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
Slide 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.
Slide 4
Pain experiences are normal and an excellent, though unpleasant
response to what our brain judges to be a threatening
situation.
Slide 5
If problems do exist in our joints, muscles, ligaments, nerves
or anywhere else: It wont hurt if our brain doesnt think we are in
danger. If problems dont exist in our body tissues, nerves or
immune system: It will hurt if our brain thinks we are in
danger.
Slide 6
The amount of pain you experience does not necessarily relate
to the amount of tissue damage you have sustained.
Slide 7
Research has shown that the amount of disc and nerve damage
rarely relates to the amount of pain experienced. 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 dont have to hurt or stop anyone from leading a
functional and active life.
Slide 8
Amazing Pain Stories Severe injuries and no pain at the time of
injury In e mergency rooms all around the world, patients present
impaled with various objects, many report little or no pain.
Slide 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.
Slide 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.
Slide 11
Surfers have had their legs bitten off by sharks and have
reported feeling nothing more than a bump at the time.
Slide 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. This is a type of
pain memory.
Slide 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.
Slide 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
Slide 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.
Slide 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.
Slide 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.
Slide 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.
Slide 19
A Possible Pain Neurotag 1. Premotor/Motor Cortex organize and
prepare movements 2. Cingulate Cortex concentrating, focusing 3.
Prefrontal Cortex problem solving, memory 4. Amygdala fear, fear
conditioning, addiction 5. Sensory Cortex sensory discrimination 6.
Hypothalmus/Thalmus stress responses, autonomic regulation,
motivation 7. Cerebellum movement and cognition 8. Hippocampus
memory, spatial cognition, fear conditioning 9. Spinal Cord gating
from the periphery
Slide 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.
Slide 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.
Slide 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.
Slide 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.
Slide 24
Bone and Joints An important factor related to joints and pain
seems to be the speed at which joints are damaged. If its 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.
Slide 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.
Slide 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.
Slide 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.
Slide 28
Nerve Pain Movement often makes it worse Stress makes it worse
Unpredictable Zings Sustained Ignition
Slide 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 doesnt
usually cause pain by itself, but with a little help form changes
in body parts and heightened alarm system sensitivity, pain can
occur.
Slide 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.
Slide 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.
Slide 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.
Slide 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 doesnt mean that pain
is not real all pain is real.
Slide 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 didnt hurt before now hurt.
Slide 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.
Slide 36
Altered Central Nervous System Alarms More long term process
also happen neurons which dont 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.
Slide 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.
Slide 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.
Slide 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.
Slide 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.
Slide 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.
Slide 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.
Slide 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.
Slide 44
Through scientific research, we are now aware of the thought
processes which are powerful enough to maintain a pain state.
Thought viruses are common in people with persistent pain and that
dont understand the physiology of pain.
Slide 45
Thought Viruses Im in pain so there must be something harmful
happening to my body. Im staying home, not going out. Im keeping
quiet and out of things. Even their whiz-bang scanning machine cant
find it it must be really bad. We can put a man on the moon, why
cant someone just fix this pain for me?
Slide 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
Slide 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.
Slide 48
Coping Coping aims to reduce the threat value of the stimulus
and the associated emotions and altered biology. Active copers
manage pain and many other health issues better than passive
copers.
Slide 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
Slide 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.
Slide 51
Management Essentials Tool 1: Education and understanding Tool
2: Your hurts wont harm you Tool 3: Pacing and graded exposure Tool
4: Accessing the virtual body
Slide 52
Education and Understanding People without any training in the
health professions or biology can understand the physiology of
pain, even though some health professionals think that they cant.
Learning about pain physiology reduces the threat value of pain.
Reduced threat will reduce the activation of all of our protective
systems: sympathetic, endocrine, and motor. This in turn helps to
restore normal immune function. Combing pain physiology education
with movement approaches will increase physical capacity, reduce
pain and improve quality of life.
Slide 53
Education and Understanding One aim of understanding the
physiology of pain is to facilitate what is called deep learning,
in which information is retained and understood and applied to
problems at hand. Knowledge is a great liberator!
Slide 54
Your Hurts Wont Harm You Remember that recurrent pains are
often protective. Recurrences occur because some cue has activated
the virtual representation of an old injury and that hurt does not
always equal harm. Practical exercise: When you are just sitting
around and you feel some pain. Think about it. Think about what you
know about pain. Think about what may have activated the alarm
systems. Reflect on what cues may have ignited the pain nodes in
your brain. Get to know your pain.
Slide 55
Pacing and Graded Exposure Movement is essential for the health
of all body systems and processes. Motion is lotion 1. Decide what
you want to do more of by picking a particular activity. Ex:
walking, working, playing with children, driving. Also Consider
what you need to do more of. 2. Find your baseline. The amount of
activity that you can do and know that your pain wont flare up. 3.
Plan your progression. Be gentle on yourself. Plan to progress a
little each time.
Slide 56
Pacing and Graded Exposure 4. Dont flare up, but dont freak out
if you do! Because the alarm system is so sensitive it is very
difficult to completely avoid flare ups. Remember what you know
about pain and dont give up! 5. Its a lifestyle thing. Seek out
happy activities they have been shown to have physiological effects
on the alarm system and pain ignition nodes. Do fun activities with
fun people, or to your favorite music. This pacing and graded
exposure process is doing some pretty complex things to your brain,
however if you stick with these principles you will gradually
return to normal life and overcome your pain.
Slide 57
Accessing the Virtual Body 1. Imagine movements The virtual
body in the brain can be exercised just like the actual body.
Imagined movements activate the brain neurotag, but dont move the
actual body. Think about the movement you know to be painful, or
watch someone perform the movement. Movement neurotags will be
activated but the pain neurotag probably wont. Sometimes if your
pain is very chronic even imagined movements will be painful. Start
with only imagining part of the movement.
Slide 58
Accessing the Virtual Body 2. Alter gravitational influences-
Changing gravitational influences allows you to run brain
representations of the movement in similar but slightly different
and novel ways: Sitting on the floor with your legs straight out in
front of you. Lie on the floor with your legs in the air. Standing
bent over at the waist leaning on a table. Perform movements in
water
Slide 59
Accessing the Virtual Body 3. Add varying balance challenges
-These inputs will provide some virtual body changes via
distraction. Sit on a fitness ball Move your body in different
directions while sitting on a fitness ball Move your arms or legs
in different directions while sitting on a fitness ball
Slide 60
Accessing the Virtual Body 4. Vary Visual Inputs Look at your
body while you perform a movement Perform a movement in front of a
mirror. Performing a movement with your eyes closed is usually a
greater challenge for the virtual body. 5. Alter the environment of
the activities Perform movements in your home, at the park, in a
Tai Chi group, in the pool.
Slide 61
Accessing the Virtual Body 6. Do the movements in different
emotional states. We tend to put off exercises and activity when we
are feeling a bit down, but if you perform the exercises in various
emotional states, it would give the virtual body a richer context
of representations in which to run.
Slide 62
Accessing the Virtual Body 7. Add Distractions - Distraction is
a powerful way to disable the pain neurotag. Distraction removes
one of the key ignition nodes, the node that is activated when you
concentrate or focus on something. You could use: music,
meditation, or visualization. 8. Break down functional movements
-When you rise from a chair, try it with one foot forward and then
the other, lead with head, try performing at different speeds.
Slide 63
Accessing the Virtual Body 9. Perform Sliders techniques that
encourage total body movement. Allows distraction plus movements
which are unlikely to aggravate sensitive neural tissue in your low
back. Lie on your back with knees bent and feet on the floor, and
flatten your back and at the same time tilting your chin upwards.
Sit upright in a chair and sag your back, hold under your thigh and
extend your knee while tipping your head back.
Slide 64
Accessing the Virtual Body 10. Perform movements with
neighboring tissues in a friendly state Sitting in a chair, if you
bend forward and have your chin tilted forwards it will slacken
some of the nerves in the back. Bending forwards when sitting will
take some tension from the tissues in your hips and legs.
Slide 65
Accessing the Virtual Body 11. Playing with your glitches
-Glitches are the ways we have all learned to wriggle and adjust
when we perform a movement. They are often caused by memories of
painful movement. These glitches may be boosters to the pain
neurotag. See if you can perform the movement without the glitch.
Sometimes moving another part of the body when the glitch occurs
can help remove them.
Slide 66
Accessing the Virtual Body Make the neurotag curious, Make it
wonder what is next. You be the master.
Slide 67
There are many other tools which may help different people at
different times. Examples include: Medication, diet,aerobic
exercise skilled attention to unhealthy tissues, cognitive and
behavioral therapy, relaxation strategies, spiritual enlightenment,
and love.
Slide 68
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