PAIN SERIES PART 1: UNDERSTANDING CHRONIC PAIN
There has been a growing concern amongst the health and wellness community, and this concern is chronic pain. More and more clinicians and trainers are having clients come to them with pain they are struggling to diagnose. So, what is chronic pain, and why is it on the rise?
First of all what is pain?
Pain is an defined as an unpleasant feeling often caused by intense or damaging stimuli. Therefore, we know that pain is a signal that tells us there is damage or something is wrong. However, with some pain conditions, the systems (including the brain) are altered. The pain sensory feedback cycle gets turned on repetitively and does not turn off, this is when we go from normal “pain,” to “chronic pain.” While acute pain is a normal sensation triggered in the nervous system to alert you to possible injury, chronic pain is different. Chronic pain occurs, when there is pain that persists over an extended period of time; where the nervous system signals continue to fire. This altered sate is often referred to as Neuroplasticity (also called brain plasticity, cortical plasticity or cortical re-mapping).
What makes pain “chronic?”
Chronic pain may be divided into “nociceptive” (caused by activation ofnociceptors), and “neuropathic” (caused by damage to or malfunction of the nervous system).
- Nociceptive pain may be divided into “superficial” and “deep”, and deep pain into “deep somatic” and “visceral”. Superficial pain is initiated by activation of nociceptors in the skin or superficial tissues. Deep somatic pain is initiated by stimulation of nociceptors in ligaments, tendons, bones, blood vessels, fascia and muscles, and is dull, aching, poorly-localized pain.
- Visceral pain originates in the viscera (organs). Visceral pain may be well-localized, but often it is extremely difficult to locate, and several visceral regions produce “referred” pain when damaged or inflamed, where the sensation is located in an area distant from the site of pathology or injury.
- Neuropathic pain is divided into “peripheral” (originating in the peripheral nervous system) and “central” (originating in the brain or spinal cord). Peripheral neuropathic pain is often described as “burning,” “tingling,” “electrical,” “stabbing,” or “pins and needles.
Does this sound repetitive? There’s that word again – Neuroplasticity. In the case of chronic pain, the somatotoic representation of the body is inappropriately reorganized following peripheral and central sensitization, and thus causes the signal to remain active. In order to understand the finite complexities, we need to have a good understanding of what “neuroplasticity” is.
What the Stats Tell Us:
Back pain, migraines, un diagnosed digestive issues and other chronic pain affect at 1 in 10 Canadians between the ages of 12 – 44. In 2010, CBC News Health provided a report featuring a case study involving 57,660 respondents, representing 14.6 million Canadians in the younger age range, and about 1 in 10, an estimated 1.5 million answered “no” if they were usually free of pain or discomfort. Among those aged 12-44, chronic pain was associated with back pain. Part of this is due to our lifestyle. We spend more time sitting, at the computer or technological devices, spend more time in cars, constantly seated in school, more and more North Americans are over-weight and over-worked. And when pain occurs, are natural response is to do less, and by this I mean, exercise less, move less and this all contributes to the onset of what is known as chronic pain.
The next question is; what causes it and why? This is the conundrum of our age, it’s extremely hard to treat and prevent something if you cannot diagnose, right? Many people who have chronic pain undergo test after test and the result is NO structural damage, no medical reason? Because, pain can’t be seen, like bleeding, or something structural found on an x-ray; medical professionals are taught to diagnose based on “the level of pain (intensity) must correlate to a specific medical finding.” When it does not, the client’s request and complaint can be easily dismissed because pain is – subjective. Two people with same injury for instance, can subjectively experience that pain in different degrees of pain; which can be based on genetic factors, pain tolerance, stress levels etc. Care must be tailored to each client, but I am getting ahead of myself (hint – teaser for the end of this article on the stigma of chronic pain). Let’s circle back to one of the bulleted points of chronic pain – neuroplasticity.
We looked at this in a previous article “Neuroplasticity: The Power of the Mind.” Let’s break it down; the word (from neural – pertaining to the nerves and/or brain and plastic – moldable or changeable in structure) refers to changes in neural pathways and synapses which are due to changes in behavior, environment and neural processes, as well as changes resulting from bodily injury. Let us also remember that the brain; in how it determines pain, does not recognize “mental” pain, from “physical” pain – it just “feels” pain. Therefore, if test, after test, after test comes back “negative” for structural damage, then as the old saying goes… “It’s all in your head.” This is actually partly true, because the brain and nervous system are stuck in “pain,” and that pain is very real to the brain – thus to you. Part of our journey towards optimal health and wellness and personal human potential is mastering, the mental, emotional and physical self. With every behavioural modification (physical and mental) there is a psychosomatic component; especially, when it comes to chronic pain, and this realm should be taken into account when screening or identifying indicators of chronic pain in a client.
And there is no wonder why so many people in the West are experiencing this phenomenon. In the Western world, we have created an external (and internal) environment of busy, busy, busy, go, go, go, start early-stay late, cram, cram cram, beta, beta, beta (brainwaves)….you get the picture. Brain activity in individuals suffering from chronic pain, measured via (EEG), has been demonstrated to be altered, suggesting pain-induced neuroplastic changes. More specifically, the relativebeta activity (compared to the rest of the brain) is increased, the relative alpha activity is decreased, and the theta activity both absolutely and relatively is diminished.
Not only are we not getting enough rest (sleep and/or recovery), we usually sacrifice nutrition and exercise to meet a deadline. This all leads to increased stress (ding, ding, ding – auto stress response – beast mode on), increased cortisol levels, increased tension in the fascia and musculoskeletal lines, shallow breathing, decreased circulation and blood flow, decreased mental acuity, anxiety, increased rate of depression, feeling of hopelessness – the list goes on and on. It’s no wonder; our bodies cry out in….pain. In the experience of pain, communication between body and brain goes both ways. Normally, the brain diverts signals of physical discomfort so that we can concentrate on the external world. When this shutoff mechanism is impaired, physical sensations, including pain, are more likely to become the center of attention.
The Stigma of Chronic Pain:
The human body is a marvelous adaptive organism. Our brains are designed to learn from our environment and adapt. Pain is very different for every person, and it is usually mis understood and undertreated, because our medical system is poorly prepared to treat it. The stigma stems from mis communication and lack of understanding. Most often those who have chronic pain are prescribed medication to treat it.
In a study done in 2011 by CTV News called “Adults With Chronic Pain Face Stigma: Study,” CTV quoted Dr. Doris K. Cope, pain chief at the University of Pittsburgh Medical Center stating; “The population’s getting older and less fit, and more survivors of diseases like cancer live for many years with side-effects from treatments that saved them. Too many patients think a pill’s the answer, she said, when there are multiple different ways to address pain including physical therapy, stress reduction, weight loss and teaching coping skills. Patients who take control of their pain fare better, but too many have unrealistic expectations. Pain is not simple.”
Pain is primitive, but it is also complex and as we have just outlined, it’s highly subjective.
It’s All in The Head: The Psychosomatic Element
In my experience, many of the clients I see for corrective movement and/or somatic healing deal with chronic pain on a daily basis. The anticipation of pain brings about fear of movement, and movement brings about the fear-memory of pain. You see the cycle?
Learning how to trust movement, identify barriers (physical, mental and emotional) is the first step towards removing stressors that contribute to the building blocks of the pain cycle. If a client comes in with high anxiety and pain, these two usually go hand in hand, starting with breathing in a supine (position 1 in FMS) will most likely reduce the level of pain. Why? Because deep breathing triggers the brain to secrete hormones that relax tissue, it also slows heart rate and induced more delta and theta brain wave frequencies. The very brain waves associated with deep relaxation, sleep and recovery. For review take a quick peek at my last article; “meditation for the mind: theta brain waves & your fascia,” and “Ride your brain wave: neuro-synchronicity and your human potential.”
The psychosomatic (mind-body) element; takes into account that the physical pain is almost always notably influenced by the client’s mental and emotional factors; which directly relates to the continued cycle. We will look at this in more depth next week. As coaches, having a background is psychology, NLP or life coaching comes in handy for cases involving both chronic pain and athletes. We all have barriers, fears, past limiting beliefs structured around painful memories. The goal is understanding the intention, the thought and response process and more importantly, how to guide a client towards dis-associating from the pain and re-connecting (re-patterning) with pain free movement AND thinking.
If the psychosomatic element is outside your scope of practice, ensure you refer to a professional. It will make your job a lot easier.
Stay tuned for next week!
Part 2: It’s All In Your Head, will feature the mental and emotional aspects of chronic pain and how you can uncover the power of language behind behavioral change.
Part 3: Movement is the Key, will feature safe and effective movement based, corrective exercises/ drills for chronic pain and how to properly coach a client who has been cleared by a physiotherapist for movement, but still has “pain.”
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CTV News Study 2011: http://www.ctvnews.ca/adults-with-chronic-pain-face-stigma-study-1.663612
Harvard Health Publications: http://www.health.harvard.edu/newsweek/Depression_and_pain.htm