What is Neuroplastic Pain?

If you are just starting to learn about neuroplastic pain, this post is for you! Different practitioners, doctors, psychologists, and researchers call neuroplastic pain different things; Mindbody syndrome, TMS, and neuroplastic pain are all synonyms.  

Pain is in the Brain

The first thing you need to understand, when learning about chronic pain recovery is how incredible human brains are! It can feel unbelievable, that the pain/symptoms you are experiencing could possibly be caused by your brain when the pain is so severe, has lasted for so long, or you have been given a myriad of diagnoses. The first thing I need you to understand is that the brain causes the perception of pain. Without a brain, pain does not exist. Pain is the brain’s way of communicating danger. Sometimes this danger signal (pain) is sent because of tissue damage, like a broken bone, torn ligament, a cut or a burn. Fascinatingly, if a person was running from a lion and they broke their ankle, the brain would likely choose NOT to send pain signals because it would be more advantageous to continue running without any pain. If, on the other hand, this person was frolicking with their partner through a field, and tripped and broke their ankle their brain would send pain signals to let them know that they need help and to protect them from further damage.

Pain is Perception

The brain will also send pain signals if it perceives it has been injured, even if no injury occurs. In this article1, the author, Rachel Zoffness Ph.D., talks about two case studies that both took place at construction sites. In the first, the patient had been working and fell onto a plank landing on a 7 inch nail which pierced through his boot, and was poking out of the top (Fisher et al, 1995). As I am sure you can imagine, the man was in agony! After sedating him in the emergency room, they removed his boot to discover that, amazingly, the nail had missed his foot altogether. It had managed to slip between his toes, without even a scratch. His brain had seen the nail and assumed that the far more likely outcome had occurred; the nail had shot through his foot and he was in desperate need of medical intervention. This man’s brain sent him extreme pain signals to ensure he would get help as quickly as he could. His pain was as real as pain can be. 

The other case study covers a man who was using a nail gun when a nail shot out and hit him in the face. He thought he was lucky, and walked away with a mild toothache and a bruise under his jaw. Almost a week later, he went to a dentist who discovered from an x-ray, that he had a 4 inch nail lodged in his head! It was even piercing his brain, putting him at high risk of severe complications. His brain had not processed what had happened and therefore did not send sufficient pain signals to warn of danger (Dimsdale & Dantzer, 2007).

Daily Neuroplastic Pain Experiences

Intellectually most people understand that the brain can cause pain without any tissue damage. You might remember a time in middle school when you got a stomach ache before a test, you probably assumed that you were nervous, and that nerves were the cause of your stomach pain. Or maybe after your first breakup, your heart literally hurt, and you did not assume you were having a heart attack, because the pain reflected your internal experience (even the term "heartbreak" suggests pain). I would imagine that within the last few weeks you probably got a headache on a really stressful or overstimulating day, and you likely attributed the headache to stress, not a brain tumor. It is likely that you have experienced a sore throat, or an achy body after learning that someone you were in close proximity to tested positive for covid even though you never did. 

These are singular experiences of pain/symptoms are culturally accepted as mind-body phenomena. However, when it comes to chronic conditions, there can be a lot of cognitive dissonance around the idea of chronic neuroplastic (brain-based) pain. Unfortunately, the idea of lasting pain originating in the brain, makes people feel like they are making it up, that it’s all in their head, and that they are just crazy. This could not be further from the truth. Pain generation is a subconscious process, and the person suffering from chronic conditions has done nothing to bring the pain on. Reminder: The brain is the genesis of all pain. There is absolutely no difference in the experience of pain caused by tissue damage or caused by neural pathways. Pain without a tissue based cause can be as bad as any other experience of pain (the brain causes it all) but the solution is completely different.

How does Neuroplastic Pain become Chronic?

You might be wondering how neuroplastic pain becomes habitual. Most lasting pain becomes chronic because the brain learns the painful neural pathways and continues to fire them even after any injury or damage has healed. Often, there was no tissue damage, and any findings are incidental. In fact, there is no correlation between chronic back pain and herniated disks, disk bulges, disk degeneration, or protrusions. 64% of adults without back pain have one or more of these findings 2, while many adults with back pain have no related findings. The same goes for osteoarthritis- no causal relationship has been found (read more in this article).  Other times , like with headaches, pelvic pain and fibromyalgia, there is no tissue based reason for the pain, and no findings that indicate injury or disease. The diagnosis is given based purely on the symptoms and by ruling out other potential causes. In fact these diagnoses are actually confirmations that the pain is neuroplastic. By now you probably understand that the brain is the cause of all pain, sometimes it triggers pain when it receives threatening information from the body warning it of tissue damage as is the case for a broken bone. But constant stress, traumatic experiences, life circumstances, nervous system dysregulation, and some personality traits can also send danger signals to the brain. When the level of threat surpasses an invisible threshold the brain will send pain signals to warn of perceived danger. These signals are neural pathways and they can become habitual. The more they are triggered, the easier it is for the brain to fire them. The same goes for learning any new skill! The first time you serve in tennis, it takes a lot of thought and effort and the ball doesn't go where you want it to. But by the thousandth time, you have gotten much better and can do it without thinking as much about it. This, too, is thanks to neuroplasticity (the ability to gain new neural pathways/learn new things). Neuroplasticity is how pain becomes chronic but also how you can get out of pain. 

How Intuitive Responses to Pain can Perpetuate Pain

Let’s imagine a scenario where neuroplastic pain is perpetuated through the danger/fear pain cycle. When Lily’s migraines started, they would only happen when she was highly stressed and sleep deprived. When she did experience migraines, she, like most people, would go into her bedroom, turn off the lights, close the door, and try to sleep them off. Most of the time when she woke up, the migraine would have resolved. But over time she started getting migraines far more frequently, and she didn’t understand why. Her fear told her she may have a brain tumor or a terrible disease. Her doctor told her she didn’t. Lily started to spend a lot of time each day anticipating and trying to avoid the onset of her next migraine. As her pain took over her mental space, she stopped seeing friends, going to her Zumba class, and participating in the board game meetup she went to weekly. She didn’t want to be sad, or a burden on her friends, and was worried that Zumba would trigger a migraine. Eventually the only time she left home was for work which she no longer enjoyed. 

Everything that Lily did/stopped doing, is completely understandable, and a natural trajectory for someone suffering from chronic migraines! If we view her behavior with the understanding that pain is a danger signal, we can see how over time, the fear, danger and pain were all being reinforced by Lily’s thoughts and actions. What started as a rare, yet painful experience, became a painful prison that Lily was trapped in. Lily reinforced the painful neural pathways by being so fearful of the pain, sending the brain the signal that the pain is really important and needed to be paid attention to. Her fear of the pain and avoidance of possible triggers, also reinforced the danger and fear. As the danger and fear increased so did the pain and the pain then became easier and easier for the brain to trigger.  At first it took a whole day of stress to cause a migraine, but as her neural pathways got established, reinforced, and embedded, almost anything with the slightest negative association would fire those painful migraine pathways. Additionally Lily stopped doing behaviors that lead the brain and nervous system to feel safe and supported, like spending time in her community and engaging in play and exercise. As someone who has struggled with chronic pain myself, I deeply empathize with how tumultuous and exhausting the road is and how natural it is to feel helpless and trapped.

Steps Towards Safety and Freedom from Chronic Pain

All of Lily’s responses make perfect sense! However, for her to get out of pain she is going to need to learn ways to respond to her pain that deescalate the danger signals and create new neural pathways. She will also need to re engage in the joyful and social parts of life to send her body signals of safety and support. As she starts to receive more safety signals from her own mind, her surroundings, and her behaviors, her pain will start to subside. 

The good news is that there IS a path towards freedom from chronic pain! It is very likely that, like Lily, your chronic condition is treatable and even curable! We can teach the brain new neural pathways and train the brain to respond differently to the learned pain pathways making them less threatening and therefore less important for the brain to respond to. 

Is Your Pain Neuroplastic?

You might be wondering how to determine whether or not your pain is neuroplastic. The following is a list of signs that the pain IS likely neuroplastic. *It is important to be seen by a medical doctor to rule out any serious injury or disease before working with us. 

-The location and/or type of of the pain shifts around

-You have the same or similar pain/sensation(s) on both sides of the body.

-Your pain comes and goes and is inconsistent

-Your pain is  triggered by the time of day, time of year, weather or other external factors. 

-You have conditioned pain responses to certain stimuli (for example, underwear triggering pelvic pain [part of my story], onset of pain after exercise, driving triggering neck pain which then leads to migraine [part of my story], etc.)

-As one type of pain is cured, another pops up (ex. Knee pain is relieved after an operation, only to develop pain in the other knee, or an all new type of pain)

-Your pain disappears when you are on vacation or away from other stressors.

-Your pain pattern doesn’t make sense based on the findings (arching your back triggers back pain, the MRI shows a disk herniation which would NOT trigger back pain while arching. No structural abnormality in your neck, only muscle spasms [both examples are part of my story]).

-You have a diagnosis that confirms neuroplastic pain such as migraines, fibromyalgia, whiplash syndrome

-Conventional treatments have not helped you

-You have not been able to nail down the cause of your symptoms (with the technology of today, it is extremely unlikely that a serious disease or injury would be missed and far more likely that incidental findings would be reported and the cause of your pain misdiagnosed.)

-Your pain started or escalated at a highly stressful time in your life, after a traumatic event or during a big change (positive or negative ex. new relationship, now job, job loss, divorce, new life season etc.) 

Sometimes a diagnosis can be comforting to receive after searching endlessly for answers! However, some diagnoses are confirmation that the pain is neuroplastic. Other diagnoses like herniated disks, torn meniscus, and osteoarthritis, occur in most adults at some point in their life. There is no correlation between pain and these wear and tear injuries. Often they are incidental findings. When conventional treatments don't alleviate pain symptoms, or the symptoms consistently return, it may be time to look into neural pathways as the root cause. 

Citations

Miller, M. (2019, November 12). A tale of two nails. Psychology Today. https://www.psychologytoday.com/us/blog/pain-explained/201911/a-tale-of-two-nails

Jensen, M. C., Brant-Zawadzki, M. N., Obuchowski, N., Modic, M. T., Malkasian, D., & Ross, J. S. (1994). Magnetic resonance imaging of the lumbar spine in people without back pain. The New England Journal of Medicine, 331(2), 69-73. https://doi.org/10.1056/NEJM199407143310201

Resources

For a more extensive list of signs of neuroplastic pain visit this link.

The Way Out by Alan Gordon and Alon Ziv is a great book to dig deeper.