Pain Neuroscience Part 5: How to Decrease Pain by Decreasing the Perception of Threat

There is one thing I have left out up to this point and it happens to be the single most important factor when it comes to my experience of pain; perceived threat. At the time of the accident, my entire being was under a large amount of stress and to the nervous system, stress equals threat.

I was in a high stress residency, a stagnant romantic relationship and a job that brought me no joy. I was putting my head down and getting through it but my body was likely experiencing the equivalent of running away from tigers with a headwind. Then the accident happened. It came out of no where. There was no time to react, no time to prepare and barely time to comprehend what had happened. When something so unlikely happens, you start living life on the edge, afraid the odds will be against you again any second of any day.

Then there were the doctors. They made sure I remained fearful for the rest of my life. There was the doctor that told me I would never be able to lift my eyebrow again and would need botox to even out the wrinkles on my forehead; the doctor that said I would never be able to smell or taste food ever again; and the one who told me to never ride a bike because I would immediately die if I suffered another head injury. Even my mom got into the mix. She told me I should have a cesarean birth for my theoretical baby because the pushing involved with natural labor would burst the “weak” blood vessels in my brain leaving my theoretical husband a single parent. Looking back on it, its painstakingly obvious I would be the 1 in 4 that would have chronic pain. RESEARCH has listed psycho-social yellow flags that predict who the 1 in 4 will be but the common theme is simple: threat perception. If you perceive threat, your nervous system will remain on high alert and you will have a heightened and prolonged experience of pain.

What I didn’t know then but I know now is this: once your injuries have healed, the first and only way to treat persistent pain is to eliminate the perception of threat. For five years I did physical therapy, acupuncture, massage, chiropractic, functional medicine, rolfing, cortisone shots, herbal and dietary changes. Sure, I got better in some respects. I returned to work and returned to some physical exercise but I was still in pain. I was functioning but I was functioning with pain. In some way, these treatments fed my perception of a threat. All of the tests, examinations and diagnoses made me think my pain was a sign something was still very wrong. The fact that even I couldn’t change my pain had to mean it was serious and beyond repair. I even went to a neurosurgeon. Yes, you read that right. I, Jenny Putt the physical therapist, went to a neurosurgeon. Thats how threatened I felt.

Then there was a shift. The first significant improvement in my pain came after I attended a lecture on neuroscience at a physical therapy conference. Remember how I have been saying that simply reading these blog posts and increasing your knowledge of how pain works decreases your pain? I’m a real life example of this but just incase you don’t want to take my word, RESEARCH shows it too. Why? How? Well once you know that your pain does not mean something is seriously wrong, once you learn that your physical injuries are healed and once you understand that it’s just your nervous system that is still on alert, the threat decreases. With a decrease in perceived threat, the nervous system starts to calm down and poof! your pain disappears.

Aside from pain neuroscience education, we have many other tools that have been shown to decrease the perception of threat, decrease the sensitivity of our nervous system and decrease pain. RESEARCH backs up the use of aerobic exercise, graded activity exposure, manual therapies, meditation, relaxation, diaphragmatic breathing, sleep, social interactions and humor as strategies to eliminate pain. This looks a lot different than our typical model of tests, medication and surgeries but thank goodness! Because the old model isn’t working all that great. The current narcotic epidemic is proof of it! Here are a few pointers from research so you can bulk up your tool box:

AEROBIC EXERCISE has been shown to improve sleep, improve motor function, improve memory, improve cortisol changes, aide the immune system, decrease chronic inflammation, decrease anxiety, decrease depression, improve mood and decrease nerve sensitivity. Aerobic activity is defined as working out at an intensity of 60-70% your age-predicted max heart rate (220 minus your age) but that can be intimidating when you have pain. The point is to get moving and the strategy of “kissing the pain” is best when it comes to returning to activity. Gradually increasing the distance and intensity while nudging the pain has been shown to have great results. The motto here is “hurt does not equal harm”. Start with 3-5 minutes at 50% of your max heart rate. Add 1-2 minutes every other day until you have worked up to 30 minutes. Then slowly start increasing the intensity to the goal of 60-70% your max heart rate.

GRADED ACTIVITY EXPOSURE has been shown to be just as effective as aerobic exercise in decreasing pain intensity and disability. So if you’re not much of an exerciser, pick an activity you want to return to and apply the same principle of starting slow, kissing the pain and gradually increasing amount and intensity.

SLEEP has so many benefits to our whole being and we just don’t get enough of it! Here are some strategies to help develop a more healthy sleep pattern: set a time to go to bed (before 11pm), stop using all screens (computer, TV, phone, iPad etc) at least an hour before bedtime, reduce fluid intake (especially alcohol and coffee) in the evening, darken and cool your bedroom, remove kids and pets from your bed, relax, meditate or read a book before bed, stay in bed even if you can’t fall asleep right away, eliminate naps or restrict naps to <20 min during the day and exercise during the day so you are more tired come night.

RELAXATION whether it be through meditation, diaphragmatic breathing or a trip to the spa, is key to calming the nervous system. The goal is to live more in the parasympathetic state (rest and digest) than the sympathetic state (fight or flight). This will look different for each individual. I am not a person that finds tranquility in meditation or yoga but being with family and friends or working on a puzzle puts me in a state of ease. Find whatever does this for you and do more of it.

OTHER THERAPIES including mobilization, manipulation, soft tissue massage and trigger point dry needling have been shown to be the most effective in decreasing chronic pain when used in combination with pain neuroscience education. So all of the time and money I spent seeing physical therapists, chiropractors and acupuncturists would have been more effective if education regarding my pain had been included.

The happy ending to this story and this series of blog posts is that most likely, some of your pain is coming from your brain and you can 100% change that. I still have pain when I’m stressed, sleep deprived, over committed, eating poorly and not moving. BUT that’s my fault. I can chose to not do these things. I can chose to be pain free. Thats some powerful sh*t.

Still have more questions about pain?

Want to see the research?

Kendall NAS, Linton SJ, Main CJ. Guide to assessing psychosocial yellow flags in acute low back pain: risk factors for long term disability and work loss. Wellington: Accident Rehabilitation & Compensation Insurance Corporation of New Zealand and the National Health Committee; 1997. Full text.

Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Archives of physical medicine and rehabilitation. Dec 2011;92(12):2041-2056. Full text.

Moseley L. Combined physiotherapy and education is efficacious for chronic low back pain. Aust J Physiother. 2002;48(4):297-302. Full text.

Van Oosterwijck J, Meeus M, Paul L, et al. Pain physiology education improves health status and endogenous pain inhibition in fibromyalgia: a double-blind randomized controlled trial. The Clinical journal of pain. Oct 2013;29(10):873-882. Abstract.

Louw A, Zimney K, O’Hotto C, Hilton S. The clinical application of teaching people about pain. Physiotherapy Theory and Practice. Jul 2016;32(5):385- 395. Full text.

George S, Wittmer V, Fillingim R, Robinson M. Comparison of Graded Exercise and Graded Exposure Clinical Outcomes for Patients With Chronic Low Back Pain Journal of Orthopedic and Sports Physical Therapy. 2010; 40(11):694-704. Full text.

Fulcher KY, White PD. Randomized controlled trial of graded exercise in patients with the chronic fatigue syndrome. BMJ. Jun 7 1997;314(7095):1647-1652. Full text.

Louw A, Zimney K, Puentedura EJ, Diener I. The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiotherapy Theory and Practice. Jul 2016;32(5):332-355. Full text.

Aure O, Nilsen J, Vasseljen O. Manual Therapy and Exercise Therapy in Patients with Chronic Low Back Pain: A Randomized, Controlled Trial with 1-Year Follow-up. Spine. March 2013: 28(6):5250531. Full text.

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