Saturday, March 31, 2018

Mindfulness of chronic pain.

I have chronic pain. I have a problem with my back, that I was born with but which didn't cause me any problems when I was a child, and which degenerated as I got older. The main problem with my back made itself known when I was 15, and more seriously when I was 26, with two acute episodes of incapacitating back pain some months apart. These kept me out of work for around a year and a half. I did several more years of rehabilitation after that, made up of various treatments, as often as weekly, plus occasional periods of medication, and daily exercises. I have done exercises every day to improve and maintain my back health for over ten years at this stage. Sometime after the two acute episodes, instead of recovering completely, my body reacted to the experiences of acute and ongoing back pain by developing a chronic pain condition. For me, having chronic pain means that I am in some level of discomfort or pain almost all the time, every day, whenever I am conscious of my body. If I am paying attention to my body, then usually what I feel is uncomfortable or in pain.

Chronic pain is very common, many people feel it for different reasons, and over the last ten to fifteen years research into and understanding of it has improved enormously, among doctors, physiotherapists, other health practitioners, and those who live with it. It is still not well understood but we do know something about it. For me, this pain is not necessarily or even usually connected to a physical problem, there may be no tissue damage, injury or physical threat that is 'causing' the pain. What has likely happened, as I understand it, is that the way that I both experience bodily sensations and interpret them in my brain has changed. At the local level, it's likely that nerves in some areas of my body have changed. Probably more nerves have grown in some highly affected areas, resulting in more signals being sent to the brain from these areas. It's also likely that some nerves have changed how they transmit information. Nerves are usually specialised to a certain kind of input, for example, temperature or pressure. In my case, it is likely that nerves that would normally only be sensitive to, say, temperature, have altered to also transmit information about pressure. This causes confusion in the nervous system. A lot of signals are being sent from local nerves to the brain that wouldn't normally be sent, by nerves that wouldn't normally send them. Further 'up' in the nervous system, major areas of the spine have likely also changed how they take in and process neurological information. Such changes in the spine frequently happen in reaction to severe, intense pain or damage to the back such as I experienced during the two major acute episodes.

Finally, it is in the brain itself that pain exists. Pain does not 'exist' in local areas of the body where it seems to appear, there are no 'pain signals' that are sent to the brain, nor is there a 'pain centre' in the brain that is solely responsible for processing pain. Rather, the brain constantly takes in a huge range of signals from the nerves such as temperature or pressure, and it interprets or puts together these signals and in some sense 'decides' what they are as a whole. At one point, a collection of signals may be interpreted as painful, at another point as pleasurable. In another situation, such signals may be interpreted as simply telling the person things like how they are standing, where their arm is positioned, or whether the weather is warm or cold. Usually such signals are interpreted relatively reliably by the brain, and the interpretation 'pain' only results when there is injury, or when temperature or pressure on a body part becomes dangerous. In my case, and for other people with chronic pain, the interpretation of these signals in the brain often goes askew, the brain itself has changed how it interprets the signals coming from the body, and as we've already seen the nerves themselves and the signals they are sending have also likely changed. Representations, connections and signalling within the brain have likely altered from how they were before for me, and differ from someone who does not have chronic pain. For me, instead of my brain putting together the signals and telling me, for example, that my arm is feeling fine lying on the armrest of my chair, my brain interprets these signals to mean that my arm is in pain. Something has changed, and daily, repeatedly changes, probably all along the nervous system, from local nerves in my arm, through my spine, and in my brain. The result is that when I pay attention to how I feel in my body, or in other words when I pay attention to how my brain is interpreting my bodily sensations, what I am usually told is that I am at least uncomfortable and on a bad day, that I am in pain.

But this pain does not exist outside of my awareness of it. It is possible to say that tension, or muscle soreness, or locked up joints, or any of many physical problems, exist outside of one's awareness of them, and I would certainly have any and all of those issues at any one time. But pain does not exist in this way. If you do not feel the pain, there is no pain. Pain is a mental event. It is not "all in your head" in the pejorative, "you're imagining it" sense, but it is all in your brain. Pain is a specific interpretation by the brain of signals it receives. If you do not experience that interpretation, if you're not aware of it at some level, it is not there. Pain exists only if you feel it.

This has been particularly on my mind (and brain) because for the last two months I have been doing a mindfulness course. This has involved a weekly class for 2.5 hours with a facilitator and thirteen other participants, as well as 30 minutes daily meditation practice at home. It has been challenging and difficult at times but also wonderful and made me feel happy. What was especially challenging about mindfulness for me as someone with chronic pain is that the practices, especially those we did in the first weeks of the course, often involve focussing and being present with whatever is going on in your body. Paying deliberate attention to bodily sensations, as they occur. For me this meant that I would focus my attention on what was happening in my body at that moment, and that would mean I would become aware that my brain was interpreting these sensations as uncomfortable or outright painful. Often I would simply be lying on the floor, not moving, or sitting quietly in a chair, meditating, listening to the voice of the facilitator, and I would be in pain. Directing attention to my body meant becoming aware of my interpretations of bodily sensations, and as outlined, due to problematic signalling at many levels, those interpretations often announced one thing: I'm in pain.

In mindfulness we were sometimes advised to direct our attention where our bodily sensations were strongest or most powerful. Part of the goal of this is to bring the meditator into closer contact and greater awareness of their body, just as it is. Even if we were not deliberately doing this, the right side of my body, where the back problems are worse, would clamour for my attention much more loudly than the quieter, less apparently painful left side. The reality is that such problems are somewhat self-reinforcing - this side of my body is in worse shape and so it generates more signals, I therefore inevitably pay more attention to that side, that attention increases the representation of the right side of my body in the brain relative to my left side, there are more connections made and experiences of interpreting its sensations as painful, it is then more likely to have attention paid to it, and more likely to be interpreted as pain. And so it goes, the right side getting louder and louder and more painful, and the left, less painful side getting comparatively quieter and being ignored.

So at times in the meditations I would simply be with my bodily sensations as they were. And that often meant the apparently 'painful' parts of my body got more attention. They were what were. And sometimes that was useful in itself in cultivating awareness. At some point in the classes, I decided to try an alternative approach. I would direct my attention deliberately to my left side. I would try to notice what the left side felt like. I would notice that it didn't feel in pain, didn't feel abnormal, didn't feel larger and louder that the other side. It felt 'normal'. It felt quiet. It felt like it was lying there, not that it was lying there in pain. I would try a little harder to feel what bodily sensations were in my left side. It took effort and a deliberate peeling of my consciousness away from the right towards the left. I would not focus on ignoring my right side, but simply on being with my left side. And that helped. By reducing my awareness of the pain in the my right side, I was reducing the pain in my right side. Because as we've already seen, awareness of pain is pain. Without awareness, there isn't pain. The goal of meditation - there are many and no goals - is not to be caught up in the sensations of the body. I don't have to feed or focus on a particularly strong sensation, or pay more attention to the most painful part of my body. The other parts and sensations are just as important. I found myself thinking, the right side of my body is like the loudest kid in the kindergarten class, who is shouting and causing trouble and demanding attention. That child deserves attention, but no more than all the other children who are being quiet. And gradually, by focussing on my left side, I felt that a greater balance was appearing in my experience. I was no longer sucked in by the right side all the time. I was learning what not being in pain felt like, having more experiences of not being in pain, through focussing on the in-the-moment experience of my left side. It began to balance up the right side experience, providing a counterpoint so that my total experience included some more 'normal' and non-painful bodily sensations. And it began to quieten my experience of the right side of my body too. It seemed less raucous, less shouty, less demanding. I had less pain. And I had more experience of not-pain.

Who knows if this focussed attention also began to change local nerves, or change what was happening in my spine, or change brain connections and representations. We can't know that, just as we can't know with any certainty what exactly has happened to cause my chronic pain because we don't have the scans or techniques to detect those changes in the nervous systems of living humans, at least not yet. We can just try to understand what is likely going on. By choosing in meditation and mindfulness to sometimes be with my left side rather than with the equally but not more deserving right side, I had experiences of not being in pain that were just as valid as my experiences of being in pain. And I was able to simply be, with whatever I experienced. To be with what I am, however I feel, whatever I think, right now.

To the facilitator, and my co-adventurers in the mindfulness class, and to myself - thanks for being here.


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