Following up on our “re-introduction” to the nervous system from two episodes ago, we are going to take a deeper dive into the topic of pain. While most people think pain is an input (“that hurt me”), pain is really an output signal from our brains. The brain triggers pain in response to perceived threat, and that threat can be real or imagined, physical or non-physical. We review some real-world applications of these principles and how it can lead us to more effective treatment strategies.
“Sports Medicine Said to Overuse MRI’s” https://www.nytimes.com/2011/10/29/health/mris-often-overused-often-mislead-doctors-warn.html
Article on Back Pain and Imaging: https://www.bmj.com/content/bmj/372/bmj.n291.full.pdf
Garrett Salpeter: 00:00 – 05:04
Hello, Neufit nation and welcome back to the new fit undercurrent podcast. This is another solo episode and it’s going to be a continuation of a topic that we talked about a couple of episodes ago. I believe it was episode 52, where we talked about the nervous system as a black box that operates as a big feedback loop and one of the most interesting topics about that about how the nervous system operates is pain and so we’re going to do a deeper dive into the topic of pain here. Pain is often misunderstood. It’s very important to people’s lives, especially for people who have chronic pain where it’s impairing their quality of life and impeding their ability to do activities that they want to do and it’s something that by learning some of these core concepts, it’s an area where we can really start to make a difference and impact people’s lives in a profound way.
So, I’m excited to dive in here, and hope that you find this as interesting as I do. When we’re talking about pain, there’s one topic that I touched on in the previous episode, that is a core of the misunderstanding and that is that pain is actually an output rather than an input. So, it’s not an input in the sense that I touch a thumbtack or something accidentally the sharp end, and I say that pains me. What actually happens is that sends a signal of nociception, or perception of threat, and that signal goes up to my brain, and then my brain interprets that as threatening, and triggers pain as a signal to get me to change my behavior. So, in that case, it’s the brain’s way of saying, oh, that hurts out, don’t do that stop touching the sharp side of that thumbtack and in that case, it’s an appropriate model and in that case, the threat is due to a physical, actual threat, not perceived or non-physical threat. So, there can be some differences there that we’ll get into.
But in terms of understanding pain, there’s one other core concept that I want to introduce first, and that is the concept of the threat bucket, and this is not my invention by any means. This comes out of the work on the bio psychosocial model of pain, biological, psychological, and social model of pain, and the threat neuro matrix. So, these are terms that you can certainly look up if you would like a deeper dive. The work also I’d have to cite of Adrienne Lo and Lorimer Moseley, and a couple others are really been really influential in this more modern understanding of pain that we’ve learned about in the last two decades. So, we’ve really come a long way, in our understanding recently and you know, it’s an evolution from the gate control theory, and some of those older models of pain and I think a real improvement in terms of what it allows us to do so. So, let’s look at this concept of the threat bucket. So, imagine an imaginary bucket that you fill up with various threats and so those can be of course, hitting your finger on the sharp end of the thumbtack, like I talked about earlier, or it could be sprain or strain tear, or some sort of injury that’s threatening, it could also be non physical, something that your brain perceives as threatening to survival, like the risk of losing your job and could cause the brain to think, oh my gosh, I might lose my source of income. I might not be able to provide for myself and my family if I have a family and that could be a real threat to my survival. So, these older, more evolutionarily speaking, older parts of our brains can interpret some of those non-physical threats as being or non-physical stressors as being threatening to our survival and they therefore go into the threat bucket also, having poor nutritional status, so they could be deficient in something or be reacting to foods that you’ve eaten have high inflammatory levels, because of diet or other inputs that will increase inflammation.
It could be being dehydrated, not getting enough sleep, those are all things that can go into this threat bucket and no matter the source of the threat, when the bucket reaches a certain threshold, it overflows and what comes out is pain. So, pain is a response to perceived threat when that threat reaches this certain threshold or milestone and it is interesting because those threats, both the physical and nonphysical, the things that that we think would hurt and things that we think would not necessarily hurt physically, all go into the same bucket. So, there’s this really interesting relationship between pain and damage. We think that when we have pain that is because something is broken, something is injured, and that sometimes is the case. Of course, those are the easiest ones to understand, but sometimes it’s not the case and there’s a couple of interesting studies I want to share with you that speak to this.
05:04 – 10:00
So one is, there’s a famous orthopedic surgeon, Dr. James Andrews and now as you know, a group of surgeons working in the Andrews’s Institute, and it’s down on the Florida Panhandle, Alabama Coast area there and their practice does a huge number of very high-profile surgeries on professional athletes. So, they’re doing a lot of ACL reconstructions, Tommy John surgeries, that are kind of the go to top few places for elite athletes to have surgeries done and James Andrews had a really interesting observation. He thought that his fellow surgeons were becoming over reliant, were depending too much on imaging for diagnosis, and not trusting their skill and ability and experience and knowledge nearly enough. So, he commissioned a study wherein he got 30, major league baseball pitchers, who all of whom were able to throw it and have any pain or symptoms. They were healthy.
They were playing in Major League Baseball and he had them go get an MRI on their shoulder and he did this with 30 pictures and I want you to think for a moment and guess out of those 30 pitchers who were healthy, how many of them had significant damage on their MRI that, you know, significant enough to justify surgery? When I was confronted with that, I guess that little maybe a few and the actual numbers surprised me when I first heard it, because it’s 25. So, 25 out of 30 actually had damage in their shoulder that was significant enough. I’m shown on the MRI damage significant enough to justify surgery. So, that was labrum issues, bicep tendon, rotator cuff tendon damage, labrum, it was any of those sorts of issues and the crazy thing is that they had this damage that that should have hurt in our, you know, kind of more traditional model of thinking and approaching pain and yet it did not. So, why not? Well, the answer is that for them, for whatever reason, that tissue damage was not threatening enough to cross that threshold in their brain to trigger the output of pain. So, they were either finding ways to work around that tissue, you know, compared potentially using other movement patterns or not loading those particular areas. So, that they weren’t at risk of injury, or they’re keeping their other threat. Other sources of threat down so low taking such good care of themselves didn’t cross the threshold or potentially, their emotional state was such that they were so focused on what they were doing that they could ignore that for a significant period of time, we see that sometimes with like special operators or with soldiers in the military.
Sometimes, they’ll have so much adrenaline, they’ll actually get shot and not realize it until many minutes later, when the mission has ended. Though, you know, notice that and that’s because they didn’t notice it happened during the actual mission or battle because they had so much adrenaline. They were so focused on what they were doing, that their brain didn’t necessarily register that because it was less important, the brain has to prioritize and the scanning the battlefield, or whatever else they were focusing on was more important to survival than actually registering that gunshot wound, interestingly enough. So, there are documented cases of that, where there is damage, but no pain. Another interesting series of studies has to do with spinal damage or tissue changes, and the absence of pain as well.
So, there’s studies that show it’s something like 30% of people in their 30s, 50% of people in their 50s, 70% of people in their 70s, who don’t have back pain will actually have bulging or herniated discs, visible issues with factettes, you know, potentially, like spondylosis, spondylolisthesis sort of thing going on, have different any anything in that sort of category of spinal injuries or damage or issues. These people will have that but no problem and so someone comes in for physical therapy, and they say, oh, of course my back hurts I have you know, a disc bulge. You can say, well 50% of people your age that don’t have back pain have that same thing. So, why is this causing pain for you and not for so many other people have the same thing? And the threat bucket concept and some of these very powerful principles allow us to help explain that and help people understand it in a way that it can be helpful and help improve the overall outcomes and so we’ll get into that, get into some of how that works. But one, the flip side of that first, we want to chat about which is the thing we just talked about the cases where there’s damage but no pain.
10:00 – 15:26
Now, we want to talk about where there’s pain, but not damage. So, this is issues where there’s chronic pain. Sometimes that chronic pain will linger in an area where there was a previous injury and yet, even after the injury is healed, the pain might still be present. So, that’s chronic pain. That can be a big problem. Chronic pain can be very debilitating for people. It can cause them to reduce activity and cause them, you know, some cases to have to use, you know, very dangerous narcotic pain medicines and we’ve seen opioid crises and in the world, and it can lead to big problems. So, helping people with chronic pain is very important and a lot of times people, you know, if they can’t find a physical cause, or they know they haven’t been injured, and no other injury is healed, they can become very, you know, disenfranchised because they can be frustrated, disappointed. They can be scared, if there’s no cause, necessarily and so explaining these principles to these patients can be even more helpful these chronic pain patients and there’s a couple of parts to this, that they’re really important. That is one of them is going back to this notion that these some of these things that go in the threat bucket are non-physical threats are things that we think would not or should not hurt physically.
But if I have stress at work, like we talked about earlier, that can be very threatening to me, because my brain thinks that I might not be able to provide for my family. I might go starving. I might lose the roof over my head, if I can’t pay rent or mortgage, you know, so that is threatening. If I have a fight with my spouse, that can be very threatening, because I might think, oh, gosh, I’m gonna get, you know, get kicked out of my tribe. I might have survival problems here. There’s these very deeply rooted evolutionarily speaking, parts of our brain that are interpreting what’s going on in our lives and so the one interesting things here is that if pain is an output signal of the brain, and the brains attempt to get us to change our behavior or do something different, then the brain has to figure out where it’s going to make that signal because if you are going to have pain, because you have work stress, and your brain is trying to tell you to change something in your change something in your life, your brain, it doesn’t have a work stress muscle or bone to send that signal to, right? Instead, your brain is going to use whatever pain pathway it has available to it. It doesn’t want to invest the energy and resources to build a new one, it’s going to use one that it has, has recently practiced and so if there was an area of previous injury, the brain is going to keep using that as the preferred pain pathway and so I want you to think about if you experience pain, hopefully, as you’re listening to this, you’re not regularly experiencing pain. But if you do, I would imagine that it is usually in the same one or two places that it’s not randomly in all these different places.
If it is that could speak to other things like different, you know, complex regional pain syndrome, or fibromyalgia or some of these other things that are a topic for another podcast, potentially. But generally speaking, when people have pain, it tends to be in the same area and sometimes it’ll be, you know, it’ll be better or worse, depending on how you sleep that night, how dehydrated or well hydrated you are, how well you’ve been eating. So, it can be influenced by some of these non-physical factors, you know, whether you took a weekend off, or whether you were up late or drinking alcohol or things like that those types of things can affect you know, your back pain or your knee pain, even though they’re not related to your knee directly or specifically, no more than they are related to your elbow or your back or your neck or you know anything else and so, understanding that those other factors can open up the whole range of different ways that we can intervene here, the different tools that are available to us, to help people with pain and there’s one other really interesting actually, so, finish this thought first before we go there. So, there is some very interesting work on pain neuroscience education. So, this work of Dr. Adrian Lowe, Liu W and he and his team have shown that by providing education to chronic pain patients typically in the form of a of a book that doctors therapists can leave in their office or can use to you know, show different slides and pictures of people.
So, by educating people on concepts like this threat bucket or threat neuro matrix and some of these non-physical causes of pain, and how the perception of threat in the in the brain can stay elevated, even after the original source of that threat has since faded. So, educating people on these principles actually empowers them in a way that improves their outcomes. There’s statistically significant improvements in treatment outcomes and chronic pain patients by sharing these educational resources with people. So, if you’re interested in this, you can just search pain neuroscience education and you can find the little illustrated books to keep in the office. Those are great possible resources or something that you could do here if you’re interested. But that’s one.
15:26 – 20:06
One really interesting point is that this absolutely does provide an avenue to improve outcomes and one other point I want to want to address is that this is also where the newbie comes in. Because if you have a perception of threat and elevated perception of threat, that’s a hypersensitivity, that’s, that’s living somewhere in the body, you’re going to be hypersensitive to inputs, typically, somewhere in the body and with the newbie, when we do our mapping process, we’re able to scan around on the body and find exactly where those hypersensitivities are, where that elevated perception of threat is. So, that we can tap into what area of the body is contributing more significantly to filling up that threat bucket and by sending input from that area, then with the unique, highly specialized dual waveform direct current, and this, this signal that has these really significant impact, really significant effects on the nervous system. By doing that, we can create input from that area and teach the brain to reduce the sensitivity to desensitize that area reduce the perception of threat, teach the brain that it’s safe.
Again, safe to allow that that area of the body to work again, as it had in the past and by doing that, with chronic or acute pain patients, we’re often able to make a big difference in their pain and that is another good avenue for explaining if you listen to us and you happen to have a newbie in your practice, or you’re using it with yourself, that can be a good way to think about and to explain to others some of how the newbie is working to knowing that pain is a response to perceive threat, knowing that that threat is somewhere in the body, that elevated perception of threat has to has to exist somewhere and with the mapping process, we’re able to find that and help with the with the process of reducing that perception of threat and therefore emptying out the threat bucket making it less likely we’re gonna reach that threshold to trigger pain. One question for that is you might be thinking, well, if it is the work stress type of related type of type of threat input into the threat bucket, how do I find my work stress muscle or something like that, right? So, that’s a good question. If it is purely that if it’s purely non-physical, there typically is a physical component to it that we can find on virtually everybody and that has, it’s hugely valuable. For the component that is just psychological. That’s where we would do what we call our master reset, we would do a protocol where we can help increase parasympathetic nervous system activity that’s the rest and digest side of the nervous system that turns off and counteracts the fight or flight sympathetic side. So, if we spend too much time in fight or flight, we want to have that available for short bursts to meet immediate challenges.
But if we’re in that state for too long, we have health problems and challenges, all these different lifestyle diseases that we that we know about or have experienced or at least have heard about, in terms of, you know, high blood pressure, digestive issues, issues of waste, elimination, fertility, all the all the main organs in the viscera of the body, those are all in the certain whole circulatory system are controlled by the nervous system and so BMO spend more time in that rest and digest parasympathetic dominant side of the nervous system helps counteract the effect of stress. So, if we are in a particularly psychologically stressful period, doing something to globally, reduce the perception of threat globally, shift the body into a more parasympathetic dominant state and allow it to recover from that stress that can help tremendously.
So, I hope that that these principles of pain that the threat bucket knowing the sources knowing that there can be a disconnect between pain and damage, they don’t necessarily always one doesn’t necessarily mean the other and vice versa and then knowing how to how to apply that threat bucket to help chronic pain patients and knowing how this can open up different avenues for treatment. I hope that’s helpful to you and give some more understanding and helps to further demystify the nervous system and the topic of pain which can be especially for chronic pain patients can be mysterious can be frustrating and yeah, hopefully this gives us some more tools to understand and improve situations for those patients or for ourselves and I thank you NeuFit nation for tuning into this episode of the Neufit undercurrent podcast and I look forward to seeing you on the next one. Thank you. Bye.