Pain – what is it? Here’s a great quote

‘..all pains are the result of a neurobiological process, – they’re all about impulses, bio-electricity, electro-chemicals, consciousness and vast levels of complexity in representational areas and homeostatic monitoring modules of the brain, far from the injured tissues and the location of the pain’. Louis Gifford

The great news is that understanding the neurobiology of pain means that we have many more access points to change the processing and hence the experience of pain. Our job is seeking the individual’s access points and levering the natural conditions for change and moving forward.

Endometriosis & Melatonin | Women and Pain Series

Endometriosis pain

Many individuals who I see with CRPS and other chronically painful conditions will describe other problems that seemingly involve other body systems. However, there is commonality in the sensitisation that arises and is expreseed in different ways. The range of complaints falls under the ‘functional pain syndrome’ banner and includes irritable bowel syndrome, migraine, chronic widespread pain, bladder dysfunction, jaw pain and pelvic pain. Here we look at one problem that can include pelvic pain, endometriosis.

Chronic pelvic pain is a troubling condition for many women. The reason for pelvic pain varies but certainly includes endometriosis where the lesions impact upon nerve health and function (see here) with consequential sensitisation. The purported mechanisms of pain include inflammatory pain and neuropathic pain with subsequent central sensitisation that underpins the persistance and variance often described – see full article here

Pain is an output, a response to the brain’s perception of what is happening in the body. The sensation of pain emerges from that part of the body deemed in need of protection. The pain itself is modulated by a range of factors including stress, fatigue, anxiety and the environment. The actual feeling of pain is the end result of the brain’s analysis of what is going on ‘now’ on the basis of what it already knows and has learned. Hence, prior experience can flavour the pain. Changes in the spinal cord and higher centres can amplify danger signals, modulate normal signals (begin as normal and communicate with nociceptors, therefore the brain receives a danger signal despite the initiating impulse being one of touch; i.e./ allodynia) and are responsible for the varying patterns of pain such as when a treatment helps on one occasion yet seemingly worsens the pain on a subsequent occasion.

Alongside the painful experience there are other body and brain responses to the perceived threat. Altered control of movement that includes guarding and protective posturing that leads to patterns of on-going chronic tension. In the case of pelvic pain this emerges around the pelvic girdle, in the abdomen and in the spinal muscles and often across the body. It is not unusual to find that there are many tender and tight areas when the body has been protected for some time, demonstrating a more widespread pattern. Often there is sensitivity expressed via other body systems , for example the gastrointestinal system in IBS, headaches, migraine and recurring bladder infections to name but a few. General health can often be impacted upon, with levels of activity diminishing alongside a fear of moving and socialising (a gradual withdrawal from being out with friends and family). This typically leads to a downward spiral affecting mood, self-esteem and manifesting with anxiety in many situations. It is really a ‘hyper-protective’ state physically and mentally where many cues become threatening and hence we protect, sometimes consciously by making choices and frequently automatically or habitually. Breaking this pattern however, is entirely possible.

We are fundamentally designed to change, evolve and grow. When we set the right conditions physically and mentally (and it has to be both), then we can move forward and change our outlook and experience. I know that an individual is going to progress when they start changing their language, metaphor use and at the same time their appearance changes via posture, facial expression and general demeanour. The spark returns.

The optimal approach requires that we consider all the dimensions of pain: physical, cognitive and emotional. This must be integrated and a programme (click here) created to meet the unique needs of the person. Concomitant with a range of strategies and training techniques to retrain normal movement, tension patterns, ease pain, tackle stress and anxiety etc, medication can play a role. The efficacy of pain medication is varied and often there are side-effects to consider. A recent study looked at the use of melatonin for endometriosis-associated pain with some very interesting results.

The commentary of Timothy Ness in Pain 154 (2013) 775 summarises the study below: ‘The article by Schwertner et al..demonstrated efficacy of the hormone, melatonin, in the treatment of endometriosis-associated pain…..one of the few medications which have proven useful in the treatment of endometriosis-associated pelvic pain but it is also notable as an example of the back-and-forth translational process associated with preclinical models of pain/analgesia and the clinical demonstration of treatment efficacy.’ And, ‘In this particular example the information flow went in both directions from humans to non-humans and then back again’. He refers to the fact that the data produced in rats was also found in humans. Many studies use rodents as subjects with obvious limitations in terms of extrapolating data for humans.

Efficacy of melatonin in the treatment of endometriosis: a phase II, randomized, double-blind, placebo-controlled trial.

Pain. 2013 Jun;154(6):874-81.

Schwertner A, Conceição Dos Santos CC, Costa GD, Deitos A, de Souza A, de Souza IC, Torres IL, da Cunha Filho JS, Caumo W.

Source

Laboratory of Pain & Neuromodulation at Hospital de Clínicas de Porto Alegre (HCPA)/Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.

Abstract

Endometriosis-associated chronic pelvic pain (EACPP) presents with an intense inflammatory reaction. Melatonin has emerged as an important analgesic, antioxidant, and antiinflammatory agent. This trial investigates the effects of melatonin compared with a placebo on EACPP, brain-derived neurotrophic factor (BDNF) level, and sleep quality. Forty females, aged 18 to 45 years, were randomized into the placebo (n = 20) or melatonin (10 mg) (n = 20) treatment groups for a period of 8 weeks. There was a significant interaction (time vs group) regarding the main outcomes of the pain scores as indexed by the visual analogue scale on daily pain, dysmenorrhea, dysuria, and dyschezia (analysis of variance, P < 0.01 for all analyses). Post hoc analysis showed that compared with placebo, the treatment reduced daily pain scores by 39.80% (95% confidence interval [CI] 12.88-43.01%) and dysmenorrhea by 38.01% (95% CI 15.96-49.15%). Melatonin improved sleep quality, reduced the risk of using an analgesic by 80%, and reduced BNDF levels independently of its effect on pain. This study provides additional evidence regarding the analgesic effects of melatonin on EACPP and melatonin’s ability to improve sleep quality. Additionally, the study revealed that melatonin modulates the secretion of BDNF and pain through distinct mechanisms.

For further information about our proactive treatment, training and coaching programmes for chronic pain and injury, or to book an appointment please call us on 07932 689081 | Women in Pain Clinic in Harley Street

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J Pain Symptom Manage. 2012 Nov 27.

Analgesic and Sedative Effects of Melatonin in Temporomandibular Disorders: A Double-Blind, Randomized, Parallel-Group, Placebo-Controlled Study.

Vidor LP, Torres IL, de Souza IC, Fregni F, Caumo W.

Source

Postgraduate Program in Medical Sciences, Faculty of Medicine, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.

Abstract

CONTEXT:

The association between myofascial temporomandibular disorder (TMD) and nonrestorative sleep supports the investigation of therapies that can modulate the sleep/wake cycle. In this context, melatonin becomes an attractive treatment option for myofascial TMD pain.

OBJECTIVES:

To investigate the effects of melatonin on pain (primary aim) and sleep (secondary aim) as compared with placebo in a double-blind, randomized, parallel-group trial.

METHODS:

Thirty-two females, aged 20-40 years, with myofascial TMD pain were randomized into placebo or melatonin (5mg) treatment groups for a period of four weeks.

RESULTS:

There was a significant interaction (time vs. group) for the main outcomes of pain scores as indexed by the visual analogue scale and pressure pain threshold (analysis of variance; P<0.05 for these analyses). Post hoc analysis showed that the treatment reduced pain scores by -44% (95% CI -57%, -26%) compared with placebo, and it also increased the pressure pain threshold by 39% (95% CI 14%, 54%). The use of analgesic doses significantly decreased with time (P<0.01). The daily analgesic doses decreased by -66% (95% CI -94%, -41%) when comparing the two groups. Additionally, melatonin improved sleep quality, but its effect on pain was independent of the effect on sleep quality.

CONCLUSION:

This study provides additional evidence supporting the analgesic effects of melatonin on pain scores and analgesic consumption in patients with mild-to-moderate chronic myofascial TMD pain. Furthermore, melatonin improves sleep quality but its effect on pain appears to be independent of changes in sleep quality.

Pain is a conscious experience

Pain is a conscious experience

With pain being a conscious experience, the study of consciousness should help us to understand the phenomena. With modern writers on pain dipping into the realms of philosophy and drawing upon 1st person and 3rd person neuroscience differences, we can adapt our practice and reasoning to ensure that the patient experience is both expressed and used to create a meaning that makes sense. This is the patient narrative that guides our thinking about their problem.

Avinash de Sousa has written a two part article seeking to integrate what we know about consciousness  This is no mean feat as consciousness is a concept that has been discussed and studied since we were first aware of ourselves.

Part 1 looks at the neurobiological and cognitive dimensions – full article here

Part 2 considers other perspectives - full article here

Pain is a ‘conscious correlate’ (Moseley) of neural activity within the brain that emerges from the body tissues with a particular quality that we seek to describe and certainly respond to with a set of behaviours. Of course this is the whole purpose of pain, to motivate action so that we may survive and adapt. Extremely useful at the point of an acute injury, less so when the tissues have healed, persisting pain in this latter case is indicative of a conditioned response that continues to protect the body but against normal or innocuous stimuli.

We are conscious of sensations from the body when they contrast from other body areas. They stand out in other words. The salient network described by Iannetti and co. provides a good framework to consider how the mechanisms function. The brain is constantly receiving updates from the body systems, responding by tweaking the knobs and dials here and there, all below our awareness. When something stands out, ‘raising it’s head above the parapet’, our brain deems the signal to be salient and thereby triggers a response. The salient network therefore, is a detection system that drives appropriate responses. If protection is deemed biologically appropriate by the brain, we will then experience pain in the body area perceived as being threatened. Of course, this is a conscious experience.

Please visit our clinic site here: Specialist Pain Physio Clinics for persisting and complex pain

Lorimer Moseley talks about the role of the brain in pain

The study of neuroscience has revealed a great deal about the role of the brain in pain and chronic pain. Here, Lorimer talks in his informal way about some very complex processes.

Understanding pain is undoubtedly a vital part of dealing with the experience. To develop understanding is to learn. To learn is to change the brain. The brain is very plastic–neuroplastic. See this blog on change

Pain is all about a perceived threat. What does the ‘perceiving’? The brain. If we can change the activity and connectivity in the brain, then we can change our conscious experience, in this case pain.

Pain is not set in stone. The quality and nature changes frequently and this is because there are a range of influences upon the experience of pain, numerous modulators of the signals in the peripheral nervous system and the central nervous system.

‘Pain depends entirely upon what the brain THINKS is happening in the tissues’

Now, it is important to understand that although the brain has a key role in the experience of pain, it is a multisystem output. This means that there are many systems in the body that have a role, such as the immune system and endocrine system (hormones).

I spend a great deal of time talking to patients about their pain, helping them to understand the main problem, their chronic pain. We can discuss the brain and the other systems, but of course it REALLY HURTS in the body, so how can it be the brain? Pain certainly emerges from the body, a location that is allocated within the tissues. But, the underpinning neural correlate exists in the brain. Similar to vision, the brain interprets the signals and information to create what we see.

Please come and visit our clinic site here for information on treatment, training & coaching for chronic pain conditions: Specialist Pain Physio Clinics

 

The meaning of pain

A Philosophy of Pain – a thought provoking read

To me, this is one of the ultimate questions. I spend many an hour pondering the meaning of pain and of course the bottom line is that pain has a unique meaning to each and every one of us. There are a wide range of influences upon our thinking as to what the pain experience means including our belief system and the context of the injury.

In the early or acute stages of an injury or sensitisation, the pain indicates that there is something wrong in the body and that we need to consciously address the problem. This is a vital part of survival and the mechanism is magnificent. Pain yes, unpleasant yes, normal yes. The consequential meaning in many cases is that the tissues are injured or heading in that direction (a warning shot across the bow so to speak) and the pain signifies a healing process that itself is potent and incredibly efficient. These are wanted mechanisms and we can understand their use.

What about the persisting pain case? What is the meaning of a pain that feels like you have just injured your back for example, yet you know that in fact the tissue basis for the pain is poor? We know very well that pain is not an accurate indicator of tissue damage–one need only study phantom limb pain to understand that pain is emergent from the body or virtual body in the phantom case, but underpinned by neural networks in the brain that allocate pain to the said and ‘felt’ location.

The meaning that the individual generates, and only the individual can generate, will affect the pain perception. Salience is another word being used to describe the importance and significance of the pain experience as determined by a neuroimmune system. The two recent studies below highlight the effect of changing the meaning of pain and how this changes the experience of pain.

One of the first interventions must be to work with the patient’s understanding of their pain, condition and the influences upon their experience, e.g./ stress, fatigue, health. By listening to the patient’s narrative, making sense of the story and the pain by explaining the mechanisms reduces the threat value by changing the meaning. Or in fact, actually providing a meaning for the on-going pain by explaining the experience fully, describing the inter-related physical, cognitive and emotional dimensions.

Pain. 2013 Mar;154(3):361-7. doi: 10.1016/j.pain.2012.11.007. Epub 2012 Nov 21.

Pain as a reward: changing the meaning of pain from negative to positive co-activates opioid and cannabinoid systems.

Benedetti F, Thoen W, Blanchard C, Vighetti S, Arduino C.

Source

Department of Neuroscience, University of Turin Medical School, Turin, Italy. fabrizio.benedetti@unito.it

Abstract

Pain is a negative emotional experience that is modulated by a variety of psychological factors through different inhibitory systems. For example, endogenous opioids and cannabinoids have been found to be involved in stress and placebo analgesia. Here we show that when the meaning of the pain experience is changed from negative to positive through verbal suggestions, the opioid and cannabinoid systems are co-activated and these, in turn, increase pain tolerance. We induced ischemic arm pain in healthy volunteers, who had to tolerate the pain as long as possible. One group was informed about the aversive nature of the task, as done in any pain study. Conversely, a second group was told that the ischemia would be beneficial to the muscles, thus emphasizing the usefulness of the pain endurance task. We found that in the second group pain tolerance was significantly higher compared to the first one, and that this effect was partially blocked by the opioid antagonist naltrexone alone and by the cannabinoid antagonist rimonabant alone. However, the combined administration of naltrexone and rimonabant antagonized the increased tolerance completely. Our results indicate that a positive approach to pain reduces the global pain experience through the co-activation of the opioid and cannabinoid systems. These findings may have a profound impact on clinical practice. For example, postoperative pain, which means healing, can be perceived as less unpleasant than cancer pain, which means death. Therefore, the behavioral and/or pharmacological manipulation of the meaning of pain can represent an effective approach to pain management.

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Pain. 2013 Mar;154(3):402-10. doi: 10.1016/j.pain.2012.11.018. Epub 2012 Dec 13.

The importance of context: when relative relief renders pain pleasant.

Leknes S, Berna C, Lee MC, Snyder GD, Biele G, Tracey I.

Source

Centre for Functional Magnetic Resonance Imaging of the Brain, Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics), University of Oxford, Oxford, UK. Siri.leknes@psykologi.uio.no

Abstract

Context can influence the experience of any event. For instance, the thought that “it could be worse” can improve feelings towards a present misfortune. In this study we measured hedonic feelings, skin conductance, and brain activation patterns in 16 healthy volunteers who experienced moderate pain in two different contexts. In the “relative relief context,” moderate pain represented the best outcome, since the alternative outcome was intense pain. However, in the control context, moderate pain represented the worst outcome and elicited negative hedonic feelings. The context manipulation resulted in a “hedonic flip,” such that moderate pain elicited positive hedonics in the relative relief context. Somewhat surprisingly, moderate pain was even rated as pleasant in this context, despite being reported as painful in the control context. This “hedonic flip” was corroborated by physiological and functional neuroimaging data. When moderate pain was perceived as pleasant, skin conductance and activity in insula and dorsal anterior cingulate were significantly attenuated relative to the control moderate stimulus. “Pleasant pain” also increased activity in reward and valuation circuitry, including the medial orbitofrontal and ventromedial prefrontal cortices. Furthermore, the change in outcome hedonics correlated with activity in the periacqueductal grey (PAG) of the descending pain modulatory system (DPMS). The context manipulation also significantly increased functional connectivity between reward circuitry and the PAG, consistent with a functional change of the DPMS due to the altered motivational state. The findings of this study point to a role for brainstem and reward circuitry in a context-induced “hedonic flip” of pain.

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For further information about our clinics, please visit our main site here: Specialist Pain Physio Clinics or call us on 07932 689081

 

Women and Pain | Part 3

Women and pain 3

A number of women who come to the clinic with a musculoskeletal complaint will describe other painful syndromes that involve other body systems (see Women and Pain blogs Part 1 & Part 2). These include irritable bowel syndrome (IBS), pelvic pain, dysmennorhoea, endometriosis, bladder dysfunction, jaw pain (TMJ), migraines and widespread musculoskeletal pain. Often hypermobility is also a feature (see blogs here and here) . These are termed functional pain syndromes and require a comprehensive approach to tackle the physical, cognitive and emotional dimensions of the pain and associated problems that impact upon quality of life.

This recent study looked at a cohort of women in Australia and showed that the presence of one condition is associated with the development of another. Certainly in functional pain syndromes we know about the underpinning central sensitisation that is a common theme that manifests in different end-organs or body systems to create the aforementioned conditions. Using strategies to cultivate health within the systems is important, but so is using therapies to target the central mechanisms and driving systems, i.e. the nervous system, the immune system and the endocrine system (including stress physiology).

Only through a detailed assessment and the creation of an environment that permits the patient’s narrative will this vital piece of the puzzle emerge (see Oliver Sack talk about narrative here).

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Clin J Pain. 2013 Mar 12. [Epub ahead of print]

The Relationship Between Incontinence, Breathing Disorders, Gastrointestinal Symptoms, and Back Pain in Women: A Longitudinal Cohort Study.

Smith MD, Russell A, Hodges PW.

Abstract

OBJECTIVES:: Recent studies suggest a relationship between incontinence, respiratory disorders, gastrointestinal (GI) symptoms, and back pain (BP). However, causality is difficult to infer. This longitudinal study aimed to determine whether the presence or development of one disorder increases risk for the development of another. METHODS:: Women from the Australian Longitudinal Study on Women’s Health were divided into subgroups; those with no BP (n=7259), no incontinence (n=18,480), no breathing problems (including allergy) (n=15,096), and no GI symptoms (n=17,623). Each subgroup was analyzed to determine the relationship between the development of the absent condition and the presence or development of the other conditions. Factors with a previously identified relationship with BP were included in analysis.

RESULTS:: Women with pre-existing and/or newly developed incontinence [prevalence ratios (PR): 1.26 to 2.12] and breathing problems (PR: 1.38 to 2.11) had an increased risk for the development of BP, and women with pre-existing and newly developed BP were more likely to develop incontinence and breathing problems (PR: 1.18 to 2.44 and 1.53 to 2.62, respectively). The presence of GI symptoms was also identified as a risk factor for the development of these conditions.

DISCUSSION:: This study provides evidence of a relationship between BP, incontinence, respiratory problems, and GI symptoms in which the presence of one symptom is associated with the development of another. This suggests that common factors may contribute to the development of symptoms across this range of conditions.

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If you suffer functional pains, please call us on 07932 689081 for further information or to book an appointment. See our clinic website here: Specialist Pain Physio Clinics

Reconceptualising pain for better treatment – a revolution? A revelation?

Traditionally pain is understood to be an unpleasant experience in the body where a problem exists, and is something to be got rid of as quickly as possible. The so-called ‘biomedical model’ considers which structures require treatment or surgery, stopping at the tissues as the cause of pain. This paradigm has been challenged over the years and rightly so in the light of recent research. Many studies have revealed the underlying physiology within the nervous system, and in particular the brain, and the role of other body systems such as the immune system and endocrine system (hormones) in pain. Understanding that pain is a normal response to a perceived threat has helped mould new treatments and ways of dealing with pain.

The most pertinent discovery and emergent shift in thinking came when it was realised that pain is a brain experience. This came via studies of the brain but also by looking at why phantom limb pain exists and how people present with a range of injuries and such varied levels of reported pain. There are many stories of people suffering severe physical injury yet experience little or no pain at the time.

The fact that we know pain is a brain experience has helped us to understand the many influences upon the pain, especially one’s emotional state. For instance, we know that the danger signals that are sent by the body to the brain via the spinal cord, travel to the emotional centres of the brain to try and give some meaning to the pain. These signals reach the brain and receive scrutiny to work out the level of threat, and this can vary enormously depending upon a range of factors. On activating a widespread group of neurons termed the ’pain matrix’, the output from the brain, a response, can be the pain experience. Knowing that there are many parts of the brain involved has meant that there are now a range of approaches that can tackle the problem of pain.

We are now far more optimistic about treating pain. This is not just with medication, which does have a role when used wisely, but with a range of contemporary treatments, strategies and techniques that address the underpinning mechanisms at a tissue level, spinal cord level and a brain level alongside beliefs, attitudes and behaviours that can be moulded to change the pain. The term used to describe the contemporary approach to pain is ’biopsychosocial’, implying a role for the overlapping biological, psychological and social factors that must be addressed.

CRPS Review 20th February 2012

A selection of papers to peruse:

Predictors of Pain Relieving Response to Sympathetic Blockade in Complex Regional Pain Syndrome Type 1

Anesthesiology: January 2012 – Volume 116 – Issue 1 – p 113–121
doi: 10.1097/ALN.0b013e31823da45f Pain Medicine

van Eijs, Frank M.D.*; Geurts, José M.Sc.†; van Kleef, Maarten M.D., Ph.D.‡; Faber, Catharina G. M.D., Ph.D.§; Perez, Roberto S. Ph.D.‖; Kessels, Alfons G.H. M.D., M.Sc.#; Van Zundert, Jan M.D., Ph.D.**

Abstract
Background: Sympathetic blockade with local anesthetics is used frequently in the management of complex regional pain syndrome type 1(CRPS-1), with variable degrees of success in pain relief. The current study investigated which signs or symptoms of CRPS-1 could be predictive of outcome. The incidence of side effects and complications of sympathetic blockade also were determined prospectively.
Methods: A prospective observational study was done of 49 patients with CRPS-1 in one extremity only and for less than 1-yr duration who had severe pain and persistent functional impairment with no response to standard treatment with medication and physical therapy.
Results: Fifteen (31%) patients had good or moderate response. The response rate was not different in patient groups with cold or warm type CRPS-1 or in those with more or less than 1.5°C differential increase in skin temperature after sympathetic blockade. Allodynia and hypoesthesia were negative predictors for treatment success in CRPS-1. There were no symptoms or signs of CRPS-1 that positively predicted treatment success. A majority of patients (84%) experienced transient side effects such as headache, dysphagia, increased pain, backache, nausea, blurred vision, groin pain, hoarseness, and hematoma at the puncture site. No major complications were reported.
Conclusions: The presence of allodynia and hypoesthesia are negative predictors for treatment success. The selection of sympathetic blockade as treatment for CRPS-1 should be balanced carefully between potential success and side effect ratio. The procedure is as likely to cause a transient increase in pain as a decrease in pain. Patients should be informed accordingly.

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Motor control in complex regional pain syndrome: A kinematic analysis

http://dx.doi.org/10.1016/j.pain.2011.12.018

  • J.C.M. Schildera, , ,
  • A.C. Schoutenb, c,
  • R.S.G.M. Perezd,
  • F.J.P.M. Huygene,
  • A. Dahanf,
  • L.P.J.J. Noldusg,
  • J.J. van Hiltena,
  • J. Marinusa

Abstract

This study evaluated movement velocity, frequency, and amplitude, as well as the number of arrests in three different subject groups, by kinematic analysis of repetitive movements during a finger tapping (FT) task. The most affected hands of 80 patients with complex regional pain syndrome (CRPS) were compared with the most affected hands of 60 patients with Parkinson disease (PD) as well as the nondominant hands of 75 healthy control (HC) subjects. Fifteen seconds of FT with thumb and index finger were recorded by a 60-Hz camera, which allowed the whole movement cycle to be evaluated and the above mentioned movement parameters to be calculated. We found that CRPS patients were slower and tapped with more arrests than the two other groups. Moreover, in comparison with the hands of the HC subjects, the unaffected hands of the CRPS patients were also impaired in these domains. Impairment was not related to pain. Dystonic CRPS patients performed less well than CRPS patients without dystonia. In conclusion, this study shows that voluntary motor control in CRPS patients is impaired at both the affected as well as the unaffected side, pointing at involvement of central motor processing circuits.

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Psychological factors associated with self-perceived pain-related disability among individuals diagnosed with complex regional pain syndrome

by Mann, Jeffrey C., Psy.D., ADLER SCHOOL OF PROFESSIONAL PSYCHOLOGY, 2010, 107 pages; 3452691

Abstract:

Over the last several decades the importance of psychological factors in understanding pain-related disability has grown tremendously. Research has explored many psychological constructs and their relationship to pain related disability with several constructs emerging as clinically significant. The research conducted to date has predominantly focused on individuals with conditions such as low-back, arthritis, or other forms of musculoskeletal pain. To date, there is no research examining the predominant psychological constructs with a population of individuals diagnosed with Complex Regional Pain Syndrome (CRPS). This study had two primary purposes: (a) To examine the relationship between pain catastrophizing, pain helplessness, active coping, passive coping and self-perceived, pain-related disability, (b) to determine the amount of variance in self-perceived, pain-related disability accounted for by pain catastrophizing, pain helplessness, active coping, and passive coping. The research sample included 102 individuals diagnosed with CRPS being treated at a pain clinic. The instruments used to measure the independent variables were: Pain Helplessness Index (PHI), Pain Catastrophizing Scale (PCS), and the Coping Strategies Questionnaire (CSQ). The dependent variable was measured with the Perceived Disability Scale (PDS). Correlation analysis indicated that pain catastrophizing, pain helplessness, and passive coping are all positively correlated with self-perceived, pain-related disability. Multiple regression results indicated that pain catastrophizing, and pain helplessness account for 15.3% of the variance in self-perceived, pain-related disability. Active coping and passive coping did not account for a statistically significant portion of the variance. The findings of this study demonstrate the importance of pain catastrophizing and pain helplessness when treating individuals diagnosed with CRPS and raises doubt about the utility of active coping and the detriment of passive coping. Further investigation is needed to determine the efficacy of interventions focused on modifying pain catastrophizing and pain helplessness as a indirect method of decreasing self-perceived disability.

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Mast Cells: Source of Inflammation in Complex Regional Pain Syndrome?

Mast Cells: Source of Inflammation in CRPS

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Targeting Cortical Representations in the Treatment of Chronic Pain: A Review

  1. G. Lorimer Moseley
  2. Herta Flor

Recent neuroscientific evidence has confirmed the important role of cognitive and behavioral factors in the development and treatment of chronic pain. Neuropathic and musculoskeletal pain are associated with substantial reorganization of the primary somatosensory and motor cortices as well as regions such as the anterior cingulate cortex and insula. What is more, in patients with chronic low back pain and fibromyalgia, the amount of reorganizational change increases with chronicity; in phantom limb pain and other neuropathic pain syndromes, cortical reorganization correlates with the magnitude of pain. These findings have implications for both our understanding of chronic pain and its prevention and treatment. For example, central alterations may be viewed as pain memories that modulate the processing of both noxious and nonnoxious input to the somatosensory system and outputs of the motor and other response systems. The cortical plasticity that is clearly important in chronic pain states also offers potential targets for rehabilitation. The authors review the cortical changes that are associated with chronic pain and the therapeutic approaches that have been shown to normalize representational changes and decrease pain and discuss future directions to train the brain to reduce chronic pain.

RSout of these papers this is the one that I am most interested in reading. A number of the techniques that I use in the clinic for CRPS are targeting the changes in the brain, including Graded Motor Imagery, 2-point discrimination training, sensorimotor integration and mindfulness. We are both obliged and wise to consider why is it that the brain continues to protect a body part(s) and how has this happened? Herta Flor talks about learning and memory in pain and the conditioning process. Reinforcements for particular beliefs and behaviours can start early after an injury or initiation of a pain state. In these stages we must seek to prevent pathological beliefs developing by using focused education, promote useful behaviours that are reinforced and set goals that sit alongside processes of healing and recovery.

Specialist Pain Physio Clinics in London for CRPS