PAIN

1. PAIN

2. 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

3. 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.

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

5. If problems do exist in our joints, muscles, ligaments, nerves or anywhere else: It won’t hurt if our brain doesn’t think we are in danger. If problems don’t exist in our body tissues, nerves or immune system: It will hurt if our brain thinks we are in danger.

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

7. Research has shown that the amount of disc and nerve damage rarely relates to the amount of pain experienced. ¹ • 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 don’t have to hurt or stop anyone from leading a functional and active life.

8. Amazing Pain StoriesSevere injuries and no pain at the time of injury In emergency rooms all around the world, patients present impaled with various objects, many report little or no pain.²

9. 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.³

10. Those who suffer traumatic amputations in wartime and comment that there was no pain, usually report the injury as a “bump” or a “thump.” ⁴

11. Surfers have had their legs bitten off by sharks and have reported feeling nothing more than a bump at the time.⁵

12. 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.⁶ This is a type of pain memory.

13. 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.

14. 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

15. 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.

16. 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.⁷

17. 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.

18. 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.

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

20. 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.

21. 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.

22. 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.

23. 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.

24. Bone and Joints • An important factor related to joints and pain seems to be the speed at which joints are damaged. If it’s 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.

25. 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.

26. 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.

27. 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.

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

29. 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 doesn’t usually cause pain by itself, but with a little help form changes in body parts and heightened alarm system sensitivity, pain can occur.

30. 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.

31. 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.

32. 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.⁸

33. 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 doesn’t mean that pain is not real – all pain is real.

34. 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 didn’t hurt before now hurt.

35. 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.

36. Altered Central Nervous System Alarms • More long term process also happen – neurons which don’t 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.

37. 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.

38. 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.

39. 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.

40. 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.

41. 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.

42. 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.

43. 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.⁹

44. Through scientific research, we are now aware of the thought processes which are powerful enough to maintain a pain state.¹⁰ Thought viruses are common in people with persistent pain and that don’t understand the physiology of pain.

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

46. 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

47. 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.

48. Coping Coping aims to reduce the threat value of the stimulus and the associated emotions and altered biology. Active coper’s manage pain and many other health issues better than passive coper’s.¹¹

49. 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

50. 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.