FREQUENTLY ASKED QUESTIONS
The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” (1). Pain is an uncomfortable feeling or sensation that tells us something may be wrong in a part of our bodies. Pain is a way for our bodies to react and prevent further tissue damage. It comes in different forms – sharp jabs, dull aches, throbbing and so on. It’s important to understand that pain is not generated by the body tissues – it’s a messaging system that involves lots of elements, including nerves, immune cells and chemicals. These elements are combined and processed in our brain and central nervous system, creating messages involving our memory, emotion and attention, in a way that is unique to each person These messages are designed to change our behaviour, in order to protect us from harm.
We feel pain when electrical signals travel through nerve fibres via the spinal cord to the brain, and the brain interprets those signals. There is no such thing as a single pain nerve that goes from the site of the injury all the way to the brain. There is also no such thing as a ‘pain centre’ in the brain (2). Rather, the information is relayed via the nervous system to the brain, which assesses the information and creates the appropriate warning signals. Say you touch a very hot surface. Your brain will interpret the signals it receives from nerve cells in your finger tissue and decide what to do, based on what it thinks is happening. As part of its assessment, your brain may refer to memories of similar experiences you may have had when touching a hot surface in the past. If your brain believes you are at risk, you start to feel an unpleasant sensation – pain. The brain then sends messages to your central nervous system and your muscles, to get you to quickly take your fingers off the hot surface, as well as releasing chemicals (such as endorphins) to help your body cope with the pain.
The IASP says pain is “always a personal experience that is influenced to varying degrees by biological, psychological, and social factors”. (3) We all experience pain in our own way. We learn about pain through life experiences and these experiences are logged as sensations, perceptions and memories by our brains, shaping how we each think and feel about pain.
Pain is also a whole-body experience and links with the emotional centres in our brain (4). This means how we are feeling in general, influences our pain. If we feel angry, depressed or anxious, our pain may be more intense, and we may feel overwhelmed by it. If we are feeling positive and happy, the pain we feel from exactly the same problem may seem less intense, and we are able to cope better, and feel more resilient.
Our past experiences can also have a significant impact on how we experience pain in the future (5), as our brain uses whatever pain information it has in its memory to make a ‘risk assessment’ about the threat the body is facing, and predict how we will experience pain.
Pain relief drugs mostly work by binding to certain receptors in the brain and spinal cord. These drugs moderate the signals being interpreted by the brain, thereby increasing our tolerance for pain. Other drugs are anti-inflammatory, reducing the swelling in the damaged tissue, which in turn helps moderate the signals being sent from the nerve fibres to the brain.
Chronic pain is pain that lasts longer than three months. It is also called persistent pain or long-term pain. It is often described as “pain that does not go away as expected after an injury or illness”. The underlying tissue damage from most injuries tends to heal within about three months.
Chronic pain is thought to occur when nerves become over-sensitive and over-stimulated, and send warning messages to the brain predicting pain, even when there is no injury, or the original injury causing the pain has healed (6). The brain keeps reacting to these signals, predicting future pain and generating pain sensations, a bit like a broken record. Another way of looking at it is thinking about pain as a ‘fire alarm’ in your body. With chronic pain, the alarm keeps ringing even, though the ‘fire’ (the underlying tissue damage) has been put out.
Eventually our brains get stuck in a rut, needing fewer and fewer signals to produce the pain experience. We can become over-sensitised to pain and become overwhelmed by the pain experience to such an extent, that it becomes our new ‘normal’. At this point the pain messaging system has malfunctioned, because it is trying to protect us from something that no longer exists (7).
It is estimated that one in five adults in the US live with some form of chronic pain (8), with similar figures (from 10-25%) estimated for many other countries throughout the world (9). For some, the pain might fluctuate in severity and intensity in response to other triggers, such as hormones or stress. For others, the pain might always be there as a constant, running in the background like a low-level noise. But for those with severe pain chronic pain, it can be very distressing and impact their emotional, physical, and psychological wellbeing.
Chronic pain is complex and can be difficult to treat. Medicines alone are not an effective way to manage chronic pain, because of the harmful side effects of using them on a long-term basis. Rather, non-pharmacological treatments and strategies for helping to better cope with how we experience pain, are more effective (10).
No it doesn’t! Remember, all pain is essentially a messaging system used by the brain that is designed to protect us. It’s just that with chronic pain, the body no longer needs that protection. The pain felt by a chronic pain sufferer is just as real as the pain felt by someone who has recently suffered a traumatic injury. A good example of this is phantom limb pain. This occurs when a person has had a limb amputated. Even though the limb is no longer there, the person can still feel pain or itching where the limb once was. This is because the brain has a map of the body and uses it to send messages about sensations, such as pain. Just because the pain is no longer there, doesn’t mean the map has changed. This map is part of the structure of the brain and this takes time to change, but it can change!
Just like other parts of the body such as our muscles, our brains have the ability to be trained and change the way they function. The question then, is: how can we help the brain to change itself? The trick to getting our brains to change is to point it in the right direction, and then it will make the changes itself. Just as we can learn a new skill, our brain can also learn and change so that it works in the best way for each person. One of the ways the brain can do this is through a scientific method called Operant Conditioning.
Operant Conditioning works by redirecting brain activity that has gotten into a negative state, into a positive, state and then reinforcing that positive state with positive feedback, until the brain learns to do it automatically. Through Operant Conditioning, people can learn to respond differently to the nerve signals that their brain interprets as pain – in essence, to ‘retrain’ their brains.
Neurofeedback uses Operant Conditioning to redirect brain activity away from predicting and experiencing pain and towards predicting and experiencing relaxation, positivity and sustained focus. This is done by using a simple interface, such as a video or animated game (11).
When we generate the desirable brain activity, we are rewarded with audio and visual feedback that keeps the game moving and achieving goals that help to redirect our brain to the desired frequencies associated with relaxation, positivity and sustained focus. Repeated sessions of Neurofeedback training can result in long-lasting changes in brain activity, which can affect how the brain functions and how it is structured. These changes can help the brain to send and receive different messages about pain, and these new messages can have positive effects on our perception of pain, which in turn helps improve our sleep, our mood and our behaviour.
EEG (short for Electroencephalography) Neurofeedback works by monitoring the brain activity associated with a particular function – in this case, detecting and responding to pain. This brain activity takes the form of electrical signals. Through the use of small sensors placed on the scalp (either directly or within an EEG headset), these signals can be recorded and fed back to the person in real time via games, creating a positive feedback loop to change how the brain perceives and responds to pain (12).
The science of electroencephalography (EEG) has been around for almost a century. It has been used in Neurofeedback treatments since the early 1960’s (including by NASA) and it has been an established part of clinical evaluation and treatments since the 1970’s (13). Every major hospital and medical university has an EEG system for monitoring brain activity. EEG neurofeedback uses that same technology to help the brain to change itself.
With a chronic pain patient, their brain is continually receiving nerve signals that it responds to by sending messages telling their body to experience pain. The brain activity associated with pain is recorded by Axon’s custom-designed EEG headset. Axon transmits these recordings via Bluetooth to the Axon app which then visually represents it to the patient via neurological exercises in the form of simple animated games. These exercises are specially calibrated to encourage the patient’s brain to spend less time generating the brain frequencies associated with chronic pain, which in turn encourages their brain to moderate the pain instructions it transmits and receives. By using the Axon system on a regular basis (about 30 minutes per day) over the course of several weeks, the patient learns how to ‘retrain’ how their brain perceives and responds to pain. This process is called “neuromodulation”.
Neither. Remember, pain is a sensation that our brains generate in response to a perceived danger to our bodies. Neurofeedback trains the brain to respond differently to the nerve signals that are received from, and sent to, the body. So, if we can train our brain well through Neurofeedback, it won’t pay as much attention to the pain signals, and it won’t send the same ‘pain’ messages to our body. The result? The pain we experience is reduced.
Conventional EEG Neurofeedback is complicated and costly for both patients and clinicians. It requires the patient to attend a specialist clinic for multiple sessions over 8-12 weeks, an expert clinician must be present to interpret the brain activity data, and the EEG Neurofeedback equipment has (until recently) cost many thousands of dollars to purchase. These complications have also limited the amount of clinical research that has been undertaken to test the effectiveness of Neurofeedback as a therapy not just for chronic pain, but for a range of other neurological conditions. Without this clinical research evidence, many doctors have been reluctant to recommend that patients undertake an expensive process that is difficult to access, and many patients were unable to afford the treatments.
(2) Stern, J., Jeanmonod, D., & Sarnthein, J. (2006). Persistent EEG overactivation in the cortical pain matrix of neurogenic pain patients. Neuroimage, 31(2), 721-731.
(4) Koechlin, H., Coakley, R., Schechter, N., Werner, C., & Kossowsky, J. (2018). The role of emotion regulation in chronic pain: A systematic literature review. Journal of psychosomatic research, 107, 38-45.
(5) Jepma, M., Koban, L., van Doorn, J., Jones, M., & Wager, T. D. (2018). Behavioural and neural evidence for self-reinforcing expectancy effects on pain. Nature human behaviour, 2(11), 838-855.
(6) Arendt‐Nielsen, L., Morlion, B., Perrot, S., Dahan, A., Dickenson, A., Kress, H. G., … & Mohr Drewes, A. (2018). Assessment and manifestation of central sensitisation across different chronic pain conditions. European Journal of Pain, 22(2), 216-241.
(7) Baller, E. B., & Ross, D. A. (2017). Your system has been hijacked: the neurobiology of chronic pain. Biological psychiatry, 82(8), e61. (8) Retrieved from https://www.washingtonpost.com/national/health-science/the-big-number-50-million-adults-experience-chronic-pain/2018/10/19/30831828-d2e0-11e8-83d6-291fcead2ab1_story.html
(9) Jackson, T., Thomas, S., Stabile, V., Shotwell, M., Han, X., & McQueen, K. (2016). A systematic review and meta-analysis of the global burden of chronic pain without clear aetiology in low-and middle-income countries: trends in heterogeneous data and a proposal for new assessment methods. Anaesthesia & Analgesia, 123(3), 739-748. (10)Retrieved from https://www.aafp.org/news/health-of-the-public/20200115nonpharmtx.html
(11)Gunkelman, J. D., & Johnstone, J. (2005). Neurofeedback and the brain. Journal of Adult Development, 12(2-3), 93-98.
(12)Enriquez-Geppert, S., Huster, R. J., & Herrmann, C. S. (2017). EEG-neurofeedback as a tool to modulate cognition and behavior: a review tutorial. Frontiers in human neuroscience, 11, 51.
(13)Masterpasqua, F., & Healey, K. N. (2003). Neurofeedback in Psychological Practice. Professional Psychology: Research and Practice, 34(6), 652–656