What is Chronic Pain?
Chronic pain is defined as any pain experienced for 3 months or longer. The term chronic pain encapsulates many different pain disorders, including, but not limited to: chronic low back pain, chronic headaches, fibromyalgia, chronic fatigue syndrome (myalgic encephalomyelitis), and chronic temporomandibular joint disorders. These conditions are poorly understood and often overlap in patients and have been termed Chronic Overlapping Pain Conditions (COPC) by the National Institutes of Health (1).
What Are the Symptoms of Chronic Pain?
Research has demonstrated that all of these conditions have certain common underlying mechanisms and these can be rooted in neural and immune system functions. According to the Chronic Pain Research Alliance, people suffering from COPC demonstrate sensory processing dysfunction. Not only do they experience a heightened sense of pain perception at the part of the body where they report their pain, but the application of pressure, touch, or vibration can cause them to perceive pain in areas far away from the primary area of concern (2).
What Happens in the Brain with Chronic Pain?
It is important to understand that pain is not a sensation, it is a perception and an experience. People tend to think of their pain system as a series of on-off switches, in that if they are not experiencing pain, their pain system must be shut off. Nothing can be further from the truth.
There are receptors called nociceptors that exist throughout your body. These receptors respond to heat, cold, chemical irritants, and mechanical compression. When these are stimulated, they come to threshold and fire nociceptive signals through small nerve fibers and into your spinal cord. These nociceptive neurons are just like any other neurons in your body; they are always firing at a baseline rate. Indeed, essentially only nociceptive neurons that are not firing at all times are the dead ones. So why are we not in 24/7, head to toe pain?
There are also several anti-nociceptive mechanisms in your nervous system, which exist in your spinal cord and brainstem. They function to filter and gate the nociceptive input, which prevents the signal from making it to the conscious parts of your brain. With enough input from the nociceptive systems, such as when there is tissue damage or inflammation, the anti-nociceptive systems are overwhelmed, and the signal is transmitted areas in the parietal lobe of the brain where we map the body. Even once this occurs, we still don’t have pain, only localized nociception. The input doesn’t become pain until we assign a negative emotional valence to it; we must decide “that sucks” for the signal to become a painful experience.
The brain’s anti-nociceptive circuits are normally very good at shutting off incoming nociception before it reaches conscious experience. These systems exist in the frontal and prefrontal cortex, the parietal lobe, the vestibular system, the brainstem, and the spinal cord. When functioning properly, the nociceptive input from an injury is maintained long enough to allow it to function as part of the healing process. Nociception allows us to automatically regulate blood flow and focus inflammation on injured tissues, which is crucial for tissue repair. Once this takes place, nociception needs to be shut back off.
There are also regions in the brain that are involved in the negative experience of pain. The amygdala is involved in threat detection and fear perception. The hypothalamus and pituitary gland are involved in the release of stress hormones that allow us to respond to threats. Some of these hormones can sensitize nociceptors, and thus make anything that hurts hurt more. The anterior cingulate cortex is involved in the perception of suffering. When this is excited, nociceptive input becomes a negative, painful experience.
Chronic pain is best seen as a loss of balance between the nociceptive and anti-nociceptive systems, coupled with a negative emotional consequence leading to ongoing painful experience. In acute pain, nociception tells your brain that tissue has been injured. In chronic pain, these signals persist and become amplified. They may even continue to exist long after the tissue has healed and returned essentially to normal.
When our bodies are stimulated by external sensations such as stubbing your toe or burning your hand, the sensory receptors in our skin relay that signal to the spinal cord. These signal travel in a pathway that delivers the message from the spinal cord to the brain. Under normal circumstances, this input is recognized as not very harmful, and no extreme signals of pain are ascribed to it. The body and brain sense and localize the external stimulus, deal with it by triggering inflammatory responses to heal the injured tissue, and move on.
In chronic pain, these pathways can produce an amplified response to the stimuli. The pain from the burn weeks ago maybe continue to be painful due to a process in the brain called central sensitization. An imbalance between the nociceptive and anti-nociceptive systems can lead to failure to properly shut off the nociceptive input once the tissue heals. This allows the nociceptive neurons to keep firing, become more sensitive, and more efficient. When these nerve cells wind up, they can become so sensitive and efficient that normal sensory input from light touch or gentle pressure, and the normal chemical environment can all become triggers. With enough central sensitization, just about any normal sensation can become painful (3).
Central pain states also involve changes in the areas of the brain where pain is perceived. Chronic pain leads to changes in sensory maps of the body, such that the brain’s ability to localize a sensory input to a body part can become impaired. As the brain’s map of the affected area is reorganized by the nociceptive signals, it loses the ability to properly regulate the anti-nociceptive system. In essence, when somatotopic reorganization takes place, the brain loses the ability to properly localize the affected body part. And if it doesn’t know where it is in space, it can’t properly send it signals to shut off the incoming pain (6).
Areas in the brain involved in negative sensory experiences also undergo changes in chronic pain. The anterior cingulate cortex, the area where we experience suffering, has been shown to become extremely sensitized in chronic pain states (3). Most chronic pain patients note that they experience negative emotions at higher levels than before their injuries, and that their ability to regulate negative thoughts and negative self-talk is decreased. This is largely due to the excessive wind up of the anterior cingulate cortex seen in chronic pain. As a result, depression and anxiety are extremely common in cases of chronic pain (7). The presence of these disorders leads to changes in stress systems, including upregulation of the hypothalamic-pituitary adrenal axis. The increase in circulating stress hormones can lead to further promotion of chronic pain (9). These changes also promote neuroinflammation, which is inflammation taking place within the spinal cord and brain, leading to further loss of the ability to shut off the experience of pain (4).
The ultimate consequence of all of these processes is that central pain responses can become exaggerated and long lasting. Worse, the perception of pain can become decoupled from the sensation of tissue damage, and the perception of pain can exist long after the tissue has fully healed, or exist in response to normal background stimulation. Worse still, the emotional changes seen with chronic pain can spill over into all domains of a person’s lived experience, creating the changes in mood, motivation, and cognition seen in chronic depression and anxiety (3).
Patients regularly struggle to find successful treatments for their chronic pain, bouncing from provider to provider chasing progressively more invasive structural interventions without success. This is usually because both the patients and their providers fail to understand that their pain is no longer about what is occurring in the tissue, but rather is about circumstances in the brain that must be addressed for their pain to improve.
How Common is Chronic Pain?
The National Institute of Health (NIH) has shown that on average, 11.2% of adults in the US suffer from chronic pain daily. This number has slightly decreased from 14.6% of all adults who suffered from generalized pain that lasted over three months from the 1990s to the early 2000s. This type of continual pain and agony for patients has led to billions of dollars in lost productivity due to days of work missed. The NIH has estimated that over 100 billion dollars of productivity is lost each year due to this condition (5).
How Is Chronic Pain Usually Managed?
The most common form of treatment in chronic pain is medication management. This usually starts with nonsteroidal anti-inflammatory medications (NSAIDs), however when these ultimately cease to be effective the next step is usually prescription opioids. While these can be helpful for a time, they come with significant risks of addiction and overdose. Other medications that are commonly prescribed are antidepressants, Gabapentin, and cannabinoids. These have variable benefits and side effects. And while the experience of pain may be decreased, the underlying problem is never addressed by medications. The pain may briefly disappear, but will always return. Over time the effects of medications fade, requiring stronger prescriptions and multiple medications with increasing lists of side effects. In many cases of chronic pain, particularly with nonspecific chronic pain, studies show little to no effect on outcomes through the use of even opiod medications (5).
How is the NeuroRescue Program different?
We understand how debilitating it can be to live with chronic pain. We utilize a wide variety of therapies designed to improve your ability to appropriately manage sensory information. We look at every neurological system that is involved, and design customized therapy programs to improve the function in everything that has been affected. Your NeuroRescue Program is tailored to your unique neurological circumstances, and yours alone. We pull from a wide variety of therapeutic technologies and rehabilitation strategies, based on the best and most current research in neuroscience.
As part of your NeuroRescue Program, we use functional neurorehabilitation for treatment of chronic pain. We employ cutting-edge diagnostics and therapies to evaluate for neurological systems that have been damaged, systems that are over-firing or under-firing, and find ways to stimulate and rehabilitate the involved pathways to bring your system back into balance. We attempt to directly address the neurological causes of your chronic pain, rather than just manage the symptoms.
One of the main things your brain does is help you determine where you are in the world. Your brain uses inputs from your inner ear to figure out where your head is in relation to gravity and how it is moving. It uses inputs from your muscles and joints to figure out where your body is in relation to your head and what your body is doing. It uses inputs from your eyes to figure out where your body is in relation to the visual environment.
Your brain needs to put all of that together to make sense of where the world is, and where you are in relation to the world. It needs to be able to localize you effectively in the environment, in order for you to be able to respond to the environment properly.
Your brain organizes all of this information in terms of maps. There is a vestibular map from the inner ear, a proprioceptive map from muscles and joints, a vascular map of your blood flow, a visual map of the world from your eyes, and several others. Your brain needs these maps to be saying largely the same thing about where you are in the world at all times.
One often overlooked feature of chronic pain is that these maps often fail to match. Your eyes, inner ear, and muscles may be creating maps that say different things about where your head is in relation to gravity, and in relation to the external world. When these maps do not match, it is difficult to unconsciously localize yourself in the world.
And as research has shown, in chronic pain these maps tend to reorganize in ways that make it difficult for your brain to shut off incoming pain signals.
This is why many patients fail to fully resolve their chronic pain with most forms of treatment. Without addressing the problems in these maps, the underlying dysfunction remains, and the best they can hope for is to gain some control over their symptoms. We would much rather try to address the underlying cause. The functional neurorehabilitation we employ in your NeuroRescue Program is the key to rehabilitating the underlying issues that are creating and promoting your chronic pain.
As would be expected from anyone treating chronic pain, we use techniques of structural rehabilitation where appropriate, including physical therapy exercises, manual therapy techniques, and of course, spinal and extremity joint manipulation. It is folly to overlook the structural component of pain, and we are well equipped to address these aspects of your pain.
Of course, most patients that come to us suffering from chronic pain have already seen multiple providers to address their structural issues without success. The real results we see through NeuroRescue treatment of chronic pain come from addressing the central neurological factors that are at the heart of these conditions.
The techniques and therapies we use for treatment of chronic pain are almost too numerous to list. We use several technologies that fall under the heading of noninvasive neuromodulation.
One of these is repetitive transcranial magnetic stimulation (rTMS). This involves the use of an MRI-strength magnet to create a focused beam of magnetic energy that we focus on your prefrontal cortex. This is an area very involved in driving anti-nociceptive mechanisms, and can be very helpful in attenuating chronic pain (11). This therapy is also safe, comfortable, and effective in treatment of the chronic depression seen with chronic pain states (12). RTMS has been shown to be beneficial for treating many neuropathic pain states including central pain, pain from peripheral nerve disorders, fibromyalgia, and migraine. Research shows that rTMS is also a promising therapy for low back pain, orofacial pain such as trigeminal neuralgia, myofascial pain syndromes, pelvic pain, and complex regional pain syndrome (12).
We also combine visual feedback with body movement to help restore not only the maps of how your body moves through space but your visual representation of the world. Integrating neuromotor exercises with visual feedback can allow for greater ease of movement and reduced perception of pain (18).
There are other types of noninvasive electrical brain stimulation we employ where appropriate, such as Transcranial Direct Current Stimulation (tDCS) and Transcutaneous Vagal Nerve Stimulation (tVNS). These have also been shown to be effective in treating central pain states (10).
We use a number of technologies classified as photobiomodulation in treatment of chronic pain. These include low level laser therapy and light emitting diode therapy. Research shows these to be very effective in the treatment of a host of chronic pain conditions (16).
We use a number of different forms of electrical stimulation that can be considered electroanalgesia. There are specific currents and techniques for a host of chronic pain conditions. Research shows that these are extremely effective when combined with laser and LED therapies. Both of these have been shown to be safer and more effective for managing chronic pain than the long-term use of opiods (17).
When we speak of body maps being impaired in chronic pain states, your brain’s foundational map comes from the vestibular system. This system includes the inner ear and all of the neurological structures that tell you about where your head is in relation to gravity and how it is moving. Direct vestibular stimulation has been shown to be effective in reducing chronic pain states. Vestibular rehabilitation is an essential component of all of our NeuroRescue Programs (13).
Reestablishing appropriate body maps also requires appropriate integration of the visual system. There are many studies that point to impaired eye movements in conditions such as chronic neck pain (15). We direct special attention to diagnosing impairments in specific classes of eye movements and tailor your NeuroRescue program towards rehabilitating these deficiencies.
We also use virtual reality therapy in the treatment of chronic pain. Virtual reality therapy is a tremendous way to reintegrate visual, vestibular and somatosensory inputs from the body. Studies show that this can be a very effective way to treat both acute and chronic pain states (14).
How does the NeuroRescue Program work?
We design your unique NeuroRescue Program to be among the most comprehensive diagnostic and therapeutic protocols available today. We create individual NeuroRescue Programs based on a comprehensive analysis of every relevant neurological system and pathway, using gold-standard, cutting edge neurodiagnostic technologies and examination procedures and state-of-the-art therapies.
We begin with your Discovery Day, wherein we perform a comprehensive history of not only your condition, but your life on a timeline. This allows us to dive deeply into your case and see all of the factors that led to where you are now. It helps us uncover hidden problems and associated conditions that may be making it difficult for you to move your recovery forward.
Our examination allows us to identify the areas and pathways of your brain that are involved in your chronic pain. We begin by precisely quantifying the function of your visual, vestibular, and proprioceptive systems through computerized analysis of your eye movements, your inner ear reflexes, and your balance in a host of different sensory conditions.
We employ technologies including Videooculography and Saccadometry to measure several classes of eye movements. We use Video Head Impulse Testing to measure the function of your inner ear, and Computerized Dynamic Posturography to assess your balance in different sensory conditions.
We use NeuroSensoryMotor Integration testing to evaluate hand-eye coordination and cognition, and Virtualis testing to assess dynamic eye tracking and perception of vertical in a virtual reality environment.
We combine all of this with a comprehensive physical and neurological examination of your sensory, motor, autonomic, and cognitive systems. We review any relevant laboratory testing, radiological imaging, and prior neurodiagnostic testing, and integrate that information with our findings.
We use this information to identify which parts of your brain are working properly, which systems are struggling, and the precise point at which your systems fatigue.
We can then design a NeuroRescue Program that is unique and specific to your brain, and yours alone. Your NeuroRescue Program works to rejuvenate and reintegrate the damaged neurons and pathways in your brain. It works to improve energy, endurance, and functional capacity within your involved fragile systems.
We use our technologies and procedures to not only see what we need to address, but also when it is time to stop and let you rest. We address your impaired neurological function from multiple angles of therapy, and provide metabolic support to improve neurological recovery.
While we cannot bring back neurons that have been lost, your NeuroRescue Program allows us to take the pathways that remain and maximize their efficiency and endurance. And by focusing on the integration of systems, we can do more than just get pathways working better, we can get them working together again. This gives us our best opportunity to return you to living a healthy, vibrant, and fulfilling life.
Your Next Best Step:
To see if the NeuroRescue Program is right for you, contact one of our patient care coordinators to schedule your Discovery Day.
And remember, it’s never too late to start getting better.
