Pain. Persistent pain. Let’s begin this blog of all-things-pelvic with the broad broad topic of pain. Although pelvic pain is where I spend most of my time, I will argue for the moment that pain is pain is pain, and for my first teaching point, announce that no matter where your pain is felt, it is 100% of the time a creation of your brain. Your knee pain is happening in your brain. Your back pain is happening in your brain. Your pelvic pain is happening…in your brain. And with some persistence, it can become wired into your central nervous system.
Dr. Lorimer Mosely, in a very compelling Ted Talk (2011), explains exactly why things hurt. He begins by describing a time when he was walking in the bush (yes – he’s Australian), and the skin of the outside of his right foot encountered something sharpish, which elicited a slight hiccup in his gait.
In that moment, neurobiology teaches us that a super-fast nerve pathway shot a message from his foot to his spinal cord and quickly up to his brain, telling the brain what has happened, in effect asking the brain to determine if there is any real danger. Simultaneously, a slower pain pathway delivered information regarding the intensity of that stimulus. The brain, considering all this information, reasons that there is no real danger – probably just a twig – because in the past this scenario has always been created by a twig. The brain issues a quick hitch in Dr. Moseley’s step in order to get rid of the twig. Um – except the twig was actually a deadly snake bite that nearly killed him.
Six months later, our bush walker returns to the scene of the crime, only to encounter an actual twig, but this time his brain prematurely guesses SNAKE!!! and produces a white hot poker pain, causing our friend to howl in agony. The pain in these two scenarios is different, because the interpretation by the brain is different.
Pain is an OUTPUT OF THE BRAIN, and overtime, usually as a result of some traumatic event, some of us get better and better at producing pain, requiring less and less intensities (from snake bite to twig encounter to the brush of a feather) to get it going. We become more sensitive – and not in a good way – because our neural circuitry has lost its capability to feel things specifically as they are, blending many different kinds of sensations into one – PAIN.
Touch is pain. Stretch is pain. Pressure is pain. Temperature is pain.
The thought of pain is pain.
Pain is no longer a response to danger. It’s becomes a defense against the possibility of danger. When there’s no actual danger, this is not helpful. Especially when life is mostly (hopefully!) just throwing us twigs.
What I’m trying to say by enlisting the help of Dr. Mosely’s TED talk is that your beliefs matter. For those of you suffering from persistent pain, let me ask you a few questions that can help determine the probability of your pain being centrally generated. Do you have any of the following thoughts?
- I worry all the time about whether the pain will end
- It’s terrible and I think it’s never going to get any better
- I become afraid that the pain will get worse
- I keep thinking of other painful events.
- I wonder whether something serious may happen
These beliefs can keep us from moving as much as we used to and being in the world in a way that brings us happiness. And the less we move and the less we connect with the world in a meaningful way, the more pain we can end up feeling. In fact one recent study indicates the possibility that becoming sedentary (as pain can cause us to do), creates pro-inflammatory chemicals in the body that can lead us to feel even more pain; while on the other hand, exercise can lead to the production of anti-inflammatory chemicals and less pain (Leung, Gregory, Allen & Sluka, 2016).
Here’s the deal. Yes, we get hurt. Tissues get injured. But they heal almost all of the time in 3 to 4 months. Any pain we experience after that is more than likely a projected experience of the brain, wired into our circuitry. If you are in pain right now, pain which has persisted for more than 3-4 months, you probably are not buying what I’m selling. You may want to tell me that your pain is real and legit. I agree. It is. And yet what I am trying to say is that the generator of your pain may not be tissue damage in your knee, back, pelvis or fill-in-the-blank. It may be the result of an old “snake bite”that got you six months ago – playing like a broken record – in your central nervous system.
Wait a second! Am I telling you this is all your fault? No. I’m telling you that we are all human. We have negative experiences and become fearful that they may happen again. We become vigilant, and that’s not a bad thing. Caution mixed with experience is practical and sensible. That cocktail, however, can go on for too long. More than needed. With an end result of centrally generated pain. A life less lived. An increasingly sedentary existence that can lead to new pains induced by pro-inflammatory chemicals, stiffness, and weakness. It can be difficult to find a way out.
Here are some potential solutions (briefly described now – to be explored more deeply in future posts) for a centrally generated pain problem.
Number 1: Move.
Shock, horror! A physical therapist just told you to move! (Wouldn’t a surgeon say operate? A chiropractor say manipulate? A nutritionist change your diet?) Mea culpa. But yes. That is my answer to most questions, and here’s what I’m banking on. Exercise can boost your immune system (due to less non-movement-induced inflammation). Exercise can induce a state of hypoalgesia (less sensitivity to painful stimuli). Exercise can improve your mood. Exercise can increase your social interaction – a known contributor to wellness. Exercise can improve other things too – like cardiovascular fitness! It’s all good! (So long as you begin and progress carefully.) And if it isn’t – might I suggest seeing a physical therapist?
Number 2: Meditate
In a recent pilot study, women with chronic pelvic pain showed benefits in daily pain scores, physical function, mental health, and social function after 8 weeks of mindfulness meditation (Fox, Flynn, Allen, 2011). Here are some very simple instructions on How To Meditate to get you started. The gist of it is: let’s get present with what is really happening in our minds and in our bodies. We can rewire this central nervous system of ours. We can rediscover all of our distinct sensations as they truly are and take a closer, more conscious look at the things we are telling ourselves. Which thoughts are helpful? Which are not? What do we want to do about it?
Number 3: Consider stress
Okay, now let’s work on stress – a known facilitator of all things painful and uncomfortable. Let’s decrease the time we spend in fight or flight. Let’s calm down our nervous systems. Let’s decrease our cortisol levels. Here it comes, folks… Let’s try yoga! Yes, the yoga teacher is now telling you to do yoga. And yes, this solution could have been covered under movement, but it definitely works here as well. If you are interested in yoga, you can try this relaxing yoga sequence Don’t like yoga? What do you like to do? Do that. Lift. Stretch. Walk. Dance. Just have some fun! It will decrease your stress level. But if it’s been awhile since you exercised, once again – begin and progress cautiously. Or go see your friendly physical therapist for help.
Movement is a great way to decrease stress (so is meditation), but also, we might want to think about reframing stress. Kelly McGonigal, Stamford researcher and psychologist, believes that we need to get better at embracing the stress in our lives (TED Blog, 2013). In fact, the better we get at doing stress, the better off we may be. She says that even the belief that stress is bad for your health actually increases mortality levels (our risk of dying). Hang on – but we all know stress is bad for us! Chronic and traumatic stress contribute to illness, depression, early mortality… Well, it turns out that stress is sort of like a Zen Koan – two opposite things being true at the same time. Stress can be both harmful and a jumping off point to greater health. Faced with these two truths, McGonigal encourages us to view our stress more positively and learn to thrive. She suggests the following strategies:
- view the way your body responds to stress as helpful
- believe that you can handle the stress, learn from it, and even grow
- know that you are not alone – we all have stress
In McGonigal’s words, “How you think and how you act can transform your experience of stress. When you choose to view your stress response as helpful, you create the biology of courage. And when you choose to connect with others under stress, you can create resilience.” To listen to her talk, check out How to make stress your friend.
To summarize, if you’ve had pain for more than 3 to 4 months, please consider that it may be more a defensive strategy of your brain than a response to an actual injury at this point. Take note of the thoughts you have about this pain. What do you tell yourself about this pain? Imagine reframing the stresses in your life – perhaps seeing them as stepping stones to building resilience. Consider meditating and inviting more movement into your life. Most importantly of all – in my humble and well-meaning opinion – connect, connect, connect. Reach out there and make your world bigger, so that pain becomes only a small part of a big life and not a big part of a small life.
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Fox, S. D., Flynn, E., & Allen, R. H. (2011). Mindfulness meditation for women with chronic pelvic pain: A pilot study. Journal of Reproductive Medicine, 56 (3-4), 158-162. Retrieved from: https://www.researchgate.net/publication/51098297_Mindfulness_Meditation_for_Women_with_Chronic_Pelvic_Pain_A_Pilot_Study
Leung, A. G., Gregory, N.S., Allen, L. A. & Sluka, K. A. (2016). Regular physical activity prevents chronic pain by altering resident muscle macrophage phenotype and increasing interleukin -10 in mice. Pain, 157 (1), 70-79. doi: 10.1097/j.pain.0000000000000312.
PCS-EN. (1995). Retrieved from http://sullivan-painresearch.mcgill.ca/pdf/pcs/Measures_PCS_Adult_English.pdf
TED Talks. (2011). Lorimer Mosely: Why things hurt. Retrieved from https://youtu.be/gwd-wLdlHjs
TED Blog. (2013). The upside of stress: Kelly McGonigal at TEDGlobal 2013. Retrieved from http://blog.ted.com/the-upside-of-stress-kelly-mcgonigal-at-tedglobal-2013/