Definition of Neuroplasticity

(Workbook Page 5)

Look at pages 4 and 5 of the Neuroplastic Transformation workbook. They are a nice introduction to the vast amount
of information your brain receives from your body and then uses to tell your body what to do. The complexity of the
brain may seem overwhelming, and it does its job so well, that people tend to assume that it can accomplish
whatever it needs without help. When it goes awry, however, the brain needs to be directed to get back on track.
Truly, there are massive changes happening in our brains all of the time. Think about the fact that the adult brain
makes and breaks 7.5 trillion synapses a week

When the first nerve cell fires the second it wires in new synapses and continues to fire the original synapses. When
networks of nerve cells are involved, the networks that fire the most take nerve cells from those around them that
are less active. When networks are inhibited from firing, more active neighboring networks take back nerve cells.
This process is the moment to moment reality of how the brain works and it is this principle that both causes pain
networks to take cells from surrounding nerve networks and give back those cells if the surrounding networks are
more active.

We literally change who we are week after week. It is even more astounding that we are able to maintain a continuity
with all these changes, but that is exactly what the brain does. Somehow the brain knows how to remain constant
enough to provide a day to day connection to oneself, while changing both itself and the body so much that we
appear and act very differently as time goes on.

The Three Rules of Neuroplasticity

(Workbook Page 5)

Where persistent pain is concerned it is important to remember the three rules of neuroplasticity, because not only is
pain something that is learned, but that learning requires those rules. Review them on page 5 of the Neuroplastic
Transformation workbook. Although it is hard to believe that we can use such simple approaches to change
something so profound and life-altering as persistent pain, it is a fact. Remembering to use the very intrusion of pain
into conscious thought, emotional awareness or physical limitation to counter-stimulate the brain is the key
to.restoring the appropriate role of pain

In acute pain, an injury sends a pain signal from the tissue to the back part of the spinal cord, where
the signal crosses to the other side of the spinal cord and travels up long nerve tracks to the brain.
Here it goes to 16 different areas. Pain is only perceived when it reaches the upper part of the brain
(Amydala, Insula, Prefrontal Cortex, Anterior Cingulate Cortex, Posterior Cingulate Cortex, Posterior
Parietal Cortex, Secondary Somatosensory Cortex, Primary Somatosensory Cortex and Supplementary
Motor Area). Acute pain tells us when we have exceeded a physical and/or emotional limit, directing us
to stop doing whatever is causing this problem. Once that problem is addressed, the brain sends a
signal to the back part of the spinal cord and intercepts and stops the incoming pain signal from the
injury.

Pain is actually the most important sensation in our body. Pain keeps us alive by telling us when we have exceeded
our limits. It is precisely because it is not there all of the time that pain is so helpful and useful. Unfortunately, when
pain persists it loses its ability to warn us of danger, and all we are left with is the unpleasantness and the fear and
anxiety that accompanies it.

Hub Treatment
(Workbook Page 8)

Neuroplastic transformation is the treatment hub for persistent pain disorders. When pain transitions from a symptom
to a disease, it is not merely more pain, longer lasting pain or constant pain. This process is one of neuroplastic
adaptation to a stimulus resulting in molecular, cellular, anatomic, physiologic, electrical and functional changes in
brain and peripheral body. Varied treatments have been established to deal with the persistence of pain. Some of
these are aimed at altering or suppressing peripheral sites and some use more systemic approaches to manage pain.
Medication, Invasive, Bodywork and Psychosocial approaches can be used individually or in concert with each other.
Multidisciplinary and Interdisciplinary treatment teams may be brought to bear. All of these treatments are aimed at
containing and managing the disease of persistent pain. None are crafted to cure the underlying neuroplastic process
that has caused pain to transform from symptom to disease. It is only by harnessing the power of neuroplasticity that
persistent pain can be resolved.

A wheel without a hub will collapse and fail. By making Neuroplastic Transformation the hub of the treatment for
persistent pain, all of the spokes of the wheel become strengthened, unified and focused.

The goal of treatment shifts from reining in pain to reversing the basic forces that have caused it be maintained.
Understanding these forces and the stages of treatment harnesses the same power that unleashed pain’s
persistence. Instead of these processes occurring randomly based upon runaway input, the incredible access to the
brain’s power is used to disconnect expanded pain networks, stop perpetually firing pain-dedicated nerves, resolve
the production and release of inflammatory molecules, reverse the energy used to maintain pain receptors and
restore normal pain response.

R.A.F.T.
(Workbook Page 9)

R.A.F.T. is one of the core concepts of Neuroplastic Transformation Treatment. Review Page 9 of the Neuroplastic Transformation workbook. People living with
persistent pain experience phases of their disorder, going through matching phases of treatment. Persistent pain marks the transformation of pain from a symptom
that warns about danger to a disease that is marked by changes in the entire body. Injury to tissue is not cleared up by normal inflammatory and anti-
inflammatory processes. Nervous System signaling is amplified by unrelenting painful input from the sensory nerves in injured parts of the peripheral body. This
results in perpetual firing of nerve cells in the spinal cord and the brain and activation of nerve cell receptors that cause rapid and long term firing of nerves.

One nerve cell fires another with enough intensity or for long enough that the second nerve cell continues to fire long past stimulation by the first nerve cell. This is
called Long-term potentiation. While this process is very useful for memory, it is also one of the factors that causes pain to last long past its usefulness.

Inflammatory discharges of non nerve cells in the brain, within which these perpetually firing nerve cells are located, results in expansion of the pain map in the
brain, at the cost of other important regional functions.

In the brain, nerve cells run through other brain cells called astrocytes. When nerve cells in the pain circuit fire continuously, these astrocytes release inflammatory
molecules that keep the nerve cells firing. This leads to the pain processing nerve cells taking on nerve cells from less active surrounding areas and expansion of the
pain map in the brain. This also results in more of the main pain neurotransmitter being produced and sent back to the area in the body where the injury or
dysfunction has occurred, resulting in a chronic inflammatory response

Taking back that expanded pain map and restoring the brain to normal can be accomplished by counter-stimulating the brain whenever pain intrudes upon
consciousness.

Examples of ways to decrease the numbers of cells dedicated to maintaining persistent pain in the brain are demonstrated. Each process
stimulates other functions in the areas where pain is experienced to stimulate the brain to take away cells from where pain is perceived,
reassigning those nerve cells to these other functions. Using these techniques and being relentless with pain spikes or intrusions by counter-
stimulating the brain, leads to changes in brain function and plasticity. This exploits the same process that pain uses to become persistent.

Inflammatory compounds are released by the brain into the injured peripheral tissue and a loop is set up.
The result of inflammation in microscopic areas of the brain is that Astrocytes and Microglia react to the long term firing of embedded nerve cells by producing
inflammatory molecules called cytokines. This in tern provokes the nerve cells to continue firing. Ultimately through changes in the nerve cells DNA and RNA more
of the main pain neurotransmitter, Substance-P is produced. When this increase in Substance-P is sent to nerve endings the brain cells dedicated to processing pain
increased three to five fold. The majority of this excessive Substance-P is sent down nerve shafts, backwards through synapses and released into the painful areas in
the body, overwhelming the unit-inflammatory response, resulting in more inflammation and a positive feedback loop promoting pain persistence.

Look at the writing under the R.A.F.T. graphic on page 9 of the Neuroplastic Transformation workbook. Review the description of the four phases
of treatment, Rescue, Adjustment, Functionality and Transformation. Like the picture of the raft full of paddlers, it takes a team to wend through these phases and
there are likely to be many treacherous traps along the way to prevent ending persistent pain’s fury. Diligent and relentless work will overcome obstacles.

Persistent vs Acute Pain

(Workbook Page 10,11)

Look at the pictures on pages 10 and 11 of the Neuroplastic Transformation workbook Notice that the areas of the
brain where pain is experienced are exactly the same, but that the amount of brain “real estate” dedicated to
perceiving pain is expanded with persistent pain.

As nerve cells involved in long-term firing in the pain circuit continue to fire, the brain real estate dedicated to processing pain
signals rapidly expands. Local nerve cells from other functions that are not being used as much are reassigned to process
pain. Not only does pain become more persistent, but other local functions like problem solving, planning, empathy,
autobiographical memory, sensory processing, emotional stability all become less active and are degraded.

Use the graphics to visualize taking back brain real estate in pain perceiving areas for other functions such as
decision making, pleasure, planning, problem solving, autobiographical and emotional memories, pleasant scents,
soothing, empathy, other sensations, physical activity. See this animation of brain pain signals changing from acute
to persistent, then to pain

This shows how the brain's pain network expands when pain transforms from acute to persistent. It also demonstrates that
when the brain responds by increasing the release of GABA, the main inhibitory neurotransmitter, from the insula to the
amygdala, pain perception is shut off.
Remember that acute pain goes away.
Counter-stimulating Pain
(Workbook Pages 11,12, 13)

The graphics on page 10, 11, 12 and 13 are some of the most important ones in the Neuroplastic Transformation workbook. On page 10 we see the 2 regions in
the spinal cord and 16 regions of the brain that make up the pain circuit. This depicts acute pain where 5% of the cells in each region are dedicated to pain
processing. These nerve cells are reserved for pain and are shut off, until signaled by sensory pathways in the body to turn on due to danger in the form of injury,
illness or inflammation. These signals are processed from the back part of the spinal cord, crossing over to the opposite side of the cord and sent up pathways to
the brain stem and mid-brain. We only perceive the signal as pain after it reaches the thinking brain. Here in the 9 regions of thinking brain where the signal is
received we experience it as pain. In acute pain some of the same regions and a few different ones send a signal back down to the spinal cord to intercept the
 incoming signal and shut off the pain so that it never reaches that upper part of the brain, which we use to perceive sensations. On page 11 we see the graphic that
shows the same regions in the spinal cord and the brain being simulated, but this time the signal covers a greater area. This represents the recruitment of other
nerve cells to expand the pain map and steal away cells from other regional processes. This is a basic principle of neuroplasticity. The brain assigns cells to
specific functions, but if one function becomes more active, cells are taken from other functions to strengthen the more active one

Look at these two pictures on page 10 and 11, turning the pages back and forth. The picture on page 11 shows one of the key reasons why persistent pain is no
longer a symptom, but has transformed to a disease. This is not because the pain is chronic, but is that expansion of brain real-estate to 15% to 25% of the cells in
these regions that are processing the pain signals. Now look at the graphic on page 12. Here we see that even in wound-up and persistent signaling below the
upper 9 regions of the thinking brain, if the signal does not advance into the thinking brain, there can be no pain. Turn page 11 and 12 back and forth and
recognize that if the signal stops below the upper 9 regions of the brain, there can be no pain. Keep looking at the graphics on page 11 and 12 until you can
memorize the difference and visualize them without the actual pictures. Remind yourself that if your brain looks like the graphic on page 12 you cannot have
pain.

Active and Passive Treatments

(Workbook Page 13)

Using this website in conjunction with the Neuroplastic Transformation workbook is a way to expand what is a written guide to something far more. It is also a
way to move from being in the role of passive patient to active leader of your own pain treatment team. While passive treatments can be very effective it is
critical to shift into a model of active care between treatment sessions by constantly counter-stimulating the brain in response to pain intrusions. Look at page 8
and reread the text. Making the transition to the leader of one’s own care by understanding neuroplastic treatment approaches, completely shifts the pain
treatment paradigm and opens a world of possibilities. The ultimate goal moves past pain management to that of life transformation. Go to page 16 and look at
the ways real people are applying the use of thoughts, images, sensations, memories, soothing emotions, movement and beliefs to make changes in brain real
estate, reassigning nerve cells to other functions by counter stimulating their pain episodes.

Provider and Patient Roles

(Workbook Page 13)

The current model of pain care tends to place providers in the active role, performing procedures, giving medications, doing body work, intervening
psychologically and recommending ways to cope and manage between treatment sessions. Patients are placed in the role of passive participants during treatment
sessions and then often left to their own devices to play a more active role between sessions. Neuroplastic Transformation treatment approaches change this
model of care. It remains important for providers to come up with a treatment plan and to use the professional training and skills they have to help people with
persistent pain. The change here is that providers also help the patient to move toward the position of leadership in this relationship. To accomplish this the care
provider must give patients specific things to try between sessions and follow up on these things when the patient returns for care. From the patient’s perspective,
this would mean that the patient needs to take the provider’s ideas and dig into these to see what really works for them. Staying with old approaches, even helpful
ones, because of a fear of trying something new must be put aside, as the brain focuses upon novelty. Going beyond ones interests and limits can open up entire
vistas of new approaches. Providers have to allow and encourage patients to bring their ideas back to treatment to hone and refine these.

This website has animations and videos keyed to specific sections of the workbook, such as this video. There are also separate animation and video (Pain Bytes)
Sections of this website that may be useful. At the end of each section of the workbook we have a page called Neuroplastic Tips. Here we make very specific
suggestions related to the section. We recommend that you try these and go beyond your current comfort zone, by trying things within your physical abilities to
challenge and delight your brain. We have also worked to provide products that are helpful to make neuroplastic change. These products have been carefully
thought out and tested to be useful for many people who live with persistent pain. These are located on the Products section of the Neuroplastix site and we have
incorporated neuroplastic education into each of these.

Shrink the Map

(Workbook Page 13)

The key graphic of the entire Neuroplastic Transformation workbook is that on page 13. This shows all of the perceptive areas of the brain where persistent pain
expands the pain map, as well as many of the other functions in these same area that are being over-run by pain perception and pain stimulation. At the top of the
page are the instructions to Shrink the Map, by accessing the brain with thoughts images sensations memories, soothing emotions, movement and beliefs. It is
important to understand that these ways we access our brains are the keys to stopping persistent pain. The more consistent and robust the counter-stimulation to
the pain the more we can take back real estate for these other functions. From simple thoughts to different sensory inputs we can teach our brains to move the
relentless, persistent and constant pain signaling to comfort and pleasure.

The key is to not let any pain signaling go by without opposing it with other signals. Remembering that we learn everything by repetition and consistency
reinforces the notion of always counter-stimulating the pain. Reviewing the patient experiences of opposing pain, helps with the ideas others have successfully
used and gives the reader the opportunity to come up with their own way of achieving pain control.

M.I.R.R.O.R.
(Workbook Page 14)

We have come up with an approach to treating persistent pain that is based upon the principles of neuroplasticity:

 Continued firing of a nerve by another nerve increases the strength of the firing and the number of synapses dedicated to those nerves. (What gets
fired, gets wired)
 Nerve cells that do not fire other nerves over time will lose synaptic strength and break synapses dedicated to those nerves. (What you don’t use, you
lose)
 To conserve the amount of energy the brain uses, old synapses must be broken, when new synapses are formed. (When you make ‘em you break
‘em; when you break ‘em you make ‘em)
The brain changes constantly from conscious input and purposeful activity to information processing that happens automatically and without any self-directed
stimulation. As stated earlier massive changes in synaptic connections occur throughout life and any new activity or learning changes the brain’s anatomy,
physiology, cell structure, synaptic strength, electrical circuits and regional functionality. This may also leave a vulnerability to runaway processes, resulting in
neuroplasticity creating a disease state. At the same time an opportunity is created to actively use neuroplasticity for something that works as an agent of positive
change. Even a process that happens below the level of the conscious, thinking and perceiving brain, can be influenced by a desire to change it. In fact all new
learning is based upon modifying what is already in place, then through repetition and mastery making most of that learning unconscious and automatic. Through
repeated awkwardness and failure a person is gradually rewarded with a fluid ability to perform the necessary tasks, that consistently work. In fact, when
something is mastered, it is surprising when it does not work. The more it is repeated and becomes part of the regular living routine, the less conscious attention it
requires to perform and the higher the level of performance.

The idea called MIRROR applies these concepts. This stand for:
Motivation
Intention
Relentlessness
Reliability
Opportunity
Restoration

Review the text on Page 14 of the Neuroplastic Transformation workbook. Utilizing these basic principles to rebalance pain processing circuits, the brain can
restore normal pain perception and control to people suffering with persistent pain. This requires a few shifts in beliefs that are held about pain. Pain is not
something that controls us. Pain is not the inevitable fate of those with persistent pain. Persistent pain is not the result of damage to the body tissue. Pain is not
experienced in the body, but is experienced in the perceptive part of the brain. The body does not act independently from the brain, and the brain relies upon the
input from the body to make all of it’s own changes. Normal activity does not damage the body after an injury has healed. Regardless of the source of the injury,
we have many opportunities to consciously change our pain perception. Learning to control persistent pain is no different than learning anything else.
Persistence, practice and failure will ultimately lead to mastery and control, if one remains relentless in one’s pursuit of pain control. Pain management is not the
goal of treating persistent pain. We can work toward a reasonable expectation of curing the disease of persistent pain. While a person may not be able to cure the
underlying disease or injury in persistent pain problems, with this approach, one can learn to shift the pain from the pain persistence to the symptom of acute
pain, that is pain that occurs because we have exceeded a limit and when that excess is corrected, returns to a baseline of painless living.

N.O.R.M.A.L.: Neuroplastic Optimization and Reduction of Medication for Adaptive Living

(Workbook Page 14)

The polypharmacy of pain treatment is criticized for side effects, drug-drug interactions, worsening pain states,
dependency, addiction and even inadvertent death. The problem is not with the medications, but in the way they are
utilized to treat persistent pain. They have become the core treatment for this disease process. If the dynamics of
persistent pain are recognized as a neuroplastic process, we must view neuroplasticity as the basis for persistent
pain and it’s treatment. All treatment should be aimed at creating neuroplastic change to oppose and halt the process
of persistent pain. Medications are an excellent way to alleviate symptoms while working on the underlying cause,
but cannot be the mainstay or central principle of any treatment program. They are a spoke in the wheel of treatment
options with neuroplastic treatment at the center.

People living with persistent pain often end up on a long list of medications designed to treat a host of pain-related
symptoms and medication-induced side effects. Over time, this becomes the primary treatment people receive. While
medications can be effective alone and in combination, theMedication management often promotes a passive patient
model of care and undermines people taking an active role in their own recovery. The body and brain adjust to the
medications, and they become less effective. Visits to pain practitioners then consist of changing or rearranging medication
regimens. Patients may improve for a time, but a vicious cycle of short-term improvement with subsequent worsening of
symptoms occurs due to tolerance, requiring more medication. Side effects and drug-drug interactions further complicate the
situation, and the body’s own ability to stabilize, rebalance and return to normal is impaired. It reaches a point where it is
unclear whether a patient’s problems are due to their underlying pain disorder or the effects of long-term medication use.

By design, medications mask symptoms. It is these very symptoms that provide the clues to possible treatment
solutions. By relying on medications every time pain increases, the opportunity to evaluate other pain relieving
treatment options is lost. Anxiety and a fear of pain ensue rather than a sense of curiosity about what is happening
and what might help. People maintained on chronic medications tend to do less, contract their lives, sense and report
higher pain, depression and anxiety levels. Mutual patient and practitioner goals should be the prudent reduction of
medications within a more active, patient-centered program based on neuroplasticity.
y have many drawbacks.

Medications can then take their rightful place and be used most effectively. They play a prominent role in the Rescue and
Adaptation phases of treatment and take on a secondary role when the patient advances to the Restoration and
Transformation phases. In the Restoration and Transformation phases patients are actively applying neuroplasticity
techniques to change their pain and medications can be used as needed for relief of symptom exacerbation

As part of the Neuroplastic Transformation treatment program, the gradual and thoughtful reduction of medications is
employed. It is called Neuroplastic Optimization and Reduction of Medication for Adaptive Living
or N.O.R.M.A.L. When people take control of the neuroplastic processes that created the pain disorder, pain
decreases and a great sense of self-control replaces the feeling of being the victim of persistent pain. At this point,
medications can be reduced gradually and continued neuroplastic approaches can hone and improve self-directed
pain and mood control guiding the process of transformational living through pleasurable experience.