Episode 138 - When Pain Persists: Finding the Victim and the Villain with Dr. Todd Riddle, Part 2

FAKTR PODCAST | EPISODE 138
When Pain Persists: Finding the Victim and the Villain, Part 2

JESSICA RIDDLE
00:00:00 | OPENING

What happens when a patient's pain persists long after the original injury should have healed, or when the intensity of their symptoms seems disproportionate to what we're finding during the examination. As healthcare providers, these can be some of the most challenging patients to treat. But what if the answer isn't necessarily found in the injured tissue itself, but in how the nervous system is processing and responding to the pain?

Welcome to the FAKTR Podcast, where we talk about the stuff they didn't teach you in school, how to grow your practice, refine your clinical skills and get better results for your patients. We're here to help you navigate the real-world challenges of being a healthcare provider, from delivering top-notch patient care to running a business that doesn't run you into the ground. Whether you're fresh out of school or scaling your practice, we're diving into effective cutting-edge treatments to get patients better, faster. We'll also talk about business strategies and tactics to help you work smarter and not harder. And the mindset shifts required to thrive as a top performer in your field. So you can build a career you love without burning out. If you're ready to learn what works and what doesn't from leading experts, industry innovators, and respected clinicians across a wide range of specialties, you're in the right place, my friend. Let's dive in.

Welcome back to the FAKTR Podcast, where we explore the latest evidence, emerging technologies, and clinical strategies to help healthcare providers deliver better outcomes for their patients. I'm Jessica Riddle, your host, and today we're continuing our series with FAKTR's Director of Education, Dr. Todd Riddle, as we take a deeper look at the complex mechanisms that influence the pain experience.

In Part One, Todd challenged us to look beyond the location of symptoms and consider the biological, psychological, and social factors that might be contributing to a patient's pain.

Today, we'll build on that foundation by exploring something called central sensitization and the role of the nervous system in persistent pain. Dr. Riddle will discuss how changes in pain processing can contribute to heightened sensitivity, how fear and other psychological factors can influence the pain experience. And we'll talk about why recognizing these patterns is so important when developing individualized treatment strategies. We'll also explore the importance of patient education, appropriate clinical assessment, and recognizing when a multidisciplinary approach may be necessary to help patients move forward. Because sometimes improving outcomes isn't just about changing what's happening in the tissues. It's about understanding how the entire nervous system is responding. Let's get into it.

DR. TODD RIDDLE

And as that continues, we start to move into central sensitization. By the time we get to this point, when we get to central sensitization, stuff is really starting to go wrong. The nervous system is beginning to do what we call winding up, where it basically becomes a feedback loop. The body starts paying attention to itself more, but it's really focusing more on the pain and creating more pain for that patient. And as we continue more to the right, that starts to change their mind, which starts to create an affective disorder where a patient becomes anxious, they become depressed and this cycle just kind of feeds on itself.

We call this to some extent, maybe a deconditioning cycle because they are expressing fear-avoidance behaviors. So they don't want to move because they're afraid it's going to hurt. And that kind of pushes our problem back down towards the left, where it starts to create more of a mechanical issue and that ramps up the pain. So we start to see more central sensitization, more peripheral sensitization. And that affects the brain even more. So you guys can see how this becomes a significant problem for a patient if we don't get to the bottom of it.

And then finally all the way over to the right, this can become a motor or autonomic problem. And we oftentimes associate a motor or autonomic problem with something like complex regional pain syndrome. So hopefully this graphic here gives you a better idea of exactly the road that we're going to be walking down here with this presentation, taking in the mechanical side of things, that biological side, looking at the nervous system as it starts to transition into processing issues, the brain's own interpretation of the problem, and then basically the body rebelling against itself when we get over to that motor or autonomic.

So this is kind of a breakdown of what we've been talking about, if you had a little difficulty keeping up with me there. So on the inflammatory side, obviously there's too much fluid. This can produce pain. Oftentimes, I have found that most of our inflammatory problems are because we weren't managing load well. You know, I go back to my example I gave earlier about moving a couch. You know, perhaps you were taking that couch down the stairs. The patient was taking the couch down the stairs and it started to slip and got away from them. And they couldn't manage the weight of the couch that far away from their body, and their low back fails. And now we have an inflammatory response.

The ischemic response again, comes from a lack of blood flow and nutrients. And this can also produce pain because now the body is basically sending the brain warning signals that something's wrong. And in this instance, there's too little load. So an example of this would be, again, an acute exacerbation of a chronic ongoing problem, where in some instances that patient just is not getting up and moving around enough. And now we're not getting enough blood flow to certain areas. And perhaps that can be compounded by comorbidities, you know, such as hypertension, or it can be diabetes or other chronic illnesses that can affect blood flow as well.

You can see here, as the time goes on, this can become a problem where central sensitization will describe what we actually have going on, which is the brain becomes overprotective. It starts to misinterpret the level of harm that is actually going on. And the way that I explain this to patients is that they're experiencing pain, sometimes very significant pain, even though there is no actual physical sign of injury. So you take an MRI and there's no disc herniation or there's a very, very minor disc herniation. Or you take an X-ray expecting to see a great deal of arthritis or a great deal of degeneration, and there's just not that much there that would explain their six, seven, or eight out of ten on the pain scale. So in this instance, I will explain to them that their brain is interpreting these bodily signals as harm. So the brain has now gone on high alert but doesn't necessarily know how to come back off of that. And that's where we as clinicians can be very valuable: first, in recognizing that, and second, in giving our patients some education that, hey, you're fine, you're not broken. We just need to change your perception of what's going on with yourself right now.

And again, that affective component: pain is caused by psychological, social, or emotional factors. So now it's become a personal thing to the patient. Consciously, that pain can be driven by the things that we think about. And then unconsciously it could be our feelings and our emotions surrounding our environment, our feelings and emotions about ourselves.

Again, I often tell patients that our brain sometimes lies to us. We all have these instances in our lives where we have negative self-talk. And for those of us that understand that sometimes our brain can be deceitful, we're able to see through that deceit. But for somebody that's, you know, been in the throes of chronic pain for a very long time, they can't see the forest for the trees any longer. They just don't know how to help themselves. And that starts to lead to feelings and emotions of inadequacy. And that, you know, it doesn't even have to be about themselves. It could be how they feel around someone. We all have people in our lives who, when we're around them, they make us feel great or they just make us feel awful. And taking those things into consideration when we're working with someone in pain can be very helpful.

I haven't put it into practice myself, but I've read a lot about people using pain diaries as a way to kind of track when pain comes on. Where were they? What were they doing? Who were they with? What did they just eat? These details can help them connect the dots about why they may be experiencing pain and who or what could be contributing to bringing that on.

And then we have our motor and autonomic. Again, this one's very, very interesting. And this one's a very tough one to deal with. Anybody with complex regional pain syndrome knows this for certain. Basically, the brain, in a roundabout way, has kind of forgotten about the body. Hopefully all of you remember that our brain basically has a body map or a homunculus, if you will. And that homunculus is basically what tracks from a sensory standpoint, what's going on with our body. So proprioception, you know, how the skin feels, where our joints are, and whatnot, but then also how we move.

Professor Paul Hodges out of Australia has done a great deal of work specifically about low back pain and these body maps and specifically how they become what many people have termed now smudged. So if you think about maps, maps have borders, you know, whether it's a country or a city or a state, there are borders. Our sensory maps and our motor maps, within our body map or our brain, the homunculus, they have borders as well. And sometimes those borders, after an injury, they become smudged. So what would have been the border between, let's say, the lips and the hands, now tends to kind of run together and there's going to be a great resource that I'm going to give you in a little while that talks about this smudging.

Many of you have probably seen it in practice and didn't know entirely what's going on, but one of the best examples I can give is phantom limb pain: why someone who no longer has a limb, for various reasons, still experiences pain in a limb that's no longer there. And the best explanation we have at this point is the cortical map. The map associated with that limb has now become smudged into another portion of that map, and now the pain from one area is beginning to overlap into another. It's a very fascinating thought process. And again, I'll give you that resource here in a moment.

So before I go into this any further, I think this is probably a good place to just pause for one or two minutes. I've covered quite a bit of information up to this point. So when we're looking at central sensitization, we're basically starting with the beginning phases of the wind-up that will eventually lead into autonomic responses, where our body is basically on autonomic overload all the time, where we're pumping out corticosteroids, glucocorticoids all the time. And if you recall, that's basically what will wind up our nervous system. So it basically becomes a feedback mechanism where the nervous system begins to wind up and the brain is interpreting something.

So let's use an ankle injury, for instance, as our example here. You get an ankle injury. Maybe you roll your ankle; maybe you break your ankle. And under normal circumstances, our body will deal with that by healing. The nervous system will take into consideration what's going on there. Our brain, if it's working appropriately, will realize that there's an injury there. It will act appropriately. A lot of times what we see with central sensitization is the brain is not interpreting the nociceptive and pressure signals that are coming back out of that ankle, and it continues to send an inflammatory response down to that area. Some of the response is reflexive, but some of it is based upon a top-down approach from the brain.

So what we see here is the brain now sends information back down to the ankle. The ankle responds by ramping up an inflammatory response. The brain starts to see that response and sends more of a response down. So it basically becomes this spiral. And eventually our body has just had enough of this. So this is where we start to see the adrenals begin to kick in, because the body is in a state of fight or flight. It's no longer able to go through a state of ease. It can't rest because the pain has now become so significant. The autonomic response of the heart rate and breathing is elevated because the brain is just not interpreting what's going on. So I hope that's enough of a response there because, again, that's a huge topic. And to be perfectly honest with you, a lot of it's very, very poorly understood. Otherwise we wouldn't have such significant problems with complex regional pain syndrome.

So the resources that I was talking about, several of them I have quoted here along the way. So the mechanisms of pain, that little graphic that I showed you, was an interpretation from a graphic that I saw in a book called A World of Hurt. It is a very technical read. So for those of you that really like to nerd out on the neurology and the psychology of what goes on with our patients, that's a really great book. A World of Hurt by Annie O'Connor. They've done some great work. So that's up there in the Chicagoland area.

Another one that I finished up reading here recently is the Graded Motor Imagery Handbook. Many of you that are in neurology and neuroscience will recognize Lorimer Moseley and David Butler. They are some of the primary contributors to that book. That one was kind of a revolutionary book for me when it came to better understanding the smudging and the body maps and how our patients' brains are really significant drivers of the dysfunction and the pain that they feel. Again, it's another very technical read. I actually had to go back and read it twice because there were some things that I was having a hard time grasping, mostly because it's a very heavy neuro book and I hadn't spent a great deal of time going through much of the neuro components up to that point.

And then finally one there at the end that I'm actually just now starting. This book has been referenced several times in the others. It's called The Sensitive Nervous System. So I've just now gotten into this one. I've heard great things about it, but The Sensitive Nervous System is a great clinician-oriented book that kind of gives you some better explanations about how the nervous system interprets what's going on with our body. And sometimes those poor interpretations can become problematic, so to speak, when we're looking at what's going on with the patient. So some good resources there. I encourage you guys to take a look at those.

JESSICA RIDDLE

One of the most important takeaways from today's episode is that pain isn't always a direct reflection of what's happening in the tissue. As Dr. Riddle explained, the nervous system plays a critical role in how pain is processed and experienced, and when that system becomes increasingly sensitized, patients may experience persistent or heightened pain. That requires us to think beyond the traditional approaches to musculoskeletal assessment and treatment. For clinicians, recognizing these patterns is an important part of developing more effective, individualized care strategies. It's also a reminder that patient education, thoughtful communication, and knowing when to involve other healthcare professionals can be just as important as the interventions we provide.

And that brings us to another fascinating aspect of the pain experience: the influence of our patients' beliefs, expectations, and perceptions. In Part Three, Dr. Riddle will explore the placebo and nocebo effects and how the words we choose, the explanations we provide, and the expectations we create can influence a patient's experience of pain and their recovery. We'll also examine why understanding the psychological influences is an essential part of becoming a more effective clinician.

If you've enjoyed this series so far, be sure to follow the FAKTR Podcast so you don't miss the next installment. And if you know a colleague who works with patients experiencing persistent or complex pain, consider sharing this episode with them. Thanks for listening and we'll see you next time.

IN CLOSING

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