Dr. Cuccaro weaves his journey throughout his discussion of concepts around modern pain science. He was trained in: anesthesiology at the University of Chicago, pain medicine fellowship at University of Michigan, and as the Associate director of a Navy medicine pain fellowship program.

He was engaged in the group practice model in the military where patients were diagnosed, treated, and followed-up by different doctors. That could be called discordant care, but his colleague’s practices were not hidden from him. Some were conservative, some aggressive, so the actual practice varied greatly. He observed patients with the same pathology and procedure got vastly different results, which he thought it was
due to the military practice model.

Afterward, he became the sole pain specialist, using standard conservative practices in a Corvallis clinic, so could follow all the evidence. He quickly realized his results were as inconsistent as the military model, which was discouraging because he wanted his patients to be back out in the community living life. He began looking with critical eye at interventional pain procedures and found very little evidence to support
them. Treatments for persistent pain had minimal if any evidential support. The procedures didn’t work, which led him to ask himself if he understood the pain problem.

He started looking at the published literature on pain and found vast amounts of good research. Lorimer Moseley of Adelaide Australia became his mentor. There was more to pain than he had been taught in school. Understanding the neuroscience of pain fundamentally changed his practice.

He stopped doing needle interventions, got involved in clinical education and changed his personal relationship with pain. Pain was no longer threatening and his new insight changed how he lived his life. He then discussed four transformative topics:

1. Pain is protection
2. Pain construction and deconstruction
3. Pain and time
4. Pain and power

What is pain? Do we actually understand what it is and is not, and how and why we experience it? He displays a picture of a large nail penetrating a worker’s boot and asks, if the wearer experienced pain? Yes, he was in a lot of pain, but in fact the nail went between his toes, so there was no tissue injury.

A second picture shows a nail through a worker’s thumb, from a video showing the crew joking while they cut the nail and pulled it out. The worker had pain, but not extreme. The current healthcare system can’t explain the different reactions in the two situations, this is not a matter of real pain vs faked pain. All pain is about protection. It’s a complex biological experience associated with each person’s past experiences. Increased threat leads to increased pain.

The common understanding is that pain comes from somewhere, but the two earlier examples demonstrate the failure of that explanation. When there is pain in the foot but no injury, the only explanation that makes sense is that the experience of pain was in the brain itself. He shows a 15 th century medical diagram suggesting that a pain-pus particle from a pain sensor in the foot stimulates the brain. Medical treatments try to block or minimize that ‘flow of pain’, so if that nerve was cut the pain should end, but it does not.

He displays a slide of statistics on treating persistent pain, showing the pain change after surgery, injections, or drugs the pain situation is not better, which is the case anywhere in the world. The correlation between tissue damage and pain experienced is not a cause-and-effect phenomenon. A linear process relationship between injury and pain doesn’t explain all pain.

He then displays a different way to think about pain, the Melzack and Wall neuromatrix theory, that he calls the construction of pain. A pain experience has: multiple inputs, including sensory inputs; long-term memory; and evaluative input.

Thinking about mastering pain is like firefighter thinking for controlling a fire. Three elements are needed for fire: fuel, oxygen and hea; so a fire is controlled by removing or reducing one or more of the elements. Similarly, pain is constructed in a dynamic process from three aspects: sensory, emotional, and cognitive. The sensory input is like fuel; pain meaning from memories is like oxygen; and finally actually paying attention, i.e. current thoughts are like heat.

Sensory inputs are not the same thing as pain. Pain is a constructed process. What else is happening that threaten the person? The Key transformation concepts are: thinking pain doesn’t equal damage; increasing a sense of safety and protection; and alignment with past experiences. Two final concepts are: the three different time perspectives in the brain: past, present, and future; and the sense of whether the person sees protection or threat in the present situation.

(The continuation of Dr. Cucarro’s Key Transformation Concepts is in PSLS 100.)