Don’t be afraid of pain – part 3 – clinical implications
In part one, I hypothesised that little pains and aches could help the protective systems cope with bigger problems. So don’t be afraid of some pains. In part two, I talked about the reasons why fear of pain is quite a problem in our western world. In this blog, I’ll focus on some of the clinical implications.
Music for today: Mercy, Mercy, Mercy (Cannonball Adderley)
I proposed a very simplified model of human behaviour to make my point: the protective measures pull us in one direction (security, rest), which is perfectly fine in case of problems, and for a certain period. But ultimately, we need factors pulling us in the opposite direction (uncertainty, movement), to heal optimally and to get us in a better position along the continuum.
Simply put, often, there’s too much pulling towards the safety side, and not enough pulling towards the movement side. Safety behaviour only works well on the long term when it is balanced by exposure to uncertainty. Our natural impulses only work when balanced with natural needs for survival (and reproduction) in a natural environment…
This leaves us with two clinical questions:
How do you get out of the grip of protection?
When do you need to get out of this grip?
In the simplified model, the answer to the first clinical question seems quite obvious: add some vectors towards the side of movement, and limit the vectors towards rest:
1. Limiting vectors causing behaviour to shift towards safety and rest: Be careful with language and information. Avoid misinformation and nocebo! Some beliefs and attitude are deeply engrained, not on a personal level, but on a cultural one, so changing these ‘idee-fixes’ is not easy. Luckily this problems is gradually being tackled in the medical world.
There’s a role for painkillers for behavioural change. Painkillers (and anti-inflammatory drugs) don’t heal, but they can change behaviour towards the optimal healing path, if used wisely and if the patient is educated correctly.
2. Adding vectors causing behaviour to shift towards movement: Think of the hunter-gatherer with low back pain of part 2, and the need for food/shelter/survival that pulls him towards movement: varied natural movements in a complex natural world. Therapists should use tasks that are progressively challenging, in load, in speed, in range of motion, in amount of repetitions, in freedom of movement, in coordinative complexity, in real life risks, … Clinicians should make use of the environment to add variety, complexity, and real life risks.
The second clinical question is a group of important questions: What is too much protection? When is the time to move from safety/rest to uncertainty/movement? When is the response maladaptive?
Well, we have our standard clinical reasoning to help us (tissue healing phases, basic science, clinical guidelines). These, on average, are very useful, but in my experience, do not help in all situations. Real life is complex, as is the human organism…
There’s another useful principle: let the protective systems decide for themselves! But is that not exactly the problem? If we let the protective systems choose, they will pull you in the safe room** and keep you there? Yes, but not if you give them the information they require to make good decisions…
Information comes in different ways: top-down and bottom-up. Top-down, more cognitive and conscious information is useful, but often only a start and thus not enough. Bottom-up information, more (but not only) unconscious and from the body is always necessary.
The better the information, the better the decisions the protective systems will make. Movement provides information. Varied movement, in form, intensity, and complexity, provides the best information.
So if we take the answers to the two questions, we understand that adding movement to the equation is absolutely necessary to balance the pull of protection. Varied movement in a varied environment seems optimal.
The best way of adding these movement forms that I know of is play! Play is varied, complex, engaging, challenging but not really stressful, fun, intrinsically motivated, … Playful movements seem ideal for pulling the organism away from protection and safety. Play is all about the tension between security and uncertainty, about the balance between order and chaos.
But, there’s only one huge problem: pain/stress/protection inhibits play! This is biologically very plausible: play is energetically costly, energy that is better used for tackling the problems/stressors at hand, and it is inherently risky, and you don’t want more risks when already in trouble.***
The answer to this problem is exploration. Exploration could be viewed as the more serious counterpart of play. Movement exploration for people with pain and/or injury is a very useful clinical tool. The kind of exploration I would suggest using makes use of the following (in random order):
careful, gentle movements,
probably rather slow,
full attention to the task at hand,
a safe environment,
a safe movement task,
not pushing too hard in the perceived danger zone,
varied movement (exploration is not just taking one look at something!)
Mind you, a safe task is not without risk (total safety is an illusion). If you explore, you will find things that are dangerous, but because of the way exploration occurs, the negative consequences will be minor, the lessons learned interesting. If a patient explores movement, he/she will almost certainly find out some things that are (perceived) ‘dangerous’, but because of the relatively safe context and the improbability that losing control will have serious consequences, the fear is kept low, injury is unlikely to occur, and the lessons learned will be interesting.
This is exactly the goal of exploration: experimenting with the task/object, looking for the dangerous aspects and learning how to handle them!
So the clinician should provide the vectors that our modern, western lives lack. Add movement tasks, add complex movement tasks, add environmental challenges, safely add risk, add novelty, and stimulate the organism to get more adaptable and resilient.
*Cave: fear of pain is a problem, but other people have the opposite issues, they just keep on going and going (until they finally burst). These people need another approach
**The points made in these blogs are very reminiscent of the ones I made in the blogs about the safe-room metaphor. Just another way of looking at the same problems…
***But when you have been in trouble for a longer time, and haven’t seem to find a solution, you have to try something different… You have to take a chance!