biology interplaying with environment then what happens to the concepts of ‘consciousness’, ‘free will’ and ‘morality’ and other qualities that are supposed to be irreducible and non-compatible with the biological/physical? I don’t have a problem with this but I suspect this is the reason why people hold on to dualism in one form or another.

  5. Many thanks Lorimer
    I think one of the oldest tenets in clinical practice is “Listen to the patient” I am too frequently reminded of the practical implications (for the Patient) of clinicians not listening, selective interpretation of information to fit the pre-concieved model, or simply not knowing enough to interpret what’s being said – which obviously determines the type of soluion proposed…

    Keep the flag flying!

  6. Hannah Wilde says:

    Hi Lorimer, thank you for your post. It’s exactly where I’m at post NOI conference. For a few years now (since digesting ‘Sensitive Nervous System,’ I’ve been trying to working out how to visually respresent the contributing mechanisms in a pain presentation, particually to aid and demonstrate clinical reasoning on my physiotherapy initial paper assessment form. I will follow this thread with great interest! I am currently working to a mechanisms ‘tick box section’ on my form. Is anybody else working along similar lines? Creating an ‘aide-to-clinical-reasoning’ assessment form? If so I would be happy to email my version to you as an ideas swap!

  7. Hi Hannah, really interested to speak with you on a number of things. Perhaps you can email me, believe we are working on similar lines and know you are looking for work too?

  8. The great danger with this flow chart is that it stimulates excessive thinking. A therapist who is thinking is not paying attention. A therapist who is lost in thought cannot cure anything!

    There’s no need to “treat the patient”. Just simply treat yourself and let the patient come along for the ride. When I say “treat yourself”, I mean drop the ego – that’s all that’s required! A simple practice and very hard to accomplish. It comes in stages.

    While treating yourself, the application of some sort of stimulation to the patient’s affected body part will help them attend to it, but in a new way… without aversion.

    Cheers.

    Cameron

  9. Cathy Turner says:

    I have sat through many sessions on “how to listen”. What I’ve learned is SILENCE is the key. Don’t be afraid of silence. We need to remember that the EXPERT of how a patient feels, the EXPERT of the pain of the patient, the EXPERT of what is happening in their life, IS THE PATIENT, THEMSELVES. Give them time, give them space, give them some quietness, and the EXPERT will speak. An attitude of “I want to help” is felt, and helps the EXPERT tell all! Throw away the paperwork (for the moment) and sit and look them in the eye (if culture permits), and let the EXPERT talk. You will learn more in those 10 minutes, than you will learn through any other venue. I’ve proven it when I was able to work, and I’ve had other’s prove it with me in my journey through pain. Listening today, is with a hand on the door knob, standing, clearly in a hurry. Your EXPERT can not tell you what you need to hear in a concise manner and not forget anything, if that is how listening is done. Great article. Thanks.

  10. Alfonso Gil says:

    Hi Lorimer, many thanks for your words!!
    I’m from Madrid and I knew you last summer in Milano. I was in your refresh course of the first day in the World Congress on Pain. We spoke with you after course, but may you don’t remember that.
    I hope to see you in Florence or in Buenos Aires in the next European or World Congress respectively.
    Kind regards.
    Alfonso Gil