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  • Writer's pictureDr. Percy

Chronic pain and the brain

If we've ever talked about your chronic pain in clinic, it's likely that we not only discussed the physical reasons for your pain, but also the role your brain is playing in your pain. This is an area I have an interest in further understanding, and this concept is becoming more mainstream in the scientific and medical community as well as in the mainstream media/popular culture. If you think about it, all the sensations we experience are processed in our brain. Sight. Sound. Smell. Sensations- including pain. So pain is processed in your brain, even if it is your shoulder, your back, or your knee that is injured. That's why people can have amputations, but still have pain in their amputated limb, AFTER it is gone- phantom pain sensations. But what happens when the tissues heal, but the pain persists? Often, your brain has created a "pain pathway", a loop that it is use to following. A group of neurons that fire together. And why create a new circuit to follow, when there is this well established, deep track to follow? The brain always wants to do the easy thing, conserve energy, and take the path of least resistance. Which for you may be the pathway of pain. This is not to say "it's all in your head", that you're "making it up". But it is saying that the way you think about and interact with your pain, even on a deeply unconscious level, is contributing to how you are experiencing your pain.

Disclaimer- I am not a chronic pain physician and do not claim to be one. As a rehabilitation physician working with a wide variety of patients, many with chronic pain for many different reasons, I have noticed that there is a very large unserved need for chronic pain management. As a result, I have put together some resources and information that may be helpful for individuals dealing with chronic pain issues.

In May 2021, The Lancet published a series on chronic pain. They used the International Association for the Study of Pain's definition of pain, which is "an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage." The series suggests changing the model of chronic pain to one of a disease, meaning changing expectations, and rather than chronic pain being something to "fix", "cure", or "eradicate", to consider it something to be controlled or managed.

They go on to classify pain into three distinct types:

Nocioceptive pain- pain due to tissue damage or the potential for tissue damage. Examples include arthritis changes, trauma, and degenerative disc disease.

Neuropathic pain- pain due to damage to or disease of the nervous system (central or peripheral). Examples include nerve root compression (radiculopathy), diabetic peripheral neuropathy, and shingles.

Nocioplastic pain- pain from abnormal processing of pain signals* with no evidence of tissue damage or discrete pathology of the somatosensory system. Examples of this include fibromyalgia, irritable bowel syndrome, and at times non-specific back pain.

(*emphasis mine)

However, not everyone falls neatly into one of these categories. You can have "mixed" pain, with some even considering chronic pain a "continuum".

This "new" category of nocioplastic pain is the one we are focusing on today. A problem with the processing of pain signals. There is an amplification of the pain stimulus, decreased inhibition of the pain stimulus, or both, likely at multiple levels in the nervous system (the nerves, spinal cord, and brain). The interesting thing is that this abnormal processing of pain can be due to one of the other two categories- nocioceptive (tissue) or neuropathic (nerve) pain, or due to something else all together. We often can't pinpoint what caused it. Often these conditions also have sleep, mood, memory disturbance and generalized fatigue. But there definitely is an emotional and psychological component to it.

While I won't go into specific treatments for chronic pain for the different categories, as these treatments should be individualized, it's worth noting that the #1 and #2 recommendations are exercises and psychotherapy. They include this as part of a recommendation for "self care" to help control the disease of chronic pain.

Exercise has been shown to improve function (a big yay from the rehab doc!) however not as much improvement in pain has been shown. However, exercise does have other positive benefits (assisting with weight reduction, sleep benefits, increases natural endorphins and reversing deconditioning). The most commonly used psychotherapy for chronic pain is cognitive behavioral therapy (CBT), which can be used as stand-alone therapy or in combination with other treatments. They do state that CBT works best when someone is motivated to participate, has well-defined goals, and also has anxiety or depression. Other treatments are likely beneficial but have not been well studied.

If we've discussed your chronic pain in clinic, it's likely that we've talked about how pain, sleep, and mental health form this vicious cycle. And how in order to treat the pain, we need to address all aspects of this cycle. The Lancet series talks about that too.

For the full studies, check out:

As you can see, chronic pain is a complex topic. Below, I'm including a few resources I've found helpful in better understanding some of the complexities of chronic pain and the brain. You may find that these are more relatable or easier to understand than the medical journals, but hopefully that background will help you see these are all based in science.

This is by no means an exhaustive lists. There are tons of books, articles, programs, podcasts, and series on chronic pain. There are all kinds of alternative and complementary treatments people swear by. But these are a few that I've checked out and am comfortable recommending. I hope to either add to this list in the future, or will post again at a later date.

Resources for more information on the brain and chronic pain:

Curable App

This is a science-based, researched-backed approach to chronic pain. Originally designed for chronic migraine, Curable has applications to all aspects of chronic pain. Using a biopsychosocial model, pain psychology and CBT, you will learn about how our brains create pain cycles and pathways that result in the feelings of recurrent pain. You will also learn how to "de-program" the chronic pain cycle with a virtual pain coach.

Subscription required.

**PG-13 language**

Kara Loewentheil is a Harvard Law grad turned certified master coach (LCS) who has created a platform/program for her feminist-based teachings and thought work called UnF*ck Your Brain and The Clutch. She has worked with thousands of "chickens" (non-gendered pronoun for her followers/clients), teaching them to "blow their own minds".

This podcast episode looks at how brains processes the sensations of pain, and how your thoughts can make the pain "mean" something about you, and make you hyperaware of your body sensations and pain. She also touches on how you can work to change those thoughts about the pain, and in turn, can decrease the emotional impact of those thoughts/your pain, and in some cases, can significantly improve your physical sensation of pain. She uses the lens of "thought work" to explore the unconscious thoughts buried under the pain, and to work towards changing those thoughts on purpose. More information on thought work as a concept can be found on her website, .

Content regarding chronic pain and illness begins around minute 6.

NPR's Invisibilia Podcast S5.E1- The Fifth Vital Sign

Invisibilia is a wonderful podcast that explores the un-seen forces that shape us through storytelling. In this episode, they explore how the attention that has been brought to pain as "the fifth vital sign" in the 1990s has changed how as a society we view pain, and how the attention we give our pain on an individual level gives the pain power over us. They discuss a specific, very intensive program to combat amplified pain syndrome by re-training the brain and body what "normal" sensations are.

I use physical therapy often to help patients create a home exercise program to accomplish a similar movement body/brain "retraining" goal, but this specific program takes PT to the extreme in combination with psychotherapy in a controlled, monitored setting.

Read all the way down to the bottom of the page for specifics on AMPS or questions regarding that treatment.

The takeaway for me is how our attention to and awareness of pain seems to amplify the symptoms. As a rehab physician (physiatrist), my interest is much more on your functional abilities, what you can and can't do because of a condition, than what your "pain score" is.

Myaim Bialik's Breakdown- Iliza Shlesinger: It Hurts To Be Awesome. Chronic Pain, Comedy, and the Mind Body Connection.

**PG-13 language**

Please note, I do not agree with all the statements discussed in this podcast. There are times when surgery, epidural injections, and physical therapy are very helpful and medically indicated. At BSSM, we utilize McKenzie-based physical therapy when indicated. The purpose of including this podcast is an introduction to the mind-body connection and complementary medicine techniques with two well known celebrities/public figures.

TV's favorite neurobiologist Myaim Bialik, PhD (Big Bang Theory's Dr. Amy Farrah Fowler) and comedian/actor Iliza Shlesinger have a long conversation around many topics, including largely female-specific confidence issues in the modern world, body-image, with a touch on nerve and chronic pain.

At around the 11 minute mark, there is some basic information on nerve pain and discs. (The nucleus pulposa is what I refer to as the "jelly" in the jelly donut metaphor in clinic!)

At around the 1hr mark, Iliza discusses her experience with cervical radiculopathy, treatment tried, and the role of how changing her thoughts about the pain helped her find some relief.

In the last 5-6 minutes, Myaim breaks down some of the neuroscience behind the mind-body connection and how our thoughts about our pain can significantly impact how we feel that pain.

Check out the links at the bottom of the podcast page for more information on the mind body connection!


Do you have other topics you'd like to have explained? Send a comment/message and keep an eye out for them in a future post!

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