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Transcript of Decoding Pain
Denver Health Decoding the message of Pain To decode the meaning of pain within the context of the physical therapy encounter. Psychological Linguistic Neuroscience Cultural Pain Management is a word... Pain Good Bad Burning Emotional Sacrificial Voluntary That depends on the context 1: the parts of a discourse that surround a word or passage and can throw light on its meaning
2: the interrelated conditions in which something exists or occurs : environment, setting <the historical context of the war> Withdrawal Protection Resolution Time Chronic pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. (IASP, 2011) V.S. Ramachandran: “pain is an opinion on the organism’s state of health rather than a mere reflexive response to an injury.” pg 54 phantoms in the brain (1998) Pain signals (in an intrinsically conscious manner) a threat to one of the subsystems or the telos [goal] of the organism as a whole. (Glucklich,1999) Through biasing operations, the main function of the proposed salience [threat] detection system would be thus to facilitate the processing of behaviorally significant (e.g., potentially threatening) sensory input and to select the appropriate response, regardless of whether this input is conveyed through nociceptive pathways. (Legrain, 2011) The person is asking if what they are experiencing is a threat to their physicality: their body. “Physical pain does not simply resist language but actively destroys it, bringing about an immediate reversion to a state anterior to language, to the sounds and cries a human being makes before language is learned.” Elaine Scarry, The Body in Pain We are social creatures of these senses..... are any directed inward? Introception Proprioception These senses are extroceptive The Imperfect sense = + Vestibular Sense The need for interaction The need for the statement of pain
leading to the ultimate question:
If this pain means a threat to me
[my body] As therapist our job is not to diagnosis with precision the problem but to guide the patient through the phases of pain. With the patient in pain If we accept the premise that they are implicitly asking: what does this pain mean for them? Withdrawal Protection Resolution First we must answer the if:
Does the patient's pain pose
a threat to their physical
being? tissue damage = pain structural/anatomical/positional
"abnormalities" = pain “Pain is a conscious correlate of the implicit perception of threat to body tissue” Lorimer Moseley Are pain behaviors defense or deficit? The nervous system, but more specifically the brain.
Complex interrelated functions between multiple systems, visual, auditory, tactile (everything).
Dependent on current situation and a priori of previous experiences. What determines threat in the nervous system? What will this feeling of threat mean to me? Is this threat serious? Do I need surgery? Am I going to miss work? Is my partner going to love me? Summary: Pain is the communication of the nervous systems threat response system to actual or potential damage to the physicality of the body. That communication in the context of the medical setting is about the patient asking if they are experiencing a threat to their body and the meaning of that such a threat. When the patient is in front of us, and we have satisfied that there is no current threat to their body, then we can answer the patient. Your tissues will heal (if they have not already) and over the long term your nervous system should adapt to these changes. This adaptation of brain to body will result in the resolution of your perceived threat and hence your pain. So the real question is not how do we heal people but, how do we keep them from getting stuck? Withdrawal Protection Resolution Time Chronic pain It is not simply put answered in one statement, one action, one modality, one movement.
It is the composition of every action contained within the therapy encounter and across multiple encounters.
It begins the second you take the subjective and ends when the patient walks out the door. Withdrawal Protection Resolution What does the MD expect? What does the therapist expect? What does the patient expect? The discrepancy between time of healing and expectation? Managing Expectations: Nocebo Impingement You need surgery Your back is that of a
90 year old Your spine is out
of alignment The Practical Process: Objective - Classification Central sensitization Peripheral neuropathic Nociceptive Focus on what can be done. Rather than what can’t be done.
Longer the pain the more entrenched the patterns The interventions: Movement Touch Talking “‘Disproportionate, non-mechanical, unpredictable pattern of pain provocation in response to multiple/non-specific aggravating/easing factors’, ‘Pain dispro- portionate to the nature and extent of injury or pathology’, ‘Strong association with maladaptive psychosocial factors (e.g. negative emotions, poor self-efficacy, maladaptive beliefs and pain behaviours)’ and ‘Diffuse/non- anatomic areas of pain/tenderness on palpation’.” Subjective - The Narrative “Pain referred in a dermatomal or cutaneous distribution’, ‘History of nerve injury, pathology or mechanical compromise’ and ‘Pain/symptom provocation with mechanical/movement tests (e.g. Active/Passive, Neurodynamic) that move/load/compress neural tissue’.” “Clear, proportionate mechanical/anatomical nature to aggravating and easing factors’, ‘Usually intermittent and sharp with movement/mechanical provocation; may be a more constant dull ache or throb at rest’, and the absence of ‘Pain in association with other dysesthesias’, ‘Night pain/disturbed sleep’, ‘Antalgic postures/movement patterns’ and ‘Pain variously described as burning, shooting, sharp or electric-shock-like’” Movement
Talking 3 E Approach Early Intervention
Encourage Movement Engagement
Process D E C O D I N G Descartes Error: That pain is a direct representation
of our external environment (circa 1664) Nociception does not equal pain