And you’d be surprised… the answer goes further back than you might think.
So if you read Part 1, we left with a series of questions — all boiling around the conundrum of what I will call “the pain education lag.” This can be defined as the time it takes for the education to take an effect (i.e. reduction of aberrant pain). Essentially, you provide a treatment, but it’s possible for no effect to be seen immediately (and its also highly likely for this to occur in such a delayed fashion). And this is something that is significant. Other treatment effects take place immediately. Yet, with pain education this is not the expectation. Pain education results are only expected to be seen in the long term, but that brings us back to the question. Why?
If that question is not thought provoking for you, consider this: You have accessed the brain of your patient with chronic pain. You have instructed that brain that all pain is the result of the CNS acting as an alarm system response to potential threats. You have also told that brain that these signals can go awry and exist without any actual or legitimate input from the the peripheral system. Even more, you can quiz and test that brain to show conscious understanding of those facts. YET, with all of that…that same brain may continue to produce errant pain signals for some time. Perhaps in some cases — indefinitely.
So I ask again…why?
Why does effecting the brain that gives out those errant signals not have an effect? Why does conscious knowledge not equal subconscious neuro-physiologic activity?
Well…without knowing much more of the neurological details than I do at the present, I can deduce this could be generalized into some form of cognitive dissonance. That same brain you have connected with, has previously built up experiences — what it may call “proof” against your theory. So it refuses to accept a new reality. There may be millions and perhaps billions of neurons which are tagged and related to this brain’s current understanding of and relationship with pain.
Think of it this way: a life time of pain experiences can be represented as a graffitied wall. Many different images and paintings all construed into one large mural of related pain stories. This mural is intricately and seamlessly woven together. All of these individual graffitied marks in the brain’s conscious and subconscious are messages that support the hypothesis that pain is only related to structure and damage. That time you fell and scraped your knee as a child. The time you dislocated your shoulder during football practice. The time you had a not so pleasant dental hygienist cleaning your teeth and you noticed blood being drawn through the clear suction hose.
In order to overcome this “cognitive dissonance mural,” you would need to (hypothetically) erase all of the images on this wall. And I would say, additionally, you need to replace these images with salient demonstrations of pain as a perception. They can be made through metaphor or live demonstrations (e.g. rubber hand illusions) or examples of cold hard facts in scientific research; but nevertheless…there is this “delay.” And yes, I just pretty much explained the reason there is a delay (because we have to unlearn our current state). But why? Why do we have to unlearn?
Why did we learn pain to be something that it’s not?
There could be any number of causes (e.g. the rational/logical cartesian pain model), but I think outside of that — the main reason is poor pain education. We’ve made drastic errors in pain education and they go much further back than the clinic…they go back to the classroom. (And not just to graduate school.)
I challenge you: if you’re fortunate enough to still hold copies of your PT school notes — or perhaps even as far back as undergrad — take a look in all of the relevant course materials. My guess is you fall into one of two (or both) categories:
1) Pain neurophysiology is not discussed (excluding reference to any PT programs, though it’s still clearly not enough)
2) Pain is spoken of incorrectly or confusingly.
Number two, in my estimation, is where we’ve messed up. It’s where we’ve missed the mark. (We’ve had correct models of pain science and neurophysiology dating back to the 1800’s.)
Examining my own course notes and text books, I saw conflicting signals. A neuroscience course that discusses pain in terms of “pain fibers,” yet a neuroscience text book that briefly attempts to dive into the complexity of pain as a perception in just two paragraphs (both of which are actually quite stunning despite their brevity). Looking at another PT course, I find both views within the same powerpoint presentation: the IASP definition for pain is provided, and on the very next slide comments about “pain fibers” are made.
If I go even further back, I find the very same in my undergrad anatomy and physiology textbooks. Two separate books for the same course; one discusses the IASP’s pain definition, and the other — pain fibers and free nerve endings sending pain signals up to the brain.
Now let me pause here. If you’re wondering, “What’s the big deal?” Then you may need some pain education yourself. These two world views on pain are fundamentally opposed. Therefore, they cannot co-exist, and furthermore, only one can be correct. Because while the experience of pain may be very subjective, the neurology of pain is not…it is central. Pain is in the brain…all the time. Nociceptors ≠ Pain Fibers.
On one hand, we have correct models of pain being taught: Pain is complex, it is a sensory/emotional experience, it occurs in the CNS.
On the other hand, we have: pain is simple, it occurs in the tissues then you become aware of it, it is always accurate.
You see what I’m getting at? Mixed signals. Add those on top of a lifetime of belief reinforcement: 1 + 1 = 2, or slam my knee(1) into the table(1) and get pain(2), and you get a confused populous. You get a 53 year old man with age related changes of the spine (better known as: “degenerative joint disease”) resulting in chronic pain requiring therapy, surgery, medication, or some combination of the three because we’ve failed to educate ourselves first.
So what’s left here? How do we cross this bridge? How do we get our patients (or maybe even practitioners) to understand pain?
Clearly we must do our part in the clinic (at the front-lines, if you will) explaining pain to our patients one-by-one, but this may be a design doomed to fail. Because if we do not address the problem of poor quality or lack of pain education at its source…it would seem the “pain cognitive dissonance mural” will naturally grow in the minds of young society — forming a never ending loop. Individuals will continue to grow into the cartesian model over and over, and we will continue to attempt to undo the city-block sized murals which have already taken place.
So for a solution other than widespread integration of pain science education throughout academia (K-12th up to grad school), I am at a loss. But maybe that’s just the solution we need. We teach elementary school students about cell biology, why can’t they learn about pain neurology?