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PAIN

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Objectives Understand Pain and Pain behaviors Learn About Danger Sensors Discuss Context of Pain and Neurotags Review Healing processes Review Structures and Systems in the body Understand Altered Nervous System Alarms Learn Management Essentials

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Pain protects us, it alerts us to danger. It makes us move differently, think differently, and behave differently, Which also makes it vital for healing.

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Pain experiences are normal and an excellent, though unpleasant response to what our brain judges to be a threatening situation.

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If problems do exist in our joints, muscles, ligaments, nerves or anywhere else: It wont hurt if our brain doesnt think we are in danger. If problems dont exist in our body tissues, nerves or immune system: It will hurt if our brain thinks we are in danger.

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The amount of pain you experience does not necessarily relate to the amount of tissue damage you have sustained.

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Research has shown that the amount of disc and nerve damage rarely relates to the amount of pain experienced. Many of us have scary sounding disc bulges, even squashed nerves, yet may never have any symptoms Many changes in tissues are just a normal part of being alive and dont have to hurt or stop anyone from leading a functional and active life.

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Amazing Pain Stories Severe injuries and no pain at the time of injury In e mergency rooms all around the world, patients present impaled with various objects, many report little or no pain.

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A World War II veteran had routine chest x-rays done. A bullet had been lodged in his neck for 60 years and he never knew.

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Those who suffer traumatic amputations in wartime and comment that there was no pain, usually report the injury as a bump or a thump.

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Surfers have had their legs bitten off by sharks and have reported feeling nothing more than a bump at the time.

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Phantom limb pain is the experience of pain in a body part that does not exist. Although the leg is missing, the virtual leg and the relationship of the leg to the rest of the body is still represented in the brain. Pain after amputation is usually more severe if there was a pain before amputation. This is a type of pain memory.

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Many and varied cues may relate to the pain experience, but it is the brain which decides whether something hurts or not, 100% of the time, with no exceptions.

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Alarm Signals Various sensors are embedded in the membrane of a neuron. If a sensor is open, ions flow through. Many sensors are designed to open to specific input. M - opens to mechanical forces A - opens to acidic or chemical forces T - opens to temperature

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Sending Messages If enough sensors open, positive ions flow into the neuron and send a danger message to the spinal cord. The message that is sent to your spinal cord and brain only says danger, it does not say pain. The brain and spinal cord have to analyze these messages and create meaningful experiences which may or may not include pain.

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Sensory information is evaluated by the central nervous system. Evaluation of these cues is extremely comprehensive. It involves: Complex Memory Reasoning Emotional Processes Consideration of the potential consequences of a response.

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The emotional and physical components of a pain experience exist in a spectrum. Some pain experiences include a lot of tissue damage, but there will always be an emotional component. In pain experiences such as grief or loss of a loved one there will be high emotional content, but there will be physical issues such as change in muscle tension and cellular healing.

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Neurotag A neurotag is a network of interconnected neurons distributed throughout the brain. When a neurotag is activated it produces an output. The output defines the neurotag.

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A Possible Pain Neurotag 1. Premotor/Motor Cortex organize and prepare movements 2. Cingulate Cortex concentrating, focusing 3. Prefrontal Cortex problem solving, memory 4. Amygdala fear, fear conditioning, addiction 5. Sensory Cortex sensory discrimination 6. Hypothalmus/Thalmus stress responses, autonomic regulation, motivation 7. Cerebellum movement and cognition 8. Hippocampus memory, spatial cognition, fear conditioning 9. Spinal Cord gating from the periphery

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Healing Process No matter what tissues you have injured a similar healing process occurs. Tissues become inflamed immune cells and rebuilding cells converge to the affected area. A scar is formed and tissue is remodeled to make it as good of a match to the original as possible. Most tissues heal in a range from 6 weeks to 3 months.

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Muscles Have many sensors and can easily be a significant part of pain. Can become unhealthy and weak. It is difficult to severely injure a muscle. Have a great blood supply that makes them champion healers. Can have altered muscle activity in part to response to injury and threat. Muscles are windows to the brain, so if your muscles are working differently.. You must ask yourself why.

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Intervertebral Discs The outer layers of intervertebral discs have a nerve supply. An injured disc may not necessarily cause instant pain. Disc Degeneration is normal part of aging, all tissues degenerate. Age changes may be indistinguishable from injury changes. Discs, spinal joints and nerves are not delicate structures.

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Skin and Soft Tissues Damaged skin heals quickly, much faster than ligaments and muscles. Skin has a high density of sensors. Fascia is a tough, strong tissue containing a lot of danger sensors. Fascia is connected throughout the body in sheets. All skin and body parts have a little section devoted to it in the brain.

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Bone and Joints An important factor related to joints and pain seems to be the speed at which joints are damaged. If its slow, the brain probably concludes that there is no real danger. Joints like movement and regular compression, which are essential for their health. Smashed bones can heal, sometimes stronger than before.

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Peripheral Nerves The neurons in a nerve can be a contributor to pain due to the increased number of sensors at a damage site. If a nerve is injured and your brain computes (rightly or wrongly) that more sensitivity is required for your survival, more stress sensors may be made by the DNA. Nerves can be injured by cutting, too much squeezing and pulling, by irritating chemicals, and by sustained reduction in the blood supply.

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Dorsal Root Ganglion-little bulge in the peripheral nerve just where it is about to enter the spinal cord Minibrain-first place that messages coming in from your tissues undergo evaluation. Contains the nucleus where the DNA of neurons resides, manufactures and transmits sensors. Very sensitive and vulnerable to whatever is in your blood. Occasionally can be set-off and keep on firing, but will eventually quiet down of its own accord.

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Backfiring Nerves Neurons can backfire. Especially if they are injured. They release chemicals at the end of the neuron which help damage tissues to heal. Backfiring can cause inflammation in the peripheral tissues, an injured nerve in the back may cause swelling in the foot. If backfiring persists, sustained inflammation may result and worsen the problem.

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Nerve Pain Movement often makes it worse Stress makes it worse Unpredictable Zings Sustained Ignition

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Sympathetic Nervous System A powerful and rapidly responding system that allows you to cope and helps protect you from threat. Releases adrenaline into you body. Designed as an on/off system quickly activated and then returning to normal once the stressful situation has gone. Chronic pain and stress are usually associated with persistently increased levels of adrenaline. Adrenaline doesnt usually cause pain by itself, but with a little help form changes in body parts and heightened alarm system sensitivity, pain can occur.

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Parasympathetic Nervous System Concerned with slowing and conserving energy. Helps with digestion, storing energy, cellular replenishment, and reproduction. More active during rest. Feeling supported and appreciated are likely to shift sympathetically excited people towards the more protective calming parasympathetic state. Meditation and relaxation during the day will help revive the parasympathetic system.

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Endocrine Response Another key player in the stress response. Works with the sympathetic system but its effects may last week or months. Includes the stress control areas of the brain: hypothalamus & pituitary gland, along with the adrenal glands on top of the kidneys. Leads to the production of the key hormone cortisol.

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Cortisol It slows down body processes which are not needed for immediate protection and enhances those which are. Persistent levels of cortisol can create a few problems. Increase cortisol has been linked to slow healing, loss of memory, depression, despair and a decline in physical performance.

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Altered Central Nervous System Alarms We know that pain persists in many cases even though the initial injury has had time to heal. In these situations, the brain concludes that a threat remains and that you need all the protection that you can get. So are you saying that the pain is all in my head? Yes, all pain is produced by the brain, no brain=no pain. This doesnt mean that pain is not real all pain is real.

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Altered Central Nervous System Alarms When impulses keep arriving at the synapse the spinal cord adapts and gets better at sending messages up to the brain. The danger messenger neuron increases its sensitivity to the incoming excitatory chemicals. This means that things that used to hurt, now hurt more and things that didnt hurt before now hurt.

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Altered Central Nervous System Alarms These sensors then change the way they work so that they stay open longer each time they are opened, which lets more charged particles into the danger messenger neuron. The Danger messenger neuron increases its manufacture of sensors for excitatory chemical.

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Altered Central Nervous System Alarms More long term process also happen neurons which dont even carry danger messages sprout in close to the danger messenger neuron so that the chemicals that they release activate that neuron. This means that just touching the skin, or slight temperature change, might cause danger messages to be sent to the brain.

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Altered Central Nervous System Alarms In a way your brain is being tricked. It is operating on faulty information about the condition of your tissues. Instead of nice clear view of the tissues, there is now a magnifier in the dorsal horn of the spinal cord.

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Altered Central Nervous System Alarms For many people in persistent pain, this is a critical issue to understand. In this sensitized state, the brain is being told that there is more danger at the tissues than there actually is. Brain responses such as movements, thoughts, autonomic and endocrine responses are now based on faulty information.

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Altered Central Nervous System Alarms This increased sensitivity should fade once the damaged structures are under control, and or you fully understand what is going on.

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The Brain The same changes which occur in the spinal cord with persistent pain are also known to occur in pain ignition nodes in the brain. Manufacture of more pain sensors Manufacture of more chemicals to activate sensors. This makes it easier to ignite a pain neurotag.

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Smudging Smudging occurs in the cortex. Brain areas normally devoted to different parts or functions, start to overlap. Areas of repeated use get larger. The more chronic pain becomes, the more advanced the changes in the brain become. The good news is smudging is reversible. In the same way that muscles and joints can be made more healthy and robust, so can the arrangements in your brain.

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The Brain is like an Orchestra The orchestra in your brain has been playing the same pain tune (neurotag) over and over again. It can no longer play a repertoire of tunes. The pain tune is not a happy tune. Tours get canceled and the orchestra stays home. The pain starts to dominate every aspect of life: work, friendships, family, hobbies, thoughts, sports, beliefs.

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Thoughts and beliefs are nerve impulses too. Some people with persistent pain need only think of a movement or watch someone else perform a movement for it to produce pain. In some patients just imagining movement can also cause swelling in the painful part.

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Through scientific research, we are now aware of the thought processes which are powerful enough to maintain a pain state. Thought viruses are common in people with persistent pain and that dont understand the physiology of pain.

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Thought Viruses Im in pain so there must be something harmful happening to my body. Im staying home, not going out. Im keeping quiet and out of things. Even their whiz-bang scanning machine cant find it it must be really bad. We can put a man on the moon, why cant someone just fix this pain for me?

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When your tissues have healed and your alarm system and brain has been enhanced to protect you, diagnoses based on tissue processes no longer fit. Often you end up with multiple diagnoses including: fibromyalgia somatoform pain disorder chronic fatigue syndrome myofascial syndrome non-specific back pain psychosomatic pain syndrome

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With the following patterns, it is likely that the pain experiences are more likely in the nervous system and brain in a very real understandable and manageable way. The pain persists past healing times. The pain is spreading. The pain is getting worse. Lots of movements (even small ones) hurt The pain is unpredictable There are other threats in life: previous, current, and anticipated.

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Coping Coping aims to reduce the threat value of the stimulus and the associated emotions and altered biology. Active copers manage pain and many other health issues better than passive copers.

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Active Coping Strategies: Learning about the problem Exploring ways to move Exploring and nudging the edges of pain Staying Positive Making Plans Passive Coping Strategies: Avoiding activity Doing nothing Waiting for something to happen Believing someone else has the answer

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Unhealthy Relationships with Pain Gradual Decline Pattern Stopping an activity when pain starts. Over time the amount of activity at which pain is experienced slowly reduces, eventually leading to disability, disuse and probably depression. Boom-Bust Pattern - Pain comes on but you persevere, tolerate and ignore it, until suddenly your pain is unbearable. This leaves you wiped out for days, maybe even weeks.

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Management Essentials Tool 1: Education and understanding Tool 2: Your hurts wont harm you Tool 3: Pacing and graded exposure Tool 4: Accessing the virtual body

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Education and Understanding People without any training in the health professions or biology can understand the physiology of pain, even though some health professionals think that they cant. Learning about pain physiology reduces the threat value of pain. Reduced threat will reduce the activation of all of our protective systems: sympathetic, endocrine, and motor. This in turn helps to restore normal immune function. Combing pain physiology education with movement approaches will increase physical capacity, reduce pain and improve quality of life.

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Education and Understanding One aim of understanding the physiology of pain is to facilitate what is called deep learning, in which information is retained and understood and applied to problems at hand. Knowledge is a great liberator!

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Your Hurts Wont Harm You Remember that recurrent pains are often protective. Recurrences occur because some cue has activated the virtual representation of an old injury and that hurt does not always equal harm. Practical exercise: When you are just sitting around and you feel some pain. Think about it. Think about what you know about pain. Think about what may have activated the alarm systems. Reflect on what cues may have ignited the pain nodes in your brain. Get to know your pain.

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Pacing and Graded Exposure Movement is essential for the health of all body systems and processes. Motion is lotion 1. Decide what you want to do more of by picking a particular activity. Ex: walking, working, playing with children, driving. Also Consider what you need to do more of. 2. Find your baseline. The amount of activity that you can do and know that your pain wont flare up. 3. Plan your progression. Be gentle on yourself. Plan to progress a little each time.

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Pacing and Graded Exposure 4. Dont flare up, but dont freak out if you do! Because the alarm system is so sensitive it is very difficult to completely avoid flare ups. Remember what you know about pain and dont give up! 5. Its a lifestyle thing. Seek out happy activities they have been shown to have physiological effects on the alarm system and pain ignition nodes. Do fun activities with fun people, or to your favorite music. This pacing and graded exposure process is doing some pretty complex things to your brain, however if you stick with these principles you will gradually return to normal life and overcome your pain.

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Accessing the Virtual Body 1. Imagine movements The virtual body in the brain can be exercised just like the actual body. Imagined movements activate the brain neurotag, but dont move the actual body. Think about the movement you know to be painful, or watch someone perform the movement. Movement neurotags will be activated but the pain neurotag probably wont. Sometimes if your pain is very chronic even imagined movements will be painful. Start with only imagining part of the movement.

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Accessing the Virtual Body 2. Alter gravitational influences- Changing gravitational influences allows you to run brain representations of the movement in similar but slightly different and novel ways: Sitting on the floor with your legs straight out in front of you. Lie on the floor with your legs in the air. Standing bent over at the waist leaning on a table. Perform movements in water

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Accessing the Virtual Body 3. Add varying balance challenges -These inputs will provide some virtual body changes via distraction. Sit on a fitness ball Move your body in different directions while sitting on a fitness ball Move your arms or legs in different directions while sitting on a fitness ball

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Accessing the Virtual Body 4. Vary Visual Inputs Look at your body while you perform a movement Perform a movement in front of a mirror. Performing a movement with your eyes closed is usually a greater challenge for the virtual body. 5. Alter the environment of the activities Perform movements in your home, at the park, in a Tai Chi group, in the pool.

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Accessing the Virtual Body 6. Do the movements in different emotional states. We tend to put off exercises and activity when we are feeling a bit down, but if you perform the exercises in various emotional states, it would give the virtual body a richer context of representations in which to run.

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Accessing the Virtual Body 7. Add Distractions - Distraction is a powerful way to disable the pain neurotag. Distraction removes one of the key ignition nodes, the node that is activated when you concentrate or focus on something. You could use: music, meditation, or visualization. 8. Break down functional movements -When you rise from a chair, try it with one foot forward and then the other, lead with head, try performing at different speeds.

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Accessing the Virtual Body 9. Perform Sliders techniques that encourage total body movement. Allows distraction plus movements which are unlikely to aggravate sensitive neural tissue in your low back. Lie on your back with knees bent and feet on the floor, and flatten your back and at the same time tilting your chin upwards. Sit upright in a chair and sag your back, hold under your thigh and extend your knee while tipping your head back.

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Accessing the Virtual Body 10. Perform movements with neighboring tissues in a friendly state Sitting in a chair, if you bend forward and have your chin tilted forwards it will slacken some of the nerves in the back. Bending forwards when sitting will take some tension from the tissues in your hips and legs.

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Accessing the Virtual Body 11. Playing with your glitches -Glitches are the ways we have all learned to wriggle and adjust when we perform a movement. They are often caused by memories of painful movement. These glitches may be boosters to the pain neurotag. See if you can perform the movement without the glitch. Sometimes moving another part of the body when the glitch occurs can help remove them.

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Accessing the Virtual Body Make the neurotag curious, Make it wonder what is next. You be the master.

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There are many other tools which may help different people at different times. Examples include: Medication, diet,aerobic exercise skilled attention to unhealthy tissues, cognitive and behavioral therapy, relaxation strategies, spiritual enlightenment, and love.

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References Moseley, G.L., Unraveling the barriers to reconceptualization of the problem in chronic pain: the actual and perceived ability of patients and health professionals to understand the neurophysiology. Journal of Pain, 2003. 4:184-189 Bhattacharjee, N. et al, A wooden foreign body in the neck. Bangladesh Medical Research Council Bulletin, 1997. 23:63-65 The Times, 17 Feb 2003, p. 5 London. Beecher, H., Relationship of the significance of the wound to the pain experience. JAMA, 1956. 161:1604-1613 www.sharkattacks.com/newsl.htm. 2003 Jensen, T.S., et al., Immediate and long term phantom limb pain in amputees: incidence, clinical characteristics and relationship to pre-amputation pain. Pain, 1985. 21:267-268 Wall, P.D., Pain, the Science of Suffering. 1999, London: Weidnefield and Nicholson. Lovallo, W.R., Stress and Health. 1997, Thousand Oaks: Sage Publications. Moseley, G.L., Imagined movements cause pain and swelling in a patient with complex regional pain syndrome. Neurology, 2004. 16:44. Price, D.D., Psychological Mechanisms of pain and analgesia. Vol. 15. 2000, Seattle: IASP Press. 223. Morley, S., C. Eccleston, and A. Williams, Systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy and behavior therapy for chronic pain in adults, excluding headache. Pain, 1999. 80:1-13. Moseley, G.L., Unraveling the barriers to reconceptualization of the problem in chronic pain: the actual and perceived ability of patients and health professionals to understand the neurophysiology. Journal of Pain, 2003. 4:184-189 Moseley, G.L., Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. Euro J Pain, 2004. 8:39-45. Moseley, G.L., Physiotherapy is effective for chronic low back pain. A randomized controlled trial. Aus J Physiotherapy, 2002. 48:297-302 Evans, B. and L. Honour, Getting inside knowledge: The application of Entwistles model of surface/deep processing producing open learning materials. Educ Psychol, 1997. 17:127-139.

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