Chronic Pain Solutions for Complete Recovery Pt. 2: Movement

In Chronic Pain Solutions for Complete Recovery Part 1, we discussed “neuroplasticity”, the ability for the amazing brain to change and grow for the better.  For a quick review, check out this cool, short YouTube video  on neuroplasticity. Part 2 Movement will focus on how and why movement is crucial to help decrease chronic pain.

Motion is lotion.

The body and brain loves movement.  A sedentary lifestyle associated with fear of movement or lack of motivation to move leads to weakened muscles, stiff joints, weight gain, increased inflammatory cells, brain atrophy and… more pain. Movement grows new neuronal connections within the brain, basically rewiring the faulty circuitry associated with our internal pain alarm. Remember the burglar and alarm analogy from Part 1?

Use it or lose it

Above is an illustration of our brain. The region highlighted in rose color is the called the motor cortex, which basically  is a map of our body located on the brain, our virtual body. Each body part is represented on a specific region of our motor cortex. The tongue and hands have a lot of real estate on the brain compared to the knee because the tongue & hands are critical for survival.

For example, when you speak, the tongue section of the motor cortex is activated.  When you turn your head to look at an attractive person passing by, the neck and upper back  on your brain’s map light up like a Christmas tree.   However, if  you have chronic neck pain and can’t rotate your neck fully, your “virtual neck” doesn’t fire as quickly or intensely and can even atrophy.  The good news is that we can retrain our brain, restoring these lost connections which reduces pain because of the brain’s neuroplasticity.

No Brain, No Pain

OK, so we know that without a functioning brain, we cannot feel pain. With chronic lower back pain, patients have a smaller “virtual lower back” on their motor cortex as compared to healthy subjects.1, 2, 3. The good news is that no matter how long you have experienced chronic pain, with consistent practice of various techniques including daily movements we’ll discuss here, the brain can learn healthier patterns which results in 1) reactivation of the motor cortex and 2) less pain.

A study in 2010 looked at motor cortex activation of patients who had 4+ years of low back pain who either participated in a  walking program or a core exercise program4.  The group who participated in the deep core exercise program gained more lower back “real estate” on their motor cortex (ie showing more brain activation) and they reported a significant decrease in lower back pain.

The group who did the walking program showed no changes in pain nor brain activation. Walking can be very helpful for the joints, muscles and heart, but specific exercises targeting the area in pain can improve brain activation and lower pain.

Core Training

Below are three videos on training the deep core muscles (Transverse Abs, deep lower back). These videos are not to be used in lieu of seeing your medical doctor or physical therapist.

Level 1 Core Video

Level 2 Core Video

Level 3 Core Video

What about other areas of the body in pain? Generally speaking, there are actually core muscles for your neck which are the deep cervical flexors; the core muscles for your arms are the scapular muscles and the core stabilizers of your legs are glutes and pelvic floor.  Exercising these muscles can help change the brain to look and act similarly to those without pain.

Strength Training

When you think of strength training what do you visualize?

 

 

 

 

 

 

 

 

 

 

 

Do you picture the bulky weightlifter power-cleaning hundreds of pounds? While this is technically strength training, so is lifting 1 lb. dumbbells for 3 sets of 5 reps.  Your “heavy” is not your boyfriends “heavy”, is not your mom’s “heavy” and may not be your ‘heavy” 2 months from today.

Strength training streamlines the body and can create a more toned, slim appearance. It helps breakdown fat up to 72 hours after a workout, stabilizes your spine so your posture keeps in good alignment and nerves can function more easily. Strength training also prevents osteoporosis by building bone density, decreases visceral (abdominal) fat linked to heart disease, helps control appetite and decreases inflammation throughout the body5. Most importantly, it can help rewire the brain and eliminate pain just like core training does.

Here are three strengthening level 1 basics for anyone. Remember these are suggestions and if you are having pain, best to first consult with your physical therapist to get tailored advice.

Squats

Region targeted: thighs and glutes Frequency: 2-3x/week
Joints stabilized: hips and knees Intensity: heavy with minimal discomfort
Helps with: bending, lifting, sit to stand 2-3 sets 8-12 reps, 30s rest -> 3-4 sets 6-8 reps, 1-2’ rest

Bent Over Rows

 

 

 

 

 

 

Region targeted: back, shoulders, trunk, arms Frequency: 2-3x/week
Joints stabilized: shoulder, elbow, spine Intensity: heavy with minimal discomfort
Helps with: pulling, lifting, carrying 2-3 sets 8-12 reps, 30s rest -> 3-4 sets 6-8 reps, 1-2’ rest

Push Ups

 

 

 

 

 

 

 

Region targeted: shoulder, chest, upper back Frequency: 2-3x/week
Joints stabilized: shoulder, elbow, spine Intensity: heavy with minimal discomfort
Helps with: pushing, carrying, lifting 2-3 sets 8-12 reps, 30s rest -> 3-4 sets 6-8 reps, 1-2’ rest

Daily Movement

Another great way to begin to counteract sedentary lifestyle, especially if you sit for work or school, is to track your steps via a pedometer or on your phone. Depending on your fitness level and pain levels, aim for 5000 steps every day and gradually increase to 8000 then 10,000 steps (over time). Research shows that doing high impact cardio workouts is too stressful for many people with chronic pain so walking can promote similar benefits6.

Even if you are house bound, taking a stroll around the house/apartment once an hour can start to add up your steps. Instead of going to the mall to shop, let it be a destination for a comfortable walk with plenty areas to rest anytime you need.  If you work, walk an extra few blocks to the subway/bus stop, or park your car farther away from your home.  Instead of taking an elevator to your exact floor, take it to the floor below.

Once walking becomes easier, begin a targeted core and strengthening program for all of the benefits listed above. There are so many! Move every day, avoid being too sedentary, get guidance to help you find your best exercise plan and most importantly keep practicing this for at least 3 months. You’ll be amazed to feel less pain by that time.

References

  1. Strutton PH, Theodorou S, Catley M, McGregor AH, Davey NJ. Corticospinal excitability in patients with chronic low back pain. Journal of Spinal Disorders & Techniques 2005;18(5):420e4.
  2. Tsao H, Galea MP, Hodges PW. Reorganization of the motor cortex is associated with postural control deficits in recurrent low back pain. Brain 2008;131(Pt 8):2161e71.
  3. Flor H, Braun C, Elbert T, Birbaumer N. Extensive reorganization of primary somatosensory cortex in chronic back pain patients. Neuroscience Letters 1997;224(1):5e8
  4. Tsao H, Galea MP, Hodges PW. Driving plasticity in the motor cortex in recurrent low back pain. European Journal of Pain, 2010; Feb 22
  5. Tatta J. Heal your pain now. Boston, MA: Da Capo Press; 2017.
  6. Kristen M. Beavers, Daniel P. Beavers, Sarah B. Martin, Anthony P. Marsh, Mary F. Lyles, Leon Lenchik, Sue A. Shapses, Barbara J. Nicklas; Change in Bone Mineral Density During Weight Loss with Resistance Versus Aerobic Exercise Training in Older Adults, The Journals of Gerontology: Series A, , glx048

Chronic Pain: New Science provides Solutions for Complete Recovery (Part 1)

Chronic pain is a worldwide epidemic, affecting 1.5 billion people1.   In the USA we spend over $635 BILLION dollars treating chronic pain, visiting multiple medical practitioners, getting  tests, injections, prescription medications, and surgeries2.     With all the amazing advances made in treating cancer, diabetes and heart conditions, the numbers of people suffering with chronic pain has not lowered; in fact it’s increasing.

The good news is that we have learned more about pain in the past 10 years than ever before. The fields of neuroscience, physical therapy, psychology and nutrition have unearthed a treasure trove of knowledge to help people truly heal from chronic pain. There are a number of non-invasive, low risk self-help treatments that people with chronic pain can do simultaneously while they receive treatments by their doctors, physical therapists and other health practitioners to achieve total chronic pain relief.

Chronic Pain Defined

Chronic pain is pain that lasts longer than the normal tissue healing time of 3-6 months. Note: this blog does not include the pain caused by active cancers nor end of life pain issues. So, by the end of 6 months all tissues (skin, muscles, fascia, tendons, ligaments, nerves and bones) should be completely healed barring no major complications such as infections, disease processes or re-injuries.

3 Phases of Healing

Below is what our body does after getting a physical injury:

Inflammatory phase 3-7 days from original injury: when you feel most pain or see redness and swelling. Swelling shows that your body is doing an excellent job of healing and prevents further injury to the area.

Repair (Proliferation) phase 2-6 weeks from original injury: depending on the tissue (skin heals faster than bone). New collagen is laid down, like weaving a basket or sewing up a hole in your socks. Collagen replaces the torn, strained, or fractured tissue.

Remodeling phase 3-6 months from original injury: this phase starts when production of new collagen stops. New collagen is usually stiff, inflexible and needs to be remodeled, lengthened, and strengthened to your pre injury state and function. This is best achieved by going to physical therapy and doing your exercises.

Acute Pain Process

If the normal healing timeline takes 6 months at most, why do so many people experience chronic pain for years, sometimes decades past the original injury? Before we can understand how pain becomes chronic, here’s how our nervous system and brain works when we are experiencing acute injury pain.

When we first sprain our ankle, specialized sensors in our skin called “nociceptors” are activated (see red “Nociceptive Information” ).  Nociceptors are not pain sensors- rather pressure sensors, chemical sensors and stretch sensors. In fact, we don’t have actual “pain sensors” in our bodies. Nociceptors sense that your ankle ligament is overstretched or your muscle fibers are torn and sends this information to the brain.

 

Brain is our Protector

Your brain’s main role is to protect your body, so when your brain receives the nociceptive signals about the overstretched/torn tissues, it also checks your surrounding environment and assesses the situation to decide how best to protect.

Let’s say you twisted your ankle in a pothole while crossing a busy NYC street. You need to run quickly or you may be hit by oncoming cars. The brain decides that you need to get to safety first so it allows you to run on your injured ankle WITHOUT PAIN by sending pain reducing chemicals to the area. Once you are safely on the sidewalk, the brain sends pain signals to your ankle so you immediately take your weight off your foot. Your brain has effectively protected you from harm both by decreasing and increasing pain. This whole process happens in milliseconds.

 Brain is the Boss of Pain

Our brains are capable of learning and creating new nerve pathways throughout our whole lifetime. This is called “neuroplasticity”3.  Areas of the brain that are used very frequently show high levels of activity (as seen in brain MRI scans) and may actually increase in size4.  Before iPhones and Google Maps, London cab drivers had to memorize the whole intricate street map of the city before they could get their licenses. Studies show that they actually have enlarged areas in the brain associated with memory. The brain changes based on how we use it.

The brain is the center where the actual sensation of physical pain originates from and gets relief. People who experience chronic pain have a brain and nervous system that has learned to be in a heightened state, always on guard awaiting the next danger signal. What leads to this “faulty wiring” of our brain and nervous system?  Some factors include:

  1. Childhood and early social experiences – did you suffer loss/lack of love or did you feel safe and supported? These experiences affect how we respond to both physical and emotional pain.
  2. Daily thoughts and self-talk – are they positive or tend to be negative/fear based?
  3. Current social interactions – are they mostly supportive, like seeing a good friend, petting your cat or stressful, like fighting with your spouse/children?
  4. Your Expectations- are you afraid of bending forward because years ago a doctor said it could flare up your back pain? 5,6

Nutrition, exercise, restful sleep plays just an important role in total healing which we will discuss in the next few blogs. While we can’t change what happened to us in the past, the good news is that our brains can relearn healthy patterns to lower/stop chronic pain.

While receiving medical care from your doctor, you can simultaneously  retrain your brain to learn healthy processes, decrease fear based movement patterns, use mindfulness to stop negative catastrophizing thoughts, breathing techniques to lower fear/anxiety and much more.

At EMH Physical Therapy, we offer a chronic pain recovery program, called re·lieve, which educates patients in the new science of pain and teaches them a scientifically proven self-help program along with providing any needed manual and movement therapies.

Stay tuned for Part 2 of  “Solutions for Complete Recovery of Chronic Pain”.

References

1.Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, D.C.: Institute of Medicine of the National Academies; 2011.

2.Darrell J. Gaskin, Patrick Richard. The economic costs of pain in the United StatesThe Journal of Pain 2012;13(8):715

3.Draganski B, May A. Training-induced structural changes in the adult human brain. Behav Brain Res 2008;192:137-42

4.Johansson BB. Brain plasticity in health and disease. Keio J Med 2004;53:231-46.

5.Seifert F, Maihofner C. Functional and structural imaging of pain-induced neuroplasticity. Curr Opin Anaesthesiol 2011; 24: 515-523

6.Sandkühler J. Learning and memory in pain pathways. Pain 2000; 88: 113-118

7.Jensen M. Magnetic resonance imaging of the lumbar spine in people without low back pain. New Eng J Med. 1994;331: 69-73.

8.Katharina A. Schwarz, Roland Pfister, Christian Büchel. Rethinking Explicit Expectations: Connecting Placebos, Social Cognition, and Contextual Perception. Trends in Cognitive Sciences, 2016