Improving Quality of Life Through Education

Mid-Columbia Medical Center

A car with four flat tires…

A person with persistent pain is like a car with four flat tires.

The right medication might fill one tire.

Exercise, pain education, healthy eating, restorative sleep, counseling and mindfulness are a few ways to fill up the other three tires.

https://www.youtube.com/watch?v=5RIii6OUK2A

Four Flat Tires Video

Pain is a complex process that does not require an actual physical injury as a cause.

Thoughts, feelings, emotions and beliefs all play a part of the pain experience.

Persistent pain is often no longer reflective of actual or ongoing injury or damage.

A “sensitized nervous system” contributes to persistent pain.

Our nervous systems are highly changeable. If they can be changed from “normal” towards a persistent pain state, then they should be able to change back towards “normal.”

Important Pain Facts

STRESS

POOR OR INADEQUATE SLEEP

UNHEALTHY DIET

NEGATIVE THOUGHTS AND BELIEFS

A sensitized nervous system can be perpetuated by…

Movement

Touch/massage

Relaxation/stress reduction/mindfulness

Restorative sleep

Changing our thoughts and beliefs

Healthy Diet (boosts the immune system and aids in healing)

Engaging in pleasurable activities such as socialization, reading, family meals, hobbies, outdoor activity, etc…

Ways to Re-train the Brain

Medications have positive effects and negative effects. It is important to incorporate ALL aspects of the pain care model (physical, mental, emotional). Medications alone are rarely adequate to manage chronic pain and in some cases, may worsen quality of life.

Opioid medications are an important tool for managing acute and chronic pain. In some cases opioids may worsen the pain experience through a process known as “opioid-induced hyperalgesia.”. It is important to know and understand the risks and benefits of these medications.

Where does medication come in?

Optimal Self Care

Eat Better

Activity

Sleep

Education

Positive Thinking

Proper meds

Stress Reduction

The Wheel of Pain Rehabilitation

By: Andy Roof, MPT, OCS

Waters Edge/MCMC Rehabilitation Services

Learning Objectives To understand the differences between acute and

chronic pain.

To understand the role of the brain and nervous

system in the creation of the “pain experience.”

To understand the physiological changes that take

place throughout the body in response to a chronic

pain state.

To learn 3 positive lifestyle changes that can be

made in order to manage chronic pain.

Why should we learn about

pain?

To learn how to put the pain in

perspective

Make new decisions based on changes

the pain has caused in our lives

Set realistic goals

Minimize the disruption the pain has

caused in our lives

All pain is real pain Each person’s pain is unique

All pain experiences are a normal response to what your brain thinks is a threat

Real pain can exist without any damage to the tissues

The construction of a pain experience in the brain relies on many sensory cues

The pain experience relies on a very complex electrical and chemical response in the body

The intensity of pain is not always related to the severity of the injury

Brain Man and Pain https://www.youtube.com/watch?v=rlsSaJcjmLg

What is pain?

An unpleasant, but

protective, sensory

experience in response to

what your brain judges to

be a threatening situation.

The BRAIN controls pain: You can have

no pain with extreme tissue damage

Even if problems exist in your

bones, joints, muscles, ligaments,

nerves or anywhere else, it won’t

hurt unless your brain thinks you

are in danger.

The BRAIN controls pain: You can experience

extreme pain with no tissue damage

Even if no problems exist in your bones, joints,

muscles, ligaments, etc…it will still hurt if your

brain thinks you are in danger.

Pain can be so effective that you can’t focus on

anything else. But if your brain thinks that

experiencing pain is not the best thing for your

survival, you may not experience pain at the

time of severe injury.

The BRAIN controls pain: Pain results from the

brain’s interpretation of what is happening to the

body

Pain is an output of the brain, not an input.

The information given to the brain by the

nervous system is: where the pain is, the

amount of danger and the nature of the

danger. The “stretching,” “ripping,”

“burning” sensations are produced by

the brain’s construction of events.

Acute Pain Experienced in response to tissue damage, for

example: being bitten, stepping on a nail,

getting burned by the fry pan, breaking a bone,

dislocating a joint, twanging your funny bone…

Experienced in response to tissue fatigue, for

example sitting at the computer too long and

developing a neck ache (body says “time to

move!”)

Pain is desirable because…This acute pain protects us by

motivating us to get out of a

threatening situation, to seek help

for an injury, or to change position.

In this way, experiencing pain

protects us and increases our

chances for survival.

Degenerative changes It is a normal process of aging for our tissues to

degenerate, or at least look a little different than

they did at age 16.

Disc degeneration, degenerative joint disease and

arthritic changes are all normal age-related

processes.

Since these processes occur slowly and over time,

our brains usually do not perceive them as

threatening, therefore there is no pain.

Pain relies on contextWe will experience more or less

pain based on sensory cues that we

are receiving in conjunction with the

pain

Stubbing your toe hurts more on a

stressful day than at your birthday

party.

Phantom limb pain 70% of people who lose a limb experience a

“phantom limb” that can itch, tingle and hurt

This relates to the “virtual limb” in our brain. There

is still a brain-constructed representation of that

limb in our heads even though the actual limb is

missing.

This “virtual limb” representation is changed in

chronic pain states.

Sensors Millions of little sensors all throughout your body

that survey their area and convey information to the

spinal cord

When sensors respond to a stimulus (can be

mechanical pressure, changes in temperature, or

chemical changes) they open so that positively

charged particles from outside the neuron rush into

the neuron; this sets up an electrical impulse in the

neuron.

Action Potential When enough sensors open, and enough +

charged particles rush in, a rapid wave of electrical

current travels up the neuron..this is called an

Action Potential

Action Potentials are the way that nerves carry a

single message. This message from the nerve to

the spinal cord only says “danger,” not “pain.” The

spinal cord and brain receive and process these

inputs to create a pain sensation.

Synapse When AP reaches the other end of the neuron at

the spinal cord, it causes chemicals to be poured

into the gap or “synapse” between the sensory

neuron, its neighboring neurons, and the second

order neuron that then goes up to the brain. If

enough of the correct chemicals are released into

the synapse and open enough sensors on the

second order neuron, an AP is produced that

carries a “danger” message to the brain.

Brain processingDanger message is ultimately delivered

to the brain, which processes that

message, along with all other information

that is arriving at the brain.

Brain uses memory, reasoning and

emotional processes and includes

consideration of the potential

consequences of a response.

Pain ignition nodes Rather than just one “pain center” in the brain,

there are multiple “ignition nodes.”

These nodes include parts of the brain used for sensation, movement, emotions and memory.

These nodes are “ignited” during a pain experience and link up to each other electrically and chemically.

In chronic pain, these nodes become overactive and nearly dedicated to creating the pain experience. ..like a skipping record…

Descending inputNeurons descend from the brain, down

the spinal cord, and terminate near the

synapse between 1st and 2nd order

neurons.

These neurons provide a flood of “happy

hormones” (opioids and serotonin) that

are 60x more powerful than any drug at

dampening alarm signals.

Nervous system changes in

chronic painDanger messenger neuron increases its

sensitivity to incoming excitatory chemicals

Sensors stay open longer

More sensors are manufactured

Other neurons that don’t carry danger messages sprout close to the synapse and activate the pain neuron (touch, temperature, movement, vibration)

Altered spinal cord inputs…These changes in the spinal cord

make it so that the brain is not

receiving accurate information about

what is happening in the tissues.

“the spinal cord as a magnifier of

tissue reality”

The Brain Learns Pain

Amount of brain “real estate”

dedicated to perceiving pain

is expanded up to 5x normal

The problem is in the nerves…

Chronic pain exists because of changes

in the brain, spinal cord and nerves. It is

no longer a result of tissue damage.

The nerves fire more frequently and with

greater strength; they keep firing without

ongoing stimulus…so… people heal but

the pain circuit remains active

Thoughts play into this pain…

Thoughts and beliefs are nerve

impulses too.

Imagining a movement or watching

someone else move can produce

pain.

Imagining movement may cause

swelling of the painful part.

Pain and Emotions OverlapEmotional circuits and pain circuits share

brain regions and nerve cells, therefore,

there is great overlap of pain disorders

and mood disturbances

Pain produces anxiety, depressed mood

and fear

Your pain can be worse

depending on:

Negative thoughts: anger,

depression, fear, stress, painful

memories, negative attitudes and

beliefs

Physical state: fatigue (lack of

sleep), hunger, cold, heat, noise

Chronic Pain ProcessKnown tissue healing time has passed,

yet pain persists

Diagnoses based on tissue processes are

no longer accurate

Pain becomes related to CNS processes

(brain, spinal cord and nerves) as

opposed to actual tissue damage

(tendons, ligaments, muscles, discs)

Chronic Pain ProcessNormal sensations produced by

movement or touch are translated by the nervous system into a pain message.

The pain becomes a false signal caused by hypersensitive nerves.

Sympathetic Nervous System

Nerve network throughout the body

Distributes adrenaline to all of your

tissues

In chronic pain states, there can be

increased adrenaline levels

Adrenaline increases the alarm system

sensitivity

Parasympathetic Nervous

System

Slows and conserves energy, aids in

digestion, cellular replacement,

tissue healing

Decreases adrenaline levels

Meditation, quality sleep, deep

breathing and relaxation all facilitate

this

Cortisol Cortisol oversees the stockpiling of fuel (fat) for

future stress. Unrelentingly high levels of cortisol in

the body leads to weight gain.

At high levels, cortisol has a toxic effect on

neurons, eroding connections between them and

breaking down muscle and nerve cells.

Remember that cortisol is a “stress” hormone, so

effective stress management strategies are important

to reduce it to “normal” levels.

Immune systemPro-inflammatory cytokines are active

when you have the flu….this is desirable

for healing response

Long term stress and pain lead to chronic

inflammatory cytokine

activity…movements are more sensitive,

old pains can come back to revisit.

Buffer the Immune SystemOptimal nutrition: more fruits and

veggies, whole grains and omega-3’s

Have family and medical support

Have a strong belief system

Have and use a sense of humor

Exercise appropriately

Mindful Walking Practice walking with a tall spine, eyes on the

horizon.

Arm swing and a little rib cage motion are critical.

Play with speeding up or slowing down.

Play with longer or shorter strides.

Focus on heel strike and toe-off.

Extra credit: Can you breathe with your belly while

doing all of this?

Passive Coping

1. Avoiding activity

2. Doing nothing

3. Wishing for something to

happen

4. Believing someone else has the

answer

Active Coping

1. Learn about the problem

2. Explore ways to move

3. Explore and nudge the edges of

your pain

4. Stay positive and active

5. Make plans

Effects of movement and

exercise

Exercise:

1. improves blood flow to the brain,

joints and muscles

2.regulates mood in a positive way

3. primes the brain for learning

4.results in a chemical release that

helps decrease pain perception.

Exercise boosts levels of

beneficial neurotransmitters

Dopamine: vital for movement, attention,

cognition, motivation and pleasure.

Serotonin: important for mood, learning,

self-esteem and decreased anxiety and

impulsiveness

Endorphins: act as natural morphine,

blocking pain and producing feelings of

pleasure, satisfaction and bliss

We say “Know Pain or No Gain”

Self Treatment for Managing

Chronic Pain Exercise: includes walking, hiking, dancing,

swimming, water aerobics, bicycling, working

out at the gym…all of this promotes the release

of “feel good” brain chemicals!

Self-massage with a tennis ball, pokey ball,

vibrating massager, your fingers,

etc…improves circulation to tight muscles

which helps them to relax and leads to less

pain and more movement.

Self Treatment for Managing

Chronic Pain Relaxation to stimulate the “feel good” brain

chemicals and decrease the “stress” chemicals.

This includes deep breathing, meditation,

mindfulness, yoga, prayer…

Proper nutrition: a healthy, whole foods diet to

optimize the immune system’s functioning and

to decrease painful inflammation in the body

Self Treatment for Managing

Chronic Pain

Proper sleep: 6-9 hours of sleep per night to allow your body time to heal.

Only YOU can commit to following up on these ideas. No one can give them to you, charge you money for them, etc…When it comes to treating your chronic pain, the best things in life really ARE free!

How to start exercising Start with something you enjoy. Walking, hiking,

biking, dancing, swimming and water aerobics are all good choices.

Start slowly and time yourself so that you have an objective measure of your exercise.

PACING: If you have a pain flare, remember that it is your nervous system “speaking up” as it gets used to a different level of activity. Decrease your time of exercise by 20% and get back out there!

Optimal Self Care

Eat Better

Activity

Sleep

Education

Positive Thinking

Proper meds

Stress Reduction

The Wheel of Pain Rehabilitation

ReferencesButler, D., Moseley, L. Explain Pain.

Noigroup Publications, Adelaide,

Australia, 2003.

Ratey, J. Spark: The Revolutionary

New Science of Exercise and the

Brain. Little, Brown and Co., 2008.

Next week…