Chronic Pain Care: When Pain Reduction Keeps Patients Stuck

Mark Kargela: [00:00:00] It's one of the most common moments in pain care is the patient sitting across from you and they say, I don't care about values or goals, I just want less pain. So what do we do with that? Of course, this is a goal that's perfectly fine to have, but when do we need to recognize that this goal is the one that has a patient stuck?

This episode digs into what actually is happening in this moment and gives you some ideas of how to manage the conversation to help a person in pain get unstuck and get their life back. Let's get into it.

This is the Modern Pain Podcast with Mark Kargela.

First we need to understand what's behind the question of, can you just help me get rid of all this pain really?

Thinking about it, it's probably the patient saying, it's help me be me again. 'cause when we have that pain, and often we'll dig into it, it's if we were able to wave a magic wand and get this pain to zero, what would we see you doing? That's a great reframe to see what is important to the person that this pain has taken away.

We have to understand that pain reduction is a goal isn't wrong, it's just incomplete. We need to go to that values component of 'cause. Otherwise pain reduction can get you stuck in a merry-go-round of pain reduction treatments. [00:01:00] 'cause you've never figured out what is the thing that's behind that pain reduction goal.

What are the values that if pain isn't present, they're gonna get back to. So as clinicians, we get stuck in this trap of this. Or thing where it's either pain reduction or valued living where our sessions and our treatments are so cordoned off to that this is my pain reduction treatment of needling, manipping, mobing, cupping, craniosacral, whatever it is that you do.

And again, none of it necessarily perfectly wrong. It's just, it's incomplete if it isn't tied to an and of, and we're gonna have these treatments, use them to maybe give you some short-term pain relief. To get you back to those values and things that you've hopefully clarified in your first sessions of how this pain has taken some things away from the person.

The thing we have to ask ourself is, has that pursuit of pain reduction allowed them to stay engaged into what matters to them or is life on hold for them? And for some people, they are living the and, and we just support that we can utilize some of our pain reducing treatments and continue on how we normally would.

They're looking for pain reduction [00:02:00] and to stay actively engaged in what matters to them. Those folks can get back into things and we know that people that get back into things that are valuable to them and the things that are meaningful to them, that helps treat some of the emotional components of pain and some of the psychological components of pain where they can start seeing themselves come back earlier in the game and probably take away some of the negative changes that happen when emotional centers and high stress and distress and depression that understandably, people who have had a difficult pain situation go through that. When those start going away, it helps our nervous system and our systems that really determine how sensitive our bodies feel really resolve things to a level that can allow them to get back to where maybe that is a full pain reduction in resolving to where they are, a zero outta 10, where at minimum it's, man, I am back doing the things in life and this pain is much more managed and not nearly as distressing or problematic for me.

So there's ways we can recognize when the pursuit is the problem, and it's not inherently problematic, as I mentioned, it's just when it narrows life as opposed to expanding it. So what are some red flags that someone's stuck in this loop? One [00:03:00] of them, the big ones is life is functioning on hold, relationships, their job, their hobbies, anything that brought meaning to them prior to their pain is completely on hold.

Other M things can be a long trail of treatments that have been tried and abandoned. They often have a laundry list of ologists and massage therapists, chiropractors, physiotherapists, osteopaths, whoever it may be that they've seen, and it just hasn't quite gotten 'em to where they want to be. And you'll hear in the language patterns that I just need to you find the right person and I just need to find the right treatment or diagnosis.

And once this, this pain gets treatment, then I'll get back to you. So it's this kind of conditional life that this person's living that I will get back to life on the condition that this pain goes to zero. That can be a very challenging spot for someone to live in. 'cause that is where they are stuck because we know that sometimes these treatments and by as evidenced by their approach, can give them short-term gains.

But if we don't help arm people with the skills to get back to life, then it can be a short-term gain that still has their life very small. Then you'll also [00:04:00] hear that these folks have been increasingly passive in their approach and where they've shifted from an active participant to really passive recipient.

They're just bopping from appointment to their calendar's full of medical appointments, waiting for someone to fix them, and there are nothing or minimally things on their calendar that are representative of things that bring them joy, happiness, and define their identity. Their identity now is unfortunately, as I tell my patients you've become a professional patient.

And unfortunately, healthcare is great at creating that with people and all the negative effects of pain emotionally and the way they feel demoralized and defeated are attributed entirely to the pain itself. And rather than the cumulative cost of all the search itself, of the loss of identity, the loss of their role in their household, the loss of their ability to do things that bring a smile to their face and bring joy to them in the past.

So we have to be careful and help people see that maybe it's more than just this zero to 10 number, that maybe there's been a lot of things that have happened around this zero to 10 number that have created a lot of the problem and this negative effects beyond just again, that zero to 10 and. The social withdrawal, of [00:05:00] course, is a problem.

We know that's a big component of the social determinants of health, and it definitely influences our pain states and our immune states and all sorts of things when we're staying social connected. But when you hear our stories, it's become a pattern where people have really taken and shrunk their life.

Because they don't feel they're safe to engage in some of the things they did socially. They're not getting outta the house with family or friends. They're opting out of things that are important to them. Their calendar, again, is very small and narrow and not really showing anything that's of meaning to them, of especially the way they were prior to their injury or their pain

there's often a gap of what they say matters. Family, work, hobbies, and then where their time and energy actually goes. And often it's, they're researching, appoint more and more cures or things like treatments. They're looking for their next opinion. They got appointments all over.

So when you hear what matters to them, their family, their work, their hobbies, and you look to see where that sits on their calendar. It's non-existent, their calendar. And when you hear what they are doing, spending their day, [00:06:00] it's very pain centric, pain focused, completely stuck in this, pain pursuit.

And there's an important distinction to have here. This isn't about judging the person, it's just about recognizing a pattern that they often can't see because they're stuck inside it. The search they're in feels productive. It feels like they have hope. They're naming it as potentially costly isn't.

Taking hope away. It's offering a more honest accounting of what's going on. And this is where creative hopelessness lives. And we'll talk about that more here in a little bit, but it's not as a confrontation where you're doing this is wrong. You should be doing this. It's really holding up a compassionate mirror where you've been working really hard at this for a long time.

How's it going and what does it cost you? And then really critically, people are sometimes are early in their journey and really haven't genuinely explored reasonable options yet. So that might be something where we have to be careful. Recognizing the difference between hasn't had the opportunity versus they have been searching for years with diminishing return. That changes the conversation entirely, right? We can still have people [00:07:00] pursue pain relieving measures or pain reduction measures. As you form the conversation of, it's important to pair that up with things that help your body learn to get back into things that are important to you.

The things that define you, the things that are your identity. 'Cause that's what paired up with those type of treatments is gonna make them the most effective. We see that time and time again in the clinic.

The other thing that's helpful for us to think about is what does a pain score actually communicate and what doesn't it communicate?

we tend to look at pain ratings like some sort of thermometer where they're objective, stable, and they measure one thing. They're not. Kenneth Craig talked about how self-reports both are the gold standard and potential fool's gold because it collapses a complex social process into a singular number.

For me, I get so driven nuts by the fact that we're gonna take such a complex emergent. Experience and try to resolve that into a zero to 10. I think it's disrespectful of the patient who's dealing with such a complex thing, and it greatly reduces a complex experience into something that is not, is supposedly simple when we know it's not.

It's a [00:08:00] lot of things go into that. So with Craig's social communication model of pain, he talks about how pain isn't just felt, it's expressed. Observed and interpreted and then responded to. So he maps this into a temporal sequence of sorts, where there's this tissue insult, or stress or onset of pain, where there's this internal experience.

The person expresses the experience, the observer infers what's going on and appraises the situation, and then cares delivered. Each stage is shaped by its own biological, psychological, and social influences with feedback loops running throughout this and the care that person receives shapes how they express pain next time.

So the person's gonna get trained on how they express their pain to really feel like they're getting the most benefit out of their treatment. And really, the most important clinical implication here is when a patient says eight outta 10, we're not receiving some sort of thermometer, readout. We're receiving a communication that's shipped by the context.

Their motives, audience around them, the language competence of how they're able to express things. And Craig points out [00:09:00] that nonverbal signals, especially facial expression, often carry more weight in credibility judgements than the number itself, which means clinicians are already decoding more than they realize, and they're often doing it with unexamined biases.

This is why we really are so big on reflective practice as clinicians to where you think about what are your unexamined biases and try to bring them explicitly out so you can better make judgements of what's going on in somebody's life and not make assumptions and use heuristics that have us jump into conclusions that aren't there for people instead of going deeper.

So the key insight for us as clinicians is this isn't just a simple message sent and receive transaction. It's a dynamic social process where it's embedded in cultural rules, power dynamics, role expectations, and individual histories. So the patient is encoding their own biases with the nociceptive or processes in there, and we're decoding it with ours

And research has shown us how the context can distort the signal that the person expresses [00:10:00] to you. So social modeling studies, for instance, exposure to a high tolerance versus a low tolerance pain model where they were able to see somebody who modeled a high tolerance versus somebody who saw somebody who modeled a low pain tolerance.

This markedly shifted a person's reported pain thresholds. So who's in the room changes that number. The other thing that can happen I think is fascinating is the parent child interaction. So pain per pain promoting maternal behavior during experimental pain tasks was associated with significantly higher child pain reports. So how we as parents express and, take in pain and discuss how what it means and what it matters is very important to our kids' expression and how they conceptualize pain.

So what does this mean for the pain reduction conversation when a patient insists on pain reduction as the primary goal, part of what they're communicating is distress, a need to be taken seriously or a fear if they don't emphasize severity. They won't get help. So if we reduce fear, build confidence, and demonstrate that we take their experience seriously reported, pain intensity often shifts not because we fixed the [00:11:00] pain, but because the communication context has changed.

We know when people feel listened to, have been empathized with things are help making sense about it. We're treating some of the things emotionally, psychologically around this. This can influence how well that signal from the tissues are internally in the body is decoded and expressed. And it's always been about the relationship.

That doesn't mean pain is imaginary or exaggerated. It just means our measurement tools capture more than we think and our understanding that changes how we listen, and it should hopefully help us examine the biases we have in that listening situation. I. So let's get into the creative hopelessness part of what have you tried and how has it worked, because this is something that's been very helpful for me.

I've been fortunate to learn from Kevin Vowles and Bronnie Lennox Thompson, where we're looking at the good and not so good of past approaches across the short term and long term. And this isn't just dropping a sledgehammer on somebody of look at all the short term stuff and look at the lack of long-term stuff.

This is ridiculous. It's really a respectful invitation for the patient to reflect and we're just constructing a conversation. To let the [00:12:00] person reflect through their experience. We're letting the person walk themselves through their own experiences and take perspective in looking at it like they're stepping away from it and looking at it from an observer's perspective.

And, many patients haven't actually tried everything. So be honest about genuine gaps about what they've done or not done. Before we move to reframing 'cause. It's important for us not just to assume that the patients had done everything and that, we just need to move on to, values-based work.

There might be some gaps that they can work towards. And again, we're gonna start framing those gaps with let's pair it up with things we know, help people get really back to the way they wanna be. Some of those valued based activities, goals, graded strengthening and exercise. All the things we're pretty good at as physios or rehab practitioners.

The key move in this is reflecting on the effect of their pursuit on valued living. Then putting that decision back in the person's hands. So if we have people list out all their treatments and go through it all, they look at all their short-term goals, which, or short-term benefits, which often there's quite a bit of short-term benefits for some of these.

Often where the pain [00:13:00] lies is the lack of long-term benefits. Often they're with you. If they were doing well, they wouldn't be seeking care anymore. So obviously there's often a lack of long-term benefits and we really then can say, as you look at that patient, what comes up? And oftentimes there's a lot of emotions, frustrations and things like that.

And then we can validate that journey from as clinicians like nobody can look at this and say, you haven't been busting your butt to fix this or get this situation and get your pain in a better spot. But what does this make you look like? Do you think? Doing more of this type of stuff is gonna be the answer, or would you be open to a different approach?

And again, there's a lot of nuance to that conversation, but I would greatly. Ask you all to just look at creative hopelessness. You can Google it and we'll put a little bit of a resource in the show notes here of how to frame that conversation in a way that hopefully can help you start getting people to see that maybe a different approach of not just strictly a pain reduction approach that maybe we need to pair this up with valued activities can be very helpful and it really can be a 180 in the [00:14:00] approach and your ability to start getting people off of treatment tables and doing things that they have been previously, very hesitant to do.

This also means though, that you need to have the skills psychologically informed care to recognize when you will encounter kinesia phobia, catastrophizing interpretations of what's going on. How do you manage that? How do you help people get back into the things off the table and manage those things?

The other thing too is to recognize is that people are never offered the opportunity to live well with pain. And if they don't even know it's possible, they're gonna continue searching for the fix. I don't think that goes with any significant surprise. Our job is to expand the menu, not dictate the order.

So we want to give them choices that they didn't even know they had. Because oftentimes, especially in our society, it's this you either are getting rid of your pain or you're not doing anything else. People don't even know that they often can still exercise, can still start getting back into activities.

They can still garden, they can still maybe, it's obviously adapted. It's done in ways that they can start gaining success with. It's maybe not where they were prior to their pain onset or injury, but it's a start that they can start [00:15:00] building off of and eventually get significant improvement in.

So we have to have an honest admission here. Many clinicians don't feel confident in navigating this conversation. I know I didn't. And recognize that's normal. This is a skill. It's not some sort of personality trait that you either have the ability to have these conversations or not. It's the skill to be know some of the things that these conversations ideally should have within them. And forming it in a way that honors your way, you interact as a clinician and then meets the patient best where they are at the current moment. The fear clinicians carry is, am I telling 'em to give up hope? And of course, we're not telling 'em to give up hope.

Some of the things we can say people is we can pursue pain reduction and begin moving towards what matters to you. Instead of the exact activity, find out what the activity represents. Why does it matter? So we, if we get to the values of you know what their movement is, maybe it represents them being a good dad.

Maybe it represents them being a reliable friend, feeling competent. Then explore other ways to express those values. Now maybe their activities they were [00:16:00] doing prior to that, they're not able to do that. Are there ways we can be a good dad, even though it doesn't mean it means we're not out on the dirt bike with our kids doing the thing that we were previously able to do.

Are there things we can do with them? Starting to do some maintenance work on the bike or doing different things that yes, it's not you perfectly on the bike yet. But it is you starting to reengage in those values and not simply just sitting on the couch, frustrated, depressed, understandably.

'cause you're not on the bike with the kids. Let's maybe work on some strategies where we can start getting you back into it. And then we need to be willing to redefine the starting point. Not where you were before the injury, but where you were at your worst. 'cause a lot of people will only see the starting point as where they were before the injury.

And if we say no, the starting point, let's look at where you were at your worst. Because sometimes the progress is small, but if we compare it to where they were at their worst, they can see progress. They can see that, yeah I have made some progress. But if they see their progress is only representative, if they are where they are before their injury, it's gonna be depressing, frustrating, and people are gonna abandon ship on activities when that's their measure of [00:17:00] success.

So the other thing, skill-wise, you need to be good with is to, when you're ready to look at a different approach, come on back. ' cause we need to recognize when somebody is just stuck in the pain reduction loop and it's not getting 'em towards the life they live. We've maybe tried creative hopelessness.

We've tried to get them off the bed. They're just really in a distressed state where this probably isn't gonna work for them under your care. I've had to make that realization numerous times in my care and you can have a respectful conversation of, it looks like we're really still in a situation where we're gonna try some of these treatments.

I hope they go amazing for you. I hope you get some amazing results if for any reason. They don't get to where you want them to be and you're still struggling. I think we can still definitely loop back. I have a lot I think we can do. This just doesn't seem like the right time to take this approach for you, and that's perfectly okay.

Let's maybe think about getting back in touch with each other if you feel like those approaches aren't getting you back to the things you want to do. And I'd reflect their values so they know that, these are the things I feel like I can do to get them back to being the dad they want to be. Or the friend or the wife or whatever it may be for that [00:18:00] person.

Big pictures, when you ask people why they want less pain, it's usually so I can do X. And then you ask, what's important about X? And you get into those values territory. And you got there by following their lead, not imposing your framework upon them. So that's just where the guided discovery of helping patients figure out what's meaningful for themselves, not us telling 'em what's meaningful and then structuring your care about how do I, if they're, if they can't be there, where they were prior to their injury, how do I creatively with the patient start coming up with some ways that they can start doing things that start looking like that and they can start comparing themselves to at their worst versus where they were prior to their injury. They can start seeing and building some success towards what's meaningful to them.

There is a lot of parallels with this to health behavior change. People know they should exercise.

I don't think that's anything really. Rocket science. The benefits though, are subtle. They're slow, they're unfelt day to day. So giving up is easy when those results aren't immediate. Pain treatment is very similar in that pattern and it's a really a human decision making bias. [00:19:00] Short-term outcomes over long-term consequences.

This isn't really some sort of character flaw. Our job though is to help people see the full picture so they can make informed choices, not just by default. Choices based bias towards that immediacy thing, right? And helping people and framing the discussion. And I'll tell people, this is not an immediate return on investment.

That's where people get stuck on the short-term pain modulating thing. And it could be something where you might incorporate some short-term pain modulation to give them some immediate ROI on pain relief. But also obviously helping them, making sure you structure that and you point that out of this will be short term and not get you back to activities.

If we don't help you start building the processes the movements and the things that move you towards the things that are valuable to you off this bed. And making sure that's a, kinda a clinical contract of sorts you have with the patient. I'm like, we can engage in some short term things as long as, would it be okay if we do that and do the things that we know are gonna help these short term pain modulating activities become most effective. And that's when we're starting to work with you to get back to the things that are important to you.

Bronnie had [00:20:00] mentioned something how humans looking towards short-term outcomes often fail to recognize the long-term consequences.

And this really makes decision making, especially in the absence of knowing that there's alternatives that exist significantly biased when they don't even know there's a live well component with pain. They're of course gonna bias towards short-term pain modulating activities that's really, should be common sense for us.

So as we wrap this up, things I think I want you to think about, we don't dictate choices. We really expand the menu. We give people the opportunity to know that maybe there's more than just pain reduction activities. Maybe there's more I can do that can help me get my life back and maybe it does mean I have to maybe move away from some of those because I've been spinning my tires in the pain reduction arena with no help.

Or maybe it can be part of the situation and that's something that you as a clinician can make decisions with and decide if incorporating some of those can be part of the journey and a supportive part, but obviously they shouldn't be the hallmark, whether it's acute, chronic persistent or non persistent pain.

Those should be supportive measures as we know [00:21:00] anyway, so living well really means how can the person express who they are and what matters to them despite changes in capability and context. That's really rehabilitation in a nutshell. It doesn't always mean returning to normal because normal is always changing. Anyway, our, my normal of what I can do.

Physically, functionally and things has changed over time. And sometimes that's a bit of it too, that sometimes as our patients are hitting ages where they're having difficulties coming to terms with some of the age related processes that are going on there, that's a discussion that is real and needs to happen as well.

And helping people have some self-compassion with that as well. So really our rule is to give people space to make their decision. We're gonna wave the flag for them, cheer them on, stand ready for when they want to try something different. And I think there's ways where we can have pain reduction and steer them in ways that get people towards their values. For some people, that means staying on some form of pain reduction and pairing it up with the things we know that are gonna get them back to their life.

For some people, it mean maybe we have to leave some of those things behind because it has us living on the [00:22:00] sidelines and focusing on pain reduction strictly and regressed from anything that is meaningful to them. And we need to start maybe leaving those things in the background and getting back to what's meaningful to that person.

I hope this has helped you clinically. I hope it's something that can help you have better discussions in your future. I'd love to hear in the comments what things have helped you, or what kind of struggles do you have when you're trying to have that tension between pain reduction measures and getting people back to their lives.

Thanks for listening or watching. We'll talk to you next week.