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Why This Doctor's Patients Cry: Two Words That Change Everything | Dr Dan Bates
107 Plays1 month ago
Dr. Dan Bates, is a sports and exercise medicine specialist, director of the Back, Neck and Joint Clinic in Melbourne, and former head doctor for both Melbourne and North Melbourne AFL teams. Dr. Bates has developed an innovative, algorithmic approach to chronic pain that's helping patients reclaim their lives.
In this episode, we tackle one of the most controversial topics in pain management: what happens when patients are told their pain is "in their head." Dr. Bates reveals why this messaging - even when well-intentioned - can drive hopelessness, helplessness, and suicidal ideation. He shares the simple phrase that makes his patients tear up with relief and teaches the powerful two-word question that gives patients their power back.
You'll learn practical strategies for managing pain amplifiers within your control: how catastrophizing language physically amplifies pain, why depression and anxiety are normal responses to chronic pain (and how they make it worse), and the importance of taking ownership. Dr. Bates reveals his clinical algorithm to determine how he treats his pain patients.
Dr. Bates offers hope for those in despair: your pain is real, you're not imagining it, and just because we can't find the cause doesn't mean there isn't one.
RESOURCES
KEY TOPICS & TIME STAMPS
00:00 - 03:02 Dr. Bates' Journey into Chronic Pain Medicine
03:52 - 07:26 The "It's In Your Head" Problem
07:26 - 13:18 Medical History of Blaming Patients
13:34 - 21:30 Understanding Pain Mechanisms
21:30 - 27:25 Pain Amplifiers You Can Control
27:25 - 32:09 The Two-Word Power Move
32:09 - 37:44 Why Doctors Struggle to Say "I Don't Know"
38:05 - 42:47 The Shocking Truth About Medication Effectiveness
42:47 - 49:36 Getting More Specific with Diagnosis
49:36 - 56:45 The Algorithmic Approach to Treatment
56:45 - 59:59 Final Words for Those in Despair
Recommended
Transcript
Understanding the Impact of Dismissed Pain
00:00:00
Speaker
They just get blatantly told it's just in your head, please get out. And what that does is that drives a sense of hopelessness. It drives then helplessness and that combination drives suicidal ideation. What would be your words for them? And I know that's a very challenging question. Oh, easy.
00:00:19
Speaker
Perfect. if That wasn't challenging at all. It's easy. And the amount of times I've said that to patients is innumerable. And the amount of time i then they then tear up Today on Pain Coach, we're joined by Dr. Dan Bates, a sports and exercise medicine specialist, director of the Back, Neck and Joint Clinic in Melbourne, and former head doctor for both Melbourne and North Melbourne AFL teams. Dan has an empathetic way of helping people take back what pain has stolen from them.
00:00:52
Speaker
This podcast is for educational purposes only. The views expressed in this podcast do not constitute medical advice and are general in nature. You should obtain specific advice from a qualified health professional before acting on any of the information within this podcast.
00:01:10
Speaker
Dan, so you're a sports and exercise physician and you found yourself in this realm of working with people with chronic pain. How did you get there? ah Look, there's probably, there's a number of reasons for that. I think that,
00:01:22
Speaker
The first reason if you look at just at the demographics of of chronic pain. So most chronic pain is musculoskeletal. the majority of chronic pain is, so if you look at the first,
00:01:39
Speaker
90% of chronic pain is actually lower back. The next 8% is neuropathic. And the last 2% is then everything else. And so just by the nature of my training, you know, in Australia, the doctors that generally look up the non-surgical musculoskeletal pain are sports physicians. And as a result, you end up just seeing tons of musculoskeletal pain.
00:02:08
Speaker
And, you know, once you and actually get booked out a couple of weeks ahead, The people that can wait have got chronic pain. So all of a sudden you go from looking after a bunch of kids that, you know, do their ACLs or, you know, blow an ankle on the weekend to looking after their mums and dads and their grandparents who have got longer term problems.
00:02:31
Speaker
And you need to come up with some different solutions. Like you need, like it's not the same management strategies that And, you know, I've been very lucky over the years that people just, you know, they they trust me and enough that they come back and they go, that didn't work. What's next?
00:02:47
Speaker
And that's just led me down the pathway where I've ended up here at, you know, looking after lots of people with chronic pain. Like my my daughter says, dad looks after, if you can move it and it hurts, dad looks after it.
00:03:02
Speaker
So, you know, do I do abdo pain? No, I don't do abdo pain. she's nailed it that's a great summary my uh my 10 year old's marketing strategy go for yeah you should put that on your website for sure you know what i think i have awesome that's great you should put her name there she needs some she needs some give her some kudos yeah that's it that's it ah Awesome. and so that's thing and And I think interestingly, like this this for me really started in osteoarthritis. And so you know within the within the world of sports medicine, you see lots of joint-related pain. And so started creating an approach to how you manage osteoarerriti so so osteoarthritis non-surgically.
00:03:52
Speaker
That then generated an algorithm, how I approached them, I then joined Metro Pain Group and I then through time started applying applying that algorithm to to back pain and then neck pain.
00:04:08
Speaker
and I found it worked. And so now here we are doing, you know, arms, legs and backs. Yeah. Yeah. Awesome. I'd love to, we'll talk about your your algorithmic way of going about things at some stage, because I'd love to sort of pick your brains about that.
Challenges in Medical Understanding of Pain
00:04:28
Speaker
But the question that I want to ask, because I know you have a podcast that says, it's not in your head, yeah is the title of the podcast. And I'd just love to hear your thoughts. So say I'm someone that I've been told that pain is in my head.
00:04:47
Speaker
What would you say to me? Yeah, okay. So I don't actually think people get told it's in their head most of the time. Okay. So what happens is the patient hears that they've been told it's in their head.
00:05:00
Speaker
And and it's it's never it's never deliberate, it's just the way it's perceived. so So phrases like, it's a false alarm, it's it's a misinterpretation of a signal, what ends up happening is that those get perceived as, so you're telling me it's in my head.
00:05:21
Speaker
Now, you're not being told you it's in in your in your head. It's being told that it's a false alarm, it's a misinterpretation, but that is how it's perceived. And so in a small number of patients, and this is really where the issue comes, and so where this is where the podcast title came from was this this very regular, and it still happens, where my patients will go see somebody else and They get told it's in their head or they heard it's in their head or like they just get blaant blatantly told it's just in your head, please get out. And what that does is that drives a sense of hopelessness.
00:06:03
Speaker
It drives then helplessness and that combination drives suicidal ideation. And so that I was just got to the point where I'm just sick of my patients coming back like in tears and suicidal because of the way something's been said to them. And so it's there is certainly a subgroup of patients out there that if you take them through the process of recognizing that, yes, your brain interprets a set of signals that then become pain, they are then able to change that and they get a substantial benefit out of it, no doubts about it.
00:06:47
Speaker
However, i think that there's also a subgroup of patients that go away, hear that as it's in my head and become suicidal. And I think the risk benefit ratio within that explanation doesn't lay out for me. And so we need to look for different words for how to explain pain to patients.
00:07:12
Speaker
Yeah. And I think that it's just those words that that are the issue. And you know what? We're trying to like promote a podcast. It's not in your head for chronic pain patients. They respond to that.
00:07:26
Speaker
So, you know, that's part of it as well. Yeah, for sure. Yeah, i I think really at at the at the but core of this is is you want people to feel validated and people should feel validated. So it's a worthy thing.
00:07:46
Speaker
It's a worthy thing. And I think I wonder whether there's – because I think what what people hear – and I'm coming from a camp of I've gone through Lorimer's, you know, training and those kind of things. yeah People kind of – they know that I've had that – ah That teaching and and Loz himself has probably has come out sort of saying, hey, there's some certain ways that we could have done things better and and this yeah you know was misinterpreted. And I think his intention and and his heart is in a good place. But I absolutely think at the core of it is this like needing of validation because if people say –
00:08:26
Speaker
it's your head has a role to play in it and therefore are you telling me I'm fabricating it, I'm making it up, I'm to blame, or it's you know it's not actually real, then that is extremely problematic because, like you said, that would lead to feelings of helplessness and suicidal ideation.
00:08:48
Speaker
But I wonder, i also see the group of people that have been to specialists you know, like yourself and and orthopedic specialists and and a number of different specialists, and they've heard this, there's nothing we can do time and time again. or there's no reason we can find for your symptoms.
00:09:08
Speaker
What do you... because Because in those people, I feel like they also experience helplessness. And look, this is a smaller demographic. I know, that absolutely do but they absolutely do. absolutely do.
00:09:20
Speaker
They experience helplessness, despair, despair and suicidal like ideation. And I think the you know your nervous system and your brain has something to do with this actually gives them hope that despite my...
00:09:34
Speaker
despite the fact that they can't find something wrong with it with me from a bodily structural point of view, there is something I can do. so yeah so I think there's that like there's a ton of stuff in that we can we can tease about. We can tease out. Okay. So firstly, the the statement, there's, yeah and really what it comes down to, there's nothing on your scan. Okay. That's really what look what the words are. I can't, there's nothing on the scan. I think what the thing you have to focus on there is that It's just that our technology is limited.
00:10:06
Speaker
You know, just because you can't see something on a scan doesn't mean there's not something wrong. it just means you can't see it on the scan. I think, you know, if you go back to if you go back to um the first the first dsm DSM, which is the diagnostic manual for, I can't even remember women um what the title is, the first DSM-1 listed um ulcerative colitis and peptic ulcers as part of the psychogenic, um what is it? It's psychogenic. It's not conversion disorders, but it basically generates, it it lists them as a psychogenic disorder.
00:10:46
Speaker
ah At that point in time, we did not have, that's 1952, we did not have the diagnostic capability to be able to recognize that peptic ulcers come from a infection called H. pylori and ulcerative colitis is an autoimmune disorder.
00:11:02
Speaker
And so what would do we do? we said it's in your head. It's psychogenic. yeah And so whenever we, we as the medical fraternity as a group throughout all of history, when we don't know, we always blame the patient.
00:11:18
Speaker
You're just crazy. You know, hysteria, you know what the first part of hisster hist is? Like hysterectomy, it refers it refers to the uterus.
00:11:29
Speaker
And so, You know, back in the day, Hippocrates blamed the wandering uterus for all the ailments that, you know, they weren't able to explain. And so we've seen, you know, devils, witches, demons, you know, you name it, you know, Brickett syndrome.
00:11:47
Speaker
It was probably the first real attempt of getting closer to, you know, what's an underlying disorder. And we just again and again and again, when we get when we hit our diagnostic limits, we blame the patients. Now, yeah that may those diagnostic limits may be our own personal knowledge base. It might be our own personal expertise.
00:12:12
Speaker
It might be the limits of technology. It might be the limits of what the pathology group build will do. Like I know that I've got a bunch of patients that have got truckloads of inflammatory stuff going on that we just can't measure. They've got normal CRPs, but we don't measure IL-6. We don't measure i r one We don't measure TNF-alpha.
00:12:35
Speaker
And so we just can't identify it. And so i think that the better way to use words that we're unable to find the cause.
00:12:45
Speaker
That doesn't mean there's not a cause. It just means i can't find it. And I think that's when you lean into These are the ways, these are some strategies that you can then cope better with your pain. You can down regulate the amplification that you get when you worry about it more, when you focus on it more, when you catastrophize about your pain.
00:13:06
Speaker
You know what? Pain causes depression and anxiety. You know what? Depression and anxiety makes it worse. Okay, we can't find the cause. Let's fix the stuff that is amplifying the pain.
00:13:18
Speaker
And that's where I think You know, a lot of the techniques from, you know Noi Group, all Lorimer stuff become really, really powerful. But it has to be balanced against, you know, the patient hearing, this is in my head.
00:13:34
Speaker
Yeah. And, you know, I sit at that. i think I wrote something recently about we only, you know, why do we think we're always right? And the reason why we think we're always right is because you only see your successes and everybody else's failures.
00:13:52
Speaker
yeahp and so and And because of the nature of that, we gain increasing confidence in what I do or you do it as a clinician because everyone who comes back is better. And the ones that don't get better, they just don't come back.
00:14:07
Speaker
and But they go and see everyone else and go, oh, that didn't work. Physio didn't work. Physio made me worse. and oh, that injection didn't work. and i i Okay.
00:14:17
Speaker
But that's just because, you know, that's the nature of human beings. You don't go back if something's failed. Yeah. Yeah. It's undoubtedly complex. And I think the problem is, is that patients don't want complexity. They want advice. They want actions. They want things that they can do that are within their control.
00:14:40
Speaker
I want to, and so let me just, because you make a really good point and that's why I was like, hey, i want to get you on the podcast because when we were conversing on LinkedIn and you you sort of, i basically said, you were basically saying the cause is always the structures, always the
Complexities of Chronic Pain Diagnosis
00:15:00
Speaker
the the body And I sort of pushed back in terms of going, well, I agree with you in 80% of cases, but what about those cases where they can't find anything? And that was your answer. And I think it was a really good answer. Yeah. Because the reality is, is there are things that we don't know and and what we didn't know 50 years ago, we now know and we're now discovering. So all i think that's awesome.
00:15:27
Speaker
But do you think that there'll come a day where... So with the rise of imaging modalities and all of these things, they're finding lots and lots of things, right? You know, everyone, 70% the population, say, i have a labral tear um and and they may be asymptomatic.
00:15:47
Speaker
What do we do with these So if I if i understand you're thinking correctly, you're saying that once we have these advancements and we're able to see things better, we will find out what are the causes of some of these these fringe or these less common, what we call nociplastic type pains. We'll find a structural cause for them one day. Is that correct or is that misinterpreting you?
00:16:18
Speaker
Yeah, ah no, i I think that if you, okay, so you get into, yeah, you get a really, if you look at pain like that, I think the whole, the nociplastic thing really gets, is interesting in the way they've sort of,
00:16:36
Speaker
built its definition. You know, i think if you look at pain, you get peripheral sensitization. So you've got inflammatory, you got an inflammatory soup around a set of peripheral nerves. You get upregulation of of receptors out there. You get increased sensitivity to those receptors and they and they fire more regularly. Yeah.
00:16:57
Speaker
They then come to the dorsal root ganglion. Dorsal root ganglion, you get upregulation of of receptors and cytokine release in that area as well. You get polarization of microglia and astrocytes, so they become pro-inflammatory. And so you're getting upregulation sensitization at a DRG level.
00:17:20
Speaker
yeah That is then taking place at a spinal cord level at the in the in the dorsal horn. It's then undoubtedly taking place in the brain and you know, amygdala, blah, blah, blah. Everything and that that is involved is experiencing this persistent upregulation of um both, ah you know, you're basically getting polarization of microglia from type two microglia, which are anti-inflammatory cells, to throw ah to type 1, which are pro-inflammatory.
00:17:59
Speaker
And then you're getting what's known as long-term potentiation. So the easiest way to think about long-term potentiation is it just memory. It's an easier way for those nerves to fire so that they use less energy.
00:18:13
Speaker
And so you're getting that combined effect. Now that's taking place throughout the entire nervous system. And then we've come up with this definition of nociplastic pain and all of a sudden we can't find the cause.
00:18:33
Speaker
We blame that it's all central, that it's, but have we lost that peripheral sensitization? Have you lost the sensitization at a DIG level? Have you lost it at a dorsal horn level?
00:18:45
Speaker
Is it like, I don't and i like I don't buy that. I just don't buy that it's just a central process. Mm-hmm. i I also, say know, we're we're trailing off into, our we're into nociplastic stuff. and I think about a pain not in the in the in in two concepts. I think about it as what's the cause, which might be a body part causing nociceptive pain, or it could be a nerve causing neuropathic pain, okay?
00:19:17
Speaker
Yeah. I then see that there's a bunch of amplifiers, all right? yeah And those amplifiers can be, can be, you know, metabolic, they can be emotional, they can be they can be social, they can be disease processes. And I think if you look at, you know, the central sensitization disorders, so the central sensitization disorders are essentially chronic fatigue syndrome, temporal mandibular joint pain, fibromyalgia, irritable bowel syndrome, you know, pots my parts of POTS probably falls into into that into that group.
00:19:56
Speaker
They're all associated with you know a number of the same disease processes. So what they're associated in I always say it's 10, but I think it's about eight.
00:20:08
Speaker
The first thing they're associated is persistent disease. nociceptive drive that it's either undiagnosed or and untreated, okay? whether be Whether you can't diagnose it or you just can't treat it, whatever. There's something there.
00:20:22
Speaker
The next thing that they're all associated with is inflammatory disorders, okay? So they're associated with rheumatoid arthritis, osteoarthritis, Sjogren's disease, SLE, blah, blah, blah, blah. You pick them like they're all associated with them.
00:20:37
Speaker
The next set of things that's associated is endocrine disorders, so hyperthyroidism, diabetes, particularly in the in this and pre-diabetic state, so insulin resistance or just hyperinsulinemia.
00:20:53
Speaker
You then also get, then celiac disease fits into that into that bucket that that bucket of regularity as well. Pre-existing, a depression, anxiety, then hypermobility,
00:21:07
Speaker
obesity, and then the last thing in that is then a subset of metabolic abnormalities that you can then go and test for. And which I do, and I do a range of different bloods that you go test for and you're trying to look for what metabolic abnormalities are there that you can treat that are then known to be associated with amplification in the nervous system.
00:21:30
Speaker
yeah And so that doesn't take out. And so and and i worked i basically work through a process where what I'm trying to do is I'm trying to go, okay, you're really sensitized.
00:21:41
Speaker
What's driving the sensitization? Right. Not yet you're sensitized, please get out, which is kind of the main diagnosis of central sensitization. But you're sensitized, there is an underlying driver to this.
00:21:55
Speaker
Can we identify what it is? And the that's where a lot of my sense that's a lot of my thinking is going. It's taken a long time to get to a point where you can go,
00:22:08
Speaker
all right, what's driving this? and we And we know that central sensitization, which is an amplification of I see central sensitization is nervous system dysfunction.
00:22:19
Speaker
Yeah. And we know that it's dominantly neuroinflammatory process. And so the question is what drives the neuroinflammation? Yeah.
00:22:30
Speaker
Yeah. Great question. And, and so yeah, you I'm trying to work out which way to go here. So if I summarize, there's there's you know there's the the stuff that happens in the body, in the part, say, um and that's what you were talking about, inflammatory soup that kind of amplifies or sends these signals. These signals are then amplified at the spinal cord level. They may also be amplified in um the the brain at the brain level. And then the output of the...
00:23:04
Speaker
yeah Spinal cord, brain, yes. Yeah. I'm just trying to simplify it for, say, the average person. So you've got your body part that's amplifying this signal, well, sending this signal, and the inflammation in around there is amplifying it. Then at the spinal cord level, it's being amplified again. and then at the brain, it can also be amplified or or or even we we're saying we're saying amplified in the bad sense, but it could also be turned down. That dial could be turned down at each of those levels, yeah?
00:23:34
Speaker
Yeah, so that that's sort of how I will be thinking about how am I going to treat this? Yeah. where Like I'm trying to identify where's the amplification coming from?
00:23:47
Speaker
So is it all peripheral? is it Is it all central? Yeah. and Or is it a mix of is it a mix both? And so you'll find that there'll be, you know, one of the main things what one of the main central drivers of of sensitization that is, you know, long way upstream is someone who's experienced sexual abuse or another one that's really big is, that seems to be very, very strong is
00:24:24
Speaker
assault at work, believe it or not. assault Being assaulted at work really drives central sensitization. I think it takes away large amount of safety within that within that environment.
00:24:38
Speaker
But so, you know, for patients that have had an assault at work, wow, that is real. they are They have a very powerful central driver that you really need to work with your psychologist, work with you we work with you or your team to deal with that trauma and get on top of that. yeah I've got to set a set of patients that, you know, that are the other way, you know, that they are, you know, there's no, they've got a great life. There's there's no major psychosocial pressures. They have, you know, but they are hypersensitive to touch. there's central when i When I'm looking for central sensitization, I do a thing called the central sensitization inventory. It's a little score that you can just download and and fill out yourself.
00:25:26
Speaker
And if their sensitization low, but they're really touchy, it's all peripheral. So you then have to work out, okay, how do I downregulate this peripheral sensitization so I can get at the underlying you know cause?
00:25:42
Speaker
Yeah. Yeah. So from a patient perspective, I mean, I think we could talk about causes of pain way, way, way too much um because there's so many types, right?
00:25:55
Speaker
But... The amplifiers of pain, what would be, you've mentioned a few of the top ones that you see, and, and you know, some of those things are out of the patient's control and they're happening happening at the, you know, at the spinal cord level and those kind of things.
00:26:13
Speaker
But for what's in the in the patient's control, What are the amplifiers that you find when people do x y and Z strategies, they seem to do better when it's, say, centrally driven or from the from the brain nervous system so its top side of things?
00:26:32
Speaker
so when youre So you're asking what are the... what are the So
Empowering Patients in Pain Management
00:26:40
Speaker
your central drivers that are non-metabolic, effectively, I would see as your anxiety and your depression, PTSD,
00:26:54
Speaker
Major social stress. And so stress is such and such an interesting discussion point when you start looking at concepts around allostatic load and how they then, you know, wind up your nervous system.
00:27:10
Speaker
Yeah. Catastrophizing. And then, and self-efficacy. So i think that if you, if you want to, if the things that you want to focus on, if you go, I,
00:27:25
Speaker
What's 100% in my control? All right. So what's 100% in your control is firstly, you've got to take control. If I guarantee if if you want to have chronic pain forever, don't own it and blame everybody else.
00:27:45
Speaker
Like that is a guarantee for this to last forever.
00:27:51
Speaker
Number two, I think you've like is then catastrophizing. So catastrophizing is when people, they catastrophize, you amplify with the words that you're using and the way that you're thinking about it.
00:28:06
Speaker
So people that catastrophize, when I'm looking for it, how I'm picking it, I'll just ask them, what you're paying out of 10? And if they tell me it's 10, well, guess what? They're catastrophizing.
00:28:17
Speaker
Because like, I think I've seen two 10s ever because what, What most people report is that they don't report the actual pain. They report how much it distresses them.
00:28:28
Speaker
I've never had two patients ever that say to me, Dan, my pain is one out of 10, but it annoys me nine out of 10. Right. Okay.
00:28:39
Speaker
So that's a rare individual that's able to split the two. What most people do is say, my pain's nine out of 10. the telling here is it just a really, really annoys them. And so other people, other ways that people you can pick, pick catastrophize, particularly in yourself. If you've been using, you know, words like, ah, feel like I'm getting hit with a sledgehammer.
00:29:00
Speaker
I feel like my legs getting cut, cut off with a, with a chainsaw. Now, yeah Okay, firstly, there is some disease processes like complex regional pain syndrome that actually feel like that. So like don't let me like put that to aside but it's the it's the use of those words that then further amplify the pain. And you can change it. You can change the words that you use.
00:29:26
Speaker
And that can help get you better control over your overview pain. recognize the yeah The other thing then is then recognizing like recognizing and just accepting you're depressed. Honestly, if you've got chronic pain, you will have lost like so many things that you love.
00:29:45
Speaker
You will have lost friends. You will have lost family. will have lost jobs. You will have lost you know the ability to do things you love to do. If that doesn't make you sad, you're not normal.
00:29:58
Speaker
And so it's okay. It's okay. Just, it's, it's okay to go, Hey, it's okay for me to feel bad about this stuff, but I've got to go on and sort it out.
00:30:09
Speaker
And it's the same with, if it moves, if you, if everything you, every time you move, it hurts and that makes you anxious, anxious, and it makes you scared to move.
00:30:20
Speaker
Well, guess what? That makes you normal. Like, and if you're not scared to move, you're not normal. But you can go on, you can manage that. That can get disproportionate and you can get and you can do a large number of strategies to improve that fear of movement to get on top of your anxiety.
00:30:37
Speaker
so they're they they're the they're the sort of things. like And if you recognize that, you know, no one tells no one comes in and tells me about, you know, their childhood. No one wants to come in and tell me about their childhood. No one comes in, or very rarely do people come in and tell me about their history of sexual abuse.
00:30:56
Speaker
But if it's there for you and you know it's there you know, i just go, okay, I have to accept this. It's here. i can deal with it and this might help my pain.
00:31:08
Speaker
And it's you're just taking ownership over, you know, all the things you can take ownership over. That's what I encourage people into. yeah It's hard though. Like and if anybody says it's easy, like they don't have chronic pain. Yeah.
00:31:26
Speaker
that's a Those are really practical answers and I appreciate that. That's exactly where i wanted you to go, try tease out some of those practical things and ways that people that are dealing with it can can reduce that amplification that we've we've discussed. do you yeah i go to give you i want to give another another practical tip okay yeah because this is one of the things that I encourage patients to do.
00:31:52
Speaker
Whenever I have someone who comes in and says someone's told me that it's in my head, what I just get them to do is say, okay, next time it takes place, I want you to do this. I just want you to say two words, one a swap, and then be silent.
00:32:09
Speaker
Because if you, someone If someone you know blatantly just says, it's just in your head, get out. If someone uses a set of words that make you feel like it's in your head, just ask them if they want to swap.
00:32:24
Speaker
But you've got to wait that moment of silence afterwards because in that moment of silence, they step into your into your shoes and they go, okay. Yeah, no.
00:32:36
Speaker
Yeah. And did you just gain that little bit of power back. So yeah, just lock that one away. next site Next time someone does it, just ask them if they want to swap. Yeah. Like you said, I think, and I think it's a fair point.
00:32:49
Speaker
Most clinicians, especially one, like to be honest, if they say it like that, they like the clinician says it it's all in your head they don't understand pain let's just be blunt like they might understand and and to be honest with you from my experience and this is just my experience yours might be different a lot of those experiences are from specialists that are very good at like and and don't get me wrong we need we need specialists that are very good at looking at this particular object or whatever it is but they're so specialized
00:33:25
Speaker
And when they don't know what to do, they go, oh, it's psychosomatic, like which I hate. I hate the phrase psychosomatic. It drives me insane. It's not real. Yeah. And and ah and yeah it's yeah, I don't know. Is that is that your experience?
00:33:42
Speaker
Yeah. So that's exactly that. And so what's what's happening there is there's a couple of things happening there that I'm glad you really bring that up. So Where we need to go is we need we are not comfortable as a profession of saying, I don't know.
00:34:00
Speaker
okay When we are training as as students, if you said, i don't know, you get destroyed. Okay.
00:34:11
Speaker
And you'll be standing next to a patient's bed and you'll get asked a question. And if you say, I don't know, You are generally stripped down and you know made to feel stupid.
00:34:25
Speaker
It's done in front of like the patient. So you just feel terrible. So the the words I don't know for a doctor are very, very hard to say. okay is This is drilled into us from the start.
00:34:39
Speaker
But I think that what we need to move to do is it's okay not to know. you know you know what? i I'm good at arms, legs, and backs, okay? I'm not great at abdo pain. I i haven't seen like chest, like internal chest pain for like ever.
00:34:55
Speaker
Am I good at doing it? And ah do I know how to manage blood pressure? Absolutely not. Like I don't know, okay? And I think that when we get to that point where you you're like, you know what?
00:35:06
Speaker
I don't know what's happening for you. it should be followed up with, but this is what we'll do. Okay? You don't need to, as as a set of doctors, we don't need to know everything.
00:35:19
Speaker
Yeah. But we do need to be able to say, i don't know. This person's, I think, the right person for you. Yeah. I don't know. I'm sorry. I'm not the one to help you here. You need to talk your GP again.
00:35:32
Speaker
And it's okay. But it's not... The answer isn't, I don't know, you're crazy, which is actually is the way, you know, which is that which is what's being said or I don't know, it's your in your head, psychosomatic. Yeah, whatever.
00:35:49
Speaker
So, yeah, ah I think that there's there's a very large change in culture that we need to make to just be able to say, i don't know. and it's okay not to know. But you have to have a plan. You have to have a next step.
00:36:05
Speaker
Yeah, I totally agree. The other thing that's interesting as well, that I think that you raise that issue that specialists are specialized. Okay, like I do arms, legs and backs. Okay, great.
00:36:20
Speaker
So the thing there is that if you're going to see a specialist who, specialist you're not going like The specialist doesn't want to sit there and go through ah like a broad-based, multidisciplinary, you know unless that's their gig, like their unless that's their actual that's their role within a special environment.
00:36:44
Speaker
That's not that they're there for. They're not there to say, have you done your rehab? Have you have you spoken to the site you know Have you worked through these medications? they're there You're going to see them for specialist knowledge to go, hey I've worked through this sort of stuff. It hasn't worked.
00:37:01
Speaker
Yeah. What's next? And they'll be sitting there like taping at the bit to lo to use whatever like whatever magic tricks they've got in their in in their back pocket. And they've all got like magic tricks in their back pocket that they want to use.
00:37:17
Speaker
But that's what you need to be yeah you need to be going you need to be going to them for. and And so when you go and see a specialist, you've got to go in with that sort of attitude.
00:37:29
Speaker
Like they're not going to give you some, you know, you're not going to find out how do I do a broad-based, you know, fix everything. yeah You're going in to go, okay, this is the problem I have that's in your, you your wheelhouse.
00:37:44
Speaker
Yeah. How do I manage this problem? And they're great at that. Totally. You know, one thing one thing I do want to, like, highlight in this is, like, this concept around number needed to treat and we'll do it within their in there around, you know, medications. And so...
00:38:05
Speaker
So with medications, particularly with nerve pain, we use four main medications. Everybody on the, let's listen and probably work through them all. So the first one's amitriptyline or N-DEP.
00:38:17
Speaker
The second one is duloxetine, commonly known as Cymbalta or Andupra. You've then got gabapentin, which is Neurontin. And then you've got Lyrica, which is also known as pregabalin.
00:38:30
Speaker
All right. So... The whole concept of number needed to treat is the idea that I have to treat a certain number of patients to get one better.
00:38:41
Speaker
Now, within the world of neuropathic pain, that the amount better that people get is about 30% to 50%. All right. So if you've got pain that's nine out of 10, you're taking somebody from a nine down to a six or an eight down to a five-ish, okay? Okay.
00:39:00
Speaker
So to get one person better with N-DEP or amitriptyline, you've got to treat four. Now, if you're a glass half port full person, that's a great number. If you're a glass half empty person, that's 75% of people don't respond to our best medication.
00:39:19
Speaker
So then you look at duloxetine, you got to treat six to get one better. With gabapentin and Lyrica, you got to treat eight to get one person 30% 50% better. eight people. Yeah.
00:39:34
Speaker
like eight people Do you know that means it only works in 11% of patients? That's the number. So pregabalin and gabapentin work in 11% of patients, which basically means 89% of patients don't respond, don't get a 30% to 50% decrease in their pain.
00:39:54
Speaker
So I see a lot of patients, they come in and they see them and they're like, oh, Dan, you know, something wrong with me, I don't respond to anything. and No, that's normal.
00:40:05
Speaker
Like you're actually just 100% normal. and And it's interesting if you do the math around, you know, if you work through all those medications, do know how many people would actually respond to those to that if you've worked through them all?
00:40:24
Speaker
50%. So half glass full, that's a great outcome. 50% of people will get a 30% to 50% decrease in pain. Half glass empty, 50% have no improvements with working through a ton of medications. And people will have worked through those medications, you know, four, six, eight weeks each medication. you know You're now six months down the track of not having got any better. Mm-hmm.
00:40:50
Speaker
Yeah. That's like, it's really important to realize that that that's the reality of this. And so- And and you can apply that you can apply that whole understanding to rehab.
00:41:05
Speaker
You know, if we do pain neuroscience and physio, what's the what's the number needed to treat to get one person better? It's somewhere between three and five, depending on which data you want to look at.
00:41:16
Speaker
So once again, that means that somewhere between, it means 20 to 30% of patients respond, And the rest don't. So the next question is, and and that's where as a specialist, what I'm seeing is I'm not seeing the ones that responded.
00:41:32
Speaker
I see the ones that didn't. And then I see the ones that tried, we try the medication and they don't respond. What do we do? we go into an intervention. And what you're in, your number needs to treat for intervention is kind of around two to three for most interventions. So where we're at now. Okay, now 50% of those don't respond. Okay, and then we're into that. then what do you go on to next?
00:41:54
Speaker
And that's sort of like, like and so if you so one of the things about this little soliloquy is it's okay if you don't respond. Like it just, unfortunately it's really annoying.
00:42:08
Speaker
It's nothing right. It's nothing to do with you. It's part of like the whole, the whole bag of chronic pain.
Limitations of Pain Relief Methods
00:42:15
Speaker
There's a reason why 20% the world suffers chronic pain. It's because hard to get better.
00:42:20
Speaker
Yeah. Yeah, for sure. And it feels for some people, it feels so isolating as well because they they feel like they just must be this like strange individual that no one can help. But the reality is there's 20% of the population are are just like you. And I thank you for pointing that out in terms of the medications. It is a little bit sobering and also depressing, though, when you do outline it. But it's the truth and it's the reality. And I appreciate you for for sharing it.
00:42:49
Speaker
I think that the the thing that's important that I find really, that i find that I find good having that understanding, right, is that, you know what, even as a clinician, i want everyone to get better.
00:43:06
Speaker
Like hate losing. That's like my, like I hate losing. And when I have a patient that's not getting better, I feel bad. Like I know they're in pain, but I feel bad because I haven't been able to help them. Like I hate it.
00:43:20
Speaker
But it's just part of it it's it's it's part of what we've got to do. You've got to look for the options and then you've got to and then you've got to take you know the next and you go, okay, you haven't responded. This is what is the next next thing. And one of the really interesting, I think we we were just talking about this before we started, and it's not that the treatment's the wrong treatment. and I think this is the key that where I've come to lately with a lot of a lot of my thinking is you've got to find the right patient or you can find the right treatment for the right patient, but it's then going to be at the right time.
00:43:56
Speaker
So, you know, if you're a, if you've got lower back pain and that back pain is coming from facet joint arthritis and it hasn't responded to to to rehab, you know what?
00:44:08
Speaker
You can do a diagnostic block. You can confirm it's facet joint arthritis. We can treat it with some radiofrequency. That can decrease the patient's pain, But you know what's the right time to do now?
00:44:21
Speaker
Now it's the right time to go back and do the rehab because the radio frequency doesn't fix the deconditioning. It doesn't fix the motor patterning. What it does is just denervate the joint and allows you to go back and then do the rehab then. That's when the rehab becomes right time.
00:44:38
Speaker
It's just getting it right treatment, right patient, right time. That's the skill base. Yeah. Yeah, for sure. And it seems what you've brought up brings me back to a conversation I had a ah few weeks back um with, well, it was months back now, but it's only released a few weeks. maybe a month or so ago, but with Professor Mark Hutchinson. So they're working on this blood test that's hopefully going to quantify pain, but also tell you what sort of pain type so we can get more precise with our treatments rather than what now seems to be sadly a little bit of guesswork. And it's kind of like you're trying to hit a home run with it with a
00:45:23
Speaker
blindfold on now that doesn't mean that does not undermine uh your skill and many people's skill in treating this stuff but man it would be lovely to have more precision when it comes to pain care and i think it's just an exciting time that that they're working on this now obviously it's a huge task and i wish them all the best but it's definitely no mark stuff's amazing and it And I think you raise a really good point there where you're getting more precision. And I think that where we are at the moment, is you look at like how accurate is history, examination, and imaging findings at defining you know the cause of pain, you know what? It's really poor.
00:46:10
Speaker
Okay. And beie if we just put the conversation within the the context of lower or back pain, If as a clinician, you are limited to history examination and and imaging findings, your diagnostic a accuracy is pretty poor.
00:46:25
Speaker
And as a result, the appropriate diagnosis becomes non-specific lower back pain. Okay. Because you just, not we don't have the skill, like we just don't have the accuracy within those tools to clearly identify the pain.
00:46:39
Speaker
Now, if you add... diagnostic blocks to that. And that's where my skill base comes in. Oh, I can do a diagnostic block. So I can, you know, for me, I think about lower back pain and there's five major causes, you know facets, sacreliate, joints, hips, discs, and nerves. Great.
00:46:58
Speaker
I've I have that additional I've been gifted with that additional skill base where I can do a diagnostic block and we can see if the pain goes away when you block the nerve supply to the facet when you block the nerve supply to the sacrileot joint when you block you know hip or you do some you know some nerve blocks for for for so as a result you go from non-specific lower back pain to specific lower back pain, which then goes, okay, now I've got some therapeutic options that I can treat this diagnosis with.
00:47:32
Speaker
As opposed to, you know, okay, we've got a diagnosis so of non-specific lower back pain. I'm going to apply, which can be one of, you know, five major things plus a whole bunch of minor things.
00:47:45
Speaker
Surprise supplies, if youre let's say that you've got two different patients. One's got, they've both got nonspecific lower back pain. One of them's actually facet. One of them's actually sacreliate joint. We're adding a third. One of them's actually disc.
00:48:01
Speaker
Treating them the same, surprise, surprise, doesn't work. And so that's where we get these very low number needed to treat or very high number needed to treat. that only 20% of patients respond because, like, you know what, you're getting it right maybe 20% of the time.
00:48:18
Speaker
Yeah. And then so so some – And so I'll just finish. It's important to be able to approach these in the you know things in that way because we have limited – you know, you have limited access to care. You've got limited access to doctors.
00:48:36
Speaker
You know, so you have to take that sort of approach, but it's not the end. in the approach, you know, it's recognizing, okay, next step is to go and become more specific about the diagnosis.
00:48:50
Speaker
Yeah. Yeah. Spot on. And yeah, I think nerve blocks have a lot of diagnostic
00:48:58
Speaker
validity, I guess, or, uh, effectiveness in terms of helping us to do that. I, I often am referring for those kinds of things with some of the sports docs up here and, and pain specialists and the like.
00:49:11
Speaker
And I think it's a great, It's a great way of us getting a bit more diagnostic certainty around what structure is is causing or um is a part of the the pain picture. But sometimes sometimes where it's where it's difficult is that sometimes we do find out and we get more diagnostic certainty and the options to treat are still crap.
00:49:36
Speaker
Yep. Frankly. And and that's that's where, you know, I'm often coming back to what you term amplifiers, which I think is a great analogy and a way of explaining it.
00:49:49
Speaker
I often coming back to those amplifiers and and sort of sorting out some of those things, whether it be stress or poor sleep or um their social situation.
Innovative Approaches to Pain Management
00:50:00
Speaker
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00:50:15
Speaker
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00:50:28
Speaker
If you're a clinician, head to paincoach.online for a free trial. it's It often, for me, comes back to that because even when we find a structural problem, the treatment options aren't always great. Now, that doesn't mean I don't think we should treat those things in some circumstances, but sometimes the risk-reward relationship just doesn't really add up for certain interventions.
00:50:55
Speaker
How often are you in your practice dealing with some of the amplifiers and how often are you sort of interventional in your approach?
00:51:06
Speaker
The answer to the both of them is all the time. Okay. It just depends on who the patient is. Okay. So but what I'll do with the patient is, so i do I do a fair bit of, you know, pre-consult cheating. Okay. So I get the patient to fill out a DAS21. So that's a depression, anxiety, and stress score. So that gives me a general indication about how much depression, anxiety, and stress is in the background.
00:51:30
Speaker
I also get them to do what's called a central sensitization inventory. So the central sensitization inventory, surprise, surprise, defines how centrally sensitized they are. Okay. And so what I'll be doing then is the central sensitization inventory splits out into into, I think it's five major categories. So subclinical.
00:51:53
Speaker
So you're pretty much not sensitized. Mild, which is between 30 and 39. Moderate, which is between 40 and 49. Severe, which is between 50 and 59. And extreme, which is over 60. Okay. And so what I'll then be doing is then i will also be asking the patient to draw their pain. Okay. And so I'll be looking for two things there. I'll be looking to see, I ask the patient when they when they draw their pain to you know scribble over an area when it is when it's an ache or burny type pain.
00:52:36
Speaker
If it's an electric shock, we do it we do a ah lightning bolt. if it's If it's pins and needles, we do some dots. And if there's numbness, we circle it. okay So I start to get a visual understanding of what's happening for their pain.
00:52:49
Speaker
So, What I'll do then is i'll take those I'll take those three things. So the perfect patient that comes in that I'm going to go towards an intervention for. So they come in, they have focal pain that's proportional.
00:53:07
Speaker
They've got central sensitization inventory of of like that's mild, like that's subclinical to, you know, mild, maybe moderate. Mm-hmm.
00:53:20
Speaker
They've seen the physio and they've done their rehab and they've got minimal depression, anxiety and stress in the background. okay So that patient, if you want to go down the track of getting them to you know meditate and think definitely about their pain, that does not work.
00:53:39
Speaker
What are you got to do in that patient is you go on you go, okay, great. This looks like it's going to be a facet, an SIJ or whatever. dirt you You pick your first, what do you think your most likely diagnosis is, do a diagnostic block and away you go.
00:53:54
Speaker
Awesome. but that is a like that That patient, that's my interventional patient. Yeah. So the other type of patient, the next patient that comes in, what do you do? So what they've got is they've got a central sensitization inventory of 75. Everything is wildly amplified.
00:54:15
Speaker
When they draw on their pain diagram, what they do is they color in most of their body or a big wide area and they've got tons of depression oil or you know anxiety or stress in the background. Okay. So that patient, everything is so amplified. If you go down an interventional track on them, I'm telling you now what will take place is that the needle hurts more in them than it does in other people.
00:54:45
Speaker
And so what happens, you do a diagnostic block and they blow up in a big ball pain afterwards, not because anything's gone wrong, but just because their nervous system is so sensitized. And so that that patient,
00:54:58
Speaker
do not do an intervention on that patient. So that's the patient where I'm then going to go, okay, what's driving the sensitization? And so I will be looking for, you know, okay, you've got a depression, anxiety, and stress score. I'll be then, you know, going through looking at their history for, you know, the things we talked about before, inflammatory disorders, hyperthyroidism, you know, diabetes, particularly we we should talk a little bit in a moment about um hyperinsulinemia and insulin resistance.
00:55:27
Speaker
And then, you know, your hypermobile patients, your obesity, looking for those things that I can then go, okay, let's go see what amplifiers are taking place. What can I actually turn down and treat? Let's get your amplification under control.
00:55:46
Speaker
use i also use in this setting, you know, I do use a reasonable amount of amitriptyline in this setting because amitriptyline a very good at decreasing size and intensity of pain in these patients.
00:55:58
Speaker
And so you look for the amplifiers, you try and decrease decrease the intensity as much as you can, and then you revisit it. And you then you're like, okay, where are we at now?
00:56:09
Speaker
How big is it? Now it's this big. Okay, great. Now we're down to it's, you know, tennis ball, grapefruit size. I can probably go find what's underlying that. And we can then go on and do a diagnostic dostic block at that time.
00:56:25
Speaker
And so... you know They're obviously the extremes. Most people are in the middle. So you got ah you know you're hedging your bets sometimes. yeah But but it you know for nearly everybody, I'll be doing like a combined approach.
00:56:45
Speaker
Yeah. so yeah that they I don't know if that answers the question, but you know that's kind of how I how i think about it. Yeah, no, I love that. it It explains your sort of your reasoning. And I think it's for for people listening on, I think it will be super helpful for them to be able to go, oh, these are kind of my options. This is what's going on. And these are the things that can be be contributing. We've covered a lot in 56 minutes or so.
00:57:16
Speaker
i want to i want to end with a question. that I ask pretty traditionally on on the show, which is if there's someone feeling helpless and despair, that person you basically described at the start of our conversation, you know, helpless, despair, suicidal ideation, what would be what would be your words for them? And I know that's a very challenging question.
00:57:43
Speaker
ah easy. It's not in your head Perfect. That wasn't challenging at all. It's easy. like and andt And the amount of times I've said that to patients and it is innumerable and the amount of time i then they then tear up just because someone said someone believes them you know, someone recognizes and someone sees them like, yeah, like like it's it's not in your head.
00:58:13
Speaker
You can think about it differently. Sure. You can think about your pain differently. That'll make you you that'll make you you better. But no one imagines themselves into a life where you lose everything you love.
00:58:29
Speaker
No one's imagining their pain. It's real. It's not in your head. Sure, think about it differently, but you know you're not imagining it. You're not making it up, yeah.
00:58:41
Speaker
No one's making it up. What if they then push back and note and they say, and I'm just um um' pushing a little bit, what if they say, but no one can find what's wrong with me? and okay then it's back to Then it's back to, you know what, you're right. We might not be able to find so what's wrong, but that doesn't mean there's nothing wrong.
00:59:01
Speaker
That just means we can't find it And while we're at a point in time where we may not be able to diagnose something, we may not be able to, like we can diagnose it, but we can't treat it, you then need to look at other strategies to cope with it better.
00:59:16
Speaker
You know, and those coping strategies are about the way you think, the way you respond, the medications you use, you know, yeah how you do exercise, you know, the diet that you eat, you know, the you know and how you own your pain. You know, that that that's the that's the stuff. let's Let's be honest, you know, pain's hard. You've got to have discipline to get better.
00:59:40
Speaker
and And pain takes away your self-efficacy. Discipline's about self-efficacy and pain takes that away as well. It's hard. a No, appreciate that. That's a great advice to end with. ah Thank you so much for coming on. I've really appreciated it.
00:59:59
Speaker
worries. Pleasure. Thanks for having me.