One of the common questions we get asked as physio’s is “Is it in my head?” or “Am I imagining it?” when people are referring to their unusual or persistent pains and syndromes.

There is generally a lot of negative connotation surrounding the diagnosis or suggestion that pain may actually be more mental than physical in cause, however there is now strong research and evidence that the brain may actually be a much more significant contributor to chronic pain than we once thought. And don’t be alarmed – this doesn’t at all mean that you are making the pain up, it simply refers to the ability (or disability) of the pain control centres of the brain to feel pain even in the absence of true or acute pathology.

brain-adam-croweThis knowledge regarding the power of brain in chronic pain will allow all health professionals to take a slightly different approach when addressing chronic pain. Studies have long shown that exercise therapy is significantly more effective than manual therapy when treating chronic pain, and it seems that adding some “brain strategies” to the exercise therapy will be even more effective.

This article is based around a recent article in The Australian on 31st January, and involves the research of MICHAEL Moskowitz, a psychiatrist turned pain specialist. Moskowitz runs a pain clinic in California which treats patients with “intractable pain”: those who have tried all other treatments, including all known drugs, “nerve blocks” (regular anaesthetic injections) and acupuncture. “We are the end of the line,” Moskowitz says. “We are where people come to die with their pain.” Moskowitz has become a world leader in the use of neuroplasticity – using the brain’s own structure and functioning in response to activity and mental experience – for treating pain only after making some discoveries while treating himself.

In 1994, whilst water-skiing Moskowitz badly hurt his neck in a fall, resulting in persistent and agonising pain, making it impossible for him to work. It soon dominated his life as no pain ever had. Morphine and other heavy-duty painkillers, and all the known treatments – physical therapy, traction (stretching the neck), massage, self-hypnosis, heat, ice, rest, anti-inflammatory drugs – barely touched it. That pain haunted and tormented him for 13 years, becoming more severe as time passed. During the depths of his despair, Moskowitz began researching the discovery that the brain was neuroplastic and relating it to pain. Acute pain alerts us to bodily injury or disease by sending a signal to the brain, saying: “This is where you are hurt – attend to it.” But sometimes an injury affects both our bodily ­tissues and the neurons in our pain system, including those in the brain and spinal cord, resulting in neuropathic pain (sometimes called central pain because the brain and spinal cord together make up our central nervous system).

Neuropathic pain occurs because of the behaviour of neurons that make up our “brain maps” for pain. The external areas of our body are represented in our brain, in specific processing areas, called brain maps. Touch a part of the body’s surface and a specific part of the brain map, devoted to that spot, will start to fire. When the neurons in our pain maps get damaged, they fire incessant false alarms, making us believe the problem is in our body when it is mostly in our brain. Long after the body has healed, the pain system is still firing. The acute pain has developed an afterlife: it becomes chronic pain.

Moskowitz defines chronic pain as “learnt pain”. It not only indicates illness; it is itself an illness. The body’s alarm system is stuck in the “on” position because the person has been unable to remedy the cause of an acute pain and the central nervous system has become damaged. “Once chronicity sets in, the pain is much more difficult to treat.”

Wishing to take charge of his own pain, in 2007 Moskowitz read 15,000 pages of neuroscience, learning amongst other things that our brain maps can expand, because the activities the brain performs regularly take up more and more space in the brain by “stealing” resources from other areas or maps.

He drew three pictures of the brain that ­summarised what he had learnt. The first was a picture of the brain in acute pain, with 16 areas showing activity. The second was of the brain in chronic pain, showing those same areas firing but expanded over a larger area of the brain, and the third picture was of the brain when it is not ­registering pain at all. As he analysed the areas that fire in chronic pain, he observed that many of those areas also process thoughts, sensations, images, memories, movements, emotions and beliefs when they are not processing pain. That observation explained why, when we are in pain, we can’t concentrate or think well; why we have sensory problems and often can’t tolerate certain sounds or light; why we can’t move more gracefully; and why we can’t control our emotions very well, become irritable and have emotional outbursts. The areas that regulate these activities have been hijacked to process the pain signal.

Moskowitz’s wondered if he could use competitive plasticity in his favour, by using counter stimulation methods when he felt pain. He would force those brain areas to process anything but pain, to weaken his chronic pain circuits. Moskowitz knew that when a particular brain area is processing acute pain, only about five per cent of the neurons in that area are dedicated to processing pain. In chronic pain, the constant firing and wiring together of neurons lead to an increase, so that 15 to 25 per cent of the neurons in the area are now dedicated to pain processing. So about 10 to 20 per cent of neurons get pirated to process chronic pain. Those were what he would have to steal back.

In April 2007 he put this theory into practice. He decided that he would first use visual activity to overpower the pain. A huge part of the brain is devoted to visual processing therefore it made sense to begin with this as his counterstimulation method. Each time he got an attack of pain he immediately began visualising the very brain maps he had drawn. First he would visualise his picture of the brain in chronic pain – and observed how much the map in chronic pain had expanded neuroplastically. Then he would imagine the areas of firing shrinking, so that they looked like the brain when there was no pain. “I had to be relentless – even more relentless than the pain signal itself,” he said. He greeted every twinge of pain with an image of his pain map shrinking, knowing that he was forcing his pain maps to process a visual image.

In the first three weeks he thought he noticed a very small decrease in pain and by six weeks, the pain between his shoulders in his back and near his shoulder blades had completely disappeared, never to return. By four months, he was having his first totally pain-free periods throughout his neck. And within a year he was almost always pain-free, his average pain 0/10. His life was totally changed after 13 years of chronic pain.
Moskowitz started to share his discovery with his patients, many with the same debilitating chronic pain, and many who, if persistent with his techniques, ended up with the same amazing result! Many of his patients have had successes with varying pain syndromes, but only when they were able to do the relentless mental work required. What’s more – the effects last as many of his patients remained relatively pain free over a five year period.

Another of Moskowitz’s most important insights is that the strong narcotics painkilling drugs that are so commonly prescribed for chronic pain syndromes, can actually make many pain problems worse! It is quite possible within days or weeks that a patient can become “tolerant” to these drugs: the size of the initial dose loses its effect, so they need ever more medication, or they experience “breakthrough pain” while on the drug. But as the dose is increased, so too is the danger of addiction and overdose. Also, says Moskowitz, “once we saturate all our God-given receptors, the brain produces new ones.” It adapts to being inundated by long-term narcotics by becoming less sensitive to them – and thus patients become more sensitive to pain, and more dependent on their drugs, which can make their chronic pain worse.

Overall, “neural plasticity” is a fascinating topic that will no doubt be the subject of many more studies to investigate its optimal use in the field of chronic pain, but with what we already know it can no doubt help us all treat chronic pain with a bit more confidence!