Pain, the Brain, and Rehabilitation

Last night as I spoke to an arthritis support group about myofascial and chronic pain, I was able to share information about the research that has taken place over the last decade that describes associations between the brain and pain. The simple idea that being "distracted" by a task eases the perception of pain brought about a story from an attendee about how riding a horse, because it required focused, unwavering attention and because it was immensely enjoyable, was an activity that reduced the rider's pain dramatically. Mentioning that playing with grandchildren or pets could be a wonderful distraction brought about smiles and nods of agreement.

Within the realm of pelvic rehabilitation, we face many patient scenarios that include chronic pain and the need for education about the brain's ever-present role in pain. A recent literature review for a pharmacology course confirmed that research continues to present fascinating advances in imaging and brain changes in response to such pain. Here is a link to a full text article about distraction and pain and the response to functional MRI (neurofeedback) with attempts to modify pain.

According to Apkarian and colleagues (who have completed pioneering work in this field) some of the topics that have been studied in relation to brain structural changes include back pain, fibromyalgia, chronic regional pain syndrome, knee pain, irritable bowel syndrome, headaches, female and chronic pelvic pain. Here is a terrific article by Apkarian that summarizes much of the development of the evolving theories about pain and the brain. The basic summary of the article includes the thought that chronic pain causes abnormal changes in the gray and white mater, and in the relationship between the two. Lorimer Mosely wrote an interesting post about Dr. Apkarian back in May, you can access it here.

Different types of chronic pain will shape the pain uniquely, and the changes can take place rather quickly or over a period of several years. In women who have endometriosis, As-Sanie and colleagues demonstrated that women with chronic pelvic pain have brain changes in multiple areas associated with pain processing, and that women with chronic pelvic pain (and not endometriosis) have changes in a separate site. The exciting news is also that within the research, reducing the pain also appears to positively affect the brain changes.

As professionals involved in helping our patients understand the complex and remarkable experience that is healing, we have a responsibility to continue to learn ourselves and to figure out how to include the brain in our approaches to pain. The Neuro Orthopaedic Institute ( has supplied various educational opportunities and resources that assist in accomplishing this type of education. There is a new resource from NOI about graded motor imaging, worth checking out in addition to the patient education book titled "Explain Pain" with which many of you are already familiar. While teaching in Seattle over the weekend, experienced course participants generously shared their strategies for educating patients in concepts of pain and healing. Here is a highly recommended video available on YouTube that explains common pain concepts while using great visual sketches to get the ideas across.

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