Retraining the Brain to Address Chronic Pain - Clementine Cheng, Physiotherapist
Clementine Cheng
Experienced and empathetic—local physiotherapist explains her role in retraining the brain to create lasting relief from chronic pain.
Hi! I’m Clementine, and I work as physiotherapist at True Physio & Pilates in the beautiful Steveston Village.
Having worked as a physiotherapist for 20 years in Toronto and in the Lower Mainland, I’m glad to call Richmond home. Originally from Alberta, I was pleasantly surprised when I first came into this little oasis away from the hustle and bustle of Richmond, BC. It is such a friendly community, so similar to the one I grew up in.
In my practice I’ve had the unique experience of working with all kinds of health conditions. I have worked with clients recovering from lung transplants and on mechanical ventilation, cancer patients going through radiation and chemotherapy, as well as patients who have suffered brain and spinal cord injuries, and various neuromuscular disorders.
I am thankful that my work connects me with a mosaic of clients who allow me to journey alongside them. It’s an honour to witness the resilience of these individuals who walk through my door. They have experienced traumatic and life altering experiences. In my work, I am reminded daily to appreciate how precious our lives truly are.
Working with clients with chronic pain
I am empowered and passionate in finding treatment for many types of physical health issues—one issue being chronic pain. Having a husband who struggles with chronic pain has taught me how to be more compassionate and empathetic towards my clients who also suffer from the condition.
So today, let’s talk about chronic pain: What it is, the problem with conventional treatment at the site of pain, and what can be done in physiotherapy to achieve long term relief.
What is chronic pain?
First, off, what is considered to be chronic pain? Chronic pain is categorized as a persistent pain that lasts longer than 3 months. As described by Canada Public Health Services, the pain can occur “without a known cause, after an injury has healed or after a condition has been treated”. An important fact to note is that not all chronic pain is triggered by physical factors, and that it is complexly multifaceted—with influences such as psychological and emotional factors that can also trigger chronic pain to persist.
Why aren’t chronic pain sufferers getting relief?
What many chronic pain clients have in common is that they have explored multiple avenues for treatment with little to minimal change. Why? That is because those pain symptoms are a revelation of a much bigger story! Many chronic pain sufferers are not getting healthier because they have sought treatment based only on symptoms or have focused their attention only on the area of pain.
Where is the root of the pain?
When I help clients to zoom out and look at the whole body, they discover that the actual factors causing their pain are not in the localized area. The problem stems from other parts of the body, painful or not.
For example, when I investigated one client’s chronic neck pain, we discovered that the problem came from her shoulders. She hadn’t noticed that her shoulders were slumped down and pulling on her neck.
When treating chronic pain patients, we need to observe their movements and look above, below and around the area of pain. How does the whole body move? How does the body look? Does the client tend to overload one side of their body, causing misalignment and irritation? How is the rest of the body affecting the local area of pain?
In my practice, it is my great joy to see clients finally discover where their real pain factors are in their body and start to experience relief from their long suffering pain.
How can we retrain the brain to get out of the pain cycle?
As these clients discover the multiple factors causing their pain, most of my work involves helping them retrain their brains. This is vital because when you’re stuck in a cycle of pain, your brain develops habits that control a conditioned set of motor pathways to respond to the pain.
What are motor pathways?
Our motor pathways carry commands from our brains to our muscles. For example when we want to pick up a water bottle, our brain will send signals through a set of motor pathways to our arms and hands to orchestrate the movements for that action. Our motor pathways also carry feedback from our muscles—such as the weight of the water bottle that we’re picking up—back up to our brains in order for our bodies to make adjustments.
During the healing or rehabilitation process, when the brain uses the same conditioned set of motor pathways to deal with new stimuli, it will only keep the client in a constant state of pain. So as a physiotherapist, my goal is to help clients find new pathways for their brain-nerve-muscle connections. These new connections will allow them to retrain their brain to move differently whenever there is a pain stimulus, which in turn allows them to break the vicious cycle of pain.
Starting with input
So what can we do to retrain the brain? We can start by providing some input to the brain first. For my client with chronic neck pain caused by her shoulders, I started by manually supporting her shoulders in the optimal position with my hands so that her brain can begin to recognize the feeling of relief.
When muscles and joints have been in an improper position for a long time, there isn’t the ability for them to re-adjust on their own. This is why BEFORE we can do training, I have to do different manual treatments to help release the muscle length-tension. This allows the client to find correct postural alignment. Next we can move on to the training: uptraining or downtraining!
Downtraining overactive muscles
In order to break the pain cycle, I also help my clients develop optimal movements from old movements that caused their pain. Often, you have to “downtrain” a muscle overactivity, in order for you to be able to strengthen the underlying weakness in other muscles. I like to give this analogy:
If the drum is playing very loudly in an orchestra, no matter how much you want the string instruments to be playing louder, you can’t hear them as the drums are too loud! In order to hear the other string instruments, the drum volume has to be turned down. This is kind of similar to how our muscles work together to make beautiful movements!
Here is an example of downtraining for my client with neck pain coming from her shoulders: I gave the client a cue so that she could learn to downtrain—“imagine butter melting down your armpits” as she is doing daily tasks, and with a prescribed exercise program. Learning to let go of a muscle they are unconsciously firing up is very key to helping them BEFORE they can strengthen.
Uptraining to strengthen muscle groups
In “uptraining” we could work on strengthening surrounding underutilized muscle groups that can support the overworked muscles within the pain area. Since these underutilized muscle groups tend to be weak, Clinical Pilates has been pivotal for clients to build up these muscle groups while performing pain-free movements in positions that take away gravitational load, or provide assistance to facilitate that pain free movement. For many clients with chronic pain who have never felt pain free movement, this is a HUGE game changer. Furthermore, the springs on the pilates equipment help to create a low level resistance that the body feeds back to the brain to activate more postural endurance type muscles.
More ways to retrain the brain
Other ways to tap into the brain include using visual tools and imagery to create more awareness of the body. I often educate clients by using anatomy apps. I also have clients look in the mirror to check that their movements and posture are optimal, and give them simple reminders such as “float your shoulders.”
Clients learn postural cues to take home with them. They can check what their movement feels like before and after they do the cues. For example, a client will first try turning their head to the left in the old way that has been causing pain. Then they try their new cue as they turn their head to the left again. They will experience less pain and more movement. This will further help them to reinforce what we are working towards.
The joy of witnessing positive transformation
It is such a joy to see the transformation—when “hopeless” clients suddenly feel significantly better by simply discovering new strategies in their movement and strengthening targeted muscles.
One of many examples is the story of an elderly lady who started off being very immobile. After working on strategies to help her move and walk better, she was finally able to squat down to feed her dog and take it for walks effortlessly around Steveston—even at the beach where the uneven ground used to be off limits for her.
When I hear from clients about their new found freedom and improved quality of life, I feel energized and motivated to continue learning and serving in this area of health care.
If you are thinking about physiotherapy for yourself, remember that the process is a journey. Yes, it can feel frustrating at first as your body and mind adjusts to building new habits, but with dedication and patience, achieving long term relief is possible!
Clementine Cheng, Physiotherapist, Steveston Village, Richmond BC