Words that hurt

There is a rhyme from school that we all know. “Sticks and stones will break your bones but words will never hurt you”. I recall getting in a schoolyard fight and being called a I don’t recall any pain from the fight but I still remember being called a fat pig and to this day, I know the person who called me that. This is Cartesian dualism in the playground – the split of brain and body. Words do hurt.

Experienced clinicians will know of many words that hurt. They come from imaging reports (e.g. rupture, compression of thecal sac, degeneration, arthritic) they come from all clinicians ("you have the back of a 60 year old", "you’ll be in a wheelchair"

"you have the back of an 80 year old", "its slipped out") and it comes from the internet, neighbours and friends.

Some therapists have plastic models of the lumbar spine including ones with a plastic disc with a big red bulge on it – its quite scary and disc bulges are not like that, nor do they have to hurt.

These words and phrases hurt. They lift awareness of the painful part and strongly suggest that there is still damage and disease. This raises the levels of stress chemicals in the body such as adrenaline and cortisol which may make the sore area even more sensitive.

I would be grateful if readers could send me example of words that hurt. Send them to b1@noigroup.info.

The vital reconceptualisation – “pain as input” to “pain as output”.

“Pain as input” is the natural way to think. When we injure ourselves it seems that the “pain bit” is something organised at the injury site and pain then goes into the nervous system to warn the brain. This is “pain as input thinking”, but the idea is biologically bankrupt and likely to be troublesome for the management of chronic pain. “Pain as output” is a better and more scientific way to think.

There are no pain fibres in the nervous system. When injured, the nerve fibres send “danger signals” not pain signals towards the brain. This is just an increase in amplitude and number of impulses in some fibres (nociception). It is up to the brain to decide if these danger signals are worth listening to. If you have a mild ankle sprain, but you are trying to escape something or score a winning goal, the brain won’t be too bothered listening to the danger signals. However if you have a backache and you have just heard that serious kidney problems can cause back ache and you have a relative with kidney problems, the brain may be particularly attentive to the danger message coming in from the back.

Therefore, while the danger messages from damaged and diseased tissue can contribute to pain, they don’t have to.

We (Butler and Moseley 2003) believe that a good way to help with this reconceptualisation is to consider the notion of threat. While we all know that pain has an emotional influence, “threat” is a wider and more overarching concept. Threats are held in the brain as old memories (“oh no, I have damaged the back again”), made in the brain as the injury occurs (“how will I work next week”), and are in the environment (workmates, insurance). There are a massive number of potential threats. If the brain perceives threats and adds them up, sometimes including the danger impulses, pain may be constructed.

There is research which shows that if a noxious chemical is placed under the skin and you check the brain activation patterns it looks similar to if the noxious chemical was put in muscle (Casey & Bushnell, 2000). This research supports the idea that the tissue injured may not be such a big contributor to pain as most of us thought in the past. Finally, lets never forget phantom limb pain – there are no tissues to create a pain input and what must be the most maddening pain now exists in fresh air.

Email me your thoughts.

Butler DS, Moseley GL (2003) Explain Pain. Noigroup Publications, Adelaide

Casey, K. L., & Bushnell, M. C. (2000). Pain imaging. Pain: Clinical Updates, 8, 1-4.

Explain Pain pain!

Writing the “Explain Pain” book with Lorimer Moseley and eccentric artist Sunyata, (previously Geoff Ween) was a most enjoyable experience - and the success of the book has been very satisfying.

In this blog I want to talk about a phenomenon which I call “Explain Pain pain”. Every now and then we hear from patients or clinicians that they have read the book, but it has given them more pain or in a few cases made them sweat a lot. At first, this was bit distressing as this was not the aim of the book, but on reflection and with a new conceptual framework of what pain is, Explain Pain pain is quite obvious.

Moseley’s attempt to reconceptualise pain as a brain output constructed by various threats plus or minus inputs from damaged tissues rather than the old and now biologically bankrupt concept of pain coming from damaged tissues, i.e. pain as an input holds true here. In Explain Pain pain, the information is a very likely a threat - it calls for change, suggests that previous management may not have been optimal, and calls for a closer look at what goes in the head of the sufferer. This for some people is quite a threat, and as pain is a way to deal with threat, the brain turns it on.

I think the good thing about Explain Pain pain, is that it can be easily explained and it makes a wonderful example of pain not related to tissue damage. After all reading a book like “Explain Pain” is unlikely to strain any muscles or joints.

Therapeutic education

The NOI group, through seminars around the world and publications teach a specialised form of therapeutic education, aimed in particular at people with problematic pain states.

There are a number of therapeutic education styles available in the world, broadly categorised as structural education (knowledge is provided about anatomy and physiology), psychological education (e.g. “The Back Book” and “Manage your Pain”) and in particular for NOI education – a blend with a twist – the neuroscience education style of which “Explain Pain” is the best example.

Explain Pain was written by David Butler and Lorimer Moseley in response to clinical practice and research including a series of studies (Moseley, Hodges et al. 2004) showing that if a person in pain understands the basic biology of why they hurt and are armed with coping strategies to self manage, they will move better, be more functional and have far better moods.

The key is that somehow we need to understand that persistent pains are constructed in the head and if we can understand this we will be better off. Unfortunately many people have been told “it's all in your head” in a derogatory way. Somehow, for chronic pain sufferers "it's in your head" has to be provided in a beneficial way. This blog addresses this huge area. Moseley GL et al 2004 Clinical Journal of Pain 20: 324-330.