Context and pain – blue light versus red light
In 2007, Moseley and Arntz showed that a difference in sensory information (red light versus blue light) can give rise to a pain of different perceived intensity and unpleasantness with the same noxious stimulus (1).
The noxious stimulus they chose was a metal rod that had a temperature of -20 degrees celcius (-4 F), which they used in conjunction with showing either a red or a blue light.
The participants were told that probes of different temperature would be placed on their skin, when in fact, the probe was the same temperature all along.
They received information that the blue light meant “cold” and the red light meant “hot”.
In short, when the participants saw the red light, they on average rated their pain higher and more unpleasant than when the blue light was shown, even though the noxious stimulus was the same!
Experience and meaning
It is obvious that our experience is strongly affected by what is happening around us, but there is also another important factor at play: The value, or meaning, we assign to the “stuff around us”, as shown in the paper by Moseley and Arntz previously discussed.
The meaning each of us assigns to a blue or a red light is surely affected by a myriad of factors, such as previous experiences and what one has been told about it.
It is also likely that meaning is changeable, that with new information and new experiences the meaning can change, for better and for worse.
Being a “contextual architect”
Cory Blickenstaff, PT, MS, OCS, came up with the term “contextual architect” to illustrate how, when meeting with a patient, a context emerges, and it would be wise to be thoughtful about our contributions to that context.
Blickenstaff wrote this in a letter to the editor of the Journal of Manual and Manipulative Therapy:
“Relevant to the inter-subjective space in therapy is the idea of soft paternalism that states that we cannot help but influence those with whom we interact. In other words, you can ignore the impact you have on context, but it will not ignore you, nor will it ignore your patient.”
Arguably, we should attempt to co-create a context where the patient feels safe and from where therapy can begin to work on achieving thoughtless, fearless movement (Gifford).
The therapist as a red or a blue light
We have the unique opportunity of being able to inform, guide, and provide patients with new experiences that may help them on the road to less pain and better function.
We can help change how they view their body and what they are capable of.
We can either strive to be a blue light, or we can be a red light.
Potential red lights:
- Showing signs of worry when the patient tells his story
- Using inappropriate language (“that is the worst knee I’ve ever seen!”)
- Providing explanations that instill a sense of fragility in the patient (“upslip” of the SI joint, “locked joints” that need “adjustment”, etc.)
- Prefacing a recommendation with never or always (“you should never bend your back!”, “Always sit straight!”, etc.)
- Framing variation in structure and movement as dysfunctions and not simple variation
Potential blue lights:
- Listening and understanding their story
- Exuding confidence
- Examining the patient thoroughly
- Using the patient history and examination to form a positive narrative with the potential for positive change
- Providing an explanation that the patient understands
- Elucidating the wonderful capabilities of the human body and how we can run marathons, climb mountains, lift enormous weights, and recover from both car-crashes and ankle sprains
Dimming down a red light – the dreaded disc herniation
A disc herniation can be a very painful event, where the patient can have a high level of distress.
“Will I always have this pain?”
“Can I work again?”
“Will it ever heal?”
Many patients seem to think that disc hernations are static events and that they don’t change.
This is a narrative that clearly constricts what expectations the patient has for positive change, and can be a major barrier in getting the patient moving again.
How wonderful is this picture?
This patient did not have surgery. She elected to have physical therapy and an epidural corticosteroid injection instead.
There are 5 months between picture A and picture B, and the patient’s symptoms resolved.
What an amazing thing to show patients, to provide them with hope and reassurance, that things get better, and showing what an amazing capacity the body has to fix itself.
In a study by Ben Darlow et. al from 2013 (3) named “the enduring impact of what clinicians say to people with low back pain, they noted that:
“Although participants searched the Internet and looked to family and friends, health care professionals had the strongest influence upon their attitudes and beliefs.”
“Health care professionals have a considerable and enduring influence upon the attitudes and beliefs of people with low back pain. It is important that this opportunity is used to positively influence attitudes and beliefs.”
Patients trust what we say is accurate, and if we tell them that they should never slump in their chair because it’s bad for your back (it’s not), that joints can go out of place (they normally don’t) or that their muscles can develop “knots”, and so on, I fear that we may be creating “red lights” that could affect the patient’s sense of resilience and strength, possibly creating an iatrogenic problem down the road.
- Moseley GL, Arntz A, The context of a noxious stimulus affects the pain it evokes, Pain (2007), doi:10.1016/j.pain.2007.03.002
- Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S. The enduring impact of what clinicians say to people with low back pain. Ann Fam Med. 2013;11(6):527–534.