Hol i sm , Pai n An d M ovement
Ara n Br ight
pain without tissue damage? Absolutely, remember phantom limb pain? Phantom limb pain was thought of as triggered by nerve damage from an amputation site, until it was noticed that people born without limbs could still develop phantom limb pain.
term, but it is becoming clear that other treatments need to be used to get meaningful long-term changes for chronic pain sufferers.
So we now know that pain can occur independently from nociception, and is ultimately an output of the brain. Researchers such as Butler and Moseley explain that pain is a normal response that acts as the body’s warning system to danger. The brain takes in huge amounts of information from the body’s sensory organs all the time, including nociceptors. If the brain interprets this information as dangerous it will trigger a pain stimulus to force the body into a protective response.
Chronic pain is difficult to treat. Anyone that has worked with a chronic pain sufferer knows that it is complex and much more than a physical injury. Evidence grows to show that holistic or biopsychosocial approaches can get results for chronic pain sufferers as well as help preventing chronic pain from occurring in the first place. For natural therapists, holism has been a central value that sometimes becomes compromised with reductionist scientific approaches. So it is important to recognise, that when dealing with pain, the whole of person approaches, are actually what the science is recommending.
Nociception in most cases will be recognised by the brain as an unpleasant sensation and pain is a common response. This is generally what happens in acute injury, strong nociception and strong pain response. In most cases, acute injuries recover in 6 to 8 weeks. Fractures, sprains, even many surgeries heal in close to 6 to 8 weeks. But for many, pain can continue even after the tissues had healed. This is what occurs with chronic pain, or neuropathy, a state where the brain has learnt to create a pain response, even though at the site of the injury, tissue healing has occurred. This can occur many ways including central changes to the brain or spinal cord. We now understand that factors such as emotion and environment play a huge part in changes that occur within the nervous system that can lead to chronic pain. Biopsychosocial Factors It is now very well proven that psychological and social factors play a larger role in the recovery from certain injuries (such as lower back) as the amount of tissue damage that occurred. Organisations such as Workcover NSW are well aware of this, one of their standard outcome measures from lower back pain is the Orebro musculoskeletal screening questionnaire. This outcome measures asks more questions about someone’s belief around their injury, than it does about the damage that occurred to their back. This outcome measure is highly accurate to when predicting if someone will recover from the injury (95%), return to work in six months (81%) or fail to return to work (86%). It is pretty clear from MRI studies that as chronic pain develops, the emotional centres of the brain tend to be more active while the sensory areas of the brain become less active. This triggers an increase in the levels of perceived threat to the body and the increased likelihood of a pain response. It could be thought of very simply, the more the brain responds to the perception of threat, the more likely it is to trigger a pain response. The opposite also appears to be true, the less the brain responds to stimulus from damaged tissue, the less likely there will be a pain response.
Summary
Words: Aran Bright B. HSc (MST) Adv Dip Myotherapy 1. Nijs, J. et al. 2014 A modern neuroscience approach to chronic spinal pain: combining pain neuroscience education with cognition targeted motor control training. Physical Therapy, vol 94, pp730-738. 2. Butler, D. Moseley, L. 2013 Explain Pain NOI Group Publications. 3. Jensen, m. et al.1994 Magnetic imaging on the lumbar spine in people without back pain, New England Journal of Medicine, Vol 331 pp 69-73. 4. Melzack, R. et al. 1997. Phantom limb pain in people with congenital limb deficiency or amputation in early childhood. Brain vol 120, pp 1603-1620. 5. Seminowicz, D. et al. 2009 MRI structural brain changes associations with sensory and emotional function in a rat model of long-term neuropathic pain. NeuroImage. Vol 47 No 3 pp
1007-1014. 6. Fersum, V. et al 2012. Efficacy of classification based cognitive functional therapy in patients with non-specific chronic lower back pain: a randomised controlled trial. European Journal of Pain. Vol 19 No 6. Pp 916-928. 7. Searle, A. et all 2015. Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Clinical Rehabilitation. Vol 29 No 12 pp 1155-1167. 8. Veehof, M. et al. 2016 Acceptance- and mindfulness-based interventions for the treatment of chronic pain: a metaanalytic review. Cognitive Behaviour Therapy. Vol 45 No 1 9. Cramer, H. et al. 2013. A Systematic Review and Metaanalysis of Yoga for Low Back Pain. Clinical Journal of Pain. Vol 29 No 5 pp 450-460. 10. Chapparro, L. et al 2014. Opioids Compared With Placebo or Other Treatments for Chronic Low Back Pain: An Update of the Cochrane Review. Spine. Vol 39 No 7 pp 556-563.
Perhaps it could be put another way, your brain has the capacity to change how it will respond to information about tissue damage, and this is largely determined by previous experience. Movement Movement approaches are being demonstrated as one of the best ways to address pain, and not just chronic pain. Movement in combination with client education, mindfulness strategies and lifestyle changes are showing clinical efficacy in areas where previous strategies have struggled. Once it becomes clear that pain is a complex interaction between body tissues and the central nervous system, then is becomes clear that a more holistic or biopsychosocial approach should be employed. Active movement strategies that are targeted at making changes to brain function are becoming very popular amongst musculoskeletal therapists of all types and the efficacy of these approaches are growing, as are mindfulness interventions and integrated approaches such as yoga. At the same time there is little to no evidence for some medical approaches such as opioid analgesia for chronic lower back pain as a long-term strategy. Opioid analgesia does have low to moderate quality evidence for disability and pain in the short THE NATURAL THERAPIST Volume 31 No.2
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