Lake Selfe

Your brain has no delete button


Yesterday, nearly five years after the devastating earthquakes in Christchurch, New Zealand, we had another rude reminder that we live on an active fault zone. A 5.7 magnitude earthquake hit just after lunch, throwing me to the ground, breaking our pendant lights, and a bottle toppled off the shelf beside the toilet, falling into the toilet and smashing the rim (lesson to the men in the house: do not leave the toilet seat up!). Needless to say, my heart was racing for a wee while afterwards!

People living in our fair city have had thousands of quakes to deal with over the past five years, most of them not as powerful as yesterday’s one, but nevertheless rather unsettling. In reflecting on the experience I’m reminded that our nervous system is wired more towards learning and reacting to immediate threat – and anything that represents a threat – than it is to calming and soothing the beast within. In fact, there’s good evidence to suggest that we don’t ever “unlearn” a learned response, instead we develop new pathways that can become stronger and more heavily myelinated than the learned paths – but given a similar context we’re as likely as not to activate that same old set of neural impulses and some researchers suggest this is because of epigenetic changes. (Take a look at this study in rats for one reason – it seems contextual memory triggered by cues is more powerful than we thought!)

As I mused on my startle response which is as well-developed as ever (though I jump less often at trucks going past than I did in the months just after the big quake), I thought about our experience of low back pain – or indeed any other chronic pain. While we’ve got very excited about neuroplasticity, and I think we should, I also think we need to temper our enthusiasm with some reality checks. Even though we seem to be able to reduce pain by using neuroplasticity within our treatments (see Pelletier, Higgins and Bourbonnais, 2015, among others), we need to remember that the pathways associated with chronic pain are many – and not just those to and from the sore part! In fact, because we’re fantastic learning creatures, there are many, many ways in which we encode an experience.

We have already seen that seeing a painful limb can increase the experience of pain in people with CRPS and vice versa (Sumitani, Shibita, Iwakura, Matsuda, Sakaue, Inoue et al, 2007), and this phenomenon has been used in mirror therapy and virtual reality treatments for people with CRPS and some other forms of pain (Foell, Bekrater-Bodmann, Diers & Flor, 2014). As a result of this fascinating finding, treatments using laterality, graded motor imagery and novel movements have all become very popular with varying degrees of effectiveness (especially outside the clinic!).

What perhaps we’ve forgotten is that because we’re incredibly good at learning, we’ve associated not just the “internal” location/intensity/quality of that experience, but also a whole bunch of other associations – words (pain, ouch, suffer, back, leg, doing, lifting, crumbling, disc – and others!), movements (sitting, walking, turning, twisting, crouching, climbing), emotions (happy, sad, glad, awestruck, helpless), images (of a back, leg, someone else sitting or walking or moving), locations (treatment facilities, workplace, the garage, making the bed, the pill bottles in the bathroom) – the list goes on! Even the smell of liniment or whatever rubbing lotion was used can bring all those associations back into consciousness.

And each association branches off and associates with other things in a never-ending network of related experiences and memories and relationships. Is it any wonder that some people don’t miraculously “get better” when we decide to “educate” someone about their pain? Especially if we haven’t given them the respect of listening to how they’ve made sense of their situation…

Now in the series of earthquakes from 2011 until now, I haven’t ever really become overwhelmed with anxiety and helplessness. Yes I have been fed up, frustrated, saddened, and I’ve grieved, got angry at bureaucracy and thought that things surely could be done more quickly. Until yesterday, when the growing anxiety (because the houses being built close to us mean there are many hundreds of thumps and thuds as foundations are hammered into the ground far deeper than ever before) I’d been feeling over the past month or so really got triggered by a very real and unexpected event.

Intellectually I know this quake is just another in the same series as we’ve been having. Nothing terribly awful happened. No-one got hurt. BUT my jitters are back – and every time I look at cracks in the ring foundation, the smashed toilet, look at my broken vase, or go to use the Pyrex jug that got smashed, I’m reminded that this event has happened – and could again. Pictures of the cliffs falling at Sumner, clouds of dust rising from them as they tumbled into the sea; images of broken crockery at Briscoes and wine and beer at the local supermarket; the news, and friends talking on Facebook – all of these remind me of what we’ve just been through and have been for so long.

Now picture the person you’re about to see today. That person with the painful back. The person who flicks through the magazines in your waiting room and sees adverts for lotions, analgesia. Who smells the scents in your area. The one who finds it so hard to roll over in bed every night. Or to sit and watch TV. Just remember that you may be able to develop new and novel pathways for moving so that the pain itself isn’t triggered by movements – but all these other associations are still there, and will be from now on. And think beyond the clinic door and into your patient’s daily life. How will you help them transfer the feeling of safety that being with YOU evokes into a feeling of safety everywhere they are? This is why developing effective self management skills, especially becoming nonjudgemental despite experiencing pain is so very, very important.

 

Foell, J., Bekrater-Bodmann, R., Diers, M., & Flor, H. (2014). Mirror therapy for phantom limb pain: Brain changes and the role of body representation. European Journal of Pain, 18(5), 729-739. doi:10.1002/j.1532-2149.2013.00433.x

Pelletier, R., Higgins, J., & Bourbonnais, D. (2015). Addressing neuroplastic changes in distributed areas of the nervous system associated with chronic musculoskeletal disorders. Physical Therapy, 95(11), 1582-1591.

Sumitani, M., Shibata, M., Iwakura, T., Matsuda, Y., Sakaue, G., Inoue, T., . . . Miyauchi, S. (2007). Pathologic pain distorts visuospatial perception. Neurology, 68(2), 152-154.

9 comments

    1. Thanks John, also triggered by reading about Relational Frame Theory – thoroughly recommend you getting the book Mastering the Clinical Conversation by Villate, Villate & Hayes, 2016, The Guilford Press. VERY good stuff on communication and how humans learn.

  1. Hi Bronnie, nice blog. I agree with you that neuroplasticity is exciting but I still feel like we are all paddling in the shallow end (no offence intended to people who have done a lot of work in this area so far),but we have to crawl before we can walk so to speak. My question is “how do we fool the magician?” The magician being the nervous system. Thanks again.

    1. Hi Nigel, I’m not quite sure I follow you here – are you suggesting we haven’t taken the neuroplasticity notion far enough? And if you are, I’d say we may eventually find super-groovy ways to do so, but at this stage we just don’t know enough. My concern is over-promising pain reduction and in doing that, robbing people of the opportunity to embrace what they DO have in pursuit of something that may never eventuate. Anyway, let me know if I’ve understood you correctly – or not!
      cheers
      Bronnie

    2. Nigel, one person can fool another and this is the stuff of magicians. But I am not clear on what you mean when you ask “how do we fool the magician?”

      1. Hi Bronnie and John, I thought that might be a bit cryptic, its hard to get across with a quick typed answer. Magician might be the wrong word, I guess I’m saying we have a long way to go yet and how do we “fool”or talk ourselves out of pain when pain isnt necessary. Im reminded of Lorimer Mosely’s infamous snake bite story. When he describes the second bite (the branch rubbing against him) and his over top reaction to this stimulus. As he said, even with all his knowledge of pain science he still had this crazy, over the top pain reaction to the stimulus. So I agree again with you Bronnie, we just dont know enough yet, we make lots of “ïnteresting” observations like peoples reactions to smells or sights that reactivate their pain but even with our new techniques/approaches of graded exposure, gmi, mirror box, ACT therapy etc etc our results are still a bit underwhelming or unreliable. That make more sense? Cheers, Nigel

      2. I understand! I think we have an incredibly long way to go to know how to help everyone we see, and to help reduce pain intensity or “yuckiness”. One thing we can always do, however, is listen and let the person know we’re their cheering squad. What I mean by this is that we can be there as empathic support while they experiment with different ways to live with their pain, and we can give the consistent message that despite their despair (at times) and frustration, and feelings of helplessness (at times) we believe in them and their resilience. TBH my preference is to focus far less on altering pain intensity than on living a life that is aligned to values and celebrates the good there is everywhere. I think we can forget to be mindful of positivity, joy and compassion and instead focus on weakness and limitations and difficulties.

  2. You write in a way that makes it easy to understand the complexities surrounding pain. This is one of your better ones. It’s this kind of writing that helps me to talk about pain. Thanks Bronnie! Looking forward to seeing you next week in San Diego!

    1. Thanks so much Bruce, I hoped this one would hit the mark. Especially after having spent the day talking to an ex-patient of mine who reminded me that every time he sees his old workplace, he’s reminded of the accident. And every time he gets into his car, he’s reminded of how painful it is to drive (when he used to love it). – we’re complicated beasts!

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