Category Archives: Functional Pain Syndromes

22Oct/14
IMG_1693.JPG

Girls, stress and pain

Stress and painI have seen a number of teenage girls over the past year who are affected by chronic pain. They are often referred because of recurring headaches or migraines but we discover that there is widespread sensitive at play. How does this happen? Why does it happen?

Headaches and migraines can be functional pains. When these pains are part of a picture of sensitivity, often accompanied by anxiety, there are often other problems such as irritable bowel syndrome, pelvic pain and jaw pain. Whilst these problems all appear to be different, they have a common biology. Typically I work with women aged between 30 and 55 who suffer these aches and pains, but increasingly this is an issue of the younger female. Having said that, when I explore the story of an adult, we often find reasons for sensitivity that begin in childhood. This priming sets the scene for later events.

As adults we face many challenges. We have body systems that are trigged by these challenges, especially if we think they are threatening to us. In particular the autonomic nervous system (ANS) is quite brilliant at preparing us to fight or run away, which is very useful…..if you are facing a wild animal. On a day to day basis, it is in fact useful for the ANS to kick in and create some feelings in the body that alert us to danger — the caveat being, nothing is dangerous until it is interpreted as so, and hence we need a construct of ‘danger’ and of the thing that is perceived to be dangerous. For example, a baby may not have the construct of a lion and hence sees this big, cuddly, moving….thingy…like my teddy (may not have a construct for any of these either!), and essentially detects no threat. As the baby detects no threat, he or she behaves in a way that may not threaten the lion and hence the lion may feel safe. Both feeling safe, they become friends. Perhaps — these things have happened apparently. Please do not try this at home, but hopefully you get the idea. Back to day to day….

London Fibromyalgia ClinicsIn the modern world we often feel anxious. This is the body warning us that something is threatening. In many cases that I see, there is a strong reaction to banal events and non-threatening cues. Or if the cue is worthy of attention, the response is well out of proportion — e.g. utter panic and defensive thinking-behaviours. To what do we respond most frequently? Definitely not lions. Muggers? Gunmen? Earthquakes? Tidal waves? These are all inherently dangerous situations, that we simply do not often face. Sadly some people do have such encounters but the majority of us do not. The answer is our own thinking. The thoughts that are evoked — seemingly appearing form nowhere at times — are not the actual problem but instead the interpretation of the thought (metacognotion; our thinking about our thinking). The meaning that we give to a thought, often automatically, will determine the body response as our thoughts are embodied. And just to complicate things further in relation to thinking, there’s a world of difference between the experiencing-self and the memory-self. The former refers to what is happening right now, the latter to what we remember, or think we remember. In terms of pain, if our memory of a painful event concludes with a high level of pain, this will flavour the memory-self and we will report as such. The story, which is a snapshot within our lives, and how it turns out has a huge impact upon the subsequent memory of what happened.

The adult within an environment that becomes threatening, the workplace for example, can become very responsive to different cues that once were innocuous. Now they pose a potential danger and each time that happens and we respond with protective thinking and behaviours, the relationship becomes stronger — conditioning. There is no reason any this cannot be the same for younger people who are consistently within an environment and context that begins to pose a threat; a demanding school environment with high expectations plus the child’s own expectations and perfectionist traits. Place this context within a changing period of life and minimal time for rest and there is the risk of burn out or development of problems that involve many body systems. We cannot, no matter what age we are, continue to work at a level that is all about survival.

I focus on girls and women because females outnumber the males coming to the clinic. Many are perfectionist, many are hypermobile, many are anxious, many are in pain and many are suffering. This is a situation that needs addressing worldwide, and starts with understanding what is happening, why it is happens and how it happens. Over the past 10 years this understanding has evolved enormously, providing tangible ways forward. This does not mean that we need to change perfectionism, but rather recognise it and use it wisely; this does not mean that anxiety is abnormal, but rather recognise it as a normal emotion that motivates learning and action; this does not mean that feeling pain is a problem to fear, but rather know it can change when we take the right action; and it does not mean that we will not suffer, but rather accept that part of living involves suffering that we can overcome and move on.

We have created an incredible, fast moving world. The body does not work at such a pace. It needs time to refresh and renew so that we can think with clarity and perform to a high level, achieve and be successful. We are humans. We are a whole-person with no division between body and mind; instead one thinking, feeling, sensing, creating, moving and living entity responding to the experience of the now and to memory of what we think happened. Gaining control over this with understanding and awareness provides a route forward to wellbeing, no matter where the start point.

+++

If you are suffering with persisting pains — body pain, joint pain, irritable bowel syndrome (IBS), headache, migraine, pelvic pain, jaw pain + feeling anxious, unwell, tired — call now and start moving forward 07518 445493 | Clinics in Harley Street, Chelsea and New Malden

06May/14
London Fibromyalgia Clinics

London Fibromyalgia Clinics | London FMS Clinics

London Fibromyalgia ClinicsI think differently about fibromyalgia, functional pain syndromes and chronic pain. Believing that there is a need to challenge the way these problems are addressed, I created a specialist clinic that draws upon neuroscience, philosophy and other disciplines to create innovative and effective ways for individuals to move forward in their lives.

Fibromyalgia is known as a functional pain syndrome, sharing a common biology with other problems such as migraine, irritable bowel syndrome (IBS), pelvic pain, musculoskeletal pain and painful bladder syndrome. This common biology is an adaptation in the central nervous system called central sensitisation with changes in the excitability of the nervous system alongside on-going responses of the immune system. The way that the body systems and the brain adapt and learn means that it has become persistently protective, igniting painful and other responses to a range of normal cues and situations. The sensitivity results in on-going pain and general sickness responses (e.g./ aches and pains, tiredness, fatigue, appetite changes, mood changes, anxiety, loss of concentration, brain fog, altered body sense); the latter just like a feeling of the flu.

Stress often plays a role. Stress is a response to a perceived threat, the meaning of which we give to the situation as an individual. The physiology that follows is designed to protect us from wild animals — either to run away or fight. Whilst this is useful when danger presents itself and in the short-term, if these responses continue, they impact upon the immune system, switch off the digestive system and reproductive system (neither eating or digesting a meal are useful in the face of danger; reproduction is not useful in the face of danger — resulting in a sensitive and/or sluggish gut, and fertility problems), prepare the motor system and mobilise energy in preparation for flight or fight.

London Fibromyalgia ClinicsIt is a combination of genetics and experience that results in the condition. Our genes are moulded by these experiences and to what we are exposed: stress, injury, pathology. Protection is triggered but not turned off, the responses continuing as if there is a problem, even when it is resolved. These on-going responses then create further changes, for example chronic inflammation, and a continued loop that maintains the condition. That is until the circumstances are changed and the conditions created to move out of the loop and onto a route of wellbeing.

Believing that pain can and does change via neuroplasticity, I create bespoke treatment and training programmes for individuals who visit the clinic from all over the UK. The programmes ensure that you fully understand the problems and comprehensively target the biological mechanisms addressing the physical, cognitive and emotional dimensions. I help you to develop the knowledge and skills that you need to move forward in your life with a range of proactive strategies, techniques and treatments grounded in neuroscience.

Call now to book your initial consultation: 07932 689081

14Jan/14
Turned on?

Are you turned on?

Turned on?

Turned on?

At the risk of sounding ambiguous, many people are turned on. In particular, city dwellers and workers who are being hit with innumerable stimuli, bombarding the senses, triggering on-going responses by the brain, the mind and the body. Whether it be the noise of the traffic, the lights at night, the phantom vibrations of the phone, pollution or close-quarter travel on the train, outputs are being generated by the nervous system, the immune system and the endocrine system that are experienced as thoughts, feelings and physical sensations, some being pleasant, others not so.

Once a chronic state of arousal has been reached, the on-going energy demands can eventually result in burn-out or a gradual state of declining physical and mental health — the two being inextricably linked.

How does this manifest?

The all-too common conditions that we see include general body-wide muscular aches and pains, headaches and migraines, irritable bowel syndrome (IBS), anxiety, indigestion, pelvic pain, fertility issues. The thread that ties these seemingly unrelated problems is stress. Stress however, is a physiological response to a situation that is perceived to be threatening. Two people can give entirely different meanings to a particular scenario, thereby having diverse experiences — it is all about an individual’s perception. Our perception is based upon beliefs about the world, sculpted over the years by exposure and influences.

stress-2The biological response to threat involves the autonomic nervous system and the motor system at least, preparing to either flee from the danger or confront the situation. An incredible set of responses, they evolved from the need to deal with wild animals. Fortunately this does not happen too often these days, but there are plenty of potential threats including the thoughts that pass through our mind. The brain does not differentiate between a thought and actually being present. The response is similar and usually thinking about something unpleasant that may happen will lead to feelings of anxiety — tingling in the tummy, tension, increased pain.

If these systems are persistently triggered by stress, there is less opportunity for smooth digestion, conception, healing and clarity. Being chronically turned on hence results in digestive issues, sensitivity of the bowel (bloating, pain etc), difficulty conceiving (thoughts of sex and conceiving are not going to be high on the brain’s agenda if there is a constant perception of danger) and pain that results from gradual changes in the tissues. In fact, every body system is impacted upon by the chemicals released during an on-going stress response. And not in a good way. Performance is affected, mood varies, sleep is disrupted, concentration is poor, catastrophising becomes rife and negative thinking about life predominates.

How do we turn off?

Specialist Pain Physio Clinics in London for pain, complex pain and injuryRelaxation or having the ability to switch off is often a skill that requires learning and practice. Going to the gym, having a cigarette or a coffee is not turning off. These are all stimulating a system that is already fraught. It is the calming, restorative, digestive and healing mechanisms that need to be fortified.

Promoting calm in a habitual way across the day is a potent way of re-programming the right responses for the right scenarios. Checking in on the body and thought processes, attending to the present moment rather than automatically drifting into the past or future, avoiding stimulation (e.g./ electronic screens, coffee, cigarettes, sugary foods and drink, certain reading material), mindful practice, breathing techniques and cultivating focused attention are all ways in which we can build our positive bank account in terms of energy and feeling good. Creating good habits. Exercise although stimulating, and certainly in a gym with bright lights and loud music, should form part of a routine for the overall healthy benefits. It is the best wonder drug that we know of and it is free.

Changing behaviours is difficult but it is achievable with the right programme that addresses both body and mind. Cultivating a routine around sleep, movement, diet, exercise, mindfulness, work and family will groove a healthy, resilient, positive and happy path forward. Turn off.

For more on our healthy programme and treatment for painful conditions, stress and anxiety, call us now on 07932 689081

10Dec/13
Brain~Body

Uncomfortably numb

Feeling numb can mean that the self has lost its physical presence, or in an emotional sense, feelings have become blunted. These are both different constructs of loss for which we are compelled to seek an answer, often causing great angst. To step out of the normal sense of self is profound, difficult to define and causes suffering, whereby one has lost his or her role.

Physical numbness, if we can say this, will usually be described in terms of a body region feeling different. Altered body sense is a common finding in persisting pain states and in post-traumatic stress disorder (PTSD). In extreme situations, an out of body experience can be described where the person views themselves from an outsider’s perspective, in the third person. Often though, one refers to numbness as an area with reduced or no sensation. This can be objective such as when a stimulus (eg/ a pin prick; a light brush) is applied to the body surface and the sensation is lacking; or subjective when an area is felt to be numb yet a stimulus can be felt normally.

Although numbness in the the body is not painful per se, it is often tarnished with an aversive element that is described as unpleasant. This seems to be a particular issue in the extremities; conditions that involve nerves such as Morton’s neuroma. The mismatch between what is physically present and can be seen yet not felt, is difficult to understand and compute until the construct is explained.

An explanation: the body is felt via its physical presence in space, interacting with the immediate environment, yet is ‘constructed’ by networks of neurons in the brain. These neurons or brain regions are integrated, working like superhighways in many cases, thereby enhancing certain experiences or responses. At any given moment, the feelings that we feel and the physical sensations that we experience are a set of responses that the brain judges to be meaningful and biologically useful. The precision with which we sense our physical self and move is determined by accurate brain (cortical) representations or maps of the body. These maps are genetically determined yet moulded with experience, for example the way the hand representation changes in a violinist. Similarly, when pain persists we know that the maps change and thereby contribute to the altered body sense that is frequently described. It is worth noting that patients can be reluctant to charge their altered body experiences for fear of disbelief when in fact they are a vital part of the picture.

Emotional numbness is consistent with physical numbness in the sense of a stunted experience, whereby the expected or normal feeling in response to a situation fails to emerge. Rather, something else happens thereby creating a mismatch between the expected feeling and that which occurs. This experience manifests as a negative and is not discriminatory, affecting a range of emotional responses. A sense of detachment from the world often accompanies the lack of feeling. One could argue that this is a form of protection against feelings of vulnerability where we can also use our physical body, our armour, to shield us from the threat. Of course the threat is down to our own perception of a situation, another example of a brain construct. A situation is a situation but we provide the meaning based upon our own belief system and respond accordingly, often automatically.

Cultivating a normal sense of self is, in my view, the primary aim of rehabilitation and this encompasses both the physical and emotional dimensions. Both are influenced by thoughts, the cognitive dimension, that emerge from our belief system that drives behaviours. Hence, a programme design must reflect the interaction as it presents in the individual, most of the clues residing in the patient’s narrative that we must attend to in great detail. Validating the story and creating meaning is the first step towards a normal sense of self, to be enhanced with specific sensorimotor training and cognitive techniques such as mindfulness based stress reduction and mindfulness per se.

Wider thinking and practice is desperately required in tackling the problem of persisting pain. One of many responses to threat, pain is part of the way in which we protect ourselves along with changes in movement and other drivers to create the conditions for recovery. Sadly, many people ignore or miss these cues in the early stages through being fed inaccurate information about pain and injury. Many common ailments that can become highly impacting and distressing such as irritable bowel syndrome, headaches, pelvic pain, widespread musculoskeletal pain, anxiety, fertility issues and low mood, gradually creep up on us as the sensitivity builds over a period of time; the slow-burners. An answer to these problems that are typically underpinned by central sensitisation and altered immune-endocrine functioning, is to create awareness and habits that do not continually provoke ‘fright or flight’ responses that essentially shut down many systems in readiness for the wild animal that is not present. Actually, the wild animal is the emotional brain that when untamed can and does create havoc through the body, affecting every system.

The ever-evolving science and consequent understanding now puts us in a great position to trigger change. Initially discussing numbness, I have purposely drifted toward a more comprehensive view looking down on the complexity of the problems that we are creating in modern existence, manifesting as common functional pains. As much as we are knowing more and more about these conditions, we are actually describing the workings of the different body systems in response to a perceived threat that may or may not exist. This is always multi-system: nervous, immune, endocrine etc. and all must be considered when we are thinking about a pain response. But let’s not just think about pain as this is one aspect of the problem, one part of the emergent experience for the individual — think movement, think language, think body language, think ‘how can we reduce the threat’ for this individual so as to change their experience of their body responses. It is at this point that we see a shift and it is possible in all of us. We are designed to change and grow and develop, so let’s create the conditions for that change physically, cognitively and emotionally.

10Jul/13

Women and Pain Clinic @ 132 Harley Street

The Women and Pain clinic is dedicated to providing contemporary treatment, training and coaching for females who suffer persisting pain.

Common examples of on-going painful problems include:

  • pelvic pain: including pain from endometriosis, bladder problems, muscular spasm & guarding of the pelvis and abdominal area
  • back pain
  • joint pain (often multiple)
  • abdominal pain (irritable bowel syndrome or similar sensitivities)
  • migraine & headache
  • jaw pain & dysfunction
  • fibromyalgia

It is not uncommon for there to be several painful areas that are seemingly unrelated. However, with the advancing understanding of the neurobiology of pain, we know that there is a common thread that ties these problems together. This is termed central sensitisation and refers to adaptations within the nervous system that both amplify pain and reduce our natural ability to dampen sensitivity. The body areas that hurt can expand and involve a range of body systems, hence why the pain can manifest in different regions and organs. The pain is an expression of this underlying sensitivity that needs to be targeted at a nervous system-immune system-endocrine system level as well as addressing the health of the body tissues. We use a contemporary and neuroscience-based programme of treatment, training and coaching to tackle the problem of pain, focusing upon the inter-related dimensions of pain: physical-cognitive-emotional.

Working closely with leading gynaecologists and gastroenterologists in Harley Street, you will have a detailed assessment that includes diagnostics as indicated, a full explanation of the nature of the pain and symptoms (pain education) and a comprehensive treatment programme designed for you. 

How do we treat these problems?

A pathological or structural basis for pain only explains part of the problem or in some cases not at all. It is the adaptations within body systems that create the pain experience to which we respond in thought and action. Whilst acute pain serves a vital survival purpose, drawing our attention to a body region that needs protecting for healing, a persisting pain becomes increasingly about the neuroimmune system and endocrine system responses. Pain certainly emerges from the body yet there is an underpinning correlate of activity within a vast network of brain cells that actually drives the experience. This network monitors the activity in the body systems and responds according to need. The response can be protective when the brain perceives the body to be in potential danger and includes pain, changes in movement and a range of other actions. In the early stages of a condition this is useful and adaptive, however if these responses continue beyond a useful time they themselves must be targeted alongside body nourishing strategies.

How can we target these systems? In an integrated manner, these systems can be re-trained with a range of sensorimotor techniques, specific exercises designed to restore a normal sense of the body and movement, strategies to deal with stress and anxiety that both affect the body systems, techniques for the progression of day to day living (work, home, sports), and general activity and exercise with confidence. Interlaced with these strategies, pain education (reduce the threat by developing your understanding of pain and the body’s ability to change), mindfulness-based stress reduction, focused attention training, resilience, coping and motivational skills, are used to optimise outcomes that are based upon improving your quality of life, sense of wellness and performance.

For further information, to book an appointment or to refer a patient please call us on 07932 689081

05Nov/12
Endometriosis & melatonin | Women and pain series

Women and pain | Part 1

‘As many as 50 million American women live with one or more neglected and poorly understood chronic pain conditions’ 

Generally I see more female patients than male. This observation supports the view that chronic pain is more prevalent in women than in men for some conditions – see the International Association for the Study of Pain fact sheet here. There are some ideas as to why this may be, including the role of the sex hormones and psychosocial factors such as emotion, coping strategies and roles in life. Additionally, experimental studies have shown that women have lower pain thresholds (this is a physiological reading) and tolerance to a range of pain stimuli when compared to men although this does not clarify that women actually feel more pain – see here. Pain is a subjective experience of course, and modulated by many factors.

A campaign for women’s pain | Chronic pain in women (2010) report

It is not uncommon for a female patient to tell me about her back pain and continue the narrative towards other body areas that hurt and cause problems. This may include pelvic pain, migraine, headache, irritable bowel syndrome, chronic knee pain, widespread sensitivity and gynaecological problems (including dysmenorrhoea, endometriosis and difficulty conceiving). These seemingly varied conditions are typically looked after by a range of medical and surgical disciplines: gynaecology, neurology, rheumatology, gastroenterology and orthopaedics. More recent science and thinking has started to join the dots on these problems, offering new insight into the underpinning mechanisms and more importantly approaches that can affect all the conditions in a positive way. This is certainly my thinking on this hugely significant matter.

Reconceptualising pain

Undoubtedly pain is complex. This is particularly the case when pain persists, disrupting and impacting upon life. Reconceptualising pain according to modern neuroscience is making a real difference to how we think and treat pain – see this video. Briefly, thinking of pain as an output from the brain as a result of a complex interaction of circumstance, biology, thought, emotion and memory begins to give an insight into the workings of the brain and body. Pain is individual, it is in the ‘now’ but so coloured by the past and what it may mean to the individual. The context or situation in which the pain arises is so very important. We talk about pain from the brain but of course we really feel it in our physical bodies, but the location is where the brain is projecting the sensation – see this video.

Neuroscience has shown us that the danger signals from the body tissues are significantly modulated by the brain before the end output is experienced. Factors that influence the messages include attention, expectation and the circustance in which the individual finds herself. We have powerful mechanisms that can both facilitate and inhibit the flow of these signals and these reside within the brain and brain stem. For this reason we must consider the person’s situation, their expectations, hopes, goals, past experiences and current difficulties, and how these can affect their current pain.

Stress & emotion

Any hugely emotive issue within someone’s life can impact enormously upon pain and sensitivity. This can be the stress of a situation including caring for a relative, losing someone close, work related issues and divorce. The problem of conception certainly features in a number of cases that I see, causing stress and turmoil for both partners but clearly in different ways. Fertility receives a great deal of attention in the media and there are a many clinics offering treatment and therapies, in effect raising awareness and attention levels towards the problem. The pain caused by difficulties having children can manifest physically through the stress that is created by the situation. Thoughts, feeling and emotions are nerve impulses in the brain like any other and will trigger physical responses including tension. Stress physiology affects all body systems, for example the gastrointestinal system (e.g./ irritable bowel), nervous system (e.g. headaches, back pain) and the immune system (e.g. repeated infections).

Lifestyle

Lifestyle factors play a significant role in persisting pain. Modern technology and habits that we form easily may not be helpful when we have a sensitive nervous system. For example, sedentary work, the light from computer screens, pressures at work, limited exercise, poor diet, binge drinking and smoking to name but a few. All are toxic in some way as can be our own thinking about ourselves. When we have a thought, and we have thousands each day, and we pay attention, becoming absorbed in the process, the brain reacts as if we are actually in that situation. Consequently we have physical and emotional responses that can be repeated over and over when we dwell on the same thinking. This is rumination and is likely due to ‘hyper-connectivity’ between certain brain areas – see here. We can challenge this in several ways including by changing our thinking and using mindfulness, both of which will alter brain activity and dampen these responses. It does take practice but the benefits are attainable for everyone.

In summary, the underlying factors that must be addressed are individual and both physical and psychological. Pain is complex and personal, potentially affecting many different areas of life. How we live our lives, what we think and how we feel are all highly relevant in the problem of pain as borne out of sensible thinking and the neuroscience of pain. Understanding the pain, learning strategies to reduce the impact, receiving treatment that targets the underlying mechanisms, making healthy changes to lifestyle and developing good habits alongside the contemporary brain based therapies can make a huge difference and provide a route forwards.

For information on our ‘join the dots’ treatment programmes for chronic pain, contact us here or call 07932 689081

 

21Jan/12

Central sensitisation is more common than you may think

Clifford Woolf recently said this about central sensitisation:

Nociceptor inputs can trigger a prolonged but reversible increase in the excitability and synaptic efficacy of neurons in central nociceptive pathways, the phenomenon of central sensitization. Central sensitization manifests as pain hypersensitivity, particularly dynamic tactile allodynia, secondary punctate or pressure hyperalgesia, aftersensations, and enhanced temporal summation. It can be readily and rapidly elicited in human volunteers by diverse experimental noxious conditioning stimuli to skin, muscles or viscera, and in addition to producing pain hypersensitivity, results in secondary changes in brain activity that can be detected by electrophysiological or imaging techniques. Studies in clinical cohorts reveal changes in pain sensitivity that have been interpreted as revealing an important contribution of central sensitization to the pain phenotype in patients with fibromyalgia, osteoarthritis, musculoskeletal disorders with generalized pain hypersensitivity, headache, temporomandibular joint disorders, dental pain, neuropathic pain, visceral pain hypersensitivity disorders and post-surgical pain. The comorbidity of those pain hypersensitivity syndromes that present in the absence of inflammation or a neural lesion, their similar pattern of clinical presentation and response to centrally acting analgesics, may reflect a commonality of central sensitization to their pathophysiology. An important question that still needs to be determined is whether there are individuals with a higher inherited propensity for developing central sensitization than others, and if so, whether this conveys an increased risk in both developing conditions with pain hypersensitivity, and their chronification. Diagnostic criteria to establish the presence of central sensitization in patients will greatly assist the phenotyping of patients for choosing treatments that produce analgesia by normalizing hyperexcitable central neural activity. We have certainly come a long way since the first discovery of activity-dependent synaptic plasticity in the spinal cord and the revelation that it occurs and produces pain hypersensitivity in patients. Nevertheless, discovering the genetic and environmental contributors to and objective biomarkers of central sensitization will be highly beneficial, as will additional treatment options to prevent or reduce this prevalent and promiscuous form of pain plasticity.

And Latremolier

Central sensitization represents an enhancement in the function of neurons and circuits in nociceptive pathways caused by increases in membrane excitability and synaptic efficacy as well as to reduced inhibition and is a manifestation of the remarkable plasticity of the somatosensory nervous system in response to activity, inflammation, and neural injury. The net effect of central sensitization is to recruit previously subthreshold synaptic inputs to nociceptive neurons, generating an increased or augmented action potential output: a state of facilitation, potentiation, augmentation, or amplification. Central sensitization is responsible for many of the temporal, spatial, and threshold changes in pain sensibility in acute and chronic clinical pain settings and exemplifies the fundamental contribution of the central nervous system to the generation of pain hypersensitivity. Because central sensitization results from changes in the properties of neurons in the central nervous system, the pain is no longer coupled, as acute nociceptive pain is, to the presence, intensity, or duration of noxious peripheral stimuli. Instead, central sensitization produces pain hypersensitivity by changing the sensory response elicited by normal inputs, including those that usually evoke innocuous sensations. PERSPECTIVE: In this article, we review the major triggers that initiate and maintain central sensitization in healthy individuals in response to nociceptor input and in patients with inflammatory and neuropathic pain, emphasizing the fundamental contribution and multiple mechanisms of synaptic plasticity caused by changes in the density, nature, and properties of ionotropic and metabotropic glutamate receptors.

In essence we are talking about changes within the central nervous system that underpin the widespread, unpredictable and varied nature of persisting pain.

When I am listening to a patient, observing their movements and performing a ‘multi-system’ examination, I am in part looking for the pain mechanisms at play, including central sensitisation. Several of my questions are: ‘what is going on here to create this experience for the person in front of me?’, ‘why are the nervous and other systems responding in such a way?’ and ‘what is influencing the behaviour of those systems?’. I really need to know what it is that is prolonging this protection and is it really worthwhile for the individual.

Suspecting that there is a component of central sensitisation at play in many cases of chronic pain that I see, it is pleasing to see a group looking at this closely and finding evidence to support this thinking:

J Bone Joint Surg Br. 2011 Apr;93(4):498-502.

Evidence that central sensitisation is present in patients with shoulder impingement syndrome and influences the outcome after surgery.

Gwilym SE, Oag HC, Tracey I, Carr AJ.

Source

Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX3 7LD, UK. [email protected]

Abstract

Impingement syndrome in the shoulder has generally been considered to be a clinical condition of mechanical origin. However, anomalies exist between the pathology in the subacromial space and the degree of pain experienced. These may be explained by variations in the processing of nociceptive inputs between different patients. We investigated the evidence for augmented pain transmission (central sensitisation) in patients with impingement, and the relationship between pre-operative central sensitisation and the outcomes following arthroscopic subacromial decompression. We recruited 17 patients with unilateral impingement of the shoulder and 17 age- and gender-matched controls, all of whom underwent quantitative sensory testing to detect thresholds for mechanical stimuli, distinctions between sharp and blunt punctate stimuli, and heat pain. Additionally Oxford shoulder scores to assess pain and function, and PainDETECT questionnaires to identify ‘neuropathic’ and referred symptoms were completed. Patients completed these questionnaires pre-operatively and three months post-operatively. A significant proportion of patients awaiting subacromial decompression had referred pain radiating down the arm and had significant hyperalgesia to punctate stimulus of the skin compared with controls (unpaired t-test, p < 0.0001). These are felt to represent peripheral manifestations of augmented central pain processing (central sensitisation). The presence of either hyperalgesia or referred pain pre-operatively resulted in a significantly worse outcome from decompression three months after surgery (unpaired t-test, p = 0.04 and p = 0.005, respectively). These observations confirm the presence of central sensitisation in a proportion of patients with shoulder pain associated with impingement. Also, if patients had relatively high levels of central sensitisation pre-operatively, as indicated by higher levels of punctate hyperalgesia and/or referred pain, the outcome three months after subacromial decompression was significantly worse.

********

Treat the brain, treat the pain

Arthritis Rheum. 2009 Sep 15;61(9):1226-34.

Psychophysical and functional imaging evidence supporting the presence of central sensitization in a cohort of osteoarthritis patients.

Gwilym SE, Keltner JR, Warnaby CE, Carr AJ, Chizh B, Chessell I, Tracey I.

Source

University of Oxford, Oxford, UK. [email protected]

Abstract

OBJECTIVE:

The groin pain experienced by patients with hip osteoarthritis (OA) is often accompanied by areas of referred pain and changes in skin sensitivity. We aimed to identify the supraspinal influences that underlie these clinical manifestations that we consider indicative of possible central sensitization.

METHODS:

Twenty patients with hip OA awaiting joint replacement and displaying signs of referred pain were recruited into the study, together with age-matched controls. All subjects completed pain psychology questionnaires and underwent quantitative sensory testing (QST) in their area of referred pain. Twelve of 20 patients and their age- and sex-matched controls underwent functional magnetic resonance imaging (MRI) while the areas of referred pain were stimulated using cold stimuli (12 degrees C) and punctate stimuli (256 mN). The remaining 8 of 20 patients underwent punctate stimulation only.

RESULTS:

Patients were found to have significantly lower threshold perception to punctate stimuli and were hyperalgesic to the noxious punctate stimulus in their areas of referred pain. Functional brain imaging illustrated significantly greater activation in the brainstem of OA patients in response to punctate stimulation of their referred pain areas compared with healthy controls, and the magnitude of this activation positively correlated with the extent of neuropathic-like elements to the patient’s pain, as indicated by the PainDETECT score.

DISCUSSION:

Using psychophysical (QST) and brain imaging methods (functional MRI), we have identified increased activity with the periaqueductal grey matter associated with stimulation of the skin in referred pain areas of patients with hip OA. This offers a central target for analgesia aimed at improving the treatment of this largely peripheral disease.

19Dec/11

Healthy tissues in 1-2-3

The simple fact is that our tissues need movement to be healthy. By tissues I am referring to muscles, tendons, ligaments, bones, fascia and skin. This does not need to be extreme movement but it must be regular and purposeful. Even without pathology, pain or an injury it is vital that the tissues are moved consistently throughout the day. It is likely that if you are recovering from a pain state, this movement will need to be ‘little and often’ to follow the principle of ‘motion is lotion’. I love this phrase. It was coined by the NOI Group guys and I use it frequently. At the moment I a considering some other phrases with similar meanings. If anyone has any suggestions please do comment below.

There are many types of movement from simple stretching to walking and more structured exercise such as yoga.  For convenience I talk to patients about the ‘themes’ of the treatment programme. In relation to movement there are three themes 1-2-3: specific exercises to re-train normal movement and control of movement, general exercise and the self-care strategies to be used throughout the day.

The specific exercises could include re-learning to walk normally, to re-establish normal control of the ankle or to concurrently develop confidence such as in bending forwards in cases of back pain. Normal control of movement is a fundamental part of recovery. When the information from the tissues to the brain is accurate, there is a clear view on what is happening, menaing that the next movement is efficient and so on.

General exercise is important for our health in body and mind. As well as reducing risk of a number of diseases, our brains benefit hugely from regular exercise. We release chemicals such as serotonin that make us feel good, endorphins that ease pain and BDNF that works like a miracle grow for brain cells. Gradually increasing exercise levels is a part of the treatment programme for all of these reasons.

Move from your seat, or buy one of these!

Regularly punctuating static positions with movement nourishes the tissues and the brain’s representation of the body. The tissues will tighten and stiffen when they remain in one position for a long period of time, and more so when there is pathology or pain. Often there is already overactivity in the muscular system when we are in pain as part of the way the brain defends the body. This overactivity leads to muscle soreness that can be eased with consistent movement.

These three simple measure are behaviours. Behaviours are based on our belief system and therefore we need to understand why it is so important to move and re-establish normal control of movement as part of recovering from an injury or pain state. This includes tackling any issues around fear of movement and hypervigilance towards painful stimuli from the body. Our treatment programmes address these factors comprehensively, employing the biopsychosocial model of care and the latest neuroscience based knowledge of pain.

Email [email protected] for more information about our treatment programmes or to book an appointment.

21Oct/11

Using neuroscience to understand and treat pain

Neuroscience to treat pain and injury

I love neuroscience. It makes my job much easier despite being a hugely complex subject. Neuroscience research has cast light over some of the vast workings of our brains and helped to explain how we experience ourselves and the richness of life. An enormous topic, in this blog I am briefly going to outline the way in which I use contemporary neuroscience to understand pain and how we can use this knowledge to treat pain more effectively. This is not about the management of pain, it is the treatment of pain. Management of pain is old news.

Understanding pain is the first step towards changing the painful experience. Knowing how the brain and nervous system operate allows us to create therapies that target the biological mechanisms that underpin pain. Appreciation of the plastic ability of the nervous system from top to bottom–brain to periphery–provides us with the opportunity to ‘re-wire’, and therefore to alter the function of the system and make things feel better. Knowing the role of the other body systems when the brain is defending us, is equally important. The synergy of inputs from the immune system, endocrine system and autonomic nervous system provides the brain with infomration about our internal physiology that it must scrutinse and act upon in the most appropriate way. We call this action the brain’s ‘output’ which is the responses that it co-ordinates to promote health and survival.

Treat the brain and to reduce pain

Excellent data from contemporary research tells us that understanding pain increases the pain threshold (harder to trigger pain), reduces anxiety in relation to pain and enhances our ability to cope and deal with the pain. We know that movement can also improve after an education session. This is because the perceived threat is reduced by learning and understanding what is going on inside, and knowing what can be done. The vast majority of patients who come to the clinic do not know why their pain has persisted, what pain really is, how it is influenced and what they can do about it themselves. For me this is the start point. Explaining the neuroscience of pain. Facts that we know people can absorb, understand and apply to themselves in such a way that the brain changes and provides a different experience.

It is the brain that gives us our experience of ourselves and the world around us. This includes the sensory and emotional experience of pain. The brain receives information from the body via the peripheral nervous system that suggests there is a threat to the tissues (input). In response, the brain must decide whether this threat is genuine based upon what is happening at the time, the emotional state, past experience, the belief system, gender, genetics, health status, culture and other factors. In the case that the brain perceives a threat, the output will be pain. The Mature Organism Model developed by Louis Gifford describes this beautifully (see below).

Pain is a motivator. It grabs our attention in the area of the body that the brain feels is threatened based upon the danger signals it is receiving from the tissues via the spinal cord. The brain actually ascribes the location of the pain via the map of the body that exist in the sensory cortex. On feeling the pain, we take action. This is the reason for pain. It motivates us to move, seek help or rest. Pain is an incredible device that we have for survival and learning, necessary to navigate life and completely normal. The brain constructs the pain experience and associated symptoms in such a way that we have to take note and do something about it immediately.

When we injure tissue there is a local release of inflammatory chemicals. These chemicals excite local nerves in the tissues called nociceptors. Normally, nociceptors are quiet but when they are stimulated by inflammation, these nerves send danger signals to the spinal cord where they meet secondary neurons. The early bombardment of signals into the spinal cord causes the secondary neurons to become excited. These cells then send danger signals up to the brain where the information is scrutinised. On the basis of this scrutiny, if the brain perceives a threat, pain will be allocated in the area of the body that is deemed to be in danger. The area of pain is allocated via the representation of the body in the brain (see previous blog here) in the sensory cortex, first mapped by Wilder Penfield and published in 1951. Therefore we know that actually there is no ‘muscle pain’ or ‘knee pain’ but rather pain as a brain experience, and not in the mind I hasten to add, that is detected in a body part or region according to the brain’s perception of threat. These are the body maps that the brain uses to know where information is coming from and to control movement.

This information is part of the neuroscience knowledge that can be used to help people understand their pain and to create therapies that treat pain. Future blogs will look at how we can change and nourish the nervous system to promote healthy tissues at one end of the spectrum with the brain end being targeted by deeper education and Graded Motor Imagery (GMI) for example–click here. The brain and the tissues are not separate, they affect each other in many ways, as do other body systems such as the immune and endocrine systems. Looking at healthy movement and functioning in a truly holistic and biopsychosocial manner with neuroscience underpinnings, provides us with an exciting route forwards in dealing with pain problems.
26Sep/11

Dysmenorrhoea & Pain

You may wonder why I am writing about dysmenorrhoea. It is because in a number of cases that I see, there is co-existing dysmenorrhea and other functional pain syndromes. These include irritable bowel syndrome (IBS), migraine, chronic low back pain, pelvic pain, bladder pain and fibromyalgia. Traditionally all of these problems are managed by different specialists with their particular end-organ in mind—e.g./ IBS = gastroenterologist; migraine = neurologist; fibromyalgia = rheumatologist. The science however, tells us that these seemingly unrelated conditions can be underpinned by a common factor, central sensitisation. This is not a blog about dysmenorrhoea per se, but considers the problem in the light of recent scientific findings and how it co-exists with other conditions.

Central sensitisation is a state of the central nervous system (CNS)—the spinal cord and the brain. This state develops when the CNS is bombarded with danger signals from the tissues and organs.  It means that when information from the body tissues, organs and systems reaches the spinal cord, it is modified before heading up to the brain. The brain scrutinises this information and responds appropriately by telling the body to respond. If there is sensitisation, these responses are protective and that includes pain. Pain is part of a protective mechanism along with changes in movement, activity in the endocrine system, the autonomic nervous system and the immune system. Pain itself is a motivator. It motivates action because it is unpleasant, and provides an opportunity to learn—e.g./ do not touch because it is hot. This is very useful with a new injury but less helpful when the injury has healed or there is no sign of persisting pathology.

Understanding that central sensitisation plays a part in these conditions creates an opportunity to target the underlying mechanisms. This can be with medication that acts upon the CNS and with contemporary non-medical approaches that focus upon the spinal cord and brain such as imagery, sensorimotor training, mindfulness and relaxation. In this way, dysmenorrhoea can be treated in a similar fashion to a chronic pain condition although traditionally it is not considered to be such a problem. The recent work by Vincent et al. (2011) observed activity in the brains of women with dysmenorrhoea and found it to be similar to women with chronic pain, highlighting the importance of early and appropriate management.

The aforementioned study joins an increasing amount of research looking at the commonality of functional pain syndromes. We must therefore, be vigilant when we are assessing pain states and consider that the presenting problem maybe just part of the bigger picture. Recognising that central processing of signals from the body is altered in a number of conditions that appear to be diverse allows us to offer better care and hence improve quality of life.

* If you are suffering with undiagnosed pain, you should consult with your GP or a health professional.