This post is directed to Austin mostly, because of his obvious masochism/sadism.
"Be kind to your nervous system. Create pleasant, safe sensory experiences — positive inputs. Seek comfort. Be a hedonist. If your brain thinks you’re safe, pain goes down — and pleasure feels safe. So be “nice” to your CNS in every way that you can think of. Make your life — or a joint — feel safer, gentler, more pleasant. Do it in general ways (soak the whole system in a hot tub), but also more specifically: pleasantly stroke a sore knee, give a screaming shoulder the “comfort” of a sling for a while, or cautiously but thoroughly move a troubled joint to demonstrate to your brain that it’s okay. (See, brain? We can do this! No big deal!) Lorimer again…"
-a passage from “Pain is Weird” at PainScience.com
To me, there seems to be a potential paradox here. On the one hand, it seem like it’s a good idea to recommend to a patient to “be kind to his or her nervous system,” i.e. take that hot Epsom Salt Bath, or baby that sore arm with a sling, etc., not because it’s a kind of a mechanistic solution to the pain he or she is experiencing, but rather because “pleasure feels safe” and “to demonstrate to your brain that it’s okay.” But surely this could have the unintended and opposite effect of leading the person to believe that she is more hurt than she actually is, and therefore make the pain worse, either in terms of intensity, frequency or duration. For instance, I’ve known a person to chronically wear one of those stretchy, Velcro back “braces” around all the time, and thus whenever someone asks him what it is, he’s forced to say things like, “Oh I just have a bad back. It’s ran in the family for generations. Leaning over at all to pick something up without it risks snapping my back in two. Etc.”
I guess the solution here is to be very sensitive in how we apply these “potential remedies” in a case by case basis, and we have to be clear on how these “remedies” are in fact remedies, i.e. how they’re not mechanistic cures or crutches for the pain, but rather a small piece in a rather large psychosocial puzzle.
Could you comment on this at all? Thanks for your time.
I obviously agree with the approach of reassurance and encouraging the perception of “safety”, as this indeed has pain modulating effects. When someone has particularly severe symptoms, using something that is directly comforting (as described in the quote, and also includes things like manual therapy) may be a reasonable starting point as well – although, as an aside, I essentially never recommend shoulder slings outside the context of immediately post-op patients.
However, all of those physically comforting interventions need to be deeply and thoroughly couched in the context of education, reassurance, setting positive expectations, and attaining patient buy-in to a plan for progression back to normal activity. Doing the former without the latter is, as you’ve observed, a recipe for dependence. Doing both shifts the locus of control onto the patient, gets them actively involved in improving, and therefore ultimately less dependent on such temporary “crutches” for physical comfort.
I see. So, in your opinion, you believe that the “education, reassurance, etc.” aspect of “physically comforting interventions” is what is absent from modern health practices and Rx’s? If so, that would seem to be a direct consequence of the mechanistic model of pain that’s dominant today, yes?
Precisely. All of those are interrelated: in order to get patient buy-in for a plan to progress back to normal activities, they need the reassurance that they won’t cause more damage, education on how it will help, the expectation that they can improve, and a feeling that this is under their control.
Instead, patients get nocebo’d based on 1) overly structuralist models and 2) recommendations from highly risk-averse healthcare providers who are literally trained to catastrophize.
That’s unfortunate. What kind of challenges can an upcoming medical student expect to face with regards to this problem? I can imagine that one will have to “swallow and regurgitate” a good bit of outdated information.
You’re going to hear outdated information, yes – but that’s easy to deal with, just by keeping up with more recent literature and guidelines, and constantly continuing to read.
The bigger issue, in my mind, is that you’re going to see lots of harm being done through language (if you haven’t read the JAMA piece “The Iatrogenic Potential of the Physician’s Words”, it is an extremely important one). You aren’t going to be able to do much about this as a medical student, but you need to arm yourself with this information now so that, when you’re taking care of patients yourself, you choose your words carefully and are always aware of their implications on the receiving end.
Fortunately, you have a huge head start compared to where I was, just because you’re already aware of this stuff before starting medical school.