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.

And in response to stress…when do you take a few moments to do absolutely nothing? #stress #mindfulness

The last post concerned the effects of stress and that we actually need it, but the right kind. There is a way to achieve this by using mindfulness – see here for a brief exercise

Andy Puddicombe talks about mindfulness and here is the bio: When is the last time you did absolutely nothing for 10 whole minutes? Not texting, talking or even thinking? Mindfulness expert Andy Puddicombe describes the transformative power of doing just that: Refreshing your mind for 10 minutes a day, simply by being mindful and experiencing the present moment. (No need for incense or sitting in strange positions.)

Mindfulness does not need to be steeped in mysticism or perceived to a religious practice but rather a practical skill that can be learned and developed for enormous benefit physically and mentally, and how the two entwine.

‘The mystery of chronic pain’ TED Talk #pain

Elliot Krane talks about his 20 years experience of working with individuals who suffer complex pain. He describes a common scenario that I see in my clinic, whereby the pain has persisted beyond the expected timeline, sometimes by many years, and is accompanied by a range of other signs and symptoms that are all manifestations of the sensitivity that has evolved and become entrenched. This includes a variety of protective behaviours and beliefs about pain and what it means, the latter usually informing the former. The belief system is molded by experiences throughout life and messages given by those responsible for their healthcare. These messages and metaphors can often evoke potent imagery and fear that leads to avoidance and strategies that appear to be useful but are actually preventing the move forwards.

Moving forwards is a challenge. But, we are designed to change, grow and develop. Hence by creating the right conditions, this is what we can achieve with the understanding of pain biology, a range of effective movement based strategies, a toolbox of motivational techniques, a progressive plan, courage, belief in oneself (self-efficacy), support, perseverance and some brain focused therapies.


Please visit our clinic site here to learn more about our treatment, training and coaching programmes or call us: 07932 689081

Widespread pain in CRPS | #pain #CRPS

In many patients whom I see, in particular female patients (see our Women & Pain Clinic), the pain that they tell me about is one of a number of problems that they suffer across their body. In the study below, the authors identified that over 10% of those with complex regional pain syndrome had widespread pain. When you understand sensitisation and how this can manifest in the musculoskeletal system and other body systems, one can see how this pattern of seemingly unrelated pains is actually underpinned by the same mechanism, central sensitisation.

The functional pain syndromes that include irritable bowel syndrome, pelvic pain, migraine, chronic back pain, fibromyalgia and bladder dysfunction are underpinned by central sensitisation in many cases. When talking to a patient it is important to ask about other body systems and how they are functioning as it provides vital information about the way in which the neuroimmune system is responding.

Treatment and training programme design relies upon a full picture of the individual and the condition(s) presenting. Permitting the patient to express themselves via the narrative allows for the emergence of key pieces of information that guides thinking about the wisest action for that individual. We are seeking to desensitise, to develop confidence in moving that is dissociated from pain and to point the patient to wellness in its widest sense so that life’s meaning can be restored.

Visit our clinic website here and learn about our treatment, training and coaching programmes for chronic pain and injury, or call us on 07932 689081

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Widespread Pain in Patients with Complex Regional Pain Syndrome.

Birley T, Goebel A. | Pain Pract. 2013 Jun 24.

Abstract

OBJECTIVES:

Our goal was to ascertain the prevalence of widespread pain in our cohort of patients with complex regional pain syndrome (CRPS).

METHODS:

We conducted a retrospective analysis of clinical letters and notes. We assessed data from consecutive patients diagnosed with CRPS according to the Budapest criteria, after a referral to one consultant at a tertiary Pain Medicine referral center.

RESULTS:

Between July 2007 and September 2012, 190 patients (149 females) received a diagnosis of CRPS according to the Budapest criteria, and an additional 26 patients received the diagnosis of CRPS NOS (not otherwise specified). The CRPS patients were an average of 44 years of age, and had a median disease duration of 18 months. Before the CRPS incident trigger, a third had already experienced other than everyday pains in the now CRPS-affected limb. Twenty-one patients (11.1%) experienced widespread pain in clinic, which was often not communicated in the referral letters. The types of triggering traumata and frequencies of Budapest signs and symptoms did not differ between patients with or without widespread pain. All patients considered their widespread pain as an important factor affecting their quality of life; for the majority it was of similar severity to the CRPS pain. Additional patients reported CRPS-concomitant regional pains, most commonly headaches/migraines, lower back pain, and irritable bowel syndrome.

DISCUSSION:

In this systematic assessment of the incidence of widespread pain in a large cohort of patients with CRPS, important widespread pain affected > 10% of patients. Our data support the inclusion of routine enquiries about additional pains in the clinical assessment of patients with CRPS.

CRPS Bugle 24th May | #CRPS

The 4th International Congress on Neuropathic Pain is currently in full swing in Toronto. You can follow the tweets via the trend #NeuPSIG and #neupsig. Here are some of the papers from the speakers.

Complex regional pain syndrome, prototype of a novel kind of autoimmune disease.

Autoimmun Rev. 2013 Apr;12(6):682-6. doi: 10.1016/j.autrev.2012.10.015. Epub 2012 Dec 6.

Goebel A, Blaes F.

Source

Pain Research Institute, Department of Translational Medicine, Liverpool University, Liverpool, UK; The Walton Centre NHS Foundation Trust, Liverpool, UK. Electronic address: andreasgoebel@rocketmail.com.

Abstract

Complex regional pain syndrome (CRPS) is a painful condition, which arises in a limb after trauma. CRPS can profoundly affect patients’ quality of life, and there is no cure. CRPS is associated with limb-confined sensory, motor, skin, bone and autonomic abnormalities. Recent research has shown that some patients respond to treatment with immunoglobulins, and that a majority have IgG serum-autoantibodies directed against, and activating autonomic receptors. CRPS serum-IgG, when transferred to mice elicits abnormal behaviour. These results suggest that CRPS is associated with an autoantibody-mediated autoimmune process in some cases. CRPS has unusual features, including a non-destructive, and regionally-confined course. We propose that CRPS constitutes a prototype of a new kind of autoimmunity, which we term ‘IRAM’ (injury-triggered, regionally-restricted autoantibody-mediated autoimmune disorder with minimally-destructive course). Understanding autoimmune contribution to CRPS should allow the exploration of novel treatment modalities in the future. Additional ‘functional’ disorders, painful or painless may be autoimmune in nature.

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Pain Pract. 2013 Mar 14. doi: 10.1111/papr.12049. [Epub ahead of print]

Mast Cells: A New Target in the Treatment of Complex Regional Pain Syndrome?

Dirckx M, Groeneweg G, van Daele PL, Stronks DL, Huygen FJ.

Source

Center for Pain Medicine, Erasmus MC, Rotterdam, The Netherlands.

Abstract

There is convincing evidence that inflammation plays a pivotal role in the pathophysiology of complex regional pain syndrome (CRPS). Besides inflammation, central sensitization is also an important phenomenon. Mast cells are known to be involved in the inflammatory process of CRPS and also play a role (at least partially) in the process of central sensitization. In the development of a more mechanism-based treatment, influencing the activity of mast cells might be important in the treatment of CRPS. We describe the rationale for using medication that counteracts the effects of mast cells in the treatment of CRPS.

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Clin J Pain. 2012 May;28(4):355-63. doi: 10.1097/AJP.0b013e31822efe30.

Effect of immunomodulating medications in complex regional pain syndrome: a systematic review.

Dirckx M, Stronks DL, Groeneweg G, Huygen FJ.

Source

Erasmus MC, Rotterdam, The Netherlands. m.dirckx@erasmusmc.nl

Abstract

BACKGROUND:

Different mechanisms are involved in a complex network of interactions resulting in the painful and impairing disorder, complex regional pain syndrome (CRPS). There is convincing evidence that inflammation plays a pivotal role in the pathophysiology of CRPS. Immunomodulating medication reduces the manifestation of inflammation by acting on the mediators of inflammation. Therefore, as inflammation is involved in the pathophysiology of CRPS, immunomodulating medication in CRPS patients may prove beneficial.

OBJECTIVES:

To describe the current empirical evidence for the efficacy of administering the most commonly used immunomodulating medication (ie, glucocorticoids, tumor necrosis factor-α antagonists, thalidomide, bisphosphonates, and immunoglobulins) in CRPS patients.

METHODS:

PubMed was searched for original articles that investigated CRPS and the use of one of the abovementioned immunomodulating agents.

RESULTS:

The search yielded 39 relevant articles: from these, information on study design, sample size, duration of disease, type and route of medication, primary outcome measures, and results was examined.

DISCUSSION:

Theoretically, the use of immunomodulating medication could counteract the ongoing inflammation and might be an important step in improving a disabled hand or foot, leading to further recovery. However, more high-quality intervention studies are needed.

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J Pain. 2012 Aug;13(8):784-9. doi: 10.1016/j.jpain.2012.05.003. Epub 2012 Jul 12.

Genetic HLA associations in complex regional pain syndrome with and without dystonia.

van Rooijen DE, Roelen DL, Verduijn W, Haasnoot GW, Huygen FJ, Perez RS, Claas FH, Marinus J, van Hilten JJ, van den Maagdenberg AM.

Source

Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands.

Abstract

We previously showed evidence for a genetic association of the human leukocyte antigen (HLA) system and complex regional pain syndrome (CRPS) with dystonia. Involvement of the HLA system suggests that CRPS has a genetic component with perturbed regulation of inflammation and neuroplasticity as possible disease mechanisms. However, it is at present unclear whether the observed association with HLA-B62 and HLA-DQ8 in CRPS patients with dystonia also holds true for patients without dystonia. Therefore, we tested the possible association with HLA-B62 and HLA-DQ8 in a clinically homogeneous group of 131 CRPS patients without dystonia. In addition, we investigated the possible association with other alleles of the HLA-A, HLA-B, HLA-C, HLA-DR, and HLA-DQ loci. We showed an increased prevalence of HLA-DQ8 (molecularly typed as HLA-DQB1*03:02; OR = 1.65 [95% CI 1.12-2.42], P = .014) in CRPS without dystonia, whereas no association was observed for HLA-B62 (molecularly typed as HLA-B*15:01; OR = 1.22 [95% CI .78-1.92], P = .458). Our data suggest that CRPS with and CRPS without dystonia may be genetically different, but overlapping, disease entities because only HLA-DQ8 is associated with both. The findings also indicate that distinct biological pathways may play a role in both CRPS subtypes. PERSPECTIVE: This study is the first to replicate a specific HLA region conferring genetic risk for the development of CRPS. Moreover, associations of HLA-DQ8 with both CRPS with and CRPS without dystonia, and HLA-B62 only with CRPS with dystonia, suggest that these disease entities may be genetically different, but overlapping.

Come and visit our clinic site Specialist Pain Physio Clinics to learn about rehabilitation, training and treatment programmes for CRPS and other persisting pain problems

Don’t stand so close to me…

The Police song came to mind recently when I was thinking about how people protect themselves and their painful body parts, especially in cases of CRPS.

Pain is part of the the protective response initiated to promote survival and healing. We attend to the painful area and take action. This action can be conscious guarding by wearing a device (e.g. a boot or splint) and posturing to show that there is a problem and to avoid actual contact with other people.

We feel pain in our bodies although it is neuronal activity in the brain that underpins the experience of pain. In other words, we experience pain in our ‘physical self’ but it is the brain that constructs the feeling and gives it an anatomical location.

We have our bodies mapped in various cortical locations including the sensory and motor centres of the brain. These maps are very well defined under normal circumstances as far as we know. This accuracy changes in cases of persisting pain, thereby affecting our ability to know where we are being touched and controlling movement. Modern treatment of persisting pain states target these changes as well as promote tissue health and overall wellness.

More recently it has been discovered that we also have a virtual body that is mapped out in the brain, meaning that we can alter the physical experience and pain by positioning the limbs in the contralateral space. For some time we have known that there is extracorporeal awareness that changes when we have nasty pain. In other words, the space around us and in particular the painful area becomes protected as well. On approaching the affected limb in CRPS, often the individual will flinch and guard before the actual contact arrives. Sensible you may think. This can happen when they have their eyes closed as well.

So, as the song says, ‘Don’t stand, don’t stand, don’t stand so close to me’ is an important protective response driven by the salient network in the brain but needs to be addressed as part of a comprehensive desensitisation programme.

For further information about our treatment programmes for CRPS, please call 07932 689081 or visit our website here: Specialist Pain Physio Clinics, London.

CRPS Bugle Extra | CRPS Treatment | Systematic review 2013 #CRPS

Specialist Pain Physio Clinics, LondonCossins et al. (2013) have just published a systematic review of the treatments for complex regional pain syndrome (CRPS).

Here is the abstract:

Complex regional pain syndrome (CRPS) is a disabling pain condition with sensory, motor and autonomic manifestations. Uncertainty remains about how CRPS can be effectively managed. We conducted a systematic review of randomized controlled trials (RCTs) for treatment and prophylactic interventions for CRPS published during the period 2000–2012, building on previous work by another group reviewing the period 1966–2000. Bibliographic database searches identified 173 papers which were filtered by three reviewers. This process generated 29 trials suitable for further analysis, each of which was reviewed and scored by two independent reviewers for methodological quality using a 15-item checklist. A number of novel and potentially effective treatments were investigated. Analysing the results from both review periods in combination, there was a steep rise in the number of published RCTs per review decade. There is evidence for the efficacy of 10 treatments (3¥ strong – bisphosphonates, repetitive transcranial magnetic stimulation and graded motor imagery, 1¥ moderate and 6¥ limited evidence), and against the efficacy of 15 treatments (1¥ strong, 1¥ moderate and ¥13 limited). The heterogeneity of trialled inter- ventions and the pilot nature of many trials militate against drawing clear conclusions about the clinical usefulness of most interventions. This and the observed phenomenon of excellent responses in CRPS subgroups would support the case for a network- and multi-centre approach in the conduct of future clinical trials. Most published trials in CRPS are small with a short follow-up period, although several novel interventions inves- tigated from 2000 to 2012 appear promising.

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Within the authors’ analysis they discuss medications, interventions and physiotherapy:

‘There is string evidence that rehabilitation/physiotherapy interventions can reduce pain and improve function for people with CRPS’

The problem with this is that it does not define what physiotherapy actually constitutes. This is with the exception of graded motor imagery (GMI) that is termed ‘a complex physiotherapy intervention’. I use GMI training for rehabilitation in CRPS, teaching individuals the principles of motor learning before guiding their training through the stages – see here. Typically alongside the GMI programme I run a range of strategies that are designed to develop resilience to the stress and anxiety associated with on-going pain. These techniques are skills that the individual learns and becomes accomplished at using to optimise their outcomes by grooving a positive mindset for rehabilitation. The benefits often pervade into other aspects of life as well as they become proficient at controlling attention and regulating emotion. This is a comprehensive and holistic approach to persisting pain using an integrated physical-cognitive-emotional model of care. Pain is multidimensional as is relief and both must be thought of in this way.

It is very useful to have a systematic review. The only omission as far as I can see is that of the effects of cognitive strategies in CRPS. In the general chronic pain literature there is a mass of evidence of the benefit and hence the absolute need to interlace such strategies into a programme.

Full article here: Treatment of CRPS | A systematic review

Visit our clinic page here: Specialist Pain Physio Clinics London

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

Pain mechanisms

Understanding pain mechanisms is the key to effective treatment. The mechanisms that have been studied, written about in science journals and discussed with patients include nociceptive pain, inflammatory pain, neuropathic pain and central sensitisation. Elucidating which are playing a role in the patient’s experience allows the doctor to prescribe the right medication and the modern physical therapist to address the issues of pain in a biopsychosocial manner. I will now clarify the latter point.

In taking a detailed history, observing patterns of movement and protection, assessing the state of the nervous system and health of the body systems, understanding behaviours and the beliefs behind them and learning of the influences upon the individual’s pain experience, one can know about the likely pain mechanisms underpinning the experience. From here the treatment strategies can be chosen to target these mechanisms. For example, top-down approaches for central sensitisation focus on the change in the properties of the central nervous system. The interventions themselves are observant of the amplification that occurs in the spinal cord and higher centres and would seek to dampen the responses with input to the brain that is perceived as normal or non-threatening. This could include sensory stimulation or movements outside of the receptive field, education to reduce fear of movement or imagery to name but a few. Inflammatory pain can also be treated with a top-down approach but local tissue based strategies would also be used. Just to note that the separation of the ‘top end’ (brain and spinal cord) from ‘bottom end’ (tissues) is really a false dichotomy as all conscious experiences are from the brain including what we see and what we feel.

Stephen McMahon and David Bennett, both experts in the field of pain science from King’s College London, produced a poster that describes these mechanisms – click here to visit the page in Nature Reviews Neuroscience. This is what they say about it:

Pain is an unpleasant sensation resulting from the intricate interplay between sensory and cognitive mechanisms. Chronic pain, resulting from disease or injury, affects nearly every fifth person in the Western world, constituting an enormous burden for the individual and society. Sensitization of pain signalling systems is a key feature of chronic pain and results in normally non-painful stimuli eliciting pain. Such sensory changes can occur not just at the sites of injury, but in surrounding normal tissues. This and other observations suggest that sensitization occurs within the CNS as well as within nociceptor terminals. Here we consider the consequences of noxious stimulus applied to our unfortunate builder’s hand, from sensory transduction to pain perception. We describe the structural and functional elements present at different levels of the nociceptive system, as well as some of the changes occurring in chronic pain states. Although our poster highlights a flow of information from the periphery to the CNS, it should be noted that higher brain centres exert both inhibitory and facilitatory controls on lower ones. The challenge for the next decade will be to effectively translate this knowledge into the development of novel analgesic agents for better pain relief.

Richmond StaceSpecialist Pain Physio Clinics, London & Surrey

“We – are – family….” Pain and significant others

Although pain is personal and only felt by the individual, the effects pervade to those closely around. It appears to be a two-way street though, with significant others having an impact upon levels of physical activity and evidence of similar attentional biases in chronic pain patients and their caregivers. Have a look at the papers below:

Pain. 2012 Jan;153(1):62-7. Epub 2011 Oct 15.

Do main caregivers selectively attend to pain-related stimuli in the same way that patients do?

Source

Family Research Institute, Shahid Beheshti University, G.C., Tehran, Iran.

Abstract

Despite increasing interest in the attentional biases of pain patients towards pain-related stimuli, there have been no investigations of whether the main caregivers of chronic pain patients also selectively attend to pain-related information. We compared the attentional biases to painful or happy faces of 120 chronic pain patients, 118 caregivers, and 50 controls. Analyses found that both patients and caregivers demonstrated biases towards painful faces that were not observed in control participants or to happy faces. Those patients and caregivers who were high in fear of pain demonstrated greater biases than those low in fear of pain, and the biases of the high-in-fear-of-pain group differed significantly from zero. When sub-groups of caregivers were compared, it was found that biases towards painful faces were not observed for those caregivers who accurately identified the level of pain the patient currently reported. In contrast, those caregivers who overestimated or underestimated the patients’ pain demonstrated biases that were significantly greater than zero. These results add to the growing weight of evidence suggesting that biases towards pain-related stimuli are observed in chronic pain patients, but that the nature of the stimuli is important. In addition, the results suggest that caregivers, particularly those who either under- or overestimate the level of pain that the patient reports, also demonstrate similar biases. Future research should investigate the links between caregivers’ biases and the way in which caregivers respond to pain.

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Pain. 2011 Nov;152(11):2521-7. Epub 2011 Aug 27.

Factors contributing to physical activity in a chronic low back pain clinical sample: a comprehensive analysis using continuous ambulatory monitoring.

Source

Department of Psychology, Eastern Michigan University, Ypsilanti, MI, USA. kalschul@uw.edu

Abstract

Back pain is one of the most common causes of disability in industrialized nations. Despite this, the variables that contribute to disability are not well understood and optimal measurement strategies of disability have not yet been determined. The present study sought to comprehensively assess the strongest predictors of physical activity as a proxy for disability. New patients in a chronic pain specialty clinic completed questionnaires to assess the predictors of physical activity and engaged in 5 days of home data collection wearing an accelerometer to assess physical activity in daily life, which is how disability was operationalised in this study. Analysis of repeated measures patient data revealed that, of 3 composite variables each representing a theoretical model, the model representative of operant factors significantly predicted physical activity. Subsequent analyses showed that pain sensitivity, fear avoidance, and solicitous spousal responses account for a significant amount of the variance in physical activity. These findings suggest that external sources of reinforcement or punishment may serve to influence physical behavior beyond that of internal cues such as fear avoidance or pain. Implications for treatment are discussed, including the potential benefits of specifically incorporating the patient’s sources of operant reinforcement or punishment into treatment.

RS Comment:

To be truly biopsychosocial, significant others and their influences must be considered. Positive strategies to involve and educate care givers, families and friends should form part of the treatment programme. I recommend that all those involved should develop an understanding of the issues of pain. We often listen to and subscribe to the beliefs of those closest to us and this powerful dynamic can be of real benefit. On occasion I am asked whether partners can attend the sessions. I encourage this participation as well as teaching techniques that are required to be used regularly at home, for example desensitisation strategies.