Fun studies about pain

Power of words
VAEGTER, HENRIK BJARKE1,2; THINGGAARD, PETER3; MADSEN, CASPER HØJ3; HASENBRING, MONIKA4; THORLUND, JONAS BLOCH3,5. Power of Words: Influence of Preexercise Information on Hypoalgesia after Exercise—
Randomized Controlled Trial. Medicine & Science in Sports & Exercise: November 2020 - Volume 52 - Issue 11 - p 2373-2379 doi: 10.1249/MSS.0000000000002396

 Outcome: Pain pressure thresholds before and after ex

 Task: 3 min isometric squat ex
 Intervention: info that ex reduces pain, info about ex, info that ex increases pain
 Result: 22% PPT increase in +ve AND neutral group, 4% decrease in -ve group

Virtual McKenzie extension exercises for LBP + leg pain

Adriaan Louw, Kevin Farrell, Anthony Nielsen, Max O’Malley, Terry Cox & Emilio J. Puentedura (2022) Virtual McKenzie extension exercises for low back and leg pain: a prospective pilot exploratory case series, Journal of
Manual & Manipulative Therapy, DOI: 10.1080/10669817.2022.2092822

 Outcome: LBP, leg pain, fear avoidance, pain catastrophizing scale, active Lx flex, SLR
 Patients with LBP that have a directional preference for extension // reduced +/- proximized Sxs
 Intervention: Patients put in prone, pre-push up position. Asked to visualize extension movement 10 times (5
mins guided visualization)
 Result: stat sig improvement in all outcomes, but only SLR reached MCID

The importance of context: When relative relief renders pain pleasant

https://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC3590449&blobtype=pdf

 Outcome: VAS, hedonic ratings, MRI findings

 Design: default intense pain, occasional moderate pain vs default mild pain, occasional moderate pain
 Result: when intense was default, mod pain = more pleasant; when mild was default, mod pain was more painful

Pain science in a nutshell

Predictive processing
 Core tenets
o We don’t experience the world as is – everything we perceive is influenced by past experiences,
expectations, beliefs… etc
 It is a pro-active process
o We subconsciously build and continuously update a model of the environment/world we are in and
that we interact with.
o And we/our body predict based on what we’ve experienced so far, what it needs to maintain
homeostasis
 If there is a prediction error, there is a potential threat to homeostasis, and something will be
done to resolve that error
 Perceptual inference: sensitization
 Active inference: withdrawal reflex, pain behaviours
o The goal is to minimize prediction errors
 Prediction model
o Prior: a collection of everything we’ve experienced and know so far about our world
 Can become “stuck”, hard to change
 Through repeated exposure, leading to a loss in plasticity
o Sensory input
 With a given precision, we chose the hypothesis with the highest probability
 Unless there is a higher precision info, and in this case, you will recalculate
 Pain
o An experience created by both the brain and physiological processes
o An overall estimation of threat posed to the body in an environment, based on the integration of
relevant info from multisensory sources + priors
o Combination of neuroendocrine, neuroimmune and autonomic nervous system
 Immune: the inflammatory response
 Endocrine: stress response
 ANS: flight or fight
 Nociception: maybe? But pain can occur without it, and nociception without pain
 o How does pain influence an individual?
 Our sense of self is largely based on how we can interact with our surroundings
 Pain occupies a lot of our attention + shrinks the space of possibilities in the world
 E.g. movement tunnel
 Can take away elements of self-identity, creating almost an existential threat to the
being
 Chronic pain: stuck priors > body predicting that the environment it is in is constantly
threatening
 Noxious info is upweighed, non-noxious info is downweighed

 Biopsychosocial elements
o Can potentially fit within PP
o Placebo: induce an expectation of safety = estimation of lower overall threat to the body > decreased
pain intensity // vice versa for nocebo
o Social factors: having social support may give support behind hypothesis that body is safe, thereby
reducing the precision of the threat indicating the uncertainty about the continued integrity of the
body
o Continued social adversity: NEI learns to predict being in a stressful and threatening situation more
often than not

Pain education
 Therefore, given PP, it makes sense that it’s hard to change chronic pain with just verbal reassurance, education
o Stuck priors + no precise prediction error has occurred to sway the system
 Best way = to find a way where they can do the provocative movement with a pain level that is less than
expected
o And to make it as precise as possible, with plenty of non-noxious sensory info
 Mirror
 Tactile cues
o Objective tests can be a good opportunity to show them that their priors are incorrect

What does manual therapy do?

 Overall increase of pain thresholds both at the MT site and distal to it – pain modulation
 Endocrine
 Autonomic
 Nervous system response
 Predictive processing
o Expectations of therapeutic touch, within the context of a clinic
o Precise sensory input that might be meaningful to the patient
o Patient’s own priors – e.g. it needs loosening off

What does exercise do for (chronic) pain?

 Physiological effects
o Activation of endogenous inhibitory systems in the CNS
o Reduction of central excitability
o Altered ion channel expression on nociceptors
o Promotion of tissue healing
o Immune system modulation
 Predictive processing
o Introduces regular prediction error with precision
 Depends on exercise design
 Wording matters!