The Four Categories of Pain– Dr. Jay Joshi

Hi everyone!

I’ve just discovered this awesome talk on central sensitization by pain management physician Dr. Jay Joshi.  It’s totally packed with information I want to share with you all– such as why it’s so hard to get help for central sensitization, and how ketamine infusion treatments can help.  There’s so much here, though, that I thought I’d break it down into bite-sized information for you.

So, to start out, let’s look at what Dr. Joshi says are the four main types of pain.  (For the purposes of this blog post, I’m actually jumping ahead to the 8:50 mark– later, we’ll come back to the beginning).  

The four types:

  1. Nociceptive
  2. Neuropathic
  3. Inflammatory
  4. Central Sensitization

1. Nociceptive pain: pain that results from actual tissue damage, or potential tissue damage (like if you’re starting to bend a joint past its normal range of motion).  It is “the common discomfort we have all experienced as a result of injury — a paper cut, a broken bone, or appendicitis, among other things.

More on nociceptive pain and its subtypes

2. Neuropathic pain: involves physical damage to the nerves or the central nervous system itself.  It can also occur when the person has a tumor that’s pressing upon a nerve.

3. Inflammatory Pain: Pain produced by the chemicals our body releases as part of the inflammatory or healing process.  On a small scale, think of how a bruise swells up and is painful to the touch.  This is because our body is sending special cells and chemical messengers to that part of our body in order to heal it– and also to make it painful, so that we know to protect the area.  This is inflammatory pain, and it can also happen on a much larger scale with more serious injuries.

4. Central Sensitization: And here we are– the type of pain that’s most affected my life.  It has to do with the concept of neuroplasticity: that the central nervous system (the brain and spinal cord) can change in response to the things it experiences.

When your body experiences a painful event or an injury, it learns from that experience, the same way it learns from anything.  Practice makes perfect– when your brain gets enough practice at sending pain signals, it gets better at it gets better at it.  In a way, this is for your protection– you learn and become more sensitive to performing the same kinds of actions or motions that may have caused this injury in the first place.

However, as a protective mechanism, central sensitization can sort of backfire.  Eventually, we can reach a point where our nervous systems are trying to protect us too much, when we’re not really at risk of injury anymore.

So these are the four main types.

Unfortunately for those of us suffering from central sensitization, it’s the type of pain that doctors and other medical professionals know the least about.

As Dr. Joshi explains, “there are physicians who claim to be pain physicians… who are anesthesiologists… who don’t even understand it.  And they’re teaching at major programs.  It’s scary.”

Central sensitization is as real a type of pain as any of the other three.  And, as Dr. Joshi says, if you’re going to be able to adequately treat pain as a doctor, you better be aware of all four categories.

***

Dr. Joshi also has some really great analogies which help to explain the phenomenon of central sensitization further.  I’ll be elaborating on some of those in my next post.

I hope this was helpful!

***

Also: you may have noticed that I’ve been playing around with my blog’s format.  I’ve honestly never truly been happy with the appearance of my blog, because I find my options are so limited with premade WordPress themes.  I’m beginning to experiment a little (and even spend a little bit extra!) to try to get things right.  If you have any thoughts or suggestions how improve the appearance of my blog, please let me know!

 

 

 

 

 

Being okay with uncertainty

IMG_3940

When I first started this blog, I was angry.  I never wrote about it, because I didn’t want to bring people down, but I was sick and tired of trying to explain my health issues to the people in my life, and feeling like they didn’t believe me.

Maybe you can’t see the anger, because you aren’t me.  But when I look back and read my earlier posts, I see the it in between the lines, in the way I wrote.  How sure I wanted to be of things; how determined I was to prove that things were, in fact, the way I understood them to be.

The funny thing is that now that I’ve taken more and more science classes, my perspective has changed.  The more I know, the more there is I realize I don’t know.  And the more I’m actually okay with that.

***

For example, one of the things I’ve written about from time to time is how researchers are beginning to use brain imaging to study chronic pain, and even to develop new treatments for it.  This is, of course, super promising research, and I’m really excited about it.

However, one of the first posts I wrote about it, I’ve since had to significantly edit.  That original post was about how I hoped that, someday, doctors would be able to use brain imaging to “test” people for pain hypersensitivity, and prove that they had central sensitization.  This, I imagined, could be used to validate patients’ disability claims, or prove that they weren’t faking it.

The more and more classes I’ve taken– and I’ve had some really great professors, who went into the ethics of research– I’ve come to realize why using brain imaging as some sort of test wouldn’t be ethical.  The body is too complex; our testing too imperfect, to allow it to be used to potentially deny someone treatment.  People with legitimate pain could still fall through the cracks.  That’s why these brain scans should probably only be used for research and developing treatment.

That’s just one example of how my perspective has changed– knowing that we may never have a definitive way of proving who is in pain or not.  I’m more comfortable with uncertainty now, because I’ve learned so much more.

I have a much better sense of where we stand now with scientific research and where we are going.  I’ve also made a lot of changes in terms of the people I choose to have in my life.

So from where I stand now, the idea of not being able to “prove” myself is no longer one of my biggest fears.

***

Something I’m learning is that you can learn a lot about people by looking at what they choose to emphasize.

For example, I once had a roommate who’d been bullied for being overweight as a child.  Of course, as an adult, this person was obsessed with clothes and makeup, and never left the house, even to make a quick run to the store, without making sure she’d done her full beauty routine.

And maybe it was the same with me– in my anger, I needed to formulate some sort of certainty about central sensitization and chronic pain, because it gave me a sense of the stability that I was lacking.   Maybe that’s why the idea of a “test” appealed to me– it offered what I wished I could provide to the people in my own life: unequivocal proof.

***

Of course, I still believe in learning about central sensitization.  No question; that is what has most empowered me.  Knowing what the problem is, and naming it: to me, that’s the first step on the road to healing.

What I’m really remarking on is the paradox: the more I know, the more I am okay with what I don’t know.

I no longer need to prove anything, so not having all the answers doesn’t scare me anymore.

 

Shedding light on central sensitization

Hi everyone!  Hope you’re all having a great summer.

I just wanted to let you know that I recently added a new section to my blog, to focus on central sensitization.

When I began this blog in late 2012, I started out writing about the topics of chronic pain and fibromyalgia, terms which most of my readers are more familiar with.

However, over time, it became more and more important to me to focus on some of the scientific research that’s been shedding light on the nervous system phenomena behind chronic, persistent pain.

Central sensitization has had a huge impact on my own life, one that’s stretched far beyond the initial injuries that caused me to develop it in the first place.  (Basically, central sensitization occurs as a response to some sort of trauma to the body, leaving the person with a heightened sensitivity to pain long after any physical injuries have healed).

I’ve recently begun to tell the story of “How I developed central sensitization.”  It’s a series posts about how, after years of abusing my body as a high school athlete with an eating disorder, I finally stretched my nervous system to the breaking point.

I’ve also written a series on my experience with pain neurophysiology education, an approach to physical therapy that taught me to better manage my condition.

These stories are incredibly personal to me, yet I really believe that central sensitization is an under-recognized problem, and I’m determined to raise awareness.  It took me years of suffering before I even knew the name of my condition (or was able to get help treating it), and it shouldn’t have to be that way.

So on my blog, I’ll be telling stories from my own personal experience, well as highlighting some of the articles, research and researchers that I find inspiring and noteworthy.

I’ll still be writing about chronic pain and fibromyalgia, recognizing that there are many factors that contribute to each patient’s experience with these conditions.

Ultimately, I believe that the more we know as patients, the better we can advocate for ourselves.  That is why I believe so strongly in raising awareness of this issue, both in terms of the scientific discoveries being made, as well as sharing the impact it’s had on my own life.

Here are some of the posts I’ve written on central sensitization so far:

What is central sensitization?

The nervous system and chronic pain

How I developed central sensitization: Part 1

How I developed central sensitization: Part 2

How Clifford Woolf discovered central sensitization (and why you shouldn’t blame yourself for chronic pain)

Central Sensitivity Syndromes

Todd Hargrove: Seven Things You Should Know About about Pain Science

Let’s give this a whirl: explaining a scientific article in plain English

All of these, of course, are listed on my new “Central Sensitization” page.

Other great links:

Central sensitization in chronic pain (from Paul Ingraham at PainScience.com)

Dr. Sean Mackey: An Update on Fibromyalgia (really interesting talk from a Stanford researcher on the role of central sensitization in fibromyalgia).

and a lot more within my “Resources” section (if you haven’t swung by in a while, I’ve been adding a lot to it).

***

I hope the things I write and link to are helpful to you.  As always, you’re welcome to contact me with any comments or questions.   (You can comment below or send me an email!).  Happy reading!

How I developed central sensitization: Part 2

Continued from Part 1

My doctor said I had what was called “glass back” syndrome.  Every muscle, from my neck to my lower back, was locked in spasm.  Even the smallest movement could set off a domino effect, each muscle triggering the next, until my entire back would feel like a blaze of pain.  I was so sensitive to movement, it’s as if I was made of glass.

The only time of day when things didn’t hurt was when I first woke up in the morning.  For those few seconds before I moved, I would feel okay.  Then, when I turned to roll out of bed, bam!  The blaze of pain would return.

I learned to keep my bottle of painkillers next to me when I slept.  That way, when I woke up, I didn’t have to reach very far for a pill.  I would gingerly edge my fingers along the mattress, grab the bottle and open it.

That would be it– the only motion I’d perform.  Reach over, take out a pill, put it in my mouth, swallow.  And then wait until I felt it set in; everything would become dull, and a little less horrible.  I was a little farther inside myself, but at least I was also farther away from the pain.

Tramadol, Tylenol, Advil, and a muscle relaxer.  And Bengay cream.  And heating pad at night.  These were all the things I needed to make it through– if you can call it that.

***

Part of what made it worse is that I was treating my back pain like it was a running injury.  That was the only type of injury I’d had before, and with all of those injuries, the important thing was to rest.

I later learned that with a back issue such as this (it wouldn’t be accurate to call it an injury) it’s actually really important to move, and strengthen the back muscles.  To an extent, you have to keep moving in spite of the pain, because if your muscles get weak, things only get worse.

But I was young, and I didn’t know.  In fact, I was tough; I was an athlete.  I’d never had “injuries” before that hadn’t been caused by a serious amount of force travelling through my body, my feet pounding into the pavement at sub-6-minute mile pace.

I was not at all familiar with this kind of pain– the kind of pain that kept spiraling beyond my grasp, beyond my wildest efforts to control it.  The kind of pain that seemed to be caused by almost nothing.

So, I thought, I needed to rest.  That’s what I’d done for all my previous injuries.  I didn’t want to strain anything, or break anything.  With this amount of pain, rest.

***

In the midst of this, I was due to start at the new school I had transferred to; a small liberal arts college in Western Massachusetts.  I contemplated not going, but ultimately I decided to take the plunge. I didn’t want to miss out on yet another experience.

Luckily, I could physically make it to class– the campus was walkable, and my legs had healed completely from the surgery.

But a lot of the time, I couldn’t concentrate.  I remember being in class knowing I was feeling the exact moment when my last dose of tramadol wore off, counting down the minutes until I could go back to my dorm room and take another.

And then, once I was safely back in my room, I’d briefly fall asleep.  Not from the tramadol (my body got used to it after a while) but from the sheer exhaustion of trying to stay awake through something so excruciating.  It was as though my conscious mind needed a break from experiencing this much pain, and sleep was the only way out.  So I’d fall asleep, and leave reality behind for a little while.

***

The way out, as I learned in physical therapy, was to get out of bed and keep moving as much as possible.  I started going for walks– long walks, which I might have once thought impossible before my leg surgery.  This, as my PT explained, helped to increase blood flow, flushing out some of the pain-producing chemicals in muscles, and also “acting like a giant heating pack from the inside,” helping the muscle to relax.

Additionally, I started doing specific exercises to strengthen my back muscles.

And you know what else?  I took my painkillers.

***

Contrary to what you might expect, my doctor at school totally understood what I was going through and encouraged me to actually take the full amount of tramadol she had prescribed (up to 6 pills a day), if it would help me move more.

From her, I had my first real experience with understanding pain science.  She explained that, with “glass back syndrome,” the pain sort of became its own cycle.  As the muscles would spasm and create pain, this would actually cause all of the other nearby muscles to tighten up as well, to protect the area.

The painkillers, it turned out, were actually helpful in reducing those pain signals telling the muscles to spasm.  When I took them, I was able to go for walks, and do my exercises, and get stronger.

(This experience is one reason why I will always believe in the power of prescription pain medication to help chronic pain patients.  Without it, I truly believe my recovery would have taken much longer).

***

Eventually, my back got stronger, and the all-encompassing muscle spasms finally stopped.  I found I no longer needed the tramadol, and I stopped that too.

However, though my “glass back syndrome” eventually subsided, the pain would never fully go away.

To be continued in Part 3!

An Update on Life with One Ovary

One of the topics readers most frequently contact me about is the time I had to have emergency surgery to remove my right ovary.

In case you aren’t familiar with the story, I had had abdominal pain throughout most of my twenties.  Doctors had told me it was nothing to worry about– just digestive issues.

Well, in February 2013– just a few days before my 28th birthday– the pain in my right side, and nausea, became so severe that I went to the emergency room.

There, an ultrasound revealed that I was suffering from ovarian torsion— something had caused my right ovary to rotate, with the Fallopian tube wrapped around it in such a way that its blood supply was being cut off.

The doctors rushed me in to surgery in an attempt to reverse this process and restore blood flow, but it was too late.  The ovary had to be removed.

For months, after this– I’d say a year, really– I suffered from both physical and emotional fall out.  And actually, a lot of what I experienced me is what my readers say they also go through.

I decided it’s high time I give everyone an update on this situation, and I’m here to tell you that, three years later, everything is alright.

***

Physical Symptoms:

I was in pretty significant pain for about two weeks following my surgery.  I really relied on narcotic painkillers.  They masked the pain so well that I’d think I was better and didn’t need them anymore.  Then my last dose would wear off and I’d feel like my world was coming to an end.  Other people (mainly my parents) would have to remind me that I was due for another Percoset, and then I’d come back into my rational mind again.  (By the way, I am a FIRM believer in the usefulness of opioid medications.  This entire ordeal would have been much more emotionally scarring if I’d had to bear the brunt of this mind-warping pain without them) .

After about two weeks I was okay… until my next period.

This is pretty graphic, but I figure if you’re here, you’re interested.  I went back to my OB doc in agony again, like I’d just had the surgery yesterday.  He explained that basically, now that I was menstruating, blood was coming out of  the side my uterus and leaking into my abdomen, because now I had a gap where the Fallopian tube used to be.  Basically, it was a totally benign phenomenon– my body would just reabsorb it– it was just causing pain because there was fluid where fluid wasn’t supposed to be.

At the time, my doctor told me it would be like this every time I got my period, and suggested I take the birth control pill to lighten my periods and ease the pain.  I did this for a few months, but eventually as time wore on, things stopped being painful.  Now I believe that my body just hadn’t fully healed from the surgery.  It’s also possible, as one nurse practitioner suggested, that my nervous system had become sensitized to pain in that area (gee, that sounds familiar!).

What I do know, for sure, is that three years later, I am having normal periods without agonizing pain.  I sometimes do notice that during my period, I’m a little sore on the right side, but it’s something I am pretty much able to ignore.

Mood/Emotions/How Do I Feel?

I feel totally and completely normal.  What all of the doctors told me is true– when you lose one ovary, the other one completely takes over.  You don’t really need two.  (In fact, there’s a reason why we have two).

My left ovary is a magical little powerhouse and it has taken over completely, doing everything I need it to do.  I feel the same.

Blame/Doubt

It took me a really, really long time to work through some of the emotions that came from this.

I am still mad at the doctors who so easily brushed my concerns aside.  To be fair, they were gastroenterologists, not ob-gyns.  But still.  One of them literally even wrote a book on digestive disorders in women.  (I don’t hate her enough to name her here– in fact, she is still my doctor because I think she’s a good gastroenterologist).

But still, on this, she did brush me aside and tell me it was irritable bowel syndrome.  Seeing that I am a woman of child-bearing age, I wish she had thought to tell me to consult an OB-GYN.

I also still think that the gluten-free craze is just a fad, and that it has power to do just as much harm as it does good.  (This doctor’s advice to me, the last time I saw her before this happened, was to try switching to a gluten-free diet to see if I felt better).

But I’m no longer mad at myself.  I did the best I could with the information I had at the time.

I try not to judge myself for the way I handle things.  There have been times I’ve under-reacted, and there have been times I’ve overreacted.  Nobody is perfect.  We do what we can.  Pragmatism is my goal.

Fear of it happening again

And this. This is really the number one thing women write to me about– the fear that the same thing will happen to your good ovary.

I can’t promise you that nothing will, but I can tell you that so far, nothing has happened to mine.  It is just fine.

They told me what happened to me was about as rare as getting hit by a bus, or being struck by lightning.  The odds are like one in a million.  The odds of it happening again? Almost minuscule.

Still, there have been a number of times that I’ve freaked out and rushed into the doctor’s office for an emergency same-day ultrasound.  (When you’ve already been that one in a million, it doesn’t really make you feel like taking chances).  But my ovary has never been twisted.

I’ll tell you the truth, in the past three years, I think I’ve had six of these.  I know that’s a lot.  But I know that it won’t seem like a lot to any of the women who’ve emailed me.

The majority of the times, the doctors were able to decipher what had happened to cause me pain.  That I had ovulated, or was about to ovulate (normal ovulation causes the formation of a little cyst, which then releases the egg).

Some of these cysts, they said, wouldn’t be enough to cause pain in every woman, but for whatever reason, in me– probably now that I’m hyper-focused to that area– I notice it.

And there were a few times I was really scared, when it hurt a lot.  But I learned that, in some women, normal ovulation can be really painful– even more painful than what I was reporting.  So I would just have to trust in the ultrasound, when it showed my ovary just doing its same normal healthy thing.

So, that is where I’m at right now.

I still hope to have kids someday, and as far as I know, there is no real reason why I won’t be able to.

Now that I write this, I can’t believe how sane and calm I sound.

Believe me, it wasn’t always this way.  I was the same as those of you who end up sending me ten panicked emails (it’s okay, I say this affectionately).  Really, I was.   But I had no one to email.  And now, for me, things are okay.  And there is every reason to think that, eventually, they will be for you too.

My two previous posts on my surgery:

So… I lost an ovary

Beware the Red Herring (follow-up post)