A pain neuromatrix approach to patients with chronic pain

doi:10.1016/S1356-689X(03)00051-1

Manual Therapy

Volume 8, Issue 3, August 2003, Pages 130-140

https://doi.org/10.1016/S1356-689X(03)00051-1 Get rights and content

Abstract

This paper presents an approach to rehabilitation of pain patients. The fundamental principles of the approach are (i) pain is an output of the brain that is produced whenever the brain concludes that body tissue is in danger and action is required, and (ii) pain is a multisystem output that is produced when an individual-specific cortical pain neuromatrix is activated. When pain becomes chronic, the efficacy of the pain neuromatrix is strengthened via nociceptive and non-nociceptive mechanisms, which means that less input, both nociceptive and non-nociceptive, is required to produce pain. The clinical approach focuses on decreasing all inputs that imply that body tissue is in danger and then on activating components of the pain neuromatrix without activating its output. Rehabilitation progresses to increase exposure to threatening input across sensory and non-sensory domains.

Introduction

Pain and movement are the primary currencies in manual therapy. Most patients present for therapy because they are in pain and most therapies incorporate movement into assessment, diagnosis, aetiology and management. Indeed, many therapies attempt to restore movement in the hope that pain will automatically get better as movement improves. However, from aetiologic and therapeutic perspectives, it is difficult to determine the chicken and the egg: is pain caused by abnormal movement or is abnormal movement caused by pain? The current paper presents a model for management in which pain and changes in motor control are considered two dimensions of a multidimensional output of the ‘pain neuromatrix’. The model is based on the author's interpretation of the current thought across the pain sciences. The theoretical background for this model is presented and the implications for assessment and intervention are discussed.

It is important to note that there are assumptions underlying the present approach that have not yet been validated and this paper is occasionally speculative for the sake of clinical relevance. There are no illusions that one approach provides the panacea for persistent pain. Rather, it is hoped that the astute reader will take from this work those aspects that can be integrated with their clinical experience and approach in order to promote better outcomes in a population for which success is elusive.

Section snippets

Background

A fundamental principle of this approach is that pain is produced by the brain when it perceives that danger to body tissue exists and that action is required. All dimensions of pain serve to promote this objective. Thus pain is a multiple system output, not just ‘an unpleasant sensory and emotional experience associated with actual or potential damage…’ (Merskey & Bogduk 1994). The principle that pain is primarily aimed at action is not novel — it was proposed by Patrick Wall a decade ago (

The clinical approach — Desensitisation and graded activation of components of the pain neuromatrix

The aim of the current approach is to utilize functional components of the individual-specific pain neuromatrix that are appropriate for movement and that are consistent with the normal aims of treatment, without reinforcing the synaptic efficacy of the neuromatrix. There are three aspects of the approach: (i) reduction of threatening input so as to reduce activity of the pain neuromatrix and thereby reduce its efficacy, (ii) targeted activation of specific components of the pain neuromatrix

Summary and conclusion

The current paper has presented the background, guiding principles and clinical approach to treating chronic pain using a pain neuromatrix approach. The approach is founded on key principles — that pain is a multiple system output that is activated by an individual-specific pain neuromatrix; that the pain neuromatrix is activated whenever the brain concludes that body tissue is in danger and action is required; and that pain is allocated an anatomical reference in the virtual body, upon which

Acknowledgements

Lorimer Moseley is supported by grant number 210348 from the National Health and Medical Research Council of Australia.

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MasterclassA pain neuromatrix approach to patients with chronic pain