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 ID: 748503
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Slide1
PAINSlide2
Objectives
Understand Pain and Pain behaviorsLearn 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 EssentialsSlide3
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
.
Slide4
Pain experiences are normal and an
excellent, though unpleasant
response to what our brain judges to be a threatening situation.Slide5
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.Slide6
The amount of pain you experience does not necessarily relate to the amount of tissue damage you have sustained.Slide7
Research has shown that the amount of disc and nerve damage rarely relates to the amount of pain experienced
. ¹Many 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.Slide8
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.² Slide9
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 Slide10
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 Slide11
Surfers have had their legs bitten off by sharks and have reported feeling nothing more than a bump at the time
.⁵ Slide12
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. Slide13
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.Slide14
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 temperatureSlide15
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.Slide16
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 Slide17
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. Slide18
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
. Slide19
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
Slide20
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.Slide21
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.Slide22
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.Slide23
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. Slide24
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.Slide25
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.Slide26
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.Slide27
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.Slide28
Nerve Pain
Movement often makes it worseStress makes it worse
Unpredictable Zings
Sustained Ignition Slide29
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. Slide30
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.Slide31
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.Slide32
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 Slide33
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.Slide34
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.Slide35
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.Slide36
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.Slide37
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.Slide38
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.Slide39
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.Slide40
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.Slide41
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.Slide42
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.Slide43
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
Slide44
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.Slide45
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?”Slide46
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 syndromeSlide47
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 unpredictableThere are other threats in life: previous, current, and anticipated.Slide48
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 Slide49
Active Coping Strategies:
Learning about the problem
Exploring ways to move
Exploring and nudging the edges of pain
Staying Positive
Making PlansPassive Coping Strategies:Avoiding activity
Doing nothing
Waiting for something to happen
Believing someone else has the answerSlide50
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.Slide51
Management Essentials
Tool 1: Education and understanding
Tool 2: Your hurts won’t harm you
Tool 3: Pacing and graded exposure
Tool 4: Accessing the virtual bodySlide52
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 can’t.
¹
²
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.¹³Combing pain physiology education with movement approaches will increase physical capacity, reduce pain and improve quality of life.¹⁴ Slide53
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.¹
⁵
Knowledge is a great liberator!Slide54
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.Slide55
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 won’t flare up.
3. Plan your progression. Be gentle on yourself. Plan to progress a little each time. Slide56
Pacing and Graded Exposure
4. Don’t flare up, but don’t 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 don’t give up!
5. It’s 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.Slide57
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 don’t 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 won’t.
Sometimes if your pain is very chronic even imagined movements will be painful. Start with only imagining part of the movement.Slide58
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 waterSlide59
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 ballSlide60
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.Slide61
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.Slide62
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.Slide63
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.Slide64
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.Slide65
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.Slide66
Accessing the Virtual Body
Make the
neurotag
curious,
Make it wonder what is next.
You be the master.Slide67
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.Slide68
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reconceptualization
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, W.R., Stress and Health. 1997, Thousand Oaks: Sage Publications.
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