Episode 24 – Pain (part 2); Addressing pain

The Body Reprograming course: https://www.plymouthhospitals.nhs.uk/body-reprogramming

Unlearn your pain – Howard Schubiner: https://www.unlearnyourpain.com/

Curable App: https://www.curablehealth.com/

SIRPA – Georgie Oldfield: https://www.sirpa.org/

Hello and welcome back. This is the fourth episode on this podcast about pain. If you are new to the series, I can understand based on the titles that you may be tempted to jump straight to this final part, I know I would…“show me the money!” But to get the most out of this episode I would really recommend listening to the other episodes first, or at the very least doing the homework from episode 23 and watching Professor Moseley’s 20 min TED talk. You can find the link for this on my website, Facebook and twitter.

At the end of the last episode we discussed a scientific perspective on how “non-medical” interventions can have “medical” consequences, and why it might be necessary to start thinking about alternative solutions if suffering from pain that has been going on for months or even years, that doesn’t seem to be responding to conventional treatment. I promised I would translate this scientific, theoretical approach into some practical solutions.

The good news is that if you have listened to the previous episodes and are on board you are already halfway there. You have already done a lot of the hard work. “Wax on, wax off!” Being able to understand and accept the role of neural networks in the production of pain, to be able to start to believe that the problem might not be entirely in the tissues of the body, but that this does not mean that it isn’t real, equally deserving of love, compassion and professional intervention, is a crucial step in the management of chronic pain syndromes.

In episode 22 we discussed how pain is a warning mechanism produced by the brain in response to perceived danger. We explored how these danger signals do not just come from pain receptors in our tissues in response to injury, but from multiple other sources; our other senses, our knowledge of our current situation, and the brains beliefs about the significance of the situation, the brains predictions about the future, and calculations on how to best increase survival. If the brain calculates that pain will improve survival, by making us move quickly out of harm’s way, or forcing us to rest an injury, it will generate pain. The example we gave was the difference in pain experienced if you twist your ankle chasing a deer, vs twisting it running away from a lion.

In our modern lives the dangers are different from those we encountered when this pain system first evolved. In general, there aren’t too many lions about. However, we may fear injuries which could interfere with our ability to work, and our livelihood, or with our hobbies, sport and recreation. Things that might be central to our enjoyment of life and make up a part of who we are. Or diseases, which may threaten not only our livelihoods, but also our lives. The brain is constantly on the lookout for threats, and this survival instinct creates a natural negativity bias, and a human tendency to always think the worst. When we experience pain, the natural immediate thought is “what is wrong?”. We don’t generally view pain as a helpful message guiding us towards health, but as a dreadful warning of impending disaster. I know this to be true because I have personal experience with it. If I’m out running and my leg stats to ache instead of just slowing down a bit, if I am not deliberately mindful of it, my mind starts running away: What’s wrong with the leg? Is it going to continue to get worse? Does this mean I will never be able to run again? Is it going to start hurting when I’m riding my bike too? I know the same thought patterns occur to a greater or lesser extent for most people. It is not a value judgement, its just a fact of the human psyche, as a consequence of the way we have evolved.

Now it is easy to see how this could be problematic. If pain is generated in response to perceived danger, and pain itself is viewed as dangerous, we have set up a positive feedback loop, and we won’t be able to maintain equilibrium. The thought “my leg is getting worse, soon I won’t be able to run at all…if it carries on this way, I won’t be able to work” itself is a danger messages that the brain internalises at a subconscious level. And the science shows us that when the brain perceives danger it creates more pain.

On another level, if we believe in the simplistic concept of pain; that all pain represents something wrong in the tissues of the body, when we experience pain the immediate response is to search for what is wrong. As we have discussed before, to the primitive “survival instinct” parts of our brain, our “lizard brain”, uncertainty is always dangerous, and we fear it. Not knowing what is wrong is incredibly distressing to us because when we don’t know what’s wrong, we naturally assume the worst, that the symptoms will never get better, or that it is a manifestation of a sinister underlying condition. A cancer that is eventually going to kill us. Not knowing creates fear, and fear drives pain. As the pain gets worse, as a result of this fear, our conviction that there must be something wrong naturally increases. The pain isn’t going to go away, and may even start spreading to other areas of our body. The more we search for a hidden cause for the pain the more anxiety, fear and pain is produced.

In addition to this the process of searching for a cause is distressing in its own right. Having tests for autoimmune diseases, or MRIs looking for tissue damage, are stressful things. All tests are stressful, from GCSEs, to driving tests, to MRIs. Tests themselves create fear and anxiety. If you go to see your GP with a problem, and they send you up to the hospital, with its fluorescent lights, strong smell of disinfectant, and proverbial “men in white coats”, who stick you though a giant yet claustrophobic futuristic clunking machine, this whole experience is reinforcing your lizard brains suspicion that something is very seriously wrong. It is enough to make any normal person anxious and afraid, even before you have had a chance to think about the results. Then the period of waiting starts. Just like all tests are stress provoking, waiting for and receiving results is almost as bad. I get fairly nervous waiting for an amazon package to arrive, and that’s something I’m looking forward to. Even worse, with medical tests, if you keep testing eventually you will find something. Far from putting your mind at rest there is a significant risk of creating even more anxiety.

Let’s take the example of low back pain. Low back pain is common and can be extremely debilitating. Often people with chronic back pain have MRIs of their back, and many are found to have “disc degeneration” or disc prolapses. If you tell somebody that their back is “degenerating” this is bound to increase fear about the back. If the brain is convinced the back is in danger it may well generate more pain, because it calculates that it is necessary to protect the back.

The obvious response to this, and the one people frequently raise when I am trying to convince my patients that an MRI of the back might not be necessary, or even desirable, is that at least we have found what is wrong. That it is better to know than to not know. However, there is increasing evidence that things are not so black and white, and that these tests may be misleading. Studies have demonstrated that there is extraordinarily little correlation between what we see on the images and the amount of pain people experience. People with very severe pain may have little to see on their images at all, and some people with severe degeneration on the MRI may have no pain at all. It seems increasingly doubtful that these changes on MRI have anything to do with the level of back pain people experience at all. Although lots of people with back pain have MRI changes, it seems the pain is probably not caused by this degeneration. Recent studies have demonstrated that disc degeneration in backs is incredibly common, so much so that they are essentially normal changes associated with aging, just like wrinkles or a receding hairline. Studies have shown that 37% of 20-year olds, and 96% of 80-year olds, with no back pain have evidence of disc degeneration on MRI. It seems doctors may have told countless people with low back pain, anxious as to the cause of the pain, that their backs are degenerating, when they only had evidence of normal signs of aging. It is difficult to imagine that such a message isn’t going to have negative effects. The more we learn about ways the body can go wrong, the more research we do on the internet, the more medical horror stories we read in forums, the more tests we have, the more anxiety and fear is generated. This all adds to the brain’s perception of imminent danger, and with it the strengthening of the neural networks that drive chronic pain. This is more than just theory and is supported by an increasing body of evidence. One fascinating study from 2007 looked at how the incidence of low back pain dramatically increased in East Germany following reunification with the West, the hypothesis being that back pain was a communicable disease, triggered by the influx of western health beliefs.

In chronic pain syndromes the sense that “nobody knows what is wrong” is one of elements that may be reinforcing neural networks to perpetuate pain cycles. If we continue to believe that all pain is an indication of danger in the body, and continue to search for the cause, to focus our attention on danger and uncertainty, then fear, anxiety and pain will continue to increase.

With chronic pain syndromes this is further complicated by emotional and social factors arising from our western culture and health beliefs. It’s why these conditions are so complex and can be so debilitating. Not only do people have pain to contend with, which is bad enough in its own right, but because these conditions are poorly understood there is the whole western medical response to deal with too. Multiple drugs that don’t work, and have unpleasant side effects, multiple tests that seem to just create more uncertainty, maybe multiple trips to different doctors and specialists, and a feeling of not getting anywhere, feelings of being dismissed by the medical professionals or of not being believed; of being blamed, of shame and uncertainty – all the things we discussed at length in the previous episodes.

This is why understanding neural networks is so powerful, and why it is itself part of the treatment for chronic pain syndromes. We are finally able to say we DO know what is wrong. We know what it is, and we have a good idea of how it arises. We know that it is biological, and it is real, but we also know that it isn’t a problem in the tissues. It’s not a cancer, it isn’t going to kill you.  We also know that there is unlikely to be a simple surgery or medication that is going to fix it, but there are treatments and techniques that are proven to have an impact. Knowing what is wrong can calm fear, and when we calm the brains fear we can start to rewire the neural networks that create pain.

Sometimes with chronic pain syndromes the situation can be even more complicated. When pain has been going on for many years it may get to the stage where it is no longer an underlying cause people fear, but the pain itself. The distress is not so much that “nobody knows what is wrong” but rather that “nothing can be done”. This is an equally frightening proposition. Of course, this is an even harder vicious cycle to break, as clearly the pain is not an unknown that can be discovered, on the contrary it is known all too well. Even in this case, though, I hope that understanding neural networks may be helpful in starting to manage the pain.

In the last episode we talked about neural plasticity. Neural networks are set up by groups of neurones firing together in a co-ordinated way, and the more times a particular combination fire together, the stronger the connection between them becomes. Despite this strengthening they never become rigid or completely stuck, and with work we can rewire these connections. This means that even if pain has been going on for many years it remains potentially reversable. Understanding the mechanisms that produce pain gives us the knowledge that something can be done. Knowing that something can be done may provide hope; and hope, along with faith and love, should not be underestimated in their role in human health.

Understanding neural networks, reducing fear and danger signals, calming and reassuring our primitive survival instincts, convincing our lizard brain that everything is going to be OK, is an essential and major step in managing chronic pain. Obviously, though, it is not the full story. As we have learnt neural networks, once ingrained and habituated are likely to carry on firing unless purposefully changed. Rewiring and relearning these patterns is no simple task, and as I have said repeatedly in this series there are no quick fixes or magic pills. It is unlikely that pain that has been going on for years is going to completely resolves just through listening to a few podcasts, and I think it would be disingenuous of me to suggest otherwise. My aim with these episodes is not to cure pain, but more to restore hope that reducing pain is possible. To give faith that we can get better. To get our lives back on track. To find joy again. And to understand that the power to do this lies within us, that we can accept responsibility without blame, and through hope, faith and acceptance of responsibility we can start to take positive steps forward in the long and difficult journey towards recovery.

I honestly believe that the power of recovery lies within each individual rather than with any professor, scientist, health care professional or indeed psychologist, life coach or spiritual leader. Our bodies and minds have an innate ability to heal and to grow. It is true that sometimes we may need some guidance to help us back onto the right path, but this guidance cannot really be given, like a pill, it can only be freely offered. Each person must come to it and explore it for themselves, from their own unique perspective and in their own individual way. This is why I consider managing chronic pain, and health in general for that matter, to be a personal journey, rather than a treatment.

This may sound frightening. If the responsibility for getting better lies with me, then there is a risk that I might fail. Most of us have a tendency towards self-depreciation and self-doubt. We judge ourselves far more harshly than we judge others, and often secretly deep down we believe we are not that great. Because of this self-doubt we would prefer to transfer responsibility to others. This isn’t always necessarily a bad thing to do, I delegate my tax return to my accountant. However, there are some things that cannot be delegated in this way, not for any moral reason, but simply because nobody else can do it. You can’t get someone else to go to the gym for you and hope to get ripped. The same is true of rewiring neural networks. If you want to work on your tennis swing you may well get a coach to teach you, but ultimately you are the one that will have to put in the hours, practice and dedication to reach the goal. And to do to this you have to first accept that your current game might need improving, that you might benefit from a coach. You need to recognise a weakness, have the will to work on it, without activating shame. Because of this, and because of the power of the nocebo and placebo effect, the first step in the journey to recovery involves learning to believe in ourselves. Until we can truly love ourselves, be genuinely compassionate to ourselves, to have trust and faith in ourselves, and in our ability to heal, we can never get off the ground.

I want to be careful to note that this is not about blame, as we have said before, responsibility and blame are not the same thing, and we can have one without the other. And it is also not something unique to chronic pain syndromes. This principle is true across the board, no matter why we are feeling unwell and regardless of what the blood tests or x-rays show. The power of recovery from chronic pain, a sports injury, depression, or cancer ultimately lies with the individual, and for the best possible recovery from all these conditions self-belief, self-love and hope are required. Of course, I’m not saying that if we have self-belief we will live forever. Everyone is going to die, and eventually you will get a disease that cannot be treated by western medicine or by a healthy lifestyle, body and mind, and it will kill you. You may think I am being unnecessarily crass, but this is a simple fact. We cannot avoid death indefinitely. But as we have previously discussed, health is not necessarily about length of life, and if we get a terminal illness, or, if we are lucky, when we get old, we can be more or less healthy in the time that we have, and this will depend on self-belief, self-love and hope.

Unfortunately, self-belief, self-love and hope are not easily come by, and again are not attributes readily acquired in 10-minute GP consultations, or indeed 20-minute podcast episodes. This is why I recommend to all my patients that they seriously consider engaging with some talking therapies. Everyone should have therapy, I have had lots of therapy, and my life is completely different as a result. Once again, I want to make it clear that the recommendation that psychological therapy might be an important step in the management of central pain syndromes in no way suggests that central pain does not have a biological cause, are “not real”, are “just anxiety” or are “all in the head”. If this is the impression you are getting, I would recommend going back and listening to these episodes on pain from the beginning. These are slightly complex concepts, so you might want to listen more than once, or look at the transcripts on my website, sometimes with tricky concepts I find reading easier than listening.

Whilst the process of rewiring neural networks and managing chronic pain is a personal journey, this doesn’t we cannot have guidance. There are various techniques that have been proven in clinical trials to improve people’s experience of pain. Techniques based in mindfulness and meditation, emotional awareness, expression and processing, journaling, visualisations, understanding of triggers and exploring fear of pain. Many of these techniques and strategies are similar in nature to much of the work we have been doing throughout the Cambridge progressive medicine podcast, and if you have not been listening from the beginning, this podcast could be a good place to start your journey. However, I am a GP and not a pain specialist, and this podcast takes a broad view of health and wellbeing and is a dedicated resource for pain. There are however programs out there that have been specifically developed for managing pain, and if what we have been discussing on this podcast makes sense to you, you might like to think about checking these out.

Unfortunately, despite the growing scientific evidence for these interventions, NHS based services providing these therapies are limited. Something which I am hopefully going to be working on in the future. There is a program based in Plymouth called “body reprogramming” which is specifically aimed at rewiring neural networks to treat chronic pain. It was developed by professor of health psychology Michael Hyland, and is based on his “Hyland model”, which I will be talking a little more about in the next episode. Although the course itself is only available to those in Plymouth their website is freely available, and has lots of helpful resources, including a patient manual which is free to download. This handbook goes through step-by-step techniques that you can start implementing in day-to-day life with the aim of reprograming neural networks and reducing pain. It is well worth checking out.

If you feel like you would benefit from a little more guidance than this self-directed approach, there are private clinicians that are doing excellent work in this field. I can recommend the organisation SIRPA, which was created by physiotherapist Georgie Oldfield based on the work of the American physician Dr John Sarno. SIRPA has been developed in conjunction with many of the leading experts in this field, including Dr Howard Schubiner, who has twice appeared on the list of the best doctors in America. I highly recommend you check out the SIRPA website. They offer a range of services, from face-to-face work with a SIRPA trained practitioner in your area, to online courses and books. I will put the links to SIRPA and body reprograming on my website. I will also add the link to Dr Schubiners website “unlearn your pain.” Although his programs are based in the US, there are lots of excellent free resources on his site, from video lectures, podcast episodes, blogs, articles and links to scientific papers, all of which are fantastic resources.

If this all seems a bit daunting, an alternative way to start exploring this work is with an App called Curable. The App has been designed as a structured program for rewiring neural networks to help to reduce pain, with the help of Clara – a virtual personal pain relief coach. The co-founders of Curable have all had personal experience of recovery from chronic pain and have developed the App in association with a fantastic team of leading experts in the field. It is free to download and is packed full of information, with expert interviews and recovery stories. There is a subscription charge for the full guided course, which includes brain retraining exercises, in-depth education, visualisations, meditations, expressive writing exercises and an online support community. They have a 30-day money back guarantee, and I think this “try before you buy” feature makes this an easily accessible resource, and a good route into exploring this work further, and may be more affordable than formal 1:1 support. The best part is you can download it and get going right away. You don’t need a referral and there is no waiting list. I will put the links for this and the other resources we have discussed on my website, Twitter and Facebook page. 

You can take your pick for your homework for this episode. I can’t wait to hear how you get on.