A week of pain?

A week of pain?
It’s Pain Week in Australia, an initiative of Chronic Pain Australia. The aim is to “create awareness, to shine a light on the dilemma and work towards creating a hopeful message about living with pain”. We think it is a great idea – chronic pain is such a hidden and deeply invasive epidemic in society. The term ‘pain week’ is also a reminder of how pain is medicalised – we don’t see ‘love week’ or ‘jealousy week’ for example, yet love and jealousy are brain constructions as well and thus not that dissimilar to pain. This should remind us that the answers to chronic pain are not all medical either. Maybe “living with pain” for many could be a bit defeatist – like “managing pain”. Pain is a biological event – all biological events cycle. Perhaps we could add more hope and say – “living with and treating pain”, notwithstanding the nastiness and horror of it for some.

A time for reflection
National Pain Week has made us reflect at NOI – what is the essence of our teaching and philosophy – are we on track? When someone says “tell us what are the most important things that you teach, summarise the key philosophies in a nutshell”, it does make you reflect. The two things I have selected are firstly that pain is an output of the brain, not an input and secondly that pain is just one of many outputs our brain makes to defend us.

We would like clinicians and patients to be aware of these philosophies as part of our contribution to National Pain Week.

1. Pain as an output
If you pinch yourself hard enough, it hurts and it is so intuitive to think that pain kind of goes into your body and brain. Biologically this is not correct. First, if pain was entirely an input it should be easy to stop it by turning off inputs such as the pinch or a thought. This may work for some pains but it clearly doesn’t work for most people with chronic pain. One billion plus people in the world can’t be wrong! Of course it is nociception* which goes in – it is up to the brain to weigh everything up and decide whether the nociception is worth a pain experience. So many health professionals still don’t get the difference between pain and nociception. (You can tell they don’t when they say things like “pain signals into the brain” and “pain nerve endings”.) If pain is regarded as a brain output experienced in a body part, it simply makes you take on the biology of the brain, all that is in it and all that can influence it.

2. Pain is just one of many brain outputs
This is a precious neuroscience base to our teaching. When we are in trouble, threatened, injured, curious or learning, there are numerous brain outputs which could be constructed to protect, defend and help us. These include the immune, sympathetic, motor and endocrine systems, but also pain, language, emotions, cognitions, respiration, inflammation and many more. It is good to have some of these turned on for a short time to help us learn and to protect and defend us, (eg being anxious can protect us, cortisol level changes can help healing, pain makes us change behaviour) but if there is non-resolution of the inputs that set off these outputs, then the outputs may become pathological in their own right. If a tiger starts following you around the suburbs, you will turn on defence systems (outputs) which will become pathological if ‘the tiger’ continues to follow for months and months. For example – pathological sympathetic, endocrine and immune responses, pathological muscle changes and ‘pathological’ thoughts and emotions. Early intervention is obviously the key. The tiger might simply be a lack of knowledge.

Freedom of the output systems
If a person has numerous outputs turned on it can become taxing for the body. That is, it takes an enormous amount of energy to run multiple systems. A typical patient with chronic pain may have unusual cortisol levels, muscle tightness, a labile sympathetic nervous system, an unbalanced immune system, and produce inflammatory immune compounds. There is not much energy left for the rest of life.

A patient, with a bit of knowledge, may be able to identify the outputs systems turned on and then perhaps the issues (could be body structures, thoughts, contexts etc) which need resolution to turn the outputs off. Just knowledge about why we hurt can give so much freedom to the output systems.

‘Control’ is a bit of a buzz word out there – pain control, motor control, control of your emotions and on it goes. But there are problems with the control doctrine. Brains don’t construct by control, they construct by freedom, creativity, curiosity, testing the edges of homeostatic behaviour. ‘Pain freedom’ and ‘motor freedom’ sits better with our teaching (acknowledging that sometimes you need control to get freedom), but ultimately it is freedom and choice, much of it subconscious, of construction which is critical for brain health.

Our aim here is to give patient freedom of choice of the output systems, essentially by movement and education so that they have brains that can weigh the world when challenged and not automatically default to a pain, motor, endocrine, language or other habit.

Promoting awareness of these issues is our contribution to National Pain Week. – David

*Nociception
There are some neurones in your tissues that respond to all manner of stimuli, if those stimuli are sufficient to be dangerous to the tissue. Activation of these special neurones sends a prioritised alarm signal to your spinal cord, which may be sent on towards your brain. Activity of this type in these nerves is called ‘nociception’, which literally means ‘danger reception’. We all have nociception happening nearly all of the time – only sometimes does it end in pain.

Butler DS & Moseley GL, Explain Pain, Adelaide, Noigroup Publications, 2003, p32

NOI 2012: early birds get a sweet deal and a chance to win!

NOI 2012Early bird registrations for NOI 2012 end this week. All early birds get a sweet deal and will also go in the draw to win a weekend for two in the South Australian wine region of your choice.

All conference delegates will receive three days of highly intellectual and clinically relevant information including the large range of workshops, an invitation to the opening drinks, the gala dinner on the second evening and involvement with the Nerdy Passions.

Get in early and save heaps, we would love you to come to our festival of clinical neuroscience! See www.noi2012.com for all current conference details.

Links
Explain Pain resources
Chronic Pain Australia
NOI 2012 brochure [1MB]
NOI 2012 Masterclasses
Lorimer Moseley – Pain. Is it all just in your mind? [49mins]
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