FC2O Episode 21 – Dr Nick Penney Show Notes

3:04. Introduction

• Talking the patient better
• 1989 Emigration to New Zealand 
• 1999 A switch to Australia
• EBM Guidelines for management of Acute Low Back Pain

6:20. Psychososcial factors – as things that may prevent patients recovering from low back pain

• Stress
• Distress
• Anxiety
• Depression
• PhD using BPS approach to pain – at University of Queensland (completed in 2009).

8:04. Dr Nick’s Outline of Working with a Persistent Pain Patient

• In the pain medicine world, patients are referred.
• The telling question… “what’s going on?”
• Pain & Depression are two sides of the same coin

11:46. What do Sir William Osler, A.T. Still and Hippocrates have in common?

• Increases breadth

12:55. Hypothetical Persistent Low Back Pain with Depression

• Figure out how much pain is interfering with their life
• Impact on enjoyment, on sleep, on ability to sleep, on emotions, on physical activities…
• How much does it bother you?
• Depression / Anxiety / Diabetes etc are all part of the patient’s life experience

15:30. Neck Pain in Women in the Workplace

• Biggest predictive factor – unsupportive management style at work

16:58. Dr Nick Penney’s 6 A’s Approach:

1. Apprenticeship
2. Application
3. Attention
4. Awareness
5. Acceptance
6. Action

• Apprenticeship – learning about pain education pain as a sign of threat, not damage.
• Learning the ropes
• One of the big factors in inhibiting recovery is fear of pain, movement or re-injury
• Shifting beliefs – a challenge when there are mixed opinions among medical professionals
• Nocebo / nocebic effect
• George Institute, Sydney: recommendation to be very careful who you offer a scan to.
• Scans… NOT so reassuring

21:17. Migrating from Biomechanics to Pain Science

• Boos et al 1995 – 76% of asymptomatic people have disc bulges
• Pain Neuroscience suggests “this is normal – and therefore not a problem”
• Mind viruses & Memes
• Pain catastrophising scale
• Doesn’t respond to simple education and reassurance
• Mindfulness based cognitive therapy
• Mindfulness based stress reduction
• Actual experience as opposed to story (or negative emotion which comes from it)

25:11. Simple take-home mindfulness technique:

• Take a single thought like “My back is damaged”… let it percolate for 10 cycles of breath
• Prefix the thought “My back is damaged” with “I’m having the thought my back is damaged.
• Prefix the thought “I’m having the thought my back is damaged” with “I notice I’m having the thought my back is damaged”.

27:40. CHEK Training: Beliefs

• Getting up from the front row and walking to the back – Diffusion technique
• Identify a painful thought or emotion and sing it to yourself to the tune of “Happy Birthday”

29:55. Application:

• Working within the limits
• The body saying “this is enough”, rather than “this is damaged”

31:27. Attention

• The Salience Network (The pain neuromatrix)
• Is paying attention to the pain helpful?
• Threat to survival can àthe pain being dropped to zero
  • Warfare
  • Sharkbite

36:09. “Pain is designed to grab our attention”

• Facilitating pain pathways…
• Toe tapping
  • Distr-Action Techniques
• Beware of avoidance!
• Acceptance can mean we stop struggling with it, which can then mean it starts to dissipate

40:44. EPOCC Collaboration.

• Acceptance vs clinical improvement
• Living well with pain, versus living well without pain
• Rewiring occurs in both directions
• Socioeconomic disadvantage – pain positively discriminates toward lower socioeconomic advantage.
• Results of Dr Nick Penney’s Integrative Pain Care

47:24. What do you put your success down to?

• Effective Application of the BioPsychoSocial Model
• Engel: getting too caught up in the data
• BPS is intertwined with other clinical tools

 49:57. Socioeconomic Disadvantage

• Trend toward increased pain in lower socioeconomic status
• … Or may just be that chronic pain is under-reported
• Chronic back pain among aboriginal people… saw it as being part of life – accepted the situation… but didn’t have the belief that it would last
• Over medicalising back pain

52:40. Awareness

• UK Mindfulness in Schools Program
• Living in our heads – in our stories…
• Non-judgemental awareness

54:18. Reconciling the clinical with the New Age or the Spiritual

• “Your biography becomes your biology” – Caroline Myss
• Lisa Feldman Barret – How Emotions Are Made – “If we change our experience today, we can change who we are tomorrow”.
• Brain as a predictive organ

56:26. Pain as an emotion

• A sensory and emotional experience
• Emotional experience of pain may be “suffering”… but suffering is optional
• Pain generates emotion, but it’s not a primary emotion 
• Life experience tells us to feel certain things in certain situations
• It takes work, time, patience, persistence to change that
• Avoiding avoidance!

58:47. Acceptance.

• Doesn’t mean being hopeless and helpless
• Accepting current reality
• Open to change
• Working towards acceptance, but have to remember “there’s no negotiation with terrorists”
• Concerns with acceptance: nutrition, lifestyle, sleep, mindset, breathing pattern
• Anxiety leads to breathing pattern disorder, which switches autonomic system sympathetic
• Slow deep breathing in the face of acute pain (in experimental conditions) is more effective than a single dose of morphine
• We have an in-built capacity to deal with pain than we’ve been led to believe

1:02:22

• Mindfulness, sleeping, breathing, moving… are free!
• Resistance from patients?  Happy when they’re healthily sceptical
• Ultimately people have to experience
• Relatively small amount of training can be enough to capture patient’s interest
• Virtual bodies – phantom limb pain and cognitive reorganization
• Guided narrations for daily practice (20 mins / day of focused practice)
• Overtraining? … Striving for change ASAP… focus is key
• Tiger Woods 
• Repetition is the mother of skill, so long as there’s skill in the repetition (P Chek)

1:08:21.  Mindfulness-based Cognitive Therapy

• Derivation of mindfulness based stress reduction (for relapsing depression)
• Nearly 50% of those trained do not relapse – because it’s a life-skill
• Avoiding the cues that make you abuse a substance

1:10:47. Unconscious Cognitive Function – versus Conscious Cognitive Function

• Choosing to pay attention gives glimpse into unconscious / subconscious
• Rummaging through the garbage!
• “Alright XXXX, what are you thinking?” …
• “Is it helpful?” …
• Drop attention to feet for ~30 seconds
• Default Mode Network (the “me” network) goes quiet when we practice formally
• Default Mode Network does not come back online as much as it did before formal practice
• Safety / Security, Sustenance, Sex 

1:16:09. Action – committed action

• Putting what we learned into play
• Values more than Goals (things that bring meaning)
• Sense of purpose 

1:18:22. Dan Siegel

• Ascending Information = Beginner’s Mind
• Integration is more about choosing & observing to understand “what is”
• Stephen Porges’ Neuroception
  • Gut sensation
• The brain is the one organ that can grow itself by thinking about itself.
  • Dawson Church – Mind to Matter… 14 minutes meditation over 8 weeks for demonstrable improvement in sense of wellbeing and happiness and brain growth.
  • Black Cab Drivers in London – doing “the knowledge”
• Plasticity – be careful of what you pay attention to
• If you blindfold someone, within 24 hours the visual cortex begins to become recruited by other parts of the brain.

1:24:45. Where Dr Penney’s work overlaps with Spirituality

• May enhance it, but not at odds with it
• Problems with beliefs as external locus as power
• Pain science was seen for many years through the lens of Christianity
• Meet patients where they are
• Beware of invalidating experience / ostracising people from their tribe
• People seeing pain as a judgement on them

1:30:57. Preventive Work / Prehabilitation

• Modifying beliefs when headed toward an orthopaedic procedure
• Easier to teach these skills BEFORE pain or stress is experienced
• Myriad Study in UK 3500 kids, 11-14year olds.  Funded by Wellcome Foundation… following for 7 years… can this set kids up for different experiences
  • http://myriadproject.org
• Pilot Study: British Journal of Psychiatry
  • Decreased anxiety & stress

1:34:54. To find Nick or learn more about his work, head to www.drnickpenney.com

In March 2020, I’m heading out to Nick’s home-turf – Auckland – to put on a 2-day Seminar to help health & fitness professionals better understand how to facilitate a return to optimal function for people experiencing persistent pain.

I will be showing how Nick’s amazing work can be applied clinically using evolutionary modelling to help prioritise; while expanding on the information presented in the “Ghost in the Machine” papers* I wrote with Paul Chek. If you’re local, I hope our paths will cross there!

To find out more or to book your place, head to this link.

*NOTE: this paper is usually behind a $31.50 pay-wall, but has been made available for free by Elsevier at this moment in time.