Mark I. Johnson
If you take a moment to carefully reflect on a situation when you have previously experienced pain, you quickly realise that pain is amorphous. Even when we attribute pain a definite simple cause, such as a broken bone, the pain experienced is a perplexing array of sensations, emotions and cognitions that flirt in and out of conscious awareness, sometimes with an unpredictable time course and severity. Pain is subjective and cannot be objectively measured. Pain is unique to an individual and cannot be experienced by an observer. Yet we continue to treat pain as if it is a simple medical condition. Remove tissue damage and pain will disappear. This works for some patients in some situations some of the time. But what about the rest?
With 1 in 4 people suffering from mental-health issues it is becoming increasingly necessary for a professional physiotherapist to be aware of the psychological presentation of the client in front of them. Pain management involves a patient-centred biopsychosocial approach using a variety of differing types of treatments and health care practitioners, including physiotherapists. Pain education is at the core of pain management and this often involves helping patients to reconceptualise the meaning of their pain.
The aim of this article is to shed light on the psychosocial pathology of pain from a patient-centred perspective to aid physiotherapists in clinical day to day practice. Our perspective asserts a monist approach to pain management, whereby all parts of the client’s unique experience are witnessed as one inclusive whole. The article is written in the first person from the perspective of Matt Hudson, a behavioural change consultant. Mark Johnson supports this view with contextual and scientific input from the perspective of an academic pain scientist who leads various experimental and clinical research projects on a variety of pain management topics.
I am a behavioural change consultant with a BA degree in education and post graduate training in hypnotherapy, psychotherapy, neurolinguistic programming (NLP) and counselling. I have spent the past 26 years studying the human mind from a range of perspectives including philosophy, neuroscience and quantum physics. At present, I am developing a model to reflect my clinical experiences on the working of the mind, called Split-Second Unearning (SSU) to be published 2021.
My clients range from 4-year-old children to geriatrics and all manner of people in between. My ‘pain caseload’ involves people living with a variety of types of bothersome pain that have failed to respond to standard pain treatment(s) including acute and chronic, nociceptive and neuropathic, musculoskeletal and visceral. Most of my clients with pain have been trying to find a ‘cure’ for their pain and have been battling within and outside of the national health care system to have their pain ‘believed’.
It is well-established that many people with persistent pain have an adversary journey with health care services. They feel that practitioners do not believe the severity of their pain and its impact on daily living and their sense of self [REF meta ethnography]. They are often labelled ‘complex pain patients’ and keep many therapists awake at night trying to work out appropriate treatment plans.
My role aligns with contemporary views on the psychophysiology of pain, recognising that a person’s final experience of pain is driven by contextual cues and the brain’s prediction of ‘threat’, including past events. Not just by activation of tissue damage detectors (nociceptors) per se [REF]. It may also help the reader to know that I was born conductively deaf, therefore, when a client comes into clinic, I am attentive to their ‘whole’ communication.
The Consultation: Detecting incongruent messages
During a clinical conversation I continually calibrate the client’s verbal and nonverbal communication of information. Nonverbal communication has been extensively studiedi. When the conversation moves to a future outcome that the client is uncertain about, the flow of their information often becomes disjointed and stifled, their posture and movements become asymmetrical. Research suggests that uncertainty, characterised via these nonverbal cues, is an indicator of psychophysiological stress.ii [REF].
Whilst the client recalls their case history. I interrupt ‘uncertain’ moments to seek out the incongruent part of the message. Observing and evaluating precise pieces of data such as a hand gesticulation, finger twitch, micro-movements of the face or eyes, changes in breathing, as well as verbal cuesiii. Exploring specific glitches in communication with the client aids self-awareness of their ‘stressor’. My intervention (interruption and subsequent exploration) is applied rapidly to prevent the client from wading deeper into their narrative, evoking stress-related neurochemicals associated with their original problem (‘uncertainty’).
Using interruptions to encourage the client to curiously explore their ‘uncertainty’ creates a still point, bringing the client’s curiosity to the surface (i.e. awareness) transforming the narrative from ‘victim’ to ‘observer’. This ‘mind reset’ occurs at the same speed it was imposed i.e. in a split-second.
Think of it like listening to an orchestra playing a piece of music. You do not have to be a musician to know when someone is playing out of key or out of time, although the player who is out of key or time may be completely oblivious to the fact. Then, like a conductor, I detect uncertainties in the ‘whole’ communication whilst a client recalls their case history, offering the client an opportunity to explore explanations for these uncertainties when they arise. My skill set has been honed through experience, although the basics are relatively easy to develop. I will use three case studies to highlight the work in practice.
Client A: A 47-year-old man living with Trigeminal Neuralgia
John (pseudonym) presented with ‘excruciating pain’ diagnosed as trigeminal neuralgia, which involves damage and dysfunction of the trigeminal nerve, which conducts nerve impulses to and from your face and brain. John recalled in fine detail a serious bicycle accident he had had some 30 years earlier that separated the skin from his left jaw to his collar bone. He was rendered unconscious for a few minutes and his journey via 2 cars and an ambulance was hazy, with the exception of the wonderful smile on the face of the nurse who greeted him upon hospital arrival. John required surgery and he recalled his father’s arrival at the post-surgical recovery room. His father ‘turned white’ and vomited when he saw the extent of his son’s injuries. John recalled that six months after the operation his trigeminal pain began. He described it as “… like a bad sunburn feeling”. John explained that over subsequent years he was given various treatments for the pain, but they only provided varying degrees of partial relief. Nothing had irradicated the pain.
I deduced that the incident with his father had a dramatic impact on John. Parents are powerful figures to children. John’s father appeared terrified when he saw the extent of his son’s injuries and this had become emblazoned in John’s mind. I surmised that this traumatic encounter with his father had amplified the seriousness of the injuries in John’s mind. This vivid memory was a reoccurring stimulus in John’s mind, contributing to John’s persistent pain state and preventing him from moving on until cleared. I surmised that the psychological impact of witnessing his father’s response was contributing to the pain more than the physical trauma of the accident.
Client B: A 7 years of age girl living with Calcaneal Apophysitis (Sever’s Disease)
A mother telephoned my office one day requesting a consultation for her daughter Sarah (pseudonym). Sarah was petite and presented with heel pain diagnosed as calcaneal apophysitis, a condition associated with overuse injuries in children who participate in sports such as running. Sarah’s pain was so severe that she could not walk without the aid of crutches. A medical specialist had explained that because Sarah was so small, a problem
had arose in the development of muscles and bones of her feet and that this was creating the pain. The specialist had explained that there was no need for an operation and that the pain would disappear by the time Sarah was 12 years old because she would have grown sufficiently for the problem to resolve on its own. There would be no long-term problems.
Knowing Sarah was a child, I took a teddy bear with me for the first consultation. Sometimes, I find it easier for children to speak to toys and animals. Presuppositional language was the key. Sarah knew that by age 12 the pain would disappear, and she would be fit and well again. I explained that she could take the teddy bear home with her, but we would have to pretend to ‘Teddy’ that she was 13 years of age which would be old enough to look after him. Acceptance of the toy presupposed that Sarah was 13, and this allowed the post hypnotic suggestion “You will be in pain until you are 12” to clear.
Client C: A 48 years of age women living with Ankylosing Spondylitis
Jane (pseudonym) presented with ankylosing spondylitis arising after a ‘slight twinge’ in her neck grew worse over a 25 year period. Jane had been ‘devouring’ pain medication for many years, and recently she had been offered spinal surgery to fuse her spine. Wishing to forgo the operation Jane contacted myself.
In the consultation, Jane revealed that her pain first began whilst she had been busy bringing up her three young children. At that time Jane explained that her mother had begun to develop dementia. Jane’s two sisters both worked full time and so it fell to Jane to look after her mother. Jane held a deep-seated resentment of her sisters, although she never voiced it openly. When the pain came along it prevented Jane from being physically able to do the things her mother needed. Eventually Jane’s sisters stepped in, which released Jane from the sole burden of caring for her mother in isolation. However, this did not free her from the guilt that weighed heavy on her shoulders. Acknowledging this during the consultation brought many tears and much relief. No operation was necessary.
In summary, each case involved being extremely attentive to the client’s non-verbal communication, focusing on ‘uncertainties’ or ‘incongruencies’ in their story. This usually results in some sort of emotional release, something that an unsuspecting practitioner may not have prepared for. Therefore, a referral to mental health services may be the next professional step. A critical aspect of the three cases is something well known to physiotherapists … often persistent pain is not driven by tissue damage (pathology), activity in nociceptors and nociceptive input to the brain. Rather, in some cases a person’s experience of persistent pain is driven by the brain’s prediction of ‘threat’ and this is strongly influenced by contextual cues and past events.
Pain: An illusion of tissue damage?
Most people know that physical stuff outside of the body is detected and coded into nerve impulses by sensory organs within the eyes, ears, tongue, nose, skin and other tissue. The nerve impulses are sent to our central nervous system and contribute to perceptual awareness. What people don’t realise is that percepts contributing to conscious experience are generated from a small amount of coded information about ‘physical stuff’ and a large amount of coded information from our beliefs, values, and past memories. Far from faithfully representing what ‘stuff’ exists in physical reality, our conscious experience is a ‘rough and ready’ perceptual prediction to drive actions that aid our survivali ii. In the words of the cognitive neuroscientist Donald Hoffman, ‘Evolution has shaped our senses to keep us alive, but not to see objective reality’ (Hoffman, 2019).
Simple visual illusions demonstrate this. Try not to see a face or a white triangle. Our brain is creating perceptual inferences by adding its own interpretation of the ‘physical stuff’ present on the page.
Donald Hoffman suggests that perception is an ‘illusion of reality’ and the neuroscientist Anil Seth describes our conscious experience like a ‘controlled hallucination’. Our sensory experiences have evolved to make sense of the situation and to predict actions appropriate to our survival needs.
The possibility that our sensory experience of pain may create an illusion of tissue damage is extremely difficult for people to accept because throughout most of life pain is a signal of actual or potential tissue damage. Pain drives avoidance behaviour to protect us from harm in the future. But people also know that pain may uncouple from tissue damage. For example, pain-free injuries occur during competitive sporting events or on the military battlefield. In health care, an ever-increasing number of ‘imaging studies’ demonstrate instances where pathology exists in the absence of pain, and pain exists in the absence of pathology [REFs]. It all seems counterintuitive. A client presenting with pain that has no attributable organic disease is likely to have a somatoform disorder, their pain being a psychosomatic symptom, seriously effecting 4–20% of the population.
The overprotective brain
Following tissue damage the body becomes sensitive to stimuli so that for example non painful movements become painful. In the presence of tissue damage the central nervous system adjusts body sensitivity to be ‘overly protective’. This can be really useful to immobilise damage structures so that they can heal and to make injured animals less vulnerable by driving their behaviour to seek shelter away from predators. The ability of the central nervous system to alter the sensitivity of the body is also markedly influenced by situational context. It is now known that situational context can contribute to central nervous system activity that is ‘overly protective’ and ‘persistently protective’, even in the absence of tissue damage.
Physiotherapists are advised to educate people living with non-specific musculoskeletal pain that movements which hurt do not necessarily cause further harm. Therefore, it is not dangerous to continue with physical activities despite minor pain or discomfort, although it is very likely that the person has already developed fear-avoidance of movement and the fear of evoking pain may be more debilitating than pain itself. Potent internal narratives develop over time that support fear-avoidance of movement evoked pain resulting in sedentary behaviours, physical disability, greater sensitivity to pain and maladapted appraisals including catastrophising that the pain is signalling a sinister condition, such as cancer.i Recently, the International Association for the Study of Pain have revised their definition of pain to “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage“ and emphasise that individuals learn the concept of pain through their life experiences and strongly influenced by social contexts. Thus, viewing pain through a cognitive-behavioural lens is critical when evaluating a client’s psychophysiological map of pain.
The relationship traumatic experience and pain
Most clients deny any adverse childhood experiences (ACEs)related to their pain, yet non-verbal communication may be incongruent with their verbal response. Allowing the client to curiously explore their ‘uncertainty’ may reveal otherwise. Studies have found that traumatic events and negative emotional experience remains in long-term memory and can influence the chronicity of musculoskeletal pain and headache.i
Evidence suggests children exposed to ACEs before age 18 are more likely to experience chronic pain than children who have not.ii ACEs include loss, isolation and uncertainty. Could your client’s persistent pain be affected by one significant imprint or the accumulation of lots of tiny mental images of past events?
Emotional Memory Images. How could the past influence pain?
The term ‘Emotional Memory Image’ was first coined by physician and neurologist, Hippolyte Bernheim (1890s). Bernheim theorised an ‘emotional memory image’ (EMI) is created unconsciously as part of an ideo-motor responsei. He observed eye and hand movements of clients that suggested they used an external point of focus when experiencing mental imagery. This early stage in psychiatry tended towards a monist paradigm: “… aberrant psychological phenomena were understood to be physical and therefore ‘nervous’ diseases” ii.
EMI’s have been termed within psychology as ‘Phantom Perceptions’ described as the occurrence of visual experience in the absence of a retinal stimulusiii. EMI’s can trigger the stress response, which couple emotions and event related memories to autonomic and endocrine changes, coordinated in part by a hub of processing structures in the limbic system called the amygdalae. The stress response can override rational thinking and can drive irrational behaviour, even when an individual is trying hard to think rationally about the future iv v.
Thus, emotions triggered by mental representations may markedly influence physiological processes. This results in a redistribution of activities and energy consumption to areas involved in fight-flight-freeze situations associated with a ‘survival response’, thus increasing the allostatic load on the clientvi Quite clearly, this will influence a person’s lived experience of pain.
Human life is a succession of moments, when one of these points in time has in some way left a person threatened an EMI remains, like a bookmark, always pointing faithfully to the same page. This somatoform disorder has been with us forever. The client, however, is often oblivious to this split-second learning that continues to plague their life, so they go in search of the ‘cure’ outside of themselves. ‘Fix me’ is the challenge given to the physiotherapist but, the problem is, they are not broken.
The Ancient Greek philosopher Plato wrote
“Let no one, however rich, or noble, or fair, persuade you to give him the cure, without the charm.”
The journey to resolve mental pain is a grave problem for the physical therapist as the aftermath of 2020 is likely to unleash a pain pandemic on a population who have no insight as to the ‘charm’.
In 2021 research to deliver the ‘charm’ or at the very least to clear the EMI for the patient will commence.
ix Bernheim, H. (1900). Suggestive therapeutics: A treatise on the nature and uses of hypnotism: GP Putnam’s sons.
x Urban, WJ. (2000). Gender, race, and the National Education Association: Professionalism and its limitations (Vol. 10): Taylor & Francis.