Explain Pain 3, Day 2

Dave opened day two, promising to close off the loop of the pain mechanism model after the sessions on nociceptive inputs to the brain yesterday, with his session on outputs. Dave asked us to consider the following situations; you’re about to be bitten by a dog, about to do an exam, you’ve just sprained some soft tissues in your back, you’ve been told its “all in your head” or you’ve been told “it’s bone on bone in there”.  What’s just happened? Essentially you are facing some form of threat, but fortunately, there will be bodily systems and process that can be engaged to protect you.

These protective systems have a number of characteristics:

• They are often activated together, not alone, which can be expensive on the body
• The systems display overlap and circular feedback and feedforward
• Some systems exist for short-term threat emergencies such as motor, endocrine and sympathetic systems. Others, such as immune and parasympathetic offer longer term assistance.
• The reasons certain systems are activated at any given time by the self are nor really known
• Pain is placed as an output system in keeping with a modern definition: “Pain is a multiple system output constructed by an individual pain neurotag. This signature is activated whenever the human concludes that body tissues are in danger and action is required and pain is allocated an anatomical reference in the virtual body”
• Output systems can be engaged by the past, present and future
• Our therapy essentially aims for “freedom of expression” of these systems, rather than a paradigm of control.

The specific output systems include:

Emotion- anxiety and fear can be useful in the right setting and context, they can increase attention and vigilance and increase pain intensity and thereby motivation to take action. In chronic pain, increased attention and vigilance has been shown to lower pain thresholds.

Thoughts- are real, are physiological, are nerve impulses. Thoguhts are the foundation of health literacy. In chronic pain, thoughts alone can be enough to fire a disinhibited neurotag and elicit pain.  Catastrophic pain cognitions hav been shown to heighten pain experiences and can be linked to illness behaviour such as pre-occupation with symptom management, use of analgesics and increased visits to health care professionals.

The sympathetic nervous system (SNS)- so often seen as the villain in some pain states, the SNS is a key response system to get us out of trouble. Increased activity in the SNS can add to the “inflammatory soup” in an unhealthy tissues, can activate Abnormal Impulse Generating Sites (AIGS) and can dribble out adrenaline into the dorsal root ganglion leading to upregulation of adrenoreceptors. The SNS can be likened to a match – easy to ignite and quick to go out.

The endocrine system- The endocrine system, in particular the Hypothalamus-Pituitary-Adrenal (HPA) Axis (the fire) can be ignited by the SNS and has longer lasting effects. Cortisol, one of the major products of activation of the HPA Axis has wide influence within the body and in periods of acute stress will activate bodily processes needed for survival and close down/inhibit bodily processes that are not.

Chronically altered cortisol production, as is often seen in chronic pain states can lead to:

• Depression, mood swings and post traumatic stress
• Memory changes, especially in women
• Poor tissue healing
• Possibly cell death in the hippocampus
• Weight gain
• Altered immunity

The motor system- much of the motor activity we see in the clinic may be based on the motor system being activated to protect a person and help them cope. Unfit, unhealthy muscles in chronic pain states can be a source of nociception.

The immune system- used to be the ‘new player’ in pain but not anymore. Modern biopsychosocial approaches to pain need to wholly embrace the neuroimmune system. Some key immune compounds include the cytokines and in particular the proinflammatory  Interleukin (IL) 1, IL6 and TNF alpha and the anti-inflammatory IL 4, IL10 and TGF beta. It is reasonable to suggest that a balance exists between the pro- and anti- inflammatory cytokines with a balance tipped towards the proinflammatory cytokines more likely to be associated with pain.

The immune system can be characterised as “a system that knows who you are and when you are not you”. The release of cytokine from the immune system can:

• contribute to local inflammation bodily tissues
• activate or sensitise AIGS
• contribute to mirrors pains
• contribute to non-responsiveness to opioids

Immune buffering behaviours that help to restore a healthy immune profile are worth considering for chronic pain states, they include:

• An ability to develop coping skills
• Dethreatening the perception of the stressor
• Social support systems
• Medical support systems with people speaking the same language
• Strong belief systems
• Exercise
• Humor
• Intimacy

In the brain, both glial cells and neurons can produce immune compounds. However the glial cells vastly outnumber neurons in the brain (about 10 to 1) and have powerful protective and functional roles.

Microglia in the CNS are constantly scanning for danger and can around in the brain is response to threat. It has been shown that in rats, lumbar spinal cord glia can move as far as the cervical cord. Microglia are involved with pruning synapses and dendrite of neurons and help to sculpt and build the brain.

Astrocytes are physically coupled with neurons in complex bidirectional relationships. 80%-90% of synapses in the CNS are ‘draped’ by astrocyte projections (the notion of the tripartite synapse). One astrocyte can enwrap hundreds of thousands of synapses around it and influence each of these, potentially forming “brotherhoods” or “sisterhoods”- coalitions of neurons and glia for protective reasons.

Immune products are also essential for learning, which can be considered a kind of sterile inflammation of the brain.

Dave suggested that we need to be aware of all of these possible protective outputs, thinking about which systems may have been turned up, which may have been turned down. Are we seeing language (a cognitive/linguistic output) drying up? Are there perturbations to breathing? Therapy aims to honour these outputs, not control them, by increasing choice and the freedom of expression of all outputs unhealthy, neuroimmune balanced ways.

After morning tea, Mark Jensen provided a very practical session on Motivational Interviewing (MI). Mark provided an overview of MI, including the key elements of MI and facilitators and barriers to change.

Mark explained that MI was built on a theoretical foundation developed by William Miller and Stephen Rollnick after a review of what we know about inhibitors and facilitators of change.

Inhibitors to change include

• Therapists that confront client behaviour by telling them to change with lots of “shoulds” and “musts”. Mark explained that he called this “shoulding on yourself” or “musterbation” and neither were useful for change

Facilitators for change include

• Developing an awareness of a discrepancy between behaviour and core values
• Accurate self perception of thoughts
• Choice (threats to freedom elicit resistance)

Mark discussed what not to do with MI, firstly don’t lecture people and secondly don’t argue with people – they very rarely change if you do.  Mark encouraged reflective listening – a skill in itself that can be practised and developed.

Mark explained that reflections can take the form of:

• Repeating/rephrasing a statement from a client
• Reflecting deeper meaning/values
• Reflecting the emotion of a statement or interaction
• Reflecting the next sentence

But, MI is not just reflective listening, although this is a skill used within MI.

The four principles of MI are:

• Express empathy – reflective listening
• Develop discrepancy – elicit change talk
• Avoid argumentation – roll with resistance
• Support self-efficacy – affirm positives

One way of thinking about MI is that it is like inviting someone to look into a mirror:

• As I hear myself talk, I learn what I believe
• If I say something and no one has forced me to say it, I must believe it
• Awareness of discrepancy between behaviour and core values creates change

The final session of the day was Dave taking us through a reasoning and neuroscience based use of metaphor. Dave highlighted some metaphors common to pain, all with a warlike/battle basis, metaphors such as- painkillers, attack of back pain, my neck is killing me, the war on pain, stabbing shooting etc. Dave advised that there had been very little research undertaken on the use of metaphors in regards to pain, but it was a rich area to explore.

Metaphors can both help and hinder rehabilitation in powerful ways, but can be “embedded” in language – so common that we no longer recognise them as metaphors- examples such as pins and needles, burning, shooting pain.

Overall, a very useful clinical reasoning question is “why is this particular expression being used at this particular time?” – the answer may provide some insight into processes occurring as well as possible rehabilitation approaches. For example disembodiment metaphors such as referring to a body part or pain as “it” and statements such as “my leg doesn’t feel like it belongs to me” indicate possible disownership of a body part an suggest that GMI approaches and ‘learning to love the past again’ might be useful.

Dave suggested that there were at leafs 4 metaphors that are held in society, but have been made redundant by neuroscience:

• Build a bridge and get over it
• Pain is weakness leaving the body
• Pain is character building
• No one ever dies of pain

Clinical use of metaphor can include

• Metaphors enriched with some literal language “Motion is lotion” – coating joint surfaces with natural lubricating fluids and keeping tissues fit and healthy
• Using a bit of humour – the book Painful Yarns being a great resource
• Adding multimedia- pictures and images such as the “twin peaks” model from Explain Pain
• Getting a bit philosophical- pain is a defender, not an offender, ships are safest in the harbour, but that is not what they are build for
• Using some quotes that are contextually relevant to the individual for example Sir Edmund Hilary in New Zealand – “we knocked the bastard off”

And that was the end of day two!

Again, I’ve been tweeting live all day and I can be followed on twitter @altThinq. @noigroup and @NOIExplainPain are also here and we are all using the hashtag #ExplainPain3.

Tomorrow is shaping up to be another great day, Lorimer is back with some explain pain evidence to convince your clients and yourself, Mark is talking about hypnotic language and Dave will be talking about story telling.

Until tomorrow

-Tim Cocks

www.noigroup.com