I heard a great story from a patient of mine last week. It’s great because it involves my absolute favorite celebrity on the planet: Jimmy Fallon. It’s also great because as the patient and I talked pain neuroscience education (PNE), his story wove right into a point I was trying to make with him, and one I think we can all agree on. We had covered the “four pillars” of an effective treatment plan for his chronic pain, including 1) understanding PNE, 2) cardiovascular exercise (appropriately dosed), 3) good sleep, and 4) patient-specific goals. We had delved into the importance of these principles at length, and then moved on to discuss some of the other supplemental treatments that can also be beneficial, such as nutrition, manual therapy, and creativity. As we touched on these things, the subject of humor came up, for which I gave my standard prescription: a daily intake of no fewer than three YouTube videos of Jimmy Fallon (I can post a list of the best ever sketches if anyone is interested!).
As it turns out, my patient actually met Jimmy Fallon about fifteen years ago! According to him, Jimmy was friends with someone he knew, and they ended up at the same cabin or some such thing! Naturally, I was awestruck and excited! I now know someone who knows my guy, Jimmy! I’m only two degrees from Jimmy Fallon! I immediately asked, “Was he nice? Was he funny? What was he like?” My patient, a sixty-five year-old man with forty years of neck pain, was less than amused with my star-struck inquisition. “He was a wise-guy,” he cynically replied. “He (Jimmy) actually said, ‘Someday, I’m going to host the Tonight Show.’”
Quick to defend my Jimmy, I gathered my thoughts and brought the rabbit-trail-conversation back to the task at hand. You see, in our discussion of the pillars, my patient had struggled with the idea of meaningful goals. I had used Adriaan Louw’s gem of a question to probe this patient and find the desires of his heart, something that would motivate him: “If I could flip a switch on the back of your neck right now, and all your pain would go away, what would you do?” He, like so many patients who have lived a life of pain, couldn’t even imagine what that might look like. “I would sleep,” was all he could come up with at the time. “Maybe Jimmy was a wise guy, actually,” I said. “Wise in the sense that he had a dream, set a goal, and went for it. He could see himself hosting the Tonight Show, all those years ago, and now he’s doing it. That brings us back up to these pillars we chatted about. If you struggle to imagine a life with less pain, do you think it is realistic that you could get there? Let’s think about that light switch question again. Is there anything in addition to a good night’s sleep that you would love to do or do again if you had less pain?…” and our conversation continued.
Clearly, what my patient lacked was hope. He simply couldn’t imagine himself with less pain. Multiple diagnostic labels, long-standing pain, numerous failed treatments, and occupational and relational strife are not unique to this gentleman. We know that depression, anxiety, and low mood are associated with chronic pain, and at the root of much of the resigned nature of those we are trying to reach is just that: lost hope.
A recent article by Duggal et al provides an excellent review of the literature on hope and resilience in the context of medical illness, particularly in neurosurgical patients. I highly recommend it, as it’s a quick read with numerous examples highlighting biopsychosocial factors mediating health outcomes. According to the authors, “Hope is an optimistic attitude of mind based on an expectation of positive outcomes. Hope is probably best conceptualized by Snyder as “a positive motivational state that is based on an interactively derived sense of successful (a) agency (goal-directed energy) and (b) pathways (planning to meet goals).”
Looking at Snyder’s description of hope, I’m struck by a couple of things. First, a positive motivational state. Unfortunately, we know that a brain “hijacked by pain” can struggle to produce motivation, with aberrant activity in the limbic system consistently seen in pain neuro-tags on fMRI scans. So, we have a challenge there. Second, that positive motivational state is based on an interactively derived sense of agency and pathways. Interaction in goal setting is so important. We need to interact with compassion, empathy, encouragement, and persistence with our patients to find what makes them tick.
If we don’t take goals seriously, the very best education, exercise plan, sleep hygiene protocol and host of other adjunctive treatments are likely to fall flat. Why on earth would a patient ever stick with the intervention plans we help them establish if they can’t even imagine the possibility of a life with less pain…if they had no hope?
Fortunately, the content of PNE itself brings hope to many of our patients. Finally, someone understands PAIN and can explain it to them in a way that makes sense! Their alarm systems start to calm down just knowing that there is a reasonable explanation for why they still hurt, and they are eager to begin their journey out of the crazy pain cycle they have been stuck in.
But what about those skeptics who don’t even think Jimmy Fallon is funny? One strategy I find helpful is to simply be frank with them. After we have some rapport established and I am confident that they understand many of the key principles of PNE, I will use the research to inspire and to put the ball in their court. Early research (Louw, submitted for publication) suggests the number needed to treat for a successful outcome in PNE is approximately 1:3. I let patients know that the pillars and individualized adjunct therapies really do work, and that for one in three individuals with long-standing pain like them, a year out, they can see a 2-3 point decrease in the 0-10 scale (Mosely, 2002). Another year out, 2 more points. There is no limit to how good they may feel some day. But that is only for the 1 out of 3 patients who takes the info we have gone over and owns it. It takes commitment, consistency, perseverance, and you guessed it… the courage to dare to hope.