Understand pain

We need a new pain definition

Richmond Stace | The Pain CoachLeave a comment

What should the definition consider?

Marsaxlokk market with traditional Luzzu fishing boats

Tomorrow I head off to Malta for the Societal Impact of Pain Conference 2017. The areas that will be discussed include:

  1. Pain as a quality indicator for health systems
  2. Building platforms to address the societal impact of pain
  3. Impact of pain on labour and employment
  4. Challenges, models and lighthouses in pain policy
  5. Evolving concepts in the definition of chronic pain: a dynamic process

Overarching the meeting is the multi-stakeholder platform (SiP) that is described on the website as:

The “Societal Impact of Pain” (SIP) is an international platform created in 2009 as a joint initiative of European Pain Federation EFIC® and the pharmaceutical Grünenthal GmbH and aims for

  • raising awareness of the relevance of the impact that pain has on our societies, health and economic systems
  • exchanging information and sharing best-practices across all member states of the European Union
  • developing and fostering European-wide policy strategies & activities for an improved pain care in Europe (Pain Policy).

The platform provides opportunities for discussion for health care professionals, pain advocacy groups, politicians, insurances, representatives of health authorities, regulators and budget holders.

The scientific framework of the SIP platform is under the responsibility of the European Pain Federation EFIC®. Co-operation partners for SIP 2017 are Pain Alliance Europe and Active Citizenship Network. The SIP 2017 symposium is co-hosted by the Malta Health Network and the No Pain Foundation. The pharmaceutical company Grünenthal GmbH is responsible for funding and non-financial support. SIP 2017 is made possible with the financial support of the Ministry for Finance in Malta.

There are some very important conversations that need to be had, and these must then be translated into positive work. I am absolutely focused on the positive work aspect because we need change, society needs change and we need results. I believe that this is achievable. Of course with all this talk of pain, the question is whether we are talking about the same thing?

The IASP definition of pain:

“an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”.

This was published in 1979 and based on work from 1964 by Harold Merskey. Perhaps it is time for an update! The IASP definition certainly captures some of the features but there is one major bit missing as far as I am concerned. The person.

Pain is a whole person experience. Regular readers will have an understanding of pain now, and the fact that pain is not grounded in any structure or pathology (the biomedical model). Instead, pain is part of a whole person state of protection when there is a perceived threat. The key word is perception and much of perception involves biology in the dark and the hidden causes of sensory events; i.e./ we are aware of certain expectations with regards to pain, but most of the biology is going on without our conscious knowing.

A person suffering chronic pain spends a significant amount of time in a state of protect, much by habit. The range of contexts within which the experience emerges in the person widens as threatening situations are increasingly interpreted (biologically and consciously via habits of thought) as threatening.

I would encourage people to think about a definition of pain encompassing these key features:

  • the whole person
  • perception
  • threat

This would be a good start point. From there we can consider the sense of self and how our understanding of this contributes to the experience of pain. I love the notion of ‘expecting yourself’ as put forward by Prof Andy Clark, a leading philosopher who’s work I think will impact enormously on our thinking about pain, together with Dr Mick Thacker and others who are leading the way.

Exciting times and exciting times ahead. There is MUCH hope now and so there should be. This thinking needs to pervade society and this is the purpose of UP, to deliver the right messages and to deliver solutions with results. Positive work to be done!

RS

Pain Coach Workshop for GPs

Richmond Stace | The Pain CoachLeave a comment

Why should GPs understand pain?

Audience Applaud Clapping Happines Appreciation Training Concept

Sat 3rd June Education Morning at New Malden Diagnostics Centre

~ Do you understand pain?

Can you confidently answer these questions:

  • what is pain?
  • what do we currently know about the causes of pain?
  • what can the person in pain do to overcome their pain?

Pain is one of the commonest reasons to seek help. And we are not only talking about back pain or neck pain, instead thinking about all the circumstances and conditions that feature pain. Digging deeper, whilst the pain is unpleasant by its very nature, it is the suffering that drives the act of going to the doctor. We can even take this a stage further and suggest that the causes of suffering result in consulting with the GP. For example, the person who cannot work, cannot play with their children, cannot play sports etc. It appears as if life’s choices have disappeared. By definition, suffering refers to the loss of sense of self, and indeed the person with persistent or chronic pain can feel such loss.

The existing understanding of pain has taken us a long way away from the biomedical model. The biopsychosocial model has gained some traction but the predominant approach continues to be driven by the search for an injury, a pathology or a structural explanation. For many years it has been known that pain and injury are not synonymous ~ the famous paper by Pat Wall was published in 1979:

“The period after injury is divided into the immediate, acute and chronic stages. In each stage it is shown that pain has only a weak connection to injury but a strong connection to the body state.”

Pain features when we are in a state of protect in the face of a perceived threat. The intensity of the pain relates to this state and not to the extent of tissue damage. Pain and injury are fundamentally different and hence any explanation or treatment for pain based upon the thinking that a ‘structure’ or biomechanics is to blame is at odds with our understanding of pain. In fact, it is this misunderstanding that contributes significantly to chronic pain being the number one global health burden. This can and must change, which is the raison d’être for UP | understand pain.

~ understand pain to change pain

This being the case, this workshop will be a brief look at this enormous societal issue, a public health concern of vast importance considering the massive costs and immeasurable suffering. Not only will we review current thinking and understanding, we will consider the role of the GP and practices that can be readily used.

  • understand pain yourself
  • know your role
  • how can you help the person understand their pain?
  • setting the person on the right course: what is their vision of success?
  • practices you can choose to use in clinic

This overview is based on the Pain Coach Programme. The programme delivers results for people who make the decision to commit to practices that bring about change in a desired direction. They understand that we are designed to change and that we have great potential to be harnessed and used to overcome pain and live a meaningful life.

1:1 Pain Coach Mentoring: for clinicians who choose to pursue understanding pain to a greater level together with the practice of Pain Coaching.

RS

We are more than a brain

Richmond Stace | The Pain CoachLeave a comment

Brain On The Wall

Have we gone brain mad!

There was a great step forward when the brain was considered to be part of the pain experience. The recent popularisation was in part due to the work of Lorimer Moseley who has been researching pain and delivering insights that have definitely caused a shift in thinking. However, it was Pat Wall and Ron Melzack who were the original thinkers, inspiring work in the field of pain science and medicine, with their Gate Theory of Pain (1965).

Brain explanations have captured the popular media as the ‘neuro’ tag is shunted onto the front of words to add scientific validation. We must always check to see if the claims are truly grounded in neuroscience of course. As much as we have people writing and blogging about how science pans out in real life, there are those who sift through the literature and comment critically. We are thankful for the latter as society is regularly hit with breakthrough claims that are sensationalised. How often do we then find out that these claims are unsubstantiated or they quietly go away?

When discussing pain, and this is a complex area, the brain is rightly included. The brain is certainly involved in any conscious experience as best we know, but we are more than a brain. Pain illustrates this well. However, we commonly hear experts talk about pain in the brain, or that we feel pain in the brain. This is not true.

If I am hammering and I accidentally rap the end of my finger instead of the nail, it is very likely to hurt. The pain that I feel will depend upon context. If there is someone else present and watching me, I will have a different experience compared to if I were alone. I may wish to show that I am ‘hard’ and brush it off whilst feeling the intense pain localised deep in my digit. Being alone, I may shout out and wave my hand around, grip the finger with my other hand and ask myself why I am doing this job anyway. There are many possibilities and many different influences upon that pain experience in that moment. This involves the brain, and if I happened to be wearing a portable functional brain scanner (that does not yet exist), you would be able to see activity in certain parts of the brain. These areas are not specific to pain.

There are no pain signals, pain centres in the brain, pain messages, pain nerves or anything else specific to pain. Pain is a ‘body state’ according to Wall (1979), and one that sets us up to heal and get better through motivation. We are motivated or compelled to take action. The relationship between pain and injury is poor and often non-existent, especially in chronic pain states. Pain is about protection and survival.

~ pain and injury are poorly related

Back to my finger. The message that the pain is in my brain is still out there in society. I have just hit my finger. Where do I feel it? Where is my brain? Can I feel the pain there, in my brain? Or do I feel it in my finger?

Pain emerges in the person (Thacker, personal communication) and we feel it in an area of the body deemed in need of protection. Even just in case, which is likely to be the reason for much chronic pain. The body systems that protect continue to do so in accordance with a range of influences and situations, in particular contexts. This is predicted to be ‘dangerous’ or threatening to the (whole) person and hence we experience the phenomena of protection, i.e. pain. Pain is allocated a location in the body where we feel it. The brain is involved in this projection and hence strategies and practices that target known brain mechanisms are to be encouraged. But we also need to address where it hurts and the local tissues and associated areas that adapt to the protect state.

It is the person who suffers pain, not the brain. It is a body area where we feel pain, not in the brain. The brain is involved but we do not feel things in there. Even in phantom limb pain when there is no body part, the sensation and experience of pain is felt in that space. Tissue state and existence has a minimal role, and less so as pain persists. It is about the interpretation and prediction of what the sensory information means based upon prior knowledge that determines our conscious experience.

In our drive to change the way society thinks about pain, this is one of our messages:

Pain is about the person. Let’s treat the person because when the person feels better, the pain feels better. We can change pain. We can live a meaningful life.

RS

5 ways a partner can support and encourage you

Richmond Stace | The Pain CoachLeave a comment

Chronic pain can be the source of huge strain upon a relationship. Partners and other people close to the suffering individual can be at a loss as to what they can do to help. Sometimes their assistance is welcomed and other times not. It can be confusing and stressful. There are many ways that a partner can help and some will be individual to those involved. Here are 5 simple ways that a partner can help:

Be an extra pair of ears and eyes

During consultations with specialists or therapists, it can be useful for a partner to come along. Beforehand you can decide upon their role. The possibilities include:

  • listening and note taking
  • offering observations about what has been happening
  • watching and learning exercises so that they can provide feedback at home
  • just being there for moral support

Sometimes having someone else in the room, even a loved one, can be distracting depending upon what is being practiced. So do discuss this with your clinician for the best outcome.

Understand pain

When your partner understands pain they will be able to further empathise and act through compassion rather than fear and worry. We do respond and are influenced by the people we are close to, meaning that if they have a working knowledge of pain they will better provide support and encouragement.

Pain can and does vary as each pain experience is as unique as each unfolding moment. Knowing that pain is related to perception of threat rather than tissue damage or injury, along with some of the main influences (e.g. emotional state, context, tiredness) helps to navigate a way forward. To overcome pain the person learns to coach themselves, making best choices in line with their picture of success. Sometimes we need help or someone to listen to us whilst making these choices.

IMG_4241
A hug

Touch is healthy, especially from a loved one. Someone recently told me about how a hug from her children relieved her pain. Why? The release of oxytocin for a starter. The feelings of compassion and love can cut through all other emotions and feelings, which is why the development of self-compassion is one of the key skills of well-being.

Sometimes a hug can be painful of course, depending on where you feel your pain. If this is the case, then simple touch somewhere else is enough. Seek to notice the good feelings that emerge in you: what do they feel like? Where do you feel them? Concentrate on them. And if you are not with that person, just imagine a hug or a loving touch. This triggers similar activity, just like when you think about that beautiful scene in nature, your body systems respond as if you are there ~ our thinking is embodied.

Practice the skills of well-being together

A good example is metta or loving kindness meditation that cultivates self-compassion. It is best to gain instruction 1:1 to start with and then use a recording as a prompt until you are familiar with the practice. Group practice is also good when the collective or community creates a soothing atmosphere in which to practice.

At home, practice metta with your partner. Doing it together, you form a bond as you spend meaningful time together. You can also practice the exercises together. These are nourishing and healthy movements with the purpose of restoring confidence as well as layering in good experiences of activity to overcome pain.

Spend time together doing something meaningful

We are designed to connect. The chemicals we release and experience as that feel-good factor, do so when we have meaningful interactions. Pain all too often appears to limit choice and our tolerance for activity. However, on thinking about what we CAN do rather than what we cannot, we begin to build and broaden the effects of choosing positive action.

Positive action is all about focusing on what we can do: e.g./ I can go for a coffee with a friend for half an hour to gain the benefits of connecting, moving, a change of scene etc. and I will concentrate on these benefits. Make some plans, working within your current tolerance level, knowing that you are safe to do so, and follow them through by keeping yourself pointed towards the picture of success*. You can then gradually build your tolerance by pushing a little with increasing confidence.

There are many other ways that a partner can be involved. The key is to communicate openly and make plans together ~ here is a great insight into communication by Thich Nhat Hanh.

* Clarifying your picture of success gives you a direction and the opportunity to check in and ask yourself: am I heading in that direction or am I being distracted?

Please note: Whilst the practices above can appear to be straightforward, you should always discuss your approaches with your healthcare professional

CRPS Diagnosis

Richmond Stace | The Pain CoachLeave a comment
CRPS Diagnosis

Complex Regional Pain Syndrome (CRPS) is a collection of signs and symptoms that define this particular condition. A syndrome according to the Oxford Dictionaries, is a ‘group of symptoms which consistently occur together, or a condition characterized by a set of associated symptoms’. Therefore, we can clump together any set of symptoms and give it a name, which is really what has happened over the years in medicine. The important point is that when we use the term, we should all know what we are talking about and know what we should look for to make a diagnosis. In other words, a set of guidelines.

The Budapest Criteria delivers guidelines for CRPS, which you can read about in this paper by Harden et al. (2013). The clinical criteria (see below) acknowledge the sensory, vasomotor, sudomotor/oedema and motor/trophic categories that really highlight the complexity of CRPS. Pain is often the primary concern, with people describing their incredible suffering in a range of graphic ways. However, it is not just the pain that causes suffering but the way in which the life of the person changes together with their sense of who they are and their sense of agency seemingly lost. One of the roles of the clinician is certainly to help restore that sense of who I am, a construct that is built from many of life’s ‘components’.

Budapest Criteria

1. Continuing pain, which is disproportionate to any inciting event

2. Must report at least one symptom in three of the four following categories

  • Sensory: Reports of hyperalgesia and/or allodynia
  • Vasomotor: Reports of temperature asymmetry and/or skin color changes and/or skin color asymmetry
  • Sudomotor/Edema: Reports of edema and/or sweating changes and/or sweating asymmetry
  • Motor/Trophic: Reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)

3. Must display at least one sign at time of evaluation in two or more of the following categories

  • Sensory: Evidence of hyperalgesia (to pinprick) and/or allodynia (to light touch and/or deep somatic pressure and/or joint movement)
  • Vasomotor: Evidence of temperature asymmetry and/or skin color changes and/or asymmetry
  • Sudomotor/Edema: Evidence of edema and/or sweating changes and/or sweating asymmetry
  • Motor/Trophic: Evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)

4. There is no other diagnosis that better explains the signs and symptoms

Importance of diagnosis

A diagnosis made in the same way, based on the same criteria means that clinicians, researchers and patients alike are all discussing the same condition. This may seem pedantic but in fact it is vital for creating a way forward. Clinicians mus know what they are treating, patients must know what they are being treated for and researchers must know what they are researching. Sounds obvious but let’s not take it for granted. So the Budapest Criteria has pointed all those with an interest in the same direction. Consequently we can focus on creating better and better treatments.

As with any painful condition, the start point must be understanding the pain itself. The following questions arise that we must be try to answer:

  • why am I in pain?
  • why this much pain?
  • why is it persisting?
  • what influences my pain?
  • what do I, the bearer of the pain, need to do to get better?
  • what will you do, the clinician or therapist, to help me get better?
  • how long will it take?

New thinking, new science, new models of pain over the past 10 years has advanced our knowledge enormously. Understanding how we change, how our body systems update, how we can make choices as individuals, and the practices we can use to change our pain experience to name but a few, create great hope as we tap into our amazing strengths and resources as human beings. Detailing the treatment approaches is for another series of blogs, but here the key point is that the first step in overcoming pain is to understand it. It is the misunderstanding of pain that causes erroneous thinking and action, which we can and must address across society — pain is a public health issue. Chronic pain is one of the largest global health burdens (Vos et al. 2012). It costs us the most alongside depression, and I believe that this need not be the case if and when we change how we think about pain, based on current and emerging knowledge.

“The first step to overcoming pain is to understand it”

upandrunThis is the reason for UP | understand pain, which we started in 2015 with the aim of changing the way people think and then approach their pain, realising their potential and knowing what they can do. We are about to launch the new website that is packed with practical information for the globe to access online. Alongside this we have plans to create a social enterprise that will purport the same messages, coming from the great thinkers and clinicians who are shaping a new era in changing pain.

In April I will be running the London Marathon to raise awareness of the work of both UP and CRPS UK. You can support the work that both are doing to change pain by donating here

Thank you!

Richmond to run London Marathon 2017 for UP and CRPS UK

Richmond Stace | The Pain CoachLeave a comment

I am very excited to announce that I will be running the London Marathon this year jointly supporting UP and CRPS UK.

Please support us here by donating whatever you can spare to help reduce suffering

CRPS UK is a registered charity that is focused upon supporting people with complex regional pain syndrome (what is CRPS?). CRPS is often a terribly impacting condition characterised by intense pain and accompanying symptoms that reach into every aspect of the person’s life. Having received little attention, CRPS is gradually becoming more recognised, thanks in great part to the on-going work of the team at CRPS UK.

Georgie, my co-founder at UP, came to see me several years ago with CRPS and therefore at UP we were thrilled to team up with CRPS UK. CRPS has been a condition that I have studied for many years, and having worked with many people living the condition, personally I am honoured to represent CRPS UK and UP in this way, hoping to make a contribution by raising money to allow the work to go on.

Chronic pain is the number one global health burden. Think about all the conditions that hurt and cause pain. This is not just musculoskeletal pain, but all pain — cancer, gastrointestinal disorders, headaches, migraines, pelvic pain, heart disease, post-surgical pain, infections, inflammatory disorders! If pain was understood globally, by society, by individuals, we would know what we can focus upon to overcome the problems and live as best we can in a meaningful way. At the moment this is not the case. There is still a focus on the tissues and pathology as an explanation, but this is not the case. We have known for years that pain and injury are poorly related, and that there is much more to pain to know and work with to create the conditions for change.

This is what we aim to do at UP and CRPS UK. Pain is a public health problem affecting millions in many different ways: home life, relationships, social activities, work to name a few. People need to know the ways in which they can navigate these issues and move onward. The money you give will directly support projects and initiatives to reach this end where we hope to influence the policy makers and healthcare providers, but in essence to help the individual ease his or her suffering.

Thank you.

Richmond

 

UP supports research into pain

Richmond Stace | The Pain CoachLeave a comment

cropped-screen-shot-2015-10-21-at-08-20-53.pngOne of our main objectives is to raise money to support vital research that will make a significant difference to the way in which pain is understood and treated. Such research is underway here in the UK. This is both exciting and necessary in moving forward our thinking so that we can have a significant impact on the global problem of pain.

Mick Thacker has been an enormous influence upon my work and beyond, and in fact I blame him entirely for my obsession with understanding pain! I still recall the lecture he gave when I had my ‘aha’ moment, realising that there was a way forward. Not looking back since, there have been incredible steps forward to where we are now. Mick has had a huge impact upon so many people over the years and this continues. We have a lot to be thankful for and I am grateful for the opportunity to support the work he describes below. I believe that this research is by far our best opportunity to truly understand pain.

‘We propose an interdisciplinary programme of research that focuses on a new approach to pain based on the Predictive Processing Framework (PP) set out by Profs Andy Clark, Jakob Hohwy, Anil Seth and Karl Friston. The main feature of this proposition is that pain arises from circular influences that link the body (including a brain) with the world. This approach sees pain as an action-orientated perception that attempts to both identify and alleviate/limit the potential causes of actual, potential or ‘imagined’ danger to the self. We believe that this approach will extend well beyond the current bio-psychosocial model.

Working closely with philosophers and neuroscientists we will reframe our current understanding of pain using models of PP and will marry empirical based experiments into nociception with current philosophical perspectives. We plan to use these newly acquired perspectives to propose and plan a series of empirical studies that examine pain from the perspective of PP. The direction of these studies are likely to employ many different approaches across the (cognitive) neurosciences including human psychophysics and neuroimaging as well as the development of modelling paradigms involving artificial neural networks and related techniques allowing us to fully understand and evaluate pain and it’s impact on the person.’

Mick Thacker PhD. MSc. Grad Dip Phys. Grad Dip MNMSD. HPC. FCSP.
Senior Consultant AHP (Pain) Guy’s & St Thomas’ NHS Foundation Trust &
Centre for Human and Aerospace Physiological Sciences. King’s College London.
Pain Section, Neuroimaging. Institute of Psychiatry. Kings College London.
Adjunct Senior Research Fellow, School of Health Sciences. University of South Australia.

What research is UP supporting?

Richmond Stace | The Pain CoachLeave a comment

Pain being hugely complex and one of the greatest examples of a conscious experience means that we have many questions to answer. This includes an understanding of pain biology, pain psychology and the social dimension. Whilst all are important, it is the unification of these that is the lived experience, the phenomena of pain. This is what we must ultimately understand so that we can have a true working knowledge of what is going on and what we can do about it.

Hence we need a model that can deliver this depth of understanding and a basis for action. We are fortunate in that such work is going on as we speak, and it is this work that UP will be supporting. The yield will be the practical application of our knowledge about pain so that individuals can really know what they can do to move forward and overcome their pain. Such knowledge will also inform healthcare practice from the outset when a person presents with a pain problem — those initial messages are vital; they must be right as they often set the scene.

Chronic pain is the number one global health burden, which means that millions are suffering. This can change. This must change. This is the reason for UP.

Please support us in our mission and come and see us at The Royal Parks run on Sunday 9th October: http://www.justgiving.com/crowdfunding/understandpain

We are on twitter @upandsing and our hashtag for the run is #upandrun

RS

If pain

Richmond Stace | The Pain CoachLeave a comment

IMG_2528If pain was understood, there would be less suffering.

If pain was understood, the right messages would be given from a young age, sculpting behaviours based on what needs to be done.

If pain was understood, there would be no fear about it.

If pain was understood, we would focus on what we can do to feel better.

If pain was understood, it would be known that listening deeply is the first step to help someone transform their pain.

If pain was understood, it would be known that understanding pain changes pain.

If pain was understood, there would be an enormous amount of money available for a better society.

If pain was understood, it would sit in the realm of public health and not medicine.

If pain was understood, there would not be the reliance on medication.

If pain was understood, what would the world be like?

— this is the mission of UP | understand pain; to globally change the understanding of pain, because put simply, the world would be a better place if pain were understood.

http://www.understandpain.com

UBER-M to overcome persistent pain

Richmond Stace | The Pain CoachLeave a comment

understand painPersisting pain pervades all aspects of life, thinking, feeling and doing. Pain affects decision making, with tendencies to avoid or sometimes overdo and lead to a flare up. This is very individual, and each person will have their stories to tell about fears, worries, beliefs and what they did.

The Pain Coach Programme gives the person knowledge about their pain and skills to make moment to moment decisions about what is best to think and do at any given moment. In effect, the Pain Coach is coaching the person to become their own coach! The person is with themselves at all times, and therefore needs the knowledge in order to make the best choice. And this choice is all about taking an action that takes you towards your vision of where you wish to be. Where you wish to be is in the answer to the question ‘why do I want to get better?’

One of the strategies I coach people with persistent pain is called UBER-M. Cheesy perhaps, but easily remembered. One of the first things we do in the Pain Coach Programme is to help the person understand their pain, this to reduce fear and increase engagement with what needs to be done to overcome pain. You cannot solve a problem unless you understand it. But it is not just telling the person about their pain, it must be a working knowledge that can be applied: what do I know, what can I do now that is wise and healthy? This is the ‘U’. And below are the others:

U – understand your pain

B – breathe (mindfulness, relaxation)

E – exercises (general exercise, specific exercises & training)

R – recharge (we need to have enough energy to engage with the programme, with others, at work etc)

M – movement is congruent with health, but you need to develop confidence to move

For more information Pain Coach | Specialist Pain Physio Clinics London | Richmond Stace