Resource Elements

He describes his journey from confusion to clarity about how pain is constructed.

In clinical practice as a Pain Specialist, Dr. Cuccaro was observing dichotomies in patient pain outcomes that didn’t make sense. In frustration, he turned to reading old and new research about pain.

  1. Neurological surgery studies demonstrated there are different types of nerve fibers that send messages to the brain.
  2. Melzack & Casey proposed three determinants of pain in 1968.
  3. In the 1970’s Dr. John Sarno concluded that repressed emotions constrict the back muscles, causing pain.

Dr. Cuccaro got interested in how trauma and emotions affect pain. Like most practitioners, he continued to believe that acute and chronic pain are fundamentally different processes. He devised a model featuring pain, sensation, and experience.

He finally had an “aha” moment when Melzack’s 1999 proposal of the three-part “Neuromatrix Model” of pain came together with the concept of “emergence” he learned about from a podcaster. “Emergence” is the idea that describes how various components come together to construct a process that is unable to be explained when you take away any one of its components.

  1. Pain is an emergent process–it’s impossible to reduce pain—whether acute, chronic, physical, or emotional—from its three components of Sensation, Cognition, and Emotion.
  2. He adapted the Fire Triangle model in order to graphically convey these concepts about pain–how it works, and therefore, how it can be treated.
  3. “Emergence” is a challenging concept, and The Pain Triangle is an effective tool for pain education and treatment. Case examples are provided.

(This is a follow-on presentation from PSLS 1007 where he describes The Pain Triangle and how he uses it in practice.)

REVIEWS

CS

Dr. Cuccaro presents valuable insights, examples, and illustrations of a thinking & research-reading physician’s process of understanding what pain is and isn’t.

Explanation of “emergence” concept and how pain isn’t a cause/effect process related to bodily damage.

The “Pain Triangle” diagram serves as a teaching tool with patients, helping them figure out how to successfully use cognitive, sensory, and/or emotional approaches to deal with pain.

Helpful illustrations and case examples for medical professionals using the “Pain Triangle” and its three aspects when treating painful patients.

JRK

Unique Aspects

  • Pain is an experience constructed by my brain to protect me from a threat it perceives and is not necessarily related to actual tissue damage.
  • He describes the pain experience as an ‘Emergent’ construction process because the process is complex, with no single cause, and not fully understood.
  • He describes the development of his ‘Pain Triangle’ model, as perhaps the best way for me to understand how to change my pain experiences.
  • The key factors of his model are: Sensations, Emotional memories, and my Current Thoughts (Cognition) about the meaning of them as potential threats.

He describes his journey from confusion to clarity about how pain is constructed.

In clinical practice as a Pain Specialist, Dr. Cuccaro was observing dichotomies in patient pain outcomes that didn’t make sense. In frustration, he turned to reading old and new research about pain.

  1. Neurological surgery studies demonstrated there are different types of nerve fibers that send messages to the brain.
  2. Melzack & Casey proposed three determinants of pain in 1968.
  3. In the 1970’s Dr. John Sarno concluded that repressed emotions constrict the back muscles, causing pain.

Dr. Cuccaro got interested in how trauma and emotions affect pain. Like most practitioners, he continued to believe that acute and chronic pain are fundamentally different processes. He devised a model featuring pain, sensation, and experience.

He finally had an “aha” moment when Melzack’s 1999 proposal of the three-part “Neuromatrix Model” of pain came together with the concept of “emergence” he learned about from a podcaster. “Emergence” is the idea that describes how various components come together to construct a process that is unable to be explained when you take away any one of its components.

  1. Pain is an emergent process–it’s impossible to reduce pain—whether acute, chronic, physical, or emotional—from its three components of Sensation, Cognition, and Emotion.
  2. He adapted the Fire Triangle model in order to graphically convey these concepts about pain–how it works, and therefore, how it can be treated.
  3. “Emergence” is a challenging concept, and The Pain Triangle is an effective tool for pain education and treatment. Case examples are provided.

(This is a follow-on presentation from PSLS 1007 where he describes The Pain Triangle and how he uses it in practice.)

Despite all of my training and everything I did in the clinic; my pain patients weren’t consistently improving; I was noticing dichotomies that didn’t make sense; and it felt like I was playing a game of “whack-a-mole.” That humbling experience started me on this transformative journey.

I started reading–including old research–focusing on neurobiology to learn more about pain. There were neurosurgical experiments which taught us about the different fibers sending signals throughout your body up to your brain, and how the brain uses them differently. Melzack and Wall originated the Gate Control Theory of Pain in 1965. In 1968, Melzack & Casey proposed a new model which identified sensory, motivational, and central control determinants of chronic pain. It was easy for me to make sense of their sensory aspect of pain—but I wasn’t well-trained regarding the emotions, depression, and understanding trauma. That led me to the 1970’s work of John Sarno, a physiatrist at Columbia University who published a very popular book called Healing Back Pain. After getting mixed treatment results, Dr. Sarno concluded that long-lasting pain without an identifiable cause is due to repressed emotions constricting the back muscles and causing pain to shoot to the brain.

I was struggling to put what I was learning all together–asking myself questions, trying to take in and make sense of this information. IF acute pain and chronic pain are different, how can we still make sense of chronic pain? IF -as Melzack posited in his 1999 “Neuromatrix Theory”- pain has a sensory-discriminative aspect, affective-motivational aspect, and cognitive-evaluative aspect, how does this make sense for chronic pain?

My very, very first pain model featured pain, sensation, and experience. It was a real struggle to put together what I had learned about how emotions, trauma, and early life experiences impact pain. The model included a microphone, sound mixing board, and a speaker system. It was very sequential, with inputs leading to pain as the output.

Currently people talk about “mind body integration” and how “bio-psycho-social factors” influence pain, but they are still equating pain with sensation, with bodily damage.   Pain is actually a protector. A lot of people, including Lorimer Moseley, identify learned pathways or learned patterns. And how can we explain experiences like Sarno’s patients, who went to a presentation or read a book and their pain went away? Unfortunately, none of these amazing practices consistently make sense and acute pain is generally not included—because it’s nociceptive and seems so easy to understand. Something was missing, so I went back to reading, reading, and reading.

The first fundamental to understanding pain is shifting away from the idea that pain indicates bodily damage. The second fundamental is understanding pain as a constructed process of Melzack’s three critical components coming together all at the same time—not sequentially. I thought I understood it, but my thoughts kept going round and round until I was listening to a business podcast introduced me to a concept called “emergence.” Our brains actually work in an emergent fashion as they deal with complex information in milliseconds in order to create a multi-faceted perception.

The Fire Triangle (commonly used in outdoor and institutional safety training settings) shows us how to put out a fire by taking away its fuel, its oxygen, and/or its heat. An experience of pain requires all three of its elements–sensation (fuel), emotion (oxygen), and cognition (heat), hence “The Pain Triangle.” Extending the analogy to pain means that reducing or removing one or more of the pain components decreases the pain experience.

The Pain Triangle dimensions diagram.

Given that pain is a constructed experience, we have to be thinking in a minimum of three dimensions when working with our patients. Three examples are given: acute pain with obvious tissue damage, acute pain with no obvious tissue damage, and chronic pain. This thinking process is a lot simpler in acute care settings.

This lack of an emergent category of thinking is by far the biggest problem that I think that we have when it comes to pain and pain education. And the Pain Triangle has been the fastest way I’ve found to teach an emergent process. Patients can sense increased control in their lives and their experiences as they understand why and how they feel, and they’re empowered to make changes. And that’s the power of the Pain Triangle.

(This is a follow-on presentation from PSLS 1007 where he describes The Pain Triangle and how he uses it in practice.)

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