I wish I’d known four things earlier in my career:
- The brain is plastic throughout the lifetime.
- Pain doesn’t equal damage.
- When you calm the brain, you keep threats down.
- Neuroplasticity is essential to rehabilitation.
Do You Know How to Manage Adults Who Are in Pain?
“Don’t touch this area! It’s sensitive!”
“I can’t even think about moving, so don’t ask me to!”
“It hurts to move. If I move, I’m going to reinjure myself.”
How do you evaluate patients who make statements like these? What do you do when a patient experiences body perception disturbances, such as an intense dislike of the painful limb? You may hear patients express that the affected limb feels distorted or like it doesn’t belong to them. These disturbances are common because of central nervous system (CNS) disorganization.
If your treatment plans have been primarily aimed at peripheral symptoms, then it’s time for an update to your pain management program. Numerous recent studies have shown that both the peripheral and central nervous systems undergo plastic reorganization (brain changes). If left untreated, these changes become maladaptive and can contribute to the patient’s symptoms.
Are Your Patient’s Symptoms Peripheral, Central, or Both?
More than a decade ago, researchers identified that pain is an output of the brain in its role as protector of the body. Sensations from the periphery come into the dorsal horn then ascend to the brain stem. From there, they go to the thalamus (your brain’s relay system) and onward to the cerebral area. The brain then makes a decision as to whether these sensations are a threat to the body. If the brain determines that a threat is present, it must then decide how to respond.
Pain processing is complex because many of the parts involved have an influence, such as the multiple synapses and reflex responses within the spinal cord along with ascending nociceptive, descending faciliatory, and inhibitory connections.
Over time, the sensation’s presence leads to sensitizing of the CNS, causing sub-threshold stimuli and otherwise non-painful stimuli to start causing abnormal sensations. This is what occurs in allodynia and hyperalgesia. At this point, the CNS sensitization problem must be addressed, but only treating peripheral symptoms is not the correct approach.
Addressing Centralization and Sensitization
So how should you treat this centralization? We now know that persistent pain causes CNS changes, or cortical disorganization. These changes include:
- Changes in the body map (cortical homunculus)
- Inability to identify right from left
- Problems identifying two-point discriminations
- Proprioceptive disturbances
- Motor-planning dysfunction
- Deficits in sterognosis, the ability to identify objects by touch
When you are managing persistent pain in adults, both the peripheral and central sensitization must be addressed.
Neuroscience Education and the Biopsychosocial Model
Therapeutic neuroscience, as coined by Louw, reduces pain, decreases catastrophization, improves movement, and reduces disability when the patient understands what pain does to the brain as well as the body.1
Since persistent pain interacts with biological, psychological, and sociocultural variables, it is necessary to use the biopsychosocial model. This model takes into account what has gone wrong in the body and brain as well as the influence of psychological and social variables. It looks at both the disease and injury, incorporating the illness as well as how the problem is lived.
This persistent pain in adults is considered an error in central processing. Often, the pain contributes to the psychological factors and social isolation. As rehab professionals, it is in our scope of practice to use psychological treatment approaches, and we should know when to refer our patients to a psychologist or other health care individual.2
Do You Treat the Brain?
The neuromatrix theory of pain suggests that pain is produced by a widely distributed neural network in the brain rather than direct sensory input evoked by injury, inflammation, or other pathology. Understanding this concept can help calm your patient. While I never tell my patients that pain is “all in their head,” I do explain how pain is aggravated by the head.
Patients need to know that their pain can be amplified as a consequence of stress, fear, and anxiety. A good place to start is developing an understanding that the CNS needs to be calmed down. Both the clinician and the patient must understand that the amygdala controls fear, anger, stress, and threat. The patient must bring the threats under control and know that they are in charge and empowered.
Numerous studies have looked at the involvement of psychological factors in the development, perpetuation, and treatment of musculoskeletal pain problems. Calming down the CNS and keeping the amygdala under control starts with an approach of reducing symptoms and avoiding firing painful neurotags.
It is important to remember that pain is a multidimensional experience of both sensory and affective components. The experience of pain includes a cognitive component, which influences how the individual perceives their overall well-being in relation to their experience of pain. Mindfulness, relaxation, and diaphragm breathing are often necessary to help the individual calm down and be in the moment.
Treating Your Patient with Central Sensitization
Identifying central sensitization is a process of evaluation to rule out CNS changes. Once central sensitization is identified, a common practice is using pacing and movement with the educated patient in control without causing maladaptive neuroplasticity. The idea behind this rehabilitation technique is to slowly use sequential pacing or a graded program without turning on additional pain neurotags. Graded motor imagery is a way to train the brain without increasing fear or threat to the patient.
- Louw, A., Zimney. K., O’hotto, C., & Hilton, S. (2016). The clinical application of teaching people about pain. Physiotherapy Theory and Practice; 32(5): 385-95.
- Russek, L. & McManus, C. (2015). A practical guide to integrating behavioral and psychologically informed approaches into physical therapist management of patients with chronic pain. Orthopedic Physical Therapy Practice, 27(1): 8-16.