For those who know me, you may know that my partner has been dealing with chronic low back pain. Every day, day in and day out, for 12 years. It's both a literal and metaphorical pain in the ass. I’ve already written a blog on ten back pain facts, but I wanted to explore further.
Joshua (the yoga teacher who is collaborating with me in the next workshops Yoga Inversions & Yoga for Healthy Backs) recommended podcast on Dolorology (PAIN), a riveting interview with Dr. Rachel Zoffness.
My burning question was: "How is it possible that there's no major injury shown on X-rays anymore, but there's still chronic pain from a slipped disc. How? Why? And what can be done?"
A little Anatomy for Pain
How would you explain how pain works?…
You might mention pain sensors in the skin, but I wonder whether you’d include the fact that all pain goes through the emotional centre of the brain.
Pain involves a network of nerves throughout our body which act as fancy communication system, sending pain signals from different body parts to our brain and spinal cord. When something hurts, specialized receptors detect the pain signals and transmit them to the brain.
Now here’s the amazing thing. Our brain actively participates in the pain experience. It has different regions that contribute to our perception of pain. The cerebral cortex handles thoughts, the prefrontal cortex focuses attention, and the limbic system is the emotion centre. All sensory signals pass through the limbic system, shaping the experience of pain. Our brain has pathways that can either make pain feel worse or diminish its intensity.
What is pain?
Now we know the anatomy of it, but what exactly the definition of pain?
It used to be "An unpleasant sensory and emotional experience associated with actual or potential tissue damage," but people criticized it for focusing too much on actual injuries. However, the definition received an update in 2020 and now reads, "An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage." So now, pain doesn't necessarily require a direct link to physical injury.
Wait, what's that little addition all about?
Picture this: You've had the worst day ever—work was a nightmare, traffic was a nightmare, you had an argument with a loved one, you barely slept, missed lunch, and you're an all-around grumpachump. And then, THWACK! You accidentally hammer your finger. How much pain will you feel compared hammering your finger whilst on a fabulous vacation, surrounded by friends, laughter, good food, and basking in the sun? The "injury" is the same, but the pain is different and here is why.
The Three Pain Bubbles
Whether your pain is acute (lasting three months or less) or chronic (persisting beyond three months or the expected healing time), it resides in the overlapping territory of three bubbles.
The biological bubble, which includes genetics, tissue damage, system dysfunction, immune functioning, sleep, diet, and exercise. (That's where most of us tend to stop, thinking our bodies must be broken. But that's just one-third of the puzzle.)
The psychological bubble, which houses our thoughts, memories, emotions, and coping mechanisms. Surprisingly, neuroscience reveals that how you think actually affects how you feel. (Going back to the finger-hammer incident, you know that in the first scenario, you're screaming your head off, while in the second, you're casually rubbing your finger and laughing with your friends.)
The sociological bubble, which involves factors like access to care and support systems. Are you surrounded by friends and family, or do you feel isolated?
All three bubbles are constantly at play, contributing to the pain experience. One may take the spotlight at times, but they're all part of the equation.
Your Personal Pain Dial
So if the hammer finger saga can produce a different pain response depending on the circumstance, then you must have a pain dial, similar to the volume knob on a car stereo, that you can adjust to turn pain up or down.
This dial resides in your central nervous system, (comprising your brain and spinal cord) which work together to control various bodily functions, including pain. Many factors can influence the volume of pain you experience, whether it's acute or chronic.
Stress and Anxiety: When stress and anxiety levels are high, your body becomes tense, your muscles tighten, and worrisome thoughts occupy your mind. In response, your brain sends a message to the pain dial, increasing the pain volume. People with chronic pain conditions often find that stress and anxiety act as triggers or amplifiers of their pain.
Mood and Emotions: Your mood and emotions also play a significant role in pain perception. When your mood is low and you feel miserable (which annoyingly often happens when you experience pain), or when negative emotions like anger or frustration dominate, your limbic system (the emotion centre in the brain) amplifies the pain volume.
Attention and Focus: Another crucial factor is what you choose to focus on. When you lie on your couch, directing your attention inward to your body and constantly thinking about your pain, your prefrontal cortex sends a message to the pain dial, raising the pain volume. That's why healthcare providers often distract children during injections or adorn hospital walls with colourful murals – to divert their attention from pain-inducing stimuli.
Reducing pain
Surely that’s good news? If we understand what can raise pain levels, we can also use the same principles to reduce them.
Stress and Anxiety Reduction: When you actively manage stress and anxiety, promoting relaxation in your body and mind, your brain sends a message to the pain dial, resulting in a decrease in pain volume. Pain feels less intense when you are in a state of calm and tranquillity.
Positive Mood and Emotions: Positive emotions such as happiness, joy, and gratitude can help lower pain volume. Engaging in activities that bring you pleasure, spending time with loved ones, laughter and enjoyment all contribute to reducing the intensity of pain.
Attention Distraction: Shifting your attention away from pain can provide temporary relief. When you become absorbed in an activity that captivates your focus, you momentarily forget about your pain. Many of us have experienced this phenomenon, where engaging in something captivating helps diminish the perception of pain.
(If only there was an activity that could do all three, maybe even move the body too… Yogaaaaaaaaaaa)
Phantom Limb Syndrome
If you are still stuck on the idea that pain is just to do with the body and not the brain, then consider the phenomenon ‘phantom limb pain’. Imagine someone who loses an arm or a leg, yet they continue to experience excruciating pain in the missing limb. How is it possible that there can be intense leg pain in a leg that isn't even there?
Surely it suggests that pain is generated elsewhere. And that somewhere is none other than our brain. Your body has receptors that send messages up to your brain, and in turn, your brain sends messages back down—it's a constant exchange. But when it comes to constructing pain, it's your brain that takes the lead.
Now before you think that what’s being said is "it's all in your head," then you are wrong. That's as misleading as claiming emotions are solely in your head. (Ever been sick with worry, flushed with anger, or peed your pants with fear?) Emotions have a way of impacting your entire being, beyond just the confines of your head. Similarly, pain extends beyond a mere physical sensation. It's a dance between your brain, body, and emotions. So, let's not oversimplify it by saying pain is purely in your head.
Chronic Backache
Acute pain often will make us look at the most obvious body part for signs of injury (e.g the throbbing finger from the evil hammer episode), but chronic pain operates on its own terms.
Think of the pathways in your brain as the muscles in your body—the more you use them, the stronger they become. Just like building a six-pack requires doing more crunches to strengthen your muscles, or practicing the piano every day to enhance your skills. The pain pathway in your brain can also grow bigger and stronger.
With chronic pain, that pain pathway in your brain becomes stronger, amplifying even minor sensory input and falsely screaming danger. This phenomenon is known as ‘central sensitization’ and it doesn’t underlie all pain, but it explains a lot of chronic pain.
So now we just need to find a way to understand that the chances are really high that your brain is hypersensitive and it’s overreacting – AND it’s not your fault – but in fact your body might not be in danger.
Treating Chronic Pain
The treatment for chronic pain is the total opposite of what you think it is. Your body and your brain are telling you, “Isolate, stay home, don’t move.” Similar to being in a dark room and someone opening the blinds just a crack. Initially, you're overwhelmed by the light and want to close the blinds, but if you give it a couple of minutes, your brain adjusts and the light becomes tolerable. Opening the blinds a bit more can still be startling, but after another couple of minutes, your brain desensitizes and you're fine.
(This is where cognitive behavioural therapy* comes in it’s a way of helping someone’s brain and body desensitize to the little bits of stimulation, like opening the blinds bit by bit.)
Yoga & Chronic Pain
If you go onto Google Scholar and research ‘yoga and back pain/ health’ you will find a slew of studies. Just to share one I looked at was a review of 10 studies involving a 967 chronic low back pain patients. The results showed strong evidence that yoga can provide short-term relief in terms of pain, back-specific disability, and overall improvement. Evidence also suggested long-term benefits for pain reduction and moderate evidence for reducing back-specific disability. More and more studies are raving about the benefits of yoga.
Hopefully understanding the nature of pain will help in managing it more effectively. A holistic approach isn’t just woowoo it’s science. My conclusion to ‘do yoga’, but that is kinda my conclusion to all my blogs.
*listen to the podcast to find out much more