I’m proud to introduce my good friend and lifelong pain geek buddy, Jack Chew to the Know Pain blog. For those of you who haven’t yet listened to Jack’s dulcet tones on his Physio Matters Podcast series, what are you waiting for?
Jack and I are running a 3 day Know Pain course in his home town of Manchester from 25th to 27th October. Here are all the details: http://knowpain.co.uk/course-dates-2/upcoming-course-dates/manchester-26th-28th-july/
Book now as places are limited!
So, it’s time for me to stop rambling and let Mr Chew tell you all about his not so wise wisdom tooth. I wonder what time he wrote this? I’m guessing about 2:30
Jack’s ironic toothache…
These days my professional life involves some rather different opportunities, challenges and responsibilities. I witter through interviews with the experts, clumsily debate with the elite and attempt to philosophise with the oracles, but one thing remains consistent; I am far from ‘wise’. And so I can’t help but smirk through my sore mouth, when I get pain attributed to a ‘wisdom tooth’. My ironic toothache.
A bout of wisdom-tooth-related-pain (WTRP) for me involves a dull ache in my jaw, some local inflammation and a fairly sharp pain whenever anything touches the area. I inevitably bite down on the red and swollen region until I adjust my habits, learn to accommodate it and relatively rest. I could of course compare the aforementioned pattern to ‘flare ups’ of pain, but I’m not one for being obvious, so instead I want to dazzle you with an insight into a radical, innovative and spectacularly effective treatment technique! I would say ‘brace yourselves’ for the big reveal, but Know Pain doesn’t advocate that. It lacks evidence…
How I was exposed to this incredible modality involves another little story. And at this point I shall stop with the sarcastic adjective emboldening to avoid being likened to every generic clinic website in the industry…
Earlier this year I was bravely battling an episode of WTRP and was round at my parent’s house for a Sunday roast, when my slow eating and occasional grimacing (textbook pain behaviour) caught my Dad’s attention. Again, I could easily digress into the relevance of such a stressful context on my pain output, but since my Mum likes to Google me (to check my grammar), I shall say that the company and the food were pretty blameless! My Dad understandably enquired as to why I was making even stranger faces than normal over dinner, and so I explained that a wisdom tooth was breaking through and giving me a bit of grief. At this point, he did what anyone with experiential knowledge of a similar scenario instinctively does; he imparted some advice based on his own encounters with related issues. So to paraphrase my old man with stereotypical northern dialect;
“Eee Jack mi lad. You’ve te keep’t tuth clean or yuv no ope! Gerr elecky tuth-brush an give it a gud scrub ont regular, even if it urts. Worked a treat fo me n I’m bluddy well wise”
Believe it or not, my Dad isn’t medical. But his advice isn’t radically different from some of the tips you will find when searching for suggestions for WTRP relief. Swilling the area with saline or anti-septic mouthwash is commonplace for example, and Senior Chew’s suggestion of ‘keep it clean’ would also help minimise infection risk with a similar mechanism. I took his advice, brushed the area regularly with an electric toothbrush; my pain decreased each time immediately post-brushing and the duration of each episode reduced if I brushed regularly. In short, it was so successful that an earlier and more naïve version of me would have declared that ‘it cured me’.
But instead of simply accepting it’s effectiveness and keeping a toothbrush handy when I have a ‘flare-up’, my burning desire to ask myself an awkward question would not settle. It’s the same awkward question that inspired me to specialise in pain, in sport and in education. The same question that led to the birth of the physio matters podcast and my gobby twitter persona. That question of course is why?
It is outside of the remit of this blog post to delve into every complexity of pain and well outside of my scope of practice to discuss the intricacies of dental practice and peripheral nociception of the mouth, but more feasibly I shall present a few reasons why I think we could learn from my ironic toothache.
An ex-patient of mine is a dentist and a fairly clued up one at that. Since helping him to overcome a neck problem, I have called on his expertise to help a couple of patients with TMJ problems and I have returned the favour helping out with a couple of his complex pain cases. Having this resource at my disposal and being geekily intrigued, I asked him whether tooth cleanliness would have any bearing on my intermittent pain:
“In episodic and self-resolving cases such as yours, especially in the absence of any superficial, deep or systemic infection, the actual cleanliness of the area would have minimal bearing on pain. Acidic substances are known to decrease thresholds and therefore increase chemoreceptive activity in the gums, however for this to play a part in your situation, you would have needed to have been eating or drinking highly acidic products just prior to brushing and brushing with an alkali toothpaste. Instead, as I’m sure you have suspected, the mechanical action of brushing is more relevant. Even when inflamed or injured the mouth is typically more chemically ‘resilient’ for want of a better word, than it is to pressure. I hope that helps your daft question and assists your teaching.” “P.S. I hope the Physio world is embracing you as the genius that you are and setting up direct debits to you in order to fund your innovative projects…” I may have made the last bit up. But the rest was interesting!
Cleaning as a mechanism of effect isn’t important according to my dental consult. So what is it about brushing?
- The act of brushing
How the mechanical act of brushing the area influences my pain is complex in itself. But we I’ll dabble with a few bits:
- Basic pain gate theory can be applied to suggest that competing ascending input will have an inhibitory affect on my pain output.
- The fact that, despite brushing being uncomfortable at the time, the local tissues tolerate it without any detrimental consequences, will reassure the central nervous system and decrease immediate and perceived threat.
- The two above points combine with other factors to allow for diffuse noxious inhibitory control (DNIC) to play its part in my pain relief.
- For these reasons amongst others, I have regular positive experiences from mechanical stimuli. As I am a relatively healthy individual with no existing persistent pain state, long term sleep disturbance or psychological distress; a cascade of events respond to these positive experiences: hormonal changes, altered endocrine system activity, resultant local and global anti-inflammatory and analgesic affects etc.
“Wow! No wonder it works! With such powerful reactions, brushing sore gums will work for everyone… right!?”
Unlikely, which leads to my third and possibly most important point:
- Daddy knows
We have recognised that although his ‘keep it clean’ mechanism is unlikely to play much of a part, the act of brushing will certainly be contributing factor to my relief. So my Dad is onto something! Although it’s not the genius, radical, innovative treatment that I joked about earlier, my Dad’s advice has very much helped his little boy. And this to me is a key variable. The advice came from my Dad. A man who I know, love, trust and admire. A man who has never, and would never, knowingly mislead me or suggest anything detrimental to my health. And so why would his advice not work? In my understanding of the neurobiology of pain, it would take some pretty strong competing input to overwhelm my underlying and engrained faith in my Dad’s advice. And since such strong competing inputs aren’t arriving at my central governor after I brush, my pain relief lasts and the episode of discomfort is shortened.
If you’ve bothered to read this far, I imagine that you’ve been able to draw plenty of comparisons between my story and your patients’, so I won’t patronise you with elaboration of all of them!
The key way in which I hope your clinical practice is influenced by blogs such as this, podcasts such as those produced by my team and courses such as our Know Pain events, is for your clinical reasoning to go beyond what you know and what has worked before. I hope you feel increasingly confident to ask yourself, your colleagues and your mentors WHY?
In clinical practice, work at being as close to the honest, reliable, well meaning and trustworthy character that my Dad was to me. Give the famous ‘non-specific effects’ of our interventions a context in which they can thrive, but then fight the urge to bask in your own self-worth when you get results. What you say, how you say it, how you act and how you’re interpreted matter much more than what you do. This is not a referenced blog, but you don’t have to look far into the fields of sociology, psychology, anthropology and even zoology to see what I mean. There are few better painkillers than adequate reassurance.
But the positives are too obvious…
I hope you can recognise some potentially unhelpful elements of my Dad’s advice. The concept of ‘keeping it clean keeps it from hurting’ seems harmless but if I was less informed in the complexities of pain, worsening symptoms would be immediately attributed to lack of cleanliness. If brushing didn’t work as well as usual, I would assume that the area had become unclean beyond my ability to help myself. I might seek professional help from someone who was a ‘better cleaner’ and, as the cleanliness-pain paradigm might suit their beliefs, I could be medicated or operated on. This escalation of care was provoked by increased pain and a different reaction to normal treatment, yet from what has been covered in this blog, I would suggest that it is more likely that factors such as:
- A poor nights sleep,
- This episode involves increased nociception,
- Some general stress,
- An element of nociception arising from elsewhere in the body,
- Or even a disagreement with someone pivotal in the context of my pain, such as my Dad,
… would be more likely have caused increased pain than any decreased cleanliness! This is my roundabout way of saying that doing something or suggesting something to patients ‘because it works’ just doesn’t cut it anymore. Giving the patient an understanding of why it works, is vital. Maybe not immediately, but we know that what we say has lasting effects on patient journey’s in both positive and negative ways. So tell them the awkward truth that, most of the time, we don’t know the mechanism of effect of our interventions! My patients often ask how certain elements of my treatments work and I find myself admitting that we don’t truly know, before telling them, in more detail, about the mechanisms in which we know they don’t work!
Helping people in pain to make meaningful links to the broad, multi-perceptual nature of pain and sensitivity is invaluable within practice; which is why it is fundamental to the Know Pain learning experiences.
A ridiculously dumbed down example:
– Patient flexes shoulder to 90 and says ‘Ow’…
– I then have a feel of the joint and wiggle it about a bit…
– As I do so, me and the patient chat, I make some bad jokes and make sure he/she is comfortable…
– Patient stands back up and flexes to 140 degrees and says ‘less Ow’…
– Patient: “Brilliant! How does that work then Sir Lord King Master Chew?”…
– Me: “A number of ways really but the key thing is that the technique is pain relieving. It’s clever physiological paracetamol. More importantly, what it doesn’t do, is move your joint back into place. It doesn’t loosen the structures or realign them. In such a short space of time it will have had no affect of your underlying problem, but it tells us about how your symptoms behave. The fact that we have influenced them is a good thing and since it was in a positive way, even better…”
– Patient: “Ok, you’re getting boring. What do I need to do to avoid seeing you ever again?”
Create a context in which your patient can trust you. Be more Dad.
Recognise times where your patients have misconceptions of their problem and your proposed solutions. EVEN IF THEY’RE GETTING BETTER.
Constantly ask WHY.
A few essential thank-yous.
To Mike Stewart, thanks for being a great mentor, friend and inspiration. It’s an honour to write a piece for the Know Pain blog and to contribute to your courses.
To Dr S.L. Jesson, thanks for your help clarifying the dental side of the story and for being available when TMJs and trigeminal nerves give me the headaches to match my patients’!
And finally to my Dad, Tony Chew. I doubt that this will be that last blog in which you get mentioned! You have taught me more about pain than you’ll ever realise… mainly through my far-from-graded exposure to adventure, sport and therefore injury.
And to YOU. Thanks for reading. I can’t believe you’re still here.
If you Chews Health, Know Pain and realise that Physio Matters. You won’t go far wrong.