MIND OVER MATTER: USING THE BRAIN TO MANAGE PAIN EFFECTIVELY

Chronic pain is estimated to affect up to 25% of the world’s population at any given time and contribute towards several of the leading causes for disability^[1].

Over the last couple of decades, researchers have been exploring the connection between the brain in creating and moderating the way in which we feel pain. Pain is discussed below in the context of the brain and body, with further insight into how the mind can be used in order to effectively manage pain.

What is Pain?

“Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” - International Association for the Study of Pain

The processes working behind the scenes to produce pain mimic our experience of it. At the micro level, pain is a collection of cellular signals that serve to coordinate an appropriate response towards a harmful stimulus. These signals begin in the body at the site of the pain. Local cells release substances that activate pain receptors, known as nociceptors. The signals get converted into nerve impulses and are sent off to the brain for further processing.

Nociceptors can be triggered by acute or chronic stressors, chemicals, extreme temperatures, or mechanical pressure. Chronic illness and tissue damage at the cellular level can also trigger nociceptors in any of these fashions. Signals of pain alert multiple systems of the body, which respond accordingly. All systems involved inform one another and operate simultaneously to generate the sensation of pain.

Pain feels unpleasant and is also synonymous with unpleasant emotion. Like physical pain, emotional pain is also a sign of damage to the psyche, highlighting the need for resolution. As similar systems of the body are involved in mediating these two types of pain, they often feed into one another to reinforce cycles of chronic pain.

The Impact of Chronic Pain on the Brain and Body

Chronic pain is an aspect of almost all forms of disease. It is perpetuated through pathological cellular processes, often arising from the primary site of disease.

The nervous system is perhaps one of the most pertinent aspects behind the biology of pain, as it governs pain perception and houses a potent tool: the mind. Often, the mind forms a critical component of pain-related diseases, able to trigger and perpetuate physical pain. However it may also exert a positive influence on the outcome (more on this below).

The immune system and the cardiovascular system are two other very important aspects to consider, playing intimate roles in the onset, resolution and perpetuation of pain.

Pain Perception and How the Brain Processes Pain

Pain perception is mediated by the nervous system. Signals from the periphery reach the brain via the spinal cord. Both the brain and spinal column play important roles in processing and mediating the sensation of pain.

Chronic Pain Builds Neuronal Networks

When we respond to something in a certain way, nerves are required to fire in a certain pattern in order to mediate the lived effect. If the response is repeated, the nerves begin to form a network, wiring together in order to increase the efficiency of future firing. The network gets stronger every time it’s used.

For the same reason, we get better at a skill when we practice. This extends towards our thoughts, feelings, behaviors, and responses to all things. This enriches our experience and serves to expand upon what we know.

Pain forms a very important part of our development, as it allows for us to know if something is harmful. It is not possible to avoid pain. However, the way we respond to pain is the same as a learned skill that builds a neuronal network in the brain.

There are roughly six key brain areas involved in pain processing, including the somatosensory cortex, insula, anterior cingulate cortex, prefrontal cortex, thalamus and brainstem. Other brain areas may wire into pain networks depending on the pain-related associations of the person. Studies highlight that sensitivity towards pain is higher when there is more connectivity between brain areas involved in pain processing^[2], which increases every time we experience pain.

In a situation where one is exposed to chronic pain, the networks governing the transmission of pain amplify^[3] as the brain frequently anticipates future harm. Eventually, the brain becomes very sensitive towards any signals that may represent the presence of a trigger. Once triggered, the brain is able to generate the sensation of pain in the periphery through instructing the spine.

Many signals in the body contribute towards generating pain, and a lot of these signals overlap with general inflammation and other factors (see immune and cardiovascular systems below).

Personality is involved in Pain Processing

Studies suggest individuals with a  resilient personality  may be less prone and may experience less intense symptoms by comparison to those that might not as resilient^[4].

One of the prime sites of the brain that are involved in generating the personality of a person is known as the insula. Many neurons pass through the insula to get to other regions of the brain. The insula helps to maintain a variety of neural processes, including pain in the body and our basic state of consciousness. These processes pertain to personality and shed light on the way in which the body and our environments condition who we are as individuals.

The prefrontal cortex is a brain region known to regulate the insula. It processes signals associated with self-reflection, cognition and logical reasoning. Studies suggest that the prefrontal cortex can be used to intervene in pain perception by reducing the communication between the areas involved in processing pain, including the insula.^[5]

The Connection between Pain, Panic and Resilience

Pain is known to activate an integrated stress response that serves to minimize damage and coordinate an appropriate immune response towards a harmful stimulus. This response increases the level of norepinephrine in the brain, which increases arousal, neurological activity and the “fight or flight” response.

Likewise, the stress response is capable of triggering pain. Chronic stress is largely linked with tissue damage, which triggers nociceptors^{[6] [7]}, increases sensitivity towards pain and can promote chronic pain as a result.

Following on from the involvement of personality and resilience in pain processing, the way in which one responds to stress largely affects one’s resilience as a person. As pain is closely related to stress in the brain, the two often wire to fire together. For many, severe stress can even seem to produce a different personality; one governed by stressed or rash behavior, anxiety and excessive or illogical rumination.

Stress reduces the ability for logical reasoning, cognition and self-reflection, by promoting reductions in brain-derived neurotropic factor (BDNF). This affects the ability of the prefrontal cortex to intervene and tone down pain processing in the brain. It also helps to incorporate disease symptoms, pain and panic into one’s identity; increasing the tendency to exaggerate perceptions of pain and triggering pain more often.

Psychological resilience that serves to reduce stress and enhance humor has been proven to ablate pain in some individuals with chronic pain disorders.^[8]

The Spine as an Extension of the Brain in Pain Processing

The spine is an extension of the brain that coordinates and regulates many responses in both the brain and body.

Signals of pain are first processed in the Dorsal Horn of the spine before the spine transmits them to the brain. Likewise the response from the brain first reaches the spine, before being transmitted to the appropriate body compartment. ^[9]  The spine is capable of amplifying or toning down the signals of pain that reach the brain or that get transmitted to the body.

As in the brain, neurons in the spine fire and wire together, which serves to form networks that strengthen over time. Chronic pain has been documented specifically to alter the shape of the neural connections in the spine^[10]. These are believed to increase pain sensitivity and amplify the response to pain. As the spine is subject to many inflammatory and other pain-related signals in the periphery, it is often involved in perpetuating cycles of chronic pain in response to abnormal stimuli.

The spine is also central to the ability of the brain to drain toxins in cerebral spinal fluid that may promote signals of pain. The brain’s blood supply passes through the spine first, making it a sensitive area for nutrient transport. It also contains its own blood barrier, which filters out unwanted substances from reaching the brain. Many who suffer from chronic pain often find that some portion of the spine also suffers symptoms, such as bad posture, back pain and stiffness.

Pain before Touch

The sensation of pain and touch are closely related, yet are processed separately. The brain processes pain roughly 60 milliseconds before processing sensations of touch^[11].

It is believed that this helps to compensate for the slow conduction of pain in the spine and periphery, so that the two responses can be coordinated together. It also helps the brain to mobilize automatic reflexes in the body very quickly in response to painful stimuli.

In this way, the brain can contribute towards increasing sensitivity towards touch and other sensory stimuli.

Pain in the Immune System

The immune system responds to pain by generating inflammation in an attempt to resolve the cause. Inflammatory signals alert immune cells and cells near the damaged area how to respond. In chronic pain disorders, inflammatory immune signals are able to trigger pain through association.

Several means by which the immune system is able to trigger pain include:

• Neuronal Immune Cells are involved in activating areas of the brain involved in pain processing.^[12] They respond to inflammatory or pain-related signals from either the brain or bloodstream.
• Mast Cells are a prime type of immune cell involved in responses pertaining to sensations of pain^[13]. They are involved in mediating the sensation of an itch^[14], of allergic reactions such as rashes and in wound healing. As they have the ability to cross the blood-brain barrier, they can trigger inflammatory responses in the brain that can serve to perpetuate pain in the body^[15]. Those with allergies, chronic infections or stress disorders are at an increased risk for chronic mast cell activation and resultant pain.
• Intense Negative Emotion has been linked to increasing  the intensity of pain in those with chronic pain^[16]. Inflammation and immune suppression are known to trigger emotional reactions which can promote pain. Positive emotion and cognitive control over emotion can reduce inflammation^[17] and are associated with reducing pain perception.
• Neurotransmitters. The immune system can make use of serotonin and other neurotransmitters in order to coordinate immune responses. These directly communicate with the nervous system, and may serve as triggers for various types of pain, including emotional pain.
• Immune Suppression. Pain triggers the release of stress chemicals, which serve to block inflammation^[18] and temporarily suppress the immune function^[19]. This helps lessen the severity of pain in the short run, yet promotes tissue damage and promotes chronic pain in the long run.
• The Vagus Nerve is a prime intersection between the nervous system, gut and immune system. It is largely responsible for regulating stress, anxiety and tension in the body. Gut problems can often trigger other types of pain in the body via the vagus nerve^{[20] [21]}; highlighting the importance of consuming a balanced, nutrient-dense diet plan.

Cardiovascular Contributions to Pain

Blood cells improve the function of all cells and tissues through providing essential nutrients and oxygen. The brain has an extensive blood vessel network and takes up a large portion of the body’s oxygen supply in order to function optimally. The same can be said of other nutrients delivered to the brain, in order to sustain the high energy demand of the central nervous system.

Platelet-activating factor is produced by blood platelets and immune cells. Aside from activating blood platelets for wound healing, it is known to drastically increase sensitivity towards pain in the skin and spine^[22]. Elevations in serum platelet-activating factor are seen in several disease states, including blood-clotting disorders, asthma, some types of cancer, stroke and myocardial infarction.^[23]

Gender Differences in Pain Processing 

Females get chronic pain disorders more on average. This is partly due to having an increased risk for acquiring autoimmune diseases and being exposed to more stressors on average. Men also tend to have higher levels of brain estrogen by comparison, which protects against inflammatory brain signaling.

When men contract pain disorders, the symptoms are frequently worse than as seen in women. This is attributed towards hormonal differences, as female hormones are more anti-inflammatory.

Biopsychosocial Pain Management

Biopsychosocial pain management refers to managing pain through natural interventions that help to balance mind and body.

These have proven to be far more effective at managing pain in the long run than using prescription medications. However, biopsychosocial pain management does not treat chronic pain disorders, it merely enhances the quality of life through improving one’s ability to live with pain.

1. Cognitive Control Over Pain, Stress and Persona

Perceptions of pain are involved in the way pain is experienced, including the intensity of it. As pain typically triggers a stress response, it can be difficult to tone down the intensity of a painful experience. It’s the stressful component of pain that makes one learn to avoid things that cause us harm. If one anticipates harm and it causes one to become stressed, this may be able to trigger pain and/or increase one’s sensitivity towards painful stimuli.

To a certain extent, we have an influence on how we perceive pain and how pain ought to shape our personality and experience. The stress component of pain is emotionally akin to that of suffering, which serves to intensify our experience. Focusing on pain tends to increase one’s sensitivity to it and intensifies the feeling. Anticipation is a form of focus that is capable of producing the same result ahead of time, before pain is experienced.

While it is very difficult to tone down the response from the brain during an event of acute pain, one can use the mind to lower the intensity of pain and prevent unnecessary pain amplification. The most effective strategy would be to manage one’s stress levels in order to lower anticipation and to distract from focusing on pain or stress.

Being able to manage stress serves to develop a resilient personality, as does lessening the anticipation of and focus on future harm. This further helps to lessen pain over time and is associated with the absence of pain-related disorders.

Any relaxing activity that distracts from pain, stress or rumination tends to reduce pain perception. Examples include:

• Deep mindful breathing exercises are very helpful for toning down rumination and the stress response, and have been shown to reduce pain perception^[24].
• Re-orienting the way one thinks and approaches painful or stressful situations can go a long way towards moderating the perception and intensity of pain. It has been proven that pain intensity is greatly reduced when one perceives the pain to be controllable, irrespective of taking countermeasures. Thinking in a new way can promote the development of neuronal networks, detracting from activity in pain-related networks.
• Reinterpreting what one feels is important for those who suffer from chronic pain disorders, who are very sensitive to most sensations. Not everything one feels is an indication that one is going to experience pain. Furthermore stressing over the unpleasant nature of the experience only serves to increase the pain. It helps to positively engage with what one is feeling in order to minimize stress, anticipation, and inadvertently increasing one’s perception of pain.
• Investing in a sense of humor is one of the most effective ways to work with pain, particularly if chronic. Laughter releases pain-relieving chemicals and neurotransmitters that promote stress relief and a good mood.
• Learning a new skill is another way to tone down the volume of pain-related networks in the brain, by promoting the development of something new and positive. Creative skills reduce stress, improve mood and often disrupt thought processes associated with anticipating pain. Dancing, playing an instrument or making art are great examples.
• A change of scene can help to provide new sensory information to the brain, which may reduce potential triggers of stress and pain, as well as encourage new connections to form.
• Psychotherapy and journaling may be good ideas for those suffering from chronic pain arising from an emotional difficulty or previous traumatic experience. Unresolved psychological tensions are a source of chronic internal stress that can trigger chronic pain in some people. Having the ability to reflect objectively on one’s mental-emotional state serves to resolve the problem and dispense with psychological triggers of pain.

2. Importance of Movement for ‘Rewiring’ the Brain and Reducing Pain

It may seem counterintuitive to exercise when in pain. However exercise is one of the best interventions for managing chronic pain disorders^{[25] [26] [27]}. It therapeutically serves to lower stress, pain and pain intensity^[28], while refreshing the brain and nervous system^[29].

Science continues to prove that physical activity is a vital requirement for the healthy functioning of the nervous system^[30]. This is due to the way in which the brain and body rely on one another to perform their functions. The body is feeding the brain information all the time from the environment and is only able to fully respond after receiving feedback from the brain.

Exercise helps to develop new neural connections in both the brain and spinal cord^{[31] [32]}. It achieves this through regulating most major neurotransmitters, including serotonin, dopamine and norepinephrine^[33]. It’s also associated with the cellular release of pain-inhibiting compounds, such as endorphins^[34]. These effects directly augment the body’s relationship with pain, through disrupting the chemical signals that alert the brain that there is a problem. Over time, regular exercise promotes new connections to form in the spine and motor regions of the brain that are able to supersede pain-related networks.

Physical activity synergistically works on both the immune and cardiovascular system in a way that serves to improve their functioning^{[35] [36]}. It improves circulation of both blood and cerebral spinal fluid, enhancing the brain’s ability to process neurological input from the body.

Resistance training is one of the best forms of exercise for promoting pain relief, through building strong healthy muscles that support the nerves and musculoskeletal system. The benefits can be increased by incorporating weight-bearing exercise for optimal bone health and metabolism, as well as aerobic exercise for better circulation.

Setting a daily routine with exercise can help to structure one’s day and provide a sense of control over the body, helping to reduce pain perception. It improves one’s mood, self-esteem, metabolism, and energy levels, making it ideal at the start of the day. 30mins of moderate intensity exercise, 5 days a week, is recommended for maintaining health.

3. Painkiller Management

Over the past few decades, it has become obvious that no painkiller is without side effects. Skilled physicians will often prescribe painkillers as a temporary measure for patients with pain-related conditions; as well as educate the patient on non-pharmaceutical pain management strategies.

Analgesics may provide relief in the short-term; however the majority of those with chronic pain disorders do not get relief from them. This is due to the fact that painkillers typically inhibit one or more cellular pathways that give rise to the sensation of pain. This does not resolve the underlying cause of pain, and may even contribute to making it worse in the long run. Furthermore, these medications do not disrupt neuronal networks associated with pain or serve to lower neurological amplification of pain signals.

Those with pain disorders tend to become addicted to painkillers, requiring more of them to achieve a desirable effect. These patients often become very ill as a result and reluctant to rehab. It is important to manage the use of painkillers if one is taking them. Implementing pain management strategies early on can help to avoid painkiller dependency.

Conclusion

Through perception, the mind is able to exert a certain degree of control over the sensations perceived from the body. This is especially pertinent for pain and the way in which it’s processed in the brain. The brain and spine are able to amplify signals of pain, contributing substantially towards perpetuating chronic pain. Brain areas affected by pain include those associated with personality, cognition and reasoning. The mind can be used to intervene with pain perception and tone down pain transmission by reducing connectivity between brain areas that amplify pain signaling.

The stressful nature of pain tends to reduce the ability for one to rationally intervene, as it affects cognition. Biopsychosocial pain management strategies have been shown to be effective at lowering stress, improving brain health and reducing the intensity of pain. Mindful breathing techniques and other relaxing activities that help to distract from pain can promote pain relief through reducing pain perception.

Exercise is vital for optimal functioning of the nervous system and is often prescribed for pain management. It serves to improve mood, self-esteem, psychological resilience, regulate cognition, lower stress and encourage new connections to form in the nervous system. These effects work synergistically over time to reduce pain perception and intensity, improving the quality of life for those with chronic pain disorders.

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