Do you suffer “Chronic Pain”?
Do you feel misunderstood and frustrated?
Here at Saanich Physio we want you to remember, the concept developed by Mosely and Butler (2017): All pain is normal, all pain is a personal experience and all pain is real.
The International Association for the Study of Pain (IASP) has classified chronic pain as “pain that persists or recurs for more than three months” (which is longer than the expected healing time of soft tissue), with the exception of pain experienced after some surgeries and some types of traumatic injuries (International Association for the Study of Pain, 2016).
To understand chronic pain, we have to understand why we can have such intense, debilitating pain, when health professionals classify our tissues “normal”.
First we will explain a little bit about inflammation and the nervous system.
Inflammation is the body’s amazing, natural, healing process whereby blood flow to a site of injury is increased and chemicals are released into the area to start healing. Symptoms of inflammation include pain, redness, swelling and heat in the area.
The Nervous System
Nerves originate in our brain and spinal cord. There are two types of nerves.
Sensory nerves: Detectors which help us to understand what is going on around us and keep sending messages, or inputs, to the brain and spinal cord, to make us aware of our environment and inform us whether it is safe or potentially dangerous. Sensory neurons have input in to the brain and spinal cord.
Motor nerves: Action causers, which cause us to move, by activating appropriate muscles or glands to release appropriate hormones. They also cause the spark of thoughts, behaviours and beliefs. Motor nerves are responsible for causing our actions based upon the brain and spinal cords calculations and are outputs.
It is hard to believe that pain is actually generated in the brain and is an OUTPUT released when harm is detected.
Basicially, when danger is detected, the brain and/or spinal cord send pain to that area, so in turn we protect the threatened tissue by changing our behaviours or positions, for example by limping to reduce weight bearing on a potentially broken foot (Littlewood et al. 2013), or moving our hand away from a flame.
It highlights that danger detected by sensory nerves from both our environment and our tissue, are sent up the spinal cord to the brain. The brain and spinal cord assess the incoming signals and produce an appropriate output to adapt to remain as safe as possible.
The brain then interprets this information, and determines whether our tissues are in danger or not. If it suspects we are in danger, it produces an output depending on whether we need to protect ourselves or not e.g. movement away from danger, or feel pain in those tissues so that we stop using them.
There are three biological mechanisms that can cause an output of pain to be produced:
Nociception (the detection of danger): the exposure of tissues to harmful stimuli occurs. These stimuli can be: chemical, mechanical (overstretch or compression of tissue leading to damage) or thermal (tissue that is too hot or cold) (Smart 2012b).
Central sensitization: a dysfunction within the brain and spinal cord is occuring, so that safe, incoming signals are interpreted as harmful (Smart & Keith 2012)
Peripheral neuropathy: there is damage to the peripheral nerves themselves (all nerves outside of the brain and spinal cord) (Smart 2012a)
It is also important to understand that high stress has also been indicated to increase pain, delays recovery and increases risk of chronic pain development (Lentz et al. 2016).
The next fact is something commonly mistaken.
The amount of pain we feel rarely reflects how much tissue damage there really is (Moseley and Butler 2017).
Think about a paper cut, and how painful this can be. Compare this to cases where people have had their entire leg bitten off by a shark, and have not felt a thing. This is all due to the analysis by the brain and spinal cord of the situation and their believed best response to produce outputs that are most likely to protect the person and give them the best chance of surviving at that given time of detected danger.
Now we will discuss two different types of injury that can occur, both which cause significant pain, yet both which have very different mechanisms of reasons why pain is caused.
Pain reported by a person with a recently broken bone, usually relates well to the extent of the tissue damage and the dominant mechanism responsible for the pain output is nociceptive pain (danger detection through chemical and mechanical changes in the tissue).
MECHANISM – FRACTURE (NOCICEPTIVE PAIN)
Bone tissue breaks due to an inability to withstand the intensity, speed and direction of an applied force. It can be caused by trauma, stress, bone weakness or disease (Westerman & Scammell 2011). Trauma causes sensory nerves to detect a harmful change in shape of tissue, which sends danger signals to the brain and spinal cord. It also causes the release of chemicals that cause inflammation to occur – to kick-start the healing process (Birklein & Schmelz 2008). This sends further danger detector signals to the brain and spinal cord. The brain and spinal cord process the input, identifies threat and outputs pain.
On the other hand, the degree of pain reported in chronic tendinopathy, does not always relate well to the extent of peripheral tissue damage or pathology, and the dominant biological mechanism responsible for the pain output can be central sensitisation (safe, incoming signals becoming interpreted as harmful by the brain and spinal cord).
MECHANISM – CHRONIC TENDINOPATHY (CENTRAL SENSITISATION PAIN)
Chronic tendinopathy, is an umbrella term for a number of conditions, and refers to a combination of pain and impaired performance of a tendon, which have lasted longer than 3 months (Seitz et al. 2011).
Non-chronic (acute) tendinopathy occurs when there are mechanical changes to the tendon. They are caused by external or internal factors, or a combination of both. Externally, tendon compression occurs, while internally, degeneration occurs (Seitz et al. 2011), both result in inflammation. Therefore both mechanisms produce the detection of harm at the environment and tissues due to chemical and mechanical changes and send this input to the spinal cord and brain, which then outputs pain to the area.
Amazingly, evidence suggests people experiencing chronic tendinopathy can have minimal or no inflammatory cells in the painful tendons. This suggests there is another reason for their brain to produce an output of pain: an altered processing of input within the brain and spinal cord, so that a threat is still detected despite little tissue damage (Littlewood et al. 2013), this can be caused by a range of things, including previous experiences with pain.
For example, if you once had a back injury, and it was painful every time you bent forward, the central nervous system may now associate bending as dangerous and therefore outputs pain to that same area in your back to feel pain before any tissue damage can occur, as a prevention and protection strategy.
Due to the differences in nature of the pain experienced with both conditions, the management strategies for both of these conditions differs substantially.
If you found any of this information useful or intriguing and would like to learn more about your pain and you would like to make an appointment with one of our physiotherapists, contact us.
By Vanessa Service, Physiotherapist
What does my vestibular system do?
Your vestibular system’s job is to process sensory information that is required to control balance and eye movements. This means that information from the inner ear, the visual system, and from the muscles and joints is analysed by the brain. Integrating this information allows you to1:
– Maintain clear sight while you move your head,
– Figure out the orientation of your head in space in relation to gravity,
– Identify how fast and in which direction your are moving, and
– Make fast and automatic adjustments to your posture so you can maintain balance (stay in your desired position).
In other words, your vestibular system coordinates your movement with your balance, allowing you to navigate through and adapt to the world. It is this process that allows you to walk down the sidewalk, to step off a curb, to sit down and stand up again and to turn your head while walking. Anytime your head moves through space you’re depending on your vestibular system.
What are vestibular disorders and what are the symptoms?
If the vestibular system encounters disease or injury, such as a viral infection or head trauma, the result may be a vestibular disorder. However, aging, some medications, and genetic or environmental factors may also cause vestibular conditions.
Symptoms of damage to the vestibular system may include:
– Vertigo (a sense of the world spinning around you)
– Dizziness (feeling lightheaded or floating/rocking in space)
– Imbalance and special disorientation (stumbling, staggering, drifting to one side while walking)
– Difficulty with changes in walking surfaces
– Tinnitus (ringing or buzzing in the ears)
– Discomfort in busy visual environments (such as the grocery store) or when looking at screens/television
Examples of vestibular disorders include:
- Benign paroxysmal positional vertigo or BPPV (a common condition where loose debris or “crystals” collect in a part of the inner ear)
- Vestibular neuritis or labyrinthitis.
- Migraine associated vertigo
- Endolymphatic hydrops
- Acoustic neuroma
- Meniere’s disease
How can a vestibular physiotherapist help?
The effect of a vestibular condition on a person’s life can be profound. Dizziness and balance problems are often a barrier to activities of daily living, to independence, and to engaging with the community. This negative impact on daily function and socialization may also contribute to anxiety and depression. As such, appropriate management of vestibular conditions is an essential component to improving quality of life for individuals and families affected by vestibular disorders.
A vestibular therapist will interview you about the history of your symptoms and perform a series of vestibular, balance, and visual tests. Treatment will depend on what is found in the assessment. For example, if you are diagnosed with BPPV, your therapist will perform a manoeuvre to reposition the associated crystals. Other vestibular disorders are treated with specific exercises and strategies that your vestibular therapist will teach you and help you progress through to reach your specific goals.
Although for most people a vestibular disorder is permanent, an exercise based plan can be designed to reduce dizziness, vertigo, and balance and gaze stability problems1. This is made possible by your brain’s incredible ability to adapt its other systems in order to effectively compensate for an improperly functioning vestibular system. Vestibular rehabilitation is a non-invasive and drug free intervention that helps to promote and maximize the amount of compensation that occurs. Current research supports the use of vestibular rehabilitation in the management of vestibular conditions2, demonstrating reduced dizziness, balance issues, and increased independence with regard to activities of daily living 3. Additionally, no adverse effects associated with vestibular rehabilitation have been reported2. As such, vestibular rehabilitation can provide a pathway to improved quality of life for those living with a vestibular condition.
1. About Vestibular Disorders (n.d) Retrieved from https://vestibular.org/understanding-vestibular-disorder
2. Hillier SL et al., Vestibular rehabilitation for unilateral peripheral vestibular dysfunction, Cochrane Database of Systematic Reviews 3, 2011.
3. Cohen HS, Kimball KT Increased independence and decreased vertigo after vestibular rehabilitation. Otolaryngol Head Neck Surg 2003 Jan;128(1):60-70
Some reflections on concussion from the author below. We can help if you do have concussion.
A Carolina Panthers player left the Super Bowl and was found to have a concussion.
By David L. Katz
Fortunately for me and the others gathered at the Katz home, we enjoyed a fabulous, Cuisinicity.com meal for the Big Game. No surprise there; my wife is the culinary genius behind the site.
Thank goodness for the wonderful dinner, because the game itself was rather disappointing. There was, I trust my fellow spectators will agree, an unusual bumper crop of penalties, some egregiously bad calls by the referees, some truly strange mistakes by players and a disquieting bounty of poor sportsmanship into the bargain. Congratulations to the Broncos and Peyton just the same, but seriously, weird game.
Alas, it also featured an announcement all fans of the game should now know is a reason for a collective wince: concussion protocol. Corey Brown, of the Carolina Panthers, left the game after a head injury, underwent neurological evaluation and was found to have a concussion.
I trust everyone now knows the ominous implications of that kind of injury if repeated periodically over the course of a career. The media attention to Chronic Traumatic Encephalopathy, or CTE, is considerable and rising. The movie “Concussion,” starring Will Smith, raises the profile further. I highly recommend the movie if you haven’t seen it, by the way. It is very well done, and beautifully acted, and entertaining even as it educates.
I have no particular expertise in CTE beyond any doctor’s basic understanding of it, and others have said plenty already. If you are interested, as every football fan should be, and certainly as every parent of a child inclined to play football must be, the relevant information is readily available. I will take the opportunity to make a different point, about the cultural malleability of “normal,” and thus, “acceptable.”
While I have no claim to the football-fan hall of fame, I like the game as much as the next guy. I am wondering more and more, though, if my entertainment is worth the price the players are paying.
Football is part of our culture, and thus normal. We might thus think that if it has occasional consequences, those, too, are normal. That may make them seem acceptable. But that’s the real danger here: complacency. We can perhaps only see it looking across cultures, rather than from corner to corner within the box that is our own.
Consider, for instance, the Gladiatorial Games of Roman times. Those were, infamously, contests to the death, whether between people, or people and wild, half-starved animals. The only vague approximations of any such barbaric entertainment in the modern world are, so far as I know, bull fighting, and the generally illegal contests between fighting dogs or roosters. There is no longer any mainstream interest in watching bloody death for entertainment.
But that’s simply because sensibilities and culture have evolved. The Romans were people just like us. Their society, too, was made up of mothers and fathers, aunts and uncles. They, too, knew love and compassion. But they cheered while watching young men, literally, kill one another. In their culture, it was normal, and thus acceptable; but I trust we agree history has reached a different verdict.
I happen to be a fan of both the late Heath Ledger, and Paul Bettany, and was thus predisposed to love the movie “A Knight’s Tale.” I’m no movie critic – I can’t say whether or not it’s a great movie – I can only say I like it.
The movie is especially noteworthy for how it handles anachronism. More than once, it features period elements, like music, and then transitions them to the modern analog, such as a rousing rendition of “The Boys Are Back in Town” by Thin Lizzy. More memorable still is a scene at a dance. Heath Ledger’s character is dancing with his love interest in the stylized manner of medieval folk dance. The music then transitions to the late, great David Bowie – “Golden Years,” to be exact – and the dancing keeps pace, morphing into what one would expect, more or less, in any given club on any given Saturday.
The director, I think, was telling us something important: The old-fashioned music and dance of medieval times would not have felt old-fashioned then. It was, simply, the music and dance of its day. It was normal. Showing medieval folk dancing to a modern audience says: this was an old-fashioned party. The director substituted “current” music and dance to show us how it felt to the participants. It was current and normal then, and no matter how it feels to us now, that’s how it would have felt to them.
That’s relevant to football. We are not willing to entertain ourselves by watching young men bash one another’s heads in with maces, as the Romans did. But we do entertain ourselves as young men bash their helmeted heads into one another repeatedly over a span of years, with all-too-often calamitous consequences.
Our gridiron heroes are latter-day gladiators. And their house – the house of football – inspires almost religious devotion in our culture. But that may be only because it is part of our culture. Imagine if football did not yet exist, and we were thinking of introducing it, and knew about CTE from the start. Would we add such a game and such a liability to our cultural entertainments?
The one-time editor of the Journal of the American Medical Association, and later Medscape, Dr. George Lundberg, reflected along similar lines in the New York Times recently. He discusses cultural evolution over a much shorter period than the Middle Ages to now, noting a marked change in his personal – and our societal – enthusiasm for the brutalities of boxing. Both the sport and its following have changed dramatically in recent years, and he conjectures that football is in that same queue.
My principal mission here is to point out the inevitability of culturally induced blindness to the unacceptable elements of what is currently normal. We live in a time of epidemic obesity and its complications in our children, yet continue to market multicolored marshmallows to them as “part of a complete breakfast.” This is absurd, and history will judge us accordingly, but it’s normal now – and so we overlook the hypocrisy. Cultures around the world justify practices as heinous as female genital mutilation. What passes for “normal” is self-defining, and to some extent, self-perpetuating.
Until, that is, we evolve beyond it. Looking back, what was normal yesterday often proves repulsive and contemptible today.
We speak routinely about “thinking outside the box,” but when the box is culture, that is much easier said than done. Everything we know is inside the box, as are we. The contents of the box at any given time are normal.
History turns the years into a ladder. Out of the box we all climb, into a bigger box presumably, as we gain the perspective of altitude, and roll our eyes at the mess we’ve left behind.
I love watching football. The Romans presumably loved their gladiatorial games. Both are normal in context. That doesn’t guarantee that either is right.
For the sake of today’s players, and our sons inclined to take their places, I hope we reform the game of football sooner than later. It’s a great game, but not when paid for with brains scrambled, and lives cut short.
In general, we need to recognize how readily we follow the gospel of any given culture telling us what’s normal. We need to recognize that normal is simply what we do now, and that it isn’t necessarily right. Perhaps the true measure of cultural enlightenment is how ably we judge ourselves in real time as history is sure to do in the fullness of time.
People who exercise have better mental fitness, and a new imaging study from UC Davis Health System shows why. Intense exercise increases levels of two common neurotransmitters — glutamate and gamma-aminobutyric acid, or GABA — that are responsible for chemical messaging within the brain.
Published in this week’s issue of The Journal of Neuroscience, the finding offers new insights into brain metabolism and why exercise could become an important part of treating depression and other neuropsychiatric disorders linked with deficiencies in neurotransmitters, which drive communications between the brain cells that regulate physical and emotional health.
“Major depressive disorder is often characterized by depleted glutamate and GABA, which return to normal when mental health is restored,” said study lead author Richard Maddock, professor in the Department of Psychiatry and Behavioral Sciences. “Our study shows that exercise activates the metabolic pathway that replenishes these neurotransmitters.”
The research also helps solve a persistent question about the brain, an energy-intensive organ that consumes a lot of fuel in the form of glucose and other carbohydrates during exercise. What does it do with that extra fuel?
“From a metabolic standpoint, vigorous exercise is the most demanding activity the brain encounters, much more intense than calculus or chess, but nobody knows what happens with all that energy,” Maddock said. “Apparently, one of the things it’s doing is making more neurotransmitters.”
The striking change in how the brain uses fuel during exercise has largely been overlooked in brain health research. While the new findings account for a small part of the brain’s energy consumption during exercise, they are an important step toward understanding the complexity of brain metabolism. The research also hints at the negative impact sedentary lifestyles might have on brain function, along with the role the brain might play in athletic endurance.
“It is not clear what causes people to ‘hit the wall’ or get suddenly fatigued when exercising,” Maddock said. “We often think of this point in terms of muscles being depleted of oxygen and energy molecules. But part of it may be that the brain has reached its limit.”
To understand how exercise affects the brain, the team studied 38 healthy volunteers. Participants exercised on a stationary bicycle, reaching around 85 percent of their predicted maximum heart rate. To measure glutamate and GABA, the researchers conducted a series of imaging studies using a powerful 3-tesla MRI to detect nuclear magnetic resonance spectra, which can identify several compounds based on the magnetic behavior of hydrogen atoms in molecules.
The researchers measured GABA and glutamate levels in two different parts of the brain immediately before and after three vigorous exercise sessions lasting between eight and 20 minutes, and made similar measurements for a control group that did not exercise. Glutamate or GABA levels increased in the participants who exercised, but not among the non-exercisers. Significant increases were found in the visual cortex, which processes visual information, and the anterior cingulate cortex, which helps regulate heart rate, some cognitive functions and emotion. While these gains trailed off over time, there was some evidence of longer-lasting effects.
“There was a correlation between the resting levels of glutamate in the brain and how much people exercised during the preceding week,” Maddock said. “It’s preliminary information, but it’s very encouraging.”
These findings point to the possibility that exercise could be used as an alternative therapy for depression. This could be especially important for patients under age 25, who sometimes have more side effects from selective serotonin reuptake inhibitors (SSRIs), anti-depressant medications that adjust neurotransmitter levels.
For follow-up studies, Maddock and the team hope to test whether a less-intense activity, such as walking, offers similar brain benefits. They would also like to use their exercise-plus-imaging method on a study of patients with depression to determine the types of exercise that offer the greatest benefit.
“We are offering another view on why regular physical activity may be important to prevent or treat depression,” Maddock said. “Not every depressed person who exercises will improve, but many will. It’s possible that we can help identify the patients who would most benefit from an exercise prescription.”