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10 Articles in Volume 9, Issue #8
Adjunctive Psychiatric Pain Management Treatment
Deep Cervical Muscle Dysfunction and Head/Neck/Face Pain–Part 2
Hackett-Hemwall Dextrose Prolotherapy for Unresolved Elbow Pain
Intradermal BTX-A Reduces Frequency and Severity of Pain for MMD
Keeping Prescribers on Board if Certification Becomes Part of REMS
Magneto-Laser Therapy of Pulpitis and Vertebra Column Osteochondrosis
Pain and Self-regulation
Pain Care of Severely Neurally-Compromised Patients
Simultaneous Use of Opioid and Electromagnetic Treatments
The Experience of Pain

Pain and Self-regulation

Humans have an adequate potential for learning self-control of a variety of bodily functions and the resulting ability is a function of adequate teaching, learning, and practice over a period of time.

Pain has been variably defined by WHO and other learned bodies by consensus. While all these definitions are valid, they have added little to classic time-respected definitions across the centuries. One of the most elegant of all is attributed to the Chinese sage Lao Tse, the founder of Taoism: “Pain is the penalty for infringing on the principle of nature.” Infringing on homeostasis may result in pain among, other consequences. Pain is a signal of suffering until one redresses the homeostatic disturbance that created it. Like ripples in a lake when a stone is thrown, the vital organs respond, each one in its way, to the presence of pain.

Autonomic Response to Pain

The responses are quite predictable: muscles will tighten, breathing will become rapid and shallow, the heart rate quickens, the blood pressure usually rises, a cold sweat may occur, the skin temperature may drop, the pupil enlarges (midriasis) and, in some extremes, there may be incontinence. In addition, the endocrine and exocrine glands respond in predictable fashion.

This massive response is quite similar in states of pain as it is in the states of ‘fight or flight.’1 The body seems to want to withdraw from the noxious factor that generated the pain. Furthermore, it will remember the event and reproduce the responses very quickly any time there is a recurrence of similar experiences.

A simple example involves pain in association with muscular injury of a limb. The initial response to the injury and consequent pain is the instinctive behavior of ‘splinting’—the generalized spasm of the affected area and not moving the limb. This behavior results in reduction of the pain or avoidance of worse pain. The secondary response is that of ‘protective guarding.’ Just as instinctive and predictable, the contra-lateral limb takes over, as much as possible, the function of the injured limb. These are examples of instinctive human behavior, probably related to an archaic neuro-motor engram—itself related to the survival instinct.2 Is the muscular activity the only expression of pain and its perception? The SNS and PNS—at times in tandem and most of the time in opposition—contribute almost instantly with multi-organ behavior related to the presence of the injury and of the pain.3

The splinting and associated pain are the starting points of reactions such as increase in the heart rate; blood pressure; respiratory rate; and change from abdominal to thoracic breathing in association with exertion of the accessory muscles of respiration; ‘cold sweat’; vaso-constriction of the lesioned area; and reduction in the peripheral circulation of ‘non-essential’ organs; etc. Given the acute presence of pain, the body gets ready for ‘flight’ and survival. There is practically no part of the brain that is not involved in the response. If one takes the presence of acute pain away—such as with anesthesia—most, if not all, of the ‘flight’ responses return to the baseline state in a very short period of time.

Whereas pain is usually the result of injury or lesions of varying etiology, in the post acute phase, it can take on a life of its own. The lesion or injury may resolve and yet the pain may become chronic and unrelenting. It has the potential to augment its ascending and descending neuro-sensory pathways in intensity and anatomic extension. The phenomena of hyperalgesia and allodynia are well known to the clinicians who deal with chronic pain. These phenomena are probably related to changes in the pain pathway CNS engram, whereby the pain intensity perception is greatly exaggerated and other sensory modalities such as touch, pressure, vibration or temperature sensation are replaced by hyperalgesic pain perception.4

There is some evidence that fibromyalgia may be a condition where there is dis-inhibition of neuro-motor pathways resulting in widespread pain and co-activation of inferior muscle girdles supposedly at rest while muscles of the superior girdle are in motion.5,6,7

Where do the perception of pain and the ability of self-regulation come together? To begin with, we have to expand our understanding of the concept of self-regulation. The Earth was flat for a long time until it was found to be round—and, even then, the courageous people who officially announced the concept suffered or died in the hands of dogmatic and self-serving officialdom.

Self-regulation

A functional definition of ‘self-regulation’ is that of the innate ability to modulate and control body and mental functions.1 Self-regulation is an essential homeostatic process. It is a vital component of the autonomic homeostatic functions of survival and reproduction.2 A number of vital organs depend on autonomic function and are regulated by autonomic controls primarily responsive to the ‘instructions’ of the sympathetic (SNS) and parasympathetic (PNS) systems and only secondarily to the central nervous system (CNS). Vital functions such as respiration, heart rate, blood pressure, sweating, excretory functions and temp-erature control may be found to be intact in conditions such as coma where the higher brain functions may not survive.

The body has the innate ability to self-regulate, when it is taught and trained to do so. Infants and young children are incontinent until they are toilet-trained, most of them very successfully early in life (usually by 12-16 months in Europe and 24-plus months in America). Of interest is that the training is done by parents or other ancillary persons who have no medical training, nor do they need double-blind control repeated studies (published in peer-reviewed journals) to proceed with the control of the urinary and fecal incontinence. The small minority of children with pathologies not enabling them to be toilet trained in a reasonable amount of time, of course, need medical attention.

If infants and small children can very rapidly learn to ‘self-regulate’ complex body systems involved in bowel and bladder control, people of any age may be able to self-regulate other systems, if taught properly to do it. Children who are taught yoga or other meditation systems of self-regulation, e.g. heart rate, breathing, mental focusing, etc, matter-of-factly learn the procedures and furthermore the training is not forgotten (assuming continued health).

In our culture, we have yet to learn to do such training, however, most people learn how to swim or bicycle and never forget to execute those activities. Needless to say, bicycling depends on our innate sense of equilibrium and swimming is a vey complex activity that involves the breathing cycle and neuromotor control involved in avoidance of sinking and drowning. These examples serve to demonstrate that we have ample abilities of self-control, should we (a) be taught to use them, (b) be motivated, and (c) be encouraged to use them.

Discussion

Self-control requires positive motivation and active participation of the learner through the process of learning. When pain is present, the individual can learn self-control through the process of control of various other symptoms or body reactions.8,9 The whole concept and process is more easily acceptable in the Eastern societies and cultures than in the Western culture. We are still a society in which the ‘apprentice-healers’ usually learn to treat people passively with pills, suppositories or injections rather than teaching and enabling them to actively self-regulate and control their symptoms. Patients learn to expect (passive) medications from ‘good’ doctors rather than active training on how to become masters of their own bodies and minds and control symptoms through self-regulation.

One important premise is that the first duty of physicians and other healers is to treat the causes of the pain and to cure them whenever possible. That being said, the next duty is to offer as many choices as feasible in terms of pain control. The healer needs to explain to the suffering person that passive treatment rarely results in any but temporary relief of pain and that, at significant financial cost, especially in chronic conditions. Far from putting down the benefits of anesthesia or analgesia, cost-benefit analyses may need to be examined and re-examined by healer and sufferer at appropriate intervals. Issues of decreasing effectiveness of medication over time, habituation and even addiction need to be reviewed at appropriate intervals. There is no contra-indication to the concomitant use of dif-ferent pain modalities so long as they do not interfere negatively with one another.

Alternative pain control methods may need to be presented when the passive modalities do not give the expected beneficial results over a short period of time—for example, three months of treatment. The healer may need to assess the patient’s ability and motivation to undertake active methods of treatment. Such treatments may involve a considerable array of methods ranging from active physical/occupational therapy to a variety of reputable self-control methods—including hypnosis, yoga, qui-cong, tai-chi and ‘biofeedback’ of neuro-muscular and autonomic function controls. Acu-puncture and other passive methods may have their role, especially in the hands of well-trained clinicians. While it would be desirable, it is highly unlikely to find a pain practitioner who is qualified in all aspects of treatment modalities. Therefore, ethical practitioners should know when the boundaries of their healing art limit further effectiveness and refer the patients to other appropriate healers.

The person who is motivated to undergo active treatment for pain control needs to know that one cannot expect instant results.3,10 ‘Mind over matter control’ is learned as a skill. Any skill requires adequate discipline and a time factor for its proper learning. Once learned, the skill needs adequate ‘practice’ in order to maintain or enhance the effectiveness of its CNS engram.11 One cannot imagine a musician who does not rehearse, in a disciplined manner, one’s musical instrument skill before playing any piece of music for an audience.

The pain sufferer who is motivated to learn an active modality of self-control needs to understand that the new skill will not only reduce the intensity or frequency of the pain but it will also enable the person to work towards re-establishing one’s active role within the family, social circle and the work environment. Unfortunately, one ‘malignant’ aspect of chronic pain in our society is the change of the role of the pain sufferer within the family and social/labor circle. It is likely that only people who wish to return realistically to a normal life-style are appropriate candidates for learning self-control of pain.

It would be appropriate to enlist the experience of pain practitioners involved in yoga, tai-chi, qui-cong, acupuncture and other such healing arts to describe how they teach self-control to pain sufferers.

Biofeedback Testing of Physiological Causes or Sequelae of Pain

Adequate testing with biofeedback instrumentation is feasible for the pain practitioner with a variety of modalities. Such instrumentation is available today and multiple modalities may be used concomitantly—either in the investigative or in the treatment mode. In the following tutorial, the pain of headache is presented as an example on how biofeedback techniques can be utilized to teach patients to minimize pain.

Headache is a common condition. It has multiple etiologies. Most frequently it is related to dysfunctional vascular control of the meningeal blood vessels and its consequences, or to ‘spasm’ of the head and neck muscles.3,12

Biofeedback testing may include the following:

  1. Vascular testing. Meningeal arteriolar vaso-spasm may be tested indirectly on facial arterioles such as the pre-auricular or extra-ocular/frontal arterioles. Abnormalities may be unilateral or bilateral. After all, the expression ‘migraine’ derives from the Italian word ‘hemicrania’ (i.e. ‘half the head’), indicating the variety that involves headache on only one side of the head.3,9
  2. Muscular testing. Abnormal increase in head and neck muscular tonus frequently accompanies tension headaches, including TMJ, etc.1,13 Surface EMG (SEMG) may be utilized to test the salient muscles through activity and rest phases. True spasm is found when the muscular activity does not vary between the ’active tonus’ and the ‘resting tonus’ and the activity is abnormally high (compared to the expected potentials from the data base).11,14 A muscle in spasm is a harbinger of pain, since it cannot relax and regain its normal oxygenation, nutrition and energy.10 Furthermore, such a muscle cannot properly get rid of catabolic products, some of which further enhance the pain mechanism (e.g. lactic acid). Commonly, muscles such as the mastoid, the temporalis, frontalis and corrugator—or its lesser variant, hypertonus—are found to be in spasm when assessed with SEMG.15,16
  3. Breathing pattern and cycle. Pain in the acute phase is commonly accompanied by a change in the respiratory pattern—from deeper abdominal, diaphragmatic breathing to shallow, thoracic breathing. Chronic pain often leads to thoracic breathing and overuse of the accessory muscles of respiration, such as the trapezius and sterno-cleido-mastoid and the scalenes.9,17 These muscles can be tested with SEMG through the breathing cycle. Special belts connected to the equipment can be applied to the thoracic and abdominal areas as part of the testing. One can investigate the ratio of abdominal/thoracic breathing pattern and possibly respiratory volume with this method.
  4. Heart rate and blood pressure. Cardiovascular effects stem from pain—including headache. The sympathetic nervous system (SNS) is in ‘overdrive’ and pulse and blood pressure may increase during episodes of headache. Both parameters can be assessed during the overall testing.3,9
  5. Temperature and the electrodermal response. Responses may vary according to the SNS reaction during headache episodes. Both parameters can be measured with biofeedback instrumentation.3,9

To summarize the paragraphs above, headache may be accompanied by a number of simultaneous muscular, vascular, respiratory, cardiac and other effects. Most typically, the headache sufferer is quite unaware of the signs and physiologic changes involved in these effects. The sensation that one feels is quite uniquely that of the resulting pain.

Biofeedback Helps Teach Self-Control to Pain Sufferers

The clinician guides the patient through one or several processes of awareness building while the person is connected via different electrodes to the equipment and indirectly to the computer monitor. Again, we will use headache pain as the example. It is fascinating to observe how the intensity of the headache can be modulated down with the ‘biofeedback’ re-education treatment. In general, the usual session of biofeedback treatment lasts no more than 20 minutes.

If facial or cervical muscular spasm is found, the person is connected via electrodes to a muscle of the body that is functioning normally in terms of resting and activity potentials. The person is taught for a few minutes how to modulate the amplitude of contraction and relaxation of the muscle in question. When one becomes proficient at it, the electrodes are connected to salient muscles of the head or neck associated with the headache. Even if the learning process is new, the person can learn in the first session how to modulate the affected muscle better and reduce the amplitude of the spasm or hypertonus.

In general, headache sufferers need about six sessions of training with SEMG biofeedback to control the salient muscle’s activity and resting tonus. If the headache is mainly of ‘tension’ type, the newly learned muscular tonus control may considerably reduce the intensity, and even the frequency of recurrence, of the pain. The new conscious memory serves to control the headache pain in its incipient phase and either abort it altogether or reduce it considerably.

Vascular type headaches (i.e., migraines) have been the subject of biofeedback vascular training/treatment for over 40 years. In general, electrodes (pletysmography) are connected to the fingers and the person is facing either a computer monitor with line graphics of the amplitude of vascular dilation or contraction or with a choice of computer graphic games. In all ‘game’ cases, one wins the game if one becomes able and proficient at vaso-dilating the salient blood vessels.3,4,9

Most children (of all ages) prefer to play a fun game and win. Moreover, the ‘winning’ is accompanied by considerable, or complete, relief of the pounding headache. For those who prefer not to play a game, the training centers around learning to increase the slope of the curve on the monitor; the curve slopes upwards as the blood vessel dilates. The sessions last around 20 minutes and, in general, one needs about 6-10 sessions to become proficient. The conscious learning is applied to any incipient migraine in order to reduce its intensity or abort it altogether.

Respiratory control for headache treatment is a very useful tool. The patient wears an abdominal and a thoracic belt. The belts are connected to the biofeedback equipment and the equipment to the computer and monitor. The patient is trained to modify their breathing from a thoracic type to an abdominal type and is also taught to reduce the number of breaths per minute to under 12. The whole process serves, directly and indirectly, to reduce the effort and over-utilization of the respiratory muscles and especially of the accessory muscles of respiration.3,4,9 The second component of breathing control is that of SEMG biofeedback training of those muscles. While general training with SEMG biofeedback has been described above, the particularity in this case is that muscles such as the upper trapezius and the SCM tend to go easily into spasm and are prone to develop trigger points in relation to the headaches. Many times, it is difficult to establish (chicken and egg fashion) whether the headache preceded the muscular spasm and trigger point development or vice-versa. Whatever the cause, self-control with biofeedback training of these muscles is quite essential in successful headache treatment.1,4,9

If the heart rate and blood pressure are found to be adversely affected in headache, appropriate instrumentation can be utilized in similar fashion to that described above to reduce or normalize both tachycardia and hypertension.3,9 Computer type games are generally preferable to graphic lines since the feeling of ‘winning’ is a great motivator to play the game until the cardiac functions normalize and the intensity of the vascular headache diminishes.

Temperature and electrodermal control are closely related to sympathetic function and its modulation via vascular biofeedback, such as described above. The methodology is quite useful in learning self-control for any purpose, especially in the realm of pain.3,9

Summary

Human beings have an adequate potential for learning self-control of a variety of bodily functions. This ability is a function of adequate teaching and learning and it can be considered a skill once it has been acquired and practiced over a period of time. It is likely that the new engrams are there for life, even if recurring ‘boosting sessions’ are needed—just as much as they are at maintaining any mental or physical skill.

Pain control through this methodology is well known in biofeedback circles as well as in traditional Eastern cultures. The reader interested in further learning is encouraged to contact the author for additional information.

Last updated on: December 20, 2011
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