Persistant pain is an epidemic leading to a widespread disability problem. The World Health Organization
has identified that the solution is to focus on Functional Independence of patients rather than treatment of structural or functional impairments. Such impairments are often present in asymptomatic individuals and are not necessarily predisposing or perpetuating factors of pain.
Disability is now viewed in a biopsychosocial context, as opposed to merely a biomedical one. The relationship of impairments to disability is influenced by a number of factors. Therefore, a person with impairments can function & socially participate at a high level. Noone needs to be disabled by pain or impairments. The modern focus is on coping strategies and rehabilitation to enhance one’s “human potential”.
I) Threat of injury or pain outlasts injury. Why?
1. Guarding occurs which becomes a subconscious habit
Janet Travell, M.D. White House Physician for John F Kennedy said, “After an injury tissues heal, but muscles learn. They readily develop habits of guarding that outlast the injury.”
To pain experts the stages a pain patient may experience are
2. Physicians label patients with terms that add “threat value”
Nik Bogduk an eminent back pain scientist tackled the problem of the diagnostic labels that we give our patients. In What’s in a name? The labelling of back pain Bogduk says,
“Diagnostic labels are important in the management of patients. Patients expect a name for their condition. A label shows that the doctor knows what is wrong. But such labels should not be incorrect or specious, lest they lead to therapeutic misadventure.”
“”Degenerative disc disease” conveys to patients that they are disintegrating, which they are not.”
3. Threat frames perception
The false positive rate for a herniated disc or disc degeneration in an asymptomatic person is 20% in 20 year olds; 50% in 50 years; & 70% in 70 year olds. Therefore, finding this in someone with pain may just be a coincidental finding. And, giving a patient who is prone to fear-avoidance beliefs such information is highly disabling. Gordon Waddell, et al reported about a questionnaire which could uncover such beliefs & that they accounted for at least 23% of the variance in disability in patients. Grotle et al found that “fear-avoidance beliefs and distress influence pain-related disability both in early acute and long-term chronic LBP.”
II) Pain is in the Brain
Phantom limb pain is a beneficial metaphor which can help patients understand they may have been overestimating the “threat value” of their pain. Clearly pain can be present even if the tissue gone, so PAIN CAN OUTLAST THE INJURY & BE PRESENT INDEPENDENT OF HARM.
The neurology of pain being in the brain, not the tissue begins with dorsal horn senstization. Pain markers in the dorsal horn undergo physical change which results in alloydnia (pain to non-noxious stimuli) & hyperalgesia (exagerrated pain responses).
In effect the volume nob is turned up
As R Dworkin a pain scientist from Bethesda, MD said, the “hurt you feel becomes FEELING you hurt”
Why? Because the brain’s representation zone for a specific tissue becomes more focused or attentive.
The key is to realize that what we experience is influenced by our perceptions
Expectation & Perception (can you trust what you see or believe?)
If you focus on one thing you completely miss other things right in front of your eyes!
- So hurt doesn’t = harm, but chronic pain patients assume it does.
- Doctors focus on labelling. MRIs w/ high false + rates
- Manual therapists focus on the site of symptoms & their new gadgets for pain – laser, Graston or
techniques like ART.
This only validates in the patient’s MIND that the tissue SITE of symptoms is the key. But, perhaps the problem is pain amplification or a processing error! Even though in many cases these treatments are successful when they fail it maybe because they increase sensitization & are therefore iatrogenic!
III) Desensitization, Attention & Magic
- It’s not where it hurts but with what movements.
- Focus on desensitization to reduce “threat” value
- This must be empirical to reduce fear-avoidance beliefs or pain expectancies. I call this the Clinical Audit Process
This is the essence of cognitive-behavioral therapy & “graded exposures to feared stimuli” or what Pr McGill calls “find the positive slope”.
It is a neurological treatment that works because of cortical plasticity
It is misleading to patients to describe this as psychological.
The pain is not imaginary it is real
In The Sleights of Mind magic tricks are shown (Scientific American) which demonstrate the neurology of attention, expectation and a ultimately a veil of ignorance.
In this case that veil or “one track mind” is
- the belief that hurt =’s harm
- that pain is in our tissues
- that our MRI accounts for our pain
To reverse this we want to desensitize our patients via distraction much as a magician does. This occurs as a result of neural adaptation. A neuron decreases it’s firing to the same stimulus because it is unchanging. This is desensitization.
CAN WE DESENSITIZE PAIN AWARENESS?
Yes! via misdirection.
Focus on function to take attention away from pain!!!
The clinicians role is to frame & direct attention.
In this article by Jason Silvernail Practicing Corrective Movement The Three Stages of Recovery of Pain are described.
Withdrawal is normal for acute pain as is protection. But, as soon as possible it is wise to begin corrective movements. Patients feel threatened by pain so pain immobilizes and disables. This is normal. It is the clinician’s role to reassure the patient & gradually reactivate them. In this way they learn that hurt does not necessarily equal harm.
Why do patients feel less pain when they are focused on function? Eric Franklin’s workshop at the World Low Back & Pelvic Pain Congress in Los Angeles showed how mental imagery can alter neural circuitry. This approach contrasts with the overemphasis on the cognitive aspects of the Queensland approach to motor control re-education.
IV) Receptor Neurology
Sensitization/desensitization involves mirror neurons, glial cells ,& astrocyte activity in the extracellular milleau. In a series of brilliant experiments in the 1970s, Kandel and his colleagues demonstrated that synapseschange in efﬁciency during learning, increasing or decreasing as appropriate, and that these changes may be either short- or long-lived. They used a combination of behavioral and neurophysiological techniques to show how learning that resulted in increases or decreases in the responsivity of organs in the Aplysia was associated with exactly corresponding changes in the amount of chemical transmitter released onto the “motor” neurons in those organs. When the changes are long-lasting, structural changes accompany this increased release of neurotransmitters.
THE FUNCTIONAL ARCHITECTURE OF NEURAL CIRCUITRY
“The scientiﬁc chasm that still needs to be bridged, in my view, is our relatively poor understanding of what information is represented in different circuits in the brain (including those involved in memory). We need to know more about how information is represented as patterns of activity (including patterns in time) and how the biophysical properties of neurons, their dendrites and axons, enable the bits and pieces of information represented at different sites to be bound together into a coherent whole. This level of analysis is one step below the behavioral domain so well described by Squire, and one step up from the cellular level occupied by Kandel.
But there is the gap to be bridged between these two levels of analysis having to do with exactly how the myriad of local circuits that have been worked out by anatomists and physiologists are tailored to the differing information processing tasks they perform. This is the level of the functional architecture of neural circuitry. While reductionists like Kandel are avidly pursuing the path of identifying proteins and the intracellular roles they perform, I am inclined to pause in a back eddy of this “post-genomics” age. There are secrets in the circuitry yet to be gleaned.”
Memory: From Mind to Molecules by Eric R. Kandel and Larry R. Squire. © 1999 by Scientiﬁc American Library.
Making Your Mind: Molecules, Motion, and Memory Lecture 3 – Making Your Mind: Molecules, Movement, and Memory Thomas M. Jessell, Ph.D.
V) Proprioception: A Clinical Roadmap to Desensitization
What is the mechanism behind phantom limb pain?
Many amputees report proprioceptive & tactile sensations yet they don’t have any nerve tissue in their limbs. Even though a person has lost their limb sensory neurons connect in the spinal cord with other neurons that relay that information up to higher centers in the brain. There is a whole circuit of neurons that connect with the central nervous system (CNS), so even though the initial peripheral nerve tissue is gone the signal still gets through. The end result is the brain is tricked into thinking that the origin of the sensory cascade is still present!
Proprioception is the sensory feedback system that monitors the periphery and communicates with the CNS. Proprioception is responsible for fine motor control, balance & agility.
In addition to the five major senses — hearing, vision, touch, taste, and smell — proprioception should be considered the sixth sense. We sense our environment with proprioception just as we do with vision, touch or hearing. The difference is that proprioception takes place on an involuntary basis. Balance is an example of how well coordinated our proprioceptive system is.
Try to stand on one leg with your eyes open. Here your vision supplements your inner ear & proprioception from the sole of your foot. Now, try to stand on one leg with your eyes closed. You can see how much harder it is. With practice you can improve your proprioception stand reasonably well.
What we have learned is that the human mind is hackable Ramachandran Method – Mirror Box Therapy as an example
I like to ask my patients
WHERE is your pain?
With WHAT movements or WHEN is your pain intensified?
- Chronic patients tend to be focused on the SITE of symptoms.
- A very simple goal with chronic patients is to re-direct them to focus on the mechanical behavior of their symptoms – provocative movements.
- Once their focus is away from tissue that hurts and on the movement that hurts we can move on to the next goal of finding the painless dysfunction. When we find an area of weakness, incoordination, or tightness that is both painless and related to the painful area or movement then we have found an area that can be trained safely without increasing their pain.
- Training is low-load (gentle), non-threatening, and pain-less. It is directed to the painless dysfunction. The focus is on fine motor control & stability.
- Clinical Audit Process: Re-assessment of provocative movements should then occur. In most cases there will be less pain with these movement. This will adjudicate as self-care Rx of the fine motor control stability exercises trained.
These exercises thus are “graded exposures” and are used to myelinate neural pathways for normal motor control with pain expectancy, threat or fear of movement. They become steppingstones in the patients recovery.
The proprioceptive basis of this fine motor control training can be clearly seen in the following example.
If I wish to teach my patients about hip hinging and squatting I may start by asking”where do you think your hips are?”
Of course they go to the iliac crest, then ASIS, then PSIS, then lateral thigh, then below ASIS but above hips, etc.. What we are doing is asking them to visualize their anatomy w/ their minds or their imagination.
Then with their fingers in their hip joints I ask them to squat with knee bend – they notice the knees go forward & they “get” that this is bad for knees
I ask them to squat by bending at the waist – they notice this is bad for the back
Then I ask them to stick their but out when they squat
They notice their fingers getting jammed bet pelvis & thigh.
They “get it”
At this point we re-check the mechanical behavior of symptoms in their back. If trunk flexion was painful before we re-check that. Typically after the proprioceptive exercise the movements that were provocative before are not painful any longer.
That this works most of the time is simple modern Pain Science. It is not magic, but like magic it depends on attention, distraction & desensitization. The brain has representation zones for the body. What we imagine is in our tissue is really in our mind. This is why “phantom limb pain” is real. Because we DON’T FEEL WITH OUR BODY. And, in chronic pain this is why the “hurt that we feel becomes the feeling that we hurt.”
Here is the kicker – this works best with active care so as to build self-efficacy. Manual therapy does not have the same potential as movement therapy to reduce the “threat value” of pain.
In effect this is a kinetic chain approach focusing on the SOURCE instead of the SITE of pain. In my practice patients tip their hand that they have a representation zone problem when during the history they focus on their pain, but can’t indicate what makes it better or worse. Then during orthopedic or ROM testing they have difficulty indicating WHAT movement is most provocative, but again focus on the WHERE the pain is.
This problem of disengaging them from the tissue SITE to the mechanical or functional SOURCE is the sign of a processing error more than tissue error.
Eric Franklin, Stuart McGill, Vladimir Janda’s sensory-motor, or cognitive-behavior graded exposures exercise training is effective because it feeds the circuitry for “thinking differently” about painful tissues without their being the presence of the “threat value”. In effect focusing on Gray Cook’s (2’s) vs the (0’s).