NOI Notes on spirituality and nerve root pain

Nasty nerve roots
Nerve root pains can be downright nasty, sometimes tricky to identify and they often last a long time – shooting pains in the leg, sleepless nights, latent pains, weird behaviour, and impaired quality of life. It may well be hard for a patient to give meaning to it, especially with the unfamiliar symptoms. “It just eats into my soul” commented a recent sufferer.

If this is the case, perhaps you should hope/pray that your patient is the spiritual type. On an analysis of basic sciences, the spiritual type may do much better than the non-spiritual person when faced with a nasty and unfamiliar nerve root problem. And you can be a spiritual assistant!

Spirituality
Differences between spirituality and religion have been argued for years and I don’t really want to get into that hot potato. Spirituality is usually defined as a personal quest for seeking meaning and purpose and a connectedness with the world. It includes a willingness to accept transcendence i.e. things that cannot be objectively demonstrated (Emblen 1992; Maliski et al. 2010). You don’t have to be religious to be spiritual although there is often overlap. Faith is a manifestation of spirituality and in the health care context this could be faith in the health care provider, self, family and the system. High levels of spirituality may be really important in getting an acute nerve root problem to calm down and to minimise the number and effect of reoccurrences. Health professionals should be aware of the spiritual needs of patients and the fact that the spiritual person will be more likely to have biopsychosocial mental frameworks to tap into.

What is so spiritual about a nerve root?
While the brain is a far more trendier part of the of the nervous system to experimentally probe, a recent revival of interest in the peripheral nervous system is noted, especially the nerve root, the ‘brain’ of the peripheral nervous system. No doubting anatomically that nerve roots (referring here to the rootlets, roots and dorsal root ganglion) are in a tricky place for modern life and surgery can be spectacularly successful for some, however the common mechanistic ‘pinched root’ and nerve root ‘compression’ thinking needs a challenge.

When a part of the peripheral nervous system is injured, immune cells such as glia, Schwann and T cells in the dorsal root ganglia, spinal cord and brain produce pro and anti-inflammatory cytokines – a sterile inflammatory response. The pro-inflammatory cytokines include interleukins 1, 6 and TNF alpha. The anti-inflammatory cytokines include interleukins 4 and 10. These two groups kind of balance each other out, with the balance ultimately contributing to how the injury plays out (Austin and Moalem-Taylor 2010). For example, people with painless neuropathies have heightened levels of anti-inflammatory cytokines and patients with painful neuropathies have heightened levels of pro-inflammatory cytokines. Other linked processes related to nerve root sensitivity include altered sensitivity to mechanical, adrenaline and ischaemic stimuli (Devor 2005). Inflammation does not necessarily show on imaging and the spiritual person may readily accept that their pain does not have to have an objective measure.

Searching for a sense of self in a nerve root?
Those more spiritual may see the nerve root problem as a microcosm of self. The inflammatory component of the nerve root problem, which will be mimicked in the cord and brain is driven in part by mind status. The ‘out of balance’ notion of mental disorders, increasingly seen as unbalanced glial activity (Fields 2009) may apply to the peripheral nerve injury. For some there may well be ‘goodies and baddies’ or ‘angels and demons’ in the inflammatory response and heightened spirituality enhanced by biological knowledge may tip the balance in favour of the anti-inflammatory immune response.

For example, catastrophisation which is known to have immune inflammatory effects (Edwards, Kronfli et al. 2008) could be minimised by a spirituality which encourages a search for meaning and knowledge, and perhaps a ‘go with the flow’ thinking. You can help the person seek meaning. For example, knowledge of the pain referral zones, that immune based ‘sympathy pains’ in the other side are common, and that immune based responses for months after are expected and normal as the system slowly balances. And in particular, the knowledge that neuroinflammation is influenced by unhelpful thoughts like catastrophisation and emotions such as fear should be welcome by the spiritual person. Ultimately early movement with minimised fear may be a beneficial outcome.

The religious discussion is inevitable here. Cusick, a minister writing in the American Pain Society Bulletin (Cusick 2003) noted five spiritual religious interpretations of pain – pain as punishment, pain as a test, pain as an opportunity for transcendence (i.e. a little pain is good for the soul), pain as atonement (i.e. experiencing pain to help other people) and pain to gain control. However, as Cusick  notes, the social meanings of pain are now changing rapidly with improved pain medications and increased understanding of its biology – that pain, like other brain constructions is a protective coping strategy to help us change behaviour and is not necessarily a voluntary and potentially harmful experience.

Assessing spirituality
Given that most people report having a spiritual life and that spirituality may well have an influence on the potency of neuro-inflammatory soup, it seems worthwhile asking about it. Questions such as “what helps you get through tough times” and “to whom do you turn when you need support” (Mueller, Plevak et al. 2001) may well be obvious questions to a health professional with a biopsychosocial framework.

More on spirituality
These are complex issues ripe for discussion. This perplexing topic of the relationship between spirituality, pain, immune and other systems will be up for discussion at the second Neurodynamics and The Neuromatrix conference in Adelaide, Australia, April 2012. The Reverend Dr Andrew Dutney, next head of the Uniting Church in Australia will talk and present a workshop with Professor Frank Keefe who has researched in the area of spirituality and arthritis and Mick Thacker, immunologist and spiritual atheist.
Keen to have your thoughts here – David

References
Austin, P. J. and G. Moalem-Taylor (2010). “The neuro-immune balance in neuropathic pain: Involvement of inflammatory immune cells, immune like glial cells and cytokines”. Journal of Neuroimmunology 229: 23-60.
Cusick, J. (2003). Spirituality and voluntary pain. APS Bulletin 13(5)..
Devor, M. (2005). Response of nerves to injury in relation to neuropathic pain. Melzack and wall’s Textbook of Pain. S. McMahon and M. Koltzenburg. Edinburgh, Elsevier.
Edwards, R. R., T. Kronfli, et al. (2008). “Association of catastrophizing with interleukin-6 responses to acute pain.” Pain 140: 135-144.
Emblen, J. D. (1992). “Religion and spirituality defined according to current use in nursing literature ” J Prof Nurs 8: 41-47.
Fields, R. D. (2009). The Other Brain. New York, Simon and Schuster.
Maliski, S. L. and e. al. (2010). “Faith among low-income, african american black men treated for prostate cancer ” Cancer Nursing 33: 470-478.
Mueller, P. S., D. J. Plevak, et al. (2001). “Religious involvement, spirituality, and medicine: Implications for clinical practice ” Mayo Clinic Proceedings 76: 1225-1235.

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3 Responses to “NOI Notes on spirituality and nerve root pain”

  1. ian stevens Says:

    Very interesting practical physiology especially the information on catastrophising and the immune system .
    The whole area of ‘spirituality’ , acceptance, coping etc are complex human individual responses shaped by cultural attitudes. Have you read any of David Morris book on this subject– there is a very good review of ‘illness and culture in the postmodern era’ by Iona Heath in the BMJ. At an individual level Havi Carel’s Illness is a brilliant book http://heroesnotzombies.wordpress.com/2009/01/21/illness-by-havi-carel/

    It is indeed a hot potato ! I wouldn’t be comfortable with venturing into this area at all personally (with other people in the NHS) but certainly find it fascinating . I am wary after yeas ago suggesting to someone that she close her eyes and do some meditative type focussing and to be told that her church thought that this could cause thoughts of the devil to enter …http://integral-options.blogspot.com/2010_09_19_archive.html
    This site is intersting and the type of culture and religious practice may affect physiolgy (in this case what we see or attend to)
    You may disagree but philosophy has a lot to offer healthcare thinking –see book review on illness for example. I don’t think neuroscience will answer all that many problems when it comes to human behaviour but I may be wrong.
    Many of the popular mindful approaches in pain management for example are taken from Buddhist practices which may suit some people more than others….Many of the age old spiritual traditions which consider a more embodied approach to living -meditaition , prayer, using beads etc are counter cultural in the way biomedicine looks at fixing problems ….n roots tend to take a long to time to slow down once they are irritated but if a person is used to instant solutions in all other aspects of life a ‘spiritual approach’ may not sit that well ?

  2. Jo Bayly Says:

    This is an interesting discussion. I work in specialist palliative care where spirituality is an overt component of multi- professional team management. David, the question you suggest, “what helps you get through tough times” is asked regularly as a normal part of a clinical encounter. Ian, if the woman whose church had told her that meditation was from the devil had been asked such a question, do you think she might have answered ‘her church’? If so would you have felt comfortable asking her asking her to try praying? Or even to have explored this area of her life with her? The question “what are you praying for at the moment” when asked of patients who profess to pray can reveal previously unspoken fears and concerns as well as potential avenues for the anti-inflammatory thinking David describes.

  3. ian stevens Says:

    Jo,
    yes its ironic that we can learn a great deal from the paliative care ethos. Applying and valuing ‘care’ to those suffering from pain would help enormously . You might find this essay to be of value.
    http://www.annfammed.org/cgi/content/abstract/7/2/170
    Yes , the question regarding asking about what gets you through difficulties seems a sensible one to ask in some situations (but I wouldn’t go any further in most work environments as the setting is not appropriate) . Perhaps in more formal pain/stress management programmes it is more appropriate . I like the idea of anti inflammatory thinking !

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