Today I'm going to show you some unique and exciting treatments in chronic pain that you can train without having to physically train. That's right, using just your brain to physically rehab an injury is not only possible but recommended in certain circumstances.
Before we can get into the fun stuff, let's really briefly recap what we know about pain.
Pain is an unpleasant sensory experience associated with (but not always in the presence of) harm. Pain is a combination of inputs from nociceptors (your pain receptors) around the body AND the brain. This means that the brain can be used to enhance pain, create pain where it shouldn't exist and even reduce pain.
Think of it like an equation: pain = nociceptor input + brain input. Anything that affects the brain's input is going to affect the pain. In this article we're going to look at ways to influence the brain's input to pain.
When a pain has been around for a while (> 3 months), your brain gets really good at sending off the pain message, making it easier for you to feel pain. We call this sensitisation. You can read more about sensitisation in this previous post feat. the wise-crack Lorimer Moseley where I've covered this topic in greater depth.
Okay, onto the fun stuff. Today is about the amazing treatments that have been scientifically proven to be effective in reducing pain, without actually having to train your body. They work by training your brain using a method called Graded Motor Imagery.
Why train the brain?
The first thing to acknowledge is the gap that exists between what your tissue (muscle, ligament, bone etc) can tolerate and when pain kicks in. Pain is an evolutionary trait that protects the body by alerting it when a tissue is close to breaking point. Pain, as an evolutionary trait is a good thing. The brain will try and stop the stimulus before it causes damage. In other words, pain comes on before injury.
Now, when an area is injured for a long time, the brain gets good at sending that "protect" signal, so even lower loads that the tissue could tolerate are producing pain. After 3 months, we can expect most tissue in the body to be practically healed (the only exceptions are nerve cells or if something is physically stopping healing such as a total tear of a ligament) so even if the tissue isn't 100% back to perfect, it should be able to take most of the load. The brain however, has lowered its pain threshold unequivocally so now the pain comes on super early and stops the tissue from performing its function. This is explained in the image below.
On the left is the tissue before getting injured. You can see the brain will protect the tissue by causing pain slightly before the tissue starts to actually get damaged. In the image on the right, the tissue tolerance has dropped slightly after the injury which is to be expected. However, the level that the brain wants to protect the tissue with pain has dropped significantly. This means the tissue may not be able to function without pain, even if the tissue can tolerate the load. This is when Graded Motor Imagery is indicated.
That's where brain training comes in. But before you begin training, you need to be able to monitor your progress.
One simple way to measure sensitisation is by using 2 point discrimination. To put it simply, this is where two points on the body are touched, then we ask if you could feel two points or one. The closer you can feel 2 distinct points, the better your body is sending accurate messages to your brain and the lower levels of sensitisation you have. This is a different distance for different body parts as the body is not equally innervated so if you want to see the average numbers you can check out this chart here.
The touch test tool in use on a finger.
Once you've got a measurement to monitor your progress, you can begin your Graded Motor Imagery training.
How to train the brain
1. Laterality training
Laterality training is watching someone else do a movement and identifying if the limb being used is the right or left. The point of laterality training is to enhance someone's ability to picture their own body, the image of which may be skewed due to pain or disuse. There is a handy app you can download called Recognise, which makes the training super easy and user friendly (and somewhat addictive if you like beating a high score like me!) although it does cost a few dollars.
Can you tell what is left and what is right? Laterality training involves looking at similar images and guessing which side of the body is shown as quickly and as accurately as possible.
2. Explicit imagery
No it's not what you're thinking... Explicit imagery involves thinking about moving, without actually moving. Sounds so simple doesn't it? By thinking about moving a body part, similar areas in the brain are used as when you actually move it. Thus, for patients who really struggle to move a certain area, this can be an excellent starting point to train the brain to move it again. The imagery needs to be as detailed as possible, starting from small movements near the affected area and slowly building to large movements of the affected area. This should be practised very regularly to have an impact, 7 times per day is the average recommended dosage.
3. Mirror therapy
Mirror therapy involves using a mirror to visually trick your brain into thinking the affected side is being used. We've all seen the hammer prank on various talk shows right? I'll post it below so you can treat yourself if you haven't already. This works because the brain always prioritises your sight, and you can trick your sight into thinking your body is moving when it isn't. This means you can actually train the brain in certain movements without actually having to do the movement! How cool is that? Similar to the previous methods of training, start with small movements and gradually build up. For more information on using mirror therapy properly (or to just trick your friends with a mallet) click here.
To put it all together, these three different methods should be used in a staged approach and will require lots of time and concentration, however, can be a really effective method for reducing pain by training your brain to change it's input. This approach should be utilised when physical approaches have all been tried but pain is still present. Below is a graph that sums up how to structure a Graded Motor Imagery program and the average results. If performed correctly, we can expect to see pain at rest drop from a 6-7/10 to a 1/10 in 20 weeks. It's a lot of hard work but to go from a 6-7/10 to 1/10 can be life changing for people living with chronic pain!
This graph from the NOI group contains a descriptive dosage at the bottom, but the most exciting part is the average pain levels. Look at them go down over the weeks! Also, I love that for weeks 5-11 you have to sit in a cafe and do some good old fashioned people watching. Next time you get caught just say "I was prescribed people watching for my health".
So there you have it. A new and exciting method for reducing your pain levels and returning to function and movement without having to physically move! Remember for most of us, it is much more effective to actually do the physical training - I hope this blog serves as a reminder of how lucky you are that you can. But for those who have tried many physical approaches, but are still in pain, perhaps they need to take a look at the other side of the equation and try Graded Motor Imagery to train their brain.
Stay strong.