Intriguing research on the perception of back pain

[Jim Pickles]

Just come across this intriguing report on the perception of back pain. It confirms what most of us would (I think) suspect already, but does so via some interesting psychological experiments, which are then capable of further development. It gives further insight into the mechanisms of back pain, and also by implication gives pointers to directions for therapy. It also has implications for the perception of stretching which we might be able to use (if we are not doing so already). The only bad thing is the researcher's annoying tone of voice.

So as not to break the ABC'c copyright, here is the link to the podcast: http://mpegmedia.abc.net.au/rn/podcast/2017/09/hrt_20170911_1730.mp3

I'm not sure whether people outside Australia can access this so I have attached the downloaded mp3 file anyway:

Jim.

hrt_20170911_1730.mp3.mp3

[Pat (pogo69)]

I haven't listened to this yet, but Tasha Stanton works with a pain research group that includes Lorimer Moseley and David Butler.  They all do very interesting work that is highly synergistic with ST.

I think it has been mentioned here before, but everyone (on the planet) should watch Lorimer's TED Talk:

He's a very engaging speaker, so it is an easy 15 mins.

Lorimer and David have written a book (now, a couple of books that go deeper into their practises for practitioners) called Explain Pain.  Their work leads to clinical practises that attempt to help people re-frame pain - from looking and feeling like prison/punishment/damage/danger/etc to a protective/nurturing/supportive/healing mechanism.

They've coined the terms SIM (Safety In Me) and DIM (Danger In Me) - increasing one's perception of safety, and decreasing perception of danger, is a powerful alleviator of pain.

https://noijam.com/2015/03/12/dim-sims/

They also stress the importance of context - many things can look like a safety and/or a danger.

Edited September 14, 2017 by pogo69

[Kit_L]

Thanks for the links.

[AlexanderEgebak]

I have their newest book "Explain Pain Supercharged" as well as having attended Lorimer's Explain Pain workshop. Highly recommendable, and their work is very interesting.

[Jim Pickles]

Here is a  link to a very erudite talk on central contributions to pain (which says the same as the above video but at greater length and in greater detail). It uses fibromyalgia as its main example, but as he states many times, the conclusions may well apply more generally (including to back pain). It is not suggesting that this type of pain is purely under voluntary control, and therefore "all your own fault", but instead due to the brain's pain "volume control" being set too high (which may have many causes, including genetics and the patient's history). Its 2 hours long, and I havent listened to it all yet, but I have listened several times to an earlier version, from 4 years ago. Nevertheless, I suggest it would be useful background for anyone involved in body therapy. I may say more when I've listened to it all.

But I am wondering - can "pain training" be used to reduce the chance that pain which might have started from tissue damage, does not become centralised, i.e. does not become the very intractable "brain pain"? (incidentally I - as an auditory specialist - have used related ideas to very effectively control my own tinnitus).

Working through - he notes the importance of non-drug therapies, such as exercise, which is more effective than drugs in treatment of long-term chronic pain (at around 1hr 40 min) - it turns down the "volume control" in the brain.

 

[AlexanderEgebak]

19 hours ago, Jim Pickles said:

Here is a  link to a very erudite talk on central contributions to pain (which says the same as the above video but at greater length and in greater detail). It uses fibromyalgia as its main example, but as he states many times, the conclusions may well apply more generally (including to back pain). It is not suggesting that this type of pain is purely under voluntary control, and therefore "all your own fault", but instead due to the brain's pain "volume control" being set too high (which may have many causes, including genetics and the patient's history). Its 2 hours long, and I havent listened to it all yet, but I have listened several times to an earlier version, from 4 years ago. Nevertheless, I suggest it would be useful background for anyone involved in body therapy. I may say more when I've listened to it all.

But I am wondering - can "pain training" be used to reduce the chance that pain which might have started from tissue damage, does not become centralised, i.e. does not become the very intractable "brain pain"? (incidentally I - as an auditory specialist - have used related ideas to very effectively control my own tinnitus).

Working through - he notes the importance of non-drug therapies, such as exercise, which is more effective than drugs in treatment of long-term chronic pain (at around 1hr 40 min) - it turns down the "volume control" in the brain.

 

Of course it can be used to regulate sensitivity

The mechanisms of descending inhibition and facilitation is control entirely by the higher cortical levels of the brain. The main factors that influence this regulation according to the bulk of the research are beliefs, expectations, experience and context; and these are both within and without conscious reach. If we take an example of lower back pain:

Patient P has acquired a prolapse in L5 directly correlated with a car injury and the MRI is 100% positive. P is assigned to rest, moderately exercise within comfort, told that she must learn to deal with the pain forever, manual therapy might help. 1 year later P has trouble working, need manual therapy to be able to go through the week, exercise does not help and believe that prolapse will last forever. How do we deal with such a patient?

First off, research has shown that prolapses will resorb over the course of a year. This will remove pressure on the nociceptors and therefore there is no biomechanical contributor to nociception any longer. Explaining this to P will help change the beliefs about the condition and therefore pain modulation. We know that cognition and behavior may trigger an immune response and spontaneously trigger spinal nociceptors. So changing this belief may change the amount of nociception that the brain receives. Since nociception is an important modulating neurotag for pain reducing this may greatly influence pain response.

Now that our patient has learned that prolapses never last forever we hypothetically assume that P is feeling a little better but P is still skeptical due to still feeling pain. We may now go on to explain the difference between passive and active strategies. That dependency of manual therapy and resting has not worked so far so P must move out of the comfort zone if P truly wants to turn the tables. Explaining the importance of impowerment, locus of control and self-efficacy may help.

Next I would move on to explaining how she must change strategy and start being active by remapping her somatosensory cortex which may be "smudged". It is best explained as a metaphor of a country map where places unexplored may put her at ease but to feel better she must explore and overcome these areas of the map. When P understands this P is ready for supervised activity.

P may be very protective of her lower back which is why we must engage that to change her beliefs about fragility and the need to protect that area. Jefferson curls is an excellent remapping exercise for cortical smudging. If weight bearing is also an issue deadlifting may do wonders. I made a girl who had chronic pain for 6 years deadlift 80 kg first time ever. People are a lot stronger than they (and their therapist) often believe.

This should change their beliefs and change somatosensory cortex. Pain scientists now work from the hypothesis that pain turns chronic due to cortical smudging. Since pain turns chronic for about 20% of all people ever experiencing back pain, and since many people are told by their therapist that they must rest - here we have a factor!

P may need more time to consolidate the changes that have happened or may have missed a few points but is definitively on way now.

If P instead had osteoarthritis I would explain that instead of focusing on the things that we cannot change we should focus on the things that we can change. Then proceed to hand statistics of how many who have OA without pain. Then they might be ready to understand that pain is a multidimensional experience and not just a sensory one, and that pain also occurs to protect the body from the RISK of tissue damage. Then go on to explain Lorimer's DIMS and SIMS model and afterwards the twin-peaks model to underline the importance of reducing the pain threshold in activities to actually decrease pain through activities, eventually.

[Jim Pickles]

AlexanderEgebak

Many thanks for your informative reply. Interestingly put: "It is best explained as a metaphor of a country map where places unexplored may put her at ease but to feel better she must explore and overcome these areas of the map" . This could also be said to be how I successfullly dealt with my own tinnitus (after other more conventional methods had not dealt with it fully) - by devising an auditory stimulus that would activate areas of my auditory cortical map that were being deprived of their normal input (I may make pages on my own website dealing with this, and with auditory stimulus files that people can download).

Jim.

 

[Kit_L]

18 hours ago, Jim Pickles said:

(I may make pages on my own website dealing with this, and with auditory stimulus files that people can download).

Please do, Jim, I will use for sure.

[AlexanderEgebak]

23 hours ago, Jim Pickles said:

AlexanderEgebak

Many thanks for your informative reply. Interestingly put: "It is best explained as a metaphor of a country map where places unexplored may put her at ease but to feel better she must explore and overcome these areas of the map" . This could also be said to be how I successfullly dealt with my own tinnitus (after other more conventional methods had not dealt with it fully) - by devising an auditory stimulus that would activate areas of my auditory cortical map that were being deprived of their normal input (I may make pages on my own website dealing with this, and with auditory stimulus files that people can download).

Jim.

 

I never thought of having an auditory cortical map. Very interesting! Is there any research behind this idea, and does this apply to smelling, tasting etc. too? What are your thoughts?

[Jim Pickles]

Attached is a review I wrote a couple of years ago. Auditory cortical maps are dealt with on pages 13 -15. There are multiple auditory maps, with different characteristics. Maps may be defined by representations of frequency, though position of the sound source in space is another factor. There may be other factors as well (less certain). The effects of denervation and restimulation that underlie my tinnitus treatment have been shown in animal experiments (not described in this review). I dont know about taste and smell, however. Cheers.

2015 Pickles HCN review Aud Pwys au ms.pdf