The Client
Diane had always considered herself a healthy person. She ran track in high school. She didn't party like her friends. She dreamed of being a nurse at a hospice nearby. She married her high school sweetheart and enrolled in a local nursing college. Things were going so well. She had a child. They were very happy, though struggling to make ends meet. Then they had another child within 18 months of the first. They were still struggling financially, but in full confidence that they would make it work. Now, in her early thirties, Diane started to experience spasms and a growing pain in her lower back that continued for the next 20+ years,
In her 40s, now with a family business to run, Diane's episodes
became more frequent. Her body was freezing up around her lower back to guard against sudden, intense flare-ups from little things like turning her head "wrong" - and coughing.
At times like this, she would lie down for two days or more until the episode subsided. Worse episodes involved ambulances, hospitals, follow-up specialist visits, endless rounds of steroids, and anti-inflammatories, Diane found herself having to lean on her family, her friends, and her kids for support, again.. and again.. and again.
Diane had degenerative disc disease. She knew what that meant because she had seen her mother suffer from it her whole life. And it would not get any better no matter what she tried. Finally, having exhausted every specialist her doctors and other well-wishers recommended, Diane opted for spinal fusion surgery.
She was hopeful. She seemed to improve at first, but then one dry, sunny spring day with a high pollen count, ACHOOO! With that one sneeze, Diane tumbled helplessly back into the same pre-op pain. She found herself trapped in the same pre-op body. With less hope than she ever had pre-op. Nothing had changed.
Diane spiraled into a deep depression punctuated by debilitating periods of anxiety. How could she face the rest of her life this way? How would she ever be able to work again? To be the wife she once was? To support her children? To dance again? Did the doctors miss something? Was she crazy?
She leaned more on the prescription painkillers she had been on for years. But now they served a new purpose. To calm the blaring alarm system in her brain as she chewed angrily on the possibility that she would know only pain until God called her home as it had her mother.
Then, Diane's doctor delivered some worse news. The opiate prescription was unsustainable. She needed to reduce her usage even though the pain was asking her to increase it. Her doctor explained that the risk of addiction was too high. And none of the research supported opiates as a long-term solution for pain that couldn't be explained by any other medical means. The surgery had been a success by all conceivable measures. Diane would have to search out new approaches to coping with her condition which the doctor called Persistent Spinal Pain Syndrome.
PSPS is a newer, kinder term for people who have had surgery to correct the structural/mechanical issues that cause pain, yet report no improvement in their pain
afterward. You may have heard other labels for this: psychosomatic, and FBSS (Failed Back Surgery Syndrome). I'm not a fan of either of these labels which imply that the pain isn't real, you're making it up in your head, or that it's the fault of you or your surgeon.
Yes, there are many reasons why someone might still have pain after the mechanical issue is corrected. There is muscle binding around the wound that could respond extremely well to physical therapy. There is the thickening of the fascia that can occur anywhere in the body as a result of chronic guarding against chronic pain. A physical therapy program along with specialty massage could help. But Diane wasn't finding any relief with these modalities. She chalked it up to her failure to follow the protocols she was given which gave her yet another reason to feel the relentless cascade of negativity.
The Assessment
In my consultation with Diane, I recognized that she had come to see me as one of her last stops before giving up. Nothing helped anymore - except the opioids and not moving. Nothing made it worse. Nothing made it better. It was just pain 24/7. And also guilt. And also grief.
I wasn't going to make any promises of relief, but I might be able to help her find ways of reducing the blaring nervous system alarm that seemed to have taken over and help her find ways of bringing meaning to her circumstances.
She had come to see me because her doctor recommended "yoga" which I put in quotes because she didn't specify what kind of yoga. Diane could have easily landed in a hot vinyasa class, which is fine for some folks and some conditions, but would not have been ok for her. I offered her a nod of encouragement for taking an active role in her process and taking a chance with something she had never tried before. This alone is evidence that she still had the hope she felt had vanished from her life. It was an act of bravery - and an act of faith.
She allowed me to lead her through some extremely gentle movements so that I could better understand the pain concentration points. It allowed me to observe the kinds of language she responded to, her level of ANS activation (ability to relax in the movement or level/speed of reactivity), and, most revealing, how she was breathing.
Her breath was very irregular as were her movements. She had a staggered, jumpy inhale and her exhale came in rushing spurts. She held her breath unconsciously while processing my cues into the movement of her limbs.
After this short assessment, Diane was clear in her conviction that her pain was from some malfunction in her mechanics. That there has to be something else going wrong for her to be in this same pain after so very, very long. And then she revealed that "my husband thinks it's all in my head".
I validated her pain. All pain is real if we perceive it. Mind and body are the same. Diane's physical pain over the years was made more complex and intense by the guarding around it. With years of frustration and feelings of unworthiness that she could only be a fraction of the wife and mother she wanted to be. The guilt that after countless thousands of dollars spent and leaning on the people she loved most, she didn't feel better.
School of Pain
I opted to let Diane know what I knew then about the neuroplastic pain cycle. It goes like this:
Pain leads to anxiety and fear.
The guarding is a fear reaction against the pain.
The pain increases around the guarding. More fear.
Ad infinitum
I thought Diane might be locked in a pain-fear cycle. It was likely that her brain had been significantly altered in all the years she had suffered with this particular pain and the pain of watching her mother suffer. There might be a psychology at work that might need some attention from me or another professional.
I explained that the pain she was experiencing wasn't necessarily "in her mind". It might be in her brain. And new research offers not just hope, but a degree of certainty that when a sufferer works with the brain in the full understanding of these concepts, freedom from that pain is not just possible, but probable.
I explained to Diane that pain is fundamentally a signal that there is potential danger. Like when you grab the handle of a Thanksgiving pot that has been in the oven for 4 hours. The pain signals that THIS IS REALLY EFFING HOT - ABORT MISSION! So you quickly and automatically pull your hand away to apply butter, aloe, ice water, or whatever grandma told you to do. And if you're successful, thank you, pain! Thanksgiving is saved again.
But pain doesn't always originate from damaged tissue like oven ouchies. Your brain can misinterpret signals and generate pain even when there is no physical harm. This is the essence of the "pain brain."
In chronic pain, like at least some of the pain Diane was experiencing, brain structures actually change. The brain becomes overly sensitive and can interpret even safe signals as dangerous. The pain is real, but it’s a false alarm—your body is not injured. The brain, in a heightened state of alert, begins to confuse signals from a variety of sources, including past injuries, emotional stress, or even prolonged periods of fear and anxiety. And we pick up these signals our bodies.
Understanding that this pain can result from misinterpretation rather than actual physical damage is the first step toward managing and reducing it.
It's called Neuroplastic Pain. If your brain is plastic enough to be trained through experience to produce pain, your brain is plastic enough to be trained to reduce pain.
Diane was open to the idea that her pain, while 100% valid, might be brain-based. She needed to chew on it for a while, which was great because it gave us time to do that while moving into simple repetitive practices that regulated breath to help balance out a nervous system that was completely out of sorts.
She began to look forward to a routine of doing whatever movement her pain would allow. Sometimes she just focused on breathing and moved her fingers and toes, then her wrists and ankles, then maybe her arms and legs. All while observing with both curiosity and kindness. No agenda to fix. Sometimes she would feel strong enough to explore larger movements both in yoga therapy practice and into her life.
She began to emerge from what she felt was a long, dark, painful sleep to recognize that she could rewire her "pain brain".
Look for When Nothing Works: A Case Study on Chronic Pain Part 2 next week where we will explore another client case study, including that client's yoga therapy practices.
In the meantime, if you are wondering if you have neuroplastic pain, see the questions below!
Is My Pain Neuroplastic?
Here is a set of standard questions that can help you determine if your pain is largely, or in part, neuroplastic.
Be sure to check with your healthcare team to discuss before you try adding anything new to your life, like exercise - or even breathing practices! Your physician, your chiropractor, your physical therapist, and your dog should agree before starting any new program.
Did your pain start as a result of injury? If your pain does not seem to come from any injury, or if it started several days after a possible injury, you might have neuroplastic pain. Sometimes, even if pain begins with an injury, if it persists after the injury has healed, it’s likely neuroplastic.
Symptoms Begin During Times of Stress: Stress puts the brain on high alert and can trigger pain.
Symptoms Are Inconsistent/Vary: When there is variation in symptom location and/or intensity, it is more likely to be neuroplastic.
Symptoms are Unexplainable by Known Structural Conditions: If doctors are unable to find any clear cause for the pain, that’s a strong indicator that it’s neuroplastic. Even with a diagnosis, the pain could still be neuroplastic.
Symptoms Triggered by Factors Unrelated to the Body: For instance, pain is triggered during times of stress or decreases when engaged in enjoyable activities. Pain linked to neutral stimuli like activities, smells, sounds, light, the time of day, weather, or physical positions is likely neuroplastic.
History of Childhood Adversity: Trauma in childhood, such as abuse or neglect, can predispose individuals to chronic pain as adults. Even less severe childhood stressors can contribute to neuroplastic pain.
Presence of Common Personality Traits: Certain traits like perfectionism, conscientiousness, people-pleasing, and anxiety can put the brain on high alert, leading to chronic pain.
Family History of Chronic Pain: Growing up with family members who have chronic pain conditions can model these behaviors and lead to shared psychological and neurobiological vulnerabilities.
About
Samantha brings warm-hearted wisdom and humility to her work, believing the answers you seek are inside you. She has always felt a deep call to honor the role suffering plays as a catalyst to personal metamorphosis.
experience with somatics (SOM), Jungian psychology (JPT), interfaith perspectives, spiritual technologies, trauma healing, polyvagal techniques such as the Felt Sense Polyvagal Model and Safe and Sound Protocols, Compassionate Inquiry (CI), Pain Reprocessing Therapy (PRT), and the Neurosequential Model (NSM).
All this is to say, there are many doorways to use on the path to healing and self-discovery, and Samantha’s breadth of experience allows for vast creativity on which approach is right for you!
Samantha seeks to be a facilitating witness to patterns of movement, thought, feeling, and behavior that can both prevent and create physical pain and emotional suffering at conscious and unconscious roots.
She aims to empower people from 6 to the age of 99 to trust their inner wisdom, allow new layers of self-compassion to emerge, and achieve positive transformations in their careers, relationships, and overall lives.
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