Thinking Fast and Slow... and Pain Part 3 | Modern Manual Therapy Blog

Thinking Fast and Slow... and Pain Part 3

So far, we’ve learned about Systems 1 and 2 and their respective roles in influencing our decision-making. We’ve also discussed associative coherence, and how the Systems make automatic “decisions” based on a given set of information. Priming is the third concept discussed by Kahneman that may play a central role in pain perception. This area is also one where I think physiotherapists may be able to have an impact. Especially as direct access continues to expand, we will be in a prime (pun intended) position to provide early and appropriate education to our customers much earlier in the health care process, before they fall into the traditional cycle of poor quality information, unnecessary tests, procedures, and prescriptions that is the state of our current medical pain-management system, and one that I believe further primes people for pain.
Priming is built on the idea that previous events, either seen or heard, subconsciously arms or strengthen our subsequent actions and emotions. One example that Kahneman describes is that, say you are given the following letters SO_P. You are more likely to fill in the empty space to make the word SOUP if you have previously just heard the word EAT. However, if you have just heard or seen the word WASH, you are more likely to make the word SOAP.
“Furthermore, the primed ideas have some ability to prime other ideas, although more weakly. Like ripples on a pond, activation spreads through a small part of the vast network of associated ideas.”
In an experiment performed at NYU, researchers found that certain sets of words primed thoughts of old age, even though the word “old” was never mentioned, and in turn, those thoughts primed behaviors, which went unnoticed by the student subjects. The students, aged 18-22, were asked to make four-word sentences from a group of five words. Half the students formed sentences with the following words: Florida, forgetful, bald, gray, and wrinkle. They were then asked to walk down the hall to do another experiment. What the researchers observed was that the young students who formed words implying older age walked more slowly down the hall to the next room!
This is known as the ideomotor effect and it can also work in reverse. A similar study was performed at a German university whereby students were asked to walk around a room at a much slower pace than normal then perform a similar word task as the NYU students. After five minutes, the students were much quicker to identify words related to old age. The results of these two studies demonstrated the phenomenon that when people were “primed” to think of old age, they acted old, and conversely, if they acted old, it would reinforce thoughts of old age.
The ideomotor effect is tragically pervasive among patients in persistent pain. Consider the patient who has just received a diagnosis of “degenerative disc disease.”  How many of you have had patients whose symptoms became more pronounced after receiving this regrettably-named “diagnosis?” The ideomotor effect helps start to make sense why that might be. I also look at “conventional wisdom” in our society’s vernacular as a source of negative priming. “Bending over is bad for your back.” “Lying on your stomach is bad for your back.” “I can’t lift more than 10 pounds.” “I have to be careful with certain things I do to protect my back.” We’ve heard it all before. Unfortunately, we often find ourselves fighting an uphill battle with patients who are coming in already having internalized many of these negative thoughts due to having heard stories from a combination of friends, family, and other healthcare practitioners. While much of this information may be well-intended, we now know what role it can play in driving fear avoidance and pain catastrophizing.  Let’s not be the ones who add to it.
“System 1 provides the impressions that often turn into your beliefs, and is the source of the impulses that often become your choices and your actions. It offers a tacit interpretation of what happens to you and around you, linking the present with the recent past, and with expectations about the near future. It contains the model of the world that instantly evaluates events as normal or surprising. It is the source of your rapid and often precise intuitive judgments. And it does most of this without your conscious awareness of its activities”
As the ideomotor effect illustrates, when people are in pain, they may start “acting” in pain. How often do you ask your patients their pain level? In all honesty, I never ask. I may ask how they are feeling or how their day is going, but I’m trying to help them reconceptualize their thoughts on pain. People in chronic pain are already surrounded by maladaptive attitudes, beliefs, and behaviors that can become trapped in a self-fulfilling prophecy.  In Aches and Pains, Louis Gifford associates pain perception and memory much in the way we normally associate pain with certain movements–“neurons that fire together, wire together.”
“I like to think of any particular ‘memory’ as an individual physical circuit of some kind. When it is active and firing and able to tap into consciousness, it is then ‘given to us’ — ‘it’s recalled’ and we become aware of the ‘fact’ — whatever it may be. This is easily illustrated. Think of your telephone number. Think of your mother’s and father’s first names…Simple cues divert your attention to the question, your brain makes sense of it and then goes and finds the answer. Think of clinical questions like ‘where is your pain right now?’ And, ‘How’s it hurting in your back?’ as triggers to switching on pain circuits and maybe keeping them running! Dwelling on symptoms may not be a good idea when you start thinking about pain from a neurobiological perspective.”
Kahneman highlights the work of Paul Slovic, who did research on the public perception of risk and developed what is referred to as the “affect heuristic.”
People make judgments and decisions by consulting their emotions: Do I like it? Do I hate it? How strongly do I feel about it?…People form opinions and make choices that directly express their feelings and their basic tendency to approach or avoid, often without realizing that they are doing so. The affect heuristic is an instance of substitution, in which the answer to an easy question (How do I feel about it?) serves as answer to a much harder question (What do I think about it?)”
This is yet another example of System 2 being lazy and letting System 1 run the show with its immediate responses.
Can we alter their focus and use the ideomotor effect to our advantage?  I try to highlight any demonstrated subjective or objective improvements regardless how small. I will even  lead or bias a patient towards a certain intervention outcome, despite  the discussions on Twitter that tend to dissuade such behaviors. “I think this technique will really help you.” I think you’ll see a lot of benefit from this exercise.” “Look how much better you’re moving today!”  Let’s put positive thoughts in their heads and see how those translate to their own  perceptions and actions.
“If you can change the way a patient thinks about their problem, you can change the way it’s processed”–Louis Gifford
The words we use and our body language can have a large influence, either positive or negative, on a patients’ physical therapy and recovery experience. Simple little things can often have a big impact, or as Tom Peters refers to them, our “soft skills” These can even consist of small gestures such as a smile and a positive attitude. Don’t get me wrong; even this little, natural human expression can sometimes be difficult to muster in the face of the attitudes and behaviors that often accompany persistent pain. But what we need to remember is, it’s not about us, it’s about them.  And when we have a better understanding of the “why” for some of the presentations that we see, it makes it much easier to look externally, rather than internally, at the situation from the patients’ perspective.
“Talk and discuss, listen and empathize, explain and encourage”–Louis Gifford
With that more complete understanding of the “why” behind chronic pain and central and peripheral sensitization, then our own “why” and “how” for treatment can become more clear. The rationale for our manual therapy techniques or movement/exercise prescription will not only be more valid, but it should also facilitate and be an extension of the pain science education we provide. The patients we are seeing now can be our “early adopters” to help influence a sea change in the way the general public starts to think about pain. It certainly won’t be easy. But nothing worthwhile ever is.
As always, thanks for reading. Comments and discussion welcome.


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