Pain And The Survival Brain

By Kieran McNally

Dive into the world of pain with 'Pain and the Survival Brain'-a book that breaks down the latest science on chronic pain in a way that's easy to grasp and even adds a sprinkle of humor to the mix. It goes beyond just the physical side of pain, exploring the mental and social aspects too.

What makes this book stand out is its knack for sim

• Language: English
• Publisher: Kieran McNally
• Release date: Dec 14, 2023
• ISBN: 9781738469512

Book preview

Dedication

I would like to dedicate this book to my parents Anne and Louis. In particular, my mother Anne who always supported and believed in me. My partner Arlene for doing an amazing job of raising our two kids. And finally, our kids Ada and Bobby that mean everything to me, and who I love so much.

I hope this book can inspire them to finding a career in something that they love.

Acknowledgements

W

hen you are self-publishing, you have to learn everything on your own. You will make many mistakes along the way, and when you are trying to source help, finding the right people can be a challenge. When you finally come across people that make your life a lot easier and can provide guidance, it is something that is welcomed. I was lucky enough to find these people.

Firstly, I would like to acknowledge my editors, Hugh Barker and Tom Feltham, for the editorial advice throughout this book. They both helped me develop my vision and enhance this book without taking away my writing style or the personality I tried to give it.

Secondly, I’d like to thank my illustrator, Roderick Brydon, for his contribution to this book. He was able to turn my words into images without any revisions. To work with someone like this is a very satisfying process.

I would also like to thank my beta readers, Aine Moran, Derek Wheatley, and Brian Jewell, for reading my manuscript and providing me with invaluable feedback before publishing.

Last but by no means least, a special mention to Phil Greenfield, who was another beta reader but from an academic perspective. I think Phil was the perfect person to beta read this book for me. Firstly, because he is himself a published author and, secondly, he is very knowledgeable on this subject. I also asked Phil if he would write the foreword, which he did beautifully. This was also greatly appreciated.

For me, writing a book was a huge challenge, but I wouldn’t have done it without the help and guidance of all that are mentioned above. For their help, I will be eternally grateful.

Table of Contents

Dedication

Acknowledgements

Foreword

Introduction

Chapter 1: The Chronic Pain Crisis

Chapter 2: What Is Pain?

Chapter 3: Stress

Chapter 4: Biological

Chapter 5: Psychological

Chapter 6: Social

Chapter 7: Sleep

Chapter 8: Your Pain Map

Chapter 9: Putting It All Together

Chapter 10: Optimise Yourself for Recovery

About the author

Foreword

by Phil Greenfield

The world has changed.

B

ack in the day, if we wanted to source reliable information on a particular subject, we’d consult a parent, or a teacher, or we’d visit the library. Now, in the internet age, we are presented with more information than we might possibly be able to consume in a lifetime, much of it conflicting. In cyberspace, we might regularly explore all sorts of fruitless cul-de-sacs, and find ourselves going down a multitude of energy-sapping rabbit holes in search of what is both useful, and accurate.

Also back in the day, there were pioneers… those who went out on a limb and travelled far in order to explore new territory, and who then went on to produce maps of their discovery. This, so that those of us who did not possess such a call to adventure might more easily navigate that new territory should we ever pass that way in the future.

There’s probably no more difficult terrain to traverse in life than the landscape of pain and suffering. Our popular narratives about the unpleasant sensation that we call ‘pain’, have been rapidly altering over the last decade. What was once viewed as a phenomenon which arose purely from bodily tissue damage is now known to have multiple factors upon which it depends for both its appearance and its persistence. The help offered by clinicians and others, to those who are in pain, has also changed to reflect this development, resulting in a blurring of lines between professions, and the arising of a greater emphasis on ‘coaching’ styles of intervention for pain sufferers.

These two worlds - the old and the new - are colliding right now, and as often happens in these situations, there’s polarisation, as those who are called to help people with pain are falling into two camps - one group doubling down on the old biomechanical, ‘damage’-based model, and the other rejecting everything that has gone before and tossing out the biomechanical baby along with the bathwater.

A truth is that we have come to understand much about the basis for our pain experience from the classical biological sciences, and the newer, more contemporary thinking serves to add an extra and helpful dimension. But to find language to easily describe this synthesis is something that clinicians are finding notoriously difficult, and in that respect may currently result in greater confusion being experienced by those sufferers who are approaching practitioners for help.

In this context, we now need pioneers and map-makers more than we ever did; those who are willing to wade through the swamps and scale the cliff faces of what’s out there on the information superhighway and make some sense of this rapidly unfolding brave new world, for the good of clinicians and sufferers alike.

I believe that in this fine book, Kieran McNally has done exactly this, and produced an impressively committed piece of work. The information presented in ‘Pain And The Survival Brain’ is comprehensive, well organised, well-referenced, and extremely accessible, striking an excellent balance between technical explanation and the world of everyday life. There’s humour and hope aplenty in here, but also appropriately uncompromising guidance for those who wish to take the often arduous journey of attempting to resolve the kind of chronic pain problems suffered by so many modern people.

Also in this book, I get a strong sense of the man behind the words… a practical but compassionate fellow whose mission it has been to both educate and inspire those who show up at his clinic for help, and who is now reaching out into the wider world through his words in this impressive volume.

Pain is complex. Our long-held ideas that pain is a ‘thing’ that can be imaged, measured, and hopefully deleted, have not resulted in the kind of spectacular outcomes that either those working in the field, or the general public, would have hoped for. Those who are now assimilating modern thinking into their practice have realised that to enter into the world of helping those in pain is to appreciate that every little piece of a personal pain puzzle may contribute to the big pain picture, and only by taking a multi-faceted approach will each contribution to that picture be acknowledged, assessed and addressed, and hopefully lead to some degree of resolution for the sufferer.

I am sure that by way of this book, Kieran’s understanding will be appreciated by many as providing a useful contribution to their ability to safely find their feet as they walk across the face of this ever-changing world, and that his style of guidance will empower and build resilience in those who are taking their first tenuous steps on the journey beyond the confines of chronic pain.

Introduction

P

ain and the Survival Brain serves as a comprehensive guide to how I see chronic pain. It’s everything that I currently comprehend about pain: its influences and causes; how we experience it and why it persists; why pain is helpful and why it can become unhelpful.

We are going to cover a vast amount of information in many key areas that could be contributing to your pain, but before we get into any of those areas, I want to spend a bit of time building a foundation so you can learn why we have pain. I will refer back to our evolution and our ancestors quite a lot. I do so because I am trying to demonstrate that much of why we are the way we are is based around survival. How we process information, think, act and behave is based around the brain’s priority of staying alive. I chose to name the book Pain and the Survival Brain for that reason. The brain had to develop into this survival organ because of the hardships we endured and the adversity we overcame to get to where we are today. But life has changed greatly since the time of our ancestors, especially in the last fifty years. This is mainly due to technology and the rapid advancement of our civilisation. But our brains are still in survival mode.

I believe that this book compiles information about pain in a way that isn’t done in any pain book that I am aware of. We will go deeper than the usual surface level information regarding pain, injuries and their causes. All of this will be done in an easy to understand and logical way. For me, it needs to be made simple because it’s for your everyday reader. Too often when it comes to pain and injuries things get confusing, complicated and scary. It’s important to me that you interpret the words I use the way they are intended, as opposed to them getting lost in translation. I am a firm believer that this information is easier to digest and comprehend if it’s done in a conversational way.

I have written the book in a way that will make this journey unique to each pain sufferer who reads it. It doesn’t focus on a specific type of pain or pathology. Usually this is not a good thing because when you try to cater to everybody, it will end up resonating with nobody. But I hope this will be the exception to the rule.

My hope is that what you learn from this book is how personal pain is. That you reach an understanding that pain isn’t a singular entity that needs fixing or turning off. When we experience pain, it’s not the same as anyone else’s, even if the pain experience seems the same.

If you are a chronic pain sufferer then you may be familiar with some of this information. It is my hope that even if you know some of this information there will still be plenty of information that will be new for you, which will give you many areas to explore.

Ultimately, the aim is to provide you with a profound understanding and empower you to navigate your pain journey. There is no one-size-fits-all solution to chronic pain, and my hope is that this book equips you with the tools and knowledge to find your unique path towards relief and recovery.

So, let’s get started.

Chapter 1

The Chronic Pain Crisis

W

hen I say there is a chronic pain crisis, I don’t say this lightly. This is a worldwide crisis with one in five people suffering from persistent pain. That’s 20% of the population that is living with persistent pain every day. Chronic pain has become such a problem that even the World Health Organization (WHO) now considers chronic pain a public health epidemic. You may wonder how it has come to this; given the advances in modern technology, surgical procedures and new pharmacological approaches, it should perhaps be expected that persistent pain would be on the decline. But on the contrary, the amount of people who are suffering every day is increasing all the time. In fact, chronic pain has risen by up to 10% since 2002.¹

This chronic pain crisis not only has devastating consequences on quality of life, mental health, function and activities, but it also costs the American medical industry 100 billion dollars every year for treatment related to pain management. This is more than cancer, diabetes and heart disease treatments combined.²

It affects the workforce, with many millions of hours lost per year. A fifth of patients surveyed with chronic pain reported having lost their job and a third reported a reduction in the hours they worked because of their pain. Furthermore, 71% of people with chronic pain consider themselves disabled.3 Not only that, but as many as 14% of chronic pain sufferers have made suicide attempts,4 and one in five chronic pain sufferers have considered suicide.

Yet despite these harrowing statistics, chronic pain remains somewhat overlooked in mainstream discourse. Its invisible nature sets it apart – unlike a visible broken leg, chronic pain doesn’t present itself on the surface. The lack of visibility fuels stigma, judgment, invalidation, disability, poverty and a compromised quality of life. The chronic pain crisis doesn’t just affect healthcare; it affects the individual, the family, the workforce and the economy. It’s a multifaceted problem that is just getting worse. It truly is a worldwide epidemic and I think it’s time we modified our approach.

Why I have written this book

After helping people with pain for the best part of a decade, and having seen thousands of pain sufferers coming through my clinic, I started to see a pattern. Time after time, patients would come in and tell me similar stories about their pain. The common thread was how uneducated people are on the subject of pain. Many of them didn’t understand why they were in pain, even though they had been suffering for years. They felt confused, hopeless, lost, afraid and anxious. They felt doomed because they felt broken and thought that their body was wearing out on them. It bothered me that this information hadn’t just been constructed in their own head, but it had also been reinforced by other health professionals. To be honest, I wasn’t surprised this was happening. In general, I believe there is a poor understanding of pain.

The main consensus is that it’s only due to tissue health. Many health professionals believe this is the case, and, as such, their approach and advice are in line with this. This was also my thought process, even after college. I began practicing with the belief that I knew it all. I have always been very passionate about my work and always wanted to provide the best treatments for my clients.

Sometimes, clients of mine weren’t getting the results I had been expecting. This frustrated me as I had always followed the protocols that I had learned through my education. But still people were suffering. I needed to know why. I began to research and learn as much as I could about the process of pain. I am a curious, logical person by nature. I don’t just accept information for what it is. I want to know the why behind something that works or doesn’t work. It needs to make sense to me before I accept information as the truth. It wasn’t until I read a book by Professor Lorimer Moseley and Dr David Butler, Explain Pain, that my eyes started to open. I could see that pain was a much more complex and fascinating process. I realised how little I knew and how much I had to learn. Anyone who has read the book will tell you that it’s an easy read, mainly because it’s written for the patient and not the practitioner. So, for the practitioner to be learning from a novice pain book like this, something must have gone wrong. The more I researched pain, the more rabbit holes I went down, which led me to research areas such as psychology, neuroscience, sociology, strength and conditioning, human movement and even some evolutionary biology. Researching these fields gave me new perspectives on how pain and the brain worked. Looking at pain through this new lens answered a lot of unanswered questions for me. It helped me understand why some of my clients in the past hadn’t gotten the results I had been expecting. It helped me understand why treatments hadn’t worked, why my advice wasn’t always appropriate and even how the words I had been using could have been confusing, frightening and ultimately more damaging.

To me, for someone in this industry to be instilling fear and worry, even unintentionally, was neglectful. But it happens every day: from doctors to physios and from chiropractors to sports therapists, and even massage therapists.

It sounds ironic but a study published by the British Medical Journal found that chronic pain was partly iatrogenic. This means that healthcare actually contributes to the development and exacerbation of chronic pain. The scientific study doesn’t suggest that a patient is getting physically harmed in a healthcare provider’s establishment. It’s alluding to the language that is used by healthcare professionals. Patients’ poor understanding of scans. Inaccurate or outdated advice and treatments provided can give the patient a pessimistic outlook on life and recovery. This in turn further disables the pain sufferer, leading them to adopt postures that are rigid and guarded out of fear; this leads to avoidant behaviours, increasing anxiety, depression and withdrawal from things that give meaning in their life. All of this increases their pain and disability.

The first rule in healthcare is first, do no harm. I’m not suggesting that healthcare providers are intentionally causing harm to their patients but if you’re treating someone with pain and you don’t understand pain yourself, then it’s neglectful, regardless if your intentions are good or not. And yes, I would have been part of this unintentional neglect. I would have given out information to people that could be disabling them further; this would have been due to my own poor understanding and education. I recognise this now. This is one reason why I have written this book.

It’s our duty as healthcare providers to stay up to date with the newest information, especially if it’s our niche. People trust us and come to us for advice. Often, they spend their hard-earned cash for this information. It’s our responsibility to provide the most up-to-date and accurate information as possible. We cannot just relay the information that we received in school and universities. Sometimes information taught in curricula can be outdated; even if it is not, science can move very quickly, which is why we need to move with science. We need to stay on top of the new research that is published in the scientific journals and convey this information to our clients in the simplest way possible. There is no excuse not to be up to date nowadays. It’s never been easier to access information. Gone are the days where you needed to go to the local library and check out a book. Today we have an incredible amount of information at our fingertips.

Now don’t get me wrong, I’m not suggesting that I am a guru and I know it all, because I don’t. I still have a lot to learn and I am hungry to keep on learning. But given a deeper understanding of pain, I believe that there will be fewer people who come into my clinic who end up more disabled than they came in.

You may question my choice to use the word disabled. But if you ask people suffering with persistent pain, 71% of them consider themselves to be disabled. Disability in its essence is defined as a physical or mental condition that limits a person’s movements, senses, or activities. This is exactly what chronic pain does. It creates limitations in movement, senses and activities.

Our healthcare system

I believe there is a big problem in how we treat pain in the West. I also don’t believe that our health systems are adequately equipped to address the sheer number of people experiencing persistent pain. Its design seems more tailored to acute problems rather than chronic ones. As many as 40% of individuals dealing with chronic pain feel they do not receive sufficient treatment within primary care settings.5

One main contributing factor to this is how much time is allocated to pain management during training. Interestingly, this varies across regions. In Europe, the median hours dedicated to this topic is around twenty, while in the US, it’s just twelve hours. Shockingly, in Romania, a mere four hours are spent on pain management education. The curricula mainly focus on neuroanatomy, neurophysiology, and pharmacology, often neglecting crucial areas like clinical assessment and non-pharmacological approaches.

Unsurprisingly, newly qualified doctors frequently express a sense of unpreparedness to handle pain management.6 In US medical school, the average hours allocated to pain education was a mere eleven hours whilst the UK was slightly better with an increase to thirteen hours.7

This is in spite of the fact that a third of appointments with general practitioners involve patients suffering from chronic pain, with many having endured this discomfort for more than six months. Reflecting on the numbers, with just eleven to thirteen hours dedicated to pain education training and a notable 20% of the population struggling with chronic pain, logically, the equation doesn’t seem to add up.

My goal

In March 2020, Covid-19 came along; unfortunately, I had to close my business for a number of months due to lockdown, so, rather than getting bogged down in being unemployed I took the opportunity to start writing this book. Little did I know that, almost four years later, I would still be writing it.

This book aims to help you comprehend the multifaceted nature of pain, its various origins, and the factors contributing to its persistence. Many individuals out there, perhaps even you, believe there’s no way to escape this agony. While this may hold true for a fraction of those experiencing pain, I firmly believe that proper education and guidance presents a genuine opportunity for transformative change.

My goal is to try to give you a deeper understanding of pain: what influences it, why you have it and more importantly what I believe is the best way to resolve it. Some of this information may be controversial or may challenge your beliefs. Some of it might be hard for you to understand or digest as it goes against everything you know or have been taught. This is partly because the majority of the industry still hasn’t caught up with the best ways to treat pain.

Conventional treatment is devoted to the symptom, pain, rather than the reason the pain is there in the first place: this often involves medication and/or rest. Although we’re slowly shifting away from the conventional approach to treating pain, it’s still too slow, with the vast majority still using a deeply outdated approach.

It is well established that pain has much more complex causes than tissue damage or tissue health. However, regardless of this knowledge, the diagnosis and treatment of pain is greatly influenced by it. Pain is deeply complex and the longer you have it, the more complex it is.

It’s my hope that I can give you new belief that your pain can be improved. At the very least, I can give you a different understanding which will help you think differently. Perhaps this will even empower you to find the best practitioner for you in your area by being more informed and educated enough to ask better questions. Finding the right healthcare provider is crucial.

For too long, our focus has been on treating the symptom of pain. There actually needs to be a radical shift across the board in the way we view and treat pain. But this can’t happen until there is a radical shift in our level of understanding of what causes pain. It’s time to move away from the conventional approach to treating pain, which we can call the biomedical model.

The conventional approach

A purely biomedical approach is at its best suboptimal

– George Engel

Throughout history there has been an overreliance on the biomedical model. I’ll explain a bit more about the model soon, but it’s essentially assumed that pain is derived from a single cause – i.e. an injury, illness or disease – and removal of this will result in reduction of the symptom. As such, any treatment that is provided is designed to remove or restore the pathology (illness, disease, injury), which will equate to a reduction in the symptom i.e., pain. This is the theory anyway.

For example, if you sprain your ankle and you go to your GP, they will assess you, prescribe something for the pain, refer you for an X-ray to rule out a broken ankle and then refer you for some physiotherapy if necessary. As the ankle heals this is essentially the removal of the pathology, which in turn reduces the pain. This approach has been tried and tested and will work fine for many acute problems. This is why it’s such a popular approach. However, it is also limited. As you will learn throughout this book, it is a simplistic way of viewing or treating pain and doesn’t work with many types of pain, especially pain that has become chronic. So, there are a great deal of patients who will slip through the net.

This conventional approach doesn’t take into consideration the many other aspects that contribute to pain beyond the biomedical model. We will discuss these in due course. You might wonder how healthcare providers differentiate between those with physical injuries and those experiencing pain due to other factors. It demands a deeper comprehension of pain and its origins, improved interviewing skills, and, most importantly, time – a resource often scarce in the healthcare domain.

It is critical that the right questions and language are used from the beginning. I don’t care who you are. Whether you’re a doctor, chiropractor, physiotherapist, the early stages of someone’s pain experiences are the most important ones.

I want to clarify that I’m not criticising doctors or healthcare professionals in any way. Quite the opposite – I hold them in high regard. They operate under overwhelming workloads and limited staffing, tasked with mastering an extensive range of knowledge across various fields and referring patients as needed.

But the biomedical model is solely designed to find the cause of the pain and removal of the pathology. This could for example mean referrals for investigation in orthopaedics, rheumatology or neurology. Each of these will look through their lens to find the source of the problem. However, the source of the pain is not