At the risk of seeming untrendy, the trend to rave on about neuroplasticity can be a bit overdone. Not, I add quickly, because it doesn’t happen, or it’s not important – in fact, quite the opposite – but because it happens all the time. And at the back of our minds, I think we’ve known this for quite a while. How else do you think we manage to learn new things even in our elder years?
The reason I’m raising this today is, after yesterday’s post on phantom limb pain and the parts of the brain that are active when we have pain and when hypnosis is used for pain relief, I started to mull over the range of treatments that are used in managing chronic pain. Now, we don’t have fMRI studies for all the treatments available. I don’t think I can recall any studies where fMRI is used to study the effects of CBT on pain, or exercise on pain. This is, in part, an artifact of the fMRI technology – it’s impossible to be physically active while inside the scanner, and scanning occurs in a rather artificial environment that is nothing like that encountered on a daily basis.
But if we move away from any notion that psychological approaches are magical and affect the being through ‘mystical’ processes, we need to draw the conclusion that any of the standard behavioural and cognitive techniques used in pain management must influence the brain somehow. While we don’t currently know how this occurs, there doesn’t seem to be any other plausible explanation.
Why is this important? Well, because it means the more we know about how the brain works, and particularly those very complex forebrain processes (see Neugebauer, Galhardo, Maione, & Mackey, 2009), the more we can see how previously ‘mind not body’ processes are actually neurobiological, and how the dualist notion of a distinction between mind and body simply doesn’t work.
And this leads me to introduce a patient of mine to you (details altered for confidentiality reasons). Let’s call him Jim. He’s a 64 year old man who crashed his motorcycle and sustained a below knee amputation about 15 years ago. He successfully managed this, and wore a prosthetic limb most of the time. Five years ago he started to experience more than his usual phantom limb, he started to have severe intermittent phantom limb pain. He was still working at the time, and told me he’d close his office door and hold his breath and brace himself every time his pain started. The episodes were initially once or twice a day, but quickly progressed to several times an hour, and each episode lasted for around a minute.
Jim tried a range of medications, and was part-way through a systematic trial of available meds when he was referred to me because he couldn’t remain working and was highly distressed at giving up his quite responsible job. I need to explain that Jim had always been an active amputee – he regularly cycled, swam, walked (should I say, hiked/tramped!) for miles, and his general health was excellent. He’d never had a bout of depression, had never been an anxious man, but was quite driven to excel and very motivated to keep his job.
It’s common to find that there are no medication solutions to phantom limb pain. Jim was ready to look at how he could regain some sense of control over his life, and most especially, a way to get through the intermittent painful ‘attacks’.
As many researchers and authors point out, knowledge about pain mechanisms, or at least a model of pain, can reduce fear. In doing this, it can reduce distress. While we don’t know exactly how this occurs, it’s fairly certain that those parts of the brain that are involved in self regulation, emotion, fear, and decision-making are activated.
In Jim’s case, I began by describing a model of pain – and included in that, a cognitive behavioural model as well. This model identifies that thoughts interact with the emotional state which interact with behaviours – and all of these in a bidirectional way.
From this model, Jim was able to identify that as soon as his pain came on, his first thought was “Oh no, not this again”, he immediately felt afraid and braced himself for the onset of pain. He also held his breath, gripped his desk, gritted his teeth, closed his eyes – and waited. The effect of this response, even in someone who doesn’t have pain, is exhaustion – just try it yourself!
I introduced diaphragmatic breathing as a first step, ensuring that Jim had an effective relaxation response before we started changing his behaviour at the onset of pain. Once he’d achieved this, we started by acknowledging his automatic thought, then allowing this thought to go by and instead of bracing himself, using a long outbreath and a cue word “Relax”. He continued then with four more long breaths out, and by then the ‘attack’ had passed.
In addition to this, we also introduced a mirror treatment. This consisted of using an old full-length mirror he had at home, sitting with the mirror in between his legs, so he could see his ‘good’ limb. He then initially looked at his leg in the mirror, and progressed after some time to asynchronous movement of both limbs (while wearing the prosthesis). While Jim told me that the initial experience was ‘weird’, he was able to experience a reduction of the continuous aching pain he had, and the frequency and intensity of the intermittent ‘attacks’. This outcome with about 20 minutes use of the mirror each day. Unfortunately after about 3 months use, the effect faded, and we’re not sure why. It has never returned despite increasing the novelty, and improving the ‘illusion’ of the limb being his. Jim told me that while he was disappointed in this, he was happy that he had other ways of coping, both the breathing/acceptance process, and he had developed more confidence to have an ‘attack’ while in the presence of other people, so it became less intrusive.
Some things to note: we can see from Flor’s work (and Moseley’s too!) that this kind of experience affects the brain regions involved in the experience of pain, while the majority of medications either don’t address it at all, or simply work to damp down the overall over-excitement of the nervous system.
We can also see that it’s important to move beyond just addressing the brain retraining via mirrorbox. It’s also vital to engage in cognitive and behavioural approaches to counter things like Jim’s concern that other people might think he was weird or pathetic when he had an attack. The breathing strategy was a nonintrusive strategy that he can use anywhere.
Iannetti, G., & Mouraux, A. (2010). From the neuromatrix to the pain matrix (and back) Experimental Brain Research, 205 (1), 1-12 DOI: 10.1007/s00221-010-2340-1
Neugebauer, V., Galhardo, V., Maione, S., & Mackey, S. (2009). Forebrain pain mechanisms Brain Research Reviews, 60 (1), 226-242 DOI: 10.1016/j.brainresrev.2008.12.014
Flor, H. (2008). Maladaptive plasticity, memory for pain and phantom limb pain: review and suggestions for new therapies Expert Review of Neurotherapeutics, 8 (5), 809-818 DOI: 10.1586/14737188.8.131.529
Flor, H., Nikolajsen, L., & Staehelin Jensen, T. (2006). Phantom limb pain: a case of maladaptive CNS plasticity? Nature Reviews Neuroscience, 7 (11), 873-881 DOI: 10.1038/nrn1991