What We Say Matters The Role of Pain Neuroscience Education (PNE) In Treating Chronic Pain Sean Smitham, PhD Clinical Psychologist Northwest Spine and Pain Management

Intro: Rubber Arm Experiment What is going on there? The experience of pain is real even when there is no actual tissue damage. Pretty cool right? But how can that be?

But First…. Pain is always real. Knowledge is power. When patients are referred to pain psychology, they almost always arrive somewhat defensive. They’re suspicious that we or their referring provider believes their pain is “all in their head”. It is this resistance and the corresponding “all in their head” neurotag that is our first target in the psychological treatment of pain. So, what’s a neurotag?

Pain Neuroscience Education (PNE) Therapeutic Neuroscience Education (TNE) Today I want to 1) summarize the science that helps explain what we saw in the opening video and 2) give you a brief glimpse into why we believe psychology has an important role in treating chronic pain – not just managing pain and not just coping with pain but treating some of the causes of chronic pain.

6 Big Ideas Behind the Neuroscience of Pain Single cell insufficiency Neurotags (Neurosignature) Dynamically created (experience) / Dynamically activated (cooperation and competition) Neuromatrix Distributed Processing Neuroplascticity The Neuroscience of Pain – Ridiculously simplified. If you understand these 6 Big Ideas you’ll have a good overview of the power and purpose of Pain Neuroscience Education.

6 Big Ideas Behind the Neuroscience of Pain Single cell insufficiency Neurotags (Neurosignature) Dynamically created / Dynamically activated Neuromatrix Distributed Processing Neuroplascticity

Three friends “Let’s meet downtown and catch a movie” Each friend “taking the bus” (same behavior, different sequence of neurotags (i.e., neurosignature)) Each moving simultaneously “meeting downtown to watch a movie” = neuromatrix

100 billion neurons 125,000 miles of neurons 1000 to 10,000 synapses for each neuron

6 Big Ideas Behind the Neuroscience of Pain Single cell insufficiency Neurotags (Neurosignature) Dynamically created / Dynamically activated Neuromatrix Distributed Processing Neuroplascticity

Neuroplasticity can by “hacked” by chronic pain Neuroplasticity can by “hacked” by chronic pain. Processing power usually reserved for other functions may be “reassigned” to focus on pain. The pain neuromatrix expands and new pain neurotags may be created (the sticky nature of the pain neuromatrix.

Eye Blink “Reflex”

Journal of Neurophysiology Iannetti, et al., 2014, 2015 Wallwork, et. al., 2016. Journal of Neurophysiology Large Size of Eye Blink Response Originally thought to be a reflex mediated by the brain stem Small

Journal of Neurophysiology Iannetti, et al., 2014, 2015 Wallwork, et. al., 2016. Journal of Neurophysiology Size of Eye Protection Reflex As perceived threat increases (neurotag), response increases. Far Near Distance to Eye

Journal of Neurophysiology Iannetti, et al., 2014, 2015 Wallwork, et. al., 2016. Journal of Neurophysiology Size of Eye Protection Reflex Hand close to eye, but strong barrier. Response is less than hand far response. Have the subject close their eyes and then sneak the barrier away – same small response. But replace the strong barrier with a weak barrier and we the blink response is strong again. You cannot fool the nervous system. Important note: notice the strong/weak barrier is based on a learning history about the properties of strong/weak materials. Cognitive historical neurotag contributing to the mind’ Strong Weak Barrier

Head Stimulator

Intensity Bayer, TL, et al. Pain. 1991

Intensity 10 Pain Min Intensity Max

Intensity 10 The power of authority figures Pain Min Intensity Max

Pain increases more than before Intensity 10 Multiple neurotags increasing the experienced pain – pain neuromatrix. Dynamically activated Pain Min Intensity Max

Recording 10 Pain Min Intensity Max

(Mental Research Institute, Palo Alto, CA circa 1966) Glip Glop (Mental Research Institute, Palo Alto, CA circa 1966)

Sample PNE Lesson Sensitive Nerves and the Pain Neuromatrix

Patient as Partner Shared Decision Making

Now to take a more detailed look into the practical ways pain psychology aims to treat patients

Putting It All Together Key Domains of Pain Care

Take Home Point #1 The mind is always working for your survival. Always. Pain is about the protection of the individual. It is an output of the mind and is influenced heavily by context (current, historical). Pain does NOT accurately communicate information about the state of the tissues. (e.g., Rubber arm, Brain stimulator, Wrist Zap)

Take Home Point #2 How we and our patients understand and talk about pain matters Thoughts, Feelings, Beliefs = internal messages that can increase (e.g., Brain Stimulator, Glip Glop)

Take Home Point #3 Knowledge is power When people learn why they hurt – they hurt less.