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Articles Of The Week November 22, 2020

As we continually push for evidence-based practice in our profession there is often discussion around the techniques we use when treating people and whether they are evidence-based techniques.  However, it’s important to remember that what we do, is important and we have value.

“Your Work, Your Massage Therapy Techniques, YOU Still Matter” – Chrystal Ladoucer

While this article is directed towards the chiropractic profession, it could be applied to any one of the manual therapy professions.  Should we do away with all our different titles and become one big group of manual therapists?

“What’s The Problem Within The Chiropractic Profession?” – Richard McIlmoyle

When I started as a therapist, all I wanted to do was work with athletes and team sports. I’ve been pretty fortunate along the way but when I took “sport massage” classes in school, it didn’t really seem all that different from any other technique. So what is the difference?

“Sports Massage. It’s Not Hot Sauce” – Taylor Laviolette

Richard does a great job of putting together educational lists we can refer to. Here are some great instagram accounts you can follow to help educate yourself a little.

“Educational Instagram Accounts For Massage Therapists” – Richard Lebert

Over the years I’ve treated a few people who have scoliosis,  some were athletes, some were office workers. This is a great review of not only what scoliosis is but also what kind of treatment helps.

“What Is Scoliosis? Review Of Evidence And Treatments” – Frances Tregurtha

What Kind of Exercise is Healthiest?

Physical activity is now considered one of the “big four” lifestyle factors (along with smoking, nutrition, and drug abuse) that have major effects on health. In 2015, the Academy of Medical Royal Colleges put out a report summarizing the benefits of exercise, calling it both a “miracle cure” and a “wonder drug.” [1] The report observes that regular exercise can prevent dementia, type 2 diabetes, some cancers, depression, heart disease, and other common serious conditions — reducing the risk of each by at least 30%. This is better than many drugs.

A recent analysis of data from more than 60,000 respondents found that people exercising 1-2 times per week had a 30% reduction in all-cause mortality compared to those who got no exercise. There was a 35% reduction for people who exercised 3-5 times. [2] Similar studies have concluded that a sedentary lifestyle is a primary cause of 36 diseases, and that exercise is an effective treatment to prevent them. [3, 4] Numerous experts have observed that if exercise came in a pill, it would be the most effective and widely prescribed medicine ever developed.

While the evidence supporting the health benefits of exercise is undeniable, I don’t find the metaphor of it being “medicine” totally appealing. First, medicine is something most people would rather not take, so the marketing is not very good. Second, the term medicine suggests cure of a particular disease, which is misleading.

Physical activity can improve your health in many different ways, just as light, water and soil will nurture a plant. But it’s not a targeted intervention that “fixes” a specific problem.

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I think a better metaphor for the benefits of physical activity is one recommended by Katy Bowman and Nick Tuminello: movement is like food. This analogy works on many different levels. First, nutrients in food are beneficial when consumed in some goldilocks amount — not too much and not too little. For example, you need a minimum dose of iron to avoid anemia, but too much is toxic. Many kinds of inputs to the body follow this pattern, even water. With physical activity, some minimum amount is essential, too much is toxic, and there is a broad range of happy mediums.

Another analogy between food and movement is that you need a well-balanced diet of many different nutrients, all of which have a different optimum dose. If you have a deficiency in Vitamin A, it won’t help to double up on Vitamin B. The same is true of physical activity. The bench press is a fine exercise, but if that’s all you ever did, you would become deficient in other areas of physical function.

If movement is like food, how do you eat a balanced diet? Part of the answer is that … it depends. A twenty-year-old athlete will need a different diet of movement than a 65-year-old with knee pain. In fact, two 65-year-olds with knee pain might benefit from completely different programs. To find what works best for an individual, you will need to explore a wide landscape of different options. The good news is that some parts of the landscape are more worth exploring than others. To get a rough idea where they are, we can look to two sources of data: (1) formal recommendations from government health groups; and (2) research analyzing the physical activity of hunter-gatherers living in natural environments. I think of these guidelines as major landmarks for orientation on the movement landscape. Fortunately, they both point in the same basic direction.

Recommendations From Health Groups

Numerous governmental agencies, including the World Health Organization, the U.S. Department of Health Services, and the National Health Service in the U.K., have published physical activity guidelines. [5, 6] They are based on expert analysis of the voluminous research looking at physical activity, fitness, and health. Here is a brief summary of their advice, which is almost the same for each source.

The Amount

The guidelines suggest at least 150 minutes per week of “moderate” physical activity or half as much “vigorous” activity. (See below for definitions.) But this is just the minimum, and a better goal would be 300 minutes of moderate activity per week. Adding more exercise may continue to reduce mortality until as much as 750 minutes per week, after which point the health benefits of physical activity seem to flatline. [7]

“Moderate” Activity Defined

Moderate activities are usually light aerobic exercise — continuous cyclic movements done at an easy pace. Examples include:

  • brisk walking

  • hiking

  • gardening or yard work

  • jogging, cycling, or swimming at an easy pace

Moderate exertion feels like you are working, but not in a way that is unpleasant or difficult to continue. Heart rate is about 60-80% of maximum, and breathing rate is elevated to a point where it would be difficult to sing, but easy to talk. You may break a light sweat but will not become significantly overheated. After finishing a session of moderate physical activity, you could probably complete another one if necessary.

“Vigorous” Activity Defined

Vigorous activity is higher intensity work that can be either continuous or intermittent. Examples include:

  • resistance training with weights, machines, bands, or bodyweight

  • sprinting or high-intensity interval training on a cycle or rowing machine

  • continuous running, cycling, swimming, or rowing at a challenging pace

  • heavy manual labor

During continuous vigorous activity such as running or cycling, you are approaching the fastest pace you can sustain for twenty or more minutes. Your breathing rate is high enough that you cannot have a conversation. Intermittent activities like weight lifting, sports or sprinting cannot be performed continuously, but only in intervals. Vigorous physical activity feels hard and requires willpower to continue. When you are finished, you will probably want to rest at least a day before completing a similarly tough workout.

Movements That Challenge Strength

Most guidelines recommend that the above weekly totals should include at least two sessions that maintain or build strength in all major muscle groups. Although the majority of research on physical activity relates to aerobic exercise, there is a large and growing number of studies showing equally impressive health gains from strength training. Some of these benefits are not available with aerobic exercise, especially preservation of muscle mass, which declines with age, often to a point where function is significantly compromised. [8]

Movements That Challenge Mobility And Basic Coordination

Some popular guidelines, but not all, recommend inclusion of movements that maintain functional ranges of motion, and basic movement skills like squatting or single-leg balance. This doesn’t mean you need exercises specifically devoted to this purpose, such as stretching or corrective exercise. Many common activities challenge mobility and functional movement skills, including dancing, swimming, martial arts, gymnastics, climbing, calisthenics, or classic compound strength exercises like pushups, pull-ups, rows, presses, squats and lunges. On the other hand, if all you do is bike or run, you will not be challenging your mobility or coordination very much.

Physical Activity Levels Of Hunter-Gatherers

Another way to approach the question of how to move is to consider the physical activity levels of humans living in more natural environments. This is the same logic you would apply to analyzing the health needs of any other animal. If you had a pet cheetah and wanted to know how much running she should do to maintain good health, you would try to learn something about how much cheetahs run in the wild. If you had a pet chimp, you would take him to the climbing gym, not the swimming pool.

Anthropologists who study hunter-gatherer cultures observe that they generally enjoy excellent health and fitness, and have low to non-existent rates of chronic diseases associated with a sedentary lifestyle. [9] They engage in high levels of physical activity, but certainly do not consider it to be exercise or medicine. [10] Movement is simply inseparable from almost every meaningful event in their lives. Although each hunter-gatherer culture has a different lifestyle, there are some general patterns and averages that are informative.

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Men usually spend the day hunting, which requires lots of walking, occasional jogging, and the odd sprint. They sometimes climb trees, dig to find tubers, and carry food back to camp, which must be butchered. Women generally spend their days gathering plants and also caring for young children, who often must be carried. Back at camp, men and women engage in toolmaking, and food preparation. Downtime is spent sitting on the ground in positions like squats that challenge lower body mobility. [9]

Although they are moving all day, the pace is not grueling. Recent studies on the Hadza tribe in Tanzania show that they do about 135 minutes per day of moderate to vigorous physical activity. [11] That’s about 900 minutes of activity a week, just a bit past the point at which recent studies have found that adding more exercise stops providing any significant additional health benefits in terms of reduced mortality.

Some days involve hard work, but they are usually followed by easy days. Presumably, some days will involve maximum intensity effort, such as sprinting or carrying a heavy load. Interestingly, activity levels do not decline much with age. The 65-year-old elders keep up just fine with the young adults. A good percentage of the total workload is walking 5-10 miles per day. If you think in terms of steps, this is about 10 to 20,000.

How does this organic, all-natural program for fitness compare to the standard-issue government cheese? There are some obvious similarities. The majority of the work is moderate continuous movement like brisk walking. Vigorous activity is a smaller percentage of the whole and includes work that challenges strength (climbing, digging, carrying, butchering) or power (sprinting).

Many of the activities require mobility, coordination, and balance, such as walking over uneven terrain, climbing, and scrambling, digging, lifting and carrying odd-shaped items, throwing, and sitting on the ground. One major difference is that hunter-gatherers do a higher volume of low-intensity work, even compared to highly active modern humans. They are not doing more bench presses, but they are getting in more steps.

Interestingly, walking is exactly the type of physical activity that modern humans would probably like to do quite a bit more, if only they had the time. Paddy Ekkekakis studies motivation to exercise and observes that although high-intensity exercise is quite effective at delivering health benefits quickly, most people don’t do it because … (prepare to be shocked) … they don’t like it. But people tend to enjoy walking. Under the right circumstances, say being with a friend in a nice environment, they do not consider it to be exercise at all, but an enjoyable and invigorating experience that delivers immediate rewards.

Another notable feature of walking is that it provides health benefits with only a minimal risk of injury. More intense exercise (e.g., a set of barbell squats) offers a relatively narrow window between too much and not enough. The difference between a good workout and an injury might be just a few extra reps or plates on the bar. But the margin of error with walking is huge. After a healthy dose of walking, most people could double it and recover easily.

It makes sense that walking delivers the highest bang for your buck because this is the movement we are best adapted to perform. Like any other animal, our primary physical function is locomotion, and walking is the most energetically efficient way to get the job done. If you did nothing else but walk a lot, you’d be in better shape than most Americans.

A Quick Summary

If you want to “play” with fitness as a way to improve general health, here are some “rules of the game” to keep in mind. Have as much fun as possible within these basic constraints:

  • Aim for at least half an hour and up to two hours of physical activity almost every day.

  • Movement should be varied in terms of volume, intensity, and type. Most activity can be fairly light. Walking is the most natural and beneficial movement for human beings.

  • Every few days, include some high-intensity work that significantly challenges your strength, power, and/or capacity to sustain high energy output for a short period of time. Climbing, running and resistance training are logical choices.

  • Include movements that challenge coordination, balance, and range of motion.

Or to put this in even simpler terms:

  • Move around a lot at a slow easy pace.

  • Frequently move with some urgency or pick up something heavy.

  • Every once in a while, move like your life depends on it.

And have fun!

Physical activity isn’t like taking medicine, you know.


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The preceding was an adapted excerpt from my new book called Playing With Movement: How to Explore the Many Dimensions of Physical Health and Performance.

Articles of the Week November 15, 2020

Here we have an article using one of our favourite terms, “resilience”. This study looks at the implications of coaches pressuring athletes to be “perfect”, which we may be able to translate right over to the effect that clinicians have on clients when doing the same.

On Perfect Technique – Derek Miles

 

We hear this one a lot in the exercise rehab world: “Don’t use the knee extension machine!” Like many old beliefs, however, it may be time to crunch the facts on this one.

Is the Knee Extension Machine Safe to Use? – Tommy Mandala

 

If you’re newly certified and fresh in the field of your practice, you may have experienced imposter syndrome at one time or another. This is a fantastic article to help you get past your barriers and be the best practitioner that you can be!

5 ways to beat imposter syndrome:  These health and fitness pros tell you how they did it. – Camille DePutter

 

It’s never okay to fat-shame a client. But, as the holiday season approaches us, many of our clients may have concerns about their weight – especially if it may exacerbate some of their pain – and look to you for advice on how to keep it under control.

Top 3 Tips for Weight Loss During Physical Therapy – Dr. Sean M. Wells

 

Hamstring strains are one of the most common sports injuries that we see, especially in active populations. It’s also common for these injuries to become a recurring problem. Mike Reinold talks on his podcast about the importance of treating these chronic strains individually to best help our clients.

Chronic Versus Acute Hamstring Strains – Mike Reinold

In Defence Of The Advice To Remain Active For Back Pain

There has recently been some discussion around a lack of evidence for the advice to remain active during back pain. I personally believe there is a lot of value in the advice to stay active and here is why!

Firstly this HERE is from the folks over at Cochrane.

“Moderate quality evidence shows that patients with acute LBP may experience small improvements in pain relief and ability to perform everyday activities if they receive advice to stay active compared to advice to rest in bed. However, patients with sciatica experience little or no difference between the two approaches”

It is important to highlight the current state of play with regards to the evidence base, that there is MODERATE evidence of a SMALL relief for pain and this pretty much is in line with most other current recommendations/treatments that we have for back pain at this point.

Now I am going to give you a bit of my opinion as well!

Being active, IMO : ),  is NOT a treatment. It’s about being a human being and getting on with your life even though you have this very normal part of the human condition…..back pain.

It’s About Belief

Certainly, we don’t want to demonize the idea of resting or taking it easy if things are too painful, that is not evidence-based either, but we also know that the dominant view of back pain seems to be that we should rest it out and that for quite a few people the belief is that activity can be problematic for back pain.

This is highlighted in the two papers below that look at people’s opinions around what affects pain in the positive AND negative.

Darlow 2014 – Beliefs about back pain: The confluence of client, clinician and community.

Setchell 2019 What decreases low back pain? A qualitative study of patient perspectives

We also have two recent papers that form an interesting pairing when viewed together. Firstly we have a self-reported perspective of what triggers back pain flares from anyone who had had back pain at any previous time point (so maybe more a test of perceptions?). Here they found that physical activities and movements dominated the vast majority of the cited reasons for flare-ups

Costa 2019 – What Triggers an LBP Flare? A Content Analysis of Individuals’ Perspectives

Then we have a paper that looked at the same subject but asked the people to report it in a different way (longitudinally), at 3-7 day intervals over 6 weeks, and they found that physical activities were not so related to flares of back pain.

Suri 2018 – Do Physical Activities Trigger Flare-ups During an Acute Low Back Pain Episode?

The implication might be that when we ask people to remember what triggered their back pain it is a simple ‘go-to’ blame physical activities (especially when other things are not considered), but when the flare-up is more recent, 3-7 days, and presented with different reporting options the association between physical activity and flare-ups seems to decrease.

This highlights for me societal beliefs around the back and its relationships with activity and that we should be counteracting this idea in healthcare as much as possible!

It’s About Positive Messages

Overcoming some of the negative beliefs that we have around the body, pain and physical activity should be a goal of healthcare interactions. There are SO many NEGATIVE messages that we need some positive ones too.

I think the advice to remain active is such a message. Trust your body, get on with things, you will be OK! This is a strong, simple, and important message from my perspective.

There is the very real potential that there is not that much that can be done in the short term for acute back pain with advice and reassurance being pretty much all we have.

But could our short term attitudes impact on the longer term?

Short Vs Longer Term

What we do seem to have some data on is that having low pain self-efficacy, or the ability to go about our lives WITH back pain, does appear to have some relationship with outcomes of back pain in the longer term (this also seems to be apparent in other MSK conditions). In this paper HERE from Foster – 2010, we see that low pain self-efficacy is related to worse disability outcomes at 6 months.

The question is how do our own attitudes, and other people’s attitudes as well, towards our backs influence our behaviours? Food for thought perhaps?

Key Messages From Advice To Remain Active

Hurt does not equal harm – It’s OK to function with some pain, especially if it is not worsening and within tolerable levels. Pain does not give a reliable indicator of what’s happening within our bodies.

Rest is not the best treatment – Resting the back is unlikely to simply make it better and not much is likely to significantly change how the back responds in the short term.

Activity is not bad – Activity is not simply related to pain or damage. In fact limiting activities you enjoy might actually make the impact of back pain on your life worse.

4 Ways To Improve Your Clinical Communication

 

My journey to learning effective communication started because I was pissed off and frustrated.

I have always wanted to help people, it’s why I became a massage therapist.

I define helping people as supporting and empowering them to be the best versions of themselves and the more I worked as an RMT the further I felt from that goal. Before me was this void, a place where I threw in my frustrations like, “well this isn’t my scope of practice so there is nothing I can do about it”, or the idea that “no ones going to change, the problem is too big anyways”. 

I could visualize that if I empower my patients it would create self-efficacy and I saw this as the best way to help.

I could see how empowering people was the goal but I was lacking something needed to achieve this which was creating a barrier.

The tools I was given in school did not prepare me for the complexities of what it means to help people, I was given a rake and told to dig a ditch. This frustration created a gap between where I was and where I wanted to be.

The first step to closing this gap was identifying the source of my frustration, which was not my patients and the complexities they presented with, but actually myself. 

I’ve also been impacted by my lived experience through trauma and healing and the frustration of feeling so overwhelmed and lost while everyone is telling you what you ‘should do’. Because of this, I knew how empowering it was to have an active involvement in my own health and healing journey, however, I also knew what worked for me wasn’t enough. This all led to the realization I was seeking, and what my patients needed was to be seen, heard, and validated and if I wanted to cross this barrier it would be through effective communication.

Why Communication Is Of Great Benefit To You And Your Patients

When I think about what brings the greatest benefit to my patients I think about emotional intelligence, the “ability to recognize and understand emotions in yourself and others, and your ability to use this awareness to manage your behaviour and relationships” (Bradberry & Greaves, 2009, p. 17).

Emotional intelligence (EQ) can further be broken down into personal and social competencies which is the “ability to stay aware of your emotions and manage your behaviour and tendencies” while also understanding “other people’s moods, behaviour, and motives in order to improve the quality of your relationships” (Bradberry & Greaves, 2009, p.23-24).

The more I became focused on developing my self-awareness, (which is one of the EQ skills), the greater my ability to acknowledge that the way I communicate with people is influenced by every past experience. This means I have to take into account my privileges, biases, and assumptions when I am communicating with my colleagues and patients.

This is a great benefit to patients because “you can only choose how to respond to an emotion actively when you’re aware of it” (p. 98) and when I am aware of how my past experiences influence my communication I can start with the intent to listen and understand before anything else.

Secondly, humbleness is needed because I’ve gotten it wrong more than I’ve gotten it right. I’m quick to jump ahead of myself and shove new information and science down my patients’ throats. I want to give them the best treatment and sometimes I get lost in making it about myself and how effective I can be instead of centering my care around their needs and concerns. 

Being humble as a therapist is a continuous reminder that patient-centered care cannot be about me, I don’t know everything, and I must consistently choose to listen first and be ok with getting it wrong. Effective communication is not about you, but it is about your actions because it creates an environment of safety by validating whatever our patients bring to the table. 

 

Four Tips To Help Improve Your Communication

 

Letting a patient be seen, heard, and validated means recognizing it is not about us and our identities as healers and therapists but about our patients and how we can use the resources we have to support and empower people to be the best version of themselves.

When it comes to communicating more effectively, think about an iceberg, most of what you will learn is internal growth and used to inform your perspective.

Some helpful tips to put effective communication into practice are:

  1. Check-in with yourself and ask questions about your intentions, “what perspective and bias am I coming into this conversation with?” The narrative behind your intentions matters and in order to work on your communication I challenge you to ask yourself if the story you created matches the facts of the situation. For example, I can tell myself a story thinking a patient is lazy and doesn’t want to get better instead of looking at how I don’t know everything that is impacting my patient and what may be a barrier in their healing journey. 
  2. Focus on inquiry over advocacy. This could look like asking your patient “tell me what you’re experiencing, where is (insert patient’s concern) having the biggest impact in your life? If your patient’s concern is, for example, persistent low back pain, by inquiring first you can get a better understanding of what the biggest driver behind their pain is and have a better idea as to what intervention would be most effective. I can recall many times where I have focused purely on advocacy, where I was driven to make my patient understand that in order to eliminate low back pain they needed to know why core bracing and hip hinging were so important. In some cases, these interventions are incredibly helpful because they create safety for the patient, but in my drive to advocate for what was best for my patient I did not ask what they needed. 
  3. Learn to be ok with what’s uncomfortable, you won’t always get it right, and changing how you communicate can feel awkward. When in doubt less is more, I frequently repeat back to the patient what they have shared with me, and confirm the treatment goals so the patient knows their concerns have been heard and will be addressed. 
  4. Stay humble and make a commitment to always ask ‘why?’. “Why am I irritated by new information that challenges my belief system as a therapist?” “Why am I apprehensive about treating a certain patient population?” “Why do I make always or never statements, and is that narrative actually true?

 

Reference

Bradberry, T., & Greaves, J. (2009). Emotional intelligence 2.0. San Diego: TalentSmart.

 

To Predict Chronic Pain, Look to the Brain

Low back pain is extremely common. In fact, if you don’t have at least some back pain every year or so, you’re kind of abnormal. (Not that you’re really missing out on anything.)

Fortunately, if you do get back pain, your chances of getting rid of it in fairly short order are excellent. More than 90% of acute back pain resolves on its own in just a few weeks or months without any specific intervention. But for some people, pain becomes chronic, lasting for years. Why does the course of back pain differ so much between different people?

The answer probably cannot be found by looking solely at the back itself. Experts have tried for years to explain back pain outcomes in reference to the results of physical examinations. But collecting evidence about posture, core strength, or the condition of vertebrae and discs does very little to help you make good predictions. Posture and MRI results correlate poorly with pain, and a single structural/physical cause for back pain is rarely found.

More recently, there has been more emphasis on subjective factors – pain intensity, negative mood, catastrophizing, depression, or job satisfaction. Accounting for these factors will help you predict back pain outcomes quite a bit better than just looking at the physical condition of the back. But a good deal of mystery would remain.

Some recent research from the lab of Vania Apkarian has led some very smart people to wonder whether he has discovered the “Holy Grail” of explaining pain –  the precise factors that cause some people to develop chronic pain and others to recover.

If Apkarian is right, the grail is in the brain. (An important reminder and caveat: even when the brain is a major player in pain, this does not imply that pain is “in your head”, that pain is your fault, that you can just think pain away, or that the body doesn’t matter.)

Following is a collection of quotes from several papers from Apkarian’s lab. (See the bottom of the post for cites. Full text for each is available free online.) These help summarize the results and interpretations of his very interesting research, which mostly involves scanning the brains of people with and without back pain, and at various stages of recovery or chronicity.

The Relationship Between Nociception, Acute Pain, Movement, and Emotion

Pain is a conscious subjective experience that is most commonly driven by nociceptive activity. Baliki 2015.

Conscious acute pain perception is highly malleable … pain perception can reflect moment-to-moment shifts in value judgments. Baliki 2015.

The emotional limbic brain plays a critical role in bridging nociception and pain perception. Baliki 2015.

[N]ociceptors can be active in the absence of pain perception . . .The primary reason I fidget in my chair while writing this article is because nociceptors innervating my skin, muscle, and bone command that my posture needs adjustment. Baliki 2015.

The nociceptive control of behavior routinely occurs in the absence of consciously perceived pain, rendering it “subconscious.” Baliki 2015.

Daily motor movements could easily produce injury and tissue damage if one exceeds their natural range of motion . . . which supports the conclusion that motor behaviors are collectively inhibited by nociceptors. Baliki 2015.

We argue that nociception continuously occurs in the absence of pain perception and it is a fundamental physiological process . . . we presume that behaviors modulated by nociception, in the absence of pain, are contingent on already established habitual repertoires. In contrast, when pain is evoked it gives rise to new peripheral and spinal cord nociceptive learning/ sensitization, as well as emotional learning that is potentiated by the salience and perceived value of the aversive event. Baliki 2015.

The Transition From Acute To Chronic Pain

[O]nly a fraction of subjects who experience an acute painful injury develop chronic pain. Hashmi 2013.

The majority (>90%) of individuals with acute low back pain recover full function in days or weeks with little or no lingering pain. Apkarian 2009.

The 2 critical questions that the field has yet to address regarding chronic pain are 1) Who is vulnerable to developing it? and 2) What underlies this vulnerability?  Hashmi 2013.

Earlier clinical studies have identified a long list of risks for chronic pain, such as demographics, affective states, lifestyle, comorbidities, and others, yet collectively such parameters account for a relatively small amount of variance for chronic pain (10% to 20%). In contrast, the brain’s anatomic and functional properties predict development of chronic pain at 80% to 100% accuracy. Hashmi 2013.

Ample evidence now shows that the anatomy and physiology of the brain in chronic pain is distinct from that of healthy subjects experiencing acute pain. Vachon-Presseau 2016.

An accumulating body of animal and human literature has identified the cortico-limbic system, which is central to reward and motivated behavior, as a modulator for acute pain and as a mediator for chronic pain. Vachon-Presseau 2016.

In a longitudinal brain-imaging study, individuals who developed an intense back pain episode were followed over a 1-year period, during which pain and brain parameters were collected repeatedly. At the time of entry into the study, strength of synchrony between the medial prefrontal cortex and nucleus accumbens (i.e. functional connectivity) was predictive (>80% accuracy) of individuals who subsequently transition to chronicity 1 year later. Apkarian 2016.

Persistently enhanced functional connectivity between the mPFC and NAc may be interpreted as an increased emotional salience signal. Vachon-Presseau 2016.

There is now good evidence that all components of the corticolimbic system are either affected by or control or amplify persistent pain states. Vachon-Presseau 2016.

Redefining Chronic Pain

The definition of chronic pain remains tautological, as it simply asserts that it is a long-lasting pain, or a pain persisting past the normal healing period. Baliki 2015.

We propose a novel definition of chronic pain. Rather than defining pain by its sensations, we propose a definition that emphasizes the neurobiological mechanisms that control behavioral adaptations, and we hypothesize that persistence of pain is likely mediated through the reorganization of the cortex by corticolimbic learning mechanisms. (Baliki 2015)

Long-term shifts in the threshold mechanisms that gate the conversion from nociception to pain also underlie the transition to chronic pain. We further propose that the threshold shift is dependent on limbic circuitry invoking synaptic learning-based reorganization. Taken together, these ideas can be simplified as a lowered mesolimbic threshold for the conscious perception of pain, which functionally renders the brain addicted to pain. (Baliki 2015)

The Connection Between Chronic Pain and Negative Mood

Just as nociception and pain protect against bodily injury by limiting behavior, negative moods minimize exposure to danger and promote survival by inhibiting behavior as well. (Baliki 2015)

Just as chronic pain conditions are associated with decreased hippocampal volume, a rich parallel literature indicates that depression is associated with hippocampal volume decrease. (Baliki 2015)

It is therefore not surprising that these conditions are often comorbid, and indeed, there is now a small but emerging literature regarding the interaction between negative moods and acute and chronic pain. (Baliki 2015).

Implications and New Questions

How does this research add to what we already know? We have known for a while that chronic pain involves central sensitization and brain changes. But it was still possible that those changes were driven by persistent peripheral input. Apkarian’s research seems to suggest that peripheral nociception is not the central driver of chronic pain.

It should be noted that some of Apkarian’s research needs to be replicated and that others may interpret his findings differently.

Apkarian was a featured speaker at the 2018 San Diego Pain Summit, I spoke there a few years ago and wrote about my experience attending here.

I was sure to ask Apkarian some questions which are basically unanswered in his various papers: if chronic pain is mostly about the brain’s emotional systems, what can we do, as a practical matter, to help treat or prevent it? And for people who do recover from chronic pain (like me and many others), how did their brains change? Did they revert or evolve?

I suspected there are no simple answers that apply to everyone, and that success for any particular person involves somehow changing the way their brain subconsciously connects movement, threat perception, and a sense of value or meaning.

Resources/Citations

Apkarian, A Vania, Marwan N Baliki, and Melissa A Farmer. 2016. “Predicting Transition to Chronic Pain” 26 (4): 360–67. doi:10.1097/WCO.0b013e32836336ad

Hashmi, Javeria A., Marwan N. Baliki, Lejian Huang, Alex T. Baria, Souraya Torbey, Kristina M. Hermann, Thomas J. Schnitzer, and A. Vania Apkarian. 2013. “Shape Shifting Pain: Chronification of Back Pain Shifts Brain Representation from Nociceptive to Emotional Circuits.” Brain 136 (9): 2751–68. doi:10.1093/brain/awt211.

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