Pain

A new view of pain

“A new view of pain as a homeostatic emotion Bud Craig”.

Neuroscientist Bud Craig wrote this research paper 20 years ago.

I just discovered in last year and was blown away by the explanation of pain through the lens of homeostasis and interoception.

It links the body and brain in a plausible and scientific explanation that is based on Mr Craig’s decades of pain staking anatomical dissection and innovative tracing methods.

Currently as a society we are going through a epidemic of pain.

Our traditional models are not helping.

It could be argued they are making the problem worse due to iatrogenic harm.

Once you are caught in the biomedical matrix, it is very challenging to escape.

I found this paper to be a game changer as it helps us to use a m0re accurate explanation of pain that links body and brain in a way that is much more empowering.

Subsequently I have been reading more of Mr Craig’s work as well as his amazing book.

Making sense of pain is arguably the greatest therapy there is.

I have included the full PDF in the link below.

Some of the highlights from the research paper I have also outlined below.

As it is written for a scientific lens, if you reading this and would likely to comment or connect to find out more - just leave a message below or send me an email dan@kinfolkwellness.com.au

“Pain is both an aspect of interoception (the sense of the physiological condition of the body) and a specific behavioral motivation. This striking conceptual shift incorporates the multiple facets of pain into one concrete framework, and it provides sound explanations for pain as both a specific sensation and a variable emotional state”.

“Changes in the mechanical, thermal and chemical status of the tissues of the body – stimuli that can cause pain – are important first of all for the homeostatic maintenance of the body.”

“Pain normally originates from a physiological condition in the body that automatic (subconscious) homeostatic systems alone cannot rectify, and it comprises a sensation and a behavioral drive with reflexive autonomic adjustments.”

“The behavioral drive that we call pain usually matches the intensity of the sensory input but it can vary under different conditions, and can become intolerable or, alternatively, disappear, just as hunger or thirst.”

“The new view of pain as a homeostatic emotion arises directly from functional anatomical findings in cat and monkey, rather than from philosophical considerations.”

“These results have identified specialized central substrates that represent pain, temperature, itch, muscle ache, sensual touch and other bodily feelings as discrete sensations within a common pathway.”

“These data indicate that in humans pain is an emotion that reflects specific primary homeostatic afferent activity.”

“Activity that produces pain in humans ascends in this pathway because its primary role has been homeostasis for millions of years.”

“Humans experience increasing discomfort at temperatures below 24C, but cold does not normally produce pain until 15C, where HPC activity accelerates and, significantly, cooling-specific lamina I cell activity plateaus.”

“This physiological evidence confirms the anatomical finding that homeostasis, rather than the heuristic simplification ‘nociception’, is the fundamental role of the small-diameter afferent fiber and lamina I system and is the essential nature of pain.”

“These findings indicate that pain in humans is a homeostatic emotion reflecting an adverse condition in the body that requires a behavioral response.”

“The new findings provide specific substrates for each of these aspects within a common framework of homeostasis.”

“This new view differs fundamentally from the prior conventional view in several ways. It incorporates specific sensory channels for different kinds of pain and for pain of different tissue origins. It provides a fast (sharp) pain channel that can elicit fight-or-flight behavior and a slow (burning) pain channel that can engage long-term responses, sickness behavior and immune function”.

“This perspective suggests new directions for research that could have strong impact on clinical therapy. For example, other homeostatic variables, such as salt and water balance, could have direct impact on the integrated activity that underlies the motivation called ‘pain’, as in the mysterious fibromyalgia syndrome.”

“Understanding the mechanisms underlying the augmentation of activity in the polymodal nociceptive channel could be particularly fruitful for identifying new therapies for chronic pain.”

When Biomechanics DOESN'T Matter

Greg Lehman has been a pioneer in helping us to understand pain and biomechanics and finding out when they matter.

He is a advocate for “Movement Optimism” - an approach that helps you build confidence in your body and avoid the common trap (fueled by well meaning health care professionals) of getting stuck in sometimes irrelevant biomechanical narratives that create fear and entanglement in the body.

I would encourage you to watch at least the first five minutes as he pulls apart the most common things you might hear coming from your health care professionals mouth.

“What I often say is, it’s not the pain science or neuroscience that challenges these biomechanical ideas, it’s the biomechanics itself. And if you know the biomechanics well, you can really see the holes in the common arguments.”

I hope you enjoy this eye opening lecture at the San Diego Pain Summit (click on image below to watch on youtube).

"Back to the Body": Charting a New Course in Physiotherapy

In the dynamic field of physiotherapy, a transformative wave is reshaping our traditional approaches to pain and injury.

This evolution, termed "Back to the Body," represents a significant departure from past practices, integrating modern science's revelations with a renewed focus on the body's intricate signals.

As we delve into this shift, it's essential to appreciate the context from which we're moving and the promising direction in which we're headed.

The Traditional Paradigm: A Focus on the Physical

Historically, physiotherapy has been deeply anchored in a biomedical model, concentrating on the body's physical aspects—its joints, muscles, and tissues.

This approach, while foundational, often adopted a reductive lens, aiming to "fix" what was perceived as broken or misaligned.

Diagnoses frequently highlighted deficiencies: a "weak" core, "tight" muscles, or "improper" posture.

While these assessments were made with the best intentions, they inadvertently introduced a nocebo effect, where the negative framing of conditions could exacerbate patients' perceptions of pain and disability, sometimes with minimal relevance to their actual experience of pain.

The Shift Toward Mind and Emotion

The field's expansion to encompass beliefs, emotions, and the broader neurocentric model—largely influenced by the pioneering work of researchers like Lorimer Moseley and David Butler—marked a significant leap.

This phase brought to light the brain's integral role in pain perception, advocating for a more comprehensive understanding that transcends mere physicality.

However, this shift, for all its merits, occasionally led to an overemphasis on the psychological at the expense of the physical.

Patients sometimes felt their pain was being dismissed as purely a construct of the brain, leaving them feeling invalidated and overlooked.

"Back to the Body": A Holistic Reintegration

Today, we stand at the precipice of a new era, inspired by Bud Craig's insights into homeostatic emotions and the complex interplay between mind and body.

"Back to the Body" advocates for a return to a more integrated approach, where pain is recognized as an interoceptive signal—a cue from our body indicating a need for attention and care.

This perspective sees pain not as a mere symptom to be eradicated but as a critical piece of feedback within our body's attempt to maintain balance.

With advancements in technology—such as heart rate variability monitors, blood glucose tracking, and sensors for lactate and inflammatory markers—we're now equipped to decode the body's signals with unprecedented clarity.

This technological leap, combined with principles of load management as outlined by Tim Gabbett, empowers us to identify and respond to the body's cues more effectively, fostering an environment where positive adaptations are more likely.

Empowering Through Understanding

This shift towards an integrated mind-body model is about empowerment and education.

It's about guiding patients to tune into their bodies' messages, recognizing the signals of overload and stress.

It encourages a response to discomfort informed by understanding and mindfulness, rather than fear or the pursuit of immediate fixes.

This approach demystifies the sensations we've labeled as pain, reframing them as part of our body's broader context of response.

Moving Forward

"Back to the Body" heralds a return to physiotherapy's roots, enriched by our journey through the realms of psychology and neuroscience.

It's a call to embrace the body's complexity, leveraging science and technology to deepen our connection with ourselves.

As we chart this new course, we embrace a model of care that is both empowering and educative, one that places the patient's experience at the forefront of the healing process.

In doing so, we not only address pain more effectively but also foster a holistic sense of well-being.

Daniel O’Grady

Expanding Your Perspective: The Power of Aerobic Exercise in Alleviating Neck Pain

Introduction

Imagine you're faced with a classic puzzle known as the "9-dot problem” (see below).

The challenge is to connect nine dots arranged in 4 straight lines without lifting your pen.

Give up? See the solution below…

Most people struggle with this task because they attempt to solve it within the confined boundaries of the grid.

But here's the twist: the solution requires you to think outside the box, literally!

Thinking Outside the Box

This concept of "thinking outside the box" translates beautifully to another common problem: persistent neck pain.

Instead of merely zooming in on the neck itself, we'll explore a groundbreaking study that shows how incorporating aerobic exercise – a step outside the box – can lead to significant relief.

The Neck Pain Conundrum

Neck pain affects a substantial portion of the population, and the quest for a solution is often met with frustration.

Individuals dealing with neck pain might find themselves in a never-ending loop of shot term quick fixes that, at best, offer temporary relief.

However, the key to solving this puzzle for good might actually be to stop focusing exclusively on the "pain area."

The Study Setup

In March 2020, a study was conducted to assess the impact of aerobic exercise in conjunction with neck-specific exercises for individuals suffering from neck pain.

This prospective double-blind randomized controlled trial was carried out in physiotherapy outpatient clinics, involving patients with nonspecific neck pain.

The Intervention: Inside and Outside the Box

Participants were randomly divided into two groups:

  1. The first group underwent a six-week regimen of neck-specific exercises. This represents the conventional "inside the box" approach.

  2. The second group received the same neck-specific exercises, but with an intriguing twist – they also incorporated aerobic exercise (AE). This represents the "outside the box" thinking, looking beyond the neck alone.

    The Aerobic Exercise (AE) program consisted of a moderate cycling exercise x 2 per week (60% of the age-predicted maximum heart rate) for 20 min during the first week, 30 min during the second week, and 45 min during the third to sixth weeks

Measuring Success: Multiple Angles

To evaluate the effectiveness of these treatments, an array of outcome measures was used, including the Visual Analogue Scale (VAS) to assess pain intensity, the Neck Disability Index (NDI) to evaluate how neck pain affects daily activities, the Fear Avoidance Beliefs Questionnaire (FABQ) to assess the impact of fear on pain-related behaviors and beliefs, and an evaluation of cervicogenic headaches.

These assessments were conducted at three crucial time points: at six weeks, then at three months, and again at six months post-interventions.

Astounding Outcomes

The results? They're nothing short of astounding!

  • The group that performed Aerobic Exercise achieved a whopping 77.4% success rate at the six-month follow-up, in stark contrast to just 40% in the control group.

  • A substantial reduction in VAS scores was observed in the AE group, plummeting from 6.73 to 1.89, while the control group's improvement was less pronounced, with scores moving from 6.65 to 3.32.

  • The AE group showcased remarkable improvements in NDI and FABQ scores within the first six weeks. For NDI, scores decreased from 16.10 to 7.78 in the AE group, compared to 17.01 to 11.09 in the control group.

  • FABQ scores exhibited a similar trend, dropping from 33.53 to 20.94 in the AE group and from 33.45 to 26.83 in the control group within the same timeframe.

  • Cervicogenic headaches, a common issue among those with neck pain, also saw a significant reduction in the AE group from baseline to six months.

The Game-Changing Conclusion

This groundbreaking study concludes that adding aerobic exercise to long-term neck-specific exercises is an effective and promising treatment for reducing neck pain and related headaches in patients with nonspecific neck pain.

The key takeaway here is the power of thinking beyond the immediate problem area and embracing a holistic approach to solving the puzzle of neck pain.

Zooming Out for a Holistic Solution

Much like the "9-dot problem," which demands expanding your perspective to find the solution, neck pain requires a broader approach.

Instead of focusing solely on the neck, a combination of neck-specific exercises and aerobic exercise yields outstanding results, offering hope for those grappling with neck pain.

Whilst this study the participants all used cycling as a form of aerobic exercise - the beauty is you could choose any form of exercise you enjoy - whether it’s jogging, walking, swimming, lawn bowls, hiking, gardening or pickleball.

The key is trying to get your body into a low to moderate intensity - around the Zone 2 mark.

You can measure this with a heart rate, RPE or use the ‘talk test’ as a guide.

The goal is to challenge the heart and lungs to continue to feed muscles with nutrients for longer periods of time (20 minutes to an hour or longer).

By considering a more holistic approach, we can finally connect the dots and find relief beyond the box we've been stuck in.

Always consult a healthcare professional before starting any exercise program, especially when dealing with pain or injury.



Wanting to get started on your journey to find relief from neck pain?

#NeckPainRelief #AerobicExercise #HolisticApproach



Research Link

The effectiveness of an aerobic exercise training on patients with neck pain during a short- and long-term follow-up: a prospective double-blind randomized controlled trial



**Solution - ONE of the possible solutions to the 9 dot puzzle:

Deepening our Understanding of Pain

Whilst at first thinking hard about pain can give you a bit of headache, doing a bit of hardwork now could well save you lots of unnecessary stress and excessive pain later on.

So you may need a nice cup of tea or coffee to get through this blog - but I promise it will be worth it !

Warning - for most people this isn’t an easy read, or easy to understand at first - that’s completely OK!

To learn about these things is not a standard part of physiotherapy currently.

But these are important conversations to have - as having accurate up to date knowledge is a big part of genuine recovery.

So if you are open to learning and being patient - you will most probably end up knowing more about pain that 95% of doctors and health care professionals, who by a large and stuck in the one-dimensional view of pain that is called the Biomedical Model (that states all pain must arise directly from tissue damage in a linear relationship).

OK, here we go….

Re-framing Pain as an Emergent Process

Pain is something we all experience and it often becomes a source of frustration and anxiety when it refuses to subside.

Whether acute or chronic, pain has a way of affecting our lives and pushing us to seek relief.

But instead of trying to attack, suppress or eliminate the pain…. what if we re-framed the pain? What if we changed the way we thought about the problem?

Rather than a simple mechanical response (damage = pain), we could view it as a complex emergent process (sensation + emotion + metabolic heath + past history + past expereinces + anxiety about the future etc = pain

By doing so, we open ourselves up to the fascinating intricacies of pain perception and potentially find new ways to address it. You gain empowerment over the pain.

Pain as an Emergent Phenomenon

The first step in re-framing pain is to understand that it is always an emergent phenomenon.

Emergence, in this context, is a concept borrowed from complex systems theory.

It implies that pain doesn't arise from a single source but rather results from a complex interplay of factors.

Let's break it down:

  1. Bottom-Up (Physiological Sensation): The physiological aspect of pain begins with the actual sensation. It's the raw data sent from the site of discomfort to our brains, signaling that something isn't right.

  2. Autonomic Nervous System (ANS) and Heart Rate Variability (HRV): Our body's autonomic nervous system, which regulates functions like heart rate and digestion, plays a crucial role. Changes in heart rate variability can affect pain perception and contribute to its complexity.

  3. Past Experiences: Our personal history with pain and related emotions can influence how we perceive and respond to it. Past traumas or experiences can amplify or diminish pain signals.

  4. Top-Down Influence: This refers to the cognitive and emotional aspects of pain. Our thoughts, beliefs, and emotions can either amplify or dampen the pain experience.

Examples of Emergent Systems

To better grasp the concept of emergence, consider everyday examples like making coffee, baking, gardening, or listening to the sound of an acoustic guitar.

These activities involve numerous elements coming together in unpredictable ways to create a unique experience.

Similarly, pain is not a straightforward cause-and-effect relationship but always a complex amalgamation of factors.

Emergent Complex Systems vs. Linear Mechanical Systems

It's important to recognize that emergent complex systems, like pain, behave differently from linear mechanical systems.

Linear systems produce predictable, proportional results.

In contrast, complex systems exhibit nonlinear behavior, leading to outcomes that may not be proportional to the inputs.

This nonlinearity makes pain a highly variable and individualized experience.

The good news!

Whilst the above few paragraphs may sound very complex, that is actually a GOOD thing!

If you notice yourself feeling a bit anxious, frustrated, confused or overwhelmed - that is a great sign and very normal.

When we start on a new road of learning - there is an initial feeling of resistance as our systems are wired to avoid feeling overwhelmed and would much prefer simplicity.

Amongst the confusion, if you feel just a tiny bit of curiosity to learn more - that’s a great achievement.

The bottom line is - Humans Are Complex Systems.

And that complexity (counter-intuitively) opens the door to non-linear improvements in the way our bodies function (and in particular our pain levels).

In simple words when we stop ‘chasing pain’ at a mechanical level, we can be open to more simple, intuitive natural ways of healing.

You don’t have to wait until you get ‘stronger’ or ‘more flexible’ or ‘looser’ until you get out of pain.

Conclusion

Re-framing pain as a complex emergent system allows us to embrace its intricacies rather than anxiously avoiding them.

By recognizing that pain is not a simple linear response, we can explore more holistic approaches to managing and treating it.

This shift in perspective encourages us to consider the multifaceted nature of pain, incorporating both physiological and psychological aspects into our understanding and treatment strategies.

In doing so, we open doors to more comprehensive and effective pain management solutions that respect the complexity of the human experience.


Has this blog sparked any curiosity? Please feel free to leave a comment and I’d love to hear your thoughts.

For more reading - this is a good starting point

The Complexity Model: A Novel Approach to Improve Chronic Pain Care

Affordance-based practice: An ecological-enactive approach to chronic musculoskeletal pain management