That’s a good one. There was a really good paper came out by…It’s probably the paper of the year. It’s really philosophy paper. It’s not even an experiment. This kid, who’s a chiropractor, is a PhD student, but they outline the history. If I want to look at it, it’s an inactive approach to pain, beyond the Biopsychosocial model, beyond the BPS model.
They outline a history of pain science essentially. They start with [laughs] voodoo cults and inhabited spirits, and then it goes to Descartes. “I doubt therefore I am” kind of duality of mind. This mind body dualism led to the belief that pain was transmitted via wires to the brain that released animal spirits.
That was the dominant belief until the ’50s and ’60s when we understood more about neuroscience, and we thought pain must be somewhere in the brain. There was also a different school of thought that was like, “Well, body pain or somatic pain must be transmitted in the nerves to the brain and the brain just outputted pain.” You had two competing ideas.
As the end of the century evolved, they were looking for a brain-centered region because some of the gate control stuff…If pain comes from the body, and when we move, we reduce it a little bit that means that we’re blocking the pain signal. Some of that data was…That model was broken a little bit because you can still perceive pain for a lot of other reasons.
There was clearly not a clear relationship between the input coming from the nerves, and the pain experience that was coming out. People were looking for the place that that was processed to drug it or to surgically alter it, like a pain center. Idea is no one ever really found a pain center.
There’s some conditions where people don’t process pain the same way, but they have pain and avoidance behavior. They don’t feel pain, but they behave as if they felt pain, which is very interesting. The problem is much of the 20th century medicine is based on finding, diagnosing, and fixing pathology. There was an assumption that noxious sensory input from the body caused pain.
If people had pain, you must find the cause of the sensory input or reduce the noxious stimulus so that we can then reduce pain or eliminate pain. We knew that was a flawed model because there’s just so many circumstances where the amount noxious stimuli doesn’t predict pain. It doesn’t predict the amount of pain. Reducing it doesn’t reduce pain.
Other therapies might reduce pain without influencing the noxious stimuli. Doing nothing reduces pain without changing the synapses. The entire model is broken. In came George Engel, and this thing called the Biopsychosocial model, which means that he basically said within a medical context, it’s like, “Hey, there is a person here.
“The status of the tissue or the biology is important, but it’s not the only thing that influences this person’s experience or their treatment. Their psychological state, their thoughts, attitudes, beliefs, and emotions influence their condition and their perception of the condition and their prognosis and their beliefs about treatment, and their social behavior, which people don’t really get.”
Again, those conditioned behaviors, those socially learned responses, those expectations set by their tribe also influenced their behaviors around their condition, or illness, or health status, and also their expectations of treatment. People learn about pain very early.
A good example is, if your dad had a bad back and he didn’t ever get out of pain, and he never lifted anything heavy, and he always got in the car very slowly. He always went to the doctor all the time is like,” Wow, oh, my dad has a bad back.” That’s what you do when you have a bad back. That’s a good example of that.
It’s like, “Oh, if my back hurts, I must have a bad back too because it’s genetic and I should also protect my back as much as he did. Now, he had one spine surgery and he could have had seven, so I only want to have one spine surgery.” I think people underestimate that socially learned component.
Even that model is limited, one because people end up talking about one of three things like, “Oh, this is a bio.” There’s something wrong with that person’s disc or fascia joint, if we’re talking about backs, or their elbow. You’re still dealing with the tissue and not the pain, or not the entire experience. They’re not the pain in context. It’s like, “What are they doing?”
What is the history? What is their total level of stress or adaptation? What are their concerns about the history of this condition? Are they afraid it’s going to get worse? What are their expectations of relief? Are they totally unrealistic about the expectations of relief? What do they think the pain means to them? Do they think that they’re hurting themselves every time they experience some pain?
All these things influence even a very simple movement triggered or tissue-entered pain experience. Patella, knee pain is a good example too. Front of knee pain. It’s like, “Yes, you’re almost always very easily triggered by some sort of movement.” It’s very clear that there’s a biological component to that.
Again, it’s never the only component because pain, by definition, is not only a biological experience. Nociception is which is just bad, which is the nerve stuff. But when we experience pain as a threat assessment, as behavior that influences other behaviors, as this emergent sense-making tool, it is more than just the bad sensation.
It is a belief and a behavior pattern. It’s a useful tool in terms of navigating potentially threatening situations, so there is a utility to it.
The idea is when we extend that BPS model or that Biopsychosocial model into someone’s environment and understand their pain in context, then we get a better sense of how we can help them move back towards the things that they love doing. Like, get back to living in a way that’s helpful for them regardless of the amount of pain they experience.
That might require reducing pain a good amount. It also might require changing the predictive value of pain. The idea is essentially we manifest pain often irrespective of the amount of damage, which might be because we anticipate damage, which is helpful to avoid death.
Sometimes that threat assessment becomes too sensitive and writes an alarm that won’t shut off. The idea is, how do we help them shut off that alarm?
That comes through desensitization and conditioning and general movement, and showing people that they can move and that they are strong, and maybe even touching pain and getting people moving through a little bit of pain.
Again, that’s in a therapy environment with the go-ahead from people who have ruled out anything potentially serious, but for people with more serious and ongoing pain. For people with a little bit sensitivity, maybe working through it a little bit and seeing it reduce, proves to you that it’s not related to any underlying damage, that you are making it better with movement.
Then over time you can, you can get back to challenging yourself and loading yourself more. You can feel confident that you’re working through any issue you had and you’re now stronger than you were prior to that pain experience, which a lot of people don’t ever get to that point.
The idea is that it was all related to how this pain experience influences an individual’s relationship to their environment. In our context, environment is their training environment. You cannot remove the pain experience from any one of those components. You can’t remove it. You can’t remove the brain, and say it’s in there. You can’t remove the body, and say it’s in there.
You also can’t remove the movement, social environmental context in which people experience pain. They need to address that in its entirety to help people develop that plan that can they can be confident to move forward with the right set of expectations and kind of empowering beliefs.