Understanding Mindfulness For Chronic Pain: A Neuroscience Perspective

If you are hard-science person considering mindfulness practice as a pain management strategy, this is for you. With research around neuroscience behind chronic pain and mindfulness practice, I hope to answer to questions from an evidence-based perspective.

• What is chronic pain?
• What is mindfulness?
• How to manage pain?
• How does pain make people change their habits?
• How does mindfulness help chronic pain?
• Can meditation help with chronic pain?
• Why do I hurt? Pain from a neuroscience perspective
• What happens to your brain when you practise mindfulness? Mindfulness from a neuroscience perspective
• Does Mindfulness-Based Stress Reduction Work?

If you’d like to read more about mindfulness in a more application perspective, check out our previous blog post on The Way Of A Mindful Warrior.

For most parts, mindfulness is about living in the present moment. That means being in control of your awareness.

When it comes to control, Shunyu Suzuki said, “To give your sleep or cow a large spacious meadow is the way to control them. So it is with people: first let them do what they want, and watch them.”

What Shunyu Suzuki was advocating for is observation. It may sound obvious to you but think of the last time you had a really, really bad pain episode.

What did you do?

Did you get on the foam roller? Perhaps you took some medication?

To let our pain run free so we can observe it is not the most intuitive response. For most of us, control is about taking charge.

Xuan Zang, another Zen monk, said, “you must make your mind as pure as still water, control your emotion-monkey’s indolence and fidgeting, and restrain your idea-horse’s haste and galloping. This is what ‘心猿意馬’ refers to.

Remember the “Monkey King” Sun Wukong in the Journey to the West? He is the personification of the monkey-mind.

p.s. This post is entirely focused on the effects of mindfulness practice in a secular environment. 

What is chronic pain?

At the simplest definition, chronic pain is pain that lasts for over 12 weeks. It refers strictly to the duration of which a person experiences pain. People may suffer from chronic pain even without any injury or illness.

On the other hand, chronic pain syndrome refers to poorly understood pain conditions such as fibromyalgia, chronic fatigue syndrome, or endometriosis.

Believe it or not, up to 40% of Singaporeans suffer from some form of body pain every week.

On a global scale, chronic pain affects one in five people with back pain being the most common complaint.

While mindfulness is NOT a physical approach to therapy,  there is a huge overlap between chronic pain and mental health conditions. It is unclear which causes which – almost like a chicken egg situation.

What is mindfulness?

Mindfulness is the state of being present at the current moment without judgement. It’s about being aware of your thoughts and feelings.

A lot of people confuse mindfulness as being focused. The more accurate way to think of mindfulness is as being present or being aware. Alternatively, you can look at mindfulness as the opposite of mindlessness.

You may also hear mindfulness being used to describe ‘mindfulness practice’. For example, “I find mindfulness exhausting.”

Mindfulness practice doesn’t have to be meditation-based. You can practise mindfulness (being aware and present) in daily activities from eating to washing your hands. For most parts, practising mindfulness is not considered to be religious.

Pain management in Singapore

Pain is poorly managed all around the world. So if you feel like your pain is not getting better, you are not alone.

For instance, a study in Europe published that 38% of chronic pain patients reported their pain management to be inadequate. Only 15% achieved adequate pain management in under three months.

It comes as no surprise because we do know that the experience of pain – physical or otherwise – is influenced by a person’s psychosocial well-being. Yet the status quo approach to treating pain only addresses the biological bit in isolation.

Chiropractic adjustments alone, exercise alone, medication alone, or even mindfulness practice alone, all fall short of what we understand as high value pain management.

Pain is the output of the our brain’s processing system. A mishmash of emotional and cognitive factors such as your mood, attitudes and beliefs, expectations, how much attention you pay to your pain, etc interact with each other to give you your unique pain experience.

(Believe it or not, there’s no such thing as a incoming pain signal. This is why pain is not one of the five sense!)

For this reason, using multidisciplinary or multimodality to treat chronic pain provides the best outcomes. It addresses the biological, psychological, and social aspects of recovery.

In short, high quality pain management has to address at least three aspects:

• Pain experience itself
• Emotion or moods e.g. poor job satisfaction, fear of pain or fear of exercise
• Cognition e.g. pain =/= damage, my body is robust and adaptable

Can you understand why regular chiropractic adjustments alone will not give you long-term results?

At Square One Active Recovery, I take a three-prong approach to helping patients find freedom from pain. With exercise, education, and advice, most of our clients achieve their recovery goals within four to seven sessions.

The exercises you do with me address the physical or biological aspect. Education and advice are aimed at helping you address the psychosocial factors that may be subconsciously contributing to your pain experience.

This is our the healthcare system works in Singapore for people with chronic pain:

• Primary care: GPs or medical doctors. Because of their generalist role, they tend to have a very patchy understanding of how pain works. For example, it’s common for GPs to prescribe paracetamol or muscle relaxants to reduce pain. This is not congruent with the latest clinical guidelines (e.g. Journal of the American Medical Association, The Lancet).
• Secondary care: allied health providers. In Singapore, this includes physiotherapists, podiatrists. Unlike Australia, both chiropractors and psychologists are not considered allied health professionals in Singapore.
• Tertiary care: multidisiciplinary centres are large, complex pain management facility. Both scientists and various healthcare professionals work together to manage a patient’s care. Members of the treatment team communicate regularly to deliver integrated, multidisciplinary care. The Pain Management Clinic at Singapore General Hospital is probably the best option we have here. While the centre does offer a multidisciplinary team of pain medicine specialists, physiotherapists, and psychologists, the nature of care offered doesn’t appear to be integrated.

p.s. There are also support groups designed to help pain suffers. These groups are rare. The quality of pain management also tend to be poor due as there are no regulations around support groups.

Pain Psychology for Dummies

Pain psychology, or what we refer to as pain science among chiropractors and physiotherapists, is really what you have to try to understand. It does explain why low value treatments tend to fail.

Imagine you start to experience pain with a physical activity you enjoy. Let’s say you love running and you’ve been running for years with no issues. Then one day, your knees hurt. It was the first time you experienced knee pain so you brushed it off. Everything went back to normal.

Then some time later, your knees started to hurt again. This time round your pain persisted for quite a few runs.

Here is where pain science kicks in.

As you ran more, you experienced more knee pain. With this experience, you may be conditioned to start to think that running causes pain. This is basic associative learning. You ran, it hurts. You ran again and it hurts again.

What happens now is that when you go for a run, you expect yourself to be in pain. This is essentially conditioning in effect.

What happens now is that you may feel afraid. As humans, we don’t just feel afraid.

We THINK about our fear. We contemplate the negative consequences that could POTENTIALLY happen. We refer to this as catastrophising.

What happens in people who catrastrophise is that they start to experience MORE pain. Studies show that if you have an expectation that it will hurt, you will likely experience MORE pain (i.e. higher pain intensity).

Your expectation can modulate the pain you experience by about ~20%. That effect size is comparable to a mild analgesic (paracetamol, NSAIDs, etc)!

Mind blowing huh?

Now that you do experience pain and more pain, the association between running and pain experience is further reinforced.

Do you see the problem here?

By this stage most people would quit running. We avoid the activities that trigger our pain. We become AFRAID of running.

Here is the problem: complete avoidance of activities that you associate with your pain removes the opportunity for you to extinguish that fear.

In order to break the association you have unknowingly built, you’ll need to be able to run without pain. Without running – now that you have stopped – we wouldn’t be able to break the association. As such, you will always be afraid.

For most people, these thoughts and the fear do transfer to other activities. Maybe you started avoiding running. With more time you may stop other daily life activities such as taking long walks, climbing stairs, etc. It is pervasive.

This is the beginning of what we refer to as fear-avoidance behaviour.

Mindfulness practice for chronic pain

What is mindfulness?

At its essence, mindfulness is about being present at the current moment. It is also about being accepting and non-judging.

In clinical practice, it is largely see as a cognitive training strategy. You are working to change your thoughts and emotions to living a moment-to-moment present life.

In chronic pain, practising mindfulness meditation may help because being mindful and catastrophising are mutually exclusive.

One cannot be thinking about some terrible pain that may potentially happen in the future yet at the same time stay present at the “right now”.

So perhaps mindfulness breaks the pathway between pain and catastrophising. Once that is broken, you cannot develop fear-avoidance behaviours.

It is also possible for mindfulness work directly on altering behaviour.

We don’t yet understand the exact mechanisms behind how mindfulness practice helps with chronic pain.

Do people who practise meditation feel pain differently from those who don’t?

The short answer is yes.

Studies have shown that mindfulness practice practitioners have an improved ability to self manage pain. They also perceived themselves to have higher control over their pain (self-efficacy related).

It is possible that the perception of being in control alone contributed to practitioners’ improved capacity at self-managing pain!

*Self-efficacy is a person’s perception of his or her ability to manage their own symptoms. People with high self-efficacy tend to recovery very quickly while individuals with low self-efficacy is at high risk of suffering from chronic pain.

Does mindfulness practice mean less pain?

When we look at pain threshold/sensitivity, i.e. how likely are they to feel pain when prod with a cattle stick, no.

If we look at their pain experience, yes. Practitioners of mindfulness reported less pain intensity. This is the affective aspect of your symptoms. The emotional processing of stimulus to give you a pain experience.

To recap, here are some possible mechanisms of why mindfulness help with chronic pain:

• Mindfulness –> directly inhibit/reduce catastrophising
• Mindfulness –> change fear experience –> knock off effect on catastrophising
• Mindfulness –> direct effect on behaviour change  without any cognitive involvement (i.e. fear extinguishing via breaking the association)

Neuroscience behind your pain control network

Earlier I talked about how if you repeatedly experience knee pain with running, you may start to expect your knees to hurt with running. Now we are going to look at what goes on in the human brain as it happens.

The anticipation of pain is essentially a fear-based emotion. It may not be obvious but think of a child who is about to be caned. The emotion the child would experience would be fear.

So the associative learning/anticipation of pain involves the amygdala (part of the brain that process the experience of fear/emotions).

With the anticipation, the salience network (specifically the insula cortex and mid cingulate cortex) becomes activated.

Salient means important. So the the salience network is the parts of the brain involved with figuring out what is more important. When you are distracted, the salience network detect and filter what is more important vs. less important.

When you anticipate pain, your brain distraction-detection network becomes activated.

(Hold that thought.)

Here is how it may look for you.

• Just another working day in the office with nothing out of the ordinary. You came back for lunch and you realised you have been sitting for the whole morning, that’s four hours. This is when you typically start to experience pain.
• Instead of thanking your body for a good day, you probably would start thinking to yourself, “when are my neck and shoulders going to start aching?”
• Now that you are anticipating for a unpleasant physical sensation, the fear-processing part of your brain (amgydala) is active. Your attention also shifts from your previous task to your pain-anticipation. You are now distracted! Your intent was focused on performing the task of the day.
• (If you think about it, your attention always shift towards whatever is distracting you and it takes effort to bring the focus back. If you are attention is still focused on the activity you were at, is it still a distraction?)
• Here is when the conflict begins – do I focus on my task-at-hand OR do I focus on the pain I am about to experience? The distraction-detection part of the brain (salience network) gets activated!
• As you try to shift your attention back to your original task, the executive control brain function (dorsolateral prefrontal cortex) gets activated. This is the brain that deals with cognitive functions such as knowing and understanding.

It’s also very important to note at this stage that chronic pain patients have a less active executive control brain (dorsolateral prefrontal cortex) compared to healthy individuals when they are anticipating pain.

What happens is that as you are more experiencing more fear and more anxiety during the anticipation, the part of the brain that you use to focus doesn’t seem to “work” as well.

Why is it important to know this?

In chronic pain patients:

• When the fear-portion of  their brain is active –> the part of the brain that can help them re-focus is inhibited, resulting in poorer executive control
• When salience network (distraction-detection portion of the brain) is active, they experience more pain.

In short, your symptom experience, quality of life, work productivity, capacity to focus, etc are all affected. All of this happen just with anticipation alone.

Neuroscience behind mindfulness practice

I wish there was neuroscience for dummies! Because research examining mindfulness practice is fairly new field, there is a lot that we aren’t completely sure about.

Here is what we do know:

• Mindfulness activates the medial prefrontal cortex (mindfulness brain), which is the part of the brain associated with self-reflection.
• The mindfulness brain also processes the sense of self, resolves emotional conflict, positive emotion, rest and relax (parasympathetic function)
• In depression patients, mindfulness brain (medial prefrontal cortex) has lower grey matter volume and poorer connection with the afraid brain (amygdala)
• When there is an emotional conflict in the brain that needs resolving, the mindfulness brain brain increases in activity. This results in an inhibition of the afraid-part of the brain. It’s thought maybe that’s how fear-associations are broken down / fear extinction.

Essentially the mindfulness brain helps with emotional conflict resolution. In depression patients, they are less able to resolve emotional conflict (pain anticipation) because that portion of the brain is literally small.

This is a possible reason why mindfulness practice may help with pain. It develops the part of the area that is involved with pain anticipation.

Salience (importance) network vs. executive control brain in experienced meditators

• Experienced meditators have less pain anticipation than non-meditators
• Less brain activity at the salience network. The more experienced the meditators are, the lesser amount of activation was observed (meaning less conflict)
• This means anticipating pain is less “salient” or less important to meditators (salient = important)
• Remember, less activation of the salience network = less pain experience

I know that’s terrible technically to wrap our heads around.

The simple version is that experienced meditators do have an expectation of pain. The difference is that their expectation doesn’t hijack the brain (salience network). This gives them LOWER pain experience.

Anticipation of pain in expert vs. notice meditators

• Experts are not activating the salience network as much as novices during anticipation of pain (as per above point)
• However, when it comes to the actual experience of pain itself, the salience network becomes more active
• Experts were observed to have less afraid-brain (amygdala) activation compared to novices when they anticipate

Remember: the mindful brain down regulate afraid-brain.

This suggests experts have more control of their emotions (or their fears) and a more accurate experience of their pain.

• Meditation group has higher medial prefrontal cortex activation during anticipation of pain
• The more they active this region, the less they experience pain

Does Mindfulness-Based Stress Reduction work?

There are two main mindfulness practice programs that are widely utilised in the clinical setting. They are the Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT) programs. Both programs are eight-weeks in duration. Is this enough?

The short answer is yes.

The 8-week Mindfulness-Based Stress Reduction (MBSR) program was originally designed by Jon Kabat Zinn to reduce stress and anxiety. However, participants of the stress reduction program have reported improvements in:

• Attention and performance of executive function
• Pain experience
• Catastrophising

However, more practice is required for them to develop the mindful brain.

When it comes to the neuroscience research, eight weeks of MBSR training shows:

• Up-regulation of the salience network (also seen in experienced meditators)
• No reduction in activity of the salience network when anticipating pain (opposite of experienced meditators)
• Down-regulation of the salience network during pain experience itself (opposite of experience meditators)

It is hypothesised that novices at the early stages are becoming aware of their mind wandering. Their response is that is to actively narrow their attention to a task (e.g. breathing) or to suppress the distraction. Both strategies are active or control driven (i.e. executive control brain).

In neuroscience words, the expectation of pain is still hijacking the salience network – potentially because the present-moment salience or “importance” is less stable. They are still distracted by their own thoughts.

In experienced mindfulness practitioners, there is no need for control as the mindful brain is better developed. It’s capacity to resolve emotion conflict is higher so there is no need to “control”.

Research is suggesting that mindfulness training evolve from a practice of cognitive of control to emotional regulation. In the initial stages, control (as per “paying attention”) is more of a feature and as the “proficiency” at being mindful improves, control becomes less of a feature.

The bottom line: mindfulness practice for just eight weeks is enough to help with improving pain experience. For long-term change, don’t stop practising.

If you are sold on the benefits of mindfulness, you certainly have options in Singapore.

Brahm Centre offers 4-session mindfulness courses at $160 as well as the full 8-week MBSR course for $550. (SkillsFuture Credit-eligible).

Palouse Mindfulness offers a free MBSR program. The online program is created by Dave Potter who is a fully certified mindfulness instructor.

For those who prefer an audio-guided meditation practice to cultivate mindful living, you may want to consider Waking Up. The app is by Sam Harris who is a neuroscientist and philosopher, who had worked with the top mindfulness researchers in the world. I find the shorter sessions (~15 minutes) to be easier for beginners to follow.

If you are looking for some one to walk with you in your chronic pain recovery journey, book in an appointment with us today. I use a combination of exercise, education, and advice to help you find freedom from pain. Discover the difference the right care can make with our biopsychosocial, evidence-based approach.