Complex and complicated pain - what's the difference and does it matter? With Todd Hargrove

In this episode with Todd Hargrove we cover the difference between complicated and complex pain. He talks us through how and why these differences matter through using a comparison of how fixing a human being is very different and much more complex to fixing a bike for multiple different reasons. Finally Todd covers what we can do when we encounter these complex and complicated issues with our own patients. 

Want to learn more about chronic and complex pain? Todd recently did an excellent Masterclass with us called “Pain, movement and play: common sense for complex problems” where he goes into further depth on all different types of pain.

👉🏻 You can watch his whole class now with our 7-day free trial: https://physio.network/masterclass-hargrove

Todd Hargrove is a Seattle-based manual and movement therapist, avid athlete, father, and former lawyer. He is a Feldenkrais practitioner, Rolfer, and author. Since 2008, he has written a blog at BetterMovement.org, which focuses on applying a modern understanding of pain science and neuroscience to movement-based therapies. 

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Our host is @James_Armstrong_Physio from Physio Network 

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Transcript

UNKNOWN 0:00

Thank you.

SPEAKER_01 0:05

When you've got a complex pain problem, that means that many, many, many different factors are interacting in dynamic ways to create the pain. Of course, that's more likely to happen with chronic pain. There might be psychological variables, social variables, variables related to the tissues, to nervous system sensitivity, to the immune system, your sleep might matter, all these different kinds of things. So that in that kind of a case, which is something that comes into our office very often, it's going to be very hard for us to identify the one factor that's causing the problem and intervene on that one factor in relative isolation from all the others to fix the problem.

SPEAKER_02 0:47

In this episode with Todd Hargrove we cover the difference between complicated and complex pain. He talks us through how and why these differences matter through using a comparison of how fixing a human being is very different and much more complex to fixing a bike for multiple different reasons. Finally Todd covers what we can do when we encounter these complex and complicated issues with our very own patients. Todd Hargrove is a Seattle-based manual and movement therapist, avid athlete, father and former lawyer and since 2008 he has written a blog at bettermovement.org, which focuses on applying a modern understanding of pain science and neuroscience to movement-based therapies. If you're enjoying the podcast, please leave us a rating or review. It really does help the podcast reach more people around the globe. And if you're interested in pain and movement and complex pain, then Todd has delivered an excellent masterclass with us at the Physio Network called Pain, Movement and Play, Common Sense for Complex Problems, where he goes into a lot more detail in the different types of pain and how you can treat your patients even better. You can watch this whole class now with our seven-day free trial. Just follow the link in the show notes. I'm James Armstrong and this is Physio Explained. So Todd, it is absolutely brilliant to have you on the podcast today. Thank you so much for joining me. Thanks for having me. You've recently done a masterclass on this topic of pain and some of the complexities of pain. So we're going to be diving straight into the podcast today on that topic. And we're going to kickstart it in terms of the nature of complexity within pain, which is something that I think we often think about. Maybe some therapists and I think a lot of us actually maybe are quite fearful of that complexity and the nature of that. Talk to us a little bit about that nature of complexity, Todd.

SPEAKER_01 2:41

Yeah, so a complex system is a system where the whole is made of many, many different parts, and the parts are interacting in a very dynamic way, in a way that would make it hard for someone to carefully measure the position and the activity of all the different variables and to account for all of the different kinds of interactions that are going on and basically predict what's going to happen in the system or or control what's going to happen in the system. So bodies are complex entities, and that very often happens in bodies. It's sometimes the case that when someone has some sort of a problem, you're able to identify exactly where the problem lives, use some sort of assessment to identify the one part of the system that's at fault, and then intervene on that one particular part in a way that fixes the problem. That might happen, let's say you fall down in the soccer field, and then you've got terrific pain, we suspect that the major cause for the problem is probably in a local area. Let's say your knee hurts. You can go in and an expert can do an assessment with an x-ray or an orthopedic test to maybe identify the one particular tissue that's at fault. That's the overwhelming cause of that pain. And then maybe a surgeon can intervene on that one particular part of your body that's at fault and correct it and fix it. That's kind of a reductionist approach to solving a problem. And And it works when you can figure out the one thing that's at fault and intervene on that one thing. But when you've got a complex pain problem, that means that many, many, many different factors are interacting in dynamic ways to create the pain. Of course, that's more likely to happen with chronic pain. There might be psychological variables, social variables, variables related to the tissues, to nervous system sensitivity, to the immune system. Your sleep might matter. All these different kinds of things. So that in that kind of a case, which is something that comes into our office very often, it's going to be very hard for us to identify the one factor that's causing the problem and intervene on that one factor in relative isolation from all the others to fix the problem. Of course, that's what we'd like to do. That's what we've been taught to do. That's what our clients want us to be able to do. So that type of distinction between these problems that can be solved by using a reductionist technique and those that can't, that's kind of the crux of a lot of problems I think that we have as therapists trying to solve problems related to pain. And I suppose that puts us out of our comfort zone as well, as you've

SPEAKER_02 5:21

alluded to already. Yeah.

SPEAKER_01 5:22

It puts us way out of our comfort zone because like when I was trained as a massage therapist, there's a particular type of thing that you want to happen. Someone says, oh, my shoulder hurts and they come up on the stage and then the therapist does some objective tests to try to identify the one thing that hides your mobility or hides this muscle that's tight. And then they intervene on that one variable and then the problem is fixed and that's what we want. The story that comes to mind that kind of illustrates this idea, I was teaching my daughter to ride a bike and her bike was not working. There was a movement problem in the bike. The chain wasn't moving well. There was like a grinding going on. And I go, oh, this is kind of like the problems my clients have. There's a movement problem with this bike. I'll take it to the expert mechanic and get it fixed. Take it into the guy. You say, this is the problem. This doesn't move. He puts it up on a stand. He looks at it for just a minute, moves a few things around. goes, aha, I know where the problem is, takes out some specialized tools, intervenes on that one exact part, fixes it. The bike is completely fixed in like 10 minutes. And I'm like, God, I wish I could do that with my clients. That's the kind of demonstration I would see in the classes that I want to do. But it's not always that way because often the problem doesn't live in one little small area or we don't have the tools to find out where that is. And so we're dealing with a more complex problem. And when you've got a more complex problem, it kind of, I think it should put you more into kind of a common sense problem solving way of thinking than this kind of expertise reductionistic way of thinking. And I first got this idea when I was looking at a paper that's kind of about complexity science, talking about the difference between complicated problems and complex problems. So these are synonyms to most people, but not complexity scientists. These are distinct terms. A complicated problem is one that you can use expertise about a system to solve with a high degree of regularity. So a complicated problem is something like fixing a VCR, or if you're a bike mechanic, fixing a bike, or sending a rocket ship to the moon. These are systems where you can have great knowledge about every different part of the system and how it's interacting with every other different part. If you have the expertise, you can control that system, have great knowledge over that system. To send a rocket ship to the moon, you definitely need to be an expert. And if you are an expert, you can send a rocket ship to the moon. But with complex problems, these are problems where your expertise is not going to matter as much. Something like getting a toddler to behave is a complex problem. You can be a world-class expert in toddler behavior, but you're going to fail all the time in trying to get a toddler to behave. You can be a world-class expert in a complex subject like the economy, but if you ask 10 different economists what's going to happen with the economy and how can we solve it, you can get 10 different answers. That's the kind of situation we often have with chronic back pain. If you have chronic back pain and go to 10 different therapists, you might get 10 different answers in how to go about correcting that problem. So with complex problems, expertise is not It's better than not being an expert at all, but it's not going to help you send a rocket ship to the moon or cure cancer or something like that. And what those experts are actually going to end up doing is using kind of a lot of common sense that most people have. So to control a toddler that's acting up, someone who's a lay person who doesn't even have any expertise or skills could just use their common sense to do pretty well. Might not do as well as the expert, but they might do pretty well because the toddler's kind of a self-organizing system anyway. And it's got its own kind of wisdom and logic. The body is like that as well. That's going to get you most of the way towards dealing with that complex problem. And you can kind of get away from that common sense if you mistake this problem for one that you can solve like an expert fixing a bicycle or fixing a VCR. So you should kind of like be aware of when the pain problem that you have is more complex versus complicated. In other words, it lives in one area and that problem could be fixed.

SPEAKER_00 9:59

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SPEAKER_02 10:27

That's a really interesting definition there, I think, in terms of we're dealing with very complex sort of interactions that we don't truly understand. Therefore, we can't be experts on those interactions. So actually bringing it back to some common sense can really help us. And that moves us lovely or really well onto the kind of why that matters for treating chronic pain with our patients.

SPEAKER_01 10:51

It matters because that means treating chronic pain is very individual. It's unpredictable. You're going to have to engage in trial and error. You're going to have to recognize that every client is very different. You're going to have to explore lots of different facts and variables that might be relevant. Whereas if you thought that there was some magic bullet to cure this and you're going to find it, you're going to be kind of looking for that one solution and maybe ignoring a lot of others that might be relevant. If you talk to the people that really know the most about back pain and they're world-class experts, they'll talk about their trajectory of learning kind of like the more I learned, the more I realized I didn't know because they grow to have greater and greater and greater respect for the complexity of the problem, which makes you humble about the problem. And it makes you realize you're really going to have to work with the person kind of on an individual basis. versus that kind of mindset that you tend to have when you just start to learn a little bit about this stuff. And it's kind of this overconfident mindset, which thinks, yeah, I can fix this problem. I can fix this problem. And you've got the hammer. And so everyone starts to look like a nail. And so that mindset of respecting the complexity of it makes you feel humble. And it puts you in the more of like this common sense mindset where you're going to kind of work through this problem kind of not much different than the way your client might have already started to work through it on their own. If it hurts to do this, don't do this. If it feels good to do this, maybe do more of this. Rest a little bit, but get moving, reduce stress, that type of thing.

SPEAKER_02 12:30

Definitely. And that kind of leads us finally onto this. So some of the things that this therapist can do when we encounter these complex problems, we've already touched on it there. And I really like this almost taking it back to this common sense approach rather than trying to be the expert. And you rightly mentioned there, I think, the Dunning-Kruger effect, as it were, of that short sort of knowledge leading to thinking we've got great expertise and then over time realizing how little we do know. What would your advice be to therapists out there when we're encountering these complex problems?

SPEAKER_01 13:02

Yeah, I think one thing is just kind of being aware of your own discomfort with uncertainty and and the pressure that's on you from yourself and from the client and from everyone else to fix this problem and how that can get you to drive the person in one direction more than explore lots of different directions. So like being uncomfortable with uncertainty, kind of looking on the bright side of complexity is that even though you are less likely to find one magic bullet because so many different things matter for pain, that means it's true that there are many different things that might help. Maybe it doesn't matter at all which one of those you try. Thank you very much. I kind of group exercises into different things. Have we tried an aerobic type of a thing? Have we tried a resistance training type of a thing? Have you tried stress reduction? Have you tried working on your sleep? I like these general categories of different things that tend to work. And I want people to kind of explore those and check them out and see which ones help them. And I'm going to base my decision based on what they like to do, what seemed to work for you in the past. And again, that's a pretty common sense, experimental kind of a process. It also

SPEAKER_02 14:45

allows us to be person-centered and treat the person and not the back pain that they've presented with, but actually treat them as an individual.

SPEAKER_01 14:54

Yeah, very much person-centered. There's a time that you treat the back. If there's a knife in the back, we treat the knife and all that person-centered stuff is maybe not that important. We could get the knife out or if there's a broken bone, we reset the bone. Yes. Those are the complicated problems where we can really be sure that the problem lives in this one specific area and we have this technique. to intervene on that one specific area. But when you're dealing with a problem that has something to do with psychology and immunology and the nervous system, you can't really work at any one small level. You have to work at the big level. The big level is the level of the person. That's why people say person-centered care. Brilliant.

SPEAKER_02 15:33

I think a big takeaway, this differential between the complex and the complicated, that is absolutely brilliant because at times we are dealing with the complicated. but a lot of the time we're going to be dealing with the complex and I should imagine there's a bit of a blur where they go together as well.

SPEAKER_01 15:49

Yeah, sure. There could be a debate about that. Like, I think if Stu McGill had a debate with Lorimer Mosley about the cause of back pain, Stu would say, these are all complicated problems and you're just not finding that little fix in there. And Lorimer would say, no, these are complex. I'm going to work at the level of the person. Stu's going to say, I'm going to find what's going on. That's somewhere in the periphery. There's one little small spot in the periphery and I'm going to find it. So there's a debate there. I think the weight of the evidence is more towards the complex, but I think with all of these problems, sometimes it's a question. Where does this problem live?

SPEAKER_02 16:22

Todd, I think this has been a real eye-opener for me. And I think that it's certainly going on to the masterclass that you've done for us on pain. I think it's going to be something that our listeners are going to find very, very useful and really interesting. So thank you so much for your time today, Todd. We've scratched the surface with this. So a reminder that if you do, listeners, if you want to learn more about this topic of pain and complex and complicated and the differences and how you might be able to use that in your practice, then be sure to check out the masterclass, which we've linked in the show notes below in the meantime Todd thank you so much for your time and I no doubt will have you on the back of the podcast at a time shortly thanks James thank you very much Todd