Written by Joanna Hermano
"I've tried everything to get rid of my pain, but nothing seems to help."
Sadly, I hear this phrase a lot.
I am a physiotherapist that works specifically with people experiencing stubborn, persistent pain or other uncomfortable symptoms in their bodies. Clients often come to me feeling very frustrated because they may have had pain for months or years, and have tried many treatments with various types of practitioners, yet they still have not found any lasting relief. Often, clients have already gone through a slew of tests and specialist consultations, yet no one can find anything abnormal, and therefore cannot offer a solution. In some cases, doctors recommend a specialized, interdisciplinary pain program, however, these programs are in such demand that the waitlists can be very long.
Meanwhile, the pain continues to wreak havoc on their quality of life, and the feeling of hopelessness is growing. It is a very tough place to be in.
What is my approach with clients experiencing persistent pain?
During our initial meeting, as I am getting to know them, I look for signs that their nervous system might be sensitized (this condition has several names, such as "Central Sensitization Syndrome", "Nociplastic Pain" or "Complex Pain"). I gather clues from their medical history, what they tell me about themselves and their lives, what I notice about them as they sit in front of me, and what I feel in my own body as our nervous systems interact. And if the info I gather points to the possibility of a sensitized nervous system, I administer a questionnaire that can help screen for that. (More info on my treatment approach will be explained later in this article.)
What exactly is "Nociplastic Pain" or "Complex Pain"?
It's a condition that can show up in many different ways, with a variety of possible symptoms. This might include widespread body pain, headaches/migraines, muscle tension, digestive issues, sleeping difficulties, brain fog or memory issues, anxiety, depression, and sensitivities to touch or other environmental stimuli. It can correlate to diagnoses like Fibromyalgia, Chronic Fatigue, Irritable Bowel Syndrome, Restless Leg Syndrome, Temporomandibular Joint (TMJ) Disorder, Chemical Sensitivities and Post-Traumatic Stress Disorder (PTSD). It is labelled "complex pain" because there can be a number of factors at play, including biological, psychological, social and environmental factors.
But with complex pain, despite all the various ways that the symptoms can show up, there is one thing in common: the neurons (nerve cells) in the central nervous system have become hypersensitive and overreactive to stimulation, resulting in a lower pain threshold and a more intense pain experience. And often, this pain occurs in the absence of any observable tissue damage.
How does this increased sensitivity of the nervous system occur?
There is much that we still don't fully understand. What we do know through psychologist Dr. Peter Levine's Somatic Experiencing model, is that the nervous system can be altered by experiences that overwhelm the system and send it into stress mode, particularly if the stressors are traumatic, persistent, or occur during the childhood years when the nervous system is still developing. The autonomic nervous system becomes dysregulated, meaning that it can get stuck in a mode where it's always activated and ready to jump into action at the slightest sign of danger. When this happens, the body will often react with a fight/flight/freeze response to stimuli that wouldn't normally elicit this big of a response. The nervous system is hypervigilant, and frequently sends signals to the body that initiate various physiological responses, including anxiety, elevated heart rate, shallow/quick breathing, tense muscles, circulation of stress hormones, and/or amplified sensation and pain signals. When faced with a real threat, these responses are an important survival mechanism, because they can help you take the action needed to get to safety. However, it can become problematic when the nervous system responds this way to normal, non-threatening stimuli on a regular basis. When the body is on high alert this way, and the pain threshold is lowered, it can make even regular day-to-day activities very challenging.
Some people can develop complex pain after an injury. Yet others can develop it without any mechanism of injury at all. However, it is common for people who have unexplained persistent pain to have a history of trauma (experiences that are overwhelming and dysregulating for the nervous system).
Ok, so if we are dealing with a possible case of complex pain, then what?
If the issue begins with, or is exacerbated by, a hypersensitive nervous system, then it makes sense that physical interventions alone, without addressing the nervous system, may not solve the problem in the long-term. Although these interventions can be helpful additions to the treatment plan, they should be used in conjunction with interventions that help to regulate/heal the nervous system.
In my practice, I use a combination of interventions that are individualized to the client's needs. If, in the assessment, I have picked up on some physical or biomechanical issues that could be contributing to the pain, then I will absolutely address that. I have a number of traditional physiotherapy interventions in my tool kit for these cases, including education, therapeutic exercise, taping, acupuncture, and manual therapy. If the assessment indicates a strong probability of a sensitized nervous system being a factor, then I know we need to address that as well. For these cases, I may introduce any combination of Somatic Experiencing, mindfulness, breath work, acupuncture and therapeutic touch. I also know how important the therapeutic relationship is, especially since an activated nervous system will be on high alert for signs of danger. So it is crucial that I always aim to create a safe and nurturing environment for my clients. It is also very important that my own nervous system is as regulated as possible, because if my client senses that I am calm, safe and open to connection, then our session is much more likely to have a regulating effect on their nervous system. In order to ensure that I am at my best so that I can be of help to others, I have to tend to my own nervous system on a regular basis with things that nourish my body and mind, including engaging in therapy for myself.
As my client's nervous system becomes more regulated and the tolerance for stimuli increases, then we will have more success with other interventions like exercise programs and lifestyle changes, which help people to get their lives back on track.
If you'd like more information, please feel free to check out my website or reach out to me with any questions.
To learn some common signs that your nervous system could be in a stress response, have a look at my article entitled: "Signs of an activated nervous system".
With love and understanding,
Joanna Hermano is a Trauma-Informed Physiotherapist and Somatic Experiencing Practitioner-in-Training with a special interest in persistent pain.