Oct 19, 2017 Neil Pearson
A recent paper in the Brazilian Journal of Physical Therapy, ‘Applying contemporary neuroscience in exercise interventions for chronic spinal pain: treatment protocol’ caught my attention (It’s open access at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5628368/).
It made me wonder two things: is this title accurate? , and is there more than one way to apply contemporary neuroscience to exercise interventions?
When I first began working in interdisciplinary pain management programs in the late ‘80’s, the dominant treatment protocol was informed by what I think were cognitive behavioural therapy principles. Patients were told that they were not to perform movement or exercises contingent on their pain. On ‘good pain days’ they were told to stick with the plan, and on ‘bad pain days’, they were told to stick with plan. Patients were also told that the way they think about their pain needed to change. Not only were they to control negative thinking, but they also were to stop negative thoughts and learn to think less about their pain. Given that similar instructions are included in this article, I wonder if it should be more accurately titled, “Applying contemporary neuroscience and cognitive behavioural therapy principles in exercise interventions for chronic spinal pain: treatment protocol”. Then again, maybe the manner in which they are suggesting we apply neuroscience to movement and exercise therapy is just different from my understanding. Science and patients make it clear that there is no one path we can follow when helping people with this complex human experience we call pain. Yet, I believe we need to think about what we read, teach and think.
Pain neuroscience tells us that pain is not an accurate indication of tissue health, nociception, injury, … This reminds me of many of the physical examination techniques we use in musculo-skeletal-neurological assessments. Typically, no single test can provide accurate evidence of the structural or physiological state of the tissues. All tests have sensitivity and specificity related to a ‘condition’. Yet we do not ignore these tests because they are not accurate. We decide that the best solution is to combine the assessment results with those of other assessment techniques in order to come to an informed conclusion.
Pain neuroscience tells us that there is a relationship between pain and the organism’s determination of safety and danger (I am using “organism” because this process is reliant on far more than the brain, yet I think there must be a better word). If I understand this neuroscience properly, when there is a determination of danger, processes and systems and the organism will become protective. All these processes involve both the typically-automatic and the conscious cognitive-emotional aspects of our existence. Concurrent with pain, we often experience other protective processes, such as tight muscles and stiffness, rapid breathing or breath-holding, fear of injury, and anxiety about more pain in the future. Does neuroscience suggest ignoring these protective responses as an adaptive strategy producing better long-term outcomes? Do we have neuroscience evidence that not paying attention to pain while moving promotes positive adaptive changes in the person, in physiology or in the brain? Or is this a strategy informed by cognitive behavioural principles.
Pain neuroscience tells us that people in pain who frequently endure increased pain (flare-ups) during activity or subsequent to increased activity are as likely to sensitize their nervous systems as those who are fear avoidant. In other words, ignoring pain may not be the best advice for all people based on neuroscience.
Science tells us that the individual in pain has no direct sensory evidence of the state of their tissues – only the ability to experience the organism’s interpretation of the state of the tissues, body and mind. Does this mean that pain science informs us to ignore how we experience our body, as a therapeutic intervention? Or does it suggest that since there is no single ‘sensory experience’ that would accurately guide us to how much we should move or exercise, therefore we should listen to multiple ‘sensory experiences’ instead in an attempt to make better judgments? Similar to our guidance to an individual with rheumatoid arthritis during a flare-up, in which our education includes using pain, heat, redness and swelling as guides for activity (because no one sign/symptoms is accurate enough), couldn’t pain neuroscience inform us to attend to multiple aspects of existence as a guide to moving with more ease? It might be difficult at first, and many might need practice to be more discerning of their experiences of body, breath, mind and pain, yet many people report that by ‘listening to’ ease of breath, tension in their body, their pain, and their mind (“am I safe”, and “will I be okay later”), they can be more successful at moving with more ease, and recovering function.
Pain neuroscience suggests that we experience less pain when there is greater evidence of safety. As an alternative to making exercise time-contigent for people in pain, can we start by considering that increased muscle tension, breath holding or rapid shallow breathing, fear of injury, and fear of a flare up might all add to the credible evidence of danger? When we succeed in building a strong caring relationship with our patients, then our pain education can potentially convince the patient that they are truly safe. This new belief about pain and attitude towards movement as recovery will likely reduce other protective responses such as tension, altered breath, and negative cognitions and emotions.
Pain neuroscience suggests there is more than one path. We can use much more than knowledge and cognitions as a source of changing the organism’s determination of danger.
If you have experienced intense lasting pain, imagine for a moment that you are about to apply a mechanical load to your body that previously worsened your pain, creating a multi-day flare of hypersensitivity and little ability to find peace, even in sleep. You trust your clinician, and you have taken the time to acquire deep understanding of pain neuroscience. You know that you are physiologically safe. You know that there is a large buffer between increased pain and injury. Yet you are experiencing your protective systems on high alert as you begin the movement. Your cognitive learning has not yet generalized to previous kinesthetic learning. Is ignoring your experiences of heightened protection your only adaptive option? Certainly, if you can fully shut down these thoughts there is likely to be greater determination of safety. Yet, what about using other aspects of your existence to further decrease evidence of danger? Might some people be more able to make the necessary cognitive shift, when those cognitions are supported by other compatible inputs to the brain? Would some find it more effective to shift the organism’s determination of safety when they are also regulating of their breath, their body tension, and/or emotions?
Neuroscience informs that pain is a biopsychosocial experience. Changing cognitions is therefore one strategy to enhance movement and exercise therapies. This same logic extends beyond cognitive strategies, to include enhancing an individuals ability to move with more ease by altering sensory signaling from the musculo-skeletal system, respiratory system, cardiovascular system, autonomic nervous system, emotions, relationships, workplace and societal forces.
Neuroscience supports a biopsychosocial view of all therapeutic interventions. As such, a logical inference is that movement and exercise can be considered as paths to changing cognitions. Movement and exercise have a role in the changes we observe in self efficacy, in hopelessness and helplessness and therefore catastrophic thinking, in body schema and body image, and in emotions such as grief, anxiety and depression.
Maltlief et al provide an instructive beginning to discussions of integrating pain neuroscience and movement therapies for people in pain. They have also infused cognitive behavioural principles into their protocol. As we move forward, applying science to get past our Cartesian and dualistic views, we have much to consider – including whether any of our protocols are effective for long-term outcomes, and whether any particular strategy can be learned and effectively used by other clinicians.