I have been an osteopath now for 20 years. We were taught to believe that whatever your scan says explains your pain. This is a “biomedical” approach to pain and is the way that the vast majority of practitioners, whether manual therapists or orthopaedic surgeons, still believe that pain operates. However since the 1960’s, due to pioneering work by scientists Melzack and Wall, a new understanding has emerged. It is that pain is complex and is just not about damage.
What also matters is how you are thinking and feeling and behaving around your pain. This in turn can be strongly influenced by whether you are stressed on a regular basis, or suffer with low mood or depression or are very anxious (especially about your pain). Also how well you sleep, whether you exercise, have a healthy diet, your work and friendships and your
ability to have a meaningful and enjoyable life all can impact on your experience of pain.
However if you fell out of a tree or you were kicked in the shins, all these things would hardly matter. Pain when acute (meaning pain lasting 0-2 weeks) is a useful method of making you aware of damage so that you protect the painful parts and learn from the experience.
Pain is essentially the experience of threat to your body.However even in these moments other things can influence your pain. For example if you are a musician and break a finger, you are likely to experience more pain because there is a higher level of threat (ie inability to play the fiddle and therefore a potential loss of earnings and even work and meaning to your life).
On the other hand if you are in a war zone and get shot, many people report feeling no pain. This is because your brain (which ultimately creates the experience of pain for you), might decide that the battlefield is currently a more important threat to your existence than the wound and therefore, rather cleverly, can produce powerful painkillers (endogenous opiates),
that flood the spinal cord stopping any signals coming from your tissues reaching your brain.
To a lesser extent this is also experienced by athletes who can push through their pain barriers to finish the race, which can be helped by the sense of reward and esteem that follows the completion.
About 10 years ago I became aware that, despite my best efforts, some patients that I gave good physical treatments to were not improving as I hoped, whilst others that perhaps had a talking session felt improvement, even though all I had done was just listen to their story!.
I realised the evidence was pointing me to the need to treat the mind and spirit as well as the body. Indeed evidence shows that having Cognitive Behavioural Therapy (CBT) has better outcomes for chronic pain than manual therapy!. This in essence involves just talking and listening, no physical contact. How could it be that we as manual therapists have the power of touch, but appear to ruin its power?.
The answer is complex but has two important factors.Firstly CBT asks the patient to look at the worrying thought, to challenge it and reframe it in a more hopeful and realistic way. For example a very strong predictor of ongoing pain is whether people exhibit “Pain Catastrophising”.This is quite common with people with chronic pain (meaning pain lasting more than 3 months). This involves people thinking that something is terribly wrong with them, that perhaps no one has found the real cause, that the future is bleak, that it can only get worse and they cannot bear it. They might then bought to the realisation,through reframing, that the doctors have all said that it will not lead to worsening disability, that they might have had a similar experience that got better. In essence alongside pain people often have a large dose of suffering.
In Buddhism this process is described as the first and second arrows. The first arrow is the pain. This on its own might be tolerable, but following up behind it is the second arrow, and this is the suffering from the pain as just described. Christopher Germer (The Mindful Path To Self Compassion) sums it up succinctly:
” Pain x Resistance = Suffering”.
The other reason I believe for poor outcomes in manual therapy for chronic pain is the “biomedical” model, in that the therapist often imparts worrying assessments of the patients pain, such as “your disc has popped out”,” your back is worn out”, “you should stop doing things (you enjoy)as they are harming you”. This simply increases catastrophising and therefore pain and suffering. This is despite the evidence that many people have degeneration in their bodies but no pain and about 30 percent of people having disc prolapses or bulges without knowing it. This is not to say a disc cannot in itself be painful, but if your mood is low or you are not exercising or suffering with insomnia, these factors are likely to put you at much higher risk of continuing pain and disability. Also all these worrying thoughts sensitise your tissues, increasing tension or spasm and keeping the cycle spinning(Please see the Vicious cycle in the Integrated Pain Management section).
So what to do about all of this?. Well I think touch is still massively important.For example it deactivates regions of the brain responsible for the anticipation of pain, people who receive touch from their doctor report them to be more caring and competent and amazingly will recover 20 percent quicker from a cold.
We need to promote a positive message, which I believe is possible in almost all patients I see. But we also need to learn to deliver care for the patients thoughts, feelings and emotions as well as our traditional role as body workers.
This is why I took a diploma in Cognitive Behavioural Hypnotherapy, which has strong positive research findings especially for chronic pain, including Irritable Bowel Syndrome. I am also undertaking a Masters in Mindfulness and Compassion, which also has very promising research findings.I currently have a Post Grad Diploma and already add this into my work with (chronic) pain. As well as this I have taken a course in manual therapy called “Cognitive Functional Therapy” which is currently the best evidenced treatment for chronic low back pain. These additions to my osteopathy and acupuncture and exercise programmes allow me to treat both the mind and body.This is in line with best practice and is termed the Biopsyschosocial approach to pain management. I try to infuse this into normal consultations, but do offer individual and group work in integrating all these elements together as needed and agreed by the patient. I believe this system is unique and powerful. I call it “Integrated Pain Management” and it requires several hourly sessions to introduce the complexity and detail required to help chronic pain patients in their recovery. It involves homework and a commitment on the patients side to help with outcomes.
Please try it out and reduce your pain and suffering.
https://healthskills.wordpress.com/2015/04/27/how-much-do-you-really-need-to-deal-with-catastrophising/ (A fantastic Blog by the way for chronic pain)