Chronic Pain:  A Neurocognitive Perspective

Peter Przekop, D.O, Ph.D.

Betty Ford Center, Department of Pediatrics, Psychiatry & Neurology, Loma Linda University School of Medicine

Allison Przekop, D.O.

Betty Ford Center, Department of Pediatrics

Loma Linda University School of Medicine

The Pain Practitioner Fall 2013

 

The authors note the results of clinical research over the past several years implicating chronic pain as a disease of the brain in which specific cortical areas are affected, causing significant negative effects upon cognition and behavior, in addition to an accumulation of adverse events and concomitant chronic stress, all of which contribute to the chronic pain syndrome and the adverse life events that follow this process. 

They note that when pain persists it is no longer a self-preservation situation, but one that can progressively disrupt higher cortical function and goal directed behavior.  They note a pain imaging study by Tracey in the Journal of Anesthesiology 2008, demonstrating that persistent pain significantly alters brain function and structure. 

They note neuroimaging studies demonstrating the dorsolateral prefrontal cortex, the anterior cingulate cortex, and the insula cortex lose functional integrity in patients with chronic pain, and they also note that structural abnormalities in these specific cortical areas have been demonstrated in chronic pain patients with associated cortical thinning in these areas, which also reflects functional abnormalities. 

They note that alterations in these areas of the brain can result in a focus on pain, inability to disengage from negative aspects of life, and withdraw from challenging situations, with an additional result of directing attention towards the pain itself.  

They cite a paper by Rusu, et al. in the Journal, Pain, 2012, in which cortical abnormalities associated with chronic pain are responsible for specific cognitive and behavioral changes, including depressive symptoms, anxiety, and hypervigilance, leading the patient to be focused on poor health and physical limitations. 

They describe anxiety as directing thoughts towards negative internal feelings with associated negative emotions and an inability to change the focus of attention away from pain and is common in chronic pain re the authors, Peter Przekop and Allison Przekop. 

They describe patients with chronic pain reporting a significant history of adversity and note that a paper recently presented at the American Academy of Pain Management meeting reported that more than 80% of older adults who reported high levels of pain and related restrictions also reported a history of significant adverse events, which in turn can create chronic stress, which negatively impacts the identical cortical areas that are affected by chronic pain. 

The authors report that all types of pain are processed by the same cortical networks, and that loss of a loved one, rejection by someone close, and back pain are processed by overlapping cortical networks causing prolonged stress and leading to any combination of emotional, social, and physical pain. 

Drs. Peter and Allison Przekop describe the process of neuroplasticity, the ability of the brain to respond to a changing environment with changing demands, and discuss that when this neuroplasticity becomes maladaptive, as is seen in chronic pain, the cortical areas modulating the pain no longer function optimally, and again the authors refer to the dorsolateral prefrontal cortex and the anterior cingulate cortex. 

They describe the innate ability to improve as adaptive neuroplasticity, which would feed off of an enriched environmental stimulation. 

The authors note that they have developed a program at the Betty Ford Center in Rancho Mirage, California, to treat chronic pain by increasing activity in the dysfunctional cortical areas, accomplishing the goal of normalizing function by enriching the environment in people with chronic pain.  They describe the approach as attenuating the chronic stress syndrome, which includes planned Qi Gong movement and mindfulness, which have been observed to dramatically improve perceived pain, depressive symptoms, anxiety, and the perceived ability to cope. 

The authors note the importance of people with chronic pain to learn routine to relax their minds, and their approach utilizes introspection, breathing, Qi Gong energy movement, and imagery. 

They note that the patient population includes those who have become dependent on opioids and other drugs of abuse, post-laminectomy syndrome, chronic migraine or tension headaches, fibromyalgia, or chronic regional pain syndrome.  They note the necessity of a pre-treatment program detoxification process and note that positive results with this program can be noted within 6 weeks. 

Editor’s Commentary:  There are several clinics and centers which provide these types of treatments, which would include Qi Gong, meditation, classes teaching sensible nutrition with the goal of transitioning to foods that enhance your health rather than the opposite, and in appropriate forms of additional recreational exercise and sporting activities. 

The goal with respect to this type of program is for functional restoration by both improving your mental health, physical health, and in a group class setting where it can be a worthwhile and fulfilling therapeutic experience.

This type of program, as with the Betty Ford Center program, can be very worthwhile for the chronic pain patient, but with the stipulation that the patient is motivated and desirous of getting into this type of program at the earliest possible time. 

Needless to say, starting such a program while using controlled substances would probably not be an optimal situation and it is probably best to wean down and off or detoxify as the need may be before starting such a program. This type of program can make a difference in the life of the chronic pain patient.

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