It has been a long time since I published anything on here. I could give you many (poor) reasons, but I have, at least, made a decent start on the following project. I’ve found this very difficult. You may have realised I’ve a tendency to elaborate rather too much. In writing this tutorial, I’ve found this temptation almost irresistible. Needless to say the editing process has been long and hard for me. I hope to publish the subsequent parts in a timely manner. (The following two are written, but needless to say the editing process goes on.) I hope you find it interesting.
PART 1
Introduction – the relationship between function, cause, and treatment
This tutorial is intended for anyone with an interest in pain treatment, whether you are a theorist, a medical professional, or a layman wanting to better understand your own or someone else’s pain.
The watchword of any effective treatment approach is ‘understanding’:
If you do not have a proper understanding of pain in the general sense you are not equipped to adequately treat specific episodes of pain.
There is nothing controversial in this broad statement. No one could disagree that doing the right things will almost always ease pain, while doing the wrong things will exacerbate pain. This rather trivial comment is intended to emphasise the reason why education and understanding are central to effective treatment:
If you understand pain, then you are ideally placed to identify what is, and what is not, appropriate for specific episodes of pain.
The aim of this tutorial is to provide the educational material needed to establish this understanding.
The tutorial is divided into two sections. Each section is further divided into a number of parts with distinct themes. The first section of the tutorial concerns crucial background theory. In essence I set out to answer the question:
Why do we feel pain?
This question, which concerns the function of pain, is fundamental to all pain treatment. It is fundamental because establishing an effective way of approaching any specific pain depends on correct theory. Crucially, mainstream science is wrong about pain’s function. Consequently, the mainstream educational to pain treatment is not as effective as it should be.
The functional theory presented in the first section underpins the more practical content of the second section. It takes the answer to the functional question ‘Why do we feel pain?’ as a means of interpreting patterns of pain so that treatment can be individualised. In metaphorical terms, the second section teaches you how to understand what pain is telling you.
The rest of this introduction serves as a summary of the first section of the tutorial.
1.1 The relationship between pain and injury – the mainstream view
The question “Why do we feel pain” concerns the functional relationship between pain and injury. It is obvious that pain and injury are linked in some way because we feel pain far more frequently when we are injured. Commonly, it is believed that injury causes pain. The mistaken idea that pain functions to make us consciously aware of injury is derived from this causal understanding of the relationship between pain and injury. Although medical professionals may say things that tend to reinforce the mistaken common view, they do not really mean that injury is a direct cause of pain. Rather, they would say that pain is normally caused by noxious stimulation. In functional terms, the scientific mainstream believes:
Pain functions to make us consciously aware of noxious stimuli.
To highlight the subtle difference between the ordinary and mainstream scientific understandings of cause, a noxious stimulus is the thermal and mechanical energy that causes or could cause injury. A noxious stimulus is not the tissue damage itself. So, according to mainstream science, pain normally makes us aware of the causes or potential causes of injury
1.2 Orthodox functional theory and treatment
For the purpose of explanation it is helpful to think of pain treatment in terms of two strands that summarise all effective approaches to treatment:
S1 Avoid or minimise the negatives – where the negatives are the things that aggravate a specific pain.
S2 Do the positives – where the positives are the things that ease a specific pain.
In a sense, the distinction between these strands is artificial because the reduction of negatives can be seen as a positive thing to do. On this understanding, the things that fall under S1 are a sub-set of the things that fall under S2. I make the distinction because there seems a natural difference between a recommendation to do something and a recommendation not to do something.
In most cases, it is easy to establish, in general terms, what aggravates pain. For example, if bending to put on socks or pick something up from the floor gives rise to pain, then bending is an aggravating factor. From the mainstream functional standpoint, this particular example means that pain is making the person aware that bending is a noxious stimulus (i.e. bending is causing or could be causing tissue damage). The benefit of this awareness is that minimising bending will usually ease pain; where ‘easing’ means that it becomes less painful to bend (i.e. bending is less aggravating). In this way, the person in pain naturally bends more and, with time, bending becomes pain free. In mainstream terms, bending becomes less and less noxious. This is true improvement.
The problem is that, in this case, avoiding or minimising bending eases pain in another way: in the short term, there is less pain simply because the action causing pain is being avoided. Sometimes this leads a person into the psychological trap of thinking that pain causing activities are inherently harmful. In this case, the fact that pain is felt when bending underpins the false belief that bending is harmful. The trouble is that prolonged avoidance of activity tends to lead to prolonged episodes of and worsening pain, which in turn gives rise to the prohibition of still more activity. A vicious spiral.
Effective treatment is aimed at educating and reassuring. Mainstream education teaches that the stimulus is no longer noxious. Prolonged inactivity has brought about changes to the nervous system. Pain is being caused by a malfunction of the biological system that generates pain (the ‘pain system’). An explanation why some pains do not indicate harm or threat is intended to reassure that pain associated with the relaxation of self-imposed prohibition of activity does not mean damage. With careful planning, a gradual increase in activity tends to reduce the frequency and intensity of pain. A virtuous spiral.
In summary, the content of the mainstream educational approach is based on the theory that pain functions to make us consciously aware of noxious stimuli. Many episodes of pain are normal, in the sense that they are deemed to satisfy the sensory function of making us consciously aware of noxious stimuli. (Whether or not many “normal” pains actually correlate with noxious stimuli is open to question.) But most people who are referred on to mainstream educational programmes are deemed to be experiencing abnormal pains; pains that are not consistent with mainstream functional theory – the pain does not correlate with noxious stimulation.
Note the logical connection between functionally normal/abnormal pains and normal/abnormal pain system function. A pain that is satisfying its function is generated by normally functioning pain system; and a pain that is not satisfying its function is generated by an abnormally functioning pain system. So mainstream functional theory drives the mainstream understanding of abnormality. A pain is normal if (and only if) it satisfies the mainstream notion of function. A pain is abnormal if (and only if) it does not satisfy the mainstream notion of function.
1.3 Reasons to reject orthodox functional theory
There are many reasons to reject mainstream functional theory, and yet pain scientists are reluctant to do so. I have no idea why!
There are biological reasons, which I need not mention in this introduction. Another reason is that a noxious stimulus is a concept without any meaningful application; there are no actual noxious stimuli. (This is briefly discussed in part 3 of the tutorial, and argued in depth in a paper I will post at the same time as part 3.) Sensory inaccuracy, which I do mention here, is yet another reason.
The mainstream idea that pain functions to make us consciously aware of noxious energy is a sensory or perceptual concept. This concept is inconsistent with the overwhelming evidence that pain weakly correlates with noxious stimuli (i.e. pain is often experienced in the absence of a noxious stimulus and vice versa; and the intensity of pain does not reflect the intensity of the stimulus). Put another way, the evidence is that pain, conceived as a sensory experience, is commonly inaccurate. As the explanation for inaccuracy is pain system malfunction, pain system malfunction must also be commonplace. This contrasts starkly with experiences that are undeniably sensory in function, like vision, which are usually functionally accurate. Sensory inaccuracy and commonplace malfunction is inconsistent with evolutionary theory. Inefficient biological systems tend to be refined or eliminated by evolutionary pressures. So mainstream theory amounts to the claim that pain is beneficial, in the evolutionary sense, even though it often (perhaps most often) does not satisfy its function. It is a mistake to accept such a claim.
The only reasonable explanation for the frequency of so-called abnormal pains is that they are not abnormal. In which case, mainstream functional theory must be false. This has important implications for treatment.
1.4 An alternative understanding – pain has a motivational function
To a certain extent I have been unfair to mainstream pain scientists and theorists. The mainstream view is that pain has both sensory and motivational functions. However, scientists tend to focus on the former, and largely disregard the latter. If sensory function is ignored the occurrence of pain makes far more sense. On my alternative understanding:
Pain functions to motivate behaviour that avoids or minimises tissue damage.
Crucially, the pain system does not need to detect noxious energy to satisfy this motivational function:
The pain system does not detect noxious energy.
The implication being that the concept of noxious stimulation is nothing more than a myth. This explains the weak correlation between pain and noxious energy.
This does not mean that sensory input is unimportant. On the contrary, it is a critical aspect of pain system function. For practical purposes, sensory input is helpfully thought of in terms of information about what is being done (more appropriately, information about physical demand). A period of relative inactivity, whatever the reason for that inactivity, is a period when the provision of information is often insufficient for the pain system to respond accurately to demand. So the alternative explanation for the persistence of many episodes of pain, even though tissue is healing or healed, is that the pain system has not received sufficient information. This is a normal aspect of pain system function; it is not an abnormality.
1.5 Concluding remarks on treatment
Note the general nature of mainstream educational advice (in 1.2); it is not harmful to increase activity. Interpreted in terms of my alternative functional theory, the reason this general approach often brings improvement is that increased activity provides more information to the pain system. However, the error of mainstream theory is such that information cannot be individually fine-tuned. This means that some increases in activity are likely to be inappropriate and hinder improvement and some beneficial increases are missed altogether.
This tutorial is intended to provide you with the intellectual material you need to enable you to interpret patterns of pain so that behaviour can be individually modified to provide appropriate information to the pain system. In this way, you will be equipped to treat pain more effectively than any approach based on mainstream functional theory. This is the advantage of the educational approach I teach in this tutorial. My hope is that this introduction, at the very least, tempts you to read on.
The Pain Jam 