Don’t Chase Pain
What’s Causing The Pain?
When we feel pain or have to assess patients with pain, there is a default mechanism to search out damage, injury or pathology. It is sometimes a prejudice that blights western medical practice, and it is a viewpoint that I have been guilty of over the years.
Of course, it is essential to examine subjectively and objectively to determine the relevance of physical markers, movements and presentations. Additionally, it is vital to exclude sinister mechanisms that often manifest as simple musculoskeletal pain.
Once that has been done, there should be a clarity of thought that outlines the recovery pathway for that individual presenting with the pain.
So many times, that pathway is never reached, and another one of failure is started on.
This is never done on purpose, but the biomedical bias of many examinations and settings means that the practitioner often focuses on the pain and misses out on the patient.
Patient Thinks Damage
Understandably, the person experiencing pain thinks they have damage, injury or pathology. They are the ones experiencing a pain that makes no sense to them, or they wouldn't be turning up at the door of someone asking for help.
The presence of pain means there’s a loss of rationale. It doesn't mean that everyone with pain is irrational. Still, by definition, the blood cannot be circulating at an optimum level in the thinking regions of the brain when a level of alarm sufficient to elicit pain is present.
There has to be a proportion of blood flow that would be ideal for the areas of the brain involved imagination, choice and free will, which is reduced because the reflex area of the brain is dominating proceedings doing its favourite thing of ensuring survival.
The presence of pain means the unconscious brain is prioritising attending to that over anything the conscious mind chooses to place its focus on.
Therefore, it is so important that the person assessing someone's pain has a viewpoint that covers all the relevant factors. Unfortunately, even with the best intentions, this is not always the case, even with the best choices.
All too often, there is a chase for the pain. Like a dog chasing a rabbit, the hunt for the damage occurs as soon as the word pain is mentioned.
12 Years of Chasing Pain
Here’s an example of one such case that spans 12 years and includes numerous diagnoses of ankle pain.
The origin of this so-called damage was a slight twist that didn't even bring on any significant swelling. It occurred whilst at work. The minor irritation felt continued for 6-8 weeks and led to a GP visit and subsequent referral to physiotherapy.
The twisted ankle or ligament sprain became the primary focus as a cause of that pain, and even though the degree of pain and lack of traumatic history didn't support this, the treatments for those problems were pursued.
Unsurprisingly medication and physiotherapy failed. That troublesome ankle created more trouble and then led to further investigations. Eventually, a cascade of procedures took place, and each was more invasive than the last.
These included an arthroscopy, lateral ligament reconstruction, ankle replacement, and eventually ankle fusion.
None of these produced the slightest bit of relief, and yet everyone one of them was held up as the answer to this ongoing pain.
Where Did It All Go Wrong?
How could so many medical professionals be so wrong and be baffled by this presentation of ongoing ankle pain?
Well, they were all looking in the wrong place.
As I said earlier, focusing on where the pain is is essential. To look at the structures underneath that pain, those that can refer to it and the joints that may contribute to it are valid assessments.
But to not consider what else was going on in that person’s life around the time of their pain means that nobody stopped to listen to the patient and look at their life circumstances.
What Else Should We Look For?
When I asked this patient what else was happening when the ankle pain appeared, he looked in his mind for the information. He was just coming to the end of an incredibly stressful marriage.
How could something like that be relevant to a pain in his ankle?
When there is no physical trauma behind pain, and when there is no apparent physical overload to justify the pain present it raises confusion. When there is no sinister, systemic or autoimmune basis for it, then something else amplifies the pain response in that individual.
For him, the relationship breakdown was massive as it would be for many others.
A minor injury has the potential to become wired to the stress and all the subsequent emotions he was feeling at the time. This means that if the pain isn't unwired from those emotions, with care, kindness, compassion and a sense of safety which we often get from those we love, then the potential for a further overload of that pain pathway appears.
Common Personality Traits
He presented with many traits we see in those with persistent pain. The drive to push through, say you're okay and carry on regardless of what pain or emotional distress you are feeling.
Using these mechanisms in the moment of injury can help in the acute stage.
But a repetition of them over the long term means that the pathways triggering the output of pain become so sensitive, not only to the small movements, load and functional tasks of the ankle but also to the presence of those associated emotions if and when they should appear on that person life again.
Cut and Chop!
Cutting and chopping bits off of the ankle is futile and proved to be so in this case.
Each subsequent operation increased the likelihood of pain with each failed operation. It increased the sense of melancholy and amplified the hopelessness of each failure.
The physical deconditioning that associated each stage compounded the physical elements of restriction, bringing him to the current point on his 12 years journey.
At the moment, he was asked to think about that time of his life when he first experienced pain, and he considered the emotions of the time he paused. I explained the relationship between that moment and his pain and got him to view the pattern it had followed over time.
What Next?
I asked him about his pain at that moment, and there was none.
Now that doesn't mean there will be no pain again, and much more can be done. Not in changing any of the structural elements already undertaken as that work is complete. But in challenging the old unhelpful beliefs about the pain and where it is experienced.
The target is in looking forward to both physical and psychological challenges in contexts where the ankle pain appears and knowing that improvement from this point is possible.
It is too late to reverse all those procedures, but it is never too late to change the pain.
However, this can only ever happen once you stop chasing it.
What’s next?
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