I've been reading The Brain That Changes Itself by Norman Doidge (His website is http://www.normandoidge.com/). The book's central theme is research into neuroplasticity, and it's application in therapy. I'm sure I'll be bringing it up again after I've finished it, but last week I finished the chapter on pain, and I have to say, it's brought into focus a couple of ideas I've been thinking about for quite some time, and radically changed another.
Research on neuroplasticity seems to be based largely around techniques to image and map the superficial structure of the brain, neuron by neuron. What they've found is that everything we do and feel is organized into "maps" that shift dynamically with use and learning. When we learn something new, our neurons grow new branches and the map grows accordingly. Adjacent maps can overlap, merge, or shrink to accommodate growing maps.
As a massage therapist, I see a lot of people in pain of various kinds. One of the hardest questions to answer is how long it will take for them to get better. Everyone's experience of pain is a little bit different, and their response to treatment is just as variable. Pain appears to be a learned experience, and I notice that generally the longer someone's been in pain, the longer it takes to get them out of it. Neuroplasticity explains this as enlargement of their pain map. Pain appears to be one of the most plastic of maps and can change moment to moment depending on our need. In other words, pain is a learned experience.
Now in the short term, the pain map "borrows" neurons from adjacent maps. If the pain subsides, the map goes back to its "resting" state taking up very little space. If the pain becomes chronic, there's potential for the map to take up residence in the borrow neurological real estate and the pain sufferer becomes over sensitized to their pain experience. They also lose the use of the borrowed neurons as they are too active in the pain map to continue with their original function.
Chronic pain suffers will often complain of their suffering "taking over their life", and from a neuroplastic perspective, this is quite literally true. I start to consider that fibromyalgia in particular might be a neuroplastic disorder. Something I've seen fairly consistently in my patients with fibro, is there's usually an underlying, often undiagnosed musculoskeletal pathology (often osteoarthritis, or spinal stenosis), or a long forgotten minor injury (ie. a fender bender that never went to insurance, or a fall down stairs or on ice). In the past I've thought that this might invalidate the fibro diagnosis, but after reading this chapter of the book, I'm thinking that the fibro might be a result of the expanded brain map.
Earlier in the book, there's a chapter on stroke in which patients are able to recover damaged neural functions (and limb movement) through exercises that give the patient small, achievable goals to help restructure the maps for their limbs and regain coordination and mobility.
Two things would appear to be necessary to treat chronic pain. First the patient needs to have their experience of pain reduced. This could be done with manual therapies (massage, chiropractic, physiotherapy, acupuncture for example) or through pain medication. The next think we need to know is what's been lost. I've been thinking it might be things like balance, fine motor control, reading, problem solving. If the patient exercises these kinds of functions while their pain experience is reduced, the reduced neural maps can reclaim their space. Over the course of treatment, pain experience returns to normal and the patient can get back to making the most of their life.
The biggest change in my perception of pain treatment is the role of pain killers.
In the past I've said (as most body workers that I've met do), that pain killers don't fix anything and shouldn't be used to replace manual therapies. I've recommended only using them when there's intense need. If neuroplasticity is correct, then it's essential that people spend as little time in pain as possible, to keep that expanded brain map from becoming fixed (in the case of acute injury) or to allow the surrounding brain maps to reclaim space (in the case of chronic pain). And lets face it, few people can get a massage daily. So it make sense to use over the counter pain medication in between.
I still think that engaging in lifestyle exercise (meditation, yoga, tai chi are all good examples of what I mean) is a better long term strategy. But short term use of pain management medication combined with manual therapies to help any underlying muscle and joint dysfunction could very well be the best course of treatment.
Hopefully I've done this topic some justice. For more information, pick up the book!
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