# Radiofrequency denervation **URL:** \ **Category:** Medical Q&A \[Moderated\]\ **Created:** [February 15, 2018, 1:36pm UTC](https://forum.barbellmedicine.com/t/radiofrequency-denervation/924 "2018-02-15T13:36:40Z")\ **Posts on this page:** 15\ **Page:** 1
**Author:** ![quark](https://avatars.discourse-cdn.com/v4/letter/q/5e9695/32.png) [@quark](https://forum.barbellmedicine.com/u/quark)\ **Post date:** [February 15, 2018, 1:36pm UTC](https://forum.barbellmedicine.com/t/radiofrequency-denervation/924/1 "2018-02-15T13:36:40Z")
Does the BMJ article summarized in [http://www.barbellmedicine.com/the-science-of-where-your-pain-comes-from/](http://www.barbellmedicine.com/the-science-of-where-your-pain-comes-from/) apply to chronic pain in the glute and upper hamstring region, not just the chronic lower back pain mentioned in the summary?I don’t have the underlying article. The context of the question is a mid-60s female with chronic pain in the glute and upper hamstring region who had a diagnostic block (anesthetic and cortisone injection) near lumbar facet joints on the side of her body with pain, which appeared to do a lot to relieve the pain, eliminating severe pain spikes and leaving low to moderate pain. The doctor said that the diagnostic block was essentially a temporary way of stopping pain signals and radiofrequency denervation (ablation, neurotomy) would be a longer lasting version of the block. She trains under the guidance of a SSC. Training usually neither helps nor hurts with pain. Training, especially deadlifts, and awareness of the biopsychosocial model, seem your main recommendation for low back pain. What else would you recommend she try to reduce this pain? Medication, ranging from nsaids to oxy, has not helped. ---
**Author:** ![Austin\_Baraki](https://sea1.discourse-cdn.com/flex001/user_avatar/forum.barbellmedicine.com/austin_baraki/32/1095_2.png) [@Austin\_Baraki](https://forum.barbellmedicine.com/u/Austin_Baraki)\ **Post date:** [February 15, 2018, 7:26pm UTC](https://forum.barbellmedicine.com/t/radiofrequency-denervation/924/2 "2018-02-15T19:26:20Z")
If they injected her lumbar facet joints for a “diagnostic block”, this is exactly what was done in the trials described. My approach for most things involves intensive pain education and graded physical exposure (with a goal of getting to “real” training, as you describe). ---
**Author:** ![quark](https://avatars.discourse-cdn.com/v4/letter/q/5e9695/32.png) [@quark](https://forum.barbellmedicine.com/u/quark)\ **Post date:** [February 16, 2018, 6:11pm UTC](https://forum.barbellmedicine.com/t/radiofrequency-denervation/924/3 "2018-02-16T18:11:13Z")
It seems odd that a diagnostic block would help, but what is essentially a long-term version of a diagnostic block would not, but what seems odd to me is not a good measure in this context. Given that she’s already doing “real” training (as well as graded exposure to walking, as walking is an important life function which has been an issue) and that she’s aware of the pain research, is there anything else you’d recommend? ---
**Author:** ![Austin\_Baraki](https://sea1.discourse-cdn.com/flex001/user_avatar/forum.barbellmedicine.com/austin_baraki/32/1095_2.png) [@Austin\_Baraki](https://forum.barbellmedicine.com/u/Austin_Baraki)\ **Post date:** [February 16, 2018, 8:05pm UTC](https://forum.barbellmedicine.com/t/radiofrequency-denervation/924/4 "2018-02-16T20:05:04Z")
It’s quite a bit more complex than just “awareness” of the research. There needs to be wholesale _conceptual change_ about pain, thought and behavioral patterns that need to be incorporated into her daily life. This is deep stuff, and may require getting some help on the matter. In addition, the exercise as you mentioned, plus patience. I’m also not making specific recommendations as to what she “shouldn’t” pursue in terms of treatment, I am just presenting the best available data on these things for patients and coaches to be more informed. ---
**Author:** ![quark](https://avatars.discourse-cdn.com/v4/letter/q/5e9695/32.png) [@quark](https://forum.barbellmedicine.com/u/quark)\ **Post date:** [February 16, 2018, 9:22pm UTC](https://forum.barbellmedicine.com/t/radiofrequency-denervation/924/5 "2018-02-16T21:22:49Z")
A problem is that she regards the biopsychosocial model as including elements of a blame the victim, it’s all in your head, attitude. Even her doctors acknowledge the low correlation between imaging and pain and have suggested that one reason pain relief is important is that it allows for activities which will increase strength. Do you have any suggestions or pointers for “getting some help on the matter”. The articles of yours that I’ve read have been more explanations of the model than, for example, behavioral or thought pattern (for want of a better phrase) recommendations. Apologies if I’ve missed this aspect of your writings. For that matter, do you have any recommendations regarding training? The current approach seems to be to pursue normal barbell training, modified as necessary to avoid things which increase pain. You are clearly not making specific recommendations, including recommendations that she not pursue any particular treatment. Even if that were not obvious, the medical forum disclaimer is very clear on the matter. ---
**Author:** ![quark](https://avatars.discourse-cdn.com/v4/letter/q/5e9695/32.png) [@quark](https://forum.barbellmedicine.com/u/quark)\ **Post date:** [February 16, 2018, 9:28pm UTC](https://forum.barbellmedicine.com/t/radiofrequency-denervation/924/6 "2018-02-16T21:28:03Z")
Following up: you have recommended: 1. Managing stress, anxiety, and depression (much easier said than done) 2. Education about back pain to reduce the fear that your pain is reflective of constant “danger” 3. Getting adequate sleep 4. Avoiding use of opiate pain medications and “muscle relaxants” (although acetaminophen/NSAIDs may be helpful) 5. Exercising – or, even better, training – to move through previously “threatening” ranges of motion 6. Continuing to participate in normal activities (i.e, avoiding immobility!) I didn’t mean to imply that there were no recommendations. I’m just looking for more detail and practical advice. ---
**Author:** ![Austin\_Baraki](https://sea1.discourse-cdn.com/flex001/user_avatar/forum.barbellmedicine.com/austin_baraki/32/1095_2.png) [@Austin\_Baraki](https://forum.barbellmedicine.com/u/Austin_Baraki)\ **Post date:** [February 16, 2018, 10:58pm UTC](https://forum.barbellmedicine.com/t/radiofrequency-denervation/924/7 "2018-02-16T22:58:36Z")
> [@quark](#): > > A problem is that she regards the biopsychosocial model as including elements of a blame the victim, it’s all in your head, attitude. Even her doctors acknowledge the low correlation between imaging and pain and have suggested that one reason pain relief is important is that it allows for activities which will increase strength. This confirms that “awareness” of the model is not the same as _understanding_ and _applying_ it. In no way is it intended to blame the victim. > [@quark](#): > > Do you have any suggestions or pointers for “getting some help on the matter”. The articles of yours that I’ve read have been more explanations of the model than, for example, behavioral or thought pattern (for want of a better phrase) recommendations. Apologies if I’ve missed this aspect of your writings. There is unfortunately no “formulaic” solution for this, as the underlying psychosocial factors involved vary from individual to individual. However, a few patient-oriented resources on the matter are the books/works of Dr. Lorimer Moseley/David Butler and Adriaan Louw. You might start here: [https://www.tamethebeast.org/](https://www.tamethebeast.org/) As well as their books, such as: > **[Explain Pain: Dr. David Butler, G. Lorimer Moseley: 9780987342669: Amazon.com:...](https://www.amazon.com/Explain-David-Butler-Lorimer-Moseley/dp/0987342665)** > > Explain Pain \[Dr. David Butler, G. Lorimer Moseley\] on Amazon.com. \*FREE\* shipping on qualifying offers. Explain Pain > **[The Explain Pain Handbook: Protectometer: Butler, David S., Moseley, G. Lorimer:...](https://www.amazon.com/Explain-Pain-Handbook-Protectometer/dp/0975091093)** > > The Explain Pain Handbook: Protectometer \[Butler, David S., Moseley, G. Lorimer\] on Amazon.com. \*FREE\* shipping on qualifying offers. The Explain Pain Handbook: Protectometer > **[Why Do I Hurt?: A Patient Book About the Neuroscience of Pain: Louw PT PhD,...](https://www.amazon.com/Why-Do-Hurt-Adriaan-Louw/dp/0985718625)** > > Why Do I Hurt?: A Patient Book About the Neuroscience of Pain \[Louw PT PhD, Adriaan Louw PT PhD\] on Amazon.com. \*FREE\* shipping on qualifying offers. Why Do I Hurt?: A Patient Book About the Neuroscience of Pain > **[Painful Yarns: Metaphors and Stories to Help Understand the Biology of Pain:...](https://www.amazon.com/Painful-Yarns-Lorimer-Moseley/dp/0979988004)** > > Painful Yarns: Metaphors and Stories to Help Understand the Biology of Pain \[Moseley, G. Lorimer\] on Amazon.com. \*FREE\* shipping on qualifying offers. Painful Yarns: Metaphors and Stories to Help Understand the Biology of Pain ---
**Author:** ![quark](https://avatars.discourse-cdn.com/v4/letter/q/5e9695/32.png) [@quark](https://forum.barbellmedicine.com/u/quark)\ **Post date:** [February 18, 2018, 3:41pm UTC](https://forum.barbellmedicine.com/t/radiofrequency-denervation/924/8 "2018-02-18T15:41:43Z")
Searching for “How can I retrain my pain system to be less protective?”, the first google hit was [http://www.retrainpain.org/](http://www.retrainpain.org/), which seems to me to be very good. The basic message appears to be that one can become inappropriately overly sensitive to pain ( a physiological change, not “all in your head”) and that this is a cause of chronic pain. One can do things to convince oneself that one is not fragile or broken, to become less sensitive, to retrain the brain’s pain system. It favors focusing on activities rather than pain relief (attempting to control pain, or even tracking pain, heightens attention to pain sensations), mindfulness exercises (which appears to be the current universal recommendation) and sleeping well. What do you think? ---
**Author:** ![Austin\_Baraki](https://sea1.discourse-cdn.com/flex001/user_avatar/forum.barbellmedicine.com/austin_baraki/32/1095_2.png) [@Austin\_Baraki](https://forum.barbellmedicine.com/u/Austin_Baraki)\ **Post date:** [February 18, 2018, 3:47pm UTC](https://forum.barbellmedicine.com/t/radiofrequency-denervation/924/9 "2018-02-18T15:47:36Z")
Yep, that’s the idea. ---
**Author:** ![Sean\_Herbison](https://sea1.discourse-cdn.com/flex001/user_avatar/forum.barbellmedicine.com/sean_herbison/32/787_2.png) [@Sean\_Herbison](https://forum.barbellmedicine.com/u/Sean_Herbison)\ **Post date:** [February 19, 2018, 5:50pm UTC](https://forum.barbellmedicine.com/t/radiofrequency-denervation/924/10 "2018-02-19T17:50:17Z")
> [@quark](#): > > A problem is that she regards the biopsychosocial model as including elements of a blame the victim, it’s all in your head, attitude. I’ve run into this problem when talking about the topic as well. I’ve had a lot of success, mostly thanks to exposure starting with Austin’s work, in getting rid of my back pain this way. It’s not a fool-proof method, and it’s not something you do once and then never have to think about again, but it works better than anything else I’ve seen. The problem is the word “blame”. Because technically, yes, it’s all my fault. Everything my brain does is something I do, since my brain is part of me. But that doesn’t imply any moral downfall on my part. It doesn’t mean that I’m doing something bad or that it’s not real. And it doesn’t mean I’m choosing to be in pain. What is does mean, and the way I’ve found it better to describe, is that we have the power to do something about the pain. We just need to know how. The bad news is it’s mostly subconscious, so it’s not something you can just flip a switch on, regardless of how good your mental discipline is. The good news is there are ways to reach that part of us anyway, and other people have done it before and know how to teach you. The even _better_ news is that you’re probably not physically broken beyond repair, regardless of how long you’ve had the pain, and how much you think it’s just how you are now. Anyway, I’ve had better luck with reaching people with that approach. There are just certain words you need to avoid with some/most people, and reframing the idea can be very helpful. ---
**Author:** ![quark](https://avatars.discourse-cdn.com/v4/letter/q/5e9695/32.png) [@quark](https://forum.barbellmedicine.com/u/quark)\ **Post date:** [February 20, 2018, 2:19pm UTC](https://forum.barbellmedicine.com/t/radiofrequency-denervation/924/11 "2018-02-20T14:19:33Z")
@Sean & Austin: “we have the power to do something about the pain. We just need to know how”. That really is the question. She’s doing well with training (with some minor modifications), is trying to walk at least a mile a day (as that’s an important life function), although that results in more pain than training, but could likely to more on the mental/brain side of things. Any additional specific suggestions would be appreciated. @Austin: some of the pain materials use the placebo effect as an illustration. However, our subject did not respond to tramadol or oxycodone. It would seem odd that so many respond to placebos but she doesn’t respond to some rather strong medicines. Any thoughts on this? ---
**Author:** ![Austin\_Baraki](https://sea1.discourse-cdn.com/flex001/user_avatar/forum.barbellmedicine.com/austin_baraki/32/1095_2.png) [@Austin\_Baraki](https://forum.barbellmedicine.com/u/Austin_Baraki)\ **Post date:** [February 20, 2018, 3:29pm UTC](https://forum.barbellmedicine.com/t/radiofrequency-denervation/924/12 "2018-02-20T15:29:33Z")
> [@quark](#): > > @Austin: some of the pain materials use the placebo effect as an illustration. However, our subject did not respond to tramadol or oxycodone. It would seem odd that so many respond to placebos but she doesn’t respond to some rather strong medicines. Any thoughts on this? As with just about every other human trait, there is significant inter-individual variation in responsiveness to opioid medications as well as variation in susceptibility to placebo effects. This variation is thought to be mediated by various genetic (e.g., CYP2D6 polymorphisms affecting opioid metabolism, or COMT gene polymorphisms in the context of placebo), as well as contextual factors (e.g.: [Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain - PMC](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5778801/) ). ---
**Author:** ![Sean\_Herbison](https://sea1.discourse-cdn.com/flex001/user_avatar/forum.barbellmedicine.com/sean_herbison/32/787_2.png) [@Sean\_Herbison](https://forum.barbellmedicine.com/u/Sean_Herbison)\ **Post date:** [February 20, 2018, 6:07pm UTC](https://forum.barbellmedicine.com/t/radiofrequency-denervation/924/13 "2018-02-20T18:07:39Z")
> [@quark](#): > > @Sean & Austin: “we have the power to do something about the pain. We just need to know how”. That really is the question. … Any additional specific suggestions would be appreciated. As I don’t have the medical background that Austin does, I can only speak for my own experience. For me, what seems to help is recognizing that blaming a physical factor, at least in my case, didn’t make any sense. If it was due to something physical causing muscle pain, the pain should have been worst when the most strain was on the muscle. Instead, I could deadlift 600 lbs and feel fine, but it would flare up when leaning forward to look in the mirror while shaving. So, since that pretty much ruled out physical causes, I started to look at what to do about the mental side. While it wasn’t a complete fix, just this realization - internalizing it, not just being academically aware of it - seemed to help. Another thing which seems to help, though on a hit or miss basis, is trying to _exactly_ locate the pain. I sometimes feel that my back is in pain, but when I try to focus on _where_ it hurts, I find that I can’t always pinpoint it. If I can, this method doesn’t help, but when I can’t, and it’s maybe 50/50, the realization hits me that my brain is making the pain and telling me it’s in my back, rather than my back actually sending a signal to my brain. Sorry if that’s a bit rambling, but it’s the best I can do at the moment, so I hope it gets the point across. ---
**Author:** ![schmatt](https://avatars.discourse-cdn.com/v4/letter/s/7feea3/32.png) [@schmatt](https://forum.barbellmedicine.com/u/schmatt)\ **Post date:** [February 20, 2018, 11:56pm UTC](https://forum.barbellmedicine.com/t/radiofrequency-denervation/924/14 "2018-02-20T23:56:17Z")
I will also chime in on this mental side of pain. I have had a few tweaks over the last year. I found myself “catastophising” the pain, thinking I had done a lot more damage than was really there. Most of these took multiple months before feeling completely pain free. Learning more about this model of pain, and taking a step back has helped a lot. It doesn’t eliminate the pain, but it does help you feel like it will go away, and that you haven’t damaged anything seriously. The best piece of advice I’ve picked up was just slowly taking yourself into those range of motions that cause pain to help tell your brain that there really isn’t any danger. Consciously understanding that I wasn’t doing any further damage with this helped a lot. I had another small tweak of a muscle in my hip yesterday. It was painful, including just walking all day yesterday. But understanding that it was most likely my brain trying to “protect” me, I didn’t worry about it. I continued to try to walk as normal as possible, even though it was painful. Surprise, today a significant amount of pain has gone away. Most of the time, I can walk normally. Although, it does go back to some pain if I’ve been sitting for a while. I think it is just my brain needing to be reminded that there is nothing to worry about. This same thing happened in my other hip last year. It took me over 3 months before I was completely pain free. I’m pretty positive that most of this was because of my mental approach to the pain. The initial onset of pain was almost identical between these two injuries. ---
**Author:** ![quark](https://avatars.discourse-cdn.com/v4/letter/q/5e9695/32.png) [@quark](https://forum.barbellmedicine.com/u/quark)\ **Post date:** [February 21, 2018, 1:05pm UTC](https://forum.barbellmedicine.com/t/radiofrequency-denervation/924/15 "2018-02-21T13:05:32Z")
Summarizing, the keys are really believing that pain is not a signal of tissue damage and progressively increasing stimulus (graduated exposure). What can one do to avoid catastrophizing, especially in personality types that are generally prone to it? I wonder if there’s a meaningful difference between problems that manifest at heavier weights, larger ranges of motion and continuing an activity for a longer time. In this case, any training pain is not a function of weight and walking pain is a function of distance (not range of motion or anything else we can think of). She’s trying to walk farther each time, although progress is far from linear.