When I was an undergraduate student I wrote a newsletter that was more of a self-indulgent exploration into the metaphysical than anything substantiated by science.
A close friend described those works back then as “existential ravings of a Mensa reject”. Postgraduate supervisors sure do a good job of pummeling that out of you with the proverbial electronic red pen when attempting to put together a scientifically valid, 25,000 word thesis.
Upon completion of this thesis and looking back on the evolution of my writing, the ravings are not too dissimilar: different flavours of different times and still impossible to understand. Mensa reject is probably still apt. However, one set of ravings earned me an A- degree. A patient said I should remove the minus though to get that kind of negativity out of my life.
For those who have been marginally interested in my ravings over the last few years, this is a brief synopsis of my thesis and subtle lessons learned thus far:
- This study was a first-time investigation of a brief mindfulness intervention into chronic pain (particularly, nociception) and the autonomic nervous system. Now, before your eyelids get heavy after reading that first sentence, I will explain things simply as we go in order to maintain high levels of enthusiasm. For this reason, I have not included the full title of the study because it’s ridiculously long. You can download the thesis below if you’re truly interested.
- Acute pain is different to chronic pain. Many people don’t understand that. Chronic pain is actually a serious problem. It’s right up there with cancer – 1 in 5 New Zealanders suffer from chronic pain but you can’t see it. It destroys lives. People mourn their old life. It’s terrible. One person I met had the veins of his leg removed from a knee surgery that went wrong; one lady suffered from a disease where the protective sheath of the nerves in your limbs gets eaten away and any touch to the skin creates accentuated pain; some people couldn’t walk or sit, or even hold their arms up for me to strap on the electrodes. Some people were “normal” folk like you and me, who experienced a little bit of trauma, physical or emotional, or a tiny fender-bender where “nothing happened”… and their pain system broke. Some people with chronic pain don’t get better and are treated like modern day lepers of society.
- Chronic pain is pain with no useful purpose. When pain persists longer than 3 months, one’s pain system can break and start to rewire. This occurs in the spinal cord and brain. Physiological, structural changes start taking place. It’s serious. This rewiring process can get set up and stay in place for a very long time. What I’ve come to appreciate is that pain can be a very dangerous thing, because when those “bad” switches get turned on, they can be difficult to turn off. Much like phantom limb pain: the person “feels” the limb, but it’s no longer there. Pain management, soon and early, is imperative. The Kiwi she’ll be right attitude absolutely does not apply.
- It’s not all your fault. This is one of the subtle lessons I discovered. A few people I met felt they were to blame for all their problems, rejected by doctors and psychologists saying it’s either all in their head or they need to live a better lifestyle conducive to not reproducing their pain. As I’ll explain in the next point, sometimes shit happens for reasons no one really understands yet, and the pain system breaks. It’s not all your fault.
- Nociception is not pain. Nociception is the sensory process that sends pain signals to the brain. Pain is how each individual experiences those signals, and that is different for everyone. Pain and nociception involve different parts of the brain. These different parts determine how painful something is, what it might mean, and what to do about it. Pain therefore becomes a complex experience. People can have different aspects of their pain system not work properly and prolong the experience of pain, or start becoming fearful about it.
- Catastrophising makes things worse. In our study we incorporated a psychological component to the measure of pain. We had a lot of people in pain attending the study. Half of them felt really “unsafe” about their pain and that things were going to get worse. This tends to amplify the experience of pain and turn the noise up in the nervous system.
- We are all different. You cannot compare your pain to anyone else’s and – even more importantly – you cannot compare treatment plans! What works for someone else may not work for you. For a select few in our study, mindfulness made them worse because it was like shining a light on exactly what was wrong with them.
- No study to date had looked at nociception and chronic pain in the context of mindfulness. Mindfulness has become very fashionable these days. Most studies involving mindfulness have either used healthy participants or only measured a person’s “experience” of pain, but not what is happening in their pain system (nociception). Especially, no one has looked at mindfulness in the context of complex conditions. Further to that! No one has looked at mindfulness in the context of complex pain conditions, nociception and its correlation with the autonomic nervous system, but we’ll get to that in a moment.
- I don’t think mindfulness is the ultimate panacea. An examiner of my thesis wrote the following remarks in the final report: “The author has completed an ambitious project and while the findings might perhaps seem a little disappointing, they are important and useful given the present, sometimes uncritical, enthusiasm for mindfulness in treating a broad range of health conditions.” A brief mindfulness intervention had no effect on nociception (the processing of pain signals). Our study only looked at a brief intervention of mindfulness, so that’s not to say mindfulness might help if someone practiced it a lot. However, no one has looked at the long term effects of mindfulness on nociception. There are plenty of studies saying people’s experience of pain is better, i.e. they have learned to live with the pain a bit better, but mindfulness on its own has not yet been proven to change the physical architecture of the pain system.
- The gravy train of mindfulness says it changes your brain. Changing various areas of your brain may or may not alter one’s pain system and nociception. The majority of mindfulness studies out there involve healthy students, not complex pain conditions. That’s what we wanted to test.
- Heart rate variability is the other gravy train. We certainly had a lot of gravy with our meat and potatoes in this study. At the same time I was poking and prodding people in pain, I was recording electrophysiological data about their autonomic nervous system to see if there were any correlations with the stress system. I use the word electrophysiological mainly to sound cool. The autonomic nervous system controls your organs, glands, blood vessels, breathing, heart beat – stuff that keeps you alive, basically. Some people with persistent pain have a broken autonomic nervous system too, which is like a double whammy (yet another reason why stress is bad, but that’s another thesis entirely). I used a number of different electrophysiological measures to see what was happening in the stress system, namely heart rate variability, mean heart rate, and skin conductance response. Skin conductance response is what they use in lie detector tests. Mindfulness didn’t change the autonomic nervous system much in our experiment with complex conditions, but people in pain did show aberrations in skin conductance when being poked. This means your nervous system definitely doesn’t like being in pain. The subtle lesson though was that for those climbing on the heart rate variability gravy train, understanding what it really means is very complicated. You can now find all sorts of $100 widgets being sold that measure “heart rate variability”. Heart rate variability is the to-and-fro of the sympathetic and parasympathetic nervous systems. It’s comprised of multiple variables, influenced by many factors in the body, e.g. blood, hormones, electrical and chemical activity, breathing, stress, temperature, brain and brainstem signals. Heart rate variability spits out a few numbers in the form of frequencies and then people try determine what is wrong with them. Those frequencies can mean so many different things across the smorgasbord of activity in your body it’s almost pointless for the lay person. For example, sometimes meditation increases sympathetic activity when breathing rate is slowed, which is counter-intuitive to everything we understand about the sympathetic nervous system.
- The brain engages both sympathetic and parasympathetic activity at all times. Heart rate variability and blood pressure are both controlled by the autonomic nervous system. So when someone has high blood pressure for instance, and requires treatment, only seeing the high value doesn’t tell you where the problem is in the body. You can put a plaster on it but it doesn’t necessarily tell you what the cause is. So another subtle lesson learned was that simply because someone has a high or low sympathetic or parasympathetic heart rate variability recording, doesn’t necessarily tell you where or what the problem is or how it needs to be treated. People can still be in pain with normal heart rate variability readings.
Your body is really, really complicated. Ignorance as an undergraduate student was bliss. Now I look at patients completely differently, which is good and bad. Good in the sense that I can now recognise and try treat more complicated conditions with better outcomes, but bad in trying to explain to people what is really wrong with them when they are in pain and just want to be fixed quickly.
“Pain is a complex perceptual experience influenced by a wide range of psychosocial factors, including emotions, social and environmental context; the meaning of pain to the person; beliefs, attitudes, expectations; as well as biological factors. The biopsychosocial view of pain provides an integrated model that incorporates mechanical, neurophysiological, psychological, as well as the social variables which may cause and perpetuate pain.”
That’s a quote from the beginning of the thesis. Ravings of a Mensa reject, really. But a reject that has come to find a passion in neurobiology after forgetting for so many years that biology was really his first calling as a 16-year old, yet didn’t know could create a life around it, help other people, and simultaneously support a family. For this, and the journey ahead into a PhD in chronic pain and the autonomic nervous system, I am grateful.
Thanks to all who have supported, read and replied to me over the years, and to everyone that supported me through this leg of the postgraduate journey. It has been incredibly difficult and challenging at times, not only learning statistics, but working, studying and finding a life somewhere in the midst. It’s been worth it. I’ll be taking the next couple months off before formalising ideas and proposals for PhD next year, however, I’m sure the next few years will be totally stress free.
Neil Bosssenger, BSc. MPhil.
