Pain changes how pain works, Part 2: what it means for patients and professionals (by Paul Ingraham)

by Peter on March 31, 2011

Today’s post comes a colleague of mine, Mr. Paul Ingraham. Paul is a health science journalist and former Registered Massage Therapist. From 2000-2009, Paul had a busy massage therapy practice in Vancouver, and published in his “spare” time. Eventually took over, and it is now his full-time business. Thank you Paul for allowing me to share your article today. Now … over to Paul.

Pain changes how pain works, Part 2: what it means for patients and professionals

by Paul Ingraham

view original article here

Back in January I published a “jargon-to-English translation of an important scientific paper by Clifford Woolf.” The punchline was:

Pain itself often modifies the way the central nervous system works, so that a patient actually becomes more sensitive and gets more pain with less provocation.

Ouch. Today I continue that discussion with some of the implications, plus practical suggestions for patients and professionals.

The trouble with not knowing the neurology: carelessly making a bad situation worse

Pain is a warning system, and central sensitization is therefore a disease of over-sensitivity to threats to the organism — a hyperactive warning system. When physical therapists, massage therapists and chiropractors treat a chronic pain patient too intensely, they are going to trigger that alarm system, and quite possibly make the situation worse instead of better.

Central sensitization is bad news, but worse still is how few health care professionals are aware of the neurology and make things worse with careless or even deliberately rough, no-pain-no-gain treatment. It’s bad enough that ignorance of central sensitization leads to wild goose chases and patients riding a merry-go-round of expensive and ineffective therapies, but many kinds of therapy are also quite painful. With tragic irony, the most likely victims are also the most vulnerable and desperate patients, patients going through the therapy grinder, their hopes leading them right into the hands of the most “intense” therapists.

The science of central sensitization is not particularly new, but its clinical implications are resisted by many health care professionals thinking well inside the box they were taught in. Their minds are firmly made up that pain is mainly “in” tissues, something wounded or irritated inside your meaty, gristly anatomy. Of course, trouble with tissues is relevant — but the science has shown us that it is much less important a factor than anyone used to think. Countless studies now have shown a surprising, counter-intuitive disconnect between symptoms and problems plainly visible on scans. It’s actually quite astonishing how little pain is caused by some seemingly dramatic issues in your tissues!

It all starts to make a lot more sense when you understand how the your pain system works.

Professionals may pay some lip service to the importance of integrating neurological considerations into treatment, but their respect is often more poetic and politically correct than practical. For example, many massage therapists regard the “magic” of touch as a sort of nice bonus or sensory gravy in massage therapy. But it’s the main thing — in fact, pretty much the only thing that massage therapists can do that may prevent or reduce the phenomenon of central sensitization, which we now know to be a major factor in many or perhaps most of the toughest cases.

Care for chronic pain of all kinds needs to soothe and normalize the nervous system — not challenge it with vigorous manipulations.

What should patients do? (Professionals should read this too!)

Patients with stubborn pain problems should start trying to decide if they are experiencing “too much” pain — more than seems to “make sense.” It’s not an easy question to answer. When we hurt, it always seems like a big deal! It’s just like a patient with oversensitive hearing (hyperacusis) trying to figure out if sounds are really “too loud.”

If you suspect that your nervous system is no longer giving you useful, sensible pain signals, then be extra cautious about painfully intense therapies and skeptical of biomechanical explanations for your pain (i.e. “you hurt because you have a short leg”) — such factors are only part of the picture, and probably the least important part. Make sure any professional you see is aware of the phenomenon of central sensitization, and start using that as a criteria for judging the quality of their services — if your doctor or therapist doesn’t act like they know what central sensitization is, take your business elsewhere.

You might go through quite a few professionals before finding one who shows some “sensitivity to sensitivity.”

Medications that work on the central nervous system are probably the most promising treatment for serious pain system dysfunction. Only a physician trained in the care of chronic pain can prescribe those medications. The best place to look for such a doctor is in a pain clinic — if you have serious chronic pain, you should start looking for one today.

Finally, regardless of whether or not central sensitization is actually happening in your body now, it always makes sense to be kind to your central nervous system. Make your life “safer” and less stressful. Gentler. Easier. Centralization of pain is the process of the central nervous system’s “opinion” of the situation becoming more important than the actual state of the tissues. This is not an “all in the head” problem, but a “strongly affected by the head” problem, like an ulcer that is caused by a very real bug but is severely aggravated by stress.

When your CNS is “freaked out” and over-interpreting every signal from the tissues as more painful than it should, therapy becomes more about soothing yourself and feeling safe than about fixing tissues. Pain is, at a very fundamental level, all about your brain’s assessment of safety: unsafe things hurt. If your brain thinks you’re safe, pain goes down.

So, for the chronic pain sufferer, cultivating “life balance” and peacefulness is a logical foundation for recovery, more important than just a pleasing philosophy — and it’s a worthwhile challenge even if it fails as therapy, of course. This is what I always meant by the idea of “healing by growing up,” long before I had even heard of central sensitization.

What should professionals do? (Patients should read this too!)

Professionals need to get their bums into gear and simply learn more about central sensitization.

Start deconstructing your assumptions about pain with my article on the follies and inconsistencies of structural models of pain, and also read Eyal Lederman’s more academic treatments of the same topic (on low back pain, and core strengthening). Then read Clifford Woolf’s excellent 2010 tutorial, “Central sensitization: Implications for the diagnosis and treatment of pain” — it’s heavy reading, but worth every mental exertion.

There are two websites that are consistently producing good, readable, science-based information and resources about central sensitization and related topics: Body In Mind and the NOI Group. Also, physical therapist Diane Jacobs is extremely active on Facebook, constantly sharing valuable information on this theme on her page, Neuroscience and Pain Science for Manual Physical Therapists.

Finally: please start treating pain patients like they might have a janky nervous system that is over-reacting to every possible perceived threat — and stop chasing the red herrings of subtle biomechanical problem of dubious clinical relevance, that are mostly nearly impossible to prove or treat anyway, and which often lead you to try to apply to much pressure to tissues. For example, a massage therapist once inflicted extreme discomfort on my armpit because she believed that there were evil “restrictions” in there and that she could rip her way to a cure of a shoulder problem I didn’t even really have. All she accomplished was to swamp my nervous system with nociception, and it could have been disastrous if I’d been a chronic pain patient.

Instead of trying to “fix” anything, seek to create (or at least contribute to) a felt experience of wellness. Make therapy pleasant, easy, and reassuring. Help the patient remember what it’s like to feel safe and good.

This transition can be immensely liberating: it can put an end to the wild goose chases for sources of pain in the tissues in many of your toughest cases.


In Health,


Peter Roach, RMT, CNMT, Laser Therapist

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