What can we do about pain?
– sometimes tissues repair but associated protective patterns may not, and that may be creating the persisting pain. Have you developed protective, but harmful, movement patterns? Are there areas of tension, tightness, weakness, compensation, that are not allowing your body to function normally as it once did?
– some tissues don’t repair as well as we would want, so have you learned how to stabilize, support, mobilize, or strengthen the area to make it as healthy as possible?
According to a European study, cancer patients felt their pain was viewed as secondary to the cancer treatment itself, and they wish more time was spent consulting on the pain they were experiencing .1 These results are important because it demonstrates the need for Pain Neuroscience Education (PNE) in treating these patients from the beginning stages of treatment and beyond. When treating cancer, it can be lost that this biological process is connected to a human being. The resulting pain can slowly strip away the interdependent, complex components that make us human.
PNE is a foundational pain management tool that helps form a greater understanding of how the biological, psychological, and sociological components of our being are important and play a role in managing and changing the pain experience.2 PNE helps accomplish this by eliminating some fear, worry, and stress through increasing knowledge, and awareness. This can lead to greater empowerment and sense of control for the patient.
PNE can be thought of as a knowledge translation process that helps patients better understand their pain experience in hopes of changing their interpretation of it. One of the main metaphors that we use for mechanical persistent pain conditions (Pain lasting more than 3 months) is this idea of hurt vs harm. This teaches that instead of pain representing damage to the tissues, that there is something wrong with the area, and that you are broken or debilitated, it can be thought of as an area that has heightened awareness or sensitivity due to multiple biopsychosocial factors.2 A common emerging theme viewing pain as a protector (Tame the Beast Video). Our brain does not want us to do a certain task because it perceived it as dangerous before and does not want us to experience that again.
PNE has been proven to be effective in reducing pain for many chronic musculoskeletal disorders,3 but what role does it have in helping active cancer patients and survivors where these biological processes are life-threatening, or in other words where hurt can equal harm?
A possible role of PNE during active cancer treatments is to help the individual learn to distinguish between active cancer pain and pain as a result of active cancer treatments.4 Helping them understand that pain is a primitive protective mechanism that can be exacerbated by context and fear can provide relief.3 The context here is cancer in our society, and the fear can be loss of life, the unknown, and the billion other worries and stress that can coincide with it. So, when going through active cancer treatments it is beneficial to know that tissue injuries are going to result, and this is going to take the natural healing process that involves pain. The difference here can be knowing that this pain is a result of a life saving treatments, not the cancer itself. A mindset that changes the perspective of the experience and can change the interpretation from life-threatening to life-saving.
Survivorship can come with its own challenges as there are often side-effects that result from these life-saving procedures. This can include increased risk of future cancers, joint and muscle pain, peripheral neuropathies,5 and central sensitization. 6 This is where the hurt vs harm analogy becomes very relevant as pain remains despite the elimination of the biological threat, and beyond the normal tissue healing time. This brings up past experiences, fears, and emotions, which all without proper knowledge and interpretation behind it, can lead to behaviours such as remaining sedentary (See Flow Model7).
Some education points through this stage:
In my opinion, PNE’s role in cancer rehabilitation should be immediate and ongoing as the European study demonstrated its importance to patients. Pain, a biopsychosocial phenomenon can take less priority to cancer, a biological entity. Although pain is a symptom of this baffling physiological process, it is the aspect that can lead us to seek help, it takes away our ability to move, it can increase fear/worry/stress and can hurt our relationships. We need to let individuals with cancer know that we are listening, that we can help them understand the what and why surrounding their pain, and that we can help them gain some control over something that is trying to take that control from them.
With regards to the brain: “All it has at its disposal is your past experience, the past experience it has wired into itself” A great quote from Lisa Feldman Barrett on how the brain works to make decisions throughout our day to day life (Interview here!)
But what does this mean for people where pain persists past normal healing time and is becoming chronic? How do your past experiences shape your current pain experience?
What Happened Before?
The brain is a phenomenal structure that drives everything we do. It receives an outstanding amount of information from your entire body in a fraction of a second, analyzes it at a ridiculous speed, tells us what action to do or not to do, and then briefly stores everything that just happened for possible future use. Beyond the fact that this happens without us even knowing, the fascinating thing is that if it keeps receiving the same information over and over, it becomes so fast and so great at analyzing the sequence, it typically has pinpoint accuracy in predicting what to do next. This is great when we are taking our next step while walking, or go to fall and are able to catch ourselves, but not so much when we are talking about pain sensitivity. So if you have been experiencing pain for a significant period of time, a major component can be that your brain is predicting things to be painful based on what’s happened previously (The Predictive Brain article here!).
The prediction of danger is a genius protective mechanism during the initial stages of healing when things need to be protected, but not so much when things are healed and life needs to return to normal. So once the danger is no longer present (i.e.,muscle/ligament is healed, cast is off etc…), thank your brain for trying to protect you, but start letting it know that it’s no longer necessary. The major question is how do you go about that? Here are a few tips: 1) Know that movement is safe and needed for healing. 2 )Pain is not a direct measure of tissue damage. 3) Keep moving within your limits. Somatic exercises can be a great place to start (Youtube One to One Wellness). Finding your limits can be difficult so seeking professional help is strongly encouraged. 4) Start loading. Our brain needs to understand that this area is capable of going under stress, and that it is safe to do so. Star with low intensity and go slowly to build up tolerance and confidence. 5)Have recovery time and sleep. Your brain and body need time to adapt to these increases in demand and it can only do so if you are getting adequate breaks and a good night’s sleep. 6) Take a look at what you are eating. There is truth to the old saying “you are what you eat”.
The changes will not happen overnight but when you provide new, SAFE experiences to help re-wire the predictive nature from danger to safety, we can change for the better.
Lisa Feldman Barrett is a neuroscientist, psychologist and author who researches how the brain constructs emotion.