Pain, placebo and nocebo, and changing experience

[Kit_L]

On 6/18/2017 at 4:20 AM, AlexanderEgebak said:

Nociception is only a very small part of the pain experience. The psychological factors and the social factors have come to stay; tissue damage is not very relevant in terms of processing pain.

I began my academic career in medical anthropology, Alexander, that part of academia that the theoretical base of Lorimer's work rests on—and a paper I wrote there in 1988 (Low back pain: review and prescription) was radical, then. Outside of physiotherapy, the bio-psycho-social model of medicine generally (Kleinman) has held sway for a very long time now. I am familiar with the literature, but science and the current narrow "evidence-based medicine" are blunt tools that do not look at the lived, subjective experience of being a human being—and that's where our present work sheds real light. Pain is simply one aspect. You have heard me mention "pain is a sensation; suffering is the story we tell ourselves about it": this is how any experience is constructed. The whole of one's life is similar in this regard.

Can you link to his book please; I could not find it on Amazon. 

[AlexanderEgebak]

7 hours ago, Kit_L said:

I began my academic career in medical anthropology, Alexander, that part of academia that construction the theoretical base of Lorimer's work—and a paper I wrote there in 1988 (Low back pain: review and prescription) was radical, then. Outside of physiotherapy, the bio-psycho-social model of medicine generally (Kleinman) has held sway for a very long time now. I am familiar with the literature, but science and the current narrow "evidence-based medicine" are blunt tools that do not look at the lived, subjective experience of being a human being—and that's where our present work sheds real light. Pain is simply one aspect. You have heard me mention "pain is a sensation' suffering is the story we tell ourselves about it": this is how any experience is constructed. The whole of one's life is similar in this regard.

Can you link to his book please; I could not find it on Amazon. 

Interesting.

The thing about the biopsychosocial model is that it is being used wrongly. It was invented in a time where our understanding of pain was still bimechanical. Although the model introduced psychosocial aspects pain was still a biomechanical issue, which then had social and psychological implications. In the original model social and psychological factors did not influence on pain experience but was still influenced by pain. As an example pain might limit social activities but no one ever stated how social activities changed the pain experience.

Newer biopsychosocial models put pain in the middle so that pain is a result of all factors. Unfortunately, this model has not yet reached the broader physiotherapist community.

I agree that pain in itself cannot be alleviated by science, but science can definitively test for generality in terms of applying certain standardized methods and then seeing if there is a pain relief. The treatment is not science itself because as you state science is generalized. I am sure Lorimer agrees with that as well. But science definitively provides a great understanding of pain - especially newer pain science coming out. I can link to more than a handful of very well-thought out studies which discovered all new aspects of pain and how we should treat it optimally. I guess I respectfully disagree if your point is that science is limiting our understanding of pain? Science does not account for the individual pain experience, but pain is still pain; a pain neurotag in one person may be vastly similar and vastly different from another person's, but generalized methods which have been double blinded for placebo have shown huge potential. Optimally, a practitioner should use the methods that science has stated to work best and then individualize these to the individual. This is also what the pain community approves of doing.

The part about pain being one aspect I both agree and disagree with. Everything evolves around reducing pain. Lorimer talks about pain being an action neurotag influenced by a lot of modulating neurotags. The modulating neurotags which decides if the pain neurotag is activated reaches out to all parts of the brain; beliefs, knowledge, memory, relationships, stress, nociception etc... To treat pain successfully one has to influence as many modulating neurotags as possible to reduce the threat level of the body. In that sense I believe that pain is everything since it wires so profoundly, and this especially holds true for longer lasting pain; less, but still for acute pain. In relation to that you may not be working on altering the pain directly, but the theory of neurotags state that changing any modulating neurotags will affect other neurotags because everything is wired together. Some will have more profound effect to change than others.

This is a link to where you can buy the book. It is not on Amazon yet, it was just published!

http://www.noigroup.com/en/Product/EPSB

[Kit_L]

5 hours ago, AlexanderEgebak said:

The thing about the biopsychosocial model is that it is being used wrongly. It was invented in a time where our understanding of pain was still bimechanical.

Please do some serious reading in this area, and come back. Revisit your much earlier comments (regarding Sherrington's laws) about not wanting a history lesson. With sincere respect, the fact is you simply do not have a wide or deep enough understanding yet about the matters you pronounce upon. No problem, either, for me.

On the other hand, if you want to go deeper into this, turn up at a workshop some time and keep an open mind (and heart). Not everything "evolves around reducing pain", as you claim.

[AlexanderEgebak]

5 hours ago, Kit_L said:

Please do some serious reading in this area, and come back. Revisit your much earlier comments (regarding Sherrington's laws) about not wanting a history lesson. With sincere respect, the fact is you simply do not have a wide or deep enough understanding yet about the matters you pronounce upon. No problem, either, for me.

On the other hand, if you want to go deeper into this, turn up at a workshop some time and keep an open mind (and heart). Not everything "evolves around reducing pain", as you claim.

This is actually not my opinion; that is the general consensus of the workshop that I was attending. But to be clear, I think that argument is pretty reasonable based on the evidence that I was presented. I am simply stating what was explained to me by Lorimer last Sunday and will leave it to this now. You will have to contact Lorimer for more in depth information and elaboration if you value his opinion.

Pain science is still a brave new world for me, and I will remain humble to that which I do not know. However, I will not change my opinion unless I hear reasonable arguments. It is completely understandable if you do not have the time nor desire to expand on your opinions, especially since I am not paying you; but since pain science is an area full of mainly opinions, not facts, I cannot change my mind with Lorimer's evidence pointing in a certain direction.

However, I am taking your advice about serious reading into this area; that has been happening for a while now, and much has happened, but much still needs to happen.

I guess we can better discuss "not everything evolves pain" if we both elaborate on what we mean here. Which I on my part am happy to do

[Kit_L]

I was not aware that Lorimer Mosley was a physiotherapist, and I will listen to his TED talk. The profession you are in the process of entering (physiotherapy,) of all the disciplines of modern medicine, seems to me to be stuck in a mostly biomechanical model of cause and effect, both with respect to dysfunction, and pain. As with all professions, though, there is a broad range of views within it, too, and many embrace wider models privately. I will report back here once I have listened to the talk.

Consider your whole journey here: as I mentioned a few pages ago, you are a different person to the one who first posted here. Please tell us what you learned on the Mosley workshop that you can put into practise now. My point in asking this is that theoretical perspectives abound, and as you say above, "pain science is an area full of mainly opinions, not facts". This is precisely why I am no longer an academic: I chose to deal with, explore, and refine the world of experience, and leave the world of concepts for others to argue about. If you learned somethings, or some things, that you can actualise now, then I am interested. My experience in helping others to move past their experience of pain is all practical; in the moments of the consultation, their perception of the problem and their direct experience of it is changed; that is the core of the ST method, in fact. Becoming more flexible is a small part of this story.

 

[AlexanderEgebak]

11 hours ago, Kit_L said:

I was not aware that Lorimer Mosley was a physiotherapist, and I will listen to his TED talk. The profession you are in the process of entering (physiotherapy,) of all the disciplines of modern medicine, seems to me to be stuck in a mostly biomechanical model of cause and effect, both with respect to dysfunction, and pain. As with all professions, though, there is a broad range of views within it, too, and many embrace wider models privately. I will report back here once I have listened to the talk.

Consider your whole journey here: as I mentioned a few pages ago, you are a different person to the one who first posted here. Please tell us what you learned on the Mosley workshop that you can put into practise now. My point in asking this is that theoretical perspectives abound, and as you say above, "pain science is an area full of mainly opinions, not facts". This is precisely why I am no longer an academic: I chose to deal with, explore, and refine the world of experience, and leave the world of concepts for others to argue about. If you learned somethings, or some things, that you can actualise now, then I am interested. My experience in helping others to move past their experience of pain is all practical; in the moments of the consultation, their perception of the problem and their direct experience of it is changed; that is the core of the ST method, in fact. Becoming more flexible is a small part of this story.

 

I agree about your comments with regards to physiotherapy. Luckily, we are seeing a revolution currently, although it is happening slowly due to a lot of factors; economy, pride, the fact that pain is hard to understand etc. I am currently being taught a lot of dogmatic approaches; both in terms of diagnostics and treatment, but with me having broadened my horizon early I hope I can provide the best possible help once I am more experienced.

With regards to your latest comment... That will be a long reply which will take a lot of time and consideration to make. I will get back to you on that at some point where I have the time to give you a good answer. However, there will definitively be answers to give, and Lorimer did a very good job of explaining how reconceptualization and education of patients may be the most worthwhile treatment that is both placebo-controlled, evidence-based and highly yielding (not necessarily stand-alone). A note on placebo; many existing treatments for pain, especially the passive and biomechanical ones, derive most if their treatment effect from a placebo (be that an enthusiastic PT, good looking, good people skills, a nice title, good references, nice clothing...); I can expand on that.

With regards to Lorimer I believe the TED Talk will not provide you with answers, really. It is too superficial and mainstream although it does get the main point through. Instead, have a watch here:

https://www.youtube.com/watch?v=NIYskLy5SJ4

This one goes a bit more into depth about placebo, sensitization, nociception, neurotags and immunology.

[Kit_L]

I agree with your comments re. the placebo effect; I have written about this myself, and I wrote one of the early papers on the less beneficial nocebo effect. Nocebo (L. for "I hurt") describes what can happen when a medical authority shows you hard evidence of irreversible somatic change on X-ray or MRI, and your condition gets worse. All practitioners rely in part, at least, on the placebo effect, which is your expectation of what a practitioner can do for you. Until antisepsis and antibiotics were invented, the placebo effect was the major tool of Western medicine (the "bedside manner").

And I agree about the value of reconceptualisation and reframing, too, in changing the pain experience, but my work both does this, and goes beyond this. On the workshops I show students how to change the experience of pain, in real time. The language of the body is sensation, and sensation is pre-conceptual, though concepts can profoundly affect experience, as Mosley describes.

I asked you above to tell us what you learned that you can put into practise now, with respect to your own pain phenomena, because I want to highlight a disconnect: the world of concepts and the world of experience. To cite a Zen story, 'the finger that points at the Moon is not the Moon'. Concepts and experience are not the same, though of course they influence each other. The ST work changes the experience, the sensations themselves, in the moment. Best practise will explicitly target both dimensions, I believe.

[Kit_L]

@AlexanderEgebak; you may find this interesting:

https://articles.mercola.com/sites/articles/archive/2018/10/27/placebo-effect-on-back-pain.aspx?utm_source=dnl&utm_medium=email&utm_content=art1&utm_campaign=20181027Z3&et_cid=DM242283&et_rid=454263820

I do not have a view about Dr Mercola, but this BBC documentary that this article references may be worth a look. 

Of most interest to me is the comments by Ted Kaptchuk, a researcher  whose work I am familiar with. One gem:

Quote

Curiously, compared to those who received no treatment, nearly twice as many in the placebo group — all of whom knew they were taking a dummy pill — reported adequate symptom relief. 

One of the truly powerful effects of ST is that its practise both builds the experience of what self-empowerment feels like. All effects, scientific and others, are enhanced.