۞Jargon Buster – for explanations ۞ used in relation to back and neck pain.
Acute pain: (Research references available)
• This usually reflects a crisis somewhere in body tissue which triggers the sending of urgent signals to the brain. The brain responds to these signals by creating and expressing response which we experience and call pain. When the crisis passes, the signals diminish and eventually cease, after healing has occurred.
• The crisis may be caused by injury, disease or a build-up of inappropriate tissue misuse, known as mechanical overload. All these and other causes frequently trigger an inflammatory response which itself signals its presence to the brain.
• It is important to understand that acute pain is quite different to chronic pain. Acute pain can be seen as a warning sign sent by the brain to make you aware of the occurring crisis.
• Some examples of acute pain include the feeling you experience when holding something too hot, abdominal pain caused by appendicitis or the pain you feel when you twist and overload the ligaments in your ankle.
• All these events send signals to your brain from special nerve transmitters (found everywhere in the body) and along special nerves to a multitude of areas throughout the brain. This is called the “nociceptive system”.
• The first time you feel an acute pain is important because the brain may download the “experience” and store it for future reference.
• An example might include, having once been hurt by touching a hot cooking pot. The next time you are in the same situation your brain may remind you to be more careful!
• The brain never forgets experiences of extreme pain or fright and this is especially true when we are at a very young age. We now know that the brain stores the memory in the subconscious, which in turn may subconsciously affect our personal development and behaviours through life.
• Many factors affect how we interpret, express and manage acute pain. For everybody, their genetic makeup in particular and life experience in general have considerable impact in most cases of what back and/or neck pain we feel and for how long it lasts.
• There is no standard response to the occurrence of an acute pain. We are all different from each other.
Affective Reassurance: (Research references available)
The reassurance given to each patient as a matter of course at first consultation and during clinical examination and treatment about their presenting problem. It tends to be descriptive rather than constructively informative.
Over the last five years there has been increasing research evidence to question whether affective reassurance used by all three manual therapy disciplines as a matter of routine and usually part of the treatment, offers little for the patient within their therapeutic package of care.
It is well established that provider currency; quality of personal knowledge, beliefs, experience to think differentially, skill of patient focussed manual therapeutic delivery are all showing to be of paramount importance in creating and maintaining a therapeutic alliance with each patient.
There is some research evidence developing that affective reassurance risks being very short term in benefit for the patient and as time passes and the patient forgets the advice offered, it can lead to worse pain and increased healthcare utilisation (the revolving door patient). [Cognitive Reassurance ۞]
Chronic Pain: (Research references available)
• There is no international definition for chronic pain. The term generally suggests pain persisting for three months or more. This maybe pain that is constant or reoccurring.
• All pain is real to the person that has it. Their pain is whatever they say it is.
• The term “chronic” is quite often unhelpful. Time and again it produces negative reactions from healthcare providers, family and employers.
• There is a general assumption that ‘chronic pain’ is difficult to treat as the current cause may not be obvious.
• An example may be seen in persistent pain still experienced in a joint which has been “injured” in the past, but the brain has not ceased expressing pain despite all healing having taken place. Tissue damage is neither necessary or needing to be of a certain amount for the expression of pain to be real to the patient.
• Patients may find themselves on a confusing and lengthy journey, involving numerous specialist, experts and ‘fellow sufferers’ to find a ‘cure’ to their chronic pain.
• This ‘journey’ can result in the patient receiving an overload of conflicting and often inappropriate information, advice, treatment options and possible outcomes. It can leave the patient feeling anxious and frustrated, and dramatically reduce quality of life and relationships within it.
This situation is sadly very common, so much so that we have an expression in the medical world for this - “Iatrogenic Confusion" ۞.
• The chronic pain sufferer can often be seen as failing to find or respond to a ‘cure’. Too often this is not helped by health care providers across all medical disciplines suggesting that there is a cure, but despite its usual success, it has not been successful with the sufferer. They must therefore continue on their hunt for a ‘cure’ elsewhere.
• Throughout the task to “treat and cure” the symptoms of chronic pain, health providers often lose sight that there still may be a genuine cause to the patient’s pain which still may need to be addressed as one part of the treatment as well as addressing the pain problem itself.
• MRI scanning suggests people who appear to be moving towards a pattern of long term pain begin to show less activity from the nociceptive system۞ of their brain (where signals of tissue distress are first logged) and increased activity in the many areas of the brain related to expressions of emotion. This process is not straight forward in the time taken or the intensity of expression but awareness that it might/does occur offers opportunity for personalised appropriate management/treatment strategies to be explored for each person.
• At any initial consultation it is important for the patient to identify empathy by the health carer. The patient must hear and feel that their symptoms are believed and real. The value of this is crucial for improvement to begin.
Negative attitude, erroneous diagnosis with repeated treatment failure assists chronic pain in being – chronic pain!
• Maybe the approach to the problem needs to be one of - management?
• There have been exciting advances towards understanding pain in the fields of neuroscience and genetics. (Genetics - the science of your chromosomes in which the design, development and production departments reside in every cell that we each have).
• A new and fresh approach to management rather than cure for chronic pain can reduce fear and anxiety to enable the patient to greatly improve their quality of life. Gaining the confidence of what new knowledge brings in the place of old myth has to be the starting point.
• Perhaps the answer to addressing chronic pain may for the patient to understand how, why and when the brain creates pain signals. Then there is the potential to help the brain recognise when pain responses are necessary and where they are not helpful or needed. [Cognitive Reassurance ۞].
Cognitive Reassurance: (Research references available)
Reflects and provides evidenced information which is relevant to that patient and no other.
Each patient gains evidence-informed knowledge about their own clinical problem in the context of their own clinical history and current life experience. This helps each patient to understand more about their situation, improves their ability to identify, implement and maintain self-care strategies (short term) and management strategies (long term) relevant to themselves.
It requires time for discussion and needs to be provided to influence or adjust the patient’s belief’s, their current clinical status and opportunities for improvement through self-care and engender realistic self-management expectations. It brings the concept of patient focussed therapy totally to the fore.
On a practical note and for only some patients, reassurance and new knowledge can be enhanced by providing bespoke notes prepared only after their first consultation for reinforcement of the conversation shared.
Research is begining to suggest evidence that Cognitive Reassurance delivered as one part of a quality service has a far greater and longer lasting benefit for the patient than "Affective Reasurance".۞
Further comment -
Carl Rogers, in the 1960s created the concept of Person Centred Counselling and offered the thought that “what assists his work is his belief that all individuals have within themselves vast resources for self-understanding and for altering self-concepts, basic attitudes and self-directed behaviours”.
In hindsight we would now suggest he was predicting the process of neuroplasticity (the brain having potential to reorganize through creating new neural pathways to adapt to the requirements of something learnt). In essence, these complex activities of the brain occur and are ongoing at all times from birth and throughout our life. A very different view from the past where it was thought the brain at birth is already hard wired and we all develop within that constraint.
Iatrogenic Confusion: text to follow soon