Brain and pain signals

[VenPTs]

Hi bikegirl

first off... i think i have to state im a final year physio student lol. however, after spending 4weeks criticaly apprasing the evidence base on chronic pain mamangement im happy discussing it. My writing is based on the theories of central sensitisation and the body-self neuromatrix, which recieves support from experts in the field and from the success of treatment interventions for chronic pain which are based on these theories. These theories have gaps, but to the best of my knowledge they are the best interpretation we have at the moment.



ok.. so we need to be certain that the pain your experiencing is not due to anything specific.. nerve root irritation etc. can you describe your symptoms - quality, location.. and what aggravates and eases your symptoms.. any specific movements etc. im sure having seen a physio they will have thorougly assessed these anyways..


if the pain your experiencing is a chronic, non-specific Low back pain (CLBP) with no underlying specific pathology.. then there are many strategies that you can adopt. as you seem to have read up on the subject allready, i reccomend the book 'explain pain' by Butler, 2007. (can be ordered off the NOI institute website, just google noi institute). The book presents a patient friendly but indepth and current explanation for chronic pain mechanisms and management.



so in brief... a chronic pain state... having had noxious (painfull) stimuli barrage your nervous system for a period of time, changes occur at various levels, which basicly result in your nervous system becoming 'sensitised'. You can think of this as your nervous system is on high alert and listening extra hard for ANY form of impulse (ie. feedback from peripheral sensors... or even just a thought of movement).

now, pain is experienced only when the brain decides that these impulses represent a threat to the body tissues.. and in chronic pain states, the brain very hapily decides that lots of normal things (for instance, simply doing a small movement) represent a threat and => triggers the experience of pain.

this pain is felt despite the fact that no tissue damage is occuring.. the pain is felt because the sensitised system falsley thinks that a threat exists... hence the common statement "Hurt does not = Harm".

(this is very brief.. again, explain pain is a worthwhile buy)


management strategies for this problem therefore focus on 'desensitising' the nervous system.

1) reduce where possible any true contributors of noxious stimuli (things causing 'threat' signals ).. for yourself these most likely to come in the form of muscle spasm, short/tight muscles



2) reduce the fear/threat that you associate with movements. remember, pain is only felt when your brain percieves a threat to the tissues... and past 'pain memories'(ie. memories of movements in the past which => caused injury/pain) are often called upon to inform this decision. => brain thinks (on a subconscious level) 'oh, that movement caused me injury in the past, im going to make her experience pain now so she doesnt do it again..' .. its a protective mechanism, albeit a counter productive one in most cases.

the mainstay of treatment here bases on the fact that you can gradually retrain your brain to think 'oh.. ok that movement didnt cause me injury last time.. so its ok.. ill let her do it and i dont need to cause pain as theres no threat'.


(this answer is long lol.. my apologies)....


now.. the way that you gradually 'retrain your brain' involves:

1. education. get read up on the mechanisms.. when you consciously understand that a movement physically can not cause damage to you, it helps inform the brains subconscious decision of whether it constitutes a threat or not.



2. gradual, very slowly increasing level of activity, from an individual baseline:
this means....

say for example.. you get your pain when you bend over to pick up something... your brain thinks that you bending over represents a threat. teach it that its wrong and that alls cool with bending over.


A)start off by determining the amount which you can bend over (or do whatever activity) .. without it causing any pain.

ie. can you bend forwards a little bit?.. half way? [nb. if the answer to this is no, you cant even think of/ initiate the movement without pain (very common in patients) .. then your starting point is imagined movements.. sounds simple.. it works.. as your teaching the brain that the thought of this movement does not result in tissue damage.. and re-wiring its pain mechanisms.]

..so youve got your baseline.. what you can do without the pain mechanism being fired off =>


B) starting from the baseline, increase the difficultly of the activity on a daily basis.. but by a VERY small amount. (e.g. walk for 1minute .. then 1.5 minutes the next day). the key here is that you stick to your gradual increases. if you feel fine after youve done your eg 1.5 min walk.. STOP! and wait untill the next day before you increase.


when increasing the difficulty of an activity, one may do so not only by altering the physical parameters of it (eg. walking further, lifting a heavier dumbell).. but also by altering the psychological factors of it. (eg. talk a walk with some cheerfull music on, in a different location to what your used to.. lift a weight out of the gym) little changes like this mean that your pain memories are less likely to contribute to the brains 'is this movement a threat' decision.. and your therefore less likely to have fireup of the pain mechanism.




i think ill sum up a very long post incase people just want the main points:


1. the brain makes you feel pain only when it decides that ther is a threat to the body, and soemthing needs doing about it. pains job is to produce an action in you that will reduce this treat!

2. in chronic pain states.. a sensitised nervous system results in non pain full impulses (which can be sensory, eg moving.. thoughts, eg thinking about moving .. anything firing in the brain).. being interpreted as threatening.. which => brain causes you to feel pain


3. mainstay of management is -

-education, understand whats acualy going on, hurt doesnt usualy = harm in chronic pain states. challenge your fears of actities. overcome your fears. retrain your brain.

- GRADUAL increase of activities.. from an individually determined non painfull baseline. stick to the gradual increases. teach your brain that these movements dont represent a threat to you.


... the long term result of getting the brain to stop firing off its threat=>pain mechanism is that overtime.. the physiological changes which lead to the initial 'sensitisation' start to reverse. a nice cycle is set in progress.




well.. that was a longer post than expected.. but im passionate that people dont just stick with a common thought of.. oh, its there..im hurting myself by doing anything.. this pains not going .. i cant do anything.. because in most cases.. thats the way to a downward spiral. GET help get advice.. yes.. you can do it yes



i know @bikergirl your above the level of most patients with chronic pain, hopefully you can see how these strategies can be adapted to your individual situation. if your interested in reading more, i refer again to the explain pain book.. its good.


HOPE this helps someone at somepoint in time! lol..

take care and best of luck,

Pete
Additional Comment I forgot:

Pete

... and if it needs saying.. make sure ur exercise technique and the intensity of the exercises are suitable. guessing youve done your share of spinal stabilisation .. corestability.

ta,


Pete

[Bikegirl]

Thanks VenPTs.

Your post might of been long but very informative. I appreciate your time and effort in sharing your knowledge.

Eventhough I don't have the scientific terms to explain it the way you do, your post confirmed me that I am doing the right thing. I use all kinds of visualization techniques, meditation and I actually control my subconscious to the best of my abilities.

I never engaged into an activity thinking that I will get hurt. I always imagine myself completing an activity with success and without pain. I always picture myself getting better and better.

Now my problem might just be that I am doing too much and I am being over positive (i.e if it starts hurting I always think that it is temporary and that it will resolve shortly...but am I wrong to assume that I might be too tolerant and that I am creating that threatening environment for my brain?) I often have a hard time understanding if it is a normal discomfort for my current state in my rehab or if indeed, it is a threatening pain...the line is so thin.

Again, I thank you for your post it was very useful.

Bikegirl
PS: Yes I have been doing a lot of spine and core stabilization exercises (multifidus, TA and so on) and I keep progressing on that level.