#67: Pain and OT with Irvin Eisenberg

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Learn more about our guest: Irvin Eisenberg, MOT

:white_check_mark: Agenda

Intro (5 minutes)

Breakdown and analysis of journal article (5 minutes)

  • 00:00:00 Intro to Pain and OT
  • 00:01:00 OT Potential Podcast Intro
  • 00:02:27 Intro to Chronic Pain
  • 00:03:02 Problems with Classical Understandings of Pain
  • 00:03:47 Intent of this Article
  • 00:04:10 The Distributed Processing of Nociceptive Information with the Spinal Cord
  • 00:05:45 The Distributed Processing of Nociceptive Information with the Brain
  • 00:07:36 Distributed Treatment
  • 00:09:12 Article Conclusion

Discussion on practical implications for OTs (50 minutes)

  • 00:10:11 Intro to Irvin Eisenberg
  • 00:15:56 Opening his Own OT practice
  • 00:20:11 Impressions of the Article
  • 00:28:28 Talking about Pain with Clients
  • 00:34:48 Story about the Tremendous Power of the Brain to Regulate Pain
  • 00:39:01 Go-to Assessments for Pain
  • 00:45:43 Irvin’s Holistic Approach to Pain
  • 00:58:43 Advice for OTs who are Interested in Starting a Pain Private Practice
  • 01:00:25 Final Thoughts

:white_check_mark: Supplemental Materials

:white_check_mark: Article Review

Read Full Text: The Distributed Nociceptive System: A Framework for Understanding Pain
Journal: Trends in neurosciences
Year Published: 2020
Ranked 100th on our 2019-2023 list of the 100 Most Influential OT Journal Articles

I once heard a neuroscientist say:

Many of our frameworks end up being wrong—because the body is more complicated than we ever imagined.

Pain science perfectly illustrates this. We are living in an era where new frameworks are being written—because classical understandings of pain have not only been inadequate, but have also led to ineffective (and even harmful) treatment.

Today, we look at a new framework for understanding pain.

And, it brings good news for OT.

The authors argue that because chronic pain is such a complex condition, it requires the kind of holistic treatment inherent to OT and PT.

To help us unpack what this all means for your daily OT practice, we are excited to welcome to the podcast Irvin Eisenberg, owner of Resilience Occupational Therapy, where he helps members of his community manage their pain.

Big-picture introduction to chronic pain

Chronic pain affects more than 30% of the global population—making it the leading cause of disability worldwide.

Part of the reason chronic pain remains so widespread and debilitating is that our understanding of the systems behind it is sharply limited.

We still can’t fully explain the central nervous system mechanisms that process potentially noxious information into our subjective experience of pain.

The article refers to this process as the “nociceptive system.”

The problem with our classical understanding of chronic pain

Focusing on single neurons, single molecules, or single brain regions has left us with an incomplete understanding of pain—thus rendering our efforts to develop new pain treatments largely unsuccessful.

Many of these efforts have revolved around pharmaceuticals. In short, we’ve been looking for a pain-busting miracle drug.

But medications for chronic pain are startlingly ineffective—and new drugs often fail to outperform a placebo.

Meanwhile, more effective and holistic therapies for chronic pain—like OT and PT—are underutilized and under-reimbursed.

What is the intent of this article?

In this article, leading pain scientist Robert Coghil, PhD, lays out a framework for understanding pain. He calls it the Distributed Nociceptive System.

Full disclosure: There is a ton of complicated science here, so I am going to stay focused on the big-picture takeaways.

The distributed processing of nociceptive information with the spinal cord

Recent research now indicates that the spinal cord BY ITSELF has the ability to:

  • Encode multiple dimensions of sensory information, like intensity and location.
  • Formulate complex motor responses to noxious stimuli.

Historically, we’ve been taught that the dorsal horns of the spinal cord are engaged in sensory processing, whereas the ventral horns are engaged in motor processing. I even found a graphic that reinforces this understanding:

We now know this to be untrue; pain processing actually is distributed across both the ventral and dorsal horns.

Additionally, nociceptive input historically has been ascribed to laminae 1-5. This also has been labeled untrue. Nociceptive processing is distributed across multiple laminae.

In short, processing can take place at multiple locations along the spinal cord—making the signal extremely hard to disrupt.

Unfortunately, these classical tenets of pain have led doctors to surgically cut the spinal cord in order to alleviate chronic pain—only to have their patients’ pain return. The theory here is that over time, an alternative pain pathway becomes engaged.

The distributed processing of nociceptive information with the brain

In the brain, the story is the same. We are discovering redundancy upon redundancy, ultimately ensuring that pain information is processed—even when one tract or large portion of the brain is damaged.

For example, classical views of pain once associated sensory processing to the lateral nuclei of the thalamus—and motivational processing to the medial nuclei. We now know that both of these brain sections have the ability to process pain.

Part of what we now know about pain processing comes from more advanced science around particular brain regions. But, we’ve also added to our knowledge by studying cases where specific brain regions are injured—yet somehow, pain persists.

In what the author calls a horrific example of the resiliency of pain, he describes the case of a patient who had facial pain following shingles. Surgery was performed to:

  • Resect the sensory root of the trigeminal nerve;
  • Excise the contralateral somatosensory cortex for the face;
  • Excise the ipsilateral somatosensory cortex for the face; and
  • Excise the bilateral prefrontal cortex.

Basically, anything that might carry the pain signal was removed—and yet, the pain remained.

This all leads to the central tenet of this new pain framework:

The extraction and utilization of nociceptive information is a process that can be accomplished separately and largely independently by multiple sites within the central nervous system.

Pain: a Distributed Problem Calling for a Distributed Treatment

We now can see why surgery often fails to disrupt pain.

We can also see why medication targeting a single neurotransmitter or neuromodulator is so ineffective.

There is a clear need for treatments that target distributed systems. Luckily, they do exist—they are simply underutilized. The author highlights two main categories of such treatment:

Multidisciplinary treatments incorporating cognitive behavioral therapy

Emerging evidence indicates that multidisciplinary teams who incorporate cognitive behavioral therapy into treatment can substantially alter pain by targeting multiple brain areas.

Specifically, combined cognitive behavioral, physical, and occupational therapy has been shown to decrease connectivity of the left amygdala with the:

  • Prefrontal cortex
  • Motor cortex
  • Cingulate cortex
  • Anterior insula

Mindfulness meditation

Compared to a topically applied placebo cream, meditation has been shown to produce greater reduction in both pain intensity and pain unpleasantness. It also demonstrated a distinct pattern of deactivation in the cingulate cortex.

Conclusion

Extraction and utilization of nociceptive information can occur at lower levels of the nervous system—and across multiple, distinct brain regions.

This framework helps explain why the nociceptive system is so resilient—and thus, difficult to disrupt.

We still rely far too heavily on focal pharmacological modalities. And, we fail to capitalize on the tremendous power of the brain to regulate pain.

Bottom line: There is a critical need for more multimodal treatments aimed at addressing both chronic and acute pain.

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Please share any other feedback below! Including, ideas for future programming, and most importantly, how you feel this podcast will impact your practice!

Thanks for an interesting and thought-provoking article, Sarah.

I am really interested in public policy and understanding how that affects our ability to provide treatment as therapists but ALSO how it affects me as a consumer of healthcare as well.

A couple things I’m thinking about here and the intersections here between OT practice, policy, and pain:
(1) Chronic pain is the leading cause of disability in the U.S. and we’re hearing here about how it’s difficult to explain/navigate due to the subjective nature of pain.
(2) Medicare supports people under 65 with disabilities. Medicaid can also support working-age people with disabilities.
(3) OT may be an essential non-pharmaceutical approach to pain management but is often, like said, under-utilized and under-reimbursed. And even FURTHER, how do Medicare/Medicaid support reimburse these other approaches to pain management?

This system is so complicated. And there’s SO much we need to do to improve the system, at individual and organization levels.

3 Likes

Yes! I agree this has been way more than a failure of sciene, it has been a public policy failure and failure around letting opiods wreak havoc.

@allison5, and anyone else interested on the systemic failure here, I highly recommends this previous article we reviewed. It is one of my favorite articles to ever cover!

Link to our discussion

Link to article: Providing chronic pain management in the "Fifth Vital Sign" Era: Historical and treatment perspectives on a modern-day medical dilemma - PubMed

(Also, @irvin this is the article I told you about!)

1 Like

Related to this, @allison5, I’ve heard that CO has successfully put forth legislation requiring an OT order each time an opioid is subscribed. Is that right, @linda5?? Do you have anything you could share about this?

This is definitely fascinating and I really resonate with this as an OT who experiences chronic pain myself. I have always been an advocate for holistic health and the power of the brain to heal but current health systems we have in Australia mean that appropriate access to holistic services is difficult and increasingly expensive. We have an opioid crisis that is not going to stop quickly because the 1st line of treatment for pain is pharmacological, and most adults with chronic pain end up taking opioids for many years with limited effect. For people who don’t want to take pain medication or who have realised from experience it doesnt work, often due to financial strain they focus on a single mode of treatment to help, which also doesnt work. I really hope that systems can change for the better in the future so that people with chronic pain can have access to multidisciplinary treatment that is also affordable. Unfortunately this will require massive shifts in health policy, frameworks and funding. From experience I also know there is a gap between when research evidence is accepted clinicially to be able to change clinical practice!

3 Likes

I am certainly looking forward to the podcast discussion. It is exciting to me to explore the new ways I may better improve the quality of life of my patients as a majority of them (from 8 years old to 90 years old) wrestle with chronic pain. It is understandably difficult for them to get beyond the pain and focus on other issues. I appreciate OTP taking on this mammoth so wrapped up in beurocracy and shame. Thank you!!!

1 Like

I’m not surprised. I work with many people that have chronic pain. Medications fail, surgeries fail, doctors assume people are seeking pain medication, and people are at their wits end. The more we can educate ourselves, the more we can help.

1 Like

Thank you so much for the article and definitely it will helps with my treatment session with my client who usually have back and leg pain . Just one question does cold weather affect the degree of pain patient has? I feel some people cold weather affect them or they start to feel more pain by winter time.
Thanks
Hanan

1 Like

For sure weather can impact pain! I think understanding the cause of the pain will help you figure out why cold might impact it.

For example here’s an article, on why cold can make joint pain worse.

Once you figure out why there weather might be impacting them, then you can help come up with options to manage the impact of cold!

Thanks for your perspective and response, Micah. I know very little about the Australian healthcare system – I have a friend there on Fulbright right now – but, correct me if I’m wrong, most people have the opportunity for private insurance through employers as well as public insurance? As someone who lives in the U.S. which is one of (if not only!) countries who has insurance tied to employment status. I’m interested to learn more about healthcare access in other countries, especially ones with public options available.