Top 5 Fridays! 5 Great Pain Explanations/Metaphors From 5 Different Clinicians | Modern Manual Therapy Blog - Manual Therapy, Videos, Neurodynamics, Podcasts, Research Reviews

Top 5 Fridays! 5 Great Pain Explanations/Metaphors From 5 Different Clinicians

Dr. Aaron Swanson, longtime Physio Answers contributor and recent contributor to The Manual Therapist with his amazing Monthly Hits list (April 2016 is here), had a great blog request.

He said after taking ISPI's course and reading Therapeutic Neuroscience Education - one of my highest recommended texts, btw, he finds himself using the same Pain Science metaphors, stories, and examples over and over. His request was for others to share theirs so he could spice it up a bit. 

1) Pain and Sunburns - via Dr. Kory Zimney

A simple pain metaphor I like to use with patients that can help them understand that our sensitivity to pain can change and sometimes it can be different from what we are used to. All too often patients
equate pain with injury, so after an injury when they still hurt they assume the injury is not healing and they are continually causing re-injury.
What “feels” dangerous might not actually “be” dangerous; or simply put by a patient of mine once: “So if I’m understanding what you are telling me, the pain I feel is not the pain I have.” 
I use the perspective of a sunburn to help teach what they feel may not be 100% accurate and that they might not always be re-injuring themselves when they feel pain. Almost everyone at one time has forgot to put on sunscreen and spent a bit too long in the warm sun only to experience the dreaded sunburn the next day. I’ll ask the patient to remember getting into the shower the next day and turning the water to a nice normal temperature and getting into the shower. What happened? This is the active part of the educational process with pain neuroscience education and let the patient answer. Usually you get the response about how the water is too hot and they have to turn the temperature of the water down. Then you can throw a bit of Socratic questioning at them, what do you think happened? Did someone sneak into your house overnight and turn up the hot water heater and mess up the temperature valve on your shower to make the water so hot? Let them ponder that a bit and then ask, so when you felt the “burning” hot water, were you really at risk for burning or injuring your skin? Sometimes what we “feel” is not actually what is happening to us, our body can make us more sensitive to things at times. What “feels” dangerous might not actually “be” dangerous; or simply put by a patient of mine once: “So if I’m understanding what you are telling me, the pain I feel is not the pain I have.”

This acute sensitivity is a good thing when we have had an injury to tell us to take it easy for a bit to allow a gradual return to activity. Because of this extra sensitivity we can bump into the pain safely and not cause further injury because our bodies alarm system has gotten super sensitive. Unfortunately, when pain turns chronic it is not so good. We know that around 1 in 4 times the pain system doesn’t reset back like it should. Often times they will ask the three most common questions: “How do you know that?”, “Why did it do that," and most importantly “What can I do about it?” These questions can lead into more educational opportunities for patients to understand why they hurt.

I have found this metaphor sometimes helps create that “ah-ha” moment for some patients in understanding that pain and injury are two different things. The more they understand with deep learning that the pain they are experiencing is not tied to injuring themselves further can be a key
turning point to help them get back on a gradual graded return to function.

2) Pain as an over-reactive protector via Dr. Greg Lehman

Pain is often helpful. It is meant to motivate us to do something when there is the potential for damage or the possible need of safety. However, pain is not proportional to damage and is quite often out of whack with the problem. Pain is also associated with a whole host of things that are also meant to protect us, might be unnecessary and might even cause more problems.

When in pain you might have muscle guarding, tentative movements or an increased stress response. When these persist they are often no longer helpful. The body has a number of responses that are similar to this type of over-reacting. In some ways, we are super-sensitive car alarms that go off with just a little contact. An example is a bee sting.
There can be a small physical or emotional stressor and BOOM! we can have pain, tightness, weakness and other symptoms of a flare up.
Most of us feel a little bit of pain when stung. It hurts, there is not much damage but in a few minutes we don't think much about it. But in some people that little string triggers a massive over-protective and non-helpful reaction. The reaction (or the immune response) is massively out of proportion to the insult. You might have swelling, redness, tingling, burning or even an anaphylactic reaction. These are often unhelpful and can be harmful.

Pain can be similar.

There can be a small physical or emotional stressor and BOOM! we can have pain, tightness, weakness and other symptoms of a flare up. What is unfortunate is that we can learn to have greater responses (i.e. greater flare ups) to smaller insults or stressors. Fortunately, treatment can desensitize us to these triggers. We can dampen our responses to these stressors. We can desensitize and ultimately build up our tolerance to all stressors. 

3) Pain is like the wind via Dr. Matt Dancigers

It can only be viewed by its interface with the environment.

We see the trees move, the leaves rustle, the flower petals quiver. We see the thick dust in the air, the yard furniture toppling in a pile by the fence, the branches dropping to the street.

Our skin turns alive with an unseen pressure. We are urged to move to the left by an unseen force from the right. It blew my hat off.

"I cannot take a picture of the wind. I can show you a picture of a windy day... but not the wind."
Now, since pain is a feeling, and not a thing, it does not show up on X-ray/MRI/CT. I cannot hand you some pain (reaching both of my cupped hands forward). 
It comes up in evaluations and interactions often. "The right knee has the tear in it, but the left one hurts more." or "The MRI showed nothing." I have a canned response since it comes up so much. "Well, you make an excellent point. Thank you for bringing that up. Now, since pain is a feeling, and not a thing, it does not show up on X-ray/MRI/CT. I cannot hand you some pain (reaching both of my cupped hands forward). There has never been a picture of feeling. There have been pictures of people wincing, or holding a body part, but since pain is a feeling, it will never show up on a picture."

I say this, generally the same way, while gauging understanding as best I can. This may be a good starting place, depending on the patient. Perhaps it's a good analogy to challenge a "seeing is believing" mindset. The wind is no less real.

Pain Wind Scale: "On a scale of 3 to 120 mph, how gusty is your pain today?" *image credit*

Now, the wind analogy is useful to look at the spectrum of what pain is in someone's life. It can blow your neighbors leaves into your yard. It can cool you down on a hot day. Pain serves a biological purpose as a threat/danger signal, but can also be a destructive force.

Not all the important things in life are made visible. 

4) Pain as a Home Alarm System via Dr. Andrew Rothschild

If your house gets broken into, you might want to call ADT and get a system installed with sensors on your front and back door, windows, etc. But then you might realize, if the alarm only goes off once someone breaks in and is inside the house, that might not be early enough warning to be able to protect your family, so you increase the sensitivity so the alarm gets triggered when someone comes up to the front door. 

Your body's alarm system can work in the same way. Even if you've had an injury in the past, over time, we know that tissues heal. However you can store memories of that injury and the pain you had as a response. Your internal alarm system can sometimes become more sensitive and go overdrive into protect mode; when you adopt certain positions or do certain movements that were once painful or difficult, you can perceive them as being painful again, even when no tissue damage is occurring. 

5) Your Brain as a Police Station via Dr. Erson Religioso III

Think of your brain as a police station, it is routinely sending out patrols all over your body - this is part of it's job, to make sure you're safe. Once you are injured, do too much of a particular activity, or for apparently a reason you are not aware of (but your brain is), pain occurs. Think of this pain as that area that hurts calling 911. Not only will the patrol go to the painful area, but several extra squads, maybe firefighters, ambulance etc. These are all the body systems, like immune response, endocrine, etc responding to either a real or perceived emergency. These emergencies lower your pain and movement thresholds. The lower your threshold, the less movement and activity you can perform before another "911" call happens again.

For some people and reasons we do not know yet, pain persists. If the area is "broken into" or 911 is called enough times, regular patrols will be continuously sent to the area whether or not there is an actual emergency. This is a cycle that needs to be broken with novel movements, education like this analogy, and hands on techniques that make the brain feel safe. The safer the area is, eventually the patrols stop coming around so often and your pain and movement thresholds return to their normal levels.

I hope everyone got something novel out of this post, and thanks for the compilation idea Aaron! Comment below or on the facebook page with your favorite analogies, metaphors, or stories to help with Pain Science Education.

header image credit

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic...

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