Like many major hospitals, the Royal Free in north west London
has a pain clinic as part of the wide range of services it offers.
Nice to see you. Come and sit down.
We met a couple of weeks ago, didn't we?
Yes. I did get quite a bit of relief, not 100% but I am sleeping at night.
I was up three-quarters of the night, I couldn't sleep.
Because you had this really bad pain down your left leg.
Unbelievable how bad it was.
You can't describe it it was so very bad.
The Gate theory originally was very simplistic
and only referred to one set of circumstances.
But it led doctors, and then more recently, patients
to understand that there isn't a simple wire, so to speak,
running from the damaged fingertip, for example, to the brain
but rather a much more complex processing and gating system.
And we've come to realise that pain transmission
can be blocked or gated in many ways.
For example, by the tricyclics which I mentioned earlier
but also by helping the patient
to change their attitude towards the pain,
maybe to be less fearful of what the pain means,
whether there's damage continuing and so on.
So there are all sorts of ways in which pain can be gated
before the nosusceptive signals get to the brain.
We certainly explain to patients how the understanding of pain
has developed historically,
starting with Descartes in 1764 with a dichotomous understanding of pain.
That it's all in the biology
and a very clinical, linear explanation of pain,
forgetting that people do have minds
and that they do think about their conditions
and that the adaptation of the conditions
will affect them very substantially.
It took many years until 1965 before Melzack and Wall
developed their so-called Gate control theory of pain,
understanding that how a person thinks about their pain,
how they conceptualise their pain, beliefs about their condition
will certainly affect their pain experience.
If you can intervene on that level and teach patients strategies
of how they can shut the gate by changing the way they think about it
for example, not to catastrophise about the pain condition
that they're going to be in a wheelchair in five years' time
and also to provide patients with strategies and tools
of how to deal with their social situation, how to deal with mood,
anxiety, how to deal with occupational stresses
in relation to the pain.
All these things can help them to shut the gate.
The more a patient focuses on their pain experience
and the more they scan their body for any changes in the pain,
the more the entire system, mind and body,
will amplify the pain experience.
I think the Gate theory still holds a lot of value for us,
not only in terms of the way we think
but also in the way that we can explain to our patients
a viable model, if you like.
I think the idea of a model
where you've got, if you like, a way of...
you can send unpleasant information up
but you can also send messages down
which are going to modulate and control that is very appealing.