Imagine The Dragon
An Exercise For You To Use
Here is an exercise that you can use whether you are in pain or working with people experiencing pain.
It gives evidence to the individual experiencing pain. It is fascinating to use in a clinical setting when you’re looking for a way to start to help people interpret the foundation of their pain and get buy-in when looking to reverse the process.
Here is an example that I've used that uses this mechanism.
The process involves identifying what the person consistently sees as a threshold for triggering their pain. It could be a specific physical task, but the same method can be applied to a time of day, a particular set of circumstances or feelings.
Once you have a definitive trigger, you've got something to work with.
Use The Mind
In this example, I describe how I take the individual back through the process of doing the said activity, but the exercise involves them only doing this in their mind.
The particular example for this patient was the activity of cleaning windows and using their right arm to do the task.
The patient is sitting or lying comfortably to know there is no actual threat of increased pain during that moment. Instead, they are asked if it is ok to go through the motion of undertaking the task, which consistently creates pain, but on this occasion, they're only going to do it in their mind.
Strange But True
It can seem a little strange, so you need some buy-in from the patient.
This patient had a history of right neck, shoulder, and upper arm pain. It would be consistent with cervical radiculopathy. This is neck pain with nerve irritation in the right upper limb. The symptoms appeared during a particularly stressful time in her life.
That activity represented what she liked to do when she felt stressed, and cleaning the windows helped her distract herself from how she was feeling and used up that nervous energy that comes with the stress response.
It frustrated her that the pain limited her ability to do this, and as soon as she saw her husband try to do it, it frustrated her even more.
Set The Scene
So we set the scene for how that activity represented safe behaviour because it made her feel better when she was stressed, and the fact that she couldn’t currently access it made her feel even more stressed. That combination can trigger a painful output from the brain sensitive to that situation. But, as the context representing that, in reality, appears, so does the likelihood of an experience of pain.
I asked her to think about what she would do if she were preparing to clean the windows and what that procedure may look like.
‘You've watched your husband attempt to clean the windows, and he just makes them look worse than when he started. Now you've got your opportunity to do it, and you're running the tap and filling a red plastic bucket with hot soapy water. Once it's full, you carry it to that big window that desperately needs a clean, and you have your cloth, squidgy and shammy leather already to complete the job.’
‘You've pulled up the blind and started putting the soapy water all over that window. It's a big window, and even though the corners feel out of your reach, you can just about get there if you go on your tiptoes and stretch your arm.’’
‘My Arm Hurts!’
The patient interrupted at that moment and said, ‘My arm has started to hurt! That’s crazy!’
‘It isn't crazy. It's how our brains and bodies work together to predict how we will feel in certain situations if we focus on doing that thing.’
‘But how can it hurt now?’
‘Because it recognises the potential for that activity as overloading a system that is already overloaded. The default behaviour of reducing stress in that organism is getting busy and pushing hard, but using that behaviour now represents additional pressure on the organism.’
Warning Of What May Come, Not What is
Pain is always a warning to attend to ourselves, and we all have defaults that listen to pain with a fight, flight, freeze or fawn response, and that is never the way to resolve persistent pain.
Once we use a safe behaviour based on rest, digest, repair, renew, and grow, the relief from behaviours with this foundation lasts much longer and eventually relieves pain completely.
Simply illustrating this mechanism is enlightening and can be the catalyst for the change the patient desires.
You can expand on this moment by asking them to regulate their nervous system with these thoughts, a slower breathing pattern for a couple of moments or reminding them of a sense of feeling safe from the environment they are currently in. Once this is done, you can repeat the process.
Rinse And Repeat
The second time around, the same description brings a different response.
I repeated the process after the patient had the opportunity to process what had happened and calmly regulate her nervous system.
As we completed the imaginary routine of cleaning the window, I asked her how she felt.
‘What are you noticing in the arm now?’
‘Nothing’.
Complete The Jigsaw
The final piece in this magical jigsaw asks the patient to move the arm in the same way they had imagined without pain, and accessing that pathway on their minds means much more potential for that actual movement to be pain-free.
She moved the arm far beyond where she had reached when she first was assessed after entering the room.
This moment is a ‘Reward Prediction Error’ where the anticipated event doesn't occur, and the brain has an opportunity to learn an alternate option for those circumstances. However, she no longer had the pain with the same movement and the surprise appearing with that is the moment of opportunity. The brain now has the pathway potential to be repeated and reinforced.
Who Is Responsible?
But responsibility for that lies with the patient. Encouraging the patient to use this mechanism in their minds and then reinforcing that moment with movement becomes the galvanisation that reignites the pain-free activity.
It takes courage to do this in the face of pain, and I know it isn't easy.
If it was, there would be no persistent pain.
Because there is, you have to find that courage or a person to help you find it within you, and then you may just find a path to a life free from the persistent pain you deserve.
What’s next?
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