Monthly Archives: May 2015

A personal foray into pain


The idea that what is going on in a person’s life can have an influence on their pain, can be a difficult sell to a patient with pain.  Sometimes even for ‘painiacs’ like myself, it is hard to see the wood for the trees and stop yourself from separating out the bio from biopsychosocial.  Being mindful about our own experiences with pain as a practitioner can teach us many things that we can use  in our clinical practice.

Years ago I had low back pain.  It had been around for about 6 years, but didn’t have any real functional impact on my life.  It was there, I was distressed about it to a degree but it didn’t stop me doing anything.  I had some funny concurrent symptoms which prompted me to present for a medical review.  I had an MRI and nothing was found.  The other symptoms disappeared and the very sensible referring doctor simply told me: Just get strong.  Three simple words, combined with his confidence and the negative MRI were incredibly reassuring.  I did get strong and about 4 months later the back pain was no longer a daily problem.  Within 12 months it had almost completely gone.  Rarely, certain biomechanical stresses will tip it over into a flare up – sitting for prolonged periods and certain exercises at the gym, if I overdo it.  When this occurs, it tends to behave like chronic pain– it doesn’t have a reliable pattern, doesn’t respond well to pain medications and the pain can be a lot more intense than what you might expect for such simple stresses.


Earlier this year I was booked to go to a conference overseas.  In preparing for it, I had thought briefly about the fact that I rarely sat these days, and that the big flight, combined with 3 days at the conference was more sitting than I was used to.  I was aware that my back might get a bit sore.  Three days prior to the departure day, we discovered a large, mysterious lump on the side of  my 22 month old daughter’s head.  We took her to the childrens hospital and an appointment with a surgeon was made for the day that I was due to be leaving.    I was beside myself with worry.

We had a lot of discussion around whether I should go or not.  The tickets were non refundable and I had been looking forward to going for a long time.  It was unlikely that any scans or surgery were going to happen in the time I was away, owing to the weekend in the middle.  My husband and I decided that I should go, and could always come back early if it were warranted.

I was a nervous wreck.  I couldn’t find my passport the day before I was due to go, I wasn’t sleeping and my back was niggling – just what I needed.  Passport found, I boarded the plane for an uncomfortable 18 hour journey.  The first day of the conference I found bearable – lots of walking in between speakers, using the hotel gym and stretching out in the evening.  Day two I was miserable – jet lag had caught up, I wasn’t able to concentrate much with the presentations and the back pain was getting much worse.  That night I skyped home to hear more about the plan that the surgeon was putting in place.  There were neurosurgeons being consulted and an appointment at the childrens hospital, following a CT scan, which was to happen on the day I arrived home.  There was a suggestion that the lump was a meningocele – a protrusion of the dura, filled with cerebrospinal fluid, caused by a defect in the skull.  Things were looking serious, and my husband, a surgeon himself, who could usually talk me through my worries, was himself distressed and upset.

Day 3 was exceedingly uncomfortable. I stood at the back of the room for several of the speakers, wriggled like a 3 year old, and was distracted.  Skyping home again that night I heard that my very calm husband, who is usually very dismissive of our children’s ailments, had had a “moment” at work, shortly after receiving the referral appointment to the childrens hospital.  It was for the Childrens Cancer Centre with an oncologist, a detail he thoughtfully left out of our skype session.  Taking my cues from his level of distress, my journey home was a bit of a nightmare.  The pain was almost unbearable, sitting was really uncomfortable and with storms across the country, my flights were delayed.  I was lucky to score 3 seats on the plane and exhausted, slept through the flight.



In a blur of jetlag and anxiety bordering on panic, we took our daughter for scans and appointments, and finally to theatre for a biopsy of this mysterious and as yet undiagnosed mass.  In the happiest of happy circumstances, the mass turned out to be a haematoma that had failed to resolve, causing some reactive bony changes around it, which made it appear nasty.  The surgeon stuck a needle in it and drained it.  She was completely fine and the bony changes disappeared over the following weeks.  My back pain went away, unnoticed.

A month later I attended a three day seminar and then flew the next day to a conference.  It was a thoroughly enjoyable four days and as I sat at breakfast the next day, I reflected on the fact that I hadn’t had even a niggle of back pain. ……  I HADN’T HAD EVEN A NIGGLE OF BACK PAIN!!!!!!   Same biomechanical stress, completely different environmental setting.

I liken this experience to concept of DIMS and SIMs that David Butler and Lorimer Moseley have created for their new pain workbook “The Protectometer”, a great resource that I have already used with a few patients.  It takes what can sometimes be seen as an esoteric concept – the idea that our thoughts, environment, worries and fears can have a massive impact on our pain, and gives it a level of structure and tangibility. In short, the things that represent danger to our brain (danger in me or DIMs) will elevate our pain levels, the things that represent safety to our brains (safety in me SIMs) will reduce our pain levels.  The exercise becomes one of recognising the presence of DIMS and SIMs, reducing the DIMs where possible and increasing the SIMs.  Sometimes, even recognising that DIMs are at play, even if you can’t change them, can reduce distress about pain……. If you can see the wood for the trees!


How ACT can help with pain

I treated a fun and bubbly lady, who worked in a law firm, as a  patient about 5 months ago.  She had  chronic neck and arm pain and had been on the “search” merry-go-round for 6 years.  She came to see me because her manual therapy practitioner, who she had been seeing roughly 2-3 times a month for 4 years, had moved away.  She was highly distressed about her pain and fixated on the idea that there was a “cure” out there for her – that she only had to look hard enough for it.  She was very knowledgeable on the various combinations of over the counter medications she could combine with her prescription drugs to get a variable level of pain relief, and consequently was taking a lot of opioids.

Functionally, she was still employed at work but was starting to take more and more sick days off work, was cancelling social events on bad days and had stopped doing some of the things that she loved like yoga and classes at the gym.  Whilst she still regularly went to the  gym and had a personal trainer, there were dozens of “rules” about what she couldn’t do – based on cause and effect assumptions she had made about flare ups following a session at the gym.  She also had a lot of pain behaviours at both work and home – talk and avoidances that painted a picture of her being “sick” or “broken”.   As with most of these cases, there was nothing on her imaging that provided a definitive answer as to why her pain was hanging around.

Despite all of this, she was a cheery and happy person, was very motivated to get better and had a lot of insight into her thinking and understanding of her condition – I knew that she was going to do really well with a bigger picture approach.

After spending the initial consult having a really good listen to her story, including her disappointment with all the failed treatments, I introduced the idea of taking a bigger picture (or biopsychosocial) approach, as it was known to get better outcomes for achieving her goals – to get back to the gym fully, to return to yoga and for pain not to dominate her life as much as it was.  She was keen to try a different approach as she acknowledged that her journey up until now had not provided the answers she had been looking for – if anything she felt like pain was becoming a bigger part of her life.

We booked in some long consults for the following three weeks and over that time, did some pain education, reviewed her thoughts and understanding of her condition, introduced some mindfulness meditation and began to create a team around her.  We enlisted the help of an exercise physiologist to review her exercise program and challenge some of the “rules” she had around exercise, especially regarding her fear of load bearing through her arms and doing anything with her arms above her shoulders.  Together with her personal trainer they started using a graded approach to re-introduce some of the exercises she had been avoiding.  We also got her GP involved for a medication review and fortunately he recognised and agreed with our intentions, and suggested that she reduce her use of opioids.

My main goal in those longer sessions was to use a level of understanding of pain neurophysiology to separate the connection between pain and tissue damage.  With this established, we were then able to take our emphasis off chasing the pain and put it onto her functional goals – we spent a lot of time talking about what was important to her, what her pain represented to her and how it was having an impact on her life.    I then began to introduce the concept that if the pain didn’t represent damage and was unlikely to get worse, she could begin to take part in some of the things that she had been missing out on in the presence of pain.  We talked at length about the concept that the complete removal of the pain wasn’t necessary, for her to live her life the way that she wanted.


ACT and mindfulness approaches in pain are both blissfully simple when you strip them down to basics.  Provided you stick to the scope of pain and refer to a psychologist or GP if you feel that there are other psychological co-morbidities, these approaches will fall nicely under the umbrella of pain education and as a manual or exercise therapist, can fall well within your scope of practice. It makes sense for practitioners who are working with people in pain to look into some of these tools and start integrating some of the approaches in their clinical approaches.  Some great resource to start are:




After a brief break in sessions, my patient returned, more bubbly than normal, with a list of all the ways she had been working towards her goals.  Most importantly she reported that she had a better outlook on what her pain meant to her.  This included dropping a lot of her pain behaviours which had been defining to both her, and the people around her that she was “broken”. Ultimately this meant that she was far less distressed.  Her pain scores had dropped considerably – she still had pain, but it wasn’t interfering with her life as much as it had been.  This was reflected by a big improvement in her Pain Catastrophising Scale scores as well.

I chose not to use manual therapy on this patient because she had been so fixated and reliant on treatment prior to coming to see me, that I felt that if I used it, any gains that we made using a more biopsychosocial approach, might have been attributed to the hands on treatment, and taken away from the emphasis I was trying to create on self-management and active approaches.  Subsequently, and for a brief flare up episode we have used some manual therapy – but in a different context than what she had been previously – she now sees its as one of many tools that she could access to help her stay on track.

One of my favourite quotes that sums up a lot about these approaches is this:

“People who have something better to do don’t suffer as much.”  (Wilbert Fordyce, 1988)

You can also read this blog by Joletta Belton, who has suffered with chronic pain, but using these approaches has managed to gain a level of control of her pain and of her life.  It is very inspiring and great to forward on to patients who might be starting to gain an understanding of the concepts.