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.