On Pain And The Biopsychosocial Model

I wanted to write this article because I wanted to further my understanding of pain and take a stab at capturing it. It’s easy to say you have pain because of bone spurs, disc herniations, arthritis, joint degeneration, or because the Knicks haven’t traded Carmelo. While all of these things sound ominous, they are not the exact reason for why your certain pain exists. Pain is a highly complex part of being a human and there are many factors to it. A good analogy would be if you were to ask five economists how to fix an economy. You’re going to get five different answers. It’s not just physical loads but also social, psychological factors involved as well. This is where the Biopsychosocial model comes in. The Biopsychosocial model takes into account the dynamic and complex interactions among physiological, psychological and social factors that contribute to individual experiences of pain uniquely (https://www.futuremedicine.com/doi/abs/10.2217/ebo.13.469). Ironically this model has been around for more than 30 years and now is being taken into consideration. I’m going to do my best to explain first how pain is mapped out in our brain and how the complexity of these different factors overfill our metaphorical cup which could lead to pain

 

Image result for load injury and pain

There are quite a lot of variables involved

    Lorimer Mosely and David Butler, authors of Explain Pain, have explained that pain is an output by the neuromatrix in our brain. The brain has to take inputs from proprioceptive, vestibular, and visual information systems to report the positions of all the different body parts. As I write this, my mind is literally blown because that is a ton of responsibility and only our brain can do that.

 

 

Pain acts as an alarm system that the brain sends off to protect the individual from a supposed threat. While we know injury happens when a load exceeds the capacity of those tissues to withstand that load, there is more to pain than the simple biomechanical model. The neuromatrix in our brain is responsible for coding literally every conscious experience with a neurotag whether it’s eating a savory great cut of steak or feeling the need to stratch a poison ivy rash. It is the patterns of our brain activity that create pain (Lehman)

 

 

 

 

 

 

 

 

 

 

 

The neurotags that code for pain in our everyday conscious experience can either activate or not. This would help explain why those people who have MRI examinations of abnormal joint structures such as disc bulges and herniations could be completely asymptomatic to any pain. Here are some studies exemplifying it. Study 1, Study 2, Study 3.

The main difference between those who experience chronic pain and those who don’t experience it goes back to the software conditions of how the brains process it and make sense of it. The pain pathway that our brain sends out is individualized based upon how one maps out and associates things such as movement, feelings, and expectations. If one does not have a clear representation of how their brain maps specific regions of their body when they move such as not being aware or cognizant of one’s hip and where it is in space then we are given unclear signals. Add this to someone who has chronic pain, which actually changes the way the brain controls perception and movement, and the pain spreads. This pain spreads because of the imprecise input of the fuzzy and unclear body maps. The imprecision of the body map makes it difficult for one’s brain to locate or identify what is truly going on.

Image result for it's fine meme

 

Pain spreads because your body is trying to make sense out of nonsense so it might as well say “Might as well have pain here in your knee too since you have no awareness and or control of whats going on in your hip and ankle”.

This software fault of having unclear body maps exemplifies a concept known sensory motor mismatch. Sensory motor mismatch deals with how whenever we make a movement, the brain predicts the sensory information that will result and the predicted feedback is compared to the actual sensory result to determine if the movement was successful (Hardgrove). If the sensory data consistently conflicts with the prediction then the body maps are smudged or inaccurate. The confusion of sensory motor mismatch can cause the perception of threat and plays a role in chronic pain conditions.

Image result for danger zone archer meme

Just like regulating the body’s hormone levels, blood and temperature, the brain needs to regulate its ability to form clear pictures of what is actually going on in the body. Again, the brain takes in all the inputs from the different systems of the body and instantly processes and filters them. Once analyzed and integrated unconsciously, the brain asks two questions. The first is “How dangerous is this really?” and the second is “Is pain necessary for protection?” Pain is the result on how the questions are answered. Interestingly enough the brain doesn’t have to only choose pain as an output but can do other outputs which serve as protective behavior such as limping, flinching, muscle guarding or the fight or flight response. It definitely helps to develop a good relationship with how one maps movement and be aware of you move in space

Image result for Check yoself

This is why Feldenkrais or any type of Somatics training is excellent because for the first time we are slowing things down and making people truly aware of their entire bodies in space and how they map their own movement. Image result for Somatics    The simple motions help people develop clear maps of the limb moving in the three-dimensional world that we inhabit. People who are not aware of their body maps don’t have a good perception or feel for their own basic movement. Those with chronic pain have been shown to have difficulty in various tasks that require good perception of body location and motor control including

  • locating the outline of the back and position of the spine
  • two-point discrimination
  • right/left discriminations of pictures of body parts
  • reducing postural sway in response to disturbance
  • control of pelvis and low back

https://pdfs.semanticscholar.org/4332/ca068f811ccf315b7a708cd2bcaae6515f78.pdf

    It’s a two-way street between perception and pain and much research has to be continued.  Do problems with perception and movement cause pain or is pain causing problems with perception and movement? These two questions need to be deciphered in order to understand whats going on in the body. Here is probably the most interesting and counter-intuitive notion regarding pain. Pain has more to do with sensitivity than about damage!

Image result for jackie chan meme

Pain is an output depending on your sensitivity threshold to a specific movement or specific way of doing something. This could be flexing your spine or just the chronic anxiety in going to a job that you absolutely hate. Some key factors that go into that threshold are how much volume is being stressed, how ready are you, and if it is progressed too quickly. You don’t have to apply these key factors to just the weight room but also to situations in life as well. This threshold could be likened to the analogy of an overfilled cup.

Image result for overfilled cup analogy

Once that cup is filled to the brim and continues filling with liquid, it’s going to spill over. You might be filling that cup differently since pain is multidimensional. You can have a lot of physical, mechanical, emotional and social stressors and have no pain. But at some point, a sudden increase in one of those stressors or a new stressor puts you just over the edge and the water flows out and now you have pain. Often people will have more pain when there are changes in the stressors in their life. It is the inability to adapt to the new stressor that contributes to pain not necessarily the amount of the stressor in your life (Lehman)

To further expand upon the complexity of the pain we need to be aware of some of the psychological and social factors in The Biopsychosocial model. I believe they are the hardest to pin down because not only are they the most insidious and hard to see but also because it’s difficult to quantify them and test them out. You would need to walk in that person’s shoes or follow them around all day or weeks to know what dialogues they are having within themselves and understand the situations behind their lives. This goes more into more difficult waters to traverse such as the way they were brought up and the traditions, what they were made to believe, especially about themselves and many other things hard to quantify.

Image result for aint nobody got time for that

There are some statistics that we should be aware of and how they tie into pain into this model. Chronic pain is often associated with negative emotions and as many as 50% of patients with chronic pain have a co-morbid depressive disorder (Study on Depression and Pain). This study detailed that those with depression experienced their view of pain to be augmented larger than previously experienced. This has to be a display of changed neuro-pathway of pain and how largely sensitive they become to pain. Also, they stated one of the biggest factors in a cognitive process is negative expectancy. This is a self-fulfilling prophecy I like to call “always expecting bad stuff to happen to you so you can confirm your negative confirmation bias about yourself”. Many of us have probably in this situation by also telling ourselves “I told you so”. Anxiety is another negative emotion frequently seen in patients with chronic pain, and which may lead to maladaptive pain behaviors aggravating and maintaining pain and disability (Fear-avoidance model of chronic musculoskeletal pain).  Anxiety could be something that changes the way you move and could contribute to pain because of the patterns it causes you to partake in.

Some sociocultural contexts attributed to pain could deal with how one expresses pain. This would deal more with behaviors of how they were brought up by parents, significant others, and other operant learning process (http://www.jpain.org/article/S1526-5900(10)00746-7/fulltext).  Acculturation, which entails adaptation to a new set of cultural norms, beliefs, and values, (Rethinking the concept of acculturation: implications for theory and research)is inherently stressful, especially for first-generation immigrants (Generational differences in vulnerability to identity denial: The role of group identification). The stress of acculturation, in turn, may influence pain sensitivity (Ethnic differences in physical pain sensitivity: role of acculturation). An example could be the unnecessary pressures that parents put on their kids to get highly stable jobs or achieve and adopt all the cultural norms of that family because it’s expected of them. This was because they lived in a different time so they assume their children live in that same time as well. Another interesting study took into account personalities of subjects and found that certain personalities such as introversion and intuition dramatically increased spine loading compared with those with the opposite personality traits such as extroversion and sensing. Does this mean that introverts and those who are intuitive on the Myers Briggs scale are going to experience more pain compared to their counterparts? No but I think we have an understanding of a factor that fills their cup. Again, pain is a complicated matter and there are many variables that go into that sensitive threshold of experiencing it. The social emphasis and how it’s linked to pain is highly individualized and would need its own post to be elaborated further.

From Greg Lehman’s Recovery Strategies -pain-guidebook, he recommends three things to look at and or consider changing
1. How much you are doing
2. How quickly you progressed
3. What are you currently ready for.
#3 is very interesting. If you are fearful, hesitant or
believe that you can’t adapt then your readiness will                                                                    be decreased and this will influence what is too much                                                       (Lehman)

The body is an ecosystem. We are more than just some parts working together like a car. It’s amazing how we move and manifest our emotions in our muscular system. While pain is a not so pretty part of the experience in life, by learning how to desensitize to certain stressors and building the capacity to cope with them we can effectively limit and get out of pain. As humans, we are built to move and adapt.  To quote Thomas Hanna, the founder of Somatics, “If you can feel it, you can change it”

 

Good old Kenny Wayne Sheperd never hurt nobody.

Enjoy!

 

 

References

A Guide To Better Movement- Todd Hargrove

https://www.futuremedicine.com/doi/abs/10.2217/ebo.13.469

Recovery Strategies – Pain- Guidebook by Dr. Greg Lehman

https://spine.osu.edu/sites/spine.osu.edu/files/uploads/Publications/2000/Ergonomics_2000_43-7_880-902.pdf

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