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.

Click here for a full list of articles on pain neuroscience

It was June 12, 2011. I was out on an evening walk when a very fast car decided to join my friend and I on the sidewalk. I will spare both you and myself the details of the accident and instead, focus on my nervous system and it’s interpretation of pain over the years…yes, years.

At the time of the accident there was significant tissue damage. Significant enough to warrant a large amount of pain however, I felt nothing. My brain had decided that the threat of my injuries did not outweigh the threat of the car that was still present and trying to reverse to flee the scene. So I quickly got up and ran out of harm’s way kind of like a super human.

Once out of harm’s way, my super human powers disappeared and I started to experience pain. Bummer. Simplified for teaching purposes, there are three nerves that pass a message from the injured tissue to the brain for interpretation. Peripheral nerves go from the body to spinal cord, in the spinal cord there is a small interneuron that acts as a gateway to the third nerve which is ironically called a second order neuron because medical terminology likes to be confusing. This second order neuron travels up the spinal cord to the brain where multiple areas go into the processing of the signal to determine what meaning the message has.

Upon impact, my injured tissues started sending signals through peripheral nerves to my spinal cord. At first, they were either stopped by the interneuron or my brain decided they weren’t a threat because a bigger threat (the car) was present. Once I was removed from danger, the messages were allowed to pass through and my brain interpreted them as the next most immediate threat so I started to perceived pain. At first, the pain experienced directly correlated to the extent of my injuries but over time, my pain became disproportionate to the tissue damage.

At first, my body’s top priority was to heal and in order to heal, the body must rest. Even as tissues started to repair, my nerves remained extra sensitive and my brain continued to interpret everything as a threat (pain) so I would minimize my movement and allow for further healing. Makes sense right? Now typically this protective pain will go away once the tissues have healed because it is no longer needed but 1 in 4 people will experience persistent pain long after the injury has resolved. I am one of those lucky people. Yay me! At first I thought this was just due to chance but knowing what I now know about pain, I believe this has nothing to do with chance and everything to do with the adaptations of my nervous system.

Let’s start with the peripheral nerves: the ones going from the body to the spinal cord. Nerves have a level of charge that must be met in order to send a message. If the threshold is met, the nerve will fire. Nerves reach their firing charge by allowing ions from the outside to the inside through ion channels. There are many types of ion channels that open or close in response to different stimuli. Some respond to chemicals (stress, immune, inflammatory) while others respond to mechanical stimuli like tension and pressure. Temperature also opens and closes ion channels. The more ion channels that are open, the more likely the nerve is to fire. With my original injury, the mechanical impact and the inflammatory response opened more than enough ion channels for nerve firing. Ion channels are only present where there isn’t myelin (a sheath that improves the speed of signaling). Over time, inflammatory chemicals can demyelinate nerves allowing an increase in ion channels and a perpetually more sensitive nerve long after the inflammation is gone. So fast forward a few months and even a few years, my nerves still have increased ion channels and still reach their firing threshold more easily. I experience pain when I’m sick, when I’m stressed and even when I’m cold all because there are more ion channels.

Moving on to the spinal cord where the peripheral nerves meet interneurons before going to the brain for interpretation. If this interneuron is bombarded by messages, it will die off. This eliminates the gate keeper of messages and allows all of them to get to the brain easier. I’m pretty sure my interneurons were obliterated. My injuries took a really long time to heal on a tissue level which meant a lot of messages were sent for a long time. The brain can also ease the passing of messages from the body through the spinal cord if it believes there is a threat. The brain becomes more interested in the danger signals and will therefore increase nerve sensitivity by keeping ion channels open longer so it can receive more information more often. For good reason, my brain perceived threat for a long time so it likely made it as easy as possible for messages to pass through.

Another thing to note is that the nervous system is messy in its organization and adaptations. These changes occurred at the nerves corresponding to the areas that were injured but there is crossover in representation of an area as the nerves enter the spinal cord and within the brain. As a consequence, the area of my perceived pain spread over time. Not because of further tissue damage but because the adaptations of my nervous system and the interpretation of where the signals were coming from are not precise.

Just like the rest of the nervous system, the brain is also adaptable. When an area of the body is used more or generates a disproportionate amount of signals, the representation of that area in the brain will grow and borders of it will become less defined. This is another reason why pain can go from being isolated to the injured tissues, to being more diffuse.

All of the magic really happens in the brain. Up to this point, all messages are just an electrical signal traveling down a nerve. It’s the brain that gives meaning to this electrical charge. It’s the brain that decides whether the message is pain, a different sensation or not worthy of any feeling at all. Many areas of the brain participate in this decision making process. The areas for sensation, emotions, memory, cognition, movement planning and stress response have all been shown to be activated during the experience of pain. This complex interaction varies for each individual and each pain experience. The specific pattern of activation is called a neurotag. Other experiences and memories also have their own neurotag. The more often a neurotag is used, the more it becomes reinforced and the easier it will be accessed. This is where the phrase “its like riding a bike” comes from. The more we practice something, the easier it is to do automatically and this can occur with a movement, a memory or the experience of pain. Specific movements and activities had become so strongly associated with the experience of pain within my neurotag that even after my body healed, these movements still generated pain.

So with all of these adaptations, am I destined to be in pain for the rest of my life because I am literally wired to experience more pain? For years, the answer was yes but once I started learning about pain neuroscience, the answer became heck no. If the nervous system can adapt in one direction, it is also capable of reverse adaptations and the key to this switch is actually quite simple. It all lies in the perception of threat.

Stay tuned for the final post of this series: How to Decrease Pain by Decreasing the Perception of Threat.

Want to see the research?

Louw A. Why Do I Hurt? A Neuroscience Approach to Pain. Minneapolis: OPTP; 2013. Textbook.

Moseley, G.L., A pain neuromatrix approach to patients with chronic pain. Man Ther, 2003. 8(3): p. 130-40. Full text.

Melzack, R., Pain and the neuromatrix in the brain Journal of Dental Education, 2001. 65: p. 1378-1382. Full text.

Woolf CJ. Central sensitization: uncovering the relation between pain and plasticity. Anesthesiology. Apr 2007;106(4):864-867. Full text.

Moseley GL. Reconceptualising pain acording to modern pain sciences. Physical Therapy Reviews. 2007;12:169-178. Full text.

Gifford LS. Pain, the tissues and the nervous system. Physiotherapy. 1998;84:27-33. Full text.

Woolf CJ, Salter MW. Neuronal plasticity: increasing End the gain in pain. Science. Jun 9, 2000;288(5472):1765-1769. Full text.

Click here for a full list of articles on pain neuroscience

Injury doesn’t always result in pain.

Simply put, the nervous system is an alarm system. But it’s not entirely that clear cut. Let’s say you were crossing the street and sprained your ankle. Ordinarily this would hurt but let’s also say a large bus is coming toward you. Would your ankle still hurt? The answer is of course not! In this situation, it would not be smart for the brain to produce pain because it would hinder your ability to get out of the way of the bus. The brain would decide that the bus was a bigger threat than the ankle sprain and would therefore not send the signal of pain. This is how people with a broken leg can escape a burning car. This is also why some people don’t feel their pain until after they have stopped working, gardening, playing etc.

You can also have pain without injury.

The brain evaluates all threats, not just tissue damage. Nerves have receptors for temperature, stress, blood flow, movement, pressure and immune responses. A change in any of these can be interpreted as a threat and thus cause pain in the body. This is why people experience more pain in colder temperatures, with stagnant postures, during times of high stress and when you are fighting off the common cold.

Everyone’s pain experience is different.

Have you wondered why you are the one that ended up with chronic pain while your friend Sally who was in the same car accident with the same injuries walked away pain free? Every brain is different and processes pain differently. It has been shown that multiple areas of the brain are involved in a pain experience. These areas include those responsible for sensation, movement, focus, concentration, fear, memory, motivation and stress. Each of these areas communicate with each other to discuss and determine the appropriate action. Its like a board meeting takes place to discuss the danger messages. If it is decided that there is a threat and an action is required, pain will be produced to protect you. The members of the board and the decision made will be different for each individual.

Aside from the brain, people experience injury in very different life environments. Someone who is in a car crash during a happy time in life will have a lesser pain experience than someone going through a divorce and layoff. Stressful life environments produce stress chemicals throughout the body that will cause the nervous system to wake up quickly, be extra-sensitive and take a long time to calm down. This is why people who get injured at work (especially at stressful jobs) have slower recoveries than someone injured at a soccer game or a destruction derby driver who crashes cars for fun.

It’s complicated.

My point here is that it is complicated. Pain is not as simple as you have an injury, it causes pain, the injury heals, the pain goes away. Confused yet? Don’t worry, you’re not alone! This very fact makes my job a million times more difficult! But the great news is this: research has proven that simply knowing pain is complicated, can and likely will reduce your pain if you are experiencing pain for reasons other than damaged tissues. Thank goodness!

Want to see the research?

Louw A, Puentedura E. Therapeutic Neuroscience Education: Teaching patients about pain. Minneapolis, MN: OPTP; 2013. Textbook.

Moseley, G.L., A pain neuromatrix approach to patients with chronic pain. Man Ther, 2003. 8(3): p. 130-40. Web. FULL TEXT

Gifford LS. Pain, the tissues and the nervous system. Physiotherapy. 1998;84:27-33. Web. FULL TEXT

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. Web. FULL TEXT

Click here for a full list of articles on pain neuroscience

A little bit about nerves…

There are 400 individual nerves (about 45 miles worth) in the human body that act as an alarm system. At all times there is a little bit of electricity traveling through each of them. Various factors including stress, movement and temperature can make this level of electricity go up or down.

Each nerve has a threshold. When a nerve gets excited enough to reach this threshold, a message will be sent to the brain for analysis and possible action. So let’s say you lift something way too heavy with horrible form. The alarm system will go off and you will react by dropping the box…maybe even hire someone else to do the moving. Once the message has been sent and you have responded, the nervous system should return to its normal resting state. However, in 1 out of 4 people, the alarm system gets activated and then rests just below the threshold rather than returning to its original resting state. This is an extra sensitive nerve.

Having extra sensitive nerves is quite common but not normal. It can significantly impede activity and function. When the nervous system is at its normal resting level, there is a lot of room for activity before reaching the threshold. For example, you can sit in a car for hours before your nerves send the signal to stop, get out of the car and stretch. Then they return to normal and you can drive for a few more hours before another signal would be sent.

After hurting your back lifting, the nerves have become extra sensitive so now there is very little room for activity before the alarm system goes off. You find that you can only sit for 5 minutes before you need to get up. And this occurs even after the tissues in your back have healed from your original injury all because the nervous system hasn’t returned to its normal resting level. 

How do I know if my alarm system is extra sensitive?

If you look at your own story it will become clear. Perhaps all diagnostic tests have come back negative but you’re still in pain. Maybe doctors keep telling you everything looks fine but you still can’t do nearly the amount of activities you used to do without consequences. Parts of your body not originally involved may all of a sudden start hurting as well. Small activities, movements and even light touch have become painful. These are all signs that your nervous system is on high alert. If you have been prescribed anti-depressants or nerve inhibitors, your physician agrees!

Why do nerves stay sensitive in some people while in others they calm down?

Two people with the same injury can end up in entirely different situations. One may be fine a week later while the other suffers from chronic pain for the rest of their life. How come? The sensitivity of your nervous system depends on many factors going on in your life. These include but are not limited to failed treatments, family issues, levels of fear, concerns about your job and even being given different explanations of your pain. Someone who has job satisfaction, healthy relationships, good sleep, a balanced diet and a clear treatment plan given by passionate health care providers will have a better chance of being pain free when compared to an individual who is sleep deprived, stressed, jacked up on sugar and worried about their prognosis.

What calms nerves down?

The short answer: A LOT! The coolest part is that just by understanding the concept of nerve sensitivity, you are already on your way to decreasing it. Research shows that if people understand more about their pain, the alarm system immediately starts turning down its sensitivity. This makes complete sense don’t you think? The alarm system is kept on high alert for good reason when there are more questions and concerns than answers and reassurances. By understanding that your pain is likely due to sensitive nerves rather than damaged tissues, fear is reduced and in turn, nerves are calmed. Research also shows that oxygen and blood flow, through aerobic activity, can help calm the nervous system. This includes a brisk walk, swim, bike ride or pretty much anything that gets you breathing a little hard and sweating a little bit. So nothing too crazy! But the easiest strategy of them all is something we do all day long: breathing. Diaphragmatic excursion has been shown to calm the whole nervous system down. The only trick is learning how to breath the right way. Don’t know how to breath right? No worries, that’s what I’m here for. Stay tuned.

Want to see the research?

Adriaan Louw, Ina Diener, David S. Butler, and Emilio J. Puentedura. “The Effect of Neuroscience Education on Pain, Disability, Anxiety, and Stress in Chronic Musculoskeletal Pain.” Archives of Physical Medicine and Rehabilitation 92.12 (2011): 2041-056. Web. FULL TEXT

Kirsten R. Ambrose, and Yvonne M. Golightly. “Physical Exercise as Non-pharmacological Treatment of Chronic Pain: Why and When.” Best Practice & Research Clinical Rheumatology 29.1 (2015): 120-30. Web. FULL TEXT

Daniela Roditi and Michael E Robinson. “The Role of Psychological Interventions in the Management of Patients with Chronic Pain.” Psychology Research and Behavior Management 4 (2011): 41–49. Web. FULL TEXT

Click here for a full list of research articles on pain neuroscience

Pain neuroscience education can be a sensitive topic. The big underlying message of it all is that our brains determine whether or not we feel pain. This statement pretty much takes everything we thought we knew and throws it out the window. For years I have treated musculoskeletal tissues under the notion that they were responsible for causing pain but maybe this isn’t always true. Pain neuroscience theorizes that the experience of pain is not caused by the injured tissue but rather by how our brain interprets messages sent from the nervous system. Mind. Blown. And yes, pun intended.

Where this topic can become a little offensive is how this new information is perceived. I am by no means saying that people make up their pain and I don’t think pain is all in people’s heads. Pain is real, no matter where it is coming from. Pain neuroscience is not discrediting people’s experience of pain BUT it does provide an explanation for why pain sometimes doesn’t go away even after the original cause has been resolved.

Let’s Start With a Little Story About Me…

I want to start with a personal story so that no one feels alone with the idea that your brain might be playing more of a role in your pain than your muscles or bones. It will also explain why I have become so interested in the topic.

I have chronic pain. 

It’s hard for me to admit to that. Its like going to a marriage counselor and finding out they have been divorced 10 times. But I think its time for me to look at my pain in a different light. It allows me to relate to all of my patients and for that, I believe I am a better physical therapist. So lets just agree that no one will ask me about my pain during their treatment time. Agreed? Cool. 

For many years I was at a plateau and I had tried EVERYTHING. Or so I thought. On many occasions I viewed myself as a failure in that I couldn’t fix my own pain. But then I went to a lecture on neuroscience and my entire perspective changed. Could my brain be the reason that I couldn’t change my pain? I started being more aware of my flare ups as they related to my emotional state. It soon became obvious that fatigue and stress definitely made my pain worse. My entire approach to my pain needed to change. Things like sleep, nutrition, exercise, meditation and even trauma counseling became my focus and my home exercise program. Today, I am by no means pain free but each time I have a flare up, I can always come up with an explanation for why I am in pain. This alone helps the flare up be shorter in duration and less intense (I will support this with research in a later post).

I am not sure how many parts there will be to this series, nor do I know how long it will take me to completely cover the topic, but here is a little preview of whats to come: how does the brain contribute to pain, how pain neuroscience education can actually decrease pain, other ways of managing pain when the brain is contributing, and lots of research articles to support all of it. If you have any questions along the way, feel free to contact me here.