The Other Dismal Science

Reading up on neuroplasticity and chronic pain this morning. Seeing a ton of support for it, and a seeming wave of embrace among an almost "heterodox" PT community.
Read a long pamphlet by Greg Lehman that basically came down to: your pain is real, but the result of sensitization over time,
in which the brain learns to catastrophize low levels of pain into high levels of pain.
As a behavior analyst, I'm very familiar with the process of sensitization, and it makes sense that this would happen with pain. But when I apply it to my 35 year experience with CP, it doesn't fit very well.
 
 
I skateboarded intensely from ages 8-21 (often 4-5 hours/day), and got very used to putting myself in situations of severe risk of injury (riding a 12' halfpipe, jumping onto handrails, jumping over long flights of stairs). It was a normal day to have many falls to the ground in which I was unable to roll, etc. to safety and received high velocity, hard contact between my body and the ground, as well as at least 1 skin damage ("razzberries"), or tissue (whacks to the shins, hip). Occasionally I would receive minor concussions. (To be honest, much of what I learned was how to attempt more extreme maneuvers requiring placing my body in precarious positions that required multiple steps of precise timing *safely*. That is, to be able to attempt but then bail out before losing control).

But my neck injury (2" surfing laceration, 1989), steadily increased pain that radiated from cervical spine to thoracic region. The constant "hum" of soreness after the initial injury progressed into occasional flare-ups in which I felt awful. Best I can describe it is a feeling as if my spinal column was reaching out within my torso and gripping my extremities, pulling them in. Like iron ligaments were sending out hooks and ratcheting them inwards.

More and more frequently, intense skateboarding sessions would result in these flare-ups, as would strenuous lifting or prolonged periods of repetitive activities or even just sitting or staying in one position. Sleeping became a nightly battle, as I could lie in one position for no more than a few minutes before the pain became unbearable, at which point I would shift and it would subside temporarily. This would sometime happen for over an hour. I found a special way of using a specific type of pillow, and took to sleeping with an ice pack under my neck. Flare-ups also began occurring for no seeming reason. I would just wake up and feel like shit with a neck/head ache all day.

I eventually had to stop skateboarding entirely due to the inevitable post-session flare-up. (I could have simply "dialed down" to a less-impactful practice, however this was so much less satisfying than the joy I received from flying through the air, spinning, riding fast, etc. that lower-level "cruising" felt incredibly dull.

Fast-forward to today, where I basically barely do anything but very mild exercise, as intensity of activity directly correlates with the intensity of flare-up. My body is now in an almost constant state of flare-up, which is now a 24/7 pain level of 6/7 out of 10 (difficult to concentrate due to pain, difficult to work or engage in cognitively taxing behavior, pain radiating to entire body, palms and arches wanting to contract), with a maximum of 8 (light sensitivity, nausea).

The Pain Science/neuroplasticity model, and from what I gather its strong proponents in the physiotherapy world would describe this as increased sensitization, e.g. the structural issues have not worsened, but the brain has wired itself to sense pain more intensely.

That makes well-enough sense as a physiological/neurological description. But the model includes a structural skepticism (that the pain is not caused by structural dysfunction, but rather causes it – to the extent that it even exists), and theories about what causes the pain that I find problematic when I relate it to my own experience.

First, I have no idea if there is or isn’t a structural dysfunction unrelated to pain sensitivity /neuroplasticity.  The pain absolutely started within a couple months of the neck laceration healing.  While it often radiated secondarily to my thoracic region, it was always primarily located in almost the exact location of the initial injury, where a large subdermal scar now sat.  As the pain has grown worse and extended its reach over the years, it’s still primarily located there. 

Pain Science (the general model) would say this is phantom pain created by neuronal pathways as a result of avoidance, or negative reinforcement, i.e. engaging in lesser activities is reinforced because pain is diminished.  But the presence of dysfunction/pain in my neck could also result in compensation in other muscles not as efficient in performing the activity leading to weakness in the primary muscles, or the misuse, or overuse of other muscles.  PS advocates will point out that the evidence in populations with pain indicate that apparent structural dysfunction does not generally correlate very well with pain levels.  Some people with poor posture feel pain, while others do not.  Some people with good posture feel pain, while others do not.  This is likened to phantom limb pain syndrome.

To continue the reasoning of the model, what is causing some people to avoid possibly painful activities while others do not.  There is evidence of correlations to demographics or gene types.  But a popular explanation in PS (a la John Sarna and others) is a sort of Freudian psychoanalytic idea that repressed emotional trauma primes people for avoidance.  So, when I am lying in bed and can’t sleep because the pain arrives shortly after laying down, my unconscious memories of fear and distress stemming from some past event have been training my brain to become hypersensitive to movement or even just subtle and normal nociceptive signals from my body and experience them as more and more intense pain over time.

Well, that’s a mindfull.  And I’m starting to get uncomfortable.  Since we don’t really know what is causing my pain (e.g., there’s no broken tissue, or disk slippage, etc.), it *could* be possible that its psychic trauma.  Of course, the treatment is a mixture of increased activity (desensitization), CBT (relaxing my overzealous mind/emotions), and deeper psychoanalytic work (uncovering the traumatic “ghosts” that I have repressed and setting them free, so to speak.
 
I suppose all of this could be true.  But it could as easily be true that I have some weird unique problem with my neck due to a serious injury and a large mass of scar tissue that interferes in some way with my body’s ability to function properly and thus causes a cascade of compensatory dysfunctions, resulting in pain, tiredness, stress, etc.
 
The psychic trauma angle feels most unreasonable.  But so too does it’s apparent mechanism of action.  I’m not sure I was traumatized much more than most.  Although I did have a somewhat chaotic homelife as a child – mother and father fought often with lots of screaming and throwing things, there was no abuse, and while there was some “acting out behavior” – early drug use, I did quite well in school and was relatively happy.  To be honest, the most traumatic thing in my life has been the pain, and now we’re circular.

But what about avoiding activity for fear of pain?  I previously described my skateboarding in detail to address this point.  Not only did I not avoid pain, but for multiple hours a day for over a decade I *actively* placed myself in situations where pain was highly likely.  I have a very long history of overcoming negative reinforcement of pain through (per matching law) by receiving rewards from activities in which pain is likely but success is highly motivating (accomplishment, thrill of uninterrupted movement). 
 
I suppose I could still be stuck in an avoidance cycle.  However, I’m not sure why it would be trauma, and why it would have not only persisted but steadily worsened over the decades.  I should note that I’ve tried just about every therapy under the sun, often multiple cycles (starting my 4th round of PT again today).
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I don’t know, I’m just a layperson, albeit one with much first hand experience.  Trying to parse the research is difficult, especially when they seem to be contradictory: good posture vs. posture doesn’t matter, listen to the pain versus ignore it, etc.  The science in general seems inconclusive and spotty, with anecdotes and miracle cures abound.
 
So, I’ll keep doing my exercises, pushing myself to mild exercise, trying to do what I love when I can.  Be a good husband and father, friend, employee, and human.  I keep watch for depression and make an effort to ignore the negative thoughts and look for the positives.  But I’d be lying if the low-level anxiety isn’t there.  I started writing this at 5am when I woke up and couldn’t fall back to sleep because I was too sore and my Bluetooth sleep headset was out of juice.  Right *now* I’m at about a 6, which is fine.  Worrying about income is the biggest concern, and I’m kind of in this weird purgatory before seriously having to go out on disability.  At age 50, which is relatively young.  But I’ve worked in pain all my life and there’s only so much I can take, especially as bad as it’s gotten.  One day at a time, as they say.