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Part 1: Holistic Pain Management: Pain Origins and Assessment with Ananda Mahoney

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Part 1: Holistic Pain Management: Pain Origins and Assessment

The agony of chronic pain is a huge burden on many, on both a personal and societal level.

Today, in part one of Holistic Pain Management, we welcome back Ananda Mahoney, an expert in the assessment and treatment of pain.

In this episode, Ananda takes us through the neurobiology and theories of pain, various assessment tools and the issues of pain in our society. Ananda also discusses what worsens and what alleviates the sensation of pain, and we'll gain some insight into integrative treatments which can offer help, especially when orthodox measures fail to relieve pain.

Covered in this episode:

[01:02] Welcoming back Ananda Mahoney
[02:39] What is the societal burden of pain?
[07:56] Contributors to pain mismanagement?
[11:18] How should pain be assessed?
[16:54] What actually is pain?
[20:41] Theories of pain 
[24:21] Factors influencing pain perception?
[35:19] Why medical care misses the mark
[40:58] Holistic approaches to care
[42:26] Inviting Ananda back to continue to discussion for Part 2.

Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. 

Joining me on the line today is Ananda Mahony. Ananda works with people who are struggling with chronic, ongoing pain that's caused by a wide range of conditions such as neuropathy, functional issues such as migraine, IBS and fibromyalgia, an autoimmune or injury-related pain amongst others. A naturopath for 20 years, Ananda has been in clinical practice for 12 years and has now a specific focus on chronic and acute pain management. Ananda's interest in pain management emerged out of the frustration of seeing patients receive inconsistent treatment, and the use of isolated pain management strategies rather than holistic care.

Ananda is a nutrition lecturer at Endeavour College of Natural Health, and is a clinician in two successful integrative practices in Brisbane. She has a passion for education and continued learning which has led to her undertaking postgraduate studies in human nutrition at Deakin University and more recently, to a master's in the science of pain management at Sydney University to align more closely with her special interest in clinical practice. Ananda is a member of the Australian Pain Society and the International Association for the Study of Pain that's the IASP

Welcome back to FX Medicine, Ananda, how are you going?

Ananda: Yeah great. Thanks for having me, Andrew, it's a real pleasure to talk to you today.

Andrew: It is our pleasure to have you back because you give us such fantastic, practical, clinical information. 

But today, we're gonna talk about a bit of a pig of a subject and that's natural pain management. So, just how much in pain are we as a society?

Ananda: Yeah. Well, it is a significant global burden, and specifically, untreated or poorly treated pain. And if we talk about chronic pain, because that's probably more my area of research and study. It is a little bit difficult to quantify because there's a natural history of pain. It fluctuates and there's acute exacerbations and there's lots of variable factors associated with pain. You know, apart from biological and biomedical aspects but psychological and social aspects. So these have different influences in pain at different times. 

But if we kind of put a definition around chronic pain, which is commonly and widely accepted and used in Australia, it’s pain that's persisted beyond expected healing time, or pain experienced for three months or more. And, sometimes, that's a very arbitrary cutoff.

Andrew: Yeah.

Ananda: But, if we look at that, then it's approximately one in five adult women and one in six adult men have persistent pain. There's multiple causes and many of the causes are unclear and, in fact, about 70% of people with pain can't trace the start of their pain to a single event. Yeah, so it's not like someone said, "Oh, well, I bent over and I felt my back go. And since then, I've had chronic pain," or, you know, "I injured myself and, since then..." You know, often it's quite an insidious onset or the person can't identify what brought it on, this is specifically contributing to the chronic pain. And it's also associated with other health issues. There's multiple comorbidities such as depression, insomnia, anxiety. And these, of course, just add to worse quality of life, you know, apart from the pain itself.

Andrew: If we're talking about one in five women and one in six men which is...I've got to say, that's significant. And given that low back pain is a significant cause of chronic pain, how much of that one in five, one and six is low back pain compared to other forms of pain?

Ananda: I was reading some work from New South Wales Health, and they looked at 23% of women have...oh no, so, I think it was still 23% of women had chronic pain or identified as chronic pain in New South Wales. 

But globally, low back pain is the number one cause of disability. And that was from 2012, The Lancet reported on that. You know, fourth was neck pain, sixth was other musculoskeletal pain, and eighth was migraine. So they're, you know, global causesof disability, we've got chronic pain having a significant burden there.

Andrew: Wow. You know, that really stuns me, how low back pain and other forms of sort of musculoskeletal pain are much higher than migraine, I thought migraine would've been right up there.

Ananda: Yes. Well, migraine tends to cluster in women more than men. So it might be that, you know, if we're looking at women, it might have a higher incidence. But across, you know, the population migraine has a lower impact than lower back pain and other musculoskeletal pain. 

Just in Australia, look, if we, by 2050 they predict that it will equate to about $34 billion a year in economic cost. So you have this kind of individual social burden but then also this is a really significant economic burden that we’ve got coming through.

Andrew: And I wanted to talk later about the economic burden reaching further than just, you know, accessing pain management. Because indeed, there's this issue of dependence and even addiction and, therefore, possibly crime in certain individuals. 

So I'm just wondering about how far reaching the issue of, I'll blame them now, the opioids, we've got a massive issue in our society with the opioids. But I wonder how far reaching those issues are beyond just medication.

Ananda: Yes, they are significant. Unfortunately, a lot of those modifiable factors, they contribute to a poorer outcome. 

So I talk about modifiable factors like if we just say pain itself, there's a lot of secondary outcomes associated with pain. But there's also, you know, factors that a prognostic of a really poor long-term outcome. And those poor relationship, low social support, and medication reliance, they're amongst those poor outcomes or poor prognostic outcomes. So unfortunately, they just feed into then, you know, more disability and quality of life issues in the individual as well.

Andrew: So you say that, you know, the reason that you've got this passion for helping people with chronic pain is because you've seen them being, not necessarily mismanaged, but let's say, they haven't been given the best management, isolated pain management, I think you've termed it, rather than holistic care. Do you think it's because of a lack of knowledge of what happens with people in pain by their normal caregivers?

Ananda: Yes, I do. And I think that that goes across the board from GPs and conventional medicine to complementary medicine. Across the board, I don't necessarily think that we have a really good understanding of the inputs and the drivers of chronic pain. Therefore, we treat it in a unimodal way. So a person might be going to their GP for pain or they might be going to a massage therapist or, indeed, that they might be doing both, but there's no communication between those health care providers. Which means that it's still, effectively, it's unimodal treatments.

And if we'd look at how chronic pain is treated, one of the biggest factors that's involved in better management and quality of life is pain education. 

Yeah, so and pain education comes at concepts like, in chronic pain, pain isn't associated with damage. 

Andrew: Right

Ananda: So if you exercise and you feel pain, people will often have excessive rest days because they post that exercise, because they're in pain, yes, and that may stop them with activity. But they I think, "I'm doing that into a better way until that pain subsides. And I better be careful about how much activity I do in the future because my back's stuffed. I saw it on an image and I've got no, my disk's degenerated. So if I do exercise and it, you know, further damages or degenerates my discs, then I'll have worse problems in the future." And that is frequently not the case.

Andrew: Gotcha, gotcha, gotcha.

Ananda: There's a lot of self-fulfilling kind of prophesies.

Andrew: Yeah, yeah, yeah. So the sort of avoidance of the healing activity because of a concern of furthering of damage?

Ananda: Yes. But unfortunately, that's a message that they're getting from a lot of their health care providers. And that, I guess, just comes from the fact that pain education isn't widely known. Or in theory, it might be known, like the biopsychosocial model of pain which is the common adopted model, is not necessarily being put into place, in clinical practice. And so, the models there, in theory, might be there but it's not being used effectively or people just don't know about the model and don't know about how pain actually works, chronic pain works, or manifests and, therefore, are treating it as a danger. I mean...sorry, a trauma or damage base, that it's being driven by trauma or damage rather than by say, central nervous system plasticity and changes. But I'm kind of jumping ahead there.

Andrew: How should we be assessing pain, like you just mentioned the biopsychosocial model? I'm familiar with things like the WOMAC, the Western Ontario Pain Scale. You've got the visual analog scale which, to me, is a little bit droll. I prefer the facial pain scale that's used in kids and I actually think that's more relevant for adults, but anyway. 

But you've got all these other ones that I just don't know about. I've heard of them, FLACC pain scale, the Abbey pain, I've never heard of them. What's their relevance?

Ananda: Well, they're part of a pain assessment workup and it's really important to have that baseline data. So that you can measure the gravity of the problem and chart progress or record progress, and even to communicate to other healthcare professionals. You know, my patient has a pain intensity of 9 out of 10 on a regular basis, that's important information to communicate. 

So that's the importance of, perhaps, something like the Visual Analog Scale or the pain facial scale or even a numerical rating scale. And I don't really think it matters which one you choose as long as you're consistent with your use within that one patient. So to me, that...the consistency is more important than the actual scale.

Andrew: Yeah, don't change to the goalpost.

Ananda: Yeah, that's right. 

But if you're looking at all of those questionnaires and measurement tools, there are some really good ones to use and as part of a workup. And a lot of them gather a whole lot of that data. And, say, the Brief Pain Inventory is a one-pager and it's got, you know, pain intensity, sensory descriptors. It also brings in aspects of associated symptoms and mood, impact on sleep and activity. 

They're quite easy to get hold of and to use, they're not complex for either the patient or you, to interpret. They're available from New South Wales Health and the Pain Management Network, and they have a huge amount of great resources. So you definitely don't have to reinvent the wheel when you come to looking at gathering data. You can just go and grab a couple of their resources and incorporate them into your pain assessment.

Andrew: Yeah, so that would be a really good, at least, one to start with until you feel comfortable about other, maybe more specific, is that right? Like WOMAC would be more specific for the arthralgias, is that correct?

Ananda: Oh yes, that's right. So the WOMAC, you'd only use for people with arthralgias. But the Visual Analog Scale or some other kind of pain intensity rating scale, you'd probably use for all people in chronic pain. 

So there will be pain...sorry, scales that are specific to a particular disease state.

Andrew: Great. So we'll definitely put some of those measurement tools, if you like, measurement resources up on the FX Medicine site and particularly that one that you mentioned, the Brief Pain Inventory, thanks for that.

Ananda: Yeah. So I just wanted to mention them, when you're doing a pain assessment, it's important not to just get the kind of physical characteristics of the pain. But associated symptoms, say fatigue and nausea, affects on quality and sleep, so activity and sleep and mood, all of those comorbid associated conditions because they interplay with one another. The worse you sleep, the worse your mood, the worse your pain. Or the worse your pain, the worse your mood. So there's that kind of... 

And the other thing is, which you may not be able to get all in one consult, obviously, but some of the other drivers of pain perception such as beliefs about the cause of pain and expectations of pain management and pain treatment and coping strategies or lack thereof. You know, they're really important for ongoing management of pain. Is if, you know, what is this patient's expectations of treatment and pain management when they come and see you, and where are they getting that from already and how can I contribute to meeting their expectations? Or even, are their expectations realistic?

Andrew: Yes. And like I've got to say, I have this unbelievable story from a naturopath who used to work with Victor Chang. So I'm gonna recount that now. And she told me that she was in Victor Chang's team and they went over to China, I think it was, to show them different ways of cardiac surgery. And there was an older lady who was at high aesthetic risk and the an anaesthetist said, "I'm sorry, I can't anaesthetise this lady." And so, Victor Chang said, "I'm sorry, we can't operate." And the Chinese surgeon said, "No, no. That's okay, she's gonna have acupuncture." And they, "No, no, no. You don't understand, we're gonna have to crack this lady's chest." And they went, "No, no, you don't understand. She's gonna have acupuncture." So there was this debate almost going on. And they said, "No, no, you don't understand."

Apparently, this lady had acupuncture, was wide awake and had no pain. Now, part of that would've been, "I believe, you know, I believe that belief, you know, obviously has a very powerful part to play in our experiences.” Absolutely. But I do believe that acupuncture certainly had a role to play there in medicating that lady outside the opioid system, which is interesting. But I just, I was flabbergasted when this naturopath, she is a nurse, naturopath recounted this story to me. 

So therefore, this leads on to my next question, what's pain?

Ananda: Oh, okay, what is pain? 

Look, I'm gonna give you the IASP definition which is...it took many years, I'm sure, to actually define. Which is, "It's an unpleasant sensory and emotional experience associated with actual or potential tissue damage." So that's the definition of it. And you see there, it talks about the sensory and the emotional. So recognising that we can get, you know, heartsick and emotional pain, it talks about actual but also potential damage. And, if I was going to simplify what pain is in one sentence, you know, apart from that definition is Pain depends on the balance of danger to safety signals.

Andrew: Ahh, very interesting. 

Ananda: Yeah, so if we talk about potential tissue damage, I'll just relay this little story, and this is a story that you can watch on YouTube, and it's by Lorimer Moseley, and he's one of the foremost researchers in pain in Adelaide...oh, I think it's in Adelaide, I'm not sure if it's Adelaide University, but in Adelaide. And he's a physiotherapist, and he has done a huge amount of work in understanding and working with chronic pain. And he relays this story as an in, kind of, indication of that idea of potential tissue damage and the inputs of danger signals aren't all about the actual tissue trauma.

And so, he was walking, he was on holidays and he was bushwalking and he'd an open toed shoe. And he felt this kind of scratch on his foot and he looked down and didn't see anything. But it became very soon apparent that he'd been bitten by a snake. And that was quite traumatic and he had to be rushed to hospital and it took a while for recovery. And, you know, he got over that and fully recovered. But a couple of years later, he was walking through the bush and maybe, not the same environment but a similar environment, and enjoying it. And a stick flipped up and scratched him on the ankle. And he had an intense, immediate response, that was grabbed his ankle, he was in really bad pain and he jumping around and in pain, and he probably tells the story slightly differently but this is my interpretation of it. And when he finally kind of pulled his hand off, he saw that he just had a superficial scratch, just a little bit of superficial blood on his leg. And it certainly wouldn't normally elicit that level of pain perception. But of course, he had really strong danger signals with his previous experience and so, that amplified that imput or that danger imput which then his brain interpreted as a really, really big noxious and dangerous event. And his body responded in kind.

Andrew: So all you wives out there, don't belittle our hurty finger stories just because we think we've been bitten by a snake.

Ananda: Maybe?

Andrew: I'm going to use that.

Ananda: Okay. Maybe watch his video, though, rather than my version.

Andrew: But it is a really interesting thing to note because, like, I've seen that in kids. You know, I've used it in my children. The old distraction, "That's okay. It's just a scratch," and they don't bother it. Particularly with very young kids. If they see you, that you're nonplussed about it, they're just like, "Oh, okay. Fine." But if you go, "Oh, are you okay?" Then the tears start and things like that. And most parents would've done this. But that's okay. And then they go, "Ooh, hell. No, that's really serious."

Ananda: Yeah. A little bit more serious than initially thought. Yeah.

Andrew: What about the theories of pain though? There was the pain gate theory. And then there's the two gate theory, I'm not sure that I'm familiar with that.

Ananda: I'm not sure that I'm familiar with the two-gate theory either. But, I’m going to talk about the general gate theory, briefly, then I'll kind of move on to more current theories. Because that was Melzack and Wall, in 1965, came up with the gate theory and it changed the thinking at the time. It moved pain from a really linear theory to a much more dynamic theory that involved the changing nature of the nervous system, central and peripheral nervous systems. 

It kind of incorporated the idea that the structure and function of both, are shaped and constantly reshaped by activity within, and at each level, the nervous system is continually amplifying or inhibiting signals. And these can be danger signals or noxious signals or non-noxious signals, but constantly amplifying or inhibiting these. And then the brain, ultimately, interprets that as pain or, you know, "That's okay, that's safe. It's not a strong danger signal."

And it is really, simply, the particular series of non-painful input to the dorsal horn such as...sorry, I should say, I made a mistake there, we never talk about the input as being painful because it's not, it's just a signal. So it could be noxious or a danger signal but non-noxious input to the dorsal horn such as touch, vibration or pressure closes the gates to noxious input, which then dampens down or prevents the noxious signal traveling to the central nervous system and, ultimately, the brain.

Andrew: Hence you hold your elbow when you've banged it.

Ananda: Yeah.

Andrew: Right.

Ananda: Or you rub it. So there's three factors that influence that and that's the level of activity of the nociceptors, and thy’re the neurons that transport noxious input. Or the activity of the beta fibers which are the ones carrying non-noxious input. So those two. Then, the brain's perception of the incoming peripheral messages and its response, the discerning messages which facilitate the opening or the closing of that gate idea. 

But this theory didn't really explain chronic pain or even the influence of previous pain appearances or gender differences in pain. So the same authors came up with the neuromatrix theory in 1999, and that kind of recognised that there's an innate network of neurons in the central nervous system, ‘the neuromatrix’, and this is unique to the individual and impacted by physical, psychological and cognitive traits and past experiences. 

So therefore, we can see that maybe cognitions or beliefs or behaviours might influence pain as well, and the perception of pain.

Andrew: Gotcha.

Ananda: Yeah. But so, currently, we now go about biopsychosocial model I talked about and that looks at the complex interplay of all of the factors, the physiological, psychological and social/cultural factors. 

So from the biomedical perspective or the physical, it might be nociceptive inputs or inflammatory inputs, or neuropathies or plasticity, central nervous system plasticity, and central sensitivity. So recognising the changes in the central nervous system, that are associated with chronic pain. But then beliefs, mood, previous experiences and the influence of peers and partners and work environment and things like that as well.

Andrew: And this goes across cultures as well. I remember, in nursing, you know, like the Asian cultures were very more stoic with regards to pain, particularly females. Whereas, you know, I'm going to be...this is so broad, so stereotypical like, of course. But, generally speaking, the more Mediterranean type of cultures, would be more expressive of pain and, indeed, would be more physical in their expression of pain. The waving of the hands and things like, "Ah," you know, that sort of thing. And it's not, you know, you've got to be very careful not to judge it. You know, "Is that person therefore not in pain because they're not showing it?" Or, "Are are they just being really stoic?" And, conversely, the person who's throwing up their hands, do you then trivialise their pain because you, you know, think they're whinging or playing on your sort of heartstrings?

Ananda: It is hard and, you see, pain is totally an individual experience. 
And so, we can't compare one person's pain to another person. And they still don't have, you know, a definitive biomedical test for an experience of pain. They're getting closer but they don't, at this stage. Yeah.

Andrew: What about different age groups? Like, you know, and I'm not thinking just emotional or, as you said, the input of safety versus danger signals. But I'm wondering about nerve impulses and neurological connections, if you like, to a noxious input. 
Are there physical, physiological, I guess is the correct term? Differences in pain between different age groups? Or indeed, maybe different cultures?

Ananda: I guess that's the initial pain response isn't it? And I think pretty much what I wanna say to you is rather than the different groups feel pain differently, do different individuals in different situations feel pain differently?

Andrew: Right, right. So you really do have to look at that person's pain.

Ananda: Yeah. Look, with the elderly, you might see decreases in nociception, and they may place less importance on pain.

Andrew: Oh, a very good point.

Ananda: So, and with very young babies, the nociceptors haven't actually, you know, properly developed into the dorsal horn yet, so you can do...you know, they still feel pain but they don't feel it via a noxious input by the nociceptors until a few weeks after birth. 

But you can still see brain activity in infants associated with pain on EEGs. 

Andrew: Well, that’s interesting…

Ananda: So yeah, they've just come up with that, I saw that the other day, that they're looking at that wave and determining whether infants, very young infants are actually in chronic...are in pain, not chronic pain, are in pain.

Andrew: Are in pain, yeah.

Ananda: Based on brain activity.

Andrew: Yeah. That's very interesting. 

And you know what? You just twigged something about pain in the elderly. I remember a warning signal and it was to do with appendicitis. Mostly, you know, the appendix is this...forgive me, the appendicitis pain is this, maybe a starting of a broad feeling in the abdomen and then, over time, it sort of localises to the right iliac fossa. But that's not always the case, indeed, one of the warning bells is the, "The shocked octogenarian, that's an 80-year-old, in no pain but septic shock." So the trick, the thing there was no pain but they’re in sepsis. So there's something going on with the nociceptive sensation.

Ananda: Yeah, yeah. And that certainly with age may be a factor.

Andrew: Yeah. So you mentioned things like people's association of a danger signal. Can we change that with techniques like meditation, distraction, I've mentioned, in lessening pain? I mean, the classic one here is childbirth. 

But what about other forms of pain like lower back pain?

Ananda: We certainly can. And I guess, probably, again, I can do a quick description and then maybe put some context around why these techniques might help modulate pain. The experience of pain. 

So if we have noxious input, and a danger signal coming into the dorsal horn. We used to think that was kind of just a relay station, but it's actually akin to a brain with computational ability. It's this kind of immense and sophisticated network of interneurons that modulate those inputs. And then, it goes up to the brain and there's no single pain centre, there's 500 parts of the brain that light up, you know, 500, however many, but a lot...

Andrew: There's 600 in my brain, Ananda.

Ananda: Yeah, exactly. Exactly. 

So and these multiple centres collaborate to produce pain. But what can happen also is that the brain says, "Well, that noxious input coming in isn't as important. And so I'm going to inhibit that, I'm gonna send down a safety signal, I'm gonna inhibit that input and bring about reduction in pain or analgesia." Or the brain can go, "No, that's much more important than the input coming in, and I'm going to facilitate those inputs, peripheral or otherwise, to increase the spread of pain by activating other prime cells and other nociceptors, and the pain spreads."

So the thing that we've got to look at, what are the factors that actually influence that perception and either that descending facilitation or inhibition? And you can look at the neuroimmune interface there. And look at the role of, say, glial cells and toll-like receptor 4 surveillance on those astrocytes in the synapses and the tripartite synapses in neuroimmune interface. And I guess I'm coming there because we wanna look at how a psychological input can actually influence pain perception and actually stimulate, or be a danger signal. 

And just one way of looking at that is the neuroimmune interface and that, so we've got the nociceptor and a second afferent, and a little astrocyte wrapped around that. And then, the toll-like receptor 4 and it's basically a surveillance camera with a long memory for molecules associated with dangerous events. And we’ve got PAMPs, pathogen damage associated, xenobiotic. We've also got cognitive and behavioural associated molecular patterns. And they then stimulate the release of molecules into the synapse, that inflammatory mediators and the like, or you know, chemicals that then either dampen down or, in this case, we're talking about danger signals that increase the sensitivity of messages, noxious inputs going to the brain. 

So if we have previous experiences, or focus on all the context of the situation…like, what am I trying to think of? An example might be childbirth, a woman goes in very scared of that experience and she doesn't feel safe in that experience, and then it's a protracted labor. Then it might be that she's getting a lot of cognitive messages or CAMPs, we call them, you know, sending danger signals into her central nervous system which is then amplifying that pain.

Andrew: Let's say somebody had more of an influence in this cognitive associated molecular pattern. Would that maybe tease out the difference between somebody experiencing chronic pain, and perhaps, experiencing depression from that chronic pain. Versus somebody who might not have that influence and might have the chronic pain without the depression?

Ananda: Yeah it sure could. Yeah it could be a factor. 

I mean there's a whole lot of other, you know, kind of cognitive patterns that might then become danger signals. And this is a classic one that you read about in the literature with pain and that is catastrophizing. So if a person catastrophizes before the onset of pain, it's a predictor for chronic pain. 

Andrew: Right

Ananda: So even, you know, they've done this research and they did it with breast cancer, with, you know... So they looked at how, what the person was like, the individual was like in their degree of catastrophizing prior to the surgery and then whether that predicted they would become, you know, be in chronic pain. And there was quite a strong association. 

So and those certainly can be dangerous signals and, if we look at the neuroimmune interface and we're saying, "Is there a role for kind of, thought processes to drive inflammation, at that neuroimmune interface which then drives an increased perception of pain, what else does it drive?” Apart from just, you know, that increased danger signals that are perceived as pain? 

It might be also be influencing the whole kind of central plasticity associated with pain. It's not just driven by that, you know, neuroimmune interface. But we've got spinal inputs, neural inputs, brain inputs, immune inputs, endocrine, psychological. So we start to see that this chronic pain is not just a peripheral issue, it's not just about dampening down peripheral inflammation or stopping that noxious input from the periphery. 

We've got to look at what are all of these factors that being associated with danger and, I mean, interpreted as danger in signals in our body or in our central nervous system, sorry, and then are interpreted as pain. What else could they be influencing? You know, could they be influencing those co-morbidities, like depression and insomnia and reduced physical activity, etc.

Andrew: Given that many caregivers...and I'm going to blame the allopathic model, particularly the Australian medical model. Where a doctor is, you know, they're on a time treadmill. Basically you've got X amount of time with your GP and there's just no way that a GP can effectively treat holistically, given what you've just mentioned. They're under the rush, the person's in pain, they want to get them out of pain and they need to see the next patient.

Ananda: Yeah. And it's unrealistic to expect them to do that, they just don't have the time...

Andrew: They don't have the resources, yeah.

Ananda: And I don't mean to...I think a lot of primary health care officials don't have the understanding about what all the inputs are, in chronic pain.

Andrew: Right, yes. But given that, what they do then is basically fall into this rabbit hole of "I need to offer some succour to my patient now," and the strongest one, the best one is either going to be a paracetamol, an NSAID, or something stronger i.e. opioids. 

And if somebody's in the chronic pain, you know, they've been in it for a long… they want something now, so there's that likelihood of the opioids being preferred, even though there is a worldwide issue and it's noted in the literature. That doctor right there and then, just wants to help their patient. But because of the time, they can only help them in one way and that's to medicate.

Ananda: Or they go down the rabbit hole of trying to determine what is actually causing the pain. And sometimes, I think, that's just like the hammer that's broken a window, we don't worry about the hammer, we look at the broken window. And so, then they go down the path of imaging, you know, and that in itself is again, a red herring. 

So you know, it's like when the common presentation might be someone goes in with pain and it's like, "Well, we need to find out what's causing this, so we'll do some imaging and then we need to give you some medication, so we'll give you panadol or an NSAID or an opioid." 

And so, two things are happening, we're giving…. chasing the hammer, or the cause, which is often not clear and imaging is not associated with better recovery outcomes. And in fact, in one study, it showed that it's associated with an eight times higher risk of surgery than not imaging. 

And then, of course, they're getting onto that medication cycle.

Andrew: So, okay. That is a rabbit hole, isn't it?

Ananda: It is.

Andrew: We'd always think about imaging giving a clearer picture… gee I’m full of the puns today aren’t I? 

Ananda: Yes! 

Andrew: But not always, it can lead to over-treatment. So I guess the big baddie of this is, mammography. Not to say that this is necessarily to do with pain but it's just this intervention, with an image, might actually lead you to over-treat.

Ananda: Yes. And in this case, it showed that with MRIs of lower back, associated with lower back pain, it did lead to, I think, a higher degree of intervention in terms of surgery. And the thing about surgery is that, you know, there is significant...there's something called failed backs...what is it? Failed back surgery syndrome? 

Andrew: Oooh, yeah!

Ananda: Yeah.So this actually has a syndrome associated with surgery, so you know, that sets off alarm bells. And, you know, sometimes it's unavoidable but I think, in many cases, it's highly avoidable.

Andrew: Not being any sort of an expert on this but, just what I observed off of very few cases and, you know, some afterwards, some outside of nursing, and I just like, certainly the older surgery, I didn't have a great opinion of it. I mean I would admit that there have been vast advances in surgery, particularly in back pain surgery, since then, but I was just, I was not impressed with what I saw.

Ananda: No. And look, I'm not kind of saying one way that, it's all bad or it's all good, but I think we need to very much see that as a last resort.

Andrew: Definitely.

Ananda: That higher level of intervention is the last resort, not the first. Yeah, or not the early intervention.

Andrew: And certainly I think, you know, given that there's the cost of surgery and then the cost of negative outcomes of that, one should always say, as you've explained, that you must really look at it holistically. And if you haven't, you're really doing another band-aid. One, which may cause unpleasant pain further on for the patient.

Ananda: It also reinforces that whole idea, I think, in many cases, that the chronic pain of the back is associated with increasing damage or instability, "Oh, my back is fragile," it just reinforces those danger messages which then, you know, facilitate and amplify pain experiences. 

So if we could, say, early intervention getting with some pain education and increased self-management techniques, self efficacy, just as a starting point. Doing any other intervention, if we could just start with those things, we'd see improvement in outcomes. So then, add all our other holistic care in, and an integrative care, and we're more likely to see better outcomes.

Andrew: So let's look at some of those integrative “cares”. I was really impressed by a trial that was done in cardiac surgery patients. Elective cardiac surgery patients at the Alfred. Indeed, it was run by Endeavour College, or it was run by the Alfred Hospital, but it included practitioners from Endeavour College in Melbourne. And they had incredible savings and benefits to the patients, with pain management. I think they even decreased inotropes after cardiac surgery by a foot massage!

Ananda: Oh, Great.

Andrew: And the reason they had a foot massage was because they didn't want to be touching drains, drips and cracked chests, anywhere that was sensitive. Plus, there was that intimacy issue, but...so they decided on a foot massage, just that. Just that thing of human touch of safety of, you know, you call it a danger signal, first, it's a safety signal. Somebody actually caring for you, lessened their pain. And it was dramatic, 50%, something like that?

Ananda: Yeah, lovely. You know, and if we look at that, as you say, it's a safety signal in this care. But there's also a social and, you know, social connection. Isolation you know, isolation is associated with increased inflammation and pain. So, if you just have social connection and human touch and that sends all those beautiful safety signals then, yeah, I can see why that worked.

Andrew: Ananda, I want to explore in depth with you, what you do, in practice with regards to interventions. And I really think that's going to require a second podcast. Would you mind rejoining us for another podcast on pain management?

Ananda: It would be an absolute pleasure.

Andrew: I would really love to delve really deeply into this because I think it's...I mean it's obviously such an important issue. But you're such an expert who gives a damn, holistically. And I really do, I just so respect you for the way that you work and the way that you care for your patients. And I really thank you for what you've educated me on today, and also opening my eyes up for other ways in which we can help our patients with chronic pain.

Ananda: Thanks, Andrew. I do, I love it, it's a difficult work sometimes.

Andrew: I'll bet.

Ananda: But yeah, you know, but I really like working with people to bring about those holistic changes, you know, using all of those areas that we talked about, social, biomedical and psychological. I really do think that we have to use that in a very, very lived way when we work with our patients. Not just rely on the theory…

Andrew: So every practitioner, if you haven't stubbed your toe yet, go out and whack yourself into a tree. But I just, you've given us such a salient points and I really thank you for what you've shared today. Brilliant work.

Ananda: Thanks, Andrew.

Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook.

Additional Resources

Ananda Mahoney
Australian Pain Society
International Association for the Study of Pain
Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)​
Visual Analogue Scale
Wong Baker: Faces Pain Rating Scale
FLACC Pain Scale
Abbey Pain Scale
Pain Management Network
Brief Pain Inventory
TEDxAdelaide: Lorimer Moseley - Why Things Hurt
Alfred Hospital: Integrative Cardiac Wellness Group
Podcast Part 2: coming soon

Research Explored in this Podcast:

Vos T, Flaxman AD, Naghavi M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012 Dec 15;380(9859):2163-2196

Other Podcasts with Ananda include:


The information provided on FX Medicine is for educational and informational purposes only. The information provided on this site is not, nor is it intended to be, a substitute for professional advice or care. Please seek the advice of a qualified health care professional in the event something you have read here raises questions or concerns regarding your health.


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