Chronic pain – Where the body meets the brain
Rebecca Tweedy, Specialist Musculoskeletal Physiotherapist, and Brad McGregor, Accredited Exercise Physiologist, join forces to present on the topic of chronic pain.
Rebecca Tweedy delves into the topic of pain biology. She discusses the brain, behavioural and emotional changes associated with chronic pain, as well as sleep and chronic pain.
Following this, Brad McGregor presents on the role of exercise in pain management. He covers the evidence regarding exercise’s capability to reduce pain. Additionally, Brad provides guidance on incorporating exercise into pain management, and the types of exercise that can be useful.
Watch the presentation
Transcript:
I’m going to mix it up and go over this side. Okay, so I’m Rebecca Tweedy, I’m a musculoskeletal physio, and I’m in, squashed in between two huge experts in this area, um, and I’ve just sort of tried to have a few areas that haven’t been covered by the other speakers. Um, we used to have a psychologist speaking at this talk, so I’m going to just cover some of the things that maybe, um, they would have, they have spoken about in the past.
So, three sort of areas, um, Uh, brain changes occur in chronic pain, which Sarah has definitely touched on. Um, the behavioral and emotional changes that occur with persistent pain. And also how we can use these to manage our persistent pain. So changing the way our emotions and our thoughts and our beliefs, um, can change our behavior and also help with management of pain.
And then just the interrelationship between sleep and pain. So, um, we’ll cover those three things in the next 15 minutes. I just did a Google search in the last week and I came up with some of the things that are in our news cycle. So there’s a, there’s always a lot of interest in, uh, chronic persistent pain.
This one was done on, on mice. Um, led the mice to be more sensitive to non, um, painful stimulus and, and they speculate to chronic pain. Um, this is an interesting one because it’s something that people who work in the area of, um, pain science and. And, uh, in, in that profession, often here, um, people say that some other doctor told them it was all in their head.
Um, and what they’re implicating is that, um, we don’t believe them. And, um, what I hope to show you today, uh, is what does actually happen within pain, and the way that we experience pain does occur in our brain, but it is not that we don’t believe you. Um, this one is about, uh, virtual reality headsets, which is done at the University of South Australia.
Um, it’s looking at, um, trying to get people to move more, um, without them realising they’re moving more. And I also work at the Royal Brisbane Hospital, um, we’re also doing one there with chronic back pain. And, um, that’s looking at people, uh, with virtual headsets on, and they are, um, doing games within this, um, within the, uh, within the virtual headset and, um, they’re moving a lot more than they normally would.
So it’s just all within, um, trying to manage their persistent pain. I’m not sure about this one. So green eyeglasses may help reduce the need for opioids. Um, maybe Sarah can tell us about that. But, uh, hopefully it’s just showing you that there’s a lot of, also many articles sensationalizing the cures for pain and, um, it’s usually.
As you, as you realize, it’s not a simple thing of wearing green eyeglasses. So, this is why there’s, uh, there’s so much interest in coming here today, but also just in the, uh, the regular media is that it’s such a common thing. So, persistent pain, they say 1 in 5, but some, um, some people say 2 in 5, depending on how you define chronic pain.
Um, it’s becomes even more common in, in aged care, and, um, up to 80%. Also, uh, many people who have chronic pain have many other health conditions such as heart disease, diabetes, um, and also mental health conditions such as, uh, um, depression, anxiety. So just remembering that we’re talking today about persistent pain.
There are many other types of pain. And the reason that this is so important is that how we manage persistent pain is very different from how we manage other types of pain. If you have acute pain, you know what you do. You break your leg, you go in and you get it fixed either by surgery or putting a cast on it.
Um, that’s a very simple way of treating pain and, um, that doesn’t work once you get to, uh, chronic pain, system pain. So we used to think about, um, uh, pain as being, uh, tissue damage, so the more tissue damage that occurs here at the periphery or wherever it be, in the leg or skin or, um, uh, in the organ, um, the more tissue damage that occurs here, the more pain that we, um, perceive.
And we know there are many situations where this is not the case. So if you think about phantom limb pain, there is no damage that’s occurring because there’s no limb there. So, um, I had a patient, um, just last week who had had a below knee amputation and he talked about having to get up in the middle of the night all the time to stretch his calf of his non existent leg.
So, it’s not as simple as a message coming up to our brain and us experiencing him. Um, and then the situations in war, you will have heard of people having been shot, but they didn’t even realise it until many years later. Or, um, surfers who just feel a bump and then they think it’s a bump, but it’s actually their whole leg gone.
Um, and then, uh, the alternatively, why paper cuts are hurting so much. So you can see the mismatch between the damage and how much we experience pain. And the reason for this is, um, it’s much more than, uh, than this one way message. We also have many descending pathways, um, through our spinal cord, um, and to our peripheral nerves, but we also have, um, are influenced by that many factors that, uh, that, that will bring on this pain experience.
So factors such as the environment that the, that the pain occurs. Um, our mood at the time, how, how much, how threatening this is. So at the time when we experienced our initial injury, um, how threatening was that? Is this going to mean that we no longer can, um, do the job that we were doing, or, um, be able to play with our children?
So, um, so certainly the environment, um, our mood and depression at the time of, um, experiencing the pain. Prior experiences, so… It may be that we have gone through our childhood with a parent who, um, was never able to work because of their chronic pain. And you can see how much influence that would have on our experience if we got pain and all the catastrophization that could occur with that, um, that we’ll never be able to work again.
And genetics certainly have experienced that, um, influence. And it’s, you can see that it is very complex, um, once you talk about the pain experience in cystic pain. So, um, they’ve done some imaging that looks at the, uh, what we experience when we get a painful stimulus. So for a healthy individual, we have small areas of our brain light up, you can see what happens in chronic pain, we’ve got a huge number of areas lighting up.
And um, why, why our body is doing this is that, um, our brain is trying to, uh, protect us, basically. So it’s trying, so many other areas of our brain will start to become involved in our experience. of having pain. So, our brain becomes overprotective. And, um, you may have experienced this, um, you know, if you’ve got back pain, sometimes you start to feel it, um, in your, in your neck pain, and it spreads in other areas.
And that’s all to do with the spread of, um, the, the sensations that we’re getting, uh, coming up into our brain and what our brain is, uh, is telling us is happening. So, um, we also get, um, we can also get unpredictable or late, late in pain. So, sometimes… We’re fine while we’re doing an activity, but it’s very painful afterwards.
And then even, um, you can even see in people who experience chronic pain, that even just thinking about doing something can cause the pain. Um, other things like loud noises can cause pain, or even wind on your, on your skin, that can become painful. So many other sensations that would normally be pain, painless, become a pain experience for us.
So, um, if we think just a little bit about how then we now know that our thoughts can, um, and our belief systems can influence our chronic pain, Um, we can then, um, just try to identify other, uh, factors such as negative past experiences, So, maybe our beliefs that, um, I’ll never be able to get rid of pain, I don’t know how, I haven’t got the ability within myself to, Uh, to, to know how to do this.
So, how, how on earth am I, how on earth am I ever going to get rid of this pain? Um, catastrophizing, so even just the fear of moving, that is going to, that is going to cause me to be in bed for the next week. So, um, that, that sort of, uh, all or nothing, that it, I just, there’s no possible way that I can do, can, can move or do any of the things that I used to be able to do to go to work, or the things that I enjoy to do, doing.
Negative affects, so depression and anxiety certainly has a contributing contribution to pain. Um, so the management of this is using the people around you, so the health professionals around you that are psychologically informed about pain. So, such as the people here, so Brad and Sarah and myself, but anyone working within this field are going to be, I’m talking to you about changing the way that you think about your pain.
So, and coming here today as well, being educated about pain and knowing how we experience pain is an important part of our management of our pain. So, our primary goal is always to improve function, to improve our ability to go to work, enjoy the things that we like in life. Um, and also seeing psychologists we have here and wherever at a pain program that specialise in pain treatment.
So to change the way that we think about the pain. So thought modification might be, um, making us, uh, believe that just because it’s hurt, it hurts doesn’t mean that it’s going to cause damage. So maybe changing the way, um, a negative way of looking at things, um, to a positive. So trying to make that switch in our brain.
So reducing the catastrophization can reduce, um, Our emotions, so, uh, our depression and our sadness about what this experience is having on our lives. So going from, um, saying to ourselves that there’s no possible way I can do it, I can’t do that. But maybe I can do, changing it to maybe I can do a small amount of this today and I’ll see how I go.
And maybe tomorrow I might be able to do a little bit more. Uh, and also, um, thoughts like I’m a burden, so I’m now, no longer can help myself or can’t dress myself or can’t go to the shop. to, maybe I’ll try the best I can today and do something small and, um, maybe that, that’s the first step in being able to change the way we think about our pain.
So leading from the way that we change our thoughts will be, um, a, our ability to then change our behaviour. So, um, things like being able to set boundaries, so today I might go and sit with my friends for 15 minutes at the coffee shop. And see how I go. Just small, small time limits and limiting the amount of intensity of the activity that we’re doing.
Trying to be proactive, um, seeking support when we need it from, um, friends and family, um, or health professionals. Trying to be as active as you can. And, um, yeah, moving into the exercise part which Brad will be talking quite a bit about in a moment. So this is, this is the way that we can try to change.
from the chronic pain state where our brain is very hypersensitive and, and overprotective to how we were when we, uh, you know experienced a painful stimulus but it really only affected just small areas of our brain rather than many, um, areas of our brain. So changing our beliefs, changing our beliefs, changing our thoughts, our emotions, and then the way that we behave.
And, um, you know, that, that’s sort of the cycle of… Trying to be able to improve our ability to start moving again and being able to function as best we can. So the second, uh, the third part of my talk is I’m just going to talk a little bit about sleep. So just, um, this interrelationship between sleep and pain and just give you a few little tips about, um, how to improve your sleep.
So, um, men, uh, up to 88% of individuals with chronic pain also have sleep disruption and insomnia. They feel as, uh, that there’s been many studies looking at this that they, um, would say that it’s a bi directional relationship. So sleep, lack of sleep or sleep issues can cause chronic pain and chronic pain certainly can cause sleep issues.
This study, a recent Swedish study, looked at a long, um, perspective study, uh, up to 18 years. People at, um, baseline who were pain free without mental health issues, um, if they had sleep issues such as initiation, getting to sleep, being able to maintain your sleep, um, early waking, waking or, um, feeling, um, still fairly fatigued when you, when you wake up.
Those are quite strong predictors of chronic, um, widespread pain at 15 and 18 years. So certainly a lack of sleep and they feel as though this might be related to. Um, increased systemic inflammation. So, um, what do we do about if, if we have sleep problems? And a combined approach is certainly the best.
Sarah’s spoken there a little bit about some of the pharmacological, um, uh, ways of managing sleep. And that’s certainly, um, speaking to GP or specialists about that. But one of the, uh, that’s got the biggest evidence is, uh, cognitive behavioral therapy. So, um, done by, um, a psychologist. So, uh, just looking at, um, education, sleep hygiene information, um, and changing the way our thoughts, our thoughts and beliefs to, um, change our behavior.
Other things such as relaxation, mindfulness, physical therapies, and exercise, which is going to be, um, the next, the next part of this talk. So, always, um, but using that combined approach is the best to try and change, um, And finally, just a couple of tips there about healthy sleep. So hopefully these are all things that you’ve heard before, but pretty important to try and maintain a regular bed, um, weights, time schedule, even on the weekends.
Um, establishing, uh, relaxing, uh, regular pre sleep routine. So whether it be having a cup of tea, having a hot shower, getting into your jammies, making sure things are starting to, Close down, not looking at your phone or your TV. Making sure that the environment where you’re going to be sleeping is a good temperature and it’s comfortable.
Make sure you use your bedroom only for sleep. So don’t use it for work or other stressful activities. If you do wake up in the night, don’t look at your clock. Try to get out of that habit. If you are unable to get back to sleep, getting out of bed. And trying to go through that same relaxing pre sleep routines, um, until you’re tired enough to get back into bed to go to sleep, just using it for sleep.
Finishing eating at least two to three hours before your bedtime. Um, try to exercise regularly but not, not at the time, not just a few hours before bedtime. Avoiding caffeine before bedtime. And also nicotine and alcohol close to bedtime. So all just, just a few tips there of things that you might be able to use to help.
With your sleep. I asked a few references, but you can get up and stretch and we’ll swap over.
I have the fun part, so I was doing some preparation for this talk and I wanted to look at some imagery, some images around paint. This was the first one that came up and ironically enough, it was why it works at the University of Queensland, so I thought this was a great way to commence. And I particularly like this researcher’s quote.
It says, you don’t need to be lifting heavy weights or running long distances every day. Um, the irony behind this is I think managing persistent pain is a marathon, not a sprint. Um, so I was taken by the first part of that quote. But I think this highlights what both Sarah and Bec were saying in that we certainly don’t have all of the answers.
And even the more contemporary research. so that you can see that he tends to reinforce that fact. So, I did, I learnt a lot about persistent pain from, um, a colleague who runs a clinic down in Melbourne called Beyond Pain. Um, and he explained, I won’t talk about pain biology because Rebecca’s done a tremendous job of speaking about that.
But he used this traffic light analogy to describe the thirst the brain has for wanting to learn more information about a different or a new experience from the periphery. So, I pinched his little image to describe that sort of phenomenon, and I’ll come back to that towards the end of my, uh, talk, um, I’m going to skip past this one, and go straight to the evidence.
So, I was interested to see what had been produced in the last five years in preparing for this. This was the first one that popped up. Cochrane Library is, um, a very high quality source of evidence. And it’s a meta review, which means researchers get together, they have certain criteria to include studies on a certain topic, and then they analyze patterns through all of those studies.
So this was published in 2021, so reasonably recent. The topic was exercise therapy for chronic low back pain. They narrowed their search to 249 trials that included almost 25, 000
people. So this is high quality evidence. And as with almost every meta review that I’ve read, the term probably always appears, maybe always appears, and further research always appears as recommendations in these. So here were the key findings of this meta analysis or meta review that exercise probably reduces pain compared to no treatment, usual care or placebo in people with chronic low back pain.
The other main conclusion that these authors drew Exercise may reduce pain and improve disability compared to common treatments such as electrotherapy or education in isolation. And I’ll reinforce what Bec and Sarah were saying at this point in terms of that multimodal intervention or management strategy towards persistent pain.
Here’s the next one, Journal of Physiotherapy. Uh, so this one was published in 2021. 217 randomised controlled trials. Just over 20, 000 participants across those trials. Most exercise types were more effective than minimal treatment for pain and functional limitation outcomes. So quite broad. The key message here is, just move and do something.
And I’ll talk more about specific modes because I’m no doubt that’s the question you’ve got is, What mode of exercise should I do for low back pain? So they looked at Pilates, uh, McKenzie technique or McKenzie therapy, and this broad term of functional restoration exercise, were more effective than other types of exercise treatment for reducing pain intensity and functional limitations.
Uh, I like this conclusion, people with chronic lower back pain should be encouraged to perform the exercise that they enjoy to promote adherence. So the best type of exercise, to come back to that rhetorical question I posed to myself previously, is the type of exercise that gets done. So if you absolutely hate Pilates, you’re not going to do Pilates.
So it’s not going to help you low back pain because you’re not going to do it. If you enjoy walking, walk. If you enjoy swimming, swim. And I can show you evidence for every mode of exercise to help address pain. All right, here’s another one. This was a really interesting article, journal of Pain Research.
This was back in 2019, a little bit smaller in terms of scope. In 26 studies, all the techniques are effective at reducing pain and disability and improving quality of life, and maintaining benefits of follow up. Um, some of the types of intervention they looked at included Pilates, completing what was known as a back school previously mentioned McKenzie technique.
Feldenkrais. Um, methods all reduce pain and are more efficient than pharmacological or instrumental approach in reducing disability and improving all psychological aspects. So we’ve gained quite good evidence in the last couple of years. To date it is difficult to affirm the superiority of one approach over another.
So this does highlight that we have more research to be done, but the message I’m trying to get across here is yes, there’s good evidence. But we can’t point you towards one specific mode to do, to address persistent pain.
Uh, this term you may have heard of, hypoalgesia. I’m going to talk about that just for a second. Uh, this was an article that was published in 2019 by the American Pain Society. Uh, and in this study we looked at healthy pain free populations and a single bout of aerobic or resistance exercise typically leads to this period.
of hypoalgesia immediately after the dose, where we have a reduction in pain and a reduction in pain sensitivity. So what they’re suggesting is, after exercise, we get this window where we don’t experience pain to the same intensity or for the same duration. Has anyone experienced this? Yeah. So that’s the official term for that phenomenon that you have experienced.
We want more of that. Great. In contrast, exercise induced hyperalgesia is more variable in chronic pain populations and is impaired. So you don’t tend to get the same window to the same extent when you have, um, a consistent pain experience. But,
I want to talk a little bit about local versus global hyperalgesia. The two studies. One looked at those who were diagnosed with shoulder myalgia. So they showed impaired hypoalgesia, i. e. they didn’t get the window as much when they were exercising muscles around the shoulder, which is where they had the pathology, but they experienced hypoalgesia when they were exercising muscles distal from where the diagnosis was.
So if you had, um, shoulder myalgia and you exercised the lower body, you could still get that hypoalgesic effect.
And similarly, people with painful knee osteoarthritis had an intact exercise induced hyperalgesia response to exercise of the upper limb, but that was impaired when they were looking at the painful lower limb. So the key message here is, you can still generate that pain free window by exercising away from the site of the pain.
That’s what this study tended to highlight. And that’s what I just said, so I’m going to skip ahead. Now this was borrowed from, um, a previous presenter that facilitated this, and this whole concept of the brain’s drug cabinet in releasing a lot of these chemicals, and you’ve probably heard of chemicals like serotonin, and oxytocin, or the love drug, and endorphins, and cannabinoids, et cetera, that can all have a very positive effect
So to open this cabinet, here’s some more specific research. So Hoffman and others in 2005 found that bike riding at a high intensity helped low back pain. And that reduction in pain lasted for 30 minutes plus, so there’s that window I was mentioning before. So Newcomb and others in 2011 found that biking at a light intensity helped low back pain.
with fibromyalgia symptoms and a reduction of pain for up to four days. That’s the kind of window we want to talk about, isn’t it? Ah, now this is a controversial topic which is exercising into discomfort or pain. I must admit when I’m in my previous life when I was working in op rehab, I tried not to use the word pain when I was in sessions with clients.
Um, but it’s hard to avoid when the topic of this talk is chronic pain. So we have this graph here. Um, that was published by Smith and others in 2017 that found that exercising into some discomfort can be okay, and I’ll go back to what Bec was saying about the fact that pain does not always equal tissue damage.
So we certainly don’t want to exercise into this not tolerable level of pain, but there is some good evidence that when we commence the exercise, we may increase our level of discomfort, but then we want to take advantage of that hypoalgesic effect that I was just speaking about. From a, from a pain biology perspective, when you crank up this discomfort, the brain’s trying to make sense of what’s going on.
It’s getting input from the periphery and then it’s getting all of that information and the brain’s trying to work out and problem solve and reconcile against previous experiences. Um, reconcile against the current pathology or diagnosis and say what am I actually experiencing here? And it wants to learn more.
So what we want to do is try and desensitise some of those pain pathways with signals going up the movement pathway. So, that’s the research and the evidence. Alright, that’s the end of my sales pitch. Now I just want to share some of my anecdotal thoughts around how I’ve worked with clients that have had a persistent pain experience.
And I use some of these strategies myself. Um, cognitive disassociation strategies. This means, this is a fancy term for taking the brain and putting it somewhere else. Exercise is wonderful for this. If you’ve ever been for a walk with a colleague and you’re just talking the whole time, how is your pain experience in that context?
Generally it’s a little better, yeah, because you’re distracted. And I, I’ve worked with clients in the past where I’ve used rhythmic exercise for this fact where I’ll just sit them on the treadmill in the gym and I’ll just chew their ear off for 10 minutes. And that’s 10 min, that’s a 10 minute window where I can help them to cognitively disassociate and they have to take their brain and put it somewhere else because they’ve got to listen to my incessant mattering.
And that’s just giving them a break. Works well with mental health as well. Uh, visualization. I do this when I run. I run to not think about work, which is a challenge cuz work comes in and then I’ve gotta kick it out. And the way I kick it out is I’ve got two or three really quality moments in my life that I try and recreate in as much multi-sensory detail as possible.
So you think about, um, what was the wind like? What sort of, uh, what was the smell of the grass? Uh, what was the, what was the, um, temperature like? And what did it feel when I replayed that event? So there’s actually some really good research around athletes using visualisation to overcome slumps. So I’ve kind of taken that research and evidence and tried to apply it to a persistent pain context.
And you know this works in my example, is because I’m going for a run and I’m 5km’s down the track and I’m at my turnaround point and I go, Oh, I’m humouring. Because I haven’t been thinking about how painful and uncomfortable the run is without being replaying. Some of those positive events in my life.
Another strategy that I’ve used is the rule of fives to disassociate. So what’s five things you can see? Five things you can smell. Five things you can hear. So there’s fifteen things. That can give you a window where you’re just taking your brain and putting it somewhere else. And I’ve already mentioned rhythmic exercise.
Separating fact from fiction, this reiterates what Sarah and Bec were mentioning before around that potential catastrophizing language and terminology around the fact that pain equals damage. Because we know that’s not always the case. Um, the locus of control is something that I’ve spoken to clients about before.
And in the trajectory of working with the client, I find you can usually identify one point where the locus of control for that client has shifted. And it shifts from looking out the rear view mirror, to all the retrospective stuff, which is, why has this happened to me, this isn’t fair, this is crap, look at what happened to me back here.
So it’s all rear view mirror stuff, and then they reach a point where they shift and the locus of control is more out the windscreen. And Bec mentioned some of these strategies as well. What can I do? I want to go to this concert, but what can I do before, during and after to help me enjoy that event? So that’s more future focused.
That’s the locus of control that’s shifting. Does that make sense? And you can almost pinpoint the day, I reckon, in a lot of clients when that locus shifts. And then in retrospect, you can speak to them and go, Hey, remember when we did this session on this type? And that’s when your vernacular started to shift, that’s when you started to look out the windscreen, and not in the review
mirror. Alright, so… Coming back to the traffic light analogy and all these signals coming from the periphery up to the central nervous system. What exercise is great at is giving the brain other information to process
rather than just all the lights being green and all the pain signals coming from the periphery of the pain highway. Because we know that pain is a multi sensory experience. So our strategy as exercise specialists is to use movement as therapy to give the brain different stuff to process, take advantage of that hypo algesic window, as Bec was saying, to improve function.
Now which exercise is best?
All types have the potential to improve persistent pain, so here were a couple of studies. 2016, 2017, 2015, that said core exercise, core exercise, quote unquote, flexibility yoga Pilates was the same or equal to general exercise for low back pain. Sometimes clients want to know that the specific exercise is the one that’s going to fix my pain.
So unfortunately I’m here to tell you that that is not the case. We don’t have this magic one special exercise. that’s going to fix persistent pain. Here’s another study in 2007, proprioceptive unstable slash balanced training was the same as stretching for neck pain. And again, Booth, who’s published a lot in this area, strength training and aerobic exercise were both effective for low back pain and also helping to manage osteoarthritis and fibromyalgia.
How much do I need to do? Again, there’s no… Panacea, there’s no magic formula that says you must walk for 30 minutes five times a week. But there are general guidelines. These are the Australian Physical Activity Guidelines that suggest we should be getting around 150, and I’ll use the word accumulating, 150 minutes of aerobic exercise.
The recent addition to those guidelines is a few strength training sessions per week. Really pleased to see that. For pain reduction, and here’s some more evidence, Newcomb and others, aerobic twice per week for 20 minutes at a light intensity still had an impact on pain. Now that’s a fairly small dose, isn’t it?
Doesn’t mean we all have to hit the 150 minutes per week in the two strength sessions. Just two doses of 20 minutes in this particular study has a positive effect. And then here’s another one from 2013. aerobic and strength twice per week at a low to moderate intensity.
