Painful Yarns Read online

  The one sentence take home message: When pain persists, it doesn’t take much to make it hurt more.

  The reason I tell people the Ornithology story is that I think it is a great metaphor for what happens when you are in pain for a long time. The metaphor draws on the idea of the brain being like an orchestra that can play many tunes (read Explain Pain to learn more about the idea of the brain being like an orchestra. I think the metaphor of the brain as an orchestra is really good and really useful).

  The best theory we have at the moment of how pain emerges from the huge bundle of neurones that is your brain, is that something causes a particular network of neurones to activate. In Explain Pain, we call the network a neurotag. When the pain neurotag is activated, pain emerges. Playing Ornithology over and over and over again is like activating the pain neurotag over and over and over again. Cortical neurones, like spinal neurones, change when they are activated a lot. They become better at firing. In fact, they become so good at firing – so sensitive - that it becomes very difficult at times to identify what set them off. This means that pain can come on without warning, without control and without an obvious stimulus. Just like Ornithology did, in the middle of Amazing Grace.

  Here is another example:

  Men who have played a bit of cricket will relate to what happens when you see a batsman cop one in the grobbitz40. When I see this happen, I almost double over and I usually let out a groan as though in some way it is I who has been hit. A mate of mine played at the highest level and got belted several times, once when his protector had slipped out of position. He assured me that when he sees someone else get hit, it actually does hurt him – right inside the pelvic bones, which is where it hurts if you get hit. That visual information alone is enough to set off the pain neurotag is probably because his pain neurotag is sensitised to bits, or hits perhaps.

  the hino story

  Or: Finding the angle in.

  I drive trucks. I guess it is more accurate to say I drove trucks because I haven’t been behind the wheel of a real truck for several years. I have pretended to be driving a truck with my boy Henry in my lap. We sometimes take the Volvo around the car park. We both really get into it – lean right over with one arm out the window and the other swivelling around the wheel. We both love putting on the air brake coming down Walton Well Road and of course releasing it when we stop – phffsssssssssssss-shooss!

  I drove trucks for several years. I did supermarket deliveries and removalist work, picked up southern tablelands’ potatoes for the Sydney fruit and veg markets, delivered pianos to simply- too-big houses in the Eastern Suburbs, transported cattle from one side of a property to the other. I did enough driving to get an idea of the idiosyncrasies of different types of trucks and the day-to-day life of someone who drives trucks. So what?

  This experience behind the wheel came in handy one day when I was trying to get across the notion of central sensitisation to a group of patients, one of whom I was simply not getting. Before I go on with that story, let me talk about what I mean by the phrase to ‘get someone’. This is exactly what TMBA would ask me, when I would return from a day at work ‘Explaining pain’ to patients with chronic pain problems:‘did you get them?’ By that she meant did I connect with them, did they buy the message, did I do whatever had to be done to ‘get inside their heads’? Getting inside their head is, I think, critical if they are to consider information that is not consistent with what they have heard before, or with their own notion of what is happening inside their body. This is a difficult issue because the structural-pathology paradigm is alive and well in most western health care systems.

  That is why I think it is critical to have an angle in, a way of communicating in the patient’s language, a way of using a metaphor, a story, a language that the patient (i) finds interesting enough to listen to, (ii) is able to get involved with because it is accessible to them and their experiences, attitudes and beliefs, and (iii) is sufficiently so that they end up running with it and applying it to their own situation.

  The truck driving story is one such situation – I was not winning with this fellow. He held a glazed look on his face as though I really wasn’t there. It is a remarkable capacity to engage sufficiently to know when one is being spoken to directly and to respond in a coherent and sensible way, but to be taking absolutely nothing in. Well, this fellow had his shields well and truly up. I was not getting to him at all. I was madly thinking:

  “An angle. An angle! I need an angle on this guy. I am losing him. He is already half-way back to his orthopaedic surgeon. He has one hand on the wheelchair.”41

  Then I realised:

  “Truck driving! This guy is a bloody truck driver! Of course! Trucks! That’s it! I’ll talk about trucks. Yes!”

  I began the next sentence with absolutely no idea how I would finish it, but by the time I realised I hadn’t actually thought of anything more than an area of common interest and knowledge, I was committed. It went like this:

  LM: “Look Bruce, it is just like driving a truck”

  With that, Bruce’s eyes locked in. His posture changed. He shifted a little in his seat, so that he could face me square- on. I reckon his chest puffed up just a fraction. ‘Here he comes’ I thought to myself. I then thought ‘Sheezamageeza – what can I say now?’ I went flying back in time to my stints behind the wheel, to the things that used to annoy me, to my experiences and then it hit me in the face like a wiper blade on a grasshopper:

  LM: “Hino’s! Hino’s Bruce! You know how Hino’s have dodgy electronics?”

  I had him. He was all of a sudden in his world, on his turf. It was as though he had arrived, like he had taken off his ‘80s beige velour tracksuit to reveal a genuinely funky pair of Nike runners. I went on:

  LM: Yeah, you know the Hino’s Bruce! You know their electronics! Well, what is happening inside your nervous system is a bit like what happens sometimes in a Hino’s electronics. Imagine this – you know what it’s like, the fuel filter light comes on, on your dash. You think ‘the fuel filter light is on, there must be something wrong with the fuel filter’. Now, this is a very sensible thing to think and it is exactly why vehicles have lights on their dash. So, you take the truck into the mechanics and you tell him, plain and true ‘there is something wrong with the fuel filter’. The mechanic looks at you as though you have just told him you’re part human, part desert wilderberry, and says ‘how d’yer know?’ to which you reply with ‘the bloody fuel filter light is on’.

  That is how you knew there was something wrong in your back. There are detectors in your back that are activated when something is in danger and they send the electrical signal to your brain. It is a bit like a light coming on in your brain saying ‘yep, something wrong down there, better check it out’. The reason you know something has happened in your back is that your brain makes your back hurt.

  Bruce was still with me. I pushed on.

  LM: So, the mechanic says ‘OK I’ll take a look at it for you’ and sure enough there is a bit of bock stuck in the fuel filter. He flushes it out. He tells you ‘no worries now mate – the boys flushed it out and it looks pretty good. You should be right now.’ So, you settle the bill, jump in, start it up and head back to work. No sooner than you are out on the main drag than ‘Pling!’, on comes the fuel filter light again. You figure that whatever was wrong with the fuel filter has obviously not been fixed and you take it back. You explain to the mechanic that there is still something wrong there and he gives you that half-vacant stare and says again ‘How d’yer know?’ You answer with ‘because the bloody light is still bloody on!’ He looks a bit surprised (which is not at all comforting – doesn’t this guy know what he is doing?) and says he will take another look. This time when you pick it up, he says to you ‘there may have been a little kink in the jubby winder as it comes into the top socket of the filter. We have smoothed that out, resealed it and stuck a new widget in there. Should be right as rain.’ Again you settle the bill, jump in th
e cab, start it up and head back to work. Not long into the day you notice the same light is coming on again, intermittently at first, but then it just sits on and you think ‘Shit. Bloody fuel filter.

  Bruce: Too right I would – that’s gotta get your blood boiling that does.

  LM: …so you take the truck in again. This time the mechanic takes the fuel filter out completely and replaces it with a brand new one, new pipes, brand new jubby winder. He shows you what he did and assures you that your truck is now ‘as good as (expletive) new!’ You figure it must be right now because that was a major overhaul, and it was bloody expensive. Again, (you mortgage your house) to settle the bill, jump in the cab, start it up and head back to work. Sure enough, a day in, on comes the fuel light. See Bruce, the thing with the Hino is-

  Bruce: It’s the electronics! There must be something wrong with the electronics!

  He had it! He got it. My story had connected with something, engaged Bruce in his world, in his language, in his domain. It felt great, the whole group had enjoyed the story. The whole group could see Bruce as something other than a pain patient, something other than an overweight belligerent and whinging bludger. They started to see Bruce as someone. They looked at him differently, as though they were thinking ‘Hang- on! Bruce is a truck driver’. In my view, these realisations are important, not just for Bruce, but for the whole group. Patients become people again, to themselves and to each other and to me. I reckon that people have stories and experiences that they can draw upon when they need to, but patients only have stories that reinforce their patient-ness. I reckon that patients tend to be defined by their pain, their disability and the toll and inconvenience they feel they are putting on other people. People don’t.

  I was cock-a-hoot. So I went on. The mere formality of relating this back to sensitisation of nociceptive networks would now be a cinch:

  LM: Exactly! Exactly! There must be something wrong with the electronics! The thing is Bruce, there is probably something wrong with the electronics inside you, and inside Dimos, and inside Shiela and Roberto and any human who has pain for as long as you guys have had it. Human ‘electronics’ change when pain persists. That is just how we are set-up – part of being a human. The system of nerves that take the danger message from the part of your body that was in danger, to your brain, becomes more sensitive. There are several ways that this happens and, unlike the truck, it is a completely normal thing for the system to become more sensitive. So, now, when the light on the dash comes on, that is, when your back hurts, it is due at least in part to the faulty electronics. You probably had an inkling for this anyway – you would do something that seemed really really minor and your back pain went through the roof. In those situations, the system is telling your brain that your back is in danger, when it probably isn’t. It’s just dodgy electronics. Just like the Hino.

  Bruce was nodding his head and he had a faint ‘ahaa’ look on his face. It was like he had realised the answer to something that had been bothering him for years. I could almost hear the inner workings of his mind saying things like ‘so that’s why my back hurts when I see someone else pick up a big box’42. I was over the moon – I had him, I had him. He looked at me, still nodding and constructing his ‘concluding remark’. I was ready for it – the climax of the educative process – the enlightenment – the victory!

  Bruce: “Yeah. I get it – I will never, ever buy a Hino!”

  Classic. There I was, basking in the sunlight of my own canniness, feeling the warm glow of self-satisfaction, and Bruce dumped a bucket of freezing cold back-to-reality water over me.

  I don’t think he was joking. I think he missed it completely. Actually, it seems I missed it completely.

  so, what on earth has the Hino story got to do with pain?

  I think there are two points to that story.

  First, despite the spectacular failure of that metaphor with Bruce, I like it and I have used it numerous times since that one, with far better adhesion. It seems a ‘sticky’ story – one with which patients engage and it seems to fit the common understanding of electronics in general. Men seem to be particularly receptive to it.

  Second, I sometimes reckon we learn more from our failures than our successes. I have had heaps of failures. There have been numerous times that I have busted my gut and tried and tried to give patients a handle on modern concepts of pain biology and I have not made a dent on the patients’ ideas about what is going on. At first I found those sort of situations really demoralising, really deflating. I find them far less demoralising now because I think that some people are simply not ready for the information – even if you took their brain out, drip filtered in the Textbook of Pain, and put it back in, they mightn’t get on board.

  My experience with Bruce reminds me that just because I might be sitting there rating myself and rating what I am saying, it doesn’t mean that the patient is.

  references & further reading

  This book is not meant to be a referenced-to-bits type of thing, obviously. Here are the references that are cited in the text, all six of them:

  Butler, D. & Moseley, G. L. Explain Pain (NOI Group Publishing, Adelaide, 2003).

  Adelson, E. in The new cognitive neurosciences (ed. Gazzaniga, M. S.) 339-351 (MIT Press, Cambridge, MA, 2000).

  Philipsen, D. Consumer age affects response to sensory characteristics of a cherry flavored beverage. J Food Sci 60, 364-368 (1995).

  Wall, P. Pain. The science of suffering (Orion Publishing, London, 1999).

  Bayer, T. L., Baer, P. E. & Early, C. Situational and psychophysiological factors in psychologically induced pain. Pain 44, 45-50. (1991).

  Sapolsky, R. M. Why zebras don’t get ulcers: an updated guide to stress, stress-related diseases, and coping. (W.H. Freeman and Co, New York, 1998).

  Now, some other stuff

  This bit is mainly for the clinicians. The idea of this book is to get down on paper some of the stories I use to Explain Pain biology. It is not a textbook. No kidding Sherlock! I would like to finish this by iterating that stories and metaphors seem to be a terrific way to get at patients – to engage them with the information you are trying to get across. Modern pain biology can seem tricky if one is coming at it from a structural-pathology understanding of pain. By that I mean, an understanding of pain in which pain provides an accurate indication of the state of the tissues, which it doesn’t. I believe, on the basis of what I consider to be very good evidence, that it is more accurate to say that pain provides a conscious correlate of the brain’s implicit perception of threat to body tissues. I have already recommended some papers that talk about this with slightly more sophistication, in the chapter called the thirsty idiots.

  I think it is important that if you are going to Explain Pain biology, that you actually understand it yourself. This way, you will find your own stories and metaphors and will be able to fit your stories to your patients and tell them in a way that plays to your strengths. In regards to this, I love being reminded that we each have strengths and preferred ways of working. This is exemplified in a terrific children’s book called Giraffes Can’t Dance (Andreae, G & Parker-Rees, G (2000) Orchard Books, London). It tells the story of a giraffe called Gerald who gets despondent at the fact that he is all legs, so to speak. However, he eventually learns to dance a whole new dance. A completely original set of moves. Moves that play to his gangly strengths. My kiddies love the story almost as much as I do. I love it because it reminds me that we don’t have to Explain Pain like Lorimer does, or like David Butler does, or like Louis Gifford does, or like anyone else does. We can explain it in our own way. Go on, be creative.

  So, back to understanding it before you try and pass it on. I think that the best place to learn pain is in Explain Pain. Explain Pain is a picture book that is full of referenced research findings, but is written in a way that patients and clinicians can access it. Ideally, this book ‘goes with’ that one. There are other places to learn stuff about pain. Here is a list of dif
ferent types of references:

  Explain Pain, Butler, DS & Moseley, GL 2003 Noigroup publications, Adelaide. I think you should buy this. Go to www.noigroup.com to find out where you can buy it. If you live in the UK, you can go to www.physiouk.co.uk

  Pain. The science of suffering. Wall, P. 1999. Orion Publishing, London. I was going to put a quote from me on the back of this book, just as a gag, but I got too many real ones from famous people. My own quote would have said that painful yarns is the most readable pain book ever, or something to that effect. That would have been a lie because The science of suffering remains the gold standard in pain books. Buy it.

  The Topical issues in pain series. By CNS press (Louis Gifford). Louis knows a great deal about pain and played a key part in getting me interested in it. Thanks Louis. He is a physiotherapist and he edits a book on issues about pain that are, well, topical, to clinicians. Much of it is written at the high-end level, so it is really aimed at people who are ‘into pain’.The Topical Issues series is a great place to get the state of the art in different areas of pain management and understanding. It is great value. It is endorsed by the Physiotherapy Pain Association. Go to www.achesandpainsonline.co.uk

  The Sensitive Nervous System, Butler DS 2001 Noigroup publications, Adelaide. This was a veritable tome of all things pain biology-related. It is a few years old now so I guess there is room for an update, should David find a spare nanosecond in his life to do one. That said, I think ‘SNS’ remains a really good source of information. A real strength in my view is that it suggests ways to integrate the scientific data into clinical reasoning.

  Wall & Melzack’s Textbook of Pain. (Editors McMahon, SB & Koltzenburg, M) 2006, Elsevier, London. Now in its 5th edition, this remains the bible. However, it is serious science so put your best brain in before you try this one.