This is Part II in a series about how Hinduism views pain and suffering.

Concepts in Hinduism that relate to pain and suffering:

Suffering, both mental and physical, is thought to be part of the unfolding of karma (karma = the principle that governs the unfolding of events and is based for a person on the integrity with which he has lived previous lives). Suffering is seen as the consequence of past inappropriate action (mental, verbal, or physical) that occurred in either one’s current life or in a past life. It isn’t seen as punishment but as a natural consequence of the moral laws of the universe in response to past negative behavior.

Hindu traditions promote coping with suffering by accepting it as a just consequence and understanding that suffering isn’t random. If a Hindu were to ask, Why me?, or feel her circumstances weren’t fair, a response would be that her current situation is the exactly correct situation for her to be in, given her soul’s previous action. Experiencing current suffering also satisfies the debt incurred for past negative behavior.

Suffering is seen as a part of living until finally reaching moksha (moksha = the complete release from the cycle of rebirths). Until reaching this state, suffering is always present on life’s path. Hindu tradition holds that as we are in human form on earth, we’re bound by the laws of our world and will experience physical pain. Pain is truly felt in our current physical bodies; it isn’t illusory in the sense of not really being felt.

But while the body may be in pain, the Self or soul isn’t affected or harmed. Arjuna, a seeker of wisdom in the Hindu holy book The Bhagavad-Gita, is told:

The self embodied in the body
of every being is indestructible.

and

Weapons do not cut it,
fire does not burn it,
waters do not wet it,
wind does not wither it.

It cannot be cut or burned;
it cannot be wet or withered;
it is enduring, all-pervasive,
fixed, immovable, and timeless.

As the Self isn’t affected, there need be no concern over temporary suffering. Those of us in pain may gain comfort by viewing our pain as only a temporary condition and one that doesn’t affect our inner Selves.

Pain and suffering aren’t seen as solely bad, but as experiences that need to be viewed from multiple perspectives. Hindu traditions hold that all things are manifestations of God/The Ultimate, so nothing is only good or bad; God/The Ultimate encompasses everything. Everything, including pain and suffering, is given by God/The Ultimate. To view suffering as bad is to see only one side of it. Suffering can be positive if it leads to progress on a spiritual path. Some even embrace suffering as a way to progress on his spiritual path, to be tested and learn from a difficult experience.

“Let me not beg for the stilling of my pain but for the heart to conquer it.”  Rabindranath Tagore (1861-1941), Indian Hindu mystic philosopher

How our pain experiences relate to our spirituality/religion is a special interest of mine. Spirituality was an important way of coping for me when I was suffering due to pain, and one of the most important ways I grew as a person because of the difficult time I had. This series looks at Hinduism’s view of pain and suffering.

Hinduism is a religious tradition of Indian origin, and, with 900 million practitioners, is the third largest religious community in the world, after Christianity and Islam. Hindus are located primarily in India, Nepal, and Bali; 2% live outside India, and 1.5 million live in the United States.

Basic Concepts of Hinduism

Several concepts are central to Hinduism:

1. The first is karma, which is the principle that governs the unfolding of events and is based for a person on the integrity with which he has lived previous lives. Karma is not imposed by an outside, punitive force, or God, but is rather an exercise of the moral law in the universe, these laws being inherently within the universe. Karma is encompassed by God/The Ultimate, as is each person’s soul. As both karma and souls are part of God/The Ultimate, karma is not external to the individual, but each is a part of the same greater whole.
2. A related belief is samsara, the process of successive rebirths until one reaches moksha, the complete release from the cycle of rebirths.
3. Hindu traditions promote living with integrity, causing no harm, and progressing further on a spiritual path by living according to dharma, stage-of-life appropriate guidelines or patterns of life, or by one’s sacred duty. A central life’s work is to become detached from overinvolvement in the world that’s apparent to us, which is seen as illusory and temporary, and turn toward God/The Ultimate. Many of these concepts are shared by or are similar to concepts in other eastern religions, for example, Buddhism.

4 different paths to achieve life goals are present:

1. the path of devotion, in which a devotee submits himself or herself to the will of God, and through devotional practices, such as prayer, aims to become one with God and attain spiritual liberation,
2. the path of ethical action, in which an individual chooses to perform work without attachment to its effects; this attitude purifies his or her mind so that he or she can attain a sense of God-vision,”
3. the path of knowledge, in which he or she dedicates himself or herself to acquiring knowledge that reveals the impermanence and ineffectuality of things in the world, and thereby frees the self from the bondage of ignorance, leading to spiritual liberation, and
4. the path of mental concentration, in which he or she practices disciplinary measures that involve physiological and psychological restraints to free the self from all impurities so that the Divine self of the person can then manifest itself, leading to spiritual liberation.

Part 2:  Concepts in Hinduism that relate to pain and suffering

Part 3:  Attachment and detachment to things in this world

Part 4:  When religion becomes a hindrance, rather than a help

Part 5:  Acceptance strategies to cope with pain

Part 6:  Is acceptance a superior coping skill?

Part 7:  What does research teach us about acceptance as a way to cope with pain?

An interesting article in Utne magazine about what mindfulness really is caught my eye. The author, Thubten Chodron, is an American-born Tibetan nun and an abbess at a Buddhist monastic community in Washington state. Chodron highlights that there is a difference between practicing mindfulness and the traditional Buddhist understanding of mindfulness as a component of the path to liberation.

She writes that Buddha described four basic ways we misunderstand our experiences in this world, and that mindfulness is a remedy to our misunderstanding. Here’s what we misunderstand:

1. We think things are permanent.
When things are good, we don’t want anything to change. However, we need to learn that people and things are impermanent. We do this by being open to our own aging, to death, and to losing people and things in our lives. Things com, things go, things change.

2. We look for happiness from things that can’t bring happiness to us.
We need to let go of the hope that happiness is just around the corner. That a new job, better partner, or more financial success will make us happy. Otherwise, we stay in the cycle of striving for things to be different from what they are, and we experience disappointment when what we’re hoping will bring us lasting happiness doesn’t do that. We need to accept things as they are.

3. We fight against nature and how things are.
Chodron gives the example of our own bodies and how we fight to make them different than they are. We want to be thinner, less wrinkly, never go gray. We need to accept our changing selves. With acceptance comes being with how things are, instead of distress over the difference between how we want things to be and how they actually are.

4. We see ourselves as separate from others.
Identifying as an “I” brings emotions such as craving, fear, hostility, anxiety, resentment, arrogance, and laziness, which all bring suffering. We fight to keep what is mine. We’re resentful that others have more – more money, more beauty, more knowledge, etc. We need to let go of evaluating and judging, and just accept things as they are.

Chodron believes that by being more aware of our misunderstandings, we’re better able to let go of our habitual, self-centered ways, and become open to others and working for the benefit of all. We become open to genuine love and compassion.

So how does mindfulness relate to pain?

Simple mindfulness exercises such as a focus on breathing or other relaxation exercises can certainly decrease stress and pain. But how about this deeper sense of mindfulness that Chodron writes about? Naturally most of us have these misunderstandings as they apply to our experience of pain, and we can use mindfulness to help ourselves.

1. We can let go of clinging to our desire for a healthy, un-painful body.

Often with pain comes clinging to the past – what our bodies and our lives used to be like – which can cause sadness and depression. (At the other end, we may over-focus on the future, which can bring anxiety – will I feel better? – and fear that we won’t.) Focusing on the present can lessen this sadness on one end and the fear on the other end.

2. We don’t need to wait until we’re pain-free to live.

Of course we’ll continue to work to make ourselves more comfortable. But we can also focus on living our lives despite pain, and avoid an “I-won’t-be-happy-until-I’m-pain-free” attitude. The goal is to be happy despite pain.

3. We can accept, nurture and care for our bodies, even in pain.

Do you practice loving kindness towards the areas of your body that are in pain? Rather than seeing those parts as the enemy, remember that they’re part of you, but that they’re in trouble and need your care.

4. We can move from an inward focus to opening up to others.

We can keep our lives meaningful despite pain – keep our focus on family and friends, and our life’s work – even if that has to change, or how we do that has to change because of pain. Again, the goal is living fully despite pain.

I do think that this is a process, a journey. Actually a journey for a lifetime.

“Letter to People Without Chronic Pain”

Having chronic pain means many things change, and a lot of them are invisible. Unlike having cancer or being hurt in an accident, most people don’t understand even a little about chronic pain and its effects, and of those who think they know, many are actually misinformed. In the spirit of informing those who wish to understand, these are the things that I’d like you to understand about me before you judge me.

1. Please understand that being sick doesn’t mean I’m not still a human being. I have to spend most of my day in considerable pain and exhaustion, and if you visit, sometimes I probably don’t seem like much fun to be with, but I’m still me – stuck inside this body. I still have work, school, family, and friends, and most of the time, I’d still like to hear you talk about yours too.

2. Please understand the difference between “happy” and “healthy.” When you’ve got the flu, you probably feel miserable with it, but I’ve been sick for years. I can’t be miserable all the time. In fact, I work hard not being miserable. So, if you’re talking to me and I sound happy, it means I’m happy. That’s all. It doesn’t mean that I’m not in a lot of pain, or extremely tired, or that I’m getting better. Please don’t say, “Oh, you’re sounding better!” or “But, you look so healthy!” I’m merely coping. I’m sounding happy and trying to look “normal.” If you want to comment on that, you’re welcome to.

3. Please understand that being able to stand up for ten minutes doesn’t necessarily mean that I can stand up for twenty minutes or an hour. Just because I managed to stand up for thirty minutes yesterday dosen’t mean that I can do the same today. With a lot of diseases, you’re paralysed or can’t move. With this one, it gets more confusing everyday. It can be like a yo-yo. I never know from day to day how I’m going to feel when I wake up. In most cases, I never know from minute to minute. This is one of the hardest and most frustrating components of chronic pain.

4. Please understand that chronic pain is variable. It’s quite possible (for many, it’s common) that one day I’m able to walk to the park and back, while the next day I’ll have trouble getting to the next room. Please don’t attack me when I’m ill by saying “You did it before” or “Oh, I know you can do this!” If you want me to do something, then ask if I can. In a similar vein, I may need to cancel a previous commitment at the last minute. If this happens, please don’t take it personally. If you’re able, please try to always remember how very lucky you are to be physically able to do all of the things that you can do.

5. Please understand that “getting out and doing things” doesn’t necessarily make me feel better, and can often make me seriously worse. You don’t know what I go through or how I suffer in my own private time. Telling me that I need exercise or to do some things to “get my mind off of it” may frustrate me to tears and isn’t correct. If I was capable of doing some things any or all of the time, don’t you think I would? I’m working with my doctor and I’m doing what I’m supposed to do.

6. Another statement that hurts is: “You just need to push yourself more, try harder.” Obviously, chronic pain can deal with the whole body, or be localized to specific areas. Sometimes participating in a single activity for a short or a long period of time can cause more damage and physical pain than you could ever imagine. Not to mention the recovery time, which can be intense. You can’t always read it on my face or in my body language. Also, chronic pain may cause secondary depression (wouldn’t you get depressed and down if you were hurting constantly for months or years?), but it’s not created by depression.

7. Please understand that if I have to sit down/lie down/stay in bed/take pills now, that probably means that I do have to do it right now. It can’t be put off or forgotten just because I’m somewhere, or I’m right in the middle of doing something. Chronic pain doesn’t forgive, nor does it wait for anyone.

8. If you want to suggest a cure to me, please don’t. It’s not because I don’t appreciate the thought, and it’s not because I don’t want to get well. Lord knows that isn’t true. In all likelihood, if you’ve heard of it or tried it, so have I. In some cases, I’ve been made sicker, not better. This can involve side effects or allergic reactions. It also has included failure, which in and of itself can make me feel even lower. If there was something that cured or even helped people with my form of chronic pain, then we’d know about it. There is worldwide networking (both on and off the Internet) between people with chronic pain. If something worked, we would know. It’s definitely not for lack of trying. If, after reading this, you still feel the need to suggest a cure, then so be it. I may take what you said and discuss it with my doctor.

9. If I seem touchy, its probably because I am. It’s not how I try to be. As a matter of fact, I try very hard to be “normal.” I know it’s difficult to understand my situation unless you have been in my shoes. But as much as possible, I’m asking you to try to be understanding in general.

10. In many ways I depend on you – people who aren’t sick. I need you to visit me when I’m too sick to go out. Sometimes I need you to help me with the shopping, cooking or cleaning. I may need you to take me to the doctor or to the store. You’re my link to normalcy of life. You can help me to keep in touch with the parts of my life that I miss and fully intend to undertake again, just as soon as I’m able.

I know that I ask a lot from you, and I thank you for listening. It really does mean a lot.

This is a wonderful letter. I hope you share it with those close to you. In trying to find information about the original author, I learned that Ricky Buchanan is credited with writing the original “Letter” about living with Chronic Fatigue Syndrome. Her original letter has then been modified for other illnesses, often by unknown authors. Ms. Buchanan’s website is www.notdoneliving.net.

Family Issues #7

This is a series of posts about family issues and your pain. You’re invited to copy these posts and discuss them with your loved ones.

How to tell how my loved one with pain is doing:

How is your loved one’s thinking?

• Is she able to stay focused and remember things? Problems with memory and concentration may indicate depressed mood or medication side effects.
• Does she know where she is, and what day it is? If not, this could be “disorientation.” It’s a serious symptom and should be discussed immediately with the patient’s physician.

Sleep?

• Is he sleeping at night, and for the right number of hours? Sleeping too much or too little may indicate depression or anxiety, or medication side effects. Insomnia can also result from being in a lot of pain.

Appetite?

• Has her appetite increased or decreased?
• Has she gained or lost weight?

Significant changes in appetite or weight can be a sign of depression. Weight gain may also result from taking certain medications and/or a reduction in activity.

Mood?

• Does he appear depressed?
• Does he look sad or seem “slowed down”?
• Is he frequently grimacing, crying, groaning, or otherwise indicating extreme distress?
• Does he appear anxious or irritable?

Functioning?

• Has she maintained relationships with family and friends, or has she become withdrawn?
• Has she kept up with those hobbies and activities that are possible, given her physical condition?
• Has she continued to work if physically able?

Is your loved one overusing drugs or alcohol?

• Has he increased his use of tobacco?
• Is he drinking more alcohol?
• Is he overusing prescription drugs?
• Is he using street drugs of any kind, including marijuana, cocaine, or amphetamines (speed)?
• Is he able to communicate, speaking clearly and audibly?
• Does what he says make sense?
• Physical signs can include appearing “out of it” or intoxicated.

Discuss any of your concerns with your loved one’s physician and therapist, so those treating your loved one understand his or her condition more fully.

What questions should family members ask the doctor?

You should go periodically with your family member to the doctor to know:

• what the overall treatment plan is.
• what medications are prescribed, in what dosages, and how often.
• what each medication does, for example, relieves pain, combats depression, helps with sleep, etc.
• what possible medication side effects are, and how you’ll know if your loved one is taking too much or too little medication.
• what the appropriate level of activity is.

Family Issues #6

This is a series of posts about family issues and your pain. You;re invited to copy these posts and discuss them with your loved ones.

What else helps besides medication?

Many other techniques have been found helpful with pain in addition to medication.

• Physical therapy includes exercise and other treatments. Exercises can focus on strengthening, flexibility, and aerobic or cardiovascular functioning, and must be tailored to the individual to be effective. Other treatments include heat and cold applications, Transcutaneous Electrical Nerve Stimulation (TENS), ultrasound, and massage.
• Assistive devices like braces, canes, telephone headsets, and orthotics can help reduce pain. So can making adjustments in seating arrangements at home or work. Adjusting the placement of a computer keyboard, for example, can help reduce repetitive strain injuries.
• Surgery is an option when it can address a specific cause of the pain. For example, some individuals with herniated discs or spinal instability may need spinal fusions (fusing vertebrae together) or discectomies (removal of the disc). Less invasive surgical options are now available to help stabilize the spine without undergoing a formal fusion. In addition to spinal surgery, surgery man be indicated to relieve nerve compression, e.g. in the wrist or elbow.
• Surgery may also be used to implant pain-relieving devices such as dorsal column stimulators or spinal medication pumps. Patients’ and family’s coping strategies are important determinants of successful outcomes in these surgeries, and psychological evaluation is generally important to maximize non-medical coping strategies and chances for the success of the proposed implants.
• Alternative medicine includes a wide variety of approaches including chiropractic care, acupuncture, the use of herbal and other nutritional supplements, traditional techniques including yoga, Tai Chi, and QiGong. These should be seen as working with and not as opposed to medical treatments, and their use should be discussed with the physician. (Many herbs, for example, can interact with medications.)
• Psychological interventions can help individuals better cope with pain and can teach techniques to help reduce pain. Therapy can change negative thinking styles and behaviors. Through mind-body techniques such as hypnosis, meditation, biofeedback, guided imagery, progressive muscle relaxation and breathing techniques, pain can be reduced and/or the patient’s tolerance for pain can increase. Mindfulness meditation and acceptance can be very useful. Additionally, therapy may help the patient identify and stick to an appropriate activity schedule. Therapy can be helpful for any patient with pain, and can be crucial if significant emotional distress, with anxiety and depression, has developed.

Successful coping with pain requires time, patience and persistence. Finding health practiioners that are very familiar working with patients with pain is crucial. And making sure that each person on your family member’s health team is aware of what everyone else is recommending is important, so the whole care plan can be right for your family member.

Family Issues #5

This is a series about family issues and your pain. You’re invited to copy these posts and discuss them with your loved ones.

What Medications are Available for Chronic Pain?

There are numerous medical and other treatments which can help patients with pain live happier and more productive lives. Sometimes complete pain relief can’t be reached, but reducing suffering and increasing a patient’s functioning can almost always be accomplished. As a loved one of a patient with pain, you need to be aware of these to help your loved one get the appropriate treatment. As every patient is different, this information is not meant as medical advice, but to give you a sense of the range of treatments.

1. NSAIDS: For mild to moderate pain and inflammation, a Non-Steroidal Anti-Inflammatory Drug (NSAID) may be recommended. This includes over-the-counter medicines like aspirin, Advil and Motrin (forms of ibuprofen) and prescription drugs like Rufen (ibuprofen), Toradol (ketorolac), Naprosyn (naproxen), and Inderol (indomethacin) as well as many others. Tylenol (acetaminophen) operates on pain like a non-steroidal anti-inflammatory, but does not reduce inflammation.
2. Narcotics: For more severe pain, narcotics (opioids) are often prescribed. These include drugs such as hydrocodone (Vicodin), morphine, hydromorphone (Dilaudid), and oxycodone (as in OxyContin). Narcotics may be short acting (taken every 4-6 hours) or longer acting (12-24 hours). They may be in the form of a patch put on the skin, such as Fentanyl in the Duragesic patch. A non-opiate which works much like narcotics is tramadol (Ultram) which is also available combined with acetaminophen (Ultracet).
3. Antidepressants: Some medications used to treat depression are useful to help with pain, and 2 types of antidepressants are most effective. These are the tricyclic antidepressants, including Elavil (amitriptyline) and Pamelor (nortriptyline); and the dual-action antidepressants, including Effexor (venlaxafine) and Cymbalta (duloxetine). Another class of commonly prescribed antidepressants, the SSRIs (Selective Serotonin Reuptake Inhibitors) are generally less effective in treating pain, but they may work for some people. Examples include Prozac, Zoloft, Paxil, Celexa, and Lexapro. Antidepressants are helpful in treating the depression that patients with pain may develop, but they treat pain even without a patient does not have depression.
4. Anticonvulsants: Medications used to treat seizure disorders may be used in treating pain, especially nerve pain. They include Neurontin (gabapentin), Tegretol (carbamazepine), and Topamax (topirimate).
5. Others: Other drugs used to treat pain include muscle relaxants like Soma (carisoprodol) and Flexeril (cyclobenzaprine). Medication to help improve sleep is often used, as patients with pain often have difficulty sleeping. These include Ambien and Lunesta.

In addition to oral medication, patients may use medicated creams on the skin. Medication can also be delivered by procedural interventions. For example, patients may receive injections, including trigger point injections, or spinal injections such as nerve root blocks and facet blocks. Anesthetic and/or steroidal medication may be used in injections.

We encourage you to talk with the pain management physician to better understand your loved one’s condition and treatment.

Family Issues #4

This is a series of posts about family issues and your pain. You’re invited to copy these posts and discuss them with your loved ones.

People in chronic pain seem most helped when those closest to them express concern for their suffering and offer help that’s genuinely needed, along with encouragement for them to be as active as possible. Don’t overdo sympathy or try to remove all obstacles and challenges from someone in pain. On the other hand, don’t punish the pain sufferer by blame and hostility. If you’re not sure how best to be helpful, you might ask the person in pain what kind of attention (s)he feels is most helpful and respectful.

Tips for Communicating with a Person Suffering from Chronic Pain, (adapted with permission from the work of Mark Grant, Ph.D.)

1. LISTEN. Pay attention not only to what your loved one is saying, but to his nonverbal communication and how he’s saying it. He may be reluctant to talk about how he feels, but give indications in his behavior.
2. DISCUSS. Good listeners are also good in conversation. Repeat and summarize what your loved one is saying. Ask questions. Some people need to be encouraged to talk more about their worries. Others need to be encouraged to focus instead on things other than pain.
3. BE GENUINE. Don’t pretend to be interested in her feelings if you’re not.
4. HAVE COMPASSION. Try to listen with an open heart, even if for a few minutes. It can be very healing and supportive.
5. BELIEVE. Accept that their pain is whatever they say it is. Don’t tell them it can’t be that bad.
6. AVOID HURTFUL COMMENTS. Comments like, “You’ll just have to live with it” or “We’ve tried everything and nothing works” are not helpful. Recognize when you’re frustrated or irritable yourself.
7. SUPPORT THEM WHEN THEY GET DISCOURAGED: Ask questions which help patients get in touch with their strengths, like “What helps you get through this?”
8. USE POSITIVE REINFORCEMENT: When your loved one acts in a positive manner, reinforce this with praise and attention. When they act more negatively or helplessly, don’t pay too much attention. Acknowledge they feel bad and wait for an opportunity to reinforce the positive.
9. BE AWARE OF YOUR NONVERBAL COMMUNICATION. Remember that you can communicate rejection not only through the words you choose, but also by how you say them – your tone of voice and volume, for example. You also communicate by facial expressions, like frowns, sneers, gestures (like putting your hands up to indicate “enough!”), and eye contact (by looking away).

This is an interview with Dr. Lorimer Moseley, an expert on brain retraining treatments for pain. Dr. Moseley got a PhD from the University of Sydney in 2001 and is a leading researcher in brain retraining.

How to Cope with Pain: What is your research practice like? Do you have a clinical practice?

Dr. Lorimer Moseley: At the moment, I guess I have three areas of research. First, research that aims to determine why some people get complex and chronic pain problems and others don’t. We are looking at a variety of factors, including the way the immune system responds to injury and the way the brain responds to injury. The immune stuff we investigate by taking blood and tissue samples from people with pain problems. The brain stuff we assess by brain imaging and different types of laboratory tests.

The second area of research aims to develop and test new treatments for people with chronic and complex pain problems. There are two main areas of interest at the moment – one is motor imagery. We have trials with patients with complex regional pain syndrome, which is a nasty condition some people get, usually after relatively minor injuries. We also have trials of motor imagery with people with phantom limb pain after an amputation or pain in paralysed legs after an injury to the spinal cord.

The third area of research looks at how we as clinicians can present patients with information about their situation that really helps them to understand it and to take their own steps to manage it. Most of this work has focussed on people with chronic pain, but there are clinical trials underway with people with acute pain problems too.

I don’t work clinically here in UK at the moment. I intend to start that up again when I have a couple of big projects under control. I’m enjoying spending time with my family actually, so work is on a bit of a backburner right now!

HTCWP: How did you get interested in Pain Medicine?

Dr. M: This is a good question. Like most people interested in anything, I was on the other side of the fence at one stage – as a young person I hurt myself playing football. I noticed that what the doctors told me and what I read in journals didn’t seem to make sense. So, I read more and more. My general clinical experience also reinforced to me the complexity of the human experience and that pain is a fundamental human experience. Finally, I guess I have for a long time been fascinated in the fact that we are indeed fearfully and wonderfully constructed and that all these things are mediated by biology. I love that.

HTCWP: What pain disorders do you research or treat most often?

Dr. M: Complex regional pain syndrome, phantom limb pain, chronic back pain, chronic neck pain.

HTCWP: Your recent article in Neurology looked at a graded motor imagery treatment – can you tell us about what that is, and how it treats pain?

Dr. M: I don’t really know how motor imagery works. The theory behind it was that some patients seem to get worse when they even think about moving. There are data that support that now I think. Anyway, we thought that motor imagery might be a way of getting under the radar of a really sensitive pain production system. We know the system gets really sensitive and we know from other conditions that if you can get under the radar and then gradually expose the system, then it should respond. So, that was the theory – start really conservative and then slowly increase. It’s possible that it works by refreshing the representation of the affected limb in the brain, but I don’t understand that very well just yet.

HTCWP: A previous study of yours which was published in Pain several years ago showed that doing the same exercises, but in a different order, doesn’t work. How come?

Dr. M: Nice question! I think, though I’m not sure, that the above theory applies to this. I think that the first stage seems important because it might unlock the connection in the brain, a completely unconscious connection, between limb movement and danger. The second stage seems to be important because it reinforces this without moving the sensitive body part. The third stage with the mirrors might use visual information, which says that everything is fine, to continue this.

There is another theory that the process remaps the body part without activating the pain networks. I’m not sure if one theory is better than the other. Perhaps both are wrong. All I think I’m confident about is that if you change the order, it doesn’t work.

HTCWP: How soon will your treatment be routinely available?

Dr. M: I have no idea. It’s not really my treatment – I just put other stuff together. Anyone can do it. There are commercially available software programs for doing the laterality recognition thing – NOI Group has one called “Recognise,” which I think is excellent. There may be others too. So, there’s nothing stopping anyone doing it.

The information that we give to people is well covered in a book called Explain Pain. It’s a great book and is aimed at patients to go through with their clinicians – I reckon that every clinician should have one that they should read, and then let their patients look at.

HTCWP: Any other research about pain treatment that you’re doing?

Dr. M: Yeah, we are doing other stuff. The main thing at the moment is in people with CRPS, and others, who haven’t responded to motor imagery and in people with other conditions who haven’t been told how their biology is making it happen. We are getting encouraging results but it is in the early days.

HTCWP: Who else is doing research in pain treatments that you feel is promising and exciting?

Dr. M: I think the mindfulness stuff that some people are doing is potentially exciting, but I don’t think there is much evidence yet. I think that a group in UCLA did a groovy study that used biofeedback to help people turn off their pain – it was with brain imaging in real time – seemed potentially excellent. Don’t know where that is up to, but it is potentially cool.

HTCWP: What advances in treatment can patients look forward to in the next 3 or so years?  What great things are coming in 5-10 years?

Dr. M: No idea really. I think that the more we learn about consciousness, the more we’ll learn about pain and pain management. However, to comment on where we’ll be in 3, 5, or 10 years requires a crystal ball I don’t have. So, no idea. Sorry.

Thanks to Dr. Moseley for a thoughtful, educational interview. In addition to the vast knowledge that Dr. Moseley has, he also shows the humbleness and ability to say ‘I don’t know’ that great clinicians and researchers share. We’ll look forward to more exciting work from Dr. Moseley and his colleagues.

Family Issues #3

This is a series of posts about family issues and your pain. Pain conditions affect not only you, but also your family, even your friends. You’re invited to copy these posts and discuss them with your loved ones.

How can family members take care of themselves, too? It’s very important to realize that the stress of pain disorders affects not just the patient, but the whole family. That means that family members need to take extra care to look after themselves, too!

As a family member, how can I take good care of myself, too?

Consider these suggestions:

• Maintain a healthy life style. Keep exercising (or start), socialize with family and friends, and eat right.
• Find others to help with the care of your loved one. This may be other family members or friends. This will allow you to take a break at times. (Your loved one may also feel less guilty if the burden doesn’t all fall on you!)
• Don’t personalize your loved one’s behavior. If they’re grouchy or depressed, don’t see it as an attack on you but as a reflection of their pain.
• Avoid being either too babying or too harsh toward your loved one. Remember they’re not doing this on purpose and are suffering just as you are. Gently encourage them to function in spite of the pain and to do as much as possible for themselves.
• Look for support wherever you can find it. If there’s a support group for loved ones of patients with pain, join it (or start one if there isn’t already one). Don’t isolate yourself from friends and family. Participate in your church, synagogue, mosque or other religious or spiritual organization. If prayer or meditation is helpful, plan time to do it.
• Learn as much as you can about your family member’s condition and the available medical and other treatment options, and discuss them with your loved one when he or she is ready to talk.
• Consider talking things over with your own therapist or counselor to help you cope better.