Central Sensitization, Chronic Pain, Pain Science, Quotes, Resources

Christopher deCharms: A look inside the brain in real time

I’ve been writing about some heavy stuff recently, so I thought it would be a good time to share something that makes me feel really hopeful:

Christopher deCharms is a neuroscientist and entrepreneur who, along with other prominent researchers such as Dr. Sean Mackey, is paving the way towards using brain imaging to study and treat chronic pain.

deCharms founded a company, Omneuron, which has developed something called rtfMRI, or “real-time functional MRI.” 

In studies of chronic pain patients, this new technology allows researchers to see exactly which area’s of a patient’s brain are the most active, and how this activity can change from moment to moment, depending on what the patient is instructed to do.

We know that the brains and nervous systems of chronic pain sufferers function differently from people who aren’t in pain– now this technology allows us to see how.

deCharms explains,

There have (historically) been three ways to try to impact the brain: the therapist’s couch, pills and the knife. This is a fourth alternative that you are soon going to have.

We all know that as we form thoughts, they form deep channels in our minds and in our brains. Chronic pain is an example. If you burn yourself, you pull your hand away. But if you’re still in pain in six months’ or six years’ time, it’s because these circuits are producing pain that’s no longer helping you.

If we can look at the activation in the brain that’s producing the pain, we can form 3D models and watch in real time the brain process information, and then we can select the areas that produce the pain.

Just as there are parts of the brain which can produce the experience of pain, there are also parts of the brain which can “turn down the volume” on pain, so to speak.

There are a few mechanisms by which the brain can inhibit pain signals.  One powerful way is through the production of our own endogenous opiates– chemicals which our own brain produces to block pain.  (These chemicals are what opiate medications such as Percoset and Oxycontin are trying to mimic).

Omneuron is researching ways which patients can learn to “turn up the volume” on the parts of their brain which inhibit the sending of pain signals.

As deCharms explains in this additional interview:

There is a built-in dial in the brain, that, when you turn it up… pain goes away.  So we hope that when we can teach people to control these systems, to control this dial in the brain, they can make the brain go down.

He explains that many of his patients report feeling empowered simply by seeing images of the pain activity in their brains on the screen.  For so long, they had felt as though the people in their lives didn’t believe them about how much pain they were in, and there, on the screen, was proof.

***

I really find this topic to be so fascinating, not to mention inspiring.

If you’d like to know more, I actually have a whole section within my “Resources” page on how fMRI is being used to study and treat chronic pain.  (I have links to a bunch more articles, as well as some interesting talks by other prominent researchers).

Hope you’ll check it out!

Central Sensitization, Chronic Pain, Nervous System, Pain Science, Resources

The best TED talk ever: Elliot Krane on the Mystery of Chronic pain

Tonight I’m throwing it back to this amazing 2011 lecture on chronic pain given by Dr. Elliot Krane of Stanford University.

I found his talk around the time I was first starting this blog, back in 2012, and it really inspired me to try to tell my own story with complex pain problems.

Dr. Krane is a pediatrician and an anesthesiologist.  He specializes in treating children with chronic pain disorders at the Lucile Packard Children’s Hospital at Stanford University.

In this talk, Dr. Krane outlines the case of a young girl who developed CRPS following a wrist sprain, and was successfully treated at his hospital.

He has some really great quotes and soundbites about chronic pain– things I want to remember, and things I think will be useful in trying to explain the multi-layered nature of pain to people who don’t quite get it (yet).

So here, I’m just going to take a few notes so I (and you, if you’re interested) can come back and remember some key points really quickly:

***

Most of the time, we think of pain as a symptom of a disease– the result of an infection or a tumor, an inflammation or an operation.  But about 10% of the time, after a patient recovers from one of those events, the pain persists for months or even years.  In those cases, pain can become its own disease.

Chronic pain is “a positive feedback loop…. It’s almost as if somebody came into your home and rewired yours walls so that the next time you turned on the light switch, the toilet flushed three doors down, or your dishwasher went on, or your computer monitor turned off.  It sounds crazy, but that’s what happens with chronic pain.”

Glial cells (a particular type of cell found in the nervous system) were once thought to be unimportant.  When I learned about them in my PT prerequisite classes, we thought of them as the supportive “glue” that provides a safe environment for neurons, the more interesting cells that were actually responsible for sending messages.

But, Dr. Krane explains, it turns out that glial cells can play a vital role in the “modulation, amplification and, in the case of pain, the distortion of sensory experiences.”  Once glial cells are triggered by chronic pain, they become overactive and help initiate that the positive feedback loop he mentioned.

Some other quotes:

“The nervous system has plasticity.  It changes, and it morphs in response to stimuli.”

On treatment:

“We treat these patients in a rather crude fashion at this point in time. ”

Dr. Krane describes the treatment protocol for CRPS patients at his center:

  • symptom modifying drugs (painkillers) “which are frankly, not very effective for this type of pain”
  • “We take nerves that are noisy and active that should be quiet, and we put them to sleep with local anesthetics.”
  • “Most importantly… we use a rigorous and often uncomfortable process of physical therapy and occupational therapy to retrain the nervous system to respond normally to the activities and sensory experiences that are part of everyday life.

The future is actually even brighter:

“…the future holds the promise that new drugs will be developed that are not symptom-modifying drugs that simply mask the problem, as we have now, but that will be disease-modifying drugs, that will actually go right to the root of the problem and attack those glial cells….that spill over and cause this central nervous system wind-up…”

***

It’s really interesting for me to look back on this talk, now, and see how my perspective has changed since I first watched it in 2011.  Back then, the point about glial cells largely went over my head (probably because I wasn’t invested at all in knowing what they were).

Now that I’ve taken anatomy & physiology as well as an undergraduate neuroscience course, I can actually see how groundbreaking this really is, to identify glial cells as a potential source of the problem.

It’s as though you’re looking at a telephone pole, and you realize that the wooden pole itself was sending signals, instead of just being there to hold up the electrical wires.  (If that metaphor makes sense).

Anyway, I really hope Dr. Krane is right, that we can begin to develop drugs that will target this mechanism for chronic pain.

Hope you enjoyed this talk!

eating disorders, Nutrition

Out with the old: Saying goodbye to 90’s nutrition advice

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In the spirit of New Year’s resolutions and goals, I thought I’d share this really great article I found recently on nutrition “myths.”  

Fitness Magazine interviewed registered dietitians on how their perspectives on healthy eating have changed over time.  These RD’s talk about some of the conventional wisdom regarding nutrition coming out of recent decades, how it influenced them, and how a lot of it turned out to be wrong.

***

As a teenager struggling with body image issues in the late 90’s and early 2000’s, I encountered much of these same nutrition trends myself from magazines and books, as well as from the nutritionist I saw for help with my eating disorder.

I remember– I was terrified of fat.  When I went out to eat, I insisted that I found mayonnaise and salad dressing “gross,” because I had read that cutting those things out was the best way to cut calories.

Each day, I only ate a certain number of calories at set times, and carefully adjusting the amount depending on the number of calories I had burned through exercise.  My treat at the end of the day would be some kind of “low-fat” dessert or “snack pack” of cookies.  Most of the food I ate was low fat– Healthy Choice ham for my sandwich at lunch, with low fat cheese.  Lean Cuisines for dinner.

It is so strange, now, to realize that so many of the “rules” I based my life around were, in fact, actually all wrong.

One of the quotes I related to the most in the article came from Lauren Harris-Pincus, M.S., R.D.N., owner of Nutrition Starring You.  She says:

“When I became a dietitian in the mid 1990s, we were in the middle of the fat-free craze. Bagels, fat-free frozen yogurt, and Snackwell cookies were all the rage. Our hospital diet materials recommended limiting nuts because of their fat content and limiting shellfish because of their cholesterol. Now, we know much more about the health benefits of fats derived from nuts and seeds, and we’ve also learned that high-sugar, fat-free foods are not nutritious choices. Unfortunately, people have long memories and to this day, so many of my patients are afraid to eat shrimp if they have elevated cholesterol. It’s exciting to work in a field with ever-evolving research.”

Yes– it absolutely was a fat-free craze.  Fat-free dressing, fat-free cheese.  Sometimes I’d even come across bread that was labeled fat free.  I always thought I was doing something great for myself when I reached for that label, not understanding that my body actually needed fat in order to function.  

I also really related to this quote from Emily Cope, M.S., R.D.N., Owner & Consulting Dietitian at Emily Kyle Nutrition:

“When I was in college, I remember being obsessed with those ‘100-calorie packs’ of cookies and crackers. I thought they were a great option—less than 100 calories for all of those tiny wafers!! Little did I know those calories were being replaced with chemicals and unnatural ingredients. These days, now that I am older and wiser, I am less concerned with calories and more concerned with the quality of my food—whole fruit and nuts are my current go-to snacks!”

Yes.  Unfortunately, that was so me as well.  I felt comfortable with pre-packaged, processed foods because they were marketed for weight-loss, and it was easy to know how many calories were in them.

***

These days, I have come so far in terms of my outlook to food that sometimes I almost forget that I ever had a problem.  (After all, I’ve had to deal with so much else with my body over the intervening years!).

I will talk more about how I overcame my eating and body image issues in future posts.  But for now, let me say that these days I think I live and eat pretty holistically.  I don’t get caught up on the idea of depriving myself of something if I really want it; I don’t count calories.  

And the funny thing is, now that I allow myself to eat whatever I want, I find that most of the time, I generally tend to crave pretty healthy choices.  Now that I’m actually well-nourished, I find myself more in touch with how my body responds to different foods, and I tend to gravitate towards the foods that make me feel best.

I’m sharing this with you for a few reasons:  

A) There’s some really good advice contained in this article, and

B) It serves as a reminder to me– and maybe to you– that things can get better.  Even if you have a problem that goes on for years; if you feel trapped and you truly seem stuck, things can change when you don’t expect it.

I truly hope this post was helpful to you.  Happy New Year!

My Story, Sacroiliac Joint

The end of my SI joint problems is officially in sight.

I’ve held off on writing this post until I was absolutely sure, but the time has come for me to make my official pronouncement.

In my post at the end of this past June, I explained how my SI joints were unexpectedly doing better following my 3 weeks in California. At first, I had thought it was something different about my routine, or being distracted by being around friends. However, once I got home and attempted to resume my regular chiropractic visits, I found myself feeling less stable. Maybe it wasn’t Boston, it wasn’t the East Coast weather, it wasn’t my routine… it was the chiropractor.

****

Now, let me back up. When I first developed my SI joint problem 5 years ago (God, has it really been that long?) my chiropractor was literally the only medical professional who could even begin to explain what was going on, much less free my leg when one side of my pelvis locked-up.

I saw several medical professionals, including two physiatrists and an orthopedist. I also saw a total of four different physical therapists. No one could tell me with any clarity what was wrong.

I saw one misguided physical therapist who specialized in “manual therapy,” meaning she actually put her hands on my hips and lower back and tried to use pressure to re-align me. This resulted in absolutely no change.

The ONLY person who seemed to be able to help me at all was my chiropractor. I walked into his office with my pelvis completely locked up, feeling as though someone had tied a belt around my legs– that’s about how well I could move them– on the verge of tears. “Oh,” he said calmly. “It’s your sacroiliac joint.”

And with a few clicks of his “activator” tool, my legs and I were free.

****

I wanted to give you this backstory so that you can see how, at one point in time, I was so grateful for the help of my chiropractor. He truly helped me at a time when no one else was able to; when all anyone else gave me were strange looks and exercises I was unable to do– followed by more strange looks when I tried to explain that it’s not that I didn’t want to do the exercises, it’s not even that pain was stopping meit’s that I literally did not have control over my legs. When my hips were stuck, my legs were stuck.

My chiropractor was able to explain to me the anatomy of the joint, and how this mysterious pain on the sides of my lower back could actually be related to me being unable to move my legs. He made me feel that I wasn’t a freak– he told me that this problem was actually quite common– and on top of that– he could make the problem (temporarily) go away.

It’s also my chiropractor who convinced me to finally work out in a pool. Despite all of my hesitations, and insistence that I really just wanted to work out on land… he repeatedly did his best to convince me that this problem was probably going to be permanent unless I found a way to strengthen my muscles without putting more stress on the joint. The adjustments were only going to be a temporary fix, he explained, until I created more muscle strength to hold the joints in place.

He was right about that, too. I didn’t really start to get better at all until I finally joined a pool. Up until that point, my land exercises just seemed to make things worse. (The pool was turning point #1).

I got even better, still, when I truly began to follow a thorough stretching routine. For a while I didn’t know how to stretch because the simple act of getting down on the floor was enough to throw my SI joints out of whack. Undoing my entire chiropractic adjustment just for the sake of stretching seemed backwards; like undoing the foundation of the building in order to adjust something on the roof.

However, I eventually found this really awesome stretching table on Amazon, and honestly– it changed my life. Finally I was able to lie down and do all of my stretches in a way that didn’t impact my hips. So that was turning point #2.

That was my life for a few years: pool, stretching, chiropractor. My life revolved around this problem, because there didn’t seem to be much of an alternative. Once my hips locked up, all else ground to a halt. As I said before, when my hips were really locked, it was as though my whole body was in chains. It honestly felt as though someone had tied a belt around my upper thighs; it was sometimes really difficult to put one foot in front of another.

But it wasn’t a permanent disability either. It made no sense to just give up, accept that I couldn’t walk, and sit in a wheelchair. Because I could walk, when my hips were aligned. During those first few moments after I left the chiropractor, I felt totally perfect and free. It’s just that things never stayed that way.

So I did my best, doggedly. I was afraid to drive– afraid that if something went wrong and I had to slam my foot on the break, I’d hurt my hip. So I had my parents drive me to the pool at the gym. Almost every night, I’d go just before closing, trying to find a time when the water wasn’t so choppy. I was so weak and out of shape when I first started going that everything hurt, if I went at at time when there were tons of lap swimmers.

So I’d try to go right before closing, when most people had already gotten out to shower. I’d stay in until the very end and then more or less have to rush outside, with my hair still wet.

There are a lot of pictures of me taken during that time period, of me out with my friends in downtown Boston. All of them are dressed up– high heels, makeup, straightened hair. And there I am– my outfit is cute, but my hair is still wet. (It sounds like a small thing, but honestly– I think my inability to keep up appearances actually affected some of my “friendships,” which I later realized weren’t really friendships.  More on that later).

I was willing to make sacrifices for the sake of getting over this problem. But now I am so frustrated, looking back, because the whole thing seems so pointless.

Turning point #3 came when one of my physical therapists finally showed me how to adjust my SI joints myself using a foam roller. As I’ve mentioned in previous posts, this was also life-changing, because now I did not need to depend on my chiropractor. When my leg got stuck, I was able to free it myself.

That brings me up to where I was in February, when I wrote my post about how I was doing better and things were feeling more stable. I had a feeling the end was sort of in sight, because I was starting to be able to do more and more. But I wasn’t out of the woods yet; I still had to check my SI joint and do my self-adjustments several times a day.

Then, this summer I realized that, after going all of June without having a chiropractic adjustment to my SI joints, I was actually doing better. I decided to experiment with not having any further adjustments to the area, to see what happens.

Here it is: turning point #4.

I can honestly tell you that my SI joints have not locked up once all summer. Things have not necessarily felt perfect, but I can tell it’s just muscle imbalance; it’s not the joint.

That same horrible dull ache at the intersection of my spine and pelvis? Gone. Just a memory at this point.

That awful, painstaking feeling of not being able to move my legs, of having a belt wrapped around my upper thighs?  Gone.  I’m almost starting to forget what it felt ike.

****

It is at once exhilarating and frustrating to realize that I think the very thing which got me started on my road to healing– the chiropractic adjustments– actually became detrimental in the end.

I have seen at least one bad chiropractor who I don’t trust, and would never for a million dollars allow to touch me again.

I don’t see my chiropractor that way.

I think he was, actually, able to correctly diagnose the problem, and I also do think his adjustments were putting my joints into proper alignment.

It’s just that, to an extent, I think my body also needed to be able to find an equilibrium.

The adjustments became too much, somehow.  Perhaps they were too much force for my ligaments, or perhaps they overly disrupted the pattern my muscles were used to holding everything in.

I definitely don’t feel that I was permanently injured by them, or anything like that.

It’s just that, at some point, my body just wanted to be able to locate some sort of homeostasis.  For my muscles and nervous system to have a chance to adapt to the way things were– even if, alignment-wise, it wasn’t “perfect.”

Now, I am certainly not suggesting that I would have gotten better if I had just left my SI joints alone, and allowed them to stay “stuck.”  That absolutely 100% would have failed.  When I think back to that horrible, dull, aching, grinding sensation, of two parts of the joint rubbing together in a way they were never meant to rub together… no.  Absolutely not.  There was no way any form of healing could have come out of that.  You can’t build muscle and get stronger when you can’t even move one of your legs.

But the chiropractic adjustments were just too rough.

I wish I had been shown how to do the self-adjustments from the beginning.  As I’ve learned in all of my PT prerequisite classes, your body has built-in reflexes that keep you from injuring yourself during normal movement.  When you perform a self-adjustment for the SI joint (which involves contracting certain muscles around the joint in a particular way), your nervous system will use these special reflexes to ensure that you don’t injure yourself, or put unhealthy levels of strain on the joint.  There is a level of precision here that no chiropractic adjustment can re-create.

Now, to be fair: I don’t know that I would have been able to develop the skills necessary to identify which way I needed to actually adjust my SI joints, without all of the feedback I’d gotten in my chiropractic visits over the years.  Compared to my PT, I actually think my chiropractor is better at diagnosing exactly what’s happening in the joint.

It’s just that his actual method of fixing that problem ends up backfiring.

Now that I know what I know, I have a lot of ideas for how someone like me could have been helped out of this situation a lot more quickly.

For example, having a PT who really took the time to teach about the SI joint, rather than just prescribing exercises.

Not just about the anatomy of the joint, but how to self-diagnose which way your pelvis is rotated, as in my experience, the self-adjustments have been the way to all healing.

Of course, as I write this,  I also reflect back on the fact that I was lucky to find a PT who knew about the SI joint at all.  Back in 2011, it did not seem that most physical therapists did not know it could cause problems (although thankfully, that seems to be changing).

I am going to continue to talk about the SI joint– both in terms of chronicling my own healing, as well as just to hopefully raise awareness.

I’m also now working on a second site, My Sacroiliac Joint Saga, where I will be talking about everything I’ve learned.

Looking back, all of the tools exist that would have allowed me not to suffer for so long.  It was only ever a matter of finding them.

 

 

 

 

 

 

 

Sacroiliac Joint

Could my frequent chiropractor visits be making my SI joint problem worse?

Normally, I tend not to share work-in-progress type posts. I don’t like to take up everyone’s time talking about something I’m not sure about.

I’ve just been through SO much– filled so many notebooks with my scribbles, had so many “epiphanies” thinking I’d figured it all out– only to find out that so many of the things I discovered turned out not to be true.

Now I tend to hold off on making pronouncements– much less asking other people to read about them– until I know I’m not barking up the wrong tree.

But there was one very interesting issue that came out of my trip from San Francisco, and I have a feeling it might be relevant to other people, too.

I think my frequent chiropractic adjustments may have been making my sacroiliac joint problem worse.

Since I developed my SI joint issues in the fall of 2011, I’ve gone to the chiropractor, on average, once a week. (Let’s not even talk about how much money I’ve spent).

When my SI joints first locked up, my chiropractor, Dr. K., was the only one who could even explain to me what was happening. I saw several different physical therapists, as well as a back specialist, and none of them were able to offer any type of diagnosis.

Dr. K., meanwhile, told me it was my sacroiliac joint making me feel like one leg was much shorter than the other. And, more importantly, he was able to fix it (at least temporarily).

However, I always noticed that during the first few hours after an adjustment, I seemed to be extra prone to having a setback. I used to try to go for walks following my appointments, but I found that even though my pelvis was “aligned,” one misplaced foot on uneven ground could make me “lose” my adjustment and end up even worse off than if I hadn’t gone to the chiropractor at all.

So I stopped doing anything extra after my appointments. I would try to sit in the car and rest for 20 minutes before driving. Then I’d come home and move gingerly throughout the house, knowing I would be extra prone to setbacks for the next 3 or 4 hours.

I’ve been in this holding pattern with this problem for years. Things are a lot better than they were in 2011, that’s for sure. But my pelvis is still unstable; I still can’t do everything I want.

***

Before I left for San Francisco, I found an interesting comment on one of the SI joint Facebook groups I follow.

Someone wrote that her physical therapist had cautioned her against getting chiropractic adjustments for her SI joint. The reason given was that the force of the adjustments could actually cause the ligaments in the area to stretch out, while they need to “tighten” back up in order to heal.

Something about this idea resonated with me, but I was about to get on a plane in a few days, and I didn’t want to try anything new. So I put it out of my mind, and actually went to the chiropractor twice in the week before I left, hoping to get myself in as good as shape as possible. Both times, my body slid back out of alignment afterwards like butter, and I got on the plane frustrated and expecting to limp for the entire trip.

Yet, during my two and a half week trip,. I actually started to feel better.

At first I thought it was in my head. It’s a new city– I was excited. I was distracted. I had my friends with me all the time– I was happy.

But now I think a big part of it had to do with the fact that I went two and a half weeks without any chiropractic adjustments.

***

Two days days ago, I went to see my chiropractor. It was actually my neck that was really bothering me– my SI joints didn’t feel bad.

During my visit, Dr. K. confirmed that my pelvic alignment was actually pretty good. He only performed one small adjustment to the pelvis (the lumbosacral junction, to be exact) just to help move things along a little further in the right direction.

But on the drive home from that visit, I felt markedly worse. I had to drive through a lot of road construction, and felt every single bump painfully in my lower back/pelvis, whereas I hadn’t really noticed the bumps on the way there. At one point, the car “thunked” down several inches off of the smooth, finished pavement onto the rough, unfinished surface that came next. A pain started there that I still had when I got home, and when I got out of the car, I was limping.

That’s when it hit me. Maybe the adjustments are making things less stable. Why, after all, would I come home so much worse off than before I had gone?

To be clear, I wasn’t limping after the adjustment itself. When I walked back out to my car from the office, I felt like everything was fine (and my neck felt a heck of a lot better).

But the adjustment itself may have put too much stress on my ligaments (and other tissues as well?) meaning that the bumpy drive home immediately afterward turned out to be detrimental.

***

It’s been two days, and I’ve been playing it by ear, trying to see if things start to feel more stable. And, guess what, they are.

I’ve had this funny feeling all along, like something about this problem didn’t add up. After all, I’d met other people with SI joint problems and they’d recovered much more quickly than I had. Why was I the one who could barely move, who I felt as though I was addicted to chiropractic treatments just to keep things lined up?

What if part of the problem has been the chiropractic treatment itself? Is it possible the adjustments have been creating a vicious cycle where, although my joints are put into alignment, my overall stability and ability to maintain that alignment is undermined?

I don’t know for sure, but given how much better and more stable I am beginning to feel again, two days later… I think it’s pretty likely.

It’s a pretty frustrating realization to have, after all the time and money I have dedicated to this “project.” Yet it is funny to note how, again, that San Francisco trip I was terrified of ended up teaching me something I could never have come to realize otherwise.

For now, I am going to forego the chiropractic adjustments, at least on my low back and pelvis, and see how things go.

***

Update, Sept. 2016: It turned out that chiropractic adjustments were absolutely making my SI joints worse.  I’ve stopped receiving adjustments to that area, and the SI problems I had for five years are beginning to fade into the background!  To find out more, check out my follow-up post The end of my SI joint issues is officially in sight!

Favorites, Inspiration, Interesting Articles, Neil Pearson, Pain Science

Neil Pearson on Building Hope and Recovery

I know I may have mentioned this once or twice before on my blog (or in like every post), but in case you missed it: Neil Pearson‘s work changed my life.

It all started when I met a physical therapist who had studied with Neil. This physical therapist opened my eyes to a relatively new approach to chronic pain treatment, called pain neurophysiology education. Ultimately, I was so inspired by what I learned that I began to consider physical therapy as a career.

I have written a lot on these experiences, and I always urge people to watch the three online lectures, given by Neil himself, that my physical therapist insisted I watch when I first began treatment with him.

For me, these lectures have always been a springboard– I come away wanting to know more.

Well, I was poking around on the Internet last night, and stumbled across this amazing webinar, Building Hope: The way through pain to self-management and recovery.  In this Neil Pearson discusses some new ideas and approaches to treatment that I hadn’t heard before.

The webinar itself is hosted by the Canadian Institute for the Relief of Pain and Disability, a really cool organization that’s worth checking out in its own right. They have a lot of great resources, and I love their compassionate, actively pro-patient stance. (Obviously, every organization tries to be “pro-patient,” but CIRPD really seems to get it right).

Here are some of the key points I’m taking away from this webinar:

1) Neuroplasticity means the nervous system can be changed, and if it can be changed one way (as in the case of chronic pain/central sensitization), it’s also possible to change it back.

2) Even just visualizing movement can help the nervous system inhibit its own pain signals. Research has established that exercise is a great way to stimulate your body’s own internal pain controls, but when the movement itself creates more pain, it can be counterproductive.

That is the beauty of just visualizing movement. As far as your brain is concerned, visualizing a movement is very, very similar to actually performing it.

As Neil explains at the 17:10 mark, visualization can actually help to stimulate the nervous system to inhibit pain. Over time, after you let your nervous system “practice” moving through visualization, you may find you have less pain when you actually go to move.

I think this is seriously SO cool. I can’t even find the words. It’s things like this that really inspire me to become a PT, and help people living with pain. (My takeaway: I want more information on this right now!!!).

3) You can help the nervous system block out pain signals by distracting it and giving it other information to process. You can use touch, or movement– even if it’s very very small movement.

4) Repetitive, rhythmic movements in particular can help to calm the nervous system by giving it something else to focus on other than pain. Rhythmic movements such as walking, breathing or even rhythmic gum chewing (what?!) have been shown to release more serotonin and help control pain.

***

I just honestly can’t even tell you how inspiring I find all this stuff.

I am fortunate that, right now, I am mostly able to move without significant pain. (Due to my SI joint concerns, I do have to be cautious).

But it’s nothing like the place I used to be in. I can remember a time in my own life when even thinking about moving was terrifying. I just felt truly stuck– like my body was a jail.

I can also think of people I’ve met– through blogging, reading stories, as well as the patients I’ve met while shadowing physical therapists– who are in equally as much pain, and seem to be trapped within their bodies.

These are people who, through no fault of their own, are in too much pain to move. It’s not that they’re lazy; it’s not that they’re depressed. It’s not that they don’t want to get better.

It’s just the way the deck was stacked; the way the cookie crumbled.

They are in too much pain; their injuries are too great; their nervous systems too sensitized. Perhaps they are obese; perhaps there are multiple health conditions going on.

Whatever the reason– it is so amazing to know that there is a way to begin to help them, without requiring them to move before they are ready.

I want to help those people. I want to be that physical therapist that comes in and helps the hard cases, the ones other medical professionals may have secretly labeled impossible. I want to sit with those people, and look them in the eye, and tell them that there is a way out of this.

***

I hope that you enjoy the video, and that you will also check out more from CIRPD and Neil Pearson. The webinar was also co-sponsored by the Canadian Pain Coalition and Pain BC— two additional groups with a lot to offer (why does Canada have all the cool organizations?). I could say more about how cool they are… but that will have to wait for another post.

I hope you are as inspired as I am! As always, don’t hesitate to let me know what you think!

Central Sensitization, Chronic Pain, Favorites, Pain Science

What is central sensitization?

Central sensitization: the back story to just about every story I tell on this blog. I’ve written the phrase a million times, but always in passing, always with a link to an article somewhere else. I think it’s high time the topic gets its own post.

Practice Makes Perfect

We’ve all heard the phrase “practice makes perfect,” right? When you want to get better at something, you practice. Want to learn how to play the piano? Practice. Want to learn how to ride a bike? Practice.

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Photo: t.spang

Our nervous systems are always changing and growing, in response to the things we do. Our brains form new connections all the time.

This is how we learn how to control our fingers, and move them more quickly and in more complicated patterns, when we practice the piano. It’s how we learn to balance when riding a bike. It becomes second nature.

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Photo: Alan Levine

Unfortunately, the same thing can happen when you give your nervous system enough changes to “practice” sending pain signals.

It sounds crazy, but basically, our nervous systems get better at sending these signals. It doesn’t happen automatically– you won’t develop central sensitization if you stub your toe, or get stung by a bee.

But it can happen if the pain goes on for long enough. For example, central sensitization can happen to someone who’s hurt their back, and has been in pain for a few months. The nervous system has been sending these pain signals over and over again, and now– just as if the person had been practicing the piano for a few months– the task has gotten easier.

Central sensitization can also occur in someone who has suffered a larger degree of trauma in a shorter time period. For example, it can happen to someone who’s had surgery– even if he or she was under anesthesia at the time.

This is because central sensitization involves nerves, your spinal cord, and the parts of your brain that process pain without conscious thought. They are still learning how to process all those pain signals, even if you are under anesthesia. (Of course, I’m not saying this will happen to everyone who has surgery. It is, however, a possibility).

In a nutshell, central sensitization means the central nervous system becomes more sensitive.

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Photo: Maryl Gonzalez

There are many different ways in which central sensitization can manifest itself– the symptoms are not always the same from person to person.

The differences have to do with the person’s individual genetic makeup, what the original illness or injury was, and other health issues the person may have. (And yes– the person’s beliefs and perspective on pain can have an impact on how they respond to central sensitization, but they do not cause it. More on this later– I have very strong feelings on the subject!).

Invisible Illness

Scientific research has shown that central sensitization tends to be present in patients suffering from many of the conditions people generally refer to when they talk about “invisible illness.” These conditions include fibromyalgia, chronic regional pain syndrome, migraine, temporal-mandibular joint disorder, chronic pelvic pain, and irritable bowel syndrome.

Sometimes central sensitization is the root of the problem: for example, researchers now generally believe it to be the cause of fibromyalgia (please, please don’t believe the other things you read!).

In other cases, central sensitization is one of several contributing factors (still playing an important role, however). This is more likely to be the case in conditions such as irritable bowel syndrome, which can also be influenced by food intolerances/imbalances in gut bacteria, and temporal-mandibular joint disorder, which involves the physical pathology of the joint. In these cases, central sensitization perpetuates the problem and causes additional pain and discomfort, but is not necessarily the primary cause.

The Common Link

Because central sensitization is the common cause, it makes sense that so many patients with fibromyalgia also suffer from other “invisible illnesses.” For example, studies have shown that significant numbers of fibromyalgia sufferers also have irritable bowel syndrome.

I have so much more to say on this topic– more research to tell you about, the history of how it was discovered, as well as my own personal stories.

But…. as I have to keep reminding myself, I’m writing a blog, not a textbook… so all of that will have to come in future posts!

Citations:

I think it’s important to always post links to scientifically-valid articles when I talk about scientific/medical concepts.

Here is a great plain-English overview on central sensitization, written by Christina Lasich, M.D., for HealthCentral.net.

Next, an incredible overview of the science on central sensitization from Paul Ingraham of PainScience.com, which is an amazing website.

Ingraham’s article is actually a “jargon-to-English” summary of this important review of the scientific literature on central sensitization written by Clifford Woolf, the researcher who first discovered central sensitization back in 1983.

Finally, check out this equally important article from Muhammad Yunus, who has done vital work exploring the common links between central sensitization and the invisible illnesses (he calls them central sensitivity syndromes in this article).

I realize that the average reader might not be able to understand all of the scientific terms in these articles (I know I struggle), but I want you to know that legitimate and credible information is out there, and this is what it looks like.

A Note to My Readers:

I am always happy to answer any questions that you might have.  I think that all of this information is so important for us to be aware of as chronic pain sufferers!  It can really be life-changing, once you start to truly understand the roots of your condition.

I am always so curious to know what you think! Did you already know that central sensitization is believed to be the cause of fibromyalgia?  Does the common link between fibro and other invisible illnesses make sense to you? Let me know!

Nervous System, Pain Science, Resources

Nervous System Basics, Part 2: Excitatory vs Inhibitory

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Continued from Part One

Nervous system cells, whether they are in the brain, the spinal cord, or the peripheral nerves, communicate with each other via a group of chemical messengers called neurotransmitters.  One nerve cell releases a neurotransmitter in order to create some kind of effect on the next nerve cell in line.

There are two major types of effects a neurotransmitter can have on a nerve cell: excitatory and inhibitory.

Excitatory refers to any stimulus that either causes a nerve cell to fire, or simply makes it more likely to fire (aka more likely to send a signal).

Inhibitory refers to any stimulus that makes a nerve cell less likely to fire (aka less likely to send a signal).

You will often find the words excitatory and inhibitory in scientific articles, whether those articles are discussing how pain works or how pain medication works.

For example, excitatory can refer to something that would encourage the nervous system to send more pain signals, more frequently. One nerve cell can have an excitatory effect on another, making that second cell want to fire.

On the other hand, some nerve cells communicate with other nerve cells and tell them not to fire. This is what is referred to as an inhibitory effect.

Many pain medications work in this way, by inhibiting the activity of nerve cells that transmit messages about pain.

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But the body also has its own built-in inhibitory system when it comes to the nervous system sending pain signals.

Scientists are still discovering how many of these pathways work, and they are incredibly complex. I read about some of them for my neuroscience class last summer, and was blown away by how intricate they are; how many different neurotransmitters and hormones are involved; how many different types of nerve cells and receptors on those cells.

But the gist of the matter is that some nerves can have an inhibitory effect on the activity of other nerves, slowing the overall transmission of pain signals.

This is one way in which the body regulates your experience of pain. Sometimes your body decides it’s important for you to feel pain– like when you are home alone and get a papercut. You look down, see you’re bleeding, and realize you need to be more careful with the papers you’re handling.

Yet sometimes, the body decides it’s more important for your survival to block out those pain signals– for example, if you’re a soldier in battle who has been badly wounded, but still needs to get out of the zone of fire. In those crisis situations, people can feel no pain at all, because of the nervous system’s own inhibitory mechanisms.

Of course, these systems do not always work perfectly. Research suggests that in people with fibromyalgia/chronic pain, the inhibitory pathways might not be working properly, which is why they seem to experience more pain in response to non-harmful stimuli than do other people.

It’s not only that the nerves sending messages about pain are working overtime (which they definitely can!). But the other piece of the puzzle is that the nerve cells responsible for reducing some of those pain signals are underactive.

I’ll be discussing this more in Part 3. Stay tuned!

The beautiful photo at the top was available through a Creative Commons license thanks to Charis Tsevis/Harrison & Star

Medication picture courtesy of Steve Smith

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Central Sensitization, Chronic Pain, Nervous System, Pain Neurophysiology Education, Pain Science

Nervous System Basics

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As I’ve said time and time again, I really feel that people living with chronic pain/fibromyalgia can benefit immensely from learning about how the body works. Even the feeling that you are just beginning to understand the complex processes making up your experience of pain can help give you a sense of control over things.

And reading about the new research that is being done on pain, even if you don’t completely understand every word, can sometimes give you a reason to remain hopeful at times when you’re feeling stuck.

With that in mind, I’m going to back way up and publish a post I’ve been meaning to write for a very long time.  Here I’ll outline a few key terms and concepts about how the nervous system works. Hopefully it will be helpful to anyone who is interested in learning more about pain.

So let’s get started.

The nervous system can be divided into two main branches.

Photo courtesy of the Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013.
Photo courtesy of the Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013.

The central nervous system consists of the brain and spinal cord, and is shown in pink in the diagram above.

The peripheral nervous system consists of all the nerves in the body, and is shown in yellow.

The brain is the command center for your body, and it is where your experience of pain is processed. It is where you think consciously, but it also controls many unconscious functions, such as breathing, your sense of balance, and the ability to orient your body in space.

The spinal cord is the relay system for messages between the brain and the peripheral nerves. (It can also play a role in affecting how strong your ultimate experience of pain is, but we’ll talk more about that later).

The peripheral nerves have two main jobs:

Sensory: Sensory nerves send signals to the central nervous system about what you are feeling physically. When you stub your toe or get a papercut, it’s sensory nerves that send that signal up your spinal cord to your brain.

Motor: This is (to me) a kind of funny scientific word. It really just means “movement.” The motor nerves of the peripheral nervous system are what tell your muscles to move, as well as tell your organs to perform specific functions.

Pain

When people talk about how pain works, they are generally talking about the relationship between the sensory nerves, the spinal cord, and the brain. The sensory nerves send signals up to the brain about any damage that may have occurred, and the brain decides how to interpret those signals.

But Pain is a Two-Way Street

Historically, people considered this pain pathway to be a very consistent, cut-and-dry system that always worked the same way every time. If a person was in a lot of pain, they had to have a lot of physical damage/injury. If they weren’t in very much pain, they must not have a very serious physical problem.

However, scientific advances in the past few decades have shown that pain is actually much more complicated than that. It turns out that the severity of a person’s pain does not always reflect accurately the amount of physical injury they have experienced.

You can have soldiers in battle who do not even realize they’ve been shot– their peripheral nerves are sending very strong messages of “damage” up to their brains, but their brains tune those signals out because they need to focus on survival.

Conversely, you can have people with chronic pain, who– due to a number of potential factors—can experience excruciating pain in response to a very minor injury, or in fact no injury at all.

Central Sensitization

At the risk of boring my long-time readers, let me define one of my most favorite terms again.  Central sensitization is the process responsible for this last phenomenon, where people can develop an increased sensitivity to pain.

The term refers to a series of changes that can take place in the central nervous system (the brain and the spinal cord) which can ultimately make a person much more sensitive to pain.  In some cases, central sensitization can become a self-perpetuating phenomenon, in which a person continues to feel pain long after their initial injury has healed.

Central sensitization is such a fascinating topic.  There is still much research to be done on it, but so far it is believed to play a role in such seemingly-diverse conditions as fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, temporomandibular disorder, and many others.

One Last Thing

When I first started trying to understand the amazing, interesting new research that’s being done in pain, I kept hitting this one term that mystified me.  The dorsal horn.  What the heck is a dorsal horn?  I was so confused by this for a long time, and it really held me back from understanding a lot of articles.

Turns out, the term dorsal horn refers to an area in the back of the spinal cord.  The back of the spinal cord is where the sensory nerves meet with the spinal cord, so their messages can continue on up to the brain.  It’s pretty simple actually– the sensory nerves connect with the back of the spinal cord, and motor nerves connect in the front.  So when people talk about the dorsal horn, they are  talking about where sensory information is entering the spinal cord and then being relayed on up to the brain.

For more info

If you want a really great overview of the divisions of the nervous system, I highly recommend this video.

Conclusion

I really hope you’ve enjoyed this post!  As you can see, it’s written in a very different tone, and for a very different target audience, than my previous post.  I’m still in the process of figuring out what type of post works best on this blog.  I really want to be able to write about advanced scientific concepts for every day people, and I’ll probably be trying to figure out the best way to do that for a while. Your thoughts/comments/suggestions are always welcome, so please let me know if you have any! Thanks!

Part Two: click here if you’d like to keep reading!

Top photo courtesy of Geralt

 

Inspiration, Uncategorized

Maybe everything is amazing

I first saw this Louis C.K. clip a couple of weeks ago, and I’ve been thinking about it ever since. (Be sure you watch until the 3:05 mark, which is where he really starts to make his point).

Studying anatomy and physiology and learning about the body has helped me to get to the point where I can start to appreciate just how crazy/complicated/complex our experience as human beings is.

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A lot of people seem to become intimidated when I talk about taking these classes, and say things like, “Yeah, but I’m not any good at science.”

It makes me really sad to hear people say that, because honestly—there was a time when I didn’t think I would be any good at science, either.

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I did pretty badly in science classes in high school because, well, my life was falling apart. I just couldn’t get it together enough to study enough, and when I did, nothing could really become cemented because I hadn’t really slept.

I did much better in the humanities classes, because it was easier to just wing it. I might have been to out of it to memorize chemical structures, but it wasn’t too hard to just read a novel and give my opinion.

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Then after high school: for years, in the back of my mind, I sometimes thought about becoming a physical therapist.

Originally, the idea was born more out of desperation than inspiration. I was so frustrated by the fact that there was always something hurting, all the time, and that I seemed to have a new physical therapy referral every few months. I was always really interested in the explanations the physical therapists gave me, and always did all my exercises, but it didn’t seem to be quite enough. I sometimes wondered if the only way out of this would be to take matters into my own hands, rather than relying on other people for the rest of my life.

Then I met Tim and watched Neil Pearson’s lectures, and all of a sudden my desperation turned to inspiration. There actually was a reason why I was hurting all the time—an overarching reason that I could work on, rather than targeting different parts my body, piecemeal, for the next several decades. And maybe I could help other people like me, like Tim had helped me.

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This is the point at which I actually started to look into what it would take to get into physical therapy school, and saw that I’d have to take all of the science classes I’d so carefully avoided in college.

Now I am grateful that I had to go back and take all of these classes. And I mean, we’re not really talking high level stuff here—we’re talking general chemistry, introduction to physics. The things you would take in your freshman or sophomore year of college.

Basic as they are, these classes have totally changed the way I look at things.

It’s like recognizing there are two sides to every coin. On one side, I can focus on my experience—the way a certain part of my body feels (or, in most cases, hurts).

If I want to flip to the other side of the coin, I can stop and think about the complex forces that are literally holding this part of my body together. The intricate chemical and electrical signals that sensations to travel from my the rest of my body to my brain, and then back again. And the different areas of my brain that are involved in letting me feel the pain, and determining how much of my attention is devoted to the pain, versus paying attention to other things.

And the thing is—you really don’t need to be an expert, at all, to develop this sense of appreciation. I mean honestly, I know nothing. If I wanted to go into more detail than what I just wrote above, well, I’d have to go open a textbook to make sure I didn’t tell you the wrong thing.

It’s not about mastering this information; it’s just about having been exposed to it, and having a sense of just how complex these things are. Complex, yet also orderly. Yes, we live in a chaotic universe, but our bodies have a blueprint that can be broken down into categories and understood.

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Sometimes I daydream about running a class for chronic pain patients. Not an academic class—more like a continuing ed class.

And we would just go over the very basics from anatomy and physiology. And my students could see that, when you just begin to learn about the body, it’s actually more like a language class than a science class.

Just as you would make a chart of the different parts of speech (past, present, future, etc.) you can make a chart of the major systems of the body. And then you can look at each system and break it down further; for example, you can break the skeletal system down into different types of bones, and then look at individual bones.

And then, as teacher, I would focus on the bones of the spine, since the spine is such a grave, sometimes threatening concept for anyone with back pain. I would explain that even though it looks like some kind of alien invention when you look at a diagram, the spine can actually be simple:

There are four parts of the spine. From top to bottom:

Cervical spine= 7 vertebrae that make up your neck

cervical vertebrae

Thoracic spine= 12 vertebrae in upper- and mid-back

thoracic vertebrae

Lumbar spine= 5 vertebrae in lower back

lumbar vertebrae

Sacrum= fused vertebrae at the bottom of the spine, which make up the center of the pelvis

sacral vertebrae

These terms are things that back pain patients hear all the time, and may even have explained to them. But, in my experience, there’s a big difference between having a doctor mention these things to you in passing—in an appointment where you’re scared of what he or she might diagnose you with—and learning something in a calm academic setting.

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The spine is just one example– there are so many different aspects of our physical being that sound complicated, even scary, when explained by a doctor, but look simple– and interesting– when broken down into smaller categories.

It’s helped me immeasurably to begin to understand this. Having a “second side of the coin” to flip to means it’s easier for me to change my perspective on the physical realities I sometimes can’t change.

Now I can’t think about how much something hurts without thinking about the fantastic nature of how it hurts. The fact that I have a bone, with muscles attached to it, with nerves that let those muscles communicate with this fantastic brain I have—it’s all pretty incredible.