But what about the muscles and joints?

Thankyou for your emails about “words that hurt”. A continuing discussion and a source of angst for some readers is the role of body tissues in a chronic pain state. The discussion on “words that hurt” may suggest that we think 'its all in the brain'. This is not true. Many chronic pain states (eg rheumatoid arthritis, severe trauma) are constructed with very significant contributions from body structures such as joints and muscles. However the key thing is that bodily damage or changes do not necessarily have to contribute to pain production. The ‘degeneration' reported on the X-ray simply does not have to hurt.

In cases of chronic pain where tests such as imaging, blood tests, and physical examination finds little to report, yet pain persists, it is quite possible that a process of central sensitisation exists – a very real, physical and increasingly understood process based on synaptic activity in the spinal cord and brain. It is the representation of the structures in the brain, rather than the actual tissues which are at fault.

However, in this state, while the tissues have been through an appropriate healing time, they can still contribute in the following ways:

• by being unhealthy, unfit, weak, unused and sensitive. But remember they have been through their healing stage of inflammation, cell proliferations, remodeling and repair, thus they can’t heal again, but they can get healthier and 'fitter'.

• by being the recipients of the brain’s attempts to help out what it perceives are the problem areas by increased levels of stress chemicals, tight muscles and inflammation.

Every human pain state is constructed by varying contributions of the body tissues, the representation of the tissues in the brain and the stress systems called upon to defend the injured tissues or the brain’s perception of the injury.

Words that hurt - Part 2

Thankyou for all the responses to the previous blog about painful words and phrases. There is no shortage of them and the context they are used in can enhance the nastiness of them.

“Degeneration” comes up a lot, probably due to its frequent use in radiological reports and so does “crumbling”, reminding one responder of an oxo cube. “Permanent” was another and a patient got “all seized up, be very careful” recently from a surgeon who should have known better. I can’t help smiling when a patient says “its bone on bone in there” or throws the thick package of imaging studies on the bed, saying “there it is”.

Different professional groups have different harmful words "your child's membranes are strained" and "there is a severe compression of the base of your skull" were sent by a therapist experienced with craniosacral techniques. Equally, any benefits from the current manual therapy focus on spinal instability could be negated depending on how a person views the word “instability”.

Most clinicians have heard these and other terms (even “slipped disc” is still around) and are realizing the impact of the language.

Reflect….. say a person is told they have “a degenerate L4 disc pressing on a nerve root and the thecal sac”. They will repeat that phrase many times and internalise it even many more times. Googling “thecal sac” will reveal that the problem is close to the spinal cord and notions of paraplegia may emerge.

When we can conceptualise that the “degenerate L 4……” phrase is a brain construction held in motor, perceptual, emotional, planning and other brain areas, we may realize that it is not much different to how a learned limp is held in the brain. Just as most therapists would try and reduce the limp, a search for new, variable and more positive language is therapeutic. Or even better, could the health community avoid the exaggeration, crazy metaphors and even lies at first encounter ?.

Please send your thoughts

Phantom pain – the great leveler

Some time ago, one of my undergraduate pain science students came up to me after a lecture on phantom limb pain and said “but it is not real pain is it?”

Hopefully later lectures fixed the misconception and you wouldn’t want to tell the amputee that its not real pain!

Phantom pain is worth reflecting on from time to time. If there was a surgeon mad enough to perform a ‘lumbarspinectomy’ for chronic low back pain, the glaring evidence is that the pain would still be there in the hole in the back and made worse by stress and movements. Yet we jiggle and zap it, poke needles into the area and take medications which are supposed to find their way to the area and pathological process in the spine.

Clinicians should tell the patient about phantom pains. It provides a gateway to education about the role of the brain in pain. And it is worth remembering that many soldiers who returned from world war two with amputations and pain were told that it is impossible to have pain in fresh air.

Tell us your phantom stories…

Image from Butler DS, Moseley GL, 2003 Explain Pain, NOI Publications, Adelaide

Calming therapeutic neuroscience narratives – mirror pains

Now there is a novel title! A part of “Explain Pain” in the clinic is to give meaning to the patient’s symptoms. By providing meaning and explanation, the “threat value” of the symptom is usually reduced, thus reducing engagement of coping systems such as the sympathetic, immune, endocrine, motor and pain systems.

One of the joys of reading clinical neuroscience is the discovery of explanation. Let me give you one example:

Mirror pains – the once perplexing state where the same pain (area and nature) is experienced in the other limb has been shown to have an immune system basis (Milligan, Twining et al. 2003). In the past, I tried to make up explanations for patients, such as that it was new or different use of the limb, but for me (and surely the patient) it was always unconvincing. And imagine the patient’s distress and fear that their problem was now spreading and seemingly out of control.

The research by Milligan’s group showed that if immune activating compounds are injected around rat sciatic nerve, ipsilateral allodynia can be observed. If more compound is injected, then the allodynia is bilateral. This response is rapidly reversed by glial metabolic inhibitors. Glia are one source of the proinflammatory cytokines such as Interleukin 1 &6 and TNF which appear to underpin the mirror pains.

My narrative may be something along the lines of “mirror pains are quite common and we are now beginning to understand them. Your brain has calculated that due to all the circumstances around your injury (eg no explanations, failed treatment to date, work pressure etc etc) that you need a bit more sensitivity, a bit more protection, so it has done a really good job and made pain on both sides. Don’t worry when we can get you in control of this, your brain will realise that it doesn’t need to make so much pain………..”

More calming therapeutic narratives in later blogs.

Milligan, E. D., C. Twining, et al. (2003). "Spinal glia and proinflammatory cytokines mediate mirror-image neuropathic pain in rats." The Journal of Neuroscience 23: 1036-1040.

Words that hurt

There is a rhyme from school that we all know. “Sticks and stones will break your bones but words will never hurt you”. I recall getting in a schoolyard fight and being called a I don’t recall any pain from the fight but I still remember being called a fat pig and to this day, I know the person who called me that. This is Cartesian dualism in the playground – the split of brain and body. Words do hurt.

Experienced clinicians will know of many words that hurt. They come from imaging reports (e.g. rupture, compression of thecal sac, degeneration, arthritic) they come from all clinicians ("you have the back of a 60 year old", "you’ll be in a wheelchair"

"you have the back of an 80 year old", "its slipped out") and it comes from the internet, neighbours and friends.

Some therapists have plastic models of the lumbar spine including ones with a plastic disc with a big red bulge on it – its quite scary and disc bulges are not like that, nor do they have to hurt.

These words and phrases hurt. They lift awareness of the painful part and strongly suggest that there is still damage and disease. This raises the levels of stress chemicals in the body such as adrenaline and cortisol which may make the sore area even more sensitive.

I would be grateful if readers could send me example of words that hurt. Send them to b1@noigroup.info.

The vital reconceptualisation – “pain as input” to “pain as output”.

“Pain as input” is the natural way to think. When we injure ourselves it seems that the “pain bit” is something organised at the injury site and pain then goes into the nervous system to warn the brain. This is “pain as input thinking”, but the idea is biologically bankrupt and likely to be troublesome for the management of chronic pain. “Pain as output” is a better and more scientific way to think.

There are no pain fibres in the nervous system. When injured, the nerve fibres send “danger signals” not pain signals towards the brain. This is just an increase in amplitude and number of impulses in some fibres (nociception). It is up to the brain to decide if these danger signals are worth listening to. If you have a mild ankle sprain, but you are trying to escape something or score a winning goal, the brain won’t be too bothered listening to the danger signals. However if you have a backache and you have just heard that serious kidney problems can cause back ache and you have a relative with kidney problems, the brain may be particularly attentive to the danger message coming in from the back.

Therefore, while the danger messages from damaged and diseased tissue can contribute to pain, they don’t have to.

We (Butler and Moseley 2003) believe that a good way to help with this reconceptualisation is to consider the notion of threat. While we all know that pain has an emotional influence, “threat” is a wider and more overarching concept. Threats are held in the brain as old memories (“oh no, I have damaged the back again”), made in the brain as the injury occurs (“how will I work next week”), and are in the environment (workmates, insurance). There are a massive number of potential threats. If the brain perceives threats and adds them up, sometimes including the danger impulses, pain may be constructed.

There is research which shows that if a noxious chemical is placed under the skin and you check the brain activation patterns it looks similar to if the noxious chemical was put in muscle (Casey & Bushnell, 2000). This research supports the idea that the tissue injured may not be such a big contributor to pain as most of us thought in the past. Finally, lets never forget phantom limb pain – there are no tissues to create a pain input and what must be the most maddening pain now exists in fresh air.

Email me your thoughts.

Butler DS, Moseley GL (2003) Explain Pain. Noigroup Publications, Adelaide

Casey, K. L., & Bushnell, M. C. (2000). Pain imaging. Pain: Clinical Updates, 8, 1-4.

Explain Pain pain!

Writing the “Explain Pain” book with Lorimer Moseley and eccentric artist Sunyata, (previously Geoff Ween) was a most enjoyable experience - and the success of the book has been very satisfying.

In this blog I want to talk about a phenomenon which I call “Explain Pain pain”. Every now and then we hear from patients or clinicians that they have read the book, but it has given them more pain or in a few cases made them sweat a lot. At first, this was bit distressing as this was not the aim of the book, but on reflection and with a new conceptual framework of what pain is, Explain Pain pain is quite obvious.

Moseley’s attempt to reconceptualise pain as a brain output constructed by various threats plus or minus inputs from damaged tissues rather than the old and now biologically bankrupt concept of pain coming from damaged tissues, i.e. pain as an input holds true here. In Explain Pain pain, the information is a very likely a threat - it calls for change, suggests that previous management may not have been optimal, and calls for a closer look at what goes in the head of the sufferer. This for some people is quite a threat, and as pain is a way to deal with threat, the brain turns it on.

I think the good thing about Explain Pain pain, is that it can be easily explained and it makes a wonderful example of pain not related to tissue damage. After all reading a book like “Explain Pain” is unlikely to strain any muscles or joints.

Therapeutic education

The NOI group, through seminars around the world and publications teach a specialised form of therapeutic education, aimed in particular at people with problematic pain states.

There are a number of therapeutic education styles available in the world, broadly categorised as structural education (knowledge is provided about anatomy and physiology), psychological education (e.g. “The Back Book” and “Manage your Pain”) and in particular for NOI education – a blend with a twist – the neuroscience education style of which “Explain Pain” is the best example.

Explain Pain was written by David Butler and Lorimer Moseley in response to clinical practice and research including a series of studies (Moseley, Hodges et al. 2004) showing that if a person in pain understands the basic biology of why they hurt and are armed with coping strategies to self manage, they will move better, be more functional and have far better moods.

The key is that somehow we need to understand that persistent pains are constructed in the head and if we can understand this we will be better off. Unfortunately many people have been told “it's all in your head” in a derogatory way. Somehow, for chronic pain sufferers "it's in your head" has to be provided in a beneficial way. This blog addresses this huge area. Moseley GL et al 2004 Clinical Journal of Pain 20: 324-330.