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This book emanates from one of the author's, Mel Pohl MD who hails from his center in Las Vegas. It perhaps seems not that far from the Sausalito Bay Area medical practice where the likes of Bleecher, Fordyce, Bradley, and others fed into the intellectual property of pain expert Michael Moskowitz who resides there. His MIRROR approach is reviewed partially here. The reasons perhaps might emanate from the fact that Pohl is a doctor and Ketcham is his co-author, a write really.
So what is his approach, if not the more neuropsychological, neuroplastic approach highlighted by Doidge in the recent review above?
Well, the brain is there, in chapter two, which notes that the brain matters indeed. His sixth point in that chapter is of neuroplasticity, but the bottom line is that the brain can adapt to stimulus and thus rewire. The major target, as it should be for a pain specialist, is that the brain shouldn't be subjected to high doses of opioids for a long time, as hyperalgesia from this exogenous source is itself a source of heightened response to pain, and as he notes in the next chapter, emotional drivers are key in the response to pain. After all, as he reminds us, all pain is real, and subjective for the most part, hence the rating scales in chapter one are subjective reporting in content. The content of these two chapters however, and the reliance on case histories, rather than studies, is clear indication that this book is for lay people who are suffering and seek information that is clear and easy to understand, if not rigorous and science based as a textbook might be structured.
Emotions are thus pain magnifiers, and require acknowledgement. Fear, anxiety, anger and resentment are discussed in more detail here. Guilt, grief and helplessness are compounders too, with medication serving the purpose of killing pain in both emotional and pain centers, although he doesn't quite distinguish them from each other, if they are separately served. Thus down the pathway after injury, secondary gains are an issue, including as he lists them, physical, social, emotional, relational, professional, financial and sexual.
In the next chapter he distinguishes dependency from addiction. A topic he defines as 'hot' is that of maintenance medication, namely the long term use of drugs such as methodone, which don't have the short term risky side effects common to the more usual culprits.
He again uses case histories to pepper his words with more graphic annotation. So I thought of my own. A patient injured in an accident at work hurts his knee. He develops what is called a complex regional pain syndrome and is medicated with all kinds of things, including patches. The whole process drives him a bit loopy and he hates the pills, but does overuse over the counter pills to keep going once he dumps the usual culprits commonly used by pain specialists. Certainly he descends into a slump, using alcohol, struggling with the disability process and retraining to a more white collar income. He is ordered to rest more than he should, and does, descending into learned helplessness. In effect he seems to be afraid that if he gets well, his benefits might cease, then what if he gets ill again? Every time he is assessed, the pain rockets, until the interview is over, then it recedes. Strength and conditioning work with him results in better movement and control, but he reports worse pain, and is advised to rest. Okay, what next.
Let's look at another pain. A young girl with a diagnosis of glossopharyngeal neuralgia is finally on morphine patches and the much reviled NSAIDS. She will easily rate her pain at 10 on his scale, unimaginable, unspeakable. He neurologist treats her, not a pain specialist, and after the above, he descends into five days on a cortisone drip, which accomplishes nothing. Challenged, her pain is downrated to about a five, which is very distressing. I note she is easily fatigued, I note she is sensitive to touch (he calls it allodynia and then hyperalgesia) and over-reacts to skin stimulus. So what next? Apparently, it would be surgery. Her doctors are just guessing, the scans are clear.
He very carefully distinguishes between addiction and dependence in such cases. I note the doctors above that called these patients addicts, did not use these helpful distinctions.
And so part two is about overcoming, namely, getting past the traps above. Here is another case. After a posterior-lateral clearance of her ankle, a young woman cannot get off her crutches. It is painful to walk, and she is not clear on what her physical therapist is asking. Eventually he shouts at her and warns her she is close to permanent disability. Returning to the surgeon, he clearly advises it is time for the anticonvulsant, Lyrica, (pregabalin). We consult and she learns how this will threaten her life, namely her ability to work, stay away, drive a car. How she will have to build up the dose, and stay on it. She baulks at that. So we move her to another therapist who explains how she will have to improve her mobility, then her strength, and finally the pain will be the last thing to go. She uses over the counter medication, and dumps her crutches three days later, accepting her leg is stable but painful, and overcoming her fear, living with pain for a while. A few months later she is walking miles at a time on an extended overseas trip. Pain will be the last thing to to. And so, here Pohl refers to such overcoming, exercise, sleep, acupressure, mindfulness, gratitude, acceptance, forgiveness and relatedness, or reconnection.
The basis of this are his twelve items which constitute unhygienic thinking: black and white, sweeping assumptions, negativity, rejecting positivity, mind reading, fortune telling, catastrophizing, minimizing, emotions ruling, should have etc., labelling and self-blame. Reframing these cognitions is part of his approach here, as laid out on page 118, leading to the creation of a thought pattern chart, writing and journaling. He describes a CBT approach briefly, as well as the value of gratitude, ACT, DBT and so on, albeit briefly.
He moves on to movement, a favorite of mine, and explains how it all works and contributes to healing, referring to an 'unmovement' syndrome, acknowledging in the process how excessively pain patients rest, and become poorly conditioned, as in my cases above. Sleep is also acknowledged as a vital pathway back to health, and he lists napping, exercising in the day, scheduling worry time, avoiding stimulants, lightening up on dinner and snacking, balancing fluid intake, practicing mindfulness, avoiding hot baths, keeping cool while sleeping, blocking out noise, investing in linen and pillows, keeping a dump pad next to the bed, darkening the room, use the bed for sleep and sex, keep a schedule. All of these are common sense, but not everyone knows them. I like this guy, he is moving further and further away from the medical approach to pain, and clearly is better aligned with the preceding experts I began with above.
And moving on, we go to the science of nutrition and a detailed discussion of other therapies, borderline medical and non-medical too. Another chapter is devoted to mindfulness, so far mentioned briefly here and there before. He does mention breathing, but neglects heart rate variability, respiratory sinus arrhythmia as an option, which I think is a mistake. He does mention this as an aside in his words of 'calming breath' but could have taken his further, given the tons of value in getting the vagus nerve and autonomic nervous segments in line.
He speaks finally of purpose, the Dan Pink triad runner up. In reality this has a more spiritual connotation for him, and he could have done more here, as relatedness and self-efficacy are huge concepts we do not see much of here in this work. Helpfully he understands the concept of small things amounting to big outcomes, and his four week plan jumpstarting recovery is a great start. He targets back pain, arthritis, breaking these down into diet, movement, sleep, meditation tasks and so on, really useful stuff. The fibromyalgia section is a great addition to things doctors know little about. This is what I gave the young girl with cranial nerve neuralgia. Neuropathy is another target.
A pain reduction diet would be a good addition, and he thought so too, adding it in the next chapter. The guidelines are well accepted, namely limiting low fat and processed foods, pesticide-targeting fruits and vegetables, gluten, toxins, sugar etc. All good information.
His final words, largely positive psychology, and some useful recipes round up the book.
So another medical practitioner has moved away from the 'all I have is a hammer' and so seek out nails, and moved to understand the body and brain boosters that should actually be part of any approach to any condition in medical practice: movement, nutrition, mindset, and recovery. He notes along the way that it is not just pain but dementia for instance that can be offset this way.
There is evidence based practice, and in Pohl's case, practice based evidence, as he draws without reference to his take on the science of a multifaceted, non-silo approach to treating pain.
Highly recommended, for the lay pain sufferer, and also, for any doctor who thinks pain medication is the sum total of ideas in this field. As one of my GPs in my practice mused, why do they keep on shoving the stuff down people's throats, it just doesn't work.
Pohl's approach does, and if we add the work of others such as Moskowitz, bringing Las Vegas and Sausalito together, we can offer more to more sufferers.
© 2016 Roy Sugarman
Roy Sugarman PhD, Director: applied neuroscience, Team EXOS USA