Teaching people about pain – why do we keep beating around the bush pt 2

Continued from previous post

… All is not lost, however. There is an emerging body of literature that suggests that we can change the way people understand their pain. We can reconceptualize pain in a way that makes clear the distinction between tissue damage, nociception and pain. The bulk of the work in this area is guided by a model that suggests three phases of intervention:

  • Provide evidence against the current (and inaccurate) conceptualization;
  • Provide evidence for a new (and accurate) conceptualization;
  • ƒTest, confirm and finally embed this new conceptualization, such that it can guide behavior.

Each phase has its challenges. For example, the first phase needs to avoid being retarded by the cognitive defenses we all possess in order to guard our own views. That is, key conceptual challenges need to be ‘snuck in under the radar’, as it were. We also need to exploit methods to make our interventions memorable – to maximize the likelihood that they will ‘stick’. For this, we need to engage emotional systems and use multiple media styles. Our group has recently tested the utility of using metaphors to induce a conceptual shift in the understanding of pain [14]. Metaphors can be described as understanding and experiencing one kind of thing in terms of another and are thought to provoke contemplation and increase the potential for reorganization of previous meanings. In short, simply giving people a book of short stories that are used as metaphors for key concepts in pain biology [15] led to measurable shifts in the knowledge of pain biology and in pain-related catastrophizing [14].

Much of the research into reconceptualization of pain has focused on the second phase of the above list – the provision of evidence for a new conceptualization. These experiments and randomized controlled trials show that ‘explaining pain’ (see [3] for coverage of material) as a therapeutic strategy leads to rapid changes in pain-related beliefs and attitudes [16,17] and increased pain threshold during movement [18,19]. When integrated into a behavioral or functional upgrading approach, explaining pain is associated with better pain- and function-related gains than upgrading alone [19–22], and when intensive cognitive–behavioral pain management is preceded by explaining pain, the long-term outcomes seem substantially better [23].

Of course, the loftier goal here is to reconceptualize pain before people have chronic pain (i.e., when they have acute pain or, better still, before they have any pain at all). This will clearly require a team effort. I argue that we can start by truly taking notice of Patrick Wall’s advice from 25 years ago and stop calling nociceptors ‘pain receptors’, nociceptive pathways ‘pain pathways’ and noxious stimuli ‘pain stimuli’. These are erroneous terms. That is, let us not fool ourselves that the mislabeling of nociceptors as ‘pain fibers’ is an elegant simplification – we need only sit with a patient in chronic pain to see that this mislabeling is indeed a most unfortunate trivialization.

Previously published in: Moseley, G. (2012). Teaching people about pain: why do we keep beating around the bush? Pain Management, 2 (1), 1-3 DOI: 10.2217/pmt.11.73

About Lorimer Moseley

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.

References

[1] Wall P, McMahon S. The relationship of perceived pain to afferent nerve impulses. Trends Neurosci. 9(6), 254–255 (1986).

[2] Wall PD, McMahon SB. Microneuronography and its relation to perceived sensation. A critical review. Pain 21(3), 209–229 (1985).

[3] Butler D, Moseley GL. Explain Pain. NOI Group Publishing, Australia (2003).

[4] Beecher H. Relationship of the significance of the wound to the pain experience. JAMA 161(17), 1609–1613 (1956).

[5] Banzett RB, Gracely RH, Lansing RW. When it’s hard to breathe, maybe pain doesn’t matter. Focus on “Dyspnea as a noxious sensation: inspiratory threshold loading may trigger diffuse noxious inhibitory controls in humans”. J. Neurophysiol. 97(2), 959–960 (2007).

[6] Meagher MW, Rhudy JL. Noise stress and human pain thresholds: divergent effects in men and women. J. Pain 2(1), 57–64 (2001).

[7] Arntz A, Claassens L. The meaning of pain influences its experienced intensity. Pain 109, 20–25 (2004).

[8] Moseley GL, Arntz A. The context of a noxious stimulus affects the pain it evokes. Pain 133, 64–71 (2007).

[9] Keltner JR, Furst A, Fan C, Redfern R, Inglis B, Fields HL. Isolating the modulatory effect of expectation on pain transmission: a functional magnetic resonance imaging study. J. Neurosci. 26(16), 4437–4443 (2006).

[10] Ren K, Dubner R. Enhanced descending modulation of nociception in rats with persistent hindpaw inflammation. 18 J. Neurophysiol. 76(5), 3025–3037 (1996).

[11] van Tulder MW, Assendelft WJ, Koes BW, Bouter LM. Spinal radiographic findings and nonspecific low back pain. A systematic review of observational studies. Spine 22(4), 19 427–434 (1997).

[12] Peterson C, Bolton J, Wood AR, Humphreys BK. A cross-sectional study correlating degeneration of the cervical spine with disability and pain in United Kingdom patients. Spine 28(2), 129–133 (2003). 20

[13] Link TM, Steinbach LS, Ghosh S et al. Osteoarthritis: MR imaging findings in different stages of disease and correlation with clinical findings. Radiology 226(2), 373–381 21 (2003).

[14] Gallagher L, McAuley J, Moseley GL. A randomised controlled trial of using a book of metaphors to reconceptualise pain and decrease catastrophising in people with chronic pain. Clin. J. Pain (2011) (In Press). 22

[15] Moseley GL. Painful Yarns. Metaphors and Stories to Help Understand the Biology of Pain. Dancing Giraffe Press, Australia (2007).

[16] Moseley GL, Nicholas MK, Hodges PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clin. J. Pain 20(5), 324–330 (2004).

[17] Meeus M, Nijs J, Van Oosterwijck J, Van Alsenoy V, Truijen S. Pain physiology education improves pain beliefs in patients with chronic fatigue syndrome compared with pacing and self-management education: a double-blind randomized controlled trial. Arch. Phys. Med. Rehabil. 91(8), 1153–1159 (2010).

[18] Moseley GL. Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. Eur. J. Pain 8(1), 39–45 (2004).

[19] Nijs J, Van Oosterwijck J, Meeus M et al. Pain neurophysiology education improves cognitions, pain thresholds, and movement performance in people with chronic whiplash: a pilot study. J. Rehabil. Res. Dev. 48(1), 43–57 (2011).

[20] Moseley GL. Combined physiotherapy and education is effective for chronic low back pain. A randomised controlled trial. Aust. J. Physiother. 48, 297–302 (2002).

[21] Moseley GL. Joining forces – combining cognition-targeted motor control training with group or individual pain physiology education: a successful treatment for chronic low back pain. J. Man. Manip. Ther. 11, 88–94 (2003).

[22] Ryan CG, Gray HG, Newton M, Granat MH. Pain biology education and exercise classes compared to pain biology education alone for individuals with chronic low back pain: a pilot randomised controlled trial. Man. Ther. 15(4), 382–387 (2010).

[23] Clarke CL, Ryan CG, Martin DJ. Pain neurophysiology education for the management of individuals with chronic low back pain: a systematic review and meta-analysis. Man. Ther. 16(6), 544–549 (2011).

[101] Website: Health, United States, 2010, with special feature on death and dying. www.cdc.gov/nchs/data/hus/hus10.pdf

 

 

Comments

  1. John Quintner says:

    Lorimer, I suggest this discussion is about whether we can help our patients to reframe their lived experience that we call “pain”. As you know, we have likened pain to an Aporia, which leaves it precisely as defined by the IASP – an unpleasant sensory and emotional experience. If one follows this way of thinking, all attempts to reify (make into a thing) the experience are bound to be problematic. I think our real need is for better theory to enable us to help our patients escape their biological predicament.

  2. Patty Nies says:

    Lorimer, I’m a person in pain. I had an initial injury Feb 2011 – since then I’ve been in almost constant pain. Just about any movement, sitting, standing, and laying down have all been difficult. All the tests have been negative for anything to still be causing my problems. Two weeks ago I watched a lecture of yours where you were explaining what is going on when you experience pain, (you used your snake bite and subsequent branch scratch as your example of the level of pain you experienced) In learning exactly what was going on in my body (mind), instead of thinking that I was further damaging myself and being told by the medical community that I should stop doing the things I love because it was causing the pain I was experiencing, I’ve been able to just about alleviate all the pain that I have had. I did this by simply examining what happened in past situations that may be contributing to it. By stating to myself “You’re OK, there is no danger here” I can just about stop what is going on in my body. I still have some resistance with this because of what my body has been going through, but it’s only been two weeks! It hasn’t been easy, their has been a lot of emotional stuff involved with all this, but I’m dealing with that too. So yes, John Quintner, as a person that has been let down by the ones that I’ve sought help from, you can easily teach your patients to reframe their minds to get rid of their pain. A good place to start is by explaining exactly how the mind handles pain. It might be a good idea to have them watch Lorimer’s lecture. I may be a unique case but for less than an hour of my time in watching that video twice, (because of all the information in it) I can now do the things I’ve always done without worrying I’m crippling myself and more importantly do it without living in pain.
    Thank you Lorimer, for the work that you do. That little video gave me back my life.

    John Quintner Reply:

    Patty, I am pleased to hear that Lorimer’s wisdom and teaching has helped you to reframe your experience. I would to use Lorimer’s analogy of “beating around the bush” in taking the liberty to change his important question to – How long will we keep beating about the bush in the vain hope that a “thing” called Pain will emerge? The same question may be asked of other “things” such as Love, God, Death, Creativity. Of course the answer is obvious – don’t waste our time looking for life’s aporias (puzzles) as if they are concrete entities. But these constructs will continue to challenge our understanding of the meaningfulness of our lives.

    Kathleen Summers MD PhD Reply:

    Thank you for the inspiring story, Patty.

    Lorimer, how can I get a copy of that video for my practice?

    Any other practical advice for how to get this message across to my patients would be appreciated.

    Thanks.
    Kathleen

    Ruth White Reply:

    Hi Kathleen
    You will need to get something like 4K Video Downloader software on your computer first. There are many free ones to choose from. Then simply type “Lorimer Moseley” into YouTube. When you find the video/lecture you want (there are many to choose from)- copy and paste the URL into your download software and then you’ll have a copy of the (YouTube movie) file for viewing when you can’t access the internet. Hope this helps, cheers Ruth

    Kathleen Summers MD PhD Reply:

    Thank you, Ruth. It’s wonderful that there are FREE videos. I didn’t realize they were on Youtube. :-)

    Patty Nies Reply:

    Kathleen, the video you are looking for is titled.”Mind and it’s Potential’ Body in Mind, The role of the brain in chronic Pain.
    Think and be Happy. Dated 4/16/12.

  3. Yannick BARDE-CABUSSON says:

    Hi Lorimer. One thing I like to ask from patients (and practitionners) is to only use the word “pain” when they speak about brain’s mechanism. In this way if they want to discuss something outside the brain, I recommand to use others terms and reserve pain for the brain. Maybe its a little bit strange at the beginning but with good explanations, repetitions and time it helps to reconceptualize what is pain.

    John Quintner Reply:

    Yannick, are you covertly “neuralizing” the experience of pain? What other terms do you offer your patients when helping them reconceptualize “what is pain’?

    Yannick Reply:

    Hi everyone,

    Thanks for this great discussion which help me a lot to enlarge my point of view.

    Sorry for replying late to your post John. I must recognise that I “neuralize” maybe too much the pain experience when I ask my patients to think “brain” when they speak about “pain”. When we use terms like nerves, nervous sytem, etc, we have to take great care not falling into the same trap than when medicine explained pain with “bones/muscles/etc models” : but a question I ask myself is : is it possible to reconceptualize the patient’s pain experience (from an old bottom-up perspective) towards a more complex and integrative explanation without passing by a neural approach ?

  4. Anonymous says:

    John the world abounds with theory (more bush beating) escape from a biological predicament is a circuitry argument we all “escape” eventually!
    Like the lobster story not everything in life is explained biologically, the discourse you keep proposing adds to the “stigma power imbalance” for those living the experience of persisting pain, telling someone who is saying they hurt, “it is” an “Aporia” is no different to saying it is “all in your head”

    John Quintner Reply:

    Dear Anonymous, I beg to disagree (respectfully, of course).

    Aporia is being used here to signify “puzzle”. In fact Ronald Melzack wrote a book in 1973 entitled “The Puzzle of Pain”. His (and Pat Wall’s) views were liberating and in my opinion did not carry the risk of adding to the stigma that society attaches to people in pain.

    My point is that our clinical practice is guided by theory (even though we may not be aware of this). Outdated theory is likely to spawn ineffective therapy!

    Where is the power imbalance when we decide to look at ourselves, and others, as being fellow living creatures? There are some fundamental properties that appear to be common to all living organisms. Theory of this type appears to be useful when applied in the clinical context of Pain Medicine/Management.

    Anonymous Reply:

    Hi John.

    “There are some fundamental properties that appear to be common to all living organisms.”
    I am totally in line with you on this one.

    If you haven’t already come across Louis Gifford’s The Mature Organism Model (in the first book in the series “Topical Issues in Pain”), I can highly recommend it. In my opinion it represents the view you’re describing here. It deals with pain in a much broader biological context.

    Adam Bjerre Reply:

    ” There are some fundamental properties that appear to be common to all living organisms.”
    Regarding pain what properties are you thinking of? Obviously threat/safety comes to mind. Others?

    Cheers
    Adam

  5. After my six year experience with pain I do still struggle with it having any other explanation than something is damaged and until it repairs the brain won’t stop harping on about it. My treatments are finally giving me some great relief and better capacity in the last year, the pain levels are much lower, can’t it simply be my injury was diagnosed, treated and I’m healing? If thought distraction can ease pain then perhaps the pain issue isn’t related to damage. I’ve had moments of distraction and ended up knocking myself out for a day or two, I’ve had them now after treatment and I have to have a short rest, in some cases I’m completely fine. And if the brain is so damn intelligent then why can’t it remember the most important and happiest scenario , ME in no pain doing yoga 4 mornings a week with my toes around my ears and creating all day?
    My current TCM is fabulous. I asked him if he thought my issue was ‘pain tunes’ or ‘injury’. He answered ‘We’ll only know that when we get to the end of treatment’…

    Patty Nies Reply:

    Soula, I thought of you all week-end. If I were you I would just assume that the pains you are experiencing are a big part of ‘pain tunes’ . I never would have thought that I could have gotten rid of my pain just by clearing the past clutter that was still causing my pain. I am still dumb founded by my recovery. It truly is amazing that I am 99% back to my old self. In only 2 weeks! Negative talk from doctors, friends, and MYSELF was standing in my way from getting rid of my pain and therefore, feeling better. Maybe not all of yours would go away from just actively trying to see where past issues are coming from. Whatever it was that you experienced was life changing. How can their not be anxiety and emotional trauma from that? How would it hurt that you figure out a way to deal with the thoughts associated with your problem and how it has changed your life along with doing what you TCM wants you to do? It certainly isn’t going to hurt you to work on the mental garbage surrounding your issues. I wish you well!

    soula Reply:

    Hi Patty,
    Thank you for your reply and for your thoughts but that approach has never gelled for me. What clutter, trauma, negative talk? Yes, I’ve heard it but it’s water under the bridge. When I’m well, I take OFF! You’re talking to someone who is in an extremely high happy state most of the time, even through these years my positivity and creative thinking stayed strong, always hopeful and if you ask me what my life is like, I’ll answer ‘so blessed, so lucky, so incredibly happy’. I don’t buy all the ‘hurt’ and bogging down in the past stuff. I bought a fitball to live with again, after minutes in the house I said to my partner, ‘Our house is back to the way it should be’, no trauma, it was normal for me, I couldn’t even see it after a while, neither did my family!!!! I honestly believe this sort of thing is not my scenario and I have injured the pelvic nerve. Simple (well, complex actually!). It needs treatment, it reacts to treatment, calms to rest. My brain is still working in those times why does it all settle? Why does the nerve block work, why does it wear off? That’s not thinking… I’ve had a blissful time while it worked… why wouldn’t that stick if my brain had ‘relearned’ what was ‘normal’?
    Of course this is my experience and nothing makes me happier (well, ok maybe my own healing would), to hear that you overcame your pain 99%. How fabulous and I wish you well also. Thank you again for taking the time to think of my case. So lovely of you. (So lovely of everyone on this forum to share their experiences!!)

  6. Adam Bjerre says:

    Hi John.

    (Sorry for this lengthy comment – I’m a “ruminator”.)

    I’m a clinician and I think I would have a terrible problem explaining to a patient that what they feel and experience and how it has come to be that way is – as I understand your writings – simply a place where scientists cannot go. This might be a misunderstanding on my part (about your writings) – and maybe you can correct me then.

    I feel as if this resembles the classical biological dispute between Steven Rose and Richard Dawkins of complexity and reductionism where I would like to quote Dawkins from his review of Rose’s book “Not In Our Genes” (mind the loaded language – Dawkins had been under heavy “reductionistic” critique in the book):

    “Why do Rose et al find it necessary to reduce a perfectly sensible belief (that complex wholes should be explained IN TERMS of their parts) to an idiotic travesty (that the properties of a complex whole are simply the SUM of those same properties in the parts)? “In terms of” covers a multitude of highly sophisticated causal interactions, and mathematical relations of which summation is only the simplest. Reductionism, in the “sum of the parts” sense, is obviously daft, and is nowhere to be found in the writings of real biologists. Reductionism, in the “in terms of ” sense, is, in the words of the Medawars, “the most successful research stratagem ever devised” (Aristotle to Zoos, 1984).”

    Regarding pain, I think that we can accept that it is a complex phenomenon with unpredictability at its core, but “that complex wholes should be explained in terms of their parts”. I don’t think there is any other way around it if one wants to keep a defensible monistic, materialistic and darwinistic view on the phenomenon (and I think we should).

    So far I understand pain this way:
    – that when it comes to pain a lot of us have been looking for pain where pain is not.
    – that we should comprehend pain as a phenomenon (as of a spectrum). Like that of complex processing and not a state or an entity.
    – that pain is like love and that we as persons/clinicians can (from the left side of the Neuromatrix) try to influence the person in front of us in a way that hopefully influences the chemical signaling processes of that person and hope for a reduction or resolution of pain.
    – that from simple atoms and cellular processes emerges complexity – a complexity that when it comes to human beings we can hardly comprehend that complexity – but that does not hinder us in exploring the parts and processes (whether internal or external) – and ultimately explaining this to the patient in their language.

    (See for example BBC’s The Secret Life of Chaos for a fascinating look at simplicity and complexity.)

    Kind regards.
    Adam Bjerre
    Physiotherapist
    Denmark

  7. John Quintner says:

    Adam, you have not misunderstood my position, which has not shifted as a result of your ruminations. Are there any neurophilosphers out there who might contribute to this discussion?

    ian stevens Reply:

    http://iai.tv/video/the-agony-and-the-ecstasy

    John , you might find some the philosophical angle here of some interest. Personally I find Havi Carel’s approach (phenemenonological enquiry) http://www.wlv.ac.uk/default.aspx?page=33801 and her excellent book ‘Illness ‘to be of value.
    http://www.amazon.co.uk/Illness-Art-Living-Havi-Carel/dp/1844651525

    John Quintner Reply:

    Thanks Ian. I enjoyed the discussion.

  8. Anonymous says:

    Pain is complex, and I agree that reconceptulizing pain from the ofset and before is important, perhaps on a grand scale as mentioned on the last blog.

    I had a great experience in clinic a few weeks ago a patient 8-10 weeks after foot surgery, kept breaking into a cold sweat (literally) any time I went near his foot. I could have panicked about his high levels of pain, sent him back to his consultant made his situation a whole lot worse and am ashamed to say I may have done things like this in the past as an inexperienced therapist. Instead I softened my voice, and talked through some relaxation, visualisation and breathing techniques. His pain was practically gone, I could happily mobilise his foot with no sweating. The patient himself was so shocked that his foot did not hurt and asked me if I had just hypnotised him! I was able to use this experience to help him recognise to influence the brain has on pain with out really having to explain anything to him at all. We as therapist can be taut and understand the neuroscience but I wish as a eighteen year old at uni we were taught some of the soft skills, its not just about what you say but how you say it

  9. Adam, pain and love can’t possibly be used in the same sentence…

    Anonymous Reply:

    Soula, as they are both examples of Aporias, I cannot see why you object to using them in the same sentence.

    The problem I have with Adam’s post is his claim that “complex wholes should be explained in terms of their parts”. My understanding is that the lived experiences that we call “love” and “pain” come to us as complete packages. This is the stuff of poets and artists, not of science.

    As Lorimer says, “let’s stop beating about the bush”! Pain is not a “thing” that will emerge from the bushes, no matter how hard we might beat them. On the other hand, Pain is not “nothing”. Complex? You bet!

    Adam Bjerre Reply:

    “My understanding is that the lived experiences that we call “love” and “pain” come to us as complete packages.”

    I agree with you on that. It’s the “baked cake”. And the ingredients and the recipe does not equal the baked cake.

    Do you disagree that we as clinicians should try and influence the person in pain? And if not – in what way then?
    What “channels” can we use? Auditory? Others?

    John Quintner Reply:

    I apologise to Anonymous for inadvertently posting my reply to Soula under his/her name.

    Soula Reply:

    Please for anyone who is a clinician and treating someone with chronic pain, don’t bring up love as a comparison. Talking about ‘aboria’ to someone with chronic pain is like having the luxury for idle chatting. Do clinicians realise how little time people with chronic pain have to focus, listen, understand, comprehend, let along try and help themselves. And along comes someone with the time for idle comparisons/chit chat. Leave it for later, it might be a good point but in the thick of it, it’s the last thing I’d have time to focus on. Is this how you’re talking to your patients? They have no hope! In the thick of it all I could think of is ‘Pleeeeze have you got anything for the pain?’ You’re way off! That’s a conversation for way down the track….

    Adam Bjerre Reply:

    Dear Soula.
    It is not mine or John’s intention in any way to try to diminish what you and others are experiencing with “chit chat”. Quite the opposite. If that hasn’t come across in the discussion I deeply apologize.

    John – I think – is bringing forth a more than timely dilemma that has haunted the clinical and scientific world for decades/centuries – namely that we have been viewing the person experiencing pain in a way that ultimately has led to “an extinction of empathy” – we have viewed a lived experience as a “thing” that we can “remove” with short-lived methods that has left patients confused, alienated and without control and understanding of their situation. This has also led to all kinds of ineffective treatment types where we have tried to cut, poke, stretch and medicate “the” pain away. I have personally studied this field for 10 years (as a scientific clinician) and we have to discuss these conceptualizations out in the open because they inform our daily practice, clinical decisions and the relationship between the patient and the clinician/the intersubjective space (whether we realize that or not). I think everyone following this blog is very aware of the linguistics used in the daily encounter with a patient.

    If we as clinicians all knew exactly what “pain” was I don’t think we would have a problem of epidemic proportions on a worldwide scale – that’s pure speculation on my part, I know. But the thing is: Pain is complex and unpredictable. I think maybe you also experience that on a daily basis?

    We have to move the professions that deal with persons experiencing pain forward based on science and philosophy and Lorimer & Co., John and many others are doing a tremendous job in that regard IMO.

    Hope this makes some sense of the wording in the discussions above. (Hope I also have understood you correct, John?)

    Kind regards
    Adam

  10. Hello again Lorimer!
    Thanks for posting my comments a few days ago.
    Anyway, Im still curious to know why there is only one reference mentioned in your “why are we still…” post regarding the effect of radiographic changes of the knee (your ref. 13)?
    There are, as mentioned, a few other studies that do find significant relations between radiographic changes of the knee and knee pain/function. Why are these not included in this consideration? As much as I am a huge supporter of most ideas of Moseley, I also know it is important also to include “inconvenient” points to a be able to present a neutral or objective (as possible) view to the public. I mean, to me, there seems to be left out studies that might not be advantageous to the modern view of pain, as presented by Moseley and colleagues. Is it so that even on this presumed “open-minded” site, there is a bias, or a selection of science that suits the presenter? Are peripheral mechanisms of pain consciously toned down to make way for the CNS big brother?As a manipulative therapist I have learned through the years that being a sceptic, and my own harshest critic, is the only way to be closer to the “thruth” in my profession. I hope you guys do not loose your perspectives in the quest for new knowledge, and are not to passionately in love with new intriguing ideas that unfavorable studies are erased from your reference lists.
    Kind regards,
    Erland

  11. John Quintner says:

    Adam, before I attempt to answer your question, could you please explain what you mean by “influence the person in pain”?

  12. John Quintner says:

    Adam, whenever two people decide to engage in a clinical context, each influences the other, albeit for better or for worse.

    We recently published a paper* exploring some of the issues (empathy/negempathy), by which we believe health professionals can inadvertently contribute to the societal stigmatisation of the person in pain.

    *Cohen ML, Quintner JL, Buchanan D, Nielsen M, Guy L. Stigmatization of patients with chronic pain: the extinction of empathy. Pain Medicine 2011; 12: 1637-1643.

  13. Suzanne Newnham says:

    As usual Lorimer’s perspective offers a practical approach to the underlying pain regardless of its origin.
    After a while the attitude I COULDN’T do something because of THE pain becomes – MY pain WOULDN’T LET ME do [whatever the “something” is].

    The more a person has to fight to be believed about the pain, the intensity, its impact the greater the reinforcement and personification of this thing called pain which is affecting the things they like to do or need to do.
    In my experience catastrophising producing very real symptoms but ultimately based on fear at that moment of the worst possible consequence ie absolutely excruciating pain or immense immediate impact on an activity they were looking forward to, from whatever direct or indirect action has acutely increased the chronic pain.

    Energy is spent on making relevant medical and health personnel understand how life is for that person. This continually reinforces the pain, the inability to cope, and creates a multitude of fears – will they ever get A life back, gone is what they have known as THEIR life.

    I believe that when a person’s identity is replaced (or in the process of being replaced) by a personification of pain then an individual based grief, pain, impact education process for both patient and medical/health professional is required, and if there is a diagnosis for the condition then individualised treatment for that condition happens concurrently. In the absence of a diagnosis – and sometimes it can take years for a definitive diagnosis then it is exceptionally important for the education process above to be started early.

    An aim would be to reconceptualise pain as THE pain NOT advancing to personalise to be MY pain, progressing from an acute to chronic pain condition.

  14. John Quintner says:

    Suzanne, you place great emphasis upon diagnosis. Of course, this forms the basis of conventional medicine as practiced in our society. But as we all know, such an approach has failed so many people in pain.

    However, what if the very act of diagnosis converts the patient’s “illness” into the clinician’s “disease”? Once this has happened, the patient recedes into the background as the clinician wages war upon this “thing” that has invaded and occupied the body of the patient. We all tend to think like this.

    Furthermore, what happens when no definitive diagnosis can be offered? Well, in practice, I believe that patients are then awarded pseudo-scientific diagnoses, such as chronic pain-as-its-own-disease, non-specific low back pain, chronic regional pain syndrome, myofascial pain syndrome, fibromyalgia syndrome, etc. The conferral of these bogus labels does no service to the patient.
    I will be interested in your reply.

    Suzanne Newnham Reply:

    John I apologise if my words gave emphasis upon diagnosis as the complete intention of my comment. My comment re: “if there is a diagnosis for the condition then individualised treatment for that condition happens concurrently.” was only to say that even when a person has a diagnosed condition their response to everything is not going to be the same as another person. “In the absence of a diagnosis…” or perhaps I should have said in the process of identifying a reason/source of the symptoms …? A “bogus” label (to use your phrase) is not helpful and can be misleading; though some labels are just a less complex way of saying twelve or fifteen symptoms and may be interim.

    However, all of this about diagnosis is way off the point I thought I was focussing on – the personification of pain THE pain transmorphing to MY pain (not necessarily me the writer of these comments but a universal “MY”).
    John, I would be interested in your thoughts on the section of my comments which includes “multitude of fears – will they ever get A life back, gone is what they have known as THEIR life.” and an approach to two way communication between person in pain and medical or health professional, especially the aspects of grief and impact of pain.
    Cheers Suzanne

    Patty Nies Reply:

    Suzanne, Thank you, your simply stated points are exactly on track of what is going on with a person in pain. In reading some of the above comments, I’m sorry, but for me, it has further complicated the facts that Lorimer is trying to clarify. As you stated, a patient is looking for a practical approach to healing. Pain consumes your entire life to the point that pain is all you know. You feel you can say, “Hello, my name is Pain” You think about it all the time, every movement, every aspect of what you are doing you are thinking how can I get “this” done without damaging myself. I’ve been told to just stop doing what gives me pain. Stop showering? Stop sleeping? Stop doing everything? Not sound advise. They are telling me to simply stop living. I had lost ME. And if you have never had debilitating pain that is a hard concept to compartmentalize. I had to find the solutions on my own to help put an end to it. I have had fantastic advice from other people who have had pain to show me the correct path to follow to do the things I needed to get better. And yes, along with the help of my Chriopractor when things went awry. Isn’t that the kind of advice we are going to health professional for? My final step was a when I watched Lorimer’s 4/16/12 video on the role of the brain in chronic pain. Through out my journey to wellness, many times it was the doctor’s ego speaking to me when I asked for their help. Telling me I won’t ever get better unless I follow their instruction. Telling me I am lazy because I won’t do the specific exercises they are prescribing, when physically, I was unable because of what it was doing to me. I am not going to be told these things from someone I am paying to help me, so I fired them and kept looking until I found one that helped me. He was not above saying he wasn’t sure what to do for me. He helped me while I was helping myself. You have to be your own patient advocate in the type of care you receive. The patient can never stop looking for information on what is going on with their situation because in my opinion, health providers can’t have all the answers. That is why their is still research going on.

    Suzanne Newnham Reply:

    Patty, I can relate to all that you have said, and watching and listening to Lorimer at the Pain Forum in Canberra last month was a highlight. He confirmed for me that he does know and the way he speaks makes a lot of sense.
    I am truly sorry that this whole digression to not only explain myself and revisit and re-answer old ground on the term diagnosis rather than the topic at hand has complicated this whole discussion. It has for me too.
    Best wishes to you.
    Suzanne

  15. I am going to have to agree and disagree with different points of Adam’s and John’s posts. While I agree with Adam in that I don’t think approaching pain as an “aporia” itself is a useful construct. Nor do I think understanding pain through reductive tendencies in isolation is productive either. While understanding pain as complex and a fundamental aspect of human nature is helpful; classification of it as disease is not. Part of the reason, clinicians have been at a loss for an appropriate model to apply to the conceptualization of pain is due to the lack of continuity between understanding how biology, psychology and the social/cultural domains interact.

    In understanding the constituents of “pain” we have to be specific about the level analysis we are applying to whatever contributing component we are discussing in relation to “pain”. Analysis of a particular component at a given level of complexity may not apply to other levels. Unfortunately pain, as being understood in scientific/medical discourse seems to be biased by a naturalistic viewpoint; with little attention given to a social constructivist perspective. From the naturalistic perspective was born the biological and subsequently neurophysiological and cognitive sciences. Both the neurophysiological and cognitive are being utilized extensively by the scientific/medical community to understand pain, with limited success–IMO. This has come at the peril of humanistic and sociological explanations for the individual’s experience of pain.

    IMO, pain should be understood as belonging to the domain of consciousness. A tripartite view of consciousness has been suggested consisting of 1) an experiential-self 2) a private-self and 3) an internalized public self. The experiential self is consisting of the phenomenological experience and requisite nonconscious processing. The private self is the internalized self-constructed narrative. The public self is internal narrative of how the others see them and they want to be seen and is created through social interactions with the person’s surrounding culture.

    It is the dialogue of between the internalized public self and the private self is the least understood within the scientific/medical community. It is this dialogue that stands at the nexus between culture and individual. It is the understanding of this nexus that is critical to understanding how to merge the naturalistic perspective with the social one. We know that the experiential self is nontransferable between individuals, yet critical components between the private self and the public self are accessible through language. And because “pain” is first and foremost a word then it is appropriate to think of it as belonging to the discourse of the private-self, the public self and other people. This is because all of these domains of the self are discoverable through language.

    It is my contention that much of what is attempted to be understood of pain is derived from a model of understanding that builds up from the sensation in the periphery and unfortunately assumes a congruent representation as information is processed and integrated from the experiential self to the private self and finally to the public self as expressed in health seeking behaviors, pain related expressions and behaviors. Unfortunately, in my experience this could not be further from the truth.

    Clinicians and schools need to develop and refine tools that allow them to probe the patient’s language based belief/justification conceptualizations. This consists of tools to disarm the patient, interview within a nonjudgmental context, confront their beliefs while minimizing cognitive dissonance and re-shape a person’s conceptualization, enhancing self-efficacy, minimizing fear and catastrophizing and understanding the difference between the superficial (public) and deep (private) versions of self: with the ultimate goal of facilitating a deep conversation with the patient.

    The trick is for clinicians is to understand the words they use can be as sharp as surgeon’s scalpel at the domain of social/cultural—should they choose to be so precise. That education of pain is not a passive or blunt process. That it is active, nuanced, personal, empathetic, non-technical, and symbolic. It may also involve discussion of ostensibly disparate aspects of patients’ lives.

    Within the domain of physical therapy it is reshaping and re-conceptualizing from the top (culturally mediated) and from the bottom up through sensorimotor habituation, re-integration and exposure that stands the best chance of creating encounters that can help patients resolve and/or cope with their pain.

    Experiential experiences such as love and pain have understandable corollaries to human behavior at multiple levels of complexity. Is not throwing up our hands in the face of complexity a premature abnegation of this very important investigation?

    Michael Negraeff Reply:

    Again, I love this discussion as I am someone who likes to sit in coffee shops with friends and colleagues (live or online) and read, think, and discuss.
    But to advocate for the people with pain, we need to find ways to translate this thinking and language into helping people at the margin, which in healthcare is the 8-30 minute visit. Is this impossible? I do not think so.
    I will repeat the first step of my colleague Neil Pearson in his model, which is “respite”. Sometimes people just need some relief before we can go any deeper. I don’t think anyone is disagreeing with this, but I wanted to remind us all.

  16. John Quintner says:

    Thanks to Adam and Eric for their eloquent responses. In our 2008 paper* we attempted to raise and explore some of these complex issues that challenge us in our day-to-day clinical practice. I do hope this long overdue discussion will continue!

    *Quintner JL, Buchanan D, Cohen ML. Katz J, Williamson O. Pain medicine and its models: helping or hindering? Pain Medicine 2008; 9: 824-834.

    Evanthis Raftopoulos Reply:

    Hi John,
    We briefly discussed your 2008 paper at Somasimple.com in this thread: http://www.somasimple.com/forums/showthread.php?p=153250#post153250

    What is your opinion of the neuromatrix theory as proposed by Melzack in 2001? A lot of us have been utilizing this theoretical framework to explain to patients the multilevel complexity of pain. Based on your rational in the article (euclidean non-circular autopoiesis standpoint?) it appeared to me that you do not support the notion of the pain experience being reduced to anything less than an aporia, including an “output” of the brain. Please correct me if I’m wrong. We like your proposition of the “intersubjective third space, from which new therapeutic possibilities can arise”. Thank you for your work and your insight and I’m very happy to find you here.

    Sincerely,
    Evan Raftopoulos, PT

  17. Adam I completely understand, of course it’s clear what yours and John’s (who is actually a very dear cyber friend) intentions are. I’m just trying to state a patient’s perspective, the desperation for pain relief in amongst all the information and opinions.

    This is a brilliant conversation.

  18. John Quintner says:

    Hi Evanthis. Melzack’s theoretical description of the neuromatrix as a means of understanding the brain’s ability to integrate incoming sensory inputs with past experience and with innate representations of the body schema and self was a major milestone in pain research. These are not my words but those of Terence Coderre, which I have extracted from his “Tribute to Ronald Melzack” in the Winter 2000 issue of Pain Research and Management. Of course this theory can lead us into useful clinical discussions.
    As to your other question, surely by definition an aporia (such as pain or love) is irreducible?
    By the way, the 2008 paper crystalized about 10 years of our pondering as to the nature of the pain experience. I am delighted to hear that it has caught the interest of your group. Our other papers do more or less follow on from this one.

    Evanthis Raftopoulos Reply:

    Thank you John. The points in your paper are thought provoking. One of the take home messages is that “we still lack an explanatory model for pain”. Do you think that a valid explanatory model can be constructed from the neuromatrix theory? Thank you for this discussion.

  19. John Quintner says:

    Suzanne, your experience is for you alone to “transmorph”. For anyone else to attempt this process would, in my opinion, be an insult or worse!
    The many fears that you and others might experience are indeed legitimate topics for airing, discussion, and negotiation in the “third space”, as are the fears and beliefs of the respective health professionals with whom you choose to engage. This is all very good in theory but there can be major obstacles to such an ideal engagement, as everyone in pain sooner or later comes to realize. Some of these issues are discussed in our Stigma/empathy paper of 2011. We do have quite a way to go!

    Suzanne Newnham Reply:

    I disagree with your first two statements John it is not just my experience. Transmorph . Going through a complete, utter, and total change in which the result is completely, utterly, and totally different from the original: pain changes a person; and in some instances THEIR WHOLE LANGUAGE CHANGES PERSONALISING THAT PAIN – this is what I meant by that statement. It is (some and certainly not every) person in pain who is transmorphing – it is not some weird process that is “attempted”!

    My comments are based on a combination of 20+ years of working in complementary health through bodywork, attending seminars, workshops, conferences as well as about 25 years (some concurrently with above) in clinical admin and there for the most part in direct contact with patients. 15 years of assisting at seminars where one of the topics discussed in the first half of the day and then mindful throughout the remainder of the seminar is: realising one’s language contributing to the ownership of the person’s condition. So as I don’t have the permission to relay stories from the many thousands of people I have had contact with who have owned their pain or health condition, witnessed over time their change in language as the condition has changed for the positive, gone, or ability to cope has increased, sometimes PART of my own story is given as an example. An example only – there are other forums/discussions where if I choose to have cyber help or conversation for me then that is the place not here or similar sites that are for educational discussion. This is the last time I am going to explain my position for any personal references in this or other discussions.

    I have no intention of applying “a categorical label that implies a negative stereotype” 1 further entrenching a generalised view or stereotyping a person in pain – my comments are based direct and indirect contact over many years, to which a deeper understanding has been gained because of my personal situation and not just limited to a professional interpretation. And yes that may sound like labelling but again not the intention.

    There is no [and to use your words] “ideal engagement” and as I said in my initial post – it is an education process for both patient and medical/health professional. Your concept of a “third space” as outlined in your Stigmatization paper appears to offer a neutral place for both patient and clinician in which to explore.

    Suzanne Newnham Reply:

    I forgot the reference: 1. Pain Medicine 2011; 12: 1637–1643 Stigmatization of Patients with Chronic Pain: The Extinction of Empathy Milton Cohen, MD, FFPMANZCA, John Quintner, MB, FFPMANZCA, David Buchanan, RN, PhD, Mandy Nielsen, BSocWk, PhD, and Lynette Guy, PhD. pg 2¶

  20. Michael Negraeff says:

    This is a great blog/website and discussion forum. In a few weeks, I am going to a small town in southwestern British Columbia to speak to an interdisciplinary group of clinicians (PT, OT, GP, etc) about the need for communities to create spaces and processes in their region to allow people with pain to heal. I think this bottom up approach, with the resources of communities, is needed as much as the top down approach health authorities can take – as NSW has done with their $26 million investment.

    But approaching this with them, I feel my first job is to help them see the need to breakdown each of their pain paradigm/treatment silos, so they can all think of pain in the way this discussion is evolving – a complex lived experience arising from innumerable modulators. I think if that can occur, then their own individual skillsets, offerings and tools in the toolbox can be coordinated in an empathetic approach with the person with pain as an active partner in their own healing (holistically speaking, not as in cure of the biomedical).

    For some there will be a greater biomedical focus and accurate diagnosis that leads to healing. For others, it will require a broader lens and deeper understanding of the factors involved in creating the lived experience of pain. One thing I would like to see is a breakdown of the dichotomy of “I’ll fix you” and “you fix you” that dominates the most common pain paradigms and find a way for these to merge and dance together to create healing with creating stigma.

    Michael Negraeff Reply:

    should say “without” creating stigma

  21. David Buchanan says:

    For mine both Lorimer and Eric’s positions frame the pain for the other in pain. Having a tripartheid apprehension of consciousness is not at all universally agreed upon ans Wittgenstein noted about Freud – i not even approaching hypothesis. That is to say – at best – it is speculation. Here is what we have: the person in pain – therson trying to help that person. For the latter the biggest obstruction to this help has been their own frames of looking at the person in pain. This has of course led to numerous and disastrous cases of iatrogenesis. What we need is conceptual clarity: stop treating pain as a thing. It is not a thing. Therefore we need to acknowledge that our understanding of things influences or frames our understanding of pain and we need to see our own frames that we mistake for pain’s nature. Pain and the person are inseparable. Given the lack of a silver bullet we need to negotiate with this person in a dialectic that crosses our sense of the objective (expertism) and their subjective state. This negotiation is crucial for without it we default back to our frames and re-run the endless futility of the caucus race (Alice in Wonderland). Wittgenstein’s aphorism 129 in PI sums up this approach. Until this occurs never have so many experts failed so completely to embrace the bleeding obvious right before their very eyes. One does not discard one’s frames just shares them with the other… If if makes no sense then together negotiions unfold until the person in pain feels they are more actively managing their pain… There is much we can share that we do not. Rather what we should be sharing we pass off as knowledge that all too often is non-negotiable. For god’s sake stop it. People in pain need you – all of you – not for your frames that fail them again and again – but for your suite of tools that they may pick and choose from to empower themselves… Otherwise we remain in a constant undeclared war bewtten the (psuedo)objective and the subjective. It is high time we understood the role of the intersubjective when it comes to deal with the imponderable nature of pain.

    Nicholas Marki Reply:

    I am newly minted into delving into the neuroscience surrounding what we commonly call pain. The neuromatrix appears to be a reasonable current explanatory model (in my frame), there appears to be good science with becoming more R brain, and there appears to be good reason to resist making pain a thing.
    If I understand your point, it is this: that we allow the patient to express their pain to us to the best of their knowledge, and we offer to the patient what we think we understand about pain to the best of our knowledge. Ending in a consensus between therapist and patient to a paradigm that suits that patient’s needs to resolve their mystery of pain.
    Am I correct in this?

  22. David Buchanan says:

    PS : Lorimer… Metaphors exist not so much to tell a story but because language is broken and plays games. As Eco pointed out: metaphors are dangerous things if their game is passed off as being the thing of itself. Descarte’s bell is a classic dangerous as hell example of how a metaphor can become all too powerful and utterly misleading. We ought not construct metaphors without first acknowledging two things: 1. they represent the brokenness of language not a true representation of reality; and, 2. their propensity to become allegorical and this allegory to take over what is really going on… We have to use metaphors… That is the nature between the brokenness of language and the complexity of our relaity. But we must be very careful when doing so except in the poetic act of course. Best d

  23. Suzanne Newnham says:

    John Q, and Patty N – I posted replies directly to both your comments this morning but neither have appeared on checking this afternoon.
    I don’t have the energy to continue corresponding. All I can say is that Lorimer’s approach makes a lot of sense to me.

  24. John Quintner says:

    Apologies Suzanne. I must admit that “transmorph” is not a word with which I was familiar. Obviously, there has been a significant change in your “person-hood”. I would not tend to reify “pain” as being a causative agent in such a change. I suspect there has been an alteration in your phenotype.
    One suggestion is that we are witnessing undamped stress response system activation, a process which can consume considerable reserves of energy and can be associated with widespread and significant bodily changes.
    In my post I was referring solely to your own narrative!

  25. Adam Bjerre says:

    Thank you all for a very worth-while conversation.

    David and John:
    Are you saying that we should remove biology from the equation when speaking about pain with the patient?

    I hope not.

  26. Adam Bjerre says:

    To David and John:
    The reason why I am bringing up my former question is because it seems that one of your core concepts in your 2008 paper is “the unique property possessed by living organisms…a process…called autopoiesis.” I’m sorry for everyone not involved in philosophy to bring up this word/description (meaning “self-creation” or “self-production”) but I think it is center to the conversation.

    As I understand it “autopoiesis” was first coined and introduced (by Maturana and Varela) with the claim that it both defined living systems and “explained” them. I think I’m not mistaken so far. The trouble since is that it originally has been such a generalized definition and explanation that it potentially could include non-living systems and culture (human social) systems. That means that it didn’t define the “living”. They also included difficult (in my opinion) rhetoric about self-reference and circularity (which I understand is just “feedback” – everything is connected and feeds back on itself, creating both pattern and complexity).

    So where am I going with this? First: with such a wide definition autopoiesis can mean just about anything you want it to be when you try to explain living systems. Second: we could go into detail, but overall several authors are worried that it comes tantalizing close to a metaphysical construct that decouples the meaning from the physical world defying natural laws of physics.

    I think that we might have a problem here regarding pain and consciousness in a scientific sense.

    Over to you.

  27. John Quintner says:

    Adam, in fact quite the opposite! The biology happens to be central to our thesis – the “structural coupling” (i.e. clinical engagement) of two self-organizing, autopoietic (self-creating), and self-referential organisms in the shared “third space”. Our issue is with those who attempt to reify (make into a thing) a lived experience that we call “pain”. Does this make sense?

  28. John Quintner says:

    Adam, Maturana and Varela argued that autopoiesis is but one defining property of living organisms. Could you imagine a Boeing 707 being able to manufacture its own components and rebuild itself whilst in flight (and you are aboard)? It is indeed a circular process. When autopoiesis ceases, life becomes extinct. It is therefore important that we “keep the show on the road,” as Pamela Lyon would say. If there is a meaning to pain, we suggest that it signifies a perceived threat to one’s autopoiesis and one’s very existence. It is the organism and not the observer who makes this decision! This is a very important message for those who decide unilaterally that their patient is or might be catastrophising!
    As for physics, in our 2008 paper we refer to “negentropy” – a term coined by Schrodinger but used by biologists to conceptualise the gain in an organism’s complexity that defies the Second Law of Thermodynamics.
    Yes, the problem of consciousness does raise its head. This is an area which we deliberately avoided, likening it to a swamp from which very few who venture into it emerge any the wiser.

  29. John Quintner says:

    Nicholas, hopefully there will be a consensus but it will not solve the mystery of pain. What may emerge is a story that makes better sense for both clinician and patient. Lorimer’s wonderful stories have allowed us to take an important step in this direction. Clinicians steeped in biomedicine have been at a considerable disadvantage over CAM practitioners in so far as they have not had good (i.e. biologically plausible) stories to tell their patients. If you can weave neuromatrix theory into a good story, all well and good. But in my view, it does not provide a “stand alone” explanatory model. Of course, I may be wrong, yet again.

  30. Adam, your position against autopoiesis seems commensurate with your previous statement that the sum of the total being is equal to the sum of the parts. It seems that you are taking the classical naturalistic reductionist method in stating a thing can be explained solely by its parts. John, correct me if I am wrong, but autopoiesis seems synonymous with the principle of emergence: the sum is greater than the sum of the parts. Just that autopoiesis infuses the idea of self-creation into emergence. Using a simple example a table is the emergent property of four legs and a top. Even though the parts can explain the constituents of the table it does not explain the emergent property of the table. That emergent property is the use of the table as a whole. That property only exists due to the relationship with the other whom uses it as a whole. The other, or me for example, has no use for the leg, or the top in isolation and in fact the specific emergent property of the table is only effective as the whole object. In other words, you will not find a table in a piece of wood, leg, or a top but only in the specific arrangement of each constituent and that whole’s (the table itself) relationship to another being. To bring this back to pain, one may understand underlying constituents of pain (nociception, pain processing centers, functional relationships within the nervous system etc) yet pain is never reducible to any of these requisite systems–just as the table is not reducible to its legs.

    Pain as an experiential experience does have importance in providing the organism with necessary information with which to act. When it is communicated to another it is done intentionally. The act of experiencing pain and communicating pain are fundamentally different things—despite being inter-related. One serves to function at the level of the organism (experiential) the other serves to inform other organisms to inform and mediate the behavior of surrounding organisms. We must not lose sight that both are extant at fundamentally different levels of complexity. The first being a property we attribute to mammals and primates (experiential pain) and the latter only to humans (communicative pain). Experiential pain which could be thought of as built on nonconscious/implicit learning and genetic factors while communicative pain is largely learned through explicit learning within social situations: with obvious interplay between the both. It is this nexus of interplay that seems the most interesting and the most fruitful to study, which brings me to a pointed question for John.

    John, I have read your article awhile back, to state that pain is an “aproria” is to patently acknowledge the uncertainty of it, correct? If we could think of the two previously conscious aspects of pain: experiential and communicative respectively, could we not plot these two as dimensions on a theoretical grid? Allow me to use a sort of metaphor for the sake of elucidation. What you are stating essentially is that we cannot locate experiential or communicative points exactly with respect to pain. That no matter how good our conceptualization (within these two dimensions) of pain becomes that there exists an almost Heisenberg uncertainty principle with respect to its exact position in each individual—I don’t mean physical position but a conceptual position within the dimensions of experiential and communicative aspects of pain. That much like physicists, we must just accept and account for the uncertainty. That it behooves practitioners to pay heed to this uncertainty and account for it within their conceptualization. That is only when we recognize that a certain aspect of pain will always and forever be uncertain in each individual do we liberate ourselves in developing novel and individual treatment approaches with each individual patient. If this is what you are stating when you state “aproria” then I whole heartedly agree with your conceptualization of it. What do you think?

    Thanks to all for the opportunity to learn, think and discuss with thinkers, writers and practitioners in this very interesting and dynamic field. I am indebted to this forum.
    Eric
    postscript: I realize that I previously used a tripartite model of consciousness and this post only highlights two dimensions, I did this solely for sake of simplicity but it easily be expanded to include my previous view.

  31. John Quintner says:

    Eric, emergence does need to be very clearly defined

  32. John Quintner says:

    Sorry, I hit the wrong button. Emergence as a phenomenon does need to be very carefully defined. I do not see it as being synonymous with autopoieis. Yes, we do have to learn to live with uncertainty and this is what we imply by our use of the term Aporia in relation to pain. Only when we accept this fact of life can a new paradigm “emerge”. Thanks to all for making this conversation so challenging.

  33. Adam Bjerre says:

    John and Eric: Thank you both for your answers and deep insights,
    I’m trying to balance a practical and theoretical perspective on “things”. (Good luck with that, Adam)

    In these discussions I always imagine myself on front of (or both of you would probably prefer I used the word “with” ;-) ) a patient who describes what he experiences with his eyes and his words forming the question at me: “why?”.
    And then “cue, Adam”. [silence, glaring eyes, question mark]

    John: Your description of two biological organisms make perfect sense. I am aware of the trap of objectification: observations in nature – leads to a conceptualization of a process – which becomes “reified” into a concept (or a category, as Sapolsky among others speaks of) – which then is treated as if it were concrete/a noun. Barrett Dorko and Diane Jacobs in my own profession have written about this during the last decade. Very difficult for both parties to escape, but especially important/crucial for the clinician to be aware of. The art in therapy, as I think that both Lorimer, but especially David Butler has delved deep into, is to be able to have a conversation with a patient including emergent phenoma. Butler points us in that regard to the studies of Michelene Chi from Arizona State University. I’m guilty of not having read a lot of Wittgenstein and his concept of language-games, but his P.I. might be one of the clues in how we as clinicians learn to see, understand and “share” what the patient is experiencing. It is a daunting task and far from my mechanistic upbringing…

    John and Eric: IMHO the concept of autopoiesis confuses more than it clarifies and it is my understanding that the conceptualization has never really gained a proper place in biology – although it seems very popular (even my wife has been introduced to the term in a distorted form in her supplementary training in management and leadership). I wholeheartedly agree that we should begin to understand the “puzzle of pain” from an organism perspective in terms of an evolutionary stress response – the zoologist and physiotherapist Louis Gifford described that eloquently in the “Topical Issues in Pain”-series in 1998 – and that we should avoid the trap of “psychologizing” the patient’s experience.

    I think it is very challenging though to bring in Maturanas critical view of “simple-minded objectivism” or “naive realist or common-sense view” when dealing with a state and experience of a human being that often originates from some sort of pathology/nociceptive activity (that we seldom can know of, in the case of “chronic widespread pain” for example). “The world does not have a causative nature”, as Dorko and others have stated. But it seems that Maturana (and Varela) in his/their writings sincerely believe that we don’t have access to “reality”. As I have come to understand autopoiesis, I think these quotes from Maturana illustrates my concern: “We literally create the world”, “what we do not see does not exist”. It seems that in Maturanas view we are in some sort of closed domain where we can never “escape from experience and language to reach the shores of pure reality” (Mingers 1994). That is so challenging to western scientific thought that I think it constitutes a problem – of Maturanas thinking. With al due respect we should be careful not to “cook up” our own metaphysical reality and keep our evolutionary biological inheritance in mind. We share 99% of our genes with chimps (correct me if I’m wrong here) but “we use our biology in ways that no other animal could” (Sapolsky).

    As for “the sum is greater than the sum of the parts”, I will refer back to the previous quote from Dawkins. Yes, I think that complex wholes should o.n.l.y. be explained in terms of their parts, but when it comes to our ability as humans with developed neocortex, prefrontal cortex and temporal lobes we are capable of abstract reasoning, introspection, problem solving and culture at a scale that no other animal is capable of. Including being able of experiencing “the [horrific] groupings of relevant response tactics and strategies” where we use the word “pain” (Wall). We are a truly complex organism, that doesn’t defy the Second Law of Thermodynamics but quite the opposite! Our complex systems, organisms, feed on the external and energy-rich organization around us. Maybe, as both Dorko and Jacobs have pointed out again and again over on SomaSimple, one of the central properties in “your project” might be exactly the thermodynamics of the organism – the oxygen, the bloodflow, the opening of blood vessels, through movement, calming touch and feeling of safety and understanding in coexistence?

    “Anyone in pain is locked in a struggle for relief. The rest of us have the option of approach or retreat.” P. Wall

    Thank you for a great great conversation.

  34. John Quintner says:

    Adam, I accept that autopoiesis has not gained traction with biologists, but nonetheless it has for me opened up this difficult theoretical area where our limited language has been so problematic. I love the quote from Pat Wall. I might be tempted to modify it – “Anyone in pain is locked in a struggle for existence.”

  35. John Quintner says:

    Yannick, I think we are all faced with this question. In my opinion, the best we can do is to be prepared to engage in the “third space” with each patient and work towards a mutually negotiated conceptualization of that person’s lived experience. This will not be easy!!!
    By contrast, chronic pain “as a disease in its own right” gets around these issues but as we have argued in our recently published (on-line) paper -“Is Chronic Pain a Disease?” – the person in pain is effectively excluded from this conversation in the interests of making a clear cut biomedical diagnosis. This is the subject of an ongoing debate in the Pain Medicine literature.

  36. As a massage therapist working exclusively in the field of chronic pain and injury rehabilitation I have used Mr. Lorimer’s videos to help educate my clients, and I also have been troubled by the slow person by person educational approach.

    Touching on the subject of gaining our clients/patients trust in this education I see a glaring omission in this discussion which I believe is indicative of the mainstream medical community’s approach, and that is the lack of palpatory observation of trigger points (hyper-irritable localized areas of chronic inflammation within muscle bellies which have predictable patterns of pain referral, most likely due to local chemical imbalance and chronic nociceptive excitation) and their role in/relationship to chronic pain.

    I hope the community here will forgive the lack of scientific evidence behind my assertion when I claim that in nearly 95% of clients with chronic pain I am able to palpate trigger points (or patterns of trigger points) which predictably recreate/aggravate my clients chronic pain experiences, and in probably 70-80% percent of clients, with skilled manipulation of those trigger points, I am able to help them to create new experiences around “letting go” of their “pain”.

    Now I declare all this not to prove what an awesome massage therapist I am, but to say that giving clients concrete “proof” through an ability to recreate their experience, is an (the?) important step in being able to inform their trust, thus providing a window of opportunity for discussion about pain as an opinion held by their brain based on nervous system feedback (although the opposite is also possible, unfortunately reinforcing the client’s belief that the condition is purely structural). Afterwards I am most times able to harness that new found understanding to help the client create new experiences surrounding those sensations, leading to palpable,objective changes in tone in the muscle tissue, and subsequent reductions in oral pain scale reporting.

    Some portion of this is due to my talent/skill as a massage therapist, but the vast majority of my ability comes through training and mentoring I received during that process. These are trainable, reproducible skills, the understanding of which has been nearly lost within the medical profession (at least in the USA), due to the obvious problems in developing double blind studies to test this work (palpation assessment and treatment effecacy).

    I want to be clear here that I am not trying to bring this back around to a purely structural hypothesis, but, also that since trigger points do not appear on diagnostic films, and palpatory observation/skill is nearly absent in the medical professions, that the structural relevance of trigger points has been a neglected piece of the puzzle.

    Those in our profession are mopping up clients due to this relative lack of understanding by medical doctors (and with a success rate far, far higher than placebo), though unfortunately to the detriment of the reputation of modern medicine. While many practitioners of “alternative medicine” are content to exploit this situation, there are many of us endeavoring to bring our practice into the mainstream health care paradigm.

    Again, this leaves the problem though of slow, person by person educational approach, for which I currently have no answers, but my hope is that by bringing this conversation to the mainstream scientific and medical communities we can together find the evidence and means to bring it to the public at large.

  37. John Quintner says:

    Aaron, the various clinical phenomena associated with trigger points lack scientifically credible explanations. In saying this I am reliant upon the copious literature generated by proponents of the “integrated” hypothesis (viz. Mense, Simons, Dommerholt et al.).

    As for treatment, the evidence from a goodly number of high-quality systematic reviews has not been supportive of the efficacy claimed for “trigger point therapy”.

    I offer the above comments in my capacity as a member of the medical profession, albeit one with an interest in Pain Medicine.

    Anonymous Reply:

    I appreciate your skepticism and realize that it is difficult to design studies which would provide the evidence the medical community requires.

    Still, anecdotally, I see a 70 to 80 percent success rate with a broad spectrum of clientele experiencing a multitude of chronic pain issues from head to toe, and so do my mentors following the same well written protocols. Many of these clients themselves are skeptics and yet are able to report appreciable decrease in pain levels sometimes after one visit. What should we do with such anecdotal evidence? What I practice is a regimented and repeatable protocol, easily enough taught to almost any individual yet entirely tainted with subjectivity to the point where it could never be double blinded. What would you propose the community should do with such results which can never be objectively isolated?

    John Quintner Reply:

    To Anon. You ask “What should we do with such anecdotal evidence?” You could follow the advice of Herbert Spencer [1820-1903]: “Every science begins by accumulating observations, and presently generalizes these empirically; but only when it reaches the stage at which its empirical generalizations are included in a rational generalization, does it become developed science.”

    Aaron Allen LMT Reply:

    Sorry to hear that is the case. I have only anecdotal evidence to back up my assertions. I will respectfully remove myself from this discussion.

    John Quintner Reply:

    Aaron, it is really up to you, and to other therapists who espouse the “trigger point” construct, to produce hard scientific evidence supporting your clinical impressions. Does this seem an unreasonable imposition?

  38. Aaron Allen LMT says:

    Sorry, I had some trouble posting replies on my mobile platform which led to the last two disjointed replies.

    Ultimately, as I have stated, the experiences as both therapist and recipient in any bodywork modality are far to subjective to perform a double blind study, and to remove the subjectivity would be to remove their efficacy. I believe this is where previous research on trigger point therapy failed. In other words, I have no way to prove to you I know what I’m talking about within a scientifically rigorous construct, but if you come to me in chronic pain I can help you, and usually within only a few sessions and I can explain for you a well written protocol which I utilize to achieve these results. I get to see these results over and over again on a daily basis by repeating that well written protocol, and many times with patients who have seen every other type of specialist regarding their pain with no success. I realize it sounds like I am asking you to believe it without evidence, but the truth is the best minds in our field and myself do a lot of thinking on this and there are some equations in which you quite simply can not remove the observer far enough from the observed to be considered scientifically sound. I have realized the folly in attempting to explain this process without such proof which is why I asked to remove myself from the discussion. It is very difficult to not be taken seriously by the same community who’s results most closely reflect your understanding of these processes, but I find solace in that every day I help another person with chronic pain return to normalcy of life.

  39. John Quintner says:

    Aaron, the answer to my question is yes. Why would you want to work in a biomedical reductionist paradigm, with its emphasis on “objectivity,” instead of one that espouses holism?

    As an aside, some physiotherapists have taken on board the “trigger point” dogma and are using it as a license for them to insert needles into muscles thought to harbour such nebulous entities. I see this as an abuse of the scientific process.

    Anonymous Reply:

    I’m not sure what trigger point “dogma” would even mean, I’ve never heard anyone espouse a dogma of trigger point therapy. I have only heard them described in purely anatomical/physiological terms.

    “Such nebulous entities” are we even talking about the same thing? A trigger point is a palpable inflamed and hypertonic knot in the muscle tissue, a physical entity, not some esoteric concept that might be there or that only some people feel, everyone has them and everyone feels them, this is not something we have to convince clients is there, it occupies physical space and when palpated it is the client who confirms the efficacy reporting yes that recreates my pain, or no that does not feel relevant to where it hurts. You may be confusing this with acupressure or Chinese medicine meridian points or something.

  40. Nicholas Marki says:

    @Aaron,
    No one is going to take the success you have with patients away. Now, this is what I hear from what you are saying:
    1.) You have created a wonderful story that your patients appear to buy into.
    2.) You help the patients reduce threat in their body with manual contact (you call it skillful manipulation of trigger points).
    3.) You provide compassionate and empathetic care to people who are in need.

    What I do not hear:
    1.) As John pointed out, you stick to this objective paradigm of trigger points, think of these more as defenses of the system rather than defects causing the problem.
    2.) You do not mention educating your patients on pain science which has been shown to help people suffering from chronic pain problems.
    I think you should make a visit to the forum at somasimple.com where pain science and chronic pain is discussed by many different clinicians (PT’s, MT’s, DC’s, DO’s).

    @John
    I completely agree that the PT’s have foolishly taken off on the bandwagon of needle sticking based on literally no scientific evidence for its mechanism or efficacy. Capitalizing on the success of acupuncture, PT’s have not looked at the long term as a profession to see that this kind of scientific nonsense does serious damage to the credibility of the profession. I am a PT, BTW.

  41. Aaron Allen says:

    Nicholas, I’m not sure why you believe I created a story and I have never asked any client to buy into anything. I am not here looking for validation of my approach and have not seen evidence of anyone attempting to take anything from me. I certainly do educate my patients on pain science, that’s how this whole discussion began, as I described how Mr.lorimers videos have been helpful in providing context to my clients experiences of my work. I’m actually familiar with somasimple and sometimes share posts from that forum with my community. You may not have read back through the entire discussion so I understand that you are confused as to my position, but I find the general discussion in this forum dovetails perfectly with the concepts my community are using to address chronic pain. Unfortunately not everyone sees that same relevance.

  42. John Quintner says:

    @ Anonymous. You have just outlined this dogma, which asserts that myofascial trigger points are regions of primary hyperalgesia – an assertion for which there is no evidence. They are better explained as being regions of secondary hyperalgesia (characterized by referred pain and allodynia/tenderness). This is still a poorly understood area of clinical practice but I do think we are talking about the same clinical phenomena.

  43. Aaron Allen LMT says:

    Im sorry, my mobile platform seems to keep posting me as anonymous. This is unintentional and confusing.

    @ John, I seem to be able to find a mountain of recent, high quality research confirming hyperalgesia in myofascial trigger points with only a simple google search, so your assertion of no evidence is tragic. Admittedly I have not investigated that entire mountain, so there may be I’m certain, evidence which also contradicts their conclusions, which you seem to have chosen to latch on to. I am not a researcher and so have not spent my time weighing the balance of proof back and forth, but I can confirm that the research espousing hyperalgesia in myofascial trigger points reflects perfectly my clinical observations with nearly one hundred percent of all clients in several medical offices over a five year period. This is not a “works with some people” hypothosis, the success rate is in the realm of 80% of all clients. Find me another treatment or drug with those numbers. I’ve certainly never heard of them, and yet medical practitioners seem content enough with the data to dole out pills for pain like they were candy.

  44. Anonymous says:

    In case it has been lost in the discussion I would like to reiterate that I do not believe that trigger points are the cause of peoples pain, so much as a very important piece of the puzzle informing peoples experience of pain. When palpating these tender points within the muscle I often hear declarations of “There! Thats where my pain is coming from.” While erroneous in their initial assumption, I do believe it is true that noxious input to the CNS from their trigger point/s is one of the main underlying messages informing my clients experience of pain, musculo-skeletal dysfunction including muscle co-contraction, inhibition and resultant joint instabilities and other proprieoceptive information are yet another layer, and then there are the clients attitudes toward, or opinions about their perceived dysfunction. All of these come into play. As well, trigger point therapy it’s only one fraction of the modalities employed to achieve recovery, physical therapy, nutritional counciling and other education are other parts of the equation. Trigger point work simply tends to be one of the the most teachable moments during therapy due to the fact that we gain the clients trust when we show that we know where they are hurting.

  45. Aaron Allen LMT says:

    This is just one out of many, many studies I was able to find providing evidence of hyperalgia in myofascial trigger points. I chose it due to its biochemical analysis via microdialysis which found elevated levels of both peripheral and central nervous system sensitizing substances in active trigger points comparatively to both latent trigger points and healthy tissue, as well as due to the fact that it comes out of the United States National Institutes of Health.
    https://www.ncbi.nlm.nih.gov/pubmed/19083696

    And secondly this study which utilized ultrasound to diagnose the presence of myofascial trigger points vs healthy tissue out of George Mason University.
    https://www.ncbi.nlm.nih.gov/pubmed/19887205

  46. Aaron Allen LMT says:

    To be clear I welcome any studies refuting the hypotheses of Travell, Simons, Dommerholt et al. I actually have never seen one.

  47. John Quintner says:

    Aaron, you left out the word “secondary” in front of hyperalgesia. In other words, where is the scientific evidence that myofascial trigger points are in fact areas of primary muscle damage/inflammation?

  48. John Quintner says:

    Aaron, the biochemical data is consistent with neurogenic inflammation. This means that the said substances may well have been released by peripheral nerves. Moreover, some are pro-inflammatory and others are anti-inflammatory. The ultrasound findings are interesting but these researchers (and others) appear to have “begged the question” as to the underlying cause of their patient’s pain (i.e. they assumed it was the TrP). Flawed science abounds in this difficult and controversial area!

  49. John Quintner says:

    Aaron, our paper is a bit dated but it does refute Travell & Simons et al.

    Quintner JL, Cohen ML. Referred pain of peripheral neural origin: an alternative to the “Myofascial Pain” construct. Clin J Pain 1994; 10: 243-251.

    We are in the process of updating our critique but the available evidence has not changed our opinion of the hypothesis. More importantly, we hope to offer a better neuroscientific interpretation of the observed phenomena, the existence of which we do not deny.

  50. John Quintner says:

    @ Anonymous. Your belief about noxious input to the CNS from trigger points resides more in the category of speculation than that of established knowledge (truth). Some have used it to unleash “search and destroy” missions upon innocent muscles. Why hide this truth from your clients? As you say, you can utilize many other strategies to help patients (i.e. sufferers).

  51. stuart miller says:

    Hi John, I really appreciate your insight as well as others in this discussion. I had been curious about pursuing a better understanding about local nocifensor systems that you spoke about and wanted some direction. In terms of accessing these local systems for temporary respite / relief (?Michael Negraeff’s comment re Neil Pearson’s optimistic model) , I see that there may be benefits in achieving even transient respite for a platform for discussion with someone with pain (whether persistent or not). I haven’t read and understood enough to be insightful but it seems that there are a number of overlapping truths in this discussion that are challenging. There are local systems, a central system and an ever changing internal and external environment. In terms of the central system, I think that Grehak’s work with pain asymbolia (with insular and opercular lesions) and the inability of differentiation of location with somatosensory lesions has provided a belief for me that the brain’s output response is important (Lorimer’s snakebite story, although brilliant about prioritization of meaning from the brain could possibly still represent ‘hyperalgesic priming’ from a local systems level as well- I am open to further understanding). This is anecdotal but I was just at a conference on lymphedema management and a woman discussed how her persistent neuropathic pain in her affected arm had disappeared after being bitten by a wasp (she had tried to shoo it out of a restaurant without killing it). After listening to the ongoing education about the critical need to avoid any threat to the local system (including prophylactic antibiotic use or immediate use with any scratch) I found this fascinating about our evaluation of threat (could be other mechanisms involved but just my interpretation). John or others, could you provide some direction (I read Alan Light’s 2004 article) on local nocifensor or nocifensive systems ? Thanks.

  52. John Quintner says:

    @ Stuart. This is a path I have tried to follow, albeit with no success. Biosemiotics is worth exploring as it is a developing field of scientific endeavor. Good luck!

  53. stuart miller says:

    John, thanks for the insight – still looking for the code words for ‘understanding pain’ but I’ll keep reading. Is there a clinician’s version of the NPQ in which one can determine one’s level of understanding ? It might be helpful for professors at some Universities to take it. I was just reading a recent Scientific American article on a Neurologist’s work with patients in India who have recovered their sight (through interventions) years after losing it. What was fascinating was that for intermodal integration of images (finding meaning in the message – making sense of things) motion was often required. I haven’t read much on intramodal and intermodal integration but I thought this might have relevance in pain research (ex. patients post wrist fracture in which noxious stimulus while immobilized seems to lead to persistent pain in some especially if they don’t return to meaningful movement). Please provide perspective. Thanks.

  54. Loved reading this discussion and it seems like the old ways of understanding the living human body are outmoded along with the presuppositions and data upon which we place our clinical reasoning . How do we start to get to grips with living in our bodies in this time of huge evolutionary shifts and then how to help our patients ?
    We now know that changes in gene pools can occur in just one generation rather than over many as previously thought. Lets look at the physical body as simply as we can, be generous with our thinking outside of the usual boxes and perhaps we may just find the answers we are looking for.
    http://ervinlaszlo.com/blog/chances-are-you-live-in-a-holographic-universe

  55. stuart miller says:

    Lorimer, in terms of GMI for pain, why do you think you got such good results in 2004 and 2006 with your RCTs ? I really loved your model of understanding chronic CRPS. I realize that vision (with motion) is a powerful force for integrating information but are there other modes/ modalities that may be important ? Alison, are you talking huge cultural evolutionary shifts ? I missed something. Epigenetic shifts, I thought, are usually individual specific. Bacteria swap genes all the time and change populations. I’m trying to think outside the usual box but I need a little more concrete guidance. Sorry – please advise. Looking for insight.