Resources for Matt Low at Le Pub Scientifique
Lorimer Moseley Master Sessions Broadcast 2 "LIVE"
What can we learn from childhood experiences of pain?
A/Professor Melanie Noel, kicked off our winter Le Pub Home Brew program by exploring the role of childhood experiences of pain in adult pain.
Melanie has contributed hugely to the scientific base on pain in children and has been recognised widely for her outstanding research, receiving early career awards from the International Association for the Study of Pain (IASP), the Canadian Pain Society, the American Pain Society, the Canadian Psychological Association, and the Society of Pediatric Psychology.
She is particularly fascinated by the role of parents and family in children’s mental and physical health and in-particular to the development of self-regulation around the pain experience. She is an absolutely awesome researcher and speaker, bringing her energy and passion to the subject.
“I’m really excited to do this, I hope there are lots of questions! I’m not really bringing much powerpoint material, I just really want to share what really gets me going, why this topic is so interesting and what I’m working on right now. I love that this is a live and open space where I can really just share my ideas with you all.”
From the first days of birth, infants can form memories of pain. Once formed, these memories play a powerful role in shaping future pain and health care experiences. As children acquire language and their explicit memory system develops, these memories become constructed and reconstructed in their interactions with others, and particularly for young children, in their interactions with parents. Memory is not like a tape recorder. You can’t play back an experience and have it recounted exactly as it happened. Rather these memories are highly susceptible to distortion. Children who develop negative biases in memory (i.e., they recall more pain than they initially experienced) are at risk for developing fears and avoidance of pain and heath care, and are also at risk for pain transitioning from an acute to chronic state. Moreover, emerging research suggests that brain regions associated with memory are implicated in the chronic pain state in youth. Once pain become chronic in adolescence, more pathological forms of remembering (e.g., in Post-Traumatic Stress Disorder) develop which further exacerbates pain and decreases quality of life. Dr. Noel will describe a program of research that is establishing factors implicated in the development of children’s memories for pain, the role of pain memories in future pain experiences, and the development of a parent-led intervention to reframe children’s pain memories to buffer against the development of memory biases and lead to better pain outcomes in the future. She will also discussed work to understand the neurobiological, cognitive-behavioural, and interpersonal factors that lead to the development and maintenance of chronic pain and PTSD in youth to improve how to tailor treatments for the most vulnerable children.
Key messages from the Le Pub for clinicians:
- Only 40 years ago it was widely believed that babies couldn’t feel pain. The things we experience the first few days of our life can affect how we experience pain throughout our entire life.
- 1 in 5 kids has chronic pain. Only in the last 7 or 8 years have we learned that, if untreated, these kids become adults with chronic pain.
- Memories matter – Pain and pain learning starts in childhood. How parents talk to their kids about painful experiences has a profound effect on pain memories and has a HUGE influence on a how a child experiences pain into adulthood
- Pain is not just a sensation…parents can create a positive or negative ‘experience’ around it. Correct exaggeration, help a child to see they have some control over the experience and offer distraction…e.g. take a deep breath, we’ll go for pizza afterwards
- There is hope! Even if you feel like you’ve messed up as a parent responding to your children’s pain experiences, just a couple of positive experiences can change your child’s pain trajectory
Key messages from Le Pub for Patients
- What happens to us, what happened to our parents, even to our grandparents, can set the stage for whether we have pain as adults. Pain and pain learning starts in childhood
- What can parents do to help raise kids with good pain coping skills? Talk about the pain experience. Highlight anything positive that happened. Remember pain is not just a sensation, but an entire experience. Help them see they have some control over the experience
- Pain is stigmatized, it’s disbelieved, it’s repressed… and because we don’t talk about it, we learn many of the things we (think we) know about pain from popular media. Stop and pay attention to what you (and your kids) are watching and how it portrays pain.
- Validation is fundamental. People experiencing pain need to feel heard
It seems outrageous that some people believed that infants didn’t experience pain. Check out this fantastic paper to find out how early painful experiences can influence us.
If you are a parent with ongoing pain can this influence your child’s experiences of pain? And if so, in what way? Check out this fascinating (free access) paper exploring the intergenerational connections between chronic pain and PTSD.
One of Melanie’s most cited papers exploring the fear/avoidance model relating to pain. Not only does this paper explore the link between fear and anxiety for the child’s experience of pain. But also touches upon the role of the parent and the impact upon the parent.
We are delighted to have had the brilliant Morten Hogh on Le Pub. Morten took us on a journey through the ins and outs of pain in the workplace, looking at the real reasons why people of working age are the most affected by musculoskeletal pain and if our traditional approaches to addressing the problem do more harm than good.
It has previously been thought that pain caused at work was a result of poor working practices and inadequate equipment and that the solution was to adjust the way we work. New research suggests that this may not be case and that the most effective approach is to continue to work, despite the pain, and that in some instances the traditional solutions may actually cause more harm than good.
This talk discussed the arising paradigms in the management of work-related pain.
Key messages about work-related pain from the perspective of a person in pain:
- “Work” is about meaningful occupation, not just remuneration, and by changing the way we view (and reward) work, we can include more people in the workforce.
- The most important question to ask (from John Loeser): “What does the pain prevent you from doing that you need or want to do?”
- The decision to RTW (return to work) should be made by the patient, because (and when) it’s the right thing to do for that person, and not under duress.
- “Work is therapy!” – working can offer huge benefits to health and well-being. How can we make work more therapeutic?
- We too often centre the economic costs of absenteeism. What would happen if we instead centred the person, and their needs/wants/goals?
Key messages about work-related pain from the perspective of a healthcare professional:
- Every person who has pain is either employed or unemployed. Therefore, work-related pain is relevant for everyone.
- Should we use the term work-related pain? Most people with chronic pain experience pain in all areas of their lives, not just when they’re at work.
- Getting a professional athlete back to their respective sport is work-related. Can we change the perspective of clinicians and employers to realise the importance of facilitating a return to work for all people in pain?
- It’s better to work painfree but if this is not possible (which may be true for many people) it is better to work with pain than not work at all.
- The cost of not working is huge for the person in pain (not just the employer). Find ways to make this happen that fit the individual. Be creative, make adaptations, create flexibility and above all open a constant dialogue between person in pain and employer (and clinician if appropriate).
After hours discussion
Tasha Stanton – I Am Stanton! Adventures in Pain, Perception and Science
When Lorimer Moseley recommends someone by saying they are quite simply ‘an excellent person, great communicator and fantastic research leader’ as he did when he introduced us to Tasha Stanton, we knew we were in for quite a night!
A/Prof Tasha Stanton’s life and work in science has truly been an adventure, we don’t use that word without good reason! Tasha’s award-winning research is focussed on understanding the deep complexity of why people hurt and why, sometimes, pain doesn’t go away. In order to do this Tasha’s work has taken her to the frontiers of perception, using technology such as virtual and mediated reality to fundamentally alter peoples’ perception of their body and their experience of pain.
- A lot of our senses have homeostatic functions, their role is to try to keep balance within us and promote us to undertake different behaviours to help us retore balance. If you feel cold, the feeling of cold has this homeostatic function to make us seek warmth
- Sensory information; sound, vision, touch influence our perception and our bodily feelings like pain and stiffness.
- Stiffness protects us from movement that might be damaging or that we believe might be damaging.
- Sensory cues can change pain. When we manipulate sensory input, there can be a significant reduction in pain and stiffness. The sound of a creaky gate can increase stiffness. The more it is repeated the larger the effect. We also see the opposite, when the noise decreases the pain and stiffness reduces.
- If bodily feelings aren’t just a ‘read out’ of the peripheral information that’s coming in then we need to rethink what those bodily functions (stiffness, pain) are for.
- We have innate processes between vision and pain. Using illusion to change the size of body parts, you can manipulate pain and swelling.
- Not only are our bodily experiences shaped by sensory cues, but we are actually altering physiological regulation of the body.
- We have a dynamic system that adapts and updates based upon the available information, for that person, in that environment, in that society.
- Clinicians- are we adding safety or danger to our sessions? Many of our treatments are targeting fear.
And there are some keypoints for patients too:
- The assumption that bodily functions like pain and stiffness solely reflect the biological state of the tissues doesn’t hold up. Many people have enormous amounts of pain and no damage or people have scans which show a great deal of damage but virtually no pain.
- We have unique experiences of the world.
- Your beliefs shape what you see.
- Its key to approach each clinical encounter with the primary aim of listening…ask questions without assumptions. Do not make quick judgements.
- Many people underestimate how challenging it is to have pain that doesn’t go away.
- Visual cues in general can have large influence on what people experience. Scary scan pictures.
- We have a need for experimental lab research because we need to better understand how our treatments work or don’t work.
- We can use perceptual alterations to promote discussion about biological process that underlie our bodily feelings like pain
- New theories are needed to underlie and underpin new treatments. To make progress we have to do the background work to understand how treatment mechanisms work .
“Does feeling back stiffness actually reflect having a stiff back?”
This (free to access) paper by Tasha Stanton demonstrates what a superstar of the pain world she is.
Relive: David Butler
Learning how to learn before we learn.
Has anyone taught you how to learn?
If you agree you, your family, clients are likely to have been victims of a learning experience. And you may have passed on your limited or faulty learning strategies to children, friends and patients. We have probably had learning errors for our lifespan. Is learning increasingly becoming a survival tool in the world of today? E.g. Medical knowledge doubles every around 73 days and half life if knowledge is shrinking. Think of virus research today! (Densen er al. 2011).
Our error with Explain Pain – I told them all how to put the lifejacket on, but did they learned it?
Dr. David Butler
If you see a client twice a week for half an hout that is 0.59% of the week. Sport coach with athletes are estimated at around 1-5%. What happens in the rest of the time? And in the chronic pain clientele, the processes constructing pain and inflammation, and long term medications are likely to affect learning. Educational psychology is one of those areas that rarely been intergrated in healthsciences. There is som much to learn. Start build a frame work or toolbox.
Educational science has broadly two areas. The learning and instruction area is definitely the biggest but a second area, the science of conceptual change is less common but probably most valuable in health. The most fundamental difference is that the conceptual change field focusses on the nature of existing knowledge (Vosniadou, 2017). This is also known as ‘androgogy’ – which refers to methods and principles used in adult education. Pedagogy on the contrary is obviously the better known big brother. Patients will bring their existing knowledge to the clinic too. And especially on health, patients bring a huge amount of experiences, beliefs en knowledge along with them. You can’t blame them. Healthcare providers have shown to be a big resource for common misconceptions too.
What is the ideal learning strategy or technique for adult learners in pain and for their deliverers? We need to address this question if we want to improve it. A philosophy that fits the context is the concept of constructivism which comes from the wider scope of learning theories. The learner is nog a passive recipient of knowledge, that knowledge is constructed by the learner. Therefore Self Regulated Learning seems to provide the ideal framework for paineducation. The Self stand for – you ultimately do it to yourself, its not done to you. The regulation parts are regulations of movements, exercises, cognitions, emotions, time, contexts, etc. Resources before, during and after the learning experience. This is getting seriously the next wave in the paineducation world. More will come soon!
Written by Bart van Buchem