The Basics

[Nick]

I really remain mystified by how resistant some people are to accepting neurobiology as the basis of pain. Thought I'd start a thread on some of the basics. I don't like to make things simpler than they actually are and pain is definitely not without complexity; however, there are some things that seem pretty self-evident once you get a little basic science under your belt:
(1) No brain, no pain
(2) The nervous system is the only tissue in the body that is truly sensitive. Everything else is sensitive because it is innervated (exceptions may be hormones and immune cells which are respnsive to their environment and, therefore, sensitive in a manner).
(3) The nervous system is chemically-sensitive, mechanically-sensitive, and temperature-sensitive.
(4) Pain releated to movement, position, or activity is primarily mechanical in origin.
(5) Mechanical sensitvity is related to some kind of restriction in neuromobility, oxygen supply to the nerve, or up-regulation of sensitivity.
(6) Central process affect all pain (see point #1)
(7) Treatment for mechanical pain should aim to reduce mechanical sensitivity
(8) Pain is not a sensation, but an experience comprised of sensation, processing, and motor response. This is not a linear or sequential process from input to output - all influence one another.
(9) All movement begins in the brain, with the exception of simple reflexes mediated by the spinal cord. Movement can be volitional or non-volitional.
(10) There are multiple points of leverage for helping people alter the pain experience; therefore, lots of things seem to help and some of them actually do!

This is my top 10, for now. Feel free to add your thoughts or critique mine. Being open to criticism and considering new things is, after all, an important way to develop new knowledge.

Nick

[nari]

There is no such thing as pain input, only output. (An extraordinary number of PTs still believe pain originates at point of injury or dysfunction)

Pain is an emotion.


nari

[Diane]

Nice list Nick, Nari. If I can think of anything else to add, I will.

[rajulvasa]

I. Feel free to add your thoughts or critique mine. Being open to criticism and considering new things is, after all, an important way to develop new knowledge.

Nick
Congratulations Nick for going to basics.It is utmost important to remain grounded with basics for any kind of advancement.
Also my salute to you for being not afraid of critiques, as you rightly said for new knowledge: to be open minded & invite healthy ctitiques is a road to further developments.

I believe if Basics of pain origin from various tissues is understood, not so many discs of lumbar spine would be sacrificed surgically & not so many back patients would come back with same pain sometimes getting worst from surgical microinjury causing further tightness & vicious circle of pain.

Therapists need to take a lead to run pain clinics with other faculties for concluding the diagnosis & treatment

[nari]

Nick

Point #10: Very true, but it gets tricky when a patient goes from one PT to another (and they do, especially the complex ones) and finds something different being applied at each clinic. At this point, they don't remember all the different techniques thrown at them, but whether the PT was nice or not.
Having worked at a pain clinic, as some of you have, this stands out and I find it personally depressing when someone with 25 years of neck pain has received traction, exercises and heat; with no result but "the PT was lovely".

So I might add a point: Education on the physiology of persistent pain in the absence of pathology, is essential for therapist and patient. How? I have nearly given up on that one.


Nari

[Barrett Dorko]

Nick,

With your permission I'll send my classes this week specifically to this thread so that they might see how much help actually turning on the computer might be.

Theoretically, we'll generate comments from about 120 new viewers, all of whom see patients with painful problems on a regular basis. They certainly could do with "The Basics."

[emad]

Hi ;

Good Basics , l liked the first basic most .

No brain ,no pain:thumbs_up

Regards
Emad

[bernard]

Education on the physiology of persistent pain in the absence of pathology
I think the phrase needs a little refinement: "in the absence of visible pathology".

It comes in (1,6)
A painful movement may not involve, a local failure in bones, joints or muscles but a light disturbance enabled by a central process that creates, a faulty feeback in the sensori-motor loop. This kind of problem is a dysfunction.

[Diane]

I disagree Bernard.. sorry Buddy, I know English isn't your first language, I don't disagree with you very often in any case.. however I prefer the way Nari put it.

If we say "visible", it implies all sorts of pathology that might be "invisible" which gives scope for all sorts of nonsense to grow.

I think the word "pathology" should be reserved for diseases in any system/cell type that are metabolic, systemic, visceral, genetic, progressive. These may result in pain, but the pain they generate won't be permanently relieved by any methods we might use.

The kind of pain we can help people eliminate is the sort that is generated by the intact nervous system itself in response to poor or non-useage of the body, not contingent upon its inherent health or lack thereof.

[bernard]

Diane,

I agree with the way you said it. I tried unfortunately to say that a disturbed neural program which not involves automaticaly neurons defects but a faulty association of opposite components may often produce a painful output.
We are asking the brain to make an ouput that is "silly" and the major result is errors in the feeback loop and pain.
Hope you understand the new explanation? :confused:

[nari]

Bernard,

Your post and Diane's remind me of the name of a little town on the West Australian coastline. Maybe it could be a signature for this topic.

It's called Useless Loop.

Nari

[Diane]

Nari your town of Useless Loop reminds me of town names on the prairies.. :)

OK, Bernard, I think we agree. Maybe if the word were changed from "visible" to "detectable" it might read better..

:),

[Nick]

Barrett,

Permission granted.


Nari,

I can't completely agree with the statement that there is no such thing as pain input. I agree that it probably should not be called pain, but the afferent signal is certainly a part of the experience. I'm not sure about pain as emotion either. Yes, there is an affective component, but also cognitive and behavioural aspects as well. I'm not sure "emotion" captures it all.

Diane,

Good points about pathology. Is pain from pathology still from mechanical or chemical processes? For instance, a tumor may not "hurt" until it has grown large enough to impinge on surrounding (innervated) tissue or is being broken down by chemo and releasing all kinds of nasty chemical irritants???

Rajulvasa,

Totally agree about pain clinics. In many cases, I think multidisciplinary intervention is unnecessary, especially if we can help these people early on with movement. Many seem to be losing sight of the critical link between pain of mechanical origin and movement. Also, physios need to realize that we are always 'talking to the brain' and that this does not make us psychologists.

I talked about leverage earlier. I think we really ought to be addressing all elements. Education and support to deal with cognitive and affective issues, movement to improve tissue health/restore mobility and bloodflow, and sensory input to alter the afferent barrage. I stopped chasing pain long ago. I stopped pretending that I could just wiggle or whack things back into place and all would be well. I stopped fooling myself that some mysterious force field generated by my intention and connection to universal harmonizing energy was flowing into my patient's fascial system and miracuously unwinding energy cysts. I realized that stretching wasn't cutting it and all those silly exercises were just a means of passing some time in the treatment room and downloading accountability for why the patient never got better. And that ultrasound was as ineffective as it was boring. Pain physiology sure seems like the 'quantum leap' this profession needs!

Nick

[Jon Newman]

Nice list Nick. I don't have much to add to a list of basics. While your list covered the following it might be appropriate to make explicit that we are amazingly adaptive (centrally and peripherally) and tend to act/move in ways that are perceived to enhance our well being (whatever that means).

[nari]

Nick

Of course there is afferent input into the processing of pain. It's calling it pain input that is erronous in my way of thinking. Semantic, maybe, but there you are.

I'm thinking of how folk like Rama, Moseley et al refer to pain as an emotion. One might argue that suffering is definitely an emotion and can be classed as one result of pain; again, it may well be academic.

Your last paragraph tells the story; stretching and strengthening, EPA, passive mobilisations...all legendary PT stuff that never ever sat well with me. Of course my cynicism often got in the way. I grew to accept, partially, that we did these things to patients which made them feel good for a day or so; and that was justifiable because we were there to make them feel better. Most did..for a day or so. Some actually felt 'normal' again and went about their lives happily on discharge. Our egos were also happy...mostly.

But in the process, the profession spent and is spending a huge amount of time and money researching stuff that we know works, or doesn't work; and in the meantime it can be 'proven' not valid because of flaws and variables.
Where is the drive, I wonder, for looking at aspects of physiotherapy with respect to known neurophysiology? Is it a fear that we are treading on psychologists' toes? I really hope not.

We certainly do talk to the brain, and not just with patients. It works both ways, as the other person's brain certainly talks back to us...often loud and clear. But we tend not to listen.

Nari

[JaneS]

Diane,
There is a paper by Siddall & Cousins (2004), which argues (successfully I think) that persistent pain is a disease in its own right. They argue that ongoing pain 'cannot be regarded as a passive symptom'. Many of the psychosocial changes are well known, so I won't repeat them. The physiological and psychological changes generated by continuous nociceptive inputs include genetic changes and changes is receptor function. The cascade of signs, symptoms and further changes are considered enough to make it a disease entity.

Unfortunately I can't get the article onto SS. However, the abstract gives a fair summary. Maybe someone else may be able to help. If the contents of this article are accepted, then pain due to 'persistent pain', as well as to isolated mechanical, chemical or thermal stimuli, could be described as an input/stimulus.

Jane

[bernard]

Anesth Analg. (http://javascript%3Cb%3E%3C/b%3E:AL_get%28this,%20%27jour%27,%20%27Anesth%20Analg.%27%29;) 2004 Aug;99(2):510-20, table of contents. Related Articles, (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Display&dopt=pubmed_pubmed&from_uid=15271732) Links (http://javascript%3Cb%3E%3C/b%3E:PopUpMenu2_Set%28Menu15271732%29;) http://www.ncbi.nlm.nih.gov/entrez/query/egifs/http:--highwire.stanford.edu-icons-externalservices-pubmed-notfree-anesthanalg-entrez.gif (http://www.ncbi.nlm.nih.gov/entrez/utils/lofref.fcgi?PrId=3051&uid=15271732&db=pubmed&url=http://www.anesthesia-analgesia.org/cgi/pmidlookup?view=long&pmid=15271732)
Persistent pain as a disease entity: implications for clinical management.

Siddall PJ (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Siddall+PJ%22%5BAuthor%5D), Cousins MJ (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Cousins+MJ%22%5BAuthor%5D).

Department of Anesthesia and Pain Management, Pain Management Research Institute, University of Sydney, Royal North Shore Hospital, St. Leonards, NSW 2065, Australia. phils@med.usyd.edu.au

Pain has often been regarded merely as a symptom that serves as a passive warning signal of an underlying disease process. Using this model, the goal of treatment has been to identify and address the pathology causing pain in the expectation that this would lead to its resolution. However, there is accumulating evidence to indicate that persistent pain cannot be regarded as a passive symptom. Continuing nociceptive inputs result in a multitude of consequences that impact on the individual, ranging from changes in receptor function to mood dysfunction, inappropriate cognitions, and social disruption. These changes that occur as a consequence of continuing nociceptive inputs argue for the consideration of persistent pain as a disease entity in its own right. As with any disease, the extent of these changes is largely determined by the internal and external environments in which they occur. Thus genetic, psychological and social factors may all contribute to the perception and expression of persistent pain. Optimal outcomes in the management of persistent pain may be achieved not simply by attempting to remove the cause of the pain, but by addressing both the consequences and contributors that together comprise the disease of persistent pain.

Publication Types:
Review (http://javascript%3Cb%3E%3C/b%3E:AL_get%28this,%20%27ptyp%27,%20%27Review%27%29;)PMID: 15271732 [PubMed - indexed for MEDLINE]

Jane, if you get the full text paper, you may share in the private section of the board => The Sound of Silence.

[Diane]

I think I know what you mean Jane.. the same thing as Butler calls central pain?

Any persistent pain that mops up easily with body work is obviously not in that category. It would be more in the category of "benign" persistent pain, that has more to do with ongoing nocioceptive input (due to misuse/abuse/nonuse of the motor output of the brain) and much less to do with central processing/receptors and neurotransmitters having gone awry from genetic causes or having been vulnerable to being driven off track by the same scenario.

I would agree that central pain is in a league of its own that way. I very much appreciate having learned about yellow flags, narrative interviewing, etc, to sort out the second from the first so as not to inadvertently treat the second sort of pain with methods much more appropriate to treating the first. I also appreciate the Explain Pain book for helping the second kind of pain people to gain greater levels of understanding.

Side story: I recently was given a lovely bouquet of flowers by a patient who returned the book to me, who had achieved a huge breakthrough in her understanding of her pain.. 7 failed back surgeries, if you can imagine.. she said it was one cartoon of a little guy holding a sign that read, "You own your own pain" that she finally took in, and understood. It was a turnaround point and she immediately began to change the way she related to her own body, went through a big emotional shift, and at the age of 39 started to learn to nurture her own physicality rather than drive herself relentlessly as an academic. She can lean on herself now. :)

[nari]

Centrally mediated pain is certainly a condition in its own right and not just a blown-up version of acute pain - but the use of the word 'disease' bothers me.
Just suggests implications of a nasty pathology being present and the meme that there is not much we can do about it.

Certainly pain should not be regarded as a passive symptom, and I am rather surprised that such a well established pain clinic assumes that people think otherwise. Where would they need to go burrowing for the cause of a 'passive' pain signal? Especially global pain??

I am surprised that such a study points out what is blatantly obvious..well, to me anyway.

Nari

[JaneS]

Bernard,
Thanks for producing the abstract.
It is not central pain to which the authors refer - although central pain would qualify as persistent pain.
Based on your replies, I realised that an abstract can only tell a certain amount. Although psychosocial issues are addressed, the paper is essentially a physiological one, dealing with pain mechanisms. Perhaps it was not a good idea to mention it here. I came across it when trying to compare physical and psych similarities between pain and tinnitus.

I'm not quite sure how you interpreted the phrase 'passive symptom'. As I read it, the term refers to the fact that ongoing pain is a trigger for further physiological and psychological changes (beyond those of acute pain). I suppose that in anoher context 'passive symptom' could also mean that pain is purely sensory with no modulation input from the brain?

The description starts at the periphery, stating the mechanism of all the changes at that level (including inflammation, afferent nerve damage and autonomic nervous system changes)the periphery. Mechanisms at the spinal cord and in cortical reorganisation and alterations to subcortical centres. Whilst physiological mechanisms are the focus in this paper, psych issues are addressed in the terms of secondary changes.

Nari, I know what you mean by the forboding term 'disease'. The authors argue for limiting stimulus input (if it can be identified and that is possible). Equally important to their argument is identifying the physiological and psychological changes which take place as a result of ongoing pain (3 months just to be arbitrary).

The paper concludes on a positive note. Where it is possible, naturally the aim is to identify the primary cause and address it. Otherwise don't waste time looking for a cause. It is equally important is to be aware of secondary changes due to the presence of ongoing pain (physical and psych) and try to prevent/reverse those. Of course it is recognised that there is still a lot to learn.

I don't know if I've attacked this the right way but in short;
1) No it is not just central pain - starts from the periphery with both nociceptive and neuropathic pain
2) I'm still not sure I get your interpretation of a passive symptom. However, the gist here is that prolonged pain can in itself produce further symptoms.
3) The concept of pain as a disease (not a symptom) is seen as a positive step towards managing persistent pain as there are more points at which the problem can be addressed.

I expect that many of you will disagree based on the abstract. However, I did find their proposal very believable.

Jane

[JaneS]

Sorry folks,
I didn't make a good job of trying to clarify your questions - I've just re-read my post. It's getting late over here, so I'd better just leave those who have access to ferret out the article and read the whole thing.
Jane

[bernard]

Jane,

I put the full text article in the Sound of Silence.