‘It is not the curse or blessing that works, but the idea.
The imagination produces the effect.’
– Paracelsus
Having come this far on the journey with me, you may by now used to expecting the unexpected. If so, good! Because now I want to introduce you to the most exciting new developments in pain relief, which consist not of clever new drugs, but of fewer drugs, or even none at all.
I’m going to tell you about the fascinating phenomenon of the placebo. Medical professionals are generally tentative about its use, as if it were in some way a tool of the dark arts. But, for me, it represents a combination of the summation of therapeutic experience and the confirmation of the existence of nature’s medicine chest.
A placebo is an inert drug or treatment that is administered to the patient; and the placebo effect is the outcome of that treatment or drug, seen as a change in the condition of the patient’s symptoms. The important fact is that the placebo is an unknown entity. It is an effect, not a thing. This very definitely does not mean that you can just take something that tastes or feels nasty, is expensive or difficult to obtain, wrap it up in mystery and call it a cure.
Traditionally, doctors have been forbidden from using the placebo effect to treat their patients, as it contravenes their ethical promise. This is because it was seen in some way to be duping or deceiving the patient. It went against the belief that the patient had the right to be informed fully about the treatment and its possible side effects, and consent to it.
In the case of placebo, you would be forgiven for thinking that side effects were an impossibility, of course, as the drug is inert. However, research has shown that if patients believe they are receiving a drug, then, despite it being a sugar pill, they will present with many of the drug’s side effects anyway. Furthermore, they will go through the symptoms of withdrawal when they stop taking it. This confirms that much of the effect is down to the power of belief alone.
The placebo effect has been calculated across many studies to account for anything between 30 per cent and 50 per cent of the response to a range of drugs.82 One outlier was antidepressants, the placebo for which was 79 per cent effective. That is pretty extraordinary! As a result of this discovery, researchers are having to factor the placebo effect into their studies, to ensure that the drug is more effective than the placebo. Studies have shown that the simple act of taking a drug creates elements of expectation and conditioning, perception, confidence, need and want in the patient. In experiments, some people believed that a more expensive ‘painkiller’ was more effective than a cheaper one, despite both being no more than sugar pills. Others reported that a more expensive sports drink relieved their fatigue more effectively than another.
I have found in my own patients that more expensive, branded drugs are perceived to be more effective than cheaper generic ones, even though they contain exactly the same active ingredients and formula. Drug companies will never admit it publicly, but this is why they colour-code tablets according to what they contain. They knowingly use the placebo effect to enhance the effect of the drug. Have you ever noticed that painkillers are usually white, anti-inflammatories yellow, pink or red, and antibiotics multicoloured capsules? Research has shown that the colour of the pill enhanced outcome when it contained only sugar.83 So, if you are running a commercial enterprise, why wouldn’t you capitalise on the advantage? The language and the visuals on the box are all designed to create maximum effect.
Conditioning, as well as belief, is involved in this response. An experiment carried out in 2009 showed that a sweet tablet given to lower the immune systems of mice was just as effective when they removed the active ingredient and left only the sweetener.84 The mice had learned to associate sweetness with a required effect. Another study made a similar finding in humans.85 The researchers gave medication to individuals with a dust-mite allergy and asked them to take it with a ‘special’ drink. When they replaced the drug with a placebo, the subjects saw just as good a reduction in their allergic symptoms as when they took the drug. However, they saw no improvement when the placebo was given with water. The ‘special drink’ had produced a conditioned response. So we can see that the placebo effect is not confined to the realms of pain. The brain is capable of mounting all sorts of internal mechanisms, its own ‘medicine chest’, when it wants to.
Surprisingly, the effect extends to surgery, too. In 2002, an American team of researchers constructed a study to examine the effectiveness of arthroscopic surgery for painful knee conditions.86 They wanted to see whether it altered the natural evolution of the condition. Some 180 patients were told that they would either have a regular arthroscopic knee operation, a simple washing-out of the joint with saline, or a sham operation (where no procedure at all was carried out). In order to convince all the patients that they had had surgery, small incisions were made in the skin to mimic those made in a real operation.
All the patients were monitored for two years after the surgery. At one stage, the placebo group was doing better than the other two groups who had undergone the real procedure, and in the end the outcomes for all three groups were about the same. Amazing!
Even the nature and structure of the healthcare system has its effect on the patient’s belief system. A study in 2017 showed that a third of Americans and Australians had reported feeling pain often or very often in the past month.87 This was in startling contrast to China at 19 per cent, South Africa at 11 per cent and just 8.5 per cent in the Czech Republic. The reasons for this are not entirely clear; certainly, the subjects’ nervous systems are no different. But the researchers established that it seems to depend on the societal expectations of the national healthcare system concerned. If the system is good and, perhaps more importantly, free, people quickly expect to be pain- and disease-free; after all, it is their ‘right’ as consumers. Thus, their tolerance for pain or disease is lowered and a feeling of loss for the health they should expect ensues. This manifests as an escalation in their pain. Furthermore, if the health system fails to deliver the expected outcome, this effect is magnified by a sense of loss and injustice, resulting in more pain. I suspect this is a key element in the overloading of our NHS service in Britain.
Thanks to the wonders of functional magnetic resonance scanning, we can test the placebo effect by looking at which part of the brain lights up when a drug or placebo has been administered. As I explained in Chapter 2, the two key areas involved are the amygdala, responsible for processing the emotional element of the stimulus, and the hippocampus, which is responsible for memory. We can deduce, therefore, that it is likely that the amygdala is where belief lies and that the hippocampus is responsible for conditioning, as it requires memory to ‘remember’ the associated response necessary. Another region, the nucleus accumbens, also comes into play. It is associated with pleasure and reward and thought to be the area involved in addiction. It would seem that when this is activated it floods with our old friend dopamine and creates pleasure. A similar effect occurs with a placebo. The pleasure centre lights up with the expectation of reward, not just the reward itself.
The piece of research that rocked the placebo boat and indeed, medical research generally, was by Ted Kaptchuk, professor of medicine at Harvard Medical School.88 He wanted to see if it mattered whether people knew that what they were taking was a placebo. He openly gave placebos to people with irritable bowel syndrome, while reinforcing the point that placebos had been shown to produce self-healing processes. The research team was gobsmacked to find that even when the drug was clearly marked ‘placebo’ it still had a marked effect on their symptoms. This showed that, despite knowing the drug was inert, the level of expectation and belief were such that it still produced the internal responses they needed.
In my view, this has loosened the ethical confines used to prevent doctors offering an element of placebo within their management of a patient. I, for one, freely admit that I try to maximise the patient experience (I guess we could call this expectation) from the moment they arrive at my clinic door; from the ride in the lift to being greeted at the reception desk. I like to think that at each step of their journey through the building they receive subliminal messages that they are in a place of healing, which will deliver its service in a confident, professional and empathic way, and which will take them and their condition seriously. I try to instil this in everyone who works in the clinic and in my students. If patients arrive in the consulting room with the subconscious mindset of ‘I really feel I could get better here’, then we have won half the battle. I want the effect of our treatment and advice to ride on the back of any placebo effect we have created before we start. Even the language we use in the clinic has an impact. For example, patients in pain often use words of conditionality and negativity, such as ‘would’, ‘could’ or ‘if’. If you couch any responses in terms of ‘will’, ‘can’ and ‘going to’, their language changes too, as does their attitude to the potential for recovery. This translates as hope. We try to turn them into possibilitarians, on the basis that seeing the possibility of recovery makes the probability of it much more likely.
One frustrating way in which modern medical services further reduce the chances of the combined effect of treatment and placebo is by removing patient choice. In the UK, patients can choose neither their GP nor the consultant they see if they are referred to hospital; they are referred to a team, not an individual. Even in the private sector in the UK, medical insurance companies have begun to set themselves up as the arbiters of whom the patient can see, very often recommending not who is best but who is cheapest. If, as we have already discussed, part of the placebo effect is based on a belief mechanism, then removing patient choice also reduces their belief in the doctor they have been allocated. In an ideal world, people would get to choose who they want to see based on the personal recommendations of friends, family or their GP. Getting a referral by reputation is key to the success of the doctor, too, as it ‘preloads’ the patient with good expectations and an anticipation of being healed, even before they arrive for their appointment.
Professor Kaptchuk put it well in a TED talk in 2014, explaining that for too long we have ignored placebos as if they were a distraction from pure hard science. Researchers have felt that they are being tasked with finding a precise pharmacological solution to an illness; that science is where the answers lie. Placebos are just fluffy stuff that is hard to quantify and so the ‘art of medicine’ has been neglected.
But placebo studies take the tools of medicine and change the art of medicine into the science of clinical care. They demonstrate that the human dimension of providing healthcare can alleviate symptoms and change the course of illness even without pharmaceuticals. This does not mean that we want to do away with pharmaceuticals. Placebos cannot shrink tumours, nor can they lower cholesterol, but they can be used effectively to make a good drug or treatment a better one. And there is no better purpose for this than the treatment of pain, in which, as we have seen, emotions, fear, expectation and conditioning play such a crucial role. What we need to envision is a healthcare system that rebalances good medicine with good human care.
OK, I hear you saying, I don’t want a cosy chat with a practitioner. I’m in pain and I want strong drugs to stop it. I hear you, and in the short term, of course, we should use drugs, to get patients over the hurdle of acute injury, or post-operative or cancer pain, but they should have little or no place in the treatment of persistent pain. The problem is that all drugs produce side effects and the crisis created by the overprescription of opiates, particularly in the US, has reached catastrophic proportions. It is not as if it is a new phenomenon; opiates in the form of morphine, used to treat the wounded in the American Civil War, left 400,000 soldiers addicted to it. But time has the capacity to fade the memory. Between 1999 and 2017, 200,000 Americans died of opiate overdose. It is believed it will take 60 years for the effects of opiate addiction to wash through society. Tragically, 90 per cent of the addicts walking the streets have no history of drug problems; they are people who had pain and were prescribed these medications. Once they could not get repeat prescriptions from doctors, they had to resort to street dealers to get relief, and the cycle of addiction began. Unfortunately, in people addicted to opioids, the pain itself gets worse rather than better, due to a phenomenon called opioid hyperalgesia. This is when the receptors become more sensitive as the drug wears off and so they need more and more to achieve the same effect. It is similar to the stress-induced hyperalgesia I mentioned in Chapter 3.
There is a closer connection between opioid drugs and the natural placebo effect than you might imagine. Most of the placebos that have an effect on pain do so by stimulating the release of our own internal opiate-based painkillers. Receptors for these chemicals can be found throughout the brain, brain stem and spinal cord, hence their having far-reaching effects, not only centrally in the brain but also on early reception of potentially pain-inducing signals from the body. The effect of placebo on these receptors was initially proven by using an agent (naloxone), which blocked the receptors from the opiates and eradicated the effect of the placebo. These receptors are particularly abundant in the parts of the brain that process emotional feelings. This is why if you ask a badly wounded soldier if he still feels pain after the administration of morphine, he will reply: ‘Yes, I still feel pain but I just don’t seem to care.’
It is this emotional blockade that is at the heart of the addictiveness of opiate medications. They remove the emotional bridge that links the primitive drives of the brain stem with the higher, more rational and thinking centres of the cortex. Rather than blocking pain itself, the drugs lift the patients out of themselves and away from their interpretation of their pain. In so doing, they remove not only the physical but also the emotional suffering, seeming to dissolve the conflict between the person’s desire to live a meaningful life and the reality of their circumstances. Thus they become dissociated from their life, and they withdraw from it. ‘No suffering’ is effectively the same as pleasure, neurologically speaking.
One can rage at the pharmaceutical companies that developed these drugs and marketed them as safe, but the genie is out of the bottle now. And the net effect of the opiate crisis in the US is that Big Pharma is in no hurry to repeat those mistakes, and the development of more powerful pain-relieving drugs has for the most part been shelved, not least because they don’t make them enough money. You may not like the idea that the way to a pain-free future lies largely in your own hands and those of a good practitioner whom you trust, but there is no silver bullet that is going to relieve you of that responsibility any time soon.
This brings us to the importance of trust in the therapeutic experience. In his fascinating book, The Patient’s Brain, Professor Fabrizio Benedetti addresses this subject, breaking down the experience of seeking therapy into four main steps:89
1. Feeling pain: this occurs through sensory information from the body (bottom-up) modulated by how the patient feels about it (top-down).
2. Seeking relief: this is where motivational and reward mechanisms are initiated to seek relief of discomfort. Presentation to the therapist follows.
3. Meeting the therapist/doctor: here the healer must incite trust and hope for there to be a positive response in the patient. This should be met with compassion and empathy by the therapist. Placebo effect begins.
4. Receiving the therapy: the therapeutic act activates expectation and further placebo mechanisms as well as anxiety reduction.
If all these experience mechanisms are positive and they incorporate a bio-psycho-social approach, the therapy/placebo combination is not only maximised but has the power to do great things.
To give just one example of how important the patient– doctor relationship is, we can look at trust as an active ingredient of that relationship. Trust is in fact the most important thing for a patient to feel towards a therapist. To be trustworthy, the practitioner must meet five requirements: competence, compassion, confidentiality, reliability and communication. No pressure there then!
The brain is capable of making decisions on trustworthiness very quickly indeed, probably because, for our ancestors, detecting how trustworthy someone was was essential for survival. In fact, just 100 milliseconds (one tenth of a second) of exposure to a face is enough for the brain to decide. That is quicker than the human eye can move around the face to scan it. Who said first impressions don’t matter?
Hope is the other key determinant of response to therapy. It has been shown to help patients to tolerate pain for longer and to adjust better to coping with it. Hopelessness has been linked to depression, as it implies a negative expectation of the future. Its partner, helplessness, can be seen as an individual’s unrealistically low impression of their own capabilities. The more dangerous version, learned helplessness, occurs when attempts at self-help have failed multiple times and the belief that all is lost has set in. With the right approach, both of these states can be prevented or at least improved through the whole therapeutic experience.
So, I hope you can see that understanding the field of placebo is vital to the whole patient experience and that we should not be afraid of using it. Practitioners should be busy factoring it into, rather than out of, their clinical work, while being mindful of its power to confuse and, of course, being honest in their intent.
There is something rather wonderful about Dr Frank Vertosick’s statement that ‘just as the source of suffering lies in humanity, the cure may be found in our humanity also’.
I have already explained why modern life, with its lack of activity and plethora of artificially induced stressors, is leading us towards a more painful future. Along with all the other problems that children will inherit from us, such as global warming, this is their destiny – unless we take positive steps to give them the necessary skills and resilience to minimise its impact. Resilience should not mean, as it has come to in some corporate circles, that you simply reframe stress and bottle it up.
If you have children, or even if you work with children, you will understand the heart-wrenching agony you feel when they are in pain. The desire to take it away from them is all-consuming. Even a simple fall in the playground makes you want to swoop over, sweep them up and reassure them. And this interaction between the carer and the child is vitally important in the development of their pain responses in later years. The mutual transference of the experience of suffering makes up part of what it is to be human.
Imagine that your daughter has just tripped and fallen on the tarmac surface at the swings. For a split second she evaluates what has happened, a rude interruption to her happy play. A brief look of utter shock and surprise. If she can see you, she assesses your response too. Is your face also shocked and horrified? Is it reinforcing her own notion of whether to scream and panic? Or is she greeted by a benevolent grimace and the reassuring low tones of ‘oh dear… upsy daisy’, as you rush forward to dust her down with a flurry of distractive physicality, designed to desensitise her to the hot burning pain of grazed knees and hands that wants to flood her nervous system, and not give her time to consider and catastrophise?
If you have a deeper interest in this subject, I would highly recommend you read Judy Foreman’s excellent book, A Nation in Pain.90 Foreman cites evidence which suggests that children who have been exposed to painful events, but who are treated with a subtle mix of concerned love and a large pinch of reassurance, distraction and physical comfort, such as a hug, manage pain in the future much better. Parents on the other hand who take a ‘suck it up’ attitude and offer little or no physical solace and those who over-respond and catastrophise over small injuries tend to produce adults with low pain thresholds or dysfunctional responses to their pain or the pain of others.
Obviously, a case can be made for the use of drug-induced pain relief when it is acute and needs relieving. Believe it or not, for many years, quite major surgery was carried out on children without any form of pain relief. Doctors believed that if surgery was necessary to save a child’s life, they should carry it out immediately and that the child probably wouldn’t remember it anyway. And, since they did not know how to anaesthetise babies, they had to believe they couldn’t feel pain. Several paediatric consultant anaesthetists whom I have interviewed have backed up these facts. Babies were routinely given paralysing agents but no pain relievers to block the peripheral pain signals, which meant that, although they could feel pain, they could not move, cry, or in any way indicate that this was so. However, it was evident they were in pain because it was reflected in the monitoring of vital signs, such as blood pressure, pulse rate and oxygen requirements, which would routinely skyrocket due to pain-induced stress hormones being released into the bloodstream.
Shocking though it may seem, until recently there has been little research into how children process pain, and it is still poorly understood. One of the first recognised papers into the undertreatment of pain in children was published in 1975 by PhD student Joann Eland at the University of Iowa.91 The paper transformed pain intervention for children in her own hospital, but it took years for this to be replicated elsewhere. Survey studies carried out in the 1980s showed that children were not at the time routinely given pain relief during painful procedures, even for full operations and burn debridement, an incredibly painful procedure, in which dead layers of skin are scraped from burns.
It was only when research into the neurobiology of brain development in children proved that babies and children did indeed feel pain that the medical world changed its view and recognised that pain management was paramount.
Pain researcher Maria Fitzgerald published several seminal papers in the UK, which tracked the postnatal growth of pain pathways and the changes that occurred in them under the assault of severe pain.92 She also importantly showed that local painkillers could reduce the risk of subsequent chronic pain, and that untreated pain in children could have long-term adverse effects.
In 1987, American scientists Anand and Hickey showed unequivocally that human newborns have the anatomical and functional components required for the perception of painful stimuli.93 Therefore, there was every reason to believe that children could have the same pain experiences as adults, if not as learned and modified.
During the process of birth itself, it is clear that babies are actively trying to manage pain. Even if the birth is relatively easy for the baby (Caesarean or quick vaginal delivery), it pumps into its bloodstream three to five times the level of endorphins (painkilling chemicals) that adults do at rest. Breech or forceps deliveries often produce even higher levels. Nature clearly gave them the means by which to handle this natural process.
It is certainly true that the use of anaesthesia and opiates in children carries greater risk than in adults, but that does not mean that we should not use them. It simply means we have to learn more about them as a specialism and develop better techniques, and also be more discerning about when we perform invasive procedures in the first place. The use of opiate drugs in treating children in pain has now been extensively tested and very little of concern has been found regarding their addictiveness, unlike in adults. Nor is there justified concern about the side effect they have of reducing breathing rate, provided they are handled by specialists.94 In fact, it has been clear for some time that children who receive good pain relief during surgery do better than those who do not. Yet we still use them far too little. Things are improving, but very slowly. It is only through pressure from the patient body, as well as doctors and nurses, that we can create a movement for change.
Fortunately, there are other non-drug-related approaches that we can use to relieve milder pain in children, such as, curiously, using things that taste sweet.95 Professor Celeste Johnston of McGill University cites the simple practice of extracting blood with a needle from a newborn’s heel to draw blood for testing, as an example. This commonplace procedure, she points out, is ‘size-wise, like a knife in the foot of an adult’; i.e. the size of the needle wound relative to the size of the child’s foot is equivalent to the extent of the injury to the nervous system. Amazingly, giving them something that tastes sweet when the blood test is performed, in the form of sugar or even artificial sweetener, significantly reduces the length of time that the newborn cries due to the pain of the needle. It is suggested that the sugar works by acting on opioid receptors, and this has been supported by the fact that mothers who are dependent on methadone (the controlled liquid version of heroin) produce children who do not benefit from the sugar response. This is because all the opioid receptors are already full and further relief cannot be stimulated.
Other more innocent approaches, such as dummies and breastfeeding, have been shown to help control minor pain. But interestingly, the best infant pain reliever, which probably comes to parents most naturally, is close, skin-to-skin contact and cuddling. This type of intervention, if we must call it such, which brings together the child and parent or carer or even protector, is born of a natural response to relieve the fear in and danger to the infant that may ensue from a potentially painful stimulus. To me it shows that intrinsic systems exist within our nervous system to link pain to a ‘fear and protection’ response and that these begin very early in our development.
We all need to look for ways to help us move out of the pain paradigm. Perhaps more than anything, we need to develop the capacity to deal with our own feelings and desires to protect ourselves from illness and pain. Psychologists call this ‘emotional competence’. Certainly, in almost all my persistent-pain patients, this is the element that is most often compromised. We need to foster it in our children as the best preventive medicine. Gabor Maté cites Ross Buck’s list of the requirements for emotional competence as follows:
• The capacity to feel our emotions, so that we are aware when we are experiencing stress.
• The ability to express our emotions effectively and thereby to assert our needs and to maintain the integrity of our emotional boundaries.
• The facility to distinguish between psychological reactions that are pertinent to the present situation and those that present residue from the past. What we want and demand from the world needs to conform to our present needs, not to unconscious, unsatisfied needs from childhood. If distinctions between past and present blur, we will perceive loss or threat of loss where none exists.
• The awareness of those genuine needs that do require satisfaction, rather than their repression for the sake of gaining the acceptance or approval of others.
If we accept that many of the issues contributing to pain are rooted deep in the unconscious, from the past as well as the present, then maybe that is where we should go looking and we need to change the way we see our current environment too. After all, we know that a large part of the placebo effect (in pain relief) is mediated through the activation of our own internal opiate and dopamine systems, so we need to find a way of inducing it in ourselves.
Shawn Achor is a psychologist, happiness researcher and author at Harvard. He is the founder of GoodThink,96 and has made amazing inroads into showing how happiness is achievable and how it can improve our lives immeasurably. He posits that most of us judge ourselves by how the average set of the population behaves and achieves. By definition, the average is only at the 50th percentile of the population. We forget that everyone else within the ‘bell curve’ above or below that line is still normal, just not average. The lens through which we see the world shapes our reality and the reality in which we live defines us. He asks how you can see the possibility of success or happiness if, in the mindset in which you sit, neither is possible.
We need, therefore, to change our reality. Achor quotes the interesting fact that every second of our lives our brains are confronted with 11 million pieces of information. Yet our brains can only process this information at 40 bits per second. Thus, we have to choose our reality based on the bits that we process. Technically, we can choose to change our reality.
Achor wants us to reverse the way we see the route to success. For most of us, happiness will come with the achievement of success, as in ‘when I am more successful, I will be happier’. So, we work harder and harder and then, when we achieve that success, we simply move the goal posts and change what success looks like. Ergo, we are never happy, only exhausted. We need to reverse the formula for success, for it undergirds our parenting and managing styles, and the way that we motivate our behaviour. If we are positive in the present, the brain floods with dopamine, which not only makes us happier but also turns on all our learning centres and changes the way we see the world. In the case of pain, it motivates us to change and allows us to see the possibility of getting better. If we can see happiness as the joy we get from achieving our potential, then we are halfway there. Achor cites five strategies for achieving this mindset:
• Showing gratitude: by writing down three things you are grateful for each day for 21 days.
• Reliving a positive experience: by journalling about something that has made you feel good over the past 24 hours.
• Doing exercise: to teach your brain that your behaviour matters and release opiates and dopamine into it.
• Practising mindfulness: to free your brain from our stressful world.
• Performing random acts of kindness: this can be something as little as opening your inbox and emailing someone in your social network and thanking or praising them for something they have done.
Such mindset changes allow us to give value and meaning to activities and encounters and help us to move forward. We feel more attuned to assuming responsibility and taking on challenges and gaining the self-esteem of achieving them. Even more importantly, as role models to our children we have to send such messages through our behaviour.
This is all about knowing ourselves better, as having such insight facilitates change. Yuval Harari, author of the wonderful book Sapiens, recently made this point in an interview.97 He said that if we are going to use technology and let it into our lives, we have to know ourselves more than ever; for, if we don’t, the tech companies will begin to remove our free will by hacking us – something I think a lot of us feel is already happening. They don’t have to understand the human brain very well, just build algorithms that know us better than we do. Then they can predict and manipulate our decisions and make choices on our behalf; and that would be very bad for us. We would become reliant on others, feel disenfranchised and powerless, stop taking responsibility and rely on the state to tell us what to do.
As long ago as the 1970s, BF Skinner discovered that media companies used a phenomenon called the Variable Reward Schedule to get us addicted to what we watch.98 It turned out that it is the inconsistency of the reward that sucks us in. If it is predictable we get bored. Therefore, with modern social media we need to check in all the time. James Williams, former Google advertising strategist and now Oxford philosopher, implores us to take back control in our relationship with tech.99
As information becomes more plentiful and floods our minds, the resource that is becoming ever more scarce is our attention. He describes what he calls the ‘Attention economy’, in which media and advertising companies are not on our side and are battling for our attention. As a result, we are so busy with ‘stuff’ that we stop achieving our own personal goals and never move forward.
The last point I want to make here is regarding our beloved British health system. It is our responsibility to respect and look after it. It is still the finest in the world and driven by amazing people. But we drive it harder and harder with more demands and constant criticism. Personally, I believe that we should not simply pump more and more money into it but take a harsh look at how we as citizens are using it and accept that there are some things we have to fund ourselves, or take steps to treat ourselves, and try to lead a healthier life.
Pain treatment, for one, could move out of hospitals entirely, if we operated a polyclinic-type system in large regional health centres where a multidisciplinary pain team could work in tandem with teams of primary-care professionals. Pain training should be part of all medical degrees; currently, the average time spent on the subject in a doctor’s degree is about an hour. Such integrated planning is the future, with communities reconnecting with and looking after each other. It could be an exciting time, too, for architects and planners to fundamentally change the buildings in which we work, once more engaging us with our environment and encouraging collaboration as well as facilitating regular movement.
It is happening, but just takes time.
This book is not meant to be a detailed step-by-step guide to easing whatever pains you. It could never be that. The reasons why each individual is suffering are too complex for that. Rather, it is designed to set you thinking about what your body is trying to tell you through the hard-to-interpret medium of pain – and how to go about listening. That said, I would be remiss if I didn’t mention some of the basic things that I would talk you through if you showed up in my clinic. Your personal lifestyle healthy habits will keep your pain away much better than any trip to a doctor. For many it will be enough.
NB: This advice is for sufferers of persistent pain that has lasted more than three months – people in whom all the tissue damage should have healed but the top-down processes are still in play. It’s not for acute pain after injury or trauma.
1. Accept that the answer rarely lies in a medical prescription, unless there is an established inflammatory process going on. Your doctor should be the judge of that. The side effects of opiate drugs can end up being worse than the pain itself. Dosage should be strictly monitored. I make an exception here for post-surgery or cancer pains, for which opiates can work very well. Otherwise use over-the-counter pain relief such as ibuprofen or paracetamol, provided you can tolerate them and you follow the instructions.
2. Don’t wait to get help. No one will give you a medal for waiting until the pain is unbearable. Express it to people and let them know you are struggling, but with a view to doing something about it rather than complaining and doing nothing.
3. Be honest with yourself. This is a hard one. Look deep into yourself and ask whether what you are seeking is what we call in the trade secondary gain from your pain. This is where, whether or not we like to admit it, there is an advantage to having and being incapacitated by pain. For example, do you get looked after more and have to do less? If you live on your own, is it an inadvertent way of getting attention from your family and friends? The answer is to address the cause, not the pain.
4. Apply the bio-psycho-social test. Once it is established that your pain is chronic, you need to review the biological, social and psychological elements to understand why your brain is persisting in sending danger messages when the immediate crisis has passed. This is best done with a qualified practitioner whom you trust and who will ask the right questions. Doing it yourself means you will miss key elements; it is difficult to be objective as the patient.
5. Find a good osteopath or physio. It is also the case that lack of activity or unbalanced movement caused by a painful episode (such as past trauma) can lead to biomechanical asymmetries and produce trigger points or shut down muscles. This can produce great discomfort but can easily be released or ‘woken up’ by a good osteopath or physiotherapist, or even home techniques, giving almost instant relief.
6. Keep moving. Bed rest is very rarely the answer and the muscle wastage caused by even a couple of weeks of inactivity will compromise your healing and embed the pathways in your brain that say you are ‘broken’. Again, a good osteopath, physio or well-qualified personal trainer can help you explore safe ways to extend your range of movement in a paced and graded way.
7. The best forms of exercise are walking, running, swimming and cycling (depending on your age and fitness level) for cardiovascular health; multidirectional or functional weight training (to improve muscle tone); and t’ai chi for balance and flexibility – also essential for a healthy old age. As I have stated, hypermobile patients love yoga and dance, where they can show off their flexibility, and swimming because it renders them weightless. But these activities won’t make you better unless you combine them with resistance exercise, such as weights. Get a programme built for you by someone who knows what they are talking about. Unbalanced training is worse than none at all. Hydrotherapy is awesome and can be in your local pool, with exercises from your physio or osteo or some good apps. The warmer the water the better. Once you have plateaued, move out of the water to floor exercises and standing balance exercises.
Pilates can be marvellous or terrible, depending on how it is taught. If it is taught well, it can produce a strong core that helps every other aspect of your health, but I see so many people in my clinic who have been taught badly or attend classes that are too large. They also never migrate from floor work. Always go to a physio-led class and get a personal or professional recommendation.
8. If you work at a desk for much of the day, get a proper ergonomic assessment of your position. If possible, install a standing desk and change your posture frequently – the best posture is the next posture. If not, get up and walk around at least once an hour. Do stretches at your desk and engage others to do so. Create your own culture, even if it isn’t your company’s. If you are on the phone, pace, don’t sit. Don’t eat lunch at your desk; go out. Beware of what I call the laptop-latte position I see in every coffee shop and communal work space, where the user is curled over a laptop on a low table. You might think you are just checking a few emails but you can easily pass an hour or more in that awkward position. If you use a laptop, put it on a desk and use a laptop stand. Don’t cross your legs at your desk or in meetings. And use the stairs… always. Easier is not the path to progress.
9. Drink water regularly and put an electrolyte tablet in the bottle every so often to make sure you don’t leach out the good chemicals you need.
10. Be sensible about heavy bags. I see too many women with their bodies pulled out of natural alignment by a stuffed shoulder bag. The worst of all are the trendy large totes that only work over a shoulder. A properly fitting rucksack and supportive trainers should be your default for commuting.
11. The shoe conundrum. The human foot is designed to move and to be in contact with the floor as much as possible, so shoes are effectively sensory deprivation devices for feet. That said, we have adapted somewhat to them and it is too late to change for most, particularly as we get older. If you want the best of both worlds Vibram and Vivobarefoot soles are great and there is a gathering number of styles out there (though they will not be to everyone’s taste). Heels if you are used to them, ladies, are not as bad as people think. So wear them, but for short periods, and not at work. During the day an inch is enough. Don’t go too flat either, as it puts your calf muscles on stretch and tilts your pelvis. Don’t go backless. Flip-flops and sling-backs are a nightmare. Fit-Flops, however, are a good summer option. Birkenstocks are a bit of a fallacy too, as they are too stiff in the sole when walking; their new rubber version is much better. MBT trainers (the rocker ones with a massive sole) are appalling and would be ceremonially burnt in my office if a pair walked in. When advising on trainers, I always tell people to avoid too much cushioning and too much correction in the soles. If you have run all your life in shoes, don’t join the barefoot-running craze unless you can commit to at least six months of guided and gradual conversion from an expert. Keep a golf ball under your desk to roll under your feet in socks to massage the muscles of the arches and heels. Don’t shuffle when walking or walk as if you are walking on two parallel rails. Add an inch to your stride and swing your arms when walking. It activates your gluteal muscles and your core.
12. Look out for pain-causing habits such as vacuuming, ironing, or any activity which involves one-way twisting or holding awkward positions for any length of time.
13. Be aware of how much extra stress you are adding to your day by unthinking use of social media. If you can’t quit it altogether, then severely curtail your use of it. Remember the old adage ‘Turn on, tune in and drop out’? The app algorithms are designed by psychologists to suck you in, get you addicted, sell you stuff directly or indirectly, and crowd you with noise, most of which is inaccurate. Stop your phone distracting you by switching off the notifications. Maybe set a time once or twice a day to check your accounts and institute screen-free weekends and holidays. Manage your internal triggers for using media – when you are susceptible it is usually because you are doing something uncomfortable; push on through. You’ll be setting a good example for your children as well. And do I really need to tell you not to keep your phone by your bed? Bedrooms are for two things, sex and sleep.
14. Confront the difficult things in life at home and work. Awkward topics are always hard but glean the most results. Reconnect with friends and family. Don’t wait for them to do come to you; life is too short. Have conversations, not arguments, with those concerned. Be vulnerable with them and they will be more honest with you. Remember, your unresolved issues come back and bite you as pain. Minimise your exposure to anyone who is bad for you.
15. If you are a type-A perfectionist or think you can multitask, then take one, if not two, things off your to-do list daily. Multitasking is a fallacy – it just means you don’t do any of the things very well. By dealing with one task at a time, stress goes down, promptness is observed without rushing and you focus better. Also delegate more; you are not the only one who can do a good job.
16. Reduce or eliminate dependencies such as alcohol, nicotine and even caffeine. If you need to, lose weight. It is estimated that, for every four kilos lost, there is a resultant 17 per cent reduction in pain. That means if you have a BMI of greater than 40, you will have up to 254 per cent more pain! Losing weight is an entirely natural form of pain relief that will benefit every other aspect of your health as well. It’s basically a question of calories in/calories out. Every diet ever designed simply reduces calories in some way, either through different food groups or a different eating behaviour, such as the ‘5:2’. With most gluten-free diets you lose weight simply because you have just cut out at least 50 per cent of the carbohydrates in your life. Don’t at any cost dump protein. If you can afford organic, go for it. Persuade your office to get a fruit bowl and get rid of any food dispensers. Nobody benefits from them.
17. Look at your sleep: ask yourself how high in quality it is. Do you feel recovered and fresh in the morning? Observe the following sleep hygiene rules and read a good sleep book:
• Keep the room cool and as dark as possible at night; blackout blinds are best.
• Do ten of my breaths in bed before sleep.
• Sleep on your side or back rather than on your front.
• Always get a good bed; go softer rather than harder.
• Use a supportive pillow (not down or feathers), preferably only one.
• Leave all electronics and screens out of the bedroom; get dozy in the sitting room and go to bed; don’t watch TV in the bedroom.
• Don’t drink coffee after 5pm.
• Limit your alcohol during the week.
• Don’t lie in, get up at a regular time.
18. Join a group. No, not the Chronic Pain Appreciation Society – a book club, snooker or bowling team, tiddlywinks or action group. See people and connect. We are social animals and thrive off social contact. Use your social media for networking positively and look for social forums around pain; research shows they help enormously. However, you cannot beat being physically there and meeting people. Watch something funny at least once a day.
19. Do some acts of random kindness. These don’t have to be grand gestures – just do small things often. Engage people’s eyeline and smile. On your commute, be civil and openly courteous. Help people rather than waiting for the ‘fat controller’ to do it – he won’t! When you get your coffee you don’t have to be chatty but just don’t be miserable. Your behaviour matters and it changes your environment and those of others. Look good, take pride and stand tall. Remember you are someone else’s scenery.
20. And, above all, practise the breathing techniques in the previous chapter a minimum of five times a day. It will take 15 minutes in total, maximum, and will do more than anything else to stimulate your vagus nerve and calm those fight or flight reactions that are exacerbating your aches and pains.
It is important, too, to say that this doesn’t have to be a perfectionist regime that you follow rigidly for the rest of your life. Once you have got your pain and your life under control and you have seen the new place you can be in or – as Martin Luther King said, ‘Once you have seen over the mountain top’ – you won’t want to go back to your old self.
I wish you well!