If you haven't yet read and watched Part 1 it may be a good time to start there. If you have, hopefully you feel you have a better understanding of where your pain is coming from – that is if we rationalise it, the tissues and joints may not actually be damaged but rather we have a malfunction in the way pain signals are sent and interpreted in the brain.

Recently I had a client (that we will name Wendy for confidentiality) who explained the last practitioner she visited had told her the pain she had was “in her head”. Wendy explained how horrible this was to experience and that she knew her pain was real. I empathised with Wendy and she was completely on point, her pain was real. Wendy’s body perceived that certain experiences and movements were so threatening that she was in excruciating pain most of the day. This pain had been going on for years, initially diagnosed as a tendonopathy (inflammation of a tendon) and had never been rectified after many types of treatments including cortisone steroid injections as well as excruciating manual therapy and massage. In my mind I started to think; the tendonopathy was diagnosed a number of years ago but we know from normal tissue healing for this kind of issue that it would eventually heal itself by 3-6 months. It was evident from her history that she had been avoiding using the painful arm - therefore continued poor loading would be unlikely. So… if it should have healed naturally (even without assistance from her physio) a long time ago, maybe these tissues are far more sensitive then before? Maybe we have an issue with not only the signals that are being sent to the brain but the output of the brain is now interpreting high levels of threat.

So what is going on?” asked Wendy, “why does me being tired, stressed or sick have a negative impact on my pain?

Wendy went on to explain how it wasn’t just knocking her arm that hurt but it would be more painful when she was tired or if work was stressful. This ticked another few boxes in my mind. During our first session Wendy and I talked about her pain experience before starting to define elements of her lifestyle and activities that threatened her system and made her pain worse. This included sleep deprivation, deadlines at work, being in a rush, times of sadness, times of sickness like the flu, knocking her arm, putting load through her arm and not moving her arm for too long. Wendy and I began a discussion about ‘nociceptors’ (the nerves that send pain signals to the brain) and how they’re effected by chemicals, pressure and temperature. For them to send these signals to the brain, the stimulus; whether it is chemical (like inflammation), thermal (a hot plate) or pressure (a brick dropped on your finger) must reach a certain threshold before it sends the signal. This stops us from just lightly having our body brushed with a feather and us jumping through the roof with pain – we would always be in pain. BUT WAIT! Wendy is almost always in pain and from small amounts of stimulus…

“So what is going on?” asked Wendy,

“Why does me being tired, stressed or sick have a negative impact on my pain?”

I continued, explaining how this threshold that the stimulus must reach for it to send signal to the brain of a noxious stimulus can change. It’s normal I explained. “Imagine if you were in a giant cage at the zoo, and it was filled with Lions and they hadn’t eaten in days. Do you think you would find it easy to sleep? Do you think if you heard a leaf rustle behind you you would jump and turn faster than you had ever moved before? Of course you would, because your body is adapting to what you perceive as threat. If you had never heard of Lions before and thought from a distance they just looked cute and cuddly do you think your body would be so ‘up-regulated’?”

“No, of course not.” She responded.

“Exactly, our previous experiences dictate our perception of what is and isn’t threat. Currently your body is in an ‘up-regulated’ state in that, like the lion scenario it perceives that it’s under threat far more often than it perceives a state of safety. Don’t get me wrong, your pain is real, but it’s not accurately indicating the level of chemical, thermal and pressure danger that is occurring in your body – we just need to turn this threshold up so that it requires a higher level of stimulus to send these signals. What is also interesting is that we have a neurotransmitter in our brain called GABA (Gaba-Aminobutyric Acid). GABA's job is to tone down sensory signals coming to the brain, so when we have a decrease in GABA we feel more pain, increased levels above base line may mean we feel less pain. This same neurotransmitter is affected by our prefrontal cortex, the area that is responsible for emotion in the brain. So if we are feeling stressed, down and anxious it leads to a drop in GABA, that physiologically means you are more susceptible to feeling more pain.”

“That makes a lot of sense, so how do we start to combat this?” Wendy asked.

“It’s different for everyone – already you’ve done a great job of identifying a number of things you find to make your pain experience worse. Now we have to identify the things that make it better.”

“But, what about moving my arm and exercise? That’s a threat, how do I move it without it threatening me?”

“Good question, that’s where we can begin turning that threat into a safety. The more threats we can turn into safeties the closer we get to managing what is going on. We don’t want to avoid moving it but we want to pace our way back to healthy, happy movement. It may not be fast but we know from good solid research that we can change your nervous system and turn that threshold back up. We just have to do it in a clever way that your body and mind can handle.”

Wendy was one example of a very common client type that I come across. Not one client suffering from chronic pain has been the same but the process that works is often similar. In my experience, it is important that the client suffering from persistent pain is ready to make change, not only in their behaviours of normal life but willingness to learn more and understand what is occurring. If not, it’s not the end of the world; a more opportune time may arise in the near future to start to address behavioural changes associated with chronic pain. The same treatment for one person won’t work for the next; this is where working with a team that understands chronic pain is really important. You should feel supported, your practitioner should be open to other therapies that may assist, and ultimately you should feel trust in your health care provider. 

To delve into moving forward and developing your own coping strategies check out part 3 of our 3 part series now!

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