How Can Pain be Changed? Brain Based Treatment Ideas

"If we’re in pain, it's changes in our total body that have lead to chronic pain, but it is changeable." - David Butler (2015)

At the end of our last post we talked about how pain treatment is evolving and growing as knowledge of pain increases. We described some neurophysiology concepts in that post, and how they relate to pain. Now let’s go one step deeper and look at an overall approach and some specific treatments that apply these concepts to clinical practice.

The neuromatrix approach described by Moseley (2003) leads to a clinical framework that involves using this knowledge of brain mechanisms to change the experience of pain.  Research into neuroplasticity has opened the door to the idea that our brains can, and do, change throughout our entire lives. The great thing about this is it creates new possibilities in the treatment of pain.

All of these ideas are based on some common themes:

• Many areas of our brain work together as part of the pain response. The network that makes up this response is unique to each individual.
• Pain is an alarm telling us that something is wrong - but the alarm can malfunction. It can respond to the wrong type of information, or require less activation of the network to produce a pain response.“Smaller and seemingly less relevant inputs are sufficient to...produce pain” (Moseley, 2003, p. 4).
• If we can decrease the threat value of the signals our brain receives, or allow more of the network to be activated before the pain response is triggered, we can decrease the pain (Moseley, 2003).

Moseley (2003)  explained three steps to treatment based on these concepts. Today, we’ll examine each step and how a variety of treatment ideas could be incorporated into the process he described.

1. An initial step in treatment involves reducing the threatening input and/or the threat value the brain assigns to these signals. The idea is that if the signals coming from the body are decreased or  interpreted as less of a threat, then the alarm doesn’t need to sound as loud. There are several ways to achieve this. One way is by fixing physical issues in order to reduce the actual input. This can be done through manual therapy, exercises, heat/ice as appropriate, pain medications, etc. Another approach is to reduce the threat value of the inputs. This can be done by things like education about pain, and techniques that calm your nervous system like relaxation, deep breathing, and even laughter yoga.

2. The next step is to figure out how to activate components of the “neuromatrix” without triggering pain. Like we talked about last time, the neuromatrix is a network comprised of different areas and processes within the brain. When enough of the network is activated the pain response is triggered. The goal with this step is to activate some components of this network without activating the pain response.   Some examples of ways to do this include:

• visualization (imagining pain free movement)
• breaking activities down into simple movements
• reducing the physical demand of a task
• changing the way tasks are done
• changing the context surrounding tasks
• changing the language we use to decrease  the  “threat” associated with a particular movement

3. Then, the next step is to gradually increase how much of the neuromatrix is activated, so that more and more of it can be activated without resulting in pain.  The key to achieving this without causing flare ups is to be aware of the threshold (how much of the neuromatrix can be activated without pain), and very gradually increase that threshold. One way to conceptualize this is the idea of  flying under the radar, as described in the graphic below. The idea is to avoid triggering enough of the neuromatrix to cause a flare-up, and gradually push the limits. This will increase how much of the neuromatrix can be activated before a flare up is triggered.

Modern science and knowledge about the brain and nervous system has opened up a variety of treatment options. Treatment can be done in several different ways, depending on the individual’s needs, and the approach can change over time as needed. Note, we have to be careful attributing everything to the brain. The brain clearly plays a huge role in pain, but human beings are vastly complex, and so is pain. In order to understand pain, clinicians need to understand “several domains...neuroscience, immunology, endocrinology, psychology, sociology, and philosophy”. (First-person neuroscience and the understanding of pain. Thacker and Moseley. 2012). We would like to suggest that because so many factors contribute to pain, there is hope that all of these factors can be used to change pain.  Even though we don’t have a cure for chronic pain yet, we do have solutions; methods to reduce and manage it, and learn to function better.

Acknowledgement:

Diagrams by Ashley and Colleen. Graphics are from freepik.com

References:

Butler, D. via  Arthritis Victoria. (2015, August 3). Treating Pain Using the Brain - David Butler [Video File]. Retrieved from https://youtu.be/4ABAS3tkkuE on April 22,  2016.

Moseley, G.L. (2003). A pain neuromatrix approach to patients with chronic pain. Manual Therapy, 8(3), 130-140.

Thacker, M.A., & Moseley, G.L. (2012). First-person neuroscience and the understanding of pain. The Medical Journal of Australia, 196(6), 410-411.

Melzack, R. (2001). Pain and the neuromatrix in the brain. Journal of Dental Education, 65(12), 1378-1382.

The Brain and Pain: Is Chronic Pain Changeable?

A while ago, I (Colleen) was having a discussion about pain with a friend who has fibromyalgia. One of her comments was that she believes it’s “all in her head.” (I cringed as she said that, but then listened to her reasoning.) She feels like there isn’t anything wrong with her tissue and body. It seems like her brain is hypersensitive to “pain signals,” just like it is to many other things (stress, sound, etc). I stopped cringing, and commented how cool it is that our brain’s perception of those signals can be changed.

Her reply was “Do you really think that can change?”

I responded: “Absolutely”

Why that answer? Back when we were in OT school we didn’t learn a lot about chronic pain other than, it was chronic. But since then, we’ve learned enough to convince us that it isn’t as static as we once thought. Yes, it is persistent, and yes, it is real. And no, there aren’t any magic wands to make it completely go away. But the research suggests that it is definitely possible to change our nervous system and our experience of pain.

So let’s take a peek at this idea. How did it become a part of the pain picture? And what is the evidence?

Some (Very) Basic Neurophysiology 

This idea of looking at the brain’s connection to pain is relatively new. A lot of it has come into play in the last few decades as new technologies have become available. We are now able to see what is going on in the brain during different activities (fMRI). Researchers and clinicians have begun to understand just how much the brain can, and does, play a role in pain. For the sake of this post, we are only touching on a few ideas. 

• Neuroplasticity: One of the key points that has come out of this research is the idea of neuroplasticity - that is, our brains are changing every day and will continue to change for our entire lives (Butler, 2014).
• Neurotags: Our brain is made up of tons of neurons that are interconnected in a complex way. A neurotag is a network of neurons from different areas of the brain. When this network is activated, it “generates a particular experience” (Cundiff & Schellinck, 2015; Moseley, Butler, Beames, & Giles, 2012). We have all kinds of neurotags, for a variety of different experiences, and the components that make up these neurotags are individual. For example, if you have experienced food poisoning after consuming a chicken burger, you could have a “food poisoning neurotag.” This neurotag would include neurons that are related to the smell of chicken, the appearance of a burger, the type of bun used, the restaurant you were at, etc. When enough of these neurons are activated, the whole neurotag gets activated, and you experience nausea (Cundiff & Schellinck, 2015). 
• Activation threshold: The activation threshold is the amount of input that is needed to cause a nerve cell to fire. Just like nerve cells have an activation threshold, neurotags need a certain amount of stimulation to be triggered. The activation threshold is the amount of the neurotag that has to be activated before it produces an output (Moseley, Butler, Beames, & Giles, 2012). In the above example, maybe just seeing a similar burger wouldn’t be enough to activate that whole network, but seeing the burger at the same food truck in the summer would activate the nauseous sensation.  

So How Does This all Relate to Pain? 

There is a prominent approach called the neuromatrix theory of pain that takes all the concepts we explained above, and turns them into a way to explain and address pain.

Back in an earlier post we talked about how pain is not simply a representation of what is happening in our tissues, but rather a judgement about the signals from our body. Our brain makes decisions about what these signals mean. Basically, “pain is produced whenever the brain concludes that body tissue is in danger and action is required” (Moseley, 2003). 

Now combine this definition of pain with the neurophysiology described above. All the concepts like neurotags and neuroplasticity can be applied to pain. The brain is always receiving signals, or messages, from the body. These signals have the potential to trigger a “danger” or “pain” response in the brain (neurotag). If enough of the neurotag is triggered (activation threshold), then the whole network is triggered. Many areas of the brain become activated at the same time and they work together to produce pain as a way to bring your attention to the threat. Because of neuroplasticity, this whole process can change over time (Moseley, 2003; Moseley, Butler, Beames, & Giles, 2012). These concepts can guide treatment planning.

The idea that pain involves many areas of the brain interacting with each other can also be helpful when considering treatment options. It means there are many more mechanisms involved in pain than previously thought. As David Butler (2015) said, this is exciting because it “underpins the ENORMOUS power of context. Say 500 areas of the brain are in action when we’re in pain - it means that there is kind of a formula for your pain.  We’re all different, and it can be changeable.” 

So back to our initial question “is chronic pain changeable?”  As our knowledge of the brain changes, so does our view on pain. Chronic pain is not as static as once thought. Current research on the brain’s role in pain has led to new ideas and theories about treatment. This post has been all about the idea that pain can change, and why we believe this is important. In future posts, we will discuss techniques and strategies that are built on these concepts.

Acknowledgement

Diagrams by Ashley and Colleen. Graphics are from freepik.com. 

References

Butler, D. (2014). noijam blog: Explain Brain. Retrived from https://noijam.com/2014/12/09/explain-brain/ on April 16, 2016. 
Butler, D. via  Arthritis Victoria. (2015, August 3). Treating Pain Using the Brain - David Butler [Video File]. Retrieved from https://youtu.be/4ABAS3tkkuE on April 22,  2016. 
Cundiff, L. & Schellinck, S. (2015). The Physiology of Pain. In Occupational Therapy Best Practice: Chronic Pain Management [Course Manual]. 
Moseley, G.L. (2003). A pain neuromatrix approach to patients with chronic pain. Manual Therapy, 8(3), 130-140. 
Moseley, G.L., Butler, D., Beames, T.B., & Giles, T, J. (2012). The Graded Motor Imagery Handbook. Adelaide, Australia: Noigroup Publications.

Neuroscience and Pain

Acknowledgement:

Diagram by Ashley and Colleen. Graphics from freepik.com with the exception of the mosquito and the tent. They are by Julia Makotinsky from JMDesigns.

References:  

Arthritis Victoria. (2015, August 3). Treating Pain Using the Brain - David Butler [Video File]. Retrieved from https://youtu.be/4ABAS3tkkuE on April 22,  2016.

Moseley, G.L. (2007). Reconceptualising pain according to modern pain science. Physical Therapy Reviews, Volume 12, 169-178.

Moseley, G.L., Butler, D., Beames, T.B., & Giles, T, J,. (2012). The Graded Motor Imagery Handbook. Adelaide, Australia: Noigroup Publications.

The Pain Management Prism

Let’s take a look at the goal of pain management. It’s a pretty good goal. We’re betting that this goal would resonate with a lot of readers, either for yourself, for a loved one or for a client. But how is it achieved? The more we learn, the more we see that pain management really can be divided into a few inter-wound, but different paths.

Let’s use the image of a prism to explain how the different aspects of pain management work together. As you see in the image above, when a beam of light hits a prism, the light is separated into a rainbow of colours. For the purposes of this post, let’s think of pain management as that beam of light. Then we can divide it into several components to examine how they connect with each other to achieve one cohesive goal. 

To begin with, let’s take a brief look at what components go into our experience of pain and how we can impact those components. To greatly oversimplify the process, first your body senses something (pressure, temperature, etc) and creates a message about it. Your nerves then transmit this message up to your brain. Your brain then combines this message with other information to come up with an interpretation of what is happening in the body. If your brain decides this is something you need to be aware of immediately, it lets you know through pain.

How This Relates to Pain Management

The message creation: One aspect of pain management is to look at what is happening in the tissue. That is, focus on what is causing the sensory neurons to fire. For example, is there a broken bone, too much pressure, or damaged cartilage? Are the muscles tense or stiff? This may be the most common approach to pain management and is particularly beneficial in acute pain situations where there is an immediate problem in the tissue. Treatment involves techniques such as stretching, strengthening, realigning, using ice or heat, massage, and electrical stimulation.

The message transmission: Another aspect of pain management is to look at quieting or blocking the signals that your brain receives from the nerve cells in your body. The theory behind this is that if you can quiet the message, you can reduce or eliminate the pain. The nervous system is more complex than a simple messaging system. It modifies the messages sent to the brain, sometimes amplifying the message. This is problematic for us when it results in chronic pain, so some treatments try to dampen the message or cut it off completely. These treatment methods include nerve blocks and some pharmaceuticals.

When most people think of pain management, they focus on treatments that address these two mechanisms. However, there is a third mechanism that is also essential in addressing the complexity of chronic pain.

The message interpretation: The final aspect of pain management we’ll discuss in this post is how the brain interprets these signals. When your brain gets a signal that something is going on in the body it gathers all the information it can to make a decision about this signal. It looks at past experiences, what you know about that area, and other sensory information. Things like mood, fatigue, and a multitude of other factors impact how these sensations are interpreted.  The brain then makes a decision about the significance of the information. It decides whether an alarm is needed, and how loud the alarm will sound. We then experience this “alarm” as pain. 

Researchers have turned this concept around and speculated that if the threat value of these incoming signals could be lowered, then the volume on the alarm could be decreased. Therefore the pain could also be reduced (Moseley, 2007).  Some examples of treatments based on this concept include relaxation techniques (telling the brain that things are okay), visualization (telling your brain that you can complete the movement pain free), and graded exposure (learning that awful pain doesn’t happen with every movement). This is the aspect of pain management that we’ve focused on the most in our blog so far, because it’s an area that we find really exciting. It’s an area that’s relatively new and full of possibilities.

The entire spectrum works together

Just like white light is made up of a spectrum of colours, we believe that effective pain management is made up of a combination of treatment techniques. There is benefit to looking at tissue based mechanisms as well as brain based mechanisms, and everything in-between. All three components discussed in this post (creation, transmission, and interpretation) have an impact on the pain message and open up possibilities for intervention. This generates a whole range of tools that can be explored and new ways to potentially change and reduce pain. But more than simply reducing pain, this opens the door to improving functioning and quality of life for individuals with chronic pain. For us, this means there is always hope.

Acknowledgements:

Diagrams by Ashley and Colleen. Nervous system graphic and brain drawing from freepik.com

References:

Moseley, G.L. (2007). Reconceptualising pain according to modern pain science. Physical Therapy Reviews, Volume 12, 169-178.

Spa or Bootcamp: A Case For Considering the Nervous System in Pain management

Once upon a time there were two ladies who had fallen and ended up with a neck injury. Both had visited the ER and were sent home with a brace. One of the ladies was super relaxed about the whole thing and was somehow okay with what had happened. The other one was still in a bit of shock about the fall and completely wound up. Even just a gentle touch made her jump and scream like she had been hit. 

What was the difference between these two individuals? Mainly it was the state of their nervous systems. One had processed the fall, her injury, and was ready to get better. (How she did that so fast is amazing!) The other lady’s nervous system was still on guard, ready to pounce on anything that might be a threat. 

So the question today is: How effective is therapy when the nervous system is so wound up? It’s pretty hard to do effective therapy if you can’t even touch the person!

One popular pain center described their program as a balance between a spa and a boot camp. You mostly saw the boot camp part in the gym; they would encourage people to push harder, keep going when they were tired, etc.  And yes, their clients did see improvement...muscles were strengthened or stretched, there were increases in people’s endurance and the amount they could lift. Progress on charts. But looking at that program we just wondered, how much more progress could have been made if they emphasized the spa part too. If they took the time to lower people's nervous system response, and didn’t add to it by the “bootcamp” approach. What would have happened?

Our guess is that they would have seen longer term, sustainable changes. From what we’ve seen, pain and all that comes with it throws a huge amount of stress on our systems. Calming the nervous system down (so that it is not constantly on edge), opens the door for you to really benefit from any other therapy. This gives you a chance to integrate it, learn from it and move towards healing. 

So, how can we do this? Well, there are many ways therapists can help to bring the nervous system back to a more balanced state. Here are just a few ideas:

• Calm the nervous system through “relaxation” methods: visualization, acupuncture,  breathing exercises, yoga, laughter, massage, etc
• Create a relationship of trust with your client and validate their experiences. They don’t have to “prove” their pain, it’s just accepted.
• Reduce disability. Enabling your clients to do the things the need to do (teaching them a different way, changing the situation, etc) reduces the impact of the pain on their lives and in turn reduces the stress it places on their body.
• Address client's fears. Listen, educate, and try to come up with a solution. There are about a zillion new worries that come with pain and even acknowledging them can take some of the pressure off the body.
• Give your clients permission to rest. Often people in pain feel the need to keep pushing, which again adds more stress to the body.

If you’re a therapist we would love to hear what you do with your clients. What do you find works, and what doesn’t? If you have pain, what has worked for you? What are your thoughts? 

You might have noticed on this blog we talk a lot about the nervous system. Well, this is why. We believe the process of  learning to live well with pain can be only be enhanced by calming the nervous system. 

It’s kind of funny that this little post about the “spa vs bootcamp” concept has been hanging out with our draft posts since the beginning. It asked a lot of questions, provided some speculation based on experience, but didn’t provide a lot of answers as to why the boot-camp approach wasn't enough. And then we went to a course that talked all about pain and the nervous system. Lightbulbs went off! In the new year we’ll carry on this discussion and talk a bit more about how the nervous system relates to pain and why it is so important to acknowledge this connection.

Acknowledgements:
Weightlifter silhouette from freepik.com