The elephant in the room. Persistent pain and neurocognitive problems.

Moving has always scared me.

I've never been in full control of my body, for some reason I don't know exactly, it's always been stumbling, comes after the mind, gets filled with anxiety, from fear of falling. My diversity in this sense has always weighed on me. A diversity inside, because outside there was nothing different. There is nothing.

Still, there is so much different.

Who knows from outside what you think of me. What do you see. Who do you see.

From inside, you often feel a lot of fatigue. If a certain thing requires a certain amount of effort for a “standard” person, in general I have to do twice as much, with my body and my head.

The inability to control the body, which has dramatically intertwined with persistent pain, inevitably led me to focus on the brain. Read, study, learn, know. Here, my definition as a person, for years, came from there.

I have read many reviews that tell me, my experience, the experience of the symptoms of a person with persistent pain.

A Systematic Review is an instrument of scientific research whose aim is to summarize data on a certain topic, with attention to the sources, which must be highly referenced, to identify all the evidence relating to a specific scientific question.

Finding yourself in Review on persistent pain, on Central Sensitization, always has a certain effect.

Finding yourself thinking about the neurocognitive problems that persistent pain brings after reading a review, however, was excruciating for me.

I have always known (and then read) that persistent pain causes cognitive problems. Finding written black on white, has something devastating: if persistent pain does not matter to anyone, the cognitive problems that pain brings with it, it matters even less, and yet they are there, elephants in a room, which they become, for those who judge you or make you a diagnosis, if you are lukcy, "stressed", or one with a bad slacker attitude if you are not.

This is not a path made of full stops. It is constantly evolving. Because I am evolving. Persistent pain, due to its multidimensional essence, requires me to tell you my own business.

Persistent pain is not something that you are here, he is there and in the meantime you can continue to have your life. He is hugging you tightly, to the point that you no longer understand who you are and who he is.

Well. Now that we are at the point where we understand a little more who I am, because the bulk of the pain has been removed and we can see that I am not a pathological plaintive, which languishes on the sofa waiting for her inexorable fate (that is, what the world evidently believed I was), I can try to deal with this somewhat complicated topic, without feeling like a perfect idiot.

Since 2003, the year in which my symptoms have definitely worsened, I have also started to experience cognitive problems. And this, for a person who identified himself with his "brain", was simply tremendous.

Let me explain: I started having short-term memory problems, the feeling that "I was missing words", of learning, of attention, an incredible slowdown in the speed of information processing. I lived with a perpetual sense of confusion. Health professionals told me I was anxious and stressed. I was afraid of having a dementia principle. In the meantime, my self-esteem was falling apart, and my life with her.

It is not easy to find yourself unable at any moment. Put your ambition aside, abandon yourself to a body and a brain (above all) that do not correspond to you. It means not recognizing yourself anymore, not knowing what to expect, having no plans.

Losing my brain was almost worse to me than losing my body. I've always been an intellectual, not an athlete. Finding myself unable to think was traumatic, frightening and painful. But I "was anxious" and in short, it was right that I stayed in the social rear, because with my way of being, so fickle, I was useful to the world as a wedding favor.

I thought that the anxiety (i.e. what they diagnosed me as anxiety, but I later discovered to be perceptual problems caused by the migraine) and the feeling of incompetence that came with it, had made me lose the ability to be mentally productive (I'm not considering the pain itself, of course). Instead I suffered from persistent pain.

Then I read a few things. With seventeen years of delay.

The basic cognitive processes of the human being are: perception, attention, memory, language and executive functions. All these functions are closely linked to decision-making and the emotional sphere. Each cognitive ability can involve a specific area of ​​the brain or be the result of a network of connections between different brain areas.

People living with chronic pain commonly have cognitive difficulties affecting short-term memory, attention, speed of information processing, speed of psychomotor reaction, higher-order skills such as planning and reasoning, mental ability to easily switch from one task to another, the ability to solve problems.

Although cognitive symptoms are not the primary concern of patients with persistent pain, they can be significantly debilitating and research suggests that it is worth tackling them.

First, cognitive inefficiencies can impact patients' response to treatment. Most of the therapies offered for the treatment of chronic pain require cognitive effort on the part of patients to manage their mood and to understand, remember and complete physiotherapy exercises.

Several mechanisms have been identified that can influence the cognitive abilities of people with persistent pain.

The first mechanism refers to the "limited resource theory", whereby the capacities, in terms of brain processing resources, are preferably assigned to the treatment of pain signals, due to their high biological importance, thus interrupting others cognitive processes.

The second mechanism is maladaptive plasticity. Over time, persistent nociceptive signals lead to structural and neurochemical changes in the nervous system. Changes in gray matter can be observed in the brain of people with chronic pain. These morphological and neurochemical changes that occur in the brain may be partially responsible for the cognitive changes that are commonly observed.

Furthermore, the contribution of secondary factors such as insomnia, fatigue, medications and mood disorders to the experience of cognitive difficulties should be considered, although further controlled studies are needed to clarify the contributions of each factor.

A promising recent development in this field of research is on the possibility of inversion of maladaptive plasticity, with the resolution of pain.

Imaging and neurocognitive studies have shown that pain resolution leads to normalization of cortical thickness and a reduction in cognitive deficit, however it is certainly necessary to understand what can be done to improve cognitive functions, despite the pain.

Certainly educating the patient about the causes and the maintenance of his deficits can be incredibly therapeutic in itself, it allows to legitimize his concerns and to help him understand the reasons for his cognitive difficulties.

After explaining to the patient the probable causes of the cognitive difficulties, the next logical step is to find together ways to better address them, using compensatory strategies. The purpose of compensatory strategies for cognitive impairment is not to repair the deficit per se. Rather, the focus is on reducing the disabilities that can result from those cognitive difficulties.

Compensation strategies may for example include the use of external memory cues, such as a diary or calendar for appointments, a pill organizer so that the correct medications are taken each day, alarms to keep track of time, and others electronic memory aids.

Compensation strategies have great potential and many can be found based on the patient's specific goals.

There is the possibility of carrying out interventions that stimulate altered or underutilized functions, to build or repair neuronal connections through neuroplasticity. For example, if a patient experiences short-term memory problems that cause him to lose the thread of the speech, a "restorative" approach could be to undertake training on memory.

Another solution available can be CBT psychotherapy, which teaches how to manage pain, with positive effects also on neurocognitive functions.

Lastly, movement has neuroprotective effects and improves cognitive function.

The best solution to cognitive problems of people with persistent pain is likely to involve a combination of approaches, individually tailored to the patient's needs based on their profile. There are certainly many translation possibilities in practice.

Everything should start from the recognition of persistent pain as a serious, pervasive, multifactorial problem. The solutions are there. Unfortunately, they seem distant horizons for many. Of course, it is not a valid reason to give up.

What do I do now to deal with all that? I use compensation strategies and try to take it ironically, but it's not easy. It is not easy not to have words, not to remember things, to struggle to move from one thought to another. And this is still tremendously difficult to accept.

But I believe in neuroplasticity and, basically, my path to change my maladaptive plasticity has only just begun. With the body, with that treacherous body that went away on its own, it went well.

Little by little, the brain will also change. He has already done so, after all. And if I lose my words, I can always laugh about it (even if it's not exactly easy for Miss Perfection).

 

Sources:

Optimizing Cognitive Function in Persons With Chronic Pain Katharine S. Baker, BPsySc (Hons), Nellie Georgiou-Karistianis, PhD, Stephen J. Gibson, PhD, and Melita J. Giummarra, PhD Clinical Journal of Pain

 

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Stories of electrical systems

The further I go, the more I know people with persistent pain, the more I realize how difficult it is to make people understand how chronic pain is a physiological problem (related to an organic function) rather than anatomical (related to the structure of the body).

We need to see what's broken in our body and, when we find something wrong, we cling with all our tenacity to that thing that, in an ideal body (where ideal would be better "fake"), not there should be, even minimal: that little thing there, becomes responsible for all our pain, even if it is not. But we see and we like this, it comforts us.

Maybe because my pain was abominable, migrant, "referred" not only to muscles and bones, but also to internal organs that were fine, so when it was explained to me that persistent pain is a problem of physiology and not of anatomy, the fact was obvious to me: "Here is an answer, finally".

But it is not so immediate for everyone.

To simplify, we can say that health professionals have a tendency to look for our pain in the building blocks (bones, muscles, etc.), while persistent pain is in the electrical system, in our nervous system (composed of the brain, spinal cord, from the sense organs and from the set of nerves that connect these organs with the rest of the body).

In short, we have a nervous system, which regulates all the functions of our body, and which nobody (none among the health professionals who have not been able to give us a solution) considers.

But how can the electrical system be seen? And how do you know if I suffer from persistent pain and not from an unknown disease that will lead me to the grave (which I know very well is the fundamental question for all of us)?

First of all, to put you at ease, there is one thing called differential diagnosis.

Differential diagnosis is a procedure that aims to eliminate pathologies based on the presence or absence of some symptoms, using a correct medical history, physical examination and various laboratory tests. The ultimate goal is a correct diagnosis. The health professionals you rely on are able to carry out a differential diagnosis, each for their own skills and, in the event of the slightest doubt, they are obliged to send you to another professional figure. If at the end of the process they tell you that you have nothing, you have nothing ... Nothing that will kill you, at least. Forgive me for being honest, but this is the topic.

One of the first things the practitioner will do is ask you to evaluate your pain. In fact, patient self-portrayals of pain are one of the most reliable sources of information and can help understand what kind of pain you are suffering from.

Some simply ask you questions about your pain, while others can use a more formal pain questionnaire, asking you to choose the words that best describe your pain (such as burning, tingling, sharp, dull, etc.).

After that, which seems to be unknown to most, there are tests that a person suffering from persistent pain can undergo. It is often possible to demonstrate a malfunction (or injury) of the nervous system in one or more modalities, by testing the affected areas with different types of touch, the temperature (using an ice cube or an alcohol swab) ... also take note of the presence and distribution of abnormal pain responses. These tests, a professional who deals with persistent pain, should know how to do them and explain to you what they are for, what they tell about your body and your pain.

But the proven proof of my pain?

Well ... All the questionnaires, questions and tests that are made to you are not the result of the madness of your physiotherapist or your doctor, but of the research on persistent pain, which has allowed us to understand how it works and therefore to develop questions and tests to recognize it and diagnose it. Your body, it is not true that it says nothing about pain. In reverse. It tells a lot. The proven proof you have it under your nose, even if it seems impossible to you.

Well ... yes. There are neuroimaging.

Thanks to neuroimaging in recent years it has been understood that the brain of patients suffering from chronic pain shows alterations with respect to function, structure and chemistry.

Neuroimaging is a relatively new technique that uses various methods for mapping the structure or function of the nervous system.

The use of brain imaging and other technologies has led to the understanding that chronic pain is mediated by the CNS ... It remains that the use of these tools as a standard diagnostic tool for persistent pain is inappropriate (according to IASP), because there are no protocols validated and this is potentially harmful to patients.

In short, even if in neuro-images we see, in people with persistent pain, the activation of certain areas of the brain, it is not possible to quantify the pain from the outside.

I can't tell you if you'll ever see pain. But I can tell you that the evaluation of chronic pain is made on the basis of your medical history, clinical examination, questionnaires ... It may seem trivial to you in our medical system made up of a thousand thousand specific tests for everything, but everything that comes to you proposed by a professional who really knows persistent pain, it is the result of research and clinical reasoning (ie the exercise of a set of complex skills, such as critical, reflective, creative thinking), not by chance.

Your body clearly tells the story of its pain. You need to know how to listen and have the knowledge to understand it, above all.

 

Schmidt-Wilcke, T. (2015). Neuroimaging of chronic pain. Best Practice & Research Clinical Rheumatology, 29 (1), 29–41. doi: 10.1016 / j.berh.2015.04.030
Davis KD, Flor H, Greely HT, et al. Brain imaging tests for chronic pain: medical, legal and ethical issues and recommendations. Nat Rev Neurol. 2017; 13 (10): 624-638.

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