We are trying something different this week by offering you a 30-minute lecture on Pain Neurobiology from our Essentials of Elite Performance course.
If you’ve ever wondered about how pain works and how different systems of the body like the eyes, inner ear or musculoskeletal interact in pain, then please take the time to watch this entire presentation.
We realize that it’s longer than our normal blogs, but we feel that this information is incredibly valuable for both professionals who work with people in pain (coaches, therapists, trainers, and doctors) AND their clients. Enjoy!
We’ve now come to one of my very favorite topics to discuss, especially in the early stages of Z-Health, because it is such a game changer. And I typically don’t use that term, but it actually really is in relationship to how you talk to clients about pain, how you deal with pain yourself. For the last probably decade and a half or so, I’ve told people in all of our courses that I think one of the biggest gifts you can give yourself is an actual understanding of pain, because pain science, pain neuroscience, or pain neurobiology has exploded, it has grown by leaps and bounds really since about 1995.
Now, obviously there have been theories around pain for the last four, 6,000 years. There was a really interesting article last year that went through all the kind of basic pain theories throughout history. And there’s been some pretty crazy ones. But now with modern technology, I think we’re getting closer and closer to having an understanding, a true understanding of how pain functions as an output. And that is going to be the real focus of this little lecture portion, is understanding that pain, as experienced by a human being, often feels like an input, right? And I think that’s because as we are children, we are kind of acculturated into this world of whenever I feel pain, it’s because I’ve injured myself. I’m running and I hit a branch with my leg or whatever, and then I feel pain.
So we tend to associate pain with injury, and we tend to associate pain as something felt in the periphery, experienced by the brain. And really modern pain neuroscience has turned that on its head. And we’re going to talk about kind of this progression and actually what this means. Because when you really understand pain and you understand how it is created by the brain and used by the brain, all of a sudden, your options for helping yourself and helping your clients expand almost exponentially. So to help really kind of nail this down, we’re going to go through this particular slide.
Now, this comes from 2007. This is from a paper by Dr. Lorimer Moseley. Lorimer is, I believe, one of the top two or three pain specialists, pain researchers in the world. He’s brilliant, he’s extremely funny to listen to. He’s written a couple of the best books, I think, available on understanding pain from a neuroscience perspective. And more than anything else, he’s helped really shape the conversation, he and his colleagues, have shaped the conversation around pain in a really unique way so that we can understand it. So I began teaching similar concepts about pain back in 2004, 2005, when I was writing T-Phase. But Lorimer’s was the first work I stumbled on. Again, I think this was in 2009 I found this paper that talked about pain kind of in the same vein where we were talking about pain occurring because of threat, all right? So what I want to do is walk you through this diagram, and we’re going to try to put this into very practical terms as we move forward, all right? So let’s begin looking at this by focusing on the brain over there, all right? So in the brain, it says one question, how dangerous is this really?
If you go back to one of our earlier slides, we have, is it safe? It’s pretty much the same question. What is the brain concerned with? It’s concerned with survival. It’s concerned with surviving through movement. It is always worried about danger or safety, all right? In fact, in the Lorimer’s work, he talks about what he calls DIMs and SIMs, dangers in me, safety in me. And this is that constant balancing act that’s always going on. Now, if the brain perceives that something is dangerous or threatening, it’s job is to protect us, right? Very simply. If the brain feels threatened, it will something to hopefully change the environment or change our behavior so that we are more safe. So if you look at this arrow over here, you can see if the brain perceives danger, if the brain perceives danger and feels the need to protect you, it has some different outputs that it can choose, all right? And remember an output is a motor activity.
So very first useful tool that the brain has to protect you from danger is pain. Whenever we injure ourselves, sometimes it’s a bad idea to keep moving. Have you ever sprained your ankle? You’re out running and, ah, uh, feel that pop and you get the immediate pain. That’s a safety mechanism. The pain is protective in that moment. It’s trying to prevent you from running on that damage ankle and making it worse. But now let’s take that exact same scenario and put it into a different context. You’re running across the street. There is a bus coming. You roll your ankle, feel that pop in a pothole, but the bus is still coming. At that point, your pain, your brain may say pain is an inappropriate output, right? Because the danger now is not from stopping grabbing the ankle, the danger is dying because that bus is about to hit me. So this has been something that pain researchers have been fascinated by and confused by for many years. But as we start to look at the model, it’s beginning to make more sense. Because, basically, pain is considered to be a behavior change tool. It is something that the brain can use to alter our behavior to either make us less active or more active, but it is not something that we sense. In other words, pain does not occur in the periphery, it’s something that the brain creates based off its evaluation of safety and danger.
Now, there are a lot of other outputs over here, right? Meaning that we may see changes in the movement system. If the brain feels threatened, it feels endangered, we may move differently. We all know that, but it’s something worth mentioning. We may see increased signs of startle. What that means, you may have known clients or people who are kind of high hypervigilant as they’re walking through life, they’re moving through life. Everything seems exaggerated to them. Sounds are exaggerated. Lights are very bothersome. Sometimes their clothes feel weird and they can’t stand certain fabrics or can’t have a tag there. These are often associated with other developmental disorders, et cetera, but those may all be indications of a brain that feels threatened beyond what it is currently capable of dealing with. We can also talk about changes in the immune system, the sympathetic nervous system, and other portions of the endocrine system. So your brain has multiple options for protection, but the one that gets our attention the most is pain.
Pain researchers will say that pain is the cortical output of highest priority, meaning it’s one of the things that’s most difficult to avoid, it’s one of the things that’s most difficult to ignore. Now, why this is really important is not only that you understand that pain is not here, right? Your arm cannot hurt by itself. All that your arm can do is send danger signals or threat signals to your brain. Your brain ultimately will decide whether or not those signals are worth paying attention to, right? That is cut and dried, straight up pain neuroscience. No arguing about it at this point. A lot of people are still like, no, no, no, I think. No, this is how it works, right? You can get threat signals from the periphery, but the brain decides about pain. How do we know that? Once again, these same examples I’ve already mentioned. I’m running across the street and the bus is coming. More real-world examples. As I said, I come from a lot of work with the military. I know many who have, over the last 20 years, been deployed, and some of them have been shot. When we got to debrief them in further training, we would always ask them how many of you felt the initial injury. A lot of times they would say, well, it felt like someone hit me, but I didn’t feel any immediate pain. Why would they not feel immediate pain? Well, because in the middle of this firefight, survival outweighs the necessity to feel that pain. So it’s very common for people in high-stress environments or high-stress incidents to not feel pain until much later, to not know that they were injured until much later.
So we know that, again, pain is an output used by the brain to change behavior, and sometimes pain is completely inappropriate. All of us have, at some point, woken up, looked down and gone, ah, where did that bruise come from? Oh, I’m bleeding. Why am I bleeding? Well, because something happened to you. Obviously, that would have caused a threat signal from what are called nociceptors in the periphery, but your brain didn’t find it important at that moment to give you a pain output. So we know all of that, but what it’s also very important is to recognize and understand that pain neurobiology is complex. Back in the 1600s, there was the Cartesian model of pain. And the kind of belief was that if we did something like got our foot too close to a fire, we would get a signal from the foot. It would go up through the nerves, up to the spinal cord, and it would go to one part of the brain, and that brain part would light up and we would experience pain, all right? That’s kind of the Cartesian model. It’s 400 years out of date. Many people still think that’s how pain works, though, including professionals. That’s not okay. Right? We’re working very hard to change that. But what you need to understand is that when we look at brains that are experiencing pain or creating pain, there are a lot of factors that go into this, all right?
So let’s discuss those really quickly. So when your brain is evaluating, how dangerous is this really? First thing it’s interested in, sensory input from the body. Sensory input. So remember our inputs? Interpretation, decision, output loop. Sensory inputs play a role in danger evaluations. What sensory inputs? Right, all of them. The visual system, the vestibular system, the tactile system, the gustatory, oil factory, interoception, all of it plays a role in deciding on the level of danger you’re about to experience. So what you should immediately take away from that is that it is possible that by changing the visual system, by changing the vestibular system, by changing the proprioceptive system, I can change the brain’s evaluation of danger level, and subsequently, change the outputs for protection. Put simply, vision drills can reduce pain. Vestibular drills can reduce pain. Movement drills can reduce pain. Breathing drills can reduce pain. All of them can also improve how you move. They can change your immune function. So what’s critical here, again, is understanding that if you come from a biomechanical background, it’s time to expand your thinking to neurobiomechanical or neuromechanical, because there are probably things that could have a tremendous impact on your own body and those of your clients that maybe you haven’t explored yet, and that’s really what this class is all about, all right?
So danger, first and foremost, is about sensory inputs. What’s next? Previous experience. Previous experience? What does this mean? Well, it means that training can play a tremendous role in your experiences of danger or safety. The example I always give here is I come from a combative martial arts background. I always tell people I’ve probably been kicked in the leg 50 to 60,000 times, and so I have a lot of experience with being kicked. Now, does it still hurt? Yeah. If someone kicks me really hard and they’re good at it, do I feel it? Absolutely. But because I have a lot of experience of having been kicked and not dying, how dangerous does my brain perceive that to be? Not very. So subsequently, the amount of pain I experience is probably much less in many cases than someone who is new to that event or that activity. So previous experience plays a huge role. So for those of you that work with athletes that need high levels of conditioning or military law enforcement, et cetera, are there times when the training environment needs to be really challenging? Absolutely, because we need to build their experience of their resilience in the face of that stress, because that can play a big role in their brains’ evaluation of danger. All right?
Next, cultural factors. Do cultural factors matter? Absolutely, all right? I always tell people, you know, my stupid example of this is if you want to look for kind of the next chronic pain population, and this is said a little bit tongue in cheek, but it is important to understand. I say, go to a playground and watch the two different types of parents, right? Because normally in a playground, you’ve got two different types of parents and two different types of kids. You’ve got the kids that are up being kids. Hanging from stuff, jumping, running, falling, doing kids’ stuff, right? You’ve got one kid, he’s running along, he trips, bang, slams on the ground, and maybe bust his mouth a little bit or hits his cheek or scratches his hands. But if you watch a kid, in general, on a playground, do something that’s kind of outside of the norm, maybe a little dangerous, what do they do? They fall, first thing, they look up, and who do they look for? Mom and dad, right? Or whoever’s there with ’em, look for the parent. And basically, what they’re trying to do is receive some feedback. Like, how bad do you think this was, right? So if the parent is the maybe slightly overcautious, overreactive parent, you may see the kid do this, they look up, and the parent goes, ha! And the kid goes, ah! Why? Because you just taught them that that impact, what happened, that scratch, is very dangerous. You also have the other kid, runs, falls, looks up, parent. Parent is like, nice one, good, good fall. I gave you a 10 on that one. And the kid gets up, runs away, and they continue on. So what’s happening is we, culturally, teach people how dangerous things are by how we react to them. If you’ve ever had the experience of maybe having a bad injury and EMTs see you or you’re in the emergency room, notice how hard they often work at providing a very calm demeanor. They want everything to look like, ah, I’ve done this 10,000 times, right? Inside that new doctor, that new EMT may be like, oh my God, I’ve never seen anything that looked like that before. But what they want to convey is you’re okay, why? ‘Cause it reduces pain, reduces stress.
So cultural factors can play a huge role. Also when it comes to how dangerous is something, social/work environment. In the early ’90s, there was a huge study done looking at back pain and trying to predict who would experience back pain. I won’t go into the study right now in depth, but basically, what came out of a multiyear, 3,000 plus person study, when they were looking for what would be predictive of back pain, they found two things that were predictive of who would experience back pain in the next year. One was smoking, the second was job dissatisfaction. In that study, they looked at core strength, extensor strength, job duties, how active they were. They looked at a ton of factors, and the only thing that they could correlate with it was how much they hated their job. When you think about that from a brain perspective, if you wake up five or six days a week thinking, I have to go there again, right? Hating it, hating the people around you. That is a dangerous scenario, and the brain may go, you know what? I’m going to give you some pain to change your behavior. Low back pain is a fantastic way to make you skip work, make it impossible to drive over there. So social/work environment.
Expectations about the consequences. We’ve all had this experience of feeling bad before a vacation or trip or something, and often feeling like the consequence of the illness or the injury is pretty great will actually, in many cases, increase our pain. And then finally, beliefs, knowledge, and logic. Understanding pain can have a tremendous impact on how dangerous things seem.
So ultimately, what I’m trying to say to you in this particular lecture is that there are some clear things that we know about pain from neuroscience at this point. Number one, we know that pain does not exist in the periphery. Pain is an opinion of the brain about what’s happening. Pain is produced when the brain feels threatened and it is trying to enact some form of behavior change. That’s where pain comes from. Pain is built out of sensory inputs, previous experiences, cultural factors, et cetera.
So if you are in this field, you may have heard of the biopsychosocial model of pain, biopsychosocial model of pain. This is where it all comes from. But often when I hear people talk about that, what’s missing is this key piece from neuroscience, which says that, ultimately, what we’re trying to figure out is what is threatening and what is not threatening, because threat tends to produce protective outputs, like pain, et cetera. And as we reduce threat, pain begins to minimize.
So for Z-Health, for working with clients, for working with athletes, for explaining this stuff, we, again, try to take complex neuroscience and boil it down to, how does this work in the real world? And what can I actually tell someone?
So for years now, we’ve been using the very, very famous Z-Health threat bucket. All right, this is how we explain pain to clients. We go, look, you have a bucket, call it the threat bucket. It’s not the pain bucket, it’s the threat bucket. So basically, as you can see, when you wake up in the morning, you have a certain amount or certain volume of threat that you can experience before your brain begins to create a protective output. In other words, you can have a lot of stuff happen to you before your brain decides that it needs to create pain to get you to change your behavior. Now, depending on your level of resilience or level of training, what you understand, et cetera, your spigot may be way down here, may be up here, right? Our job over time is to move this as far up as we can so that you have a very, very large threat bucket prior to having some kind of protective output, all right?
So we wake up in the morning, we begin to collect threats, all right? And you wake up, you roll over to your significant other, and they give you that special look that they reserve for when they’re unhappy with you, right? Like, oh, okay, one of those days. And you get up and you go out and there’s 14 messages from work already on your cell phone. And you look at that and you’re like, I don’t even want to know. But you listen to the first one, hey, you got to get here in a hurry. We have this problem. So you’re stressed. And then you hop in the car, ’cause you’re in a hurry. You forget your phone, you got to turn around and go back. So really by like 8:30 in the morning, you’re already starting to fill this up, right? You’ve got work stress, you maybe have some relationship stress, and this thing is starting to fill up. Now, hopefully you get to work, things are better. You get to exercise a little bit and things calm down, and your brain never feels the need to change your behavior by giving you some pain. But we need to understand that going into this threat bucket are far more things than just your relationships and your work stress. What else can potentially go into your threat bucket? Well, let’s start over here with your eyes. Let’s say that your eyes are aging and you’re not taking care of them. You have very habitual visual patterns. You have maybe a loss of good visual movement. You have poor binocular vision, okay? Well, guess what? You spend eight hours a day looking at screens. And because you have this weird vision issue, that’s adding threats to your threat bucket. Maybe you exercise, but you do maybe the same 5 to 10 exercises every week, and so there are certain movement patterns that are problematic for you.
Maybe you have that PMRF pattern that we talked about when we were talking about posture. That can maybe increase your threat levels. Maybe you have a mild vestibular problem. You don’t even know it. There was a study recently, it was of an older population, people 75 and older, in a retirement area. All of ’em were participating in a regular exercise class. It was 104 in the study, and they took them all and did vestibular evaluations on them. And 85% of them had vestibular deficits. None of them knew it, but it was influencing their balance, it was influencing their visual system. We will talk more about that as we get into the vestibular arena tomorrow. But it is very possible for you to have mild vestibular deficits that you’re unaware of that are, again, increasing your threat bucket, because you’re more unstable than you realize. The way that you exercise. We have hopefully shown you conclusively already today that exercise can be a drug and there can be a dosage issue, right? We’ve talked about minimal effective dose. We’ve done assess, reassess over and over.
So, is it possible that the thing that you’re doing to keep you healthy may actually be increasing your threat levels because you’re not testing it? Then we have your education. Do you understand pain or do you not understand pain? Understanding pain tends to lower threat, not understanding it, tends to raise threat. There’s an entire field out there now called pain neuroscience education that is specifically dedicated to teaching professionals how to communicate about pain to their clients to hopefully reduce catastrophic thinking around pain, because that can absolutely manifest as more pain and more threat for that individual. Sleep. We all know this, right? Just are you doing anything about it? Are you coaching your clients on sleep? Are you coaching your clients on nutrition? So all of these different things, collectively, can fill up our threat bucket, and as that threat bucket fills, at some point, as I said, the brain may feel threatened enough to invoke some type of protective response. The most classic protective response is pain. If you, however, grew up in that social environment that says, toughen up, deal with it, often you can ignore that pain for a prolonged period of time. If you ignore it, the brain may choose other tools. Very commonly, we see pain that then progresses toward kind have a generalized anxiety, generalized anxiety that proceeds to move to depression.
So it is not the only tool that the brain uses, but it is one of the most frequent tools that it uses. Also, interestingly, when we look at pain, the brain will usually use the same few areas of pain over and over to get your attention, why? Because it’s gotten good at it. If you had a history, you had initially a back injury at some point and you had a lot of low back pain, guess what? Your brain learned how to generate that low back pain at will. So things have been good, haven’t had back pain for a year. You know, things are great, moving along, and then all of a sudden, you get a call from your ex and you get into kind of a weird argument about money or whatever. And all of a sudden, you’re like, oh, wow, weird. What’s up? I haven’t done anything.
How many times have you heard that? I didn’t do anything. My back just started hurting. I didn’t do anything, it’s my shoulder. Well, the reason that happened is you probably did not re-injure it, is that your brain got stressed, it got threatened, it said, I want something to change, I want you to change your behavior, so I’m going to use pain. It will usually default to the pain that you’re already good at, rather than create a new one. Because creating a new pain system or a new pain experience costs more calories than revisiting the one that you’re already good at. And that is generally how pain neurobiology works. Now, from a practical perspective, what the heck does this mean? Why are we going through this? Here’s hopefully the big gold nugget out of this whole lecture. Most of us who have been in this movement world for a long period of time were raised on the idea that if someone came in with knee pain, right? We could put any label here that we want. That we needed to identify the movement pattern dysfunction that was causing that pain to occur. Right? And we would spend lots and lots of time looking at gait and posture and maybe muscles and muscle length and all kind of stuff, it depends on your background. And very often, you would work on that and work on that and work on that, and it would not help. Sometimes it would help, sometimes it wouldn’t.
But the takeaway here is that whenever we understand pain and true pain neurobiology, it helps us become less focused on fixing only one thing that’s going to fill up the threat bucket. If you have pain anywhere, understand that that pain is a collection of threats going into your central nervous system, probably not just one. When I learned this for myself, when I finally got into neuroscience, I started to understand pain, and when I stumbled on this idea and understood it, everything began to change, because it suddenly made sense to me that if someone’s in pain, I often do not need to identify the specific biomechanical deficit, and in fact, usually can’t, what I need to do is lower overall threat. So what that then made possible was to go, okay, let’s try some vision drills. Let’s try some vestibular drills,. Let’s change and test how you’re doing exercise. Let’s work on your nutrition, work on your sleep. Let’s refer you to a counselor, whatever. And whenever I began approaching pain from that perspective, my entire work life and personal life changed, because all of a sudden, the things that we were seeing made sense.
So hopefully, the takeaway point for you in all of this is that if you really start to grasp this concept and grasp this idea, it will make you more open in your own body and in working with your clients to trying many different approaches, because, really, you have to understand this. It’s when the threat bucket is filled that we get the protective output. You now have a lot of different options that you can bring into play to reduce threat. You don’t often have to find the specific one, you just have to find the collection of threat reduction modalities working together that will lower the threat below the output point. And this is where some very, very cool, magical stuff can kind of start to occur. All right? So hopefully you guys enjoyed that.
I’m going to show you one more slide to wrap up this section, because we are often asked after this, “Okay, so, what does this really mean in terms of Z-Health? How does it show in the curriculum?” Well, it shows up like this. Over the past, again, decade or so, I’ve tried to put together a model that takes advantage of the pain neuroscience that we know, along with all the other exercises and things that we bring in from all these different systems, and put it into something that you can hold onto. So ultimately in Z, all that we do boils down to this, what we call 8 Levels of Assessment Model. So you can see here at the crux of it, pain and performance. You need to recognize that everything that I was just saying about pain neurobiology also applies to performance.
Whether your brain feels threatened or how much your brain feels threatened is going to play an increasingly important role in how well you perform. You’ve already seen that up here with some of the stuff that we’ve done in terms of assess, reassess. So we’re playing kind of the Goldilocks game of trying to find just the right amount of threat for the person in front of us to maximize their response to everything that we do. Now, from a neurologic perspective, whenever we take all this kind of complicated stuff that we’re doing, we break it down, we can actually break neuro-performance or apply neuroscience down into kind of eight critical areas, each of which has assessments and exercises that we can apply to try to reduce or modulate threat.
So in the human body, we have receptors, right? We have lots of receptors in the periphery. Mechanoreceptors, nociceptors, baroreceptors. We have electromagnetic receptors. We have receptors in the eyes, et cetera. So at a basic level in Z-Health, we spend a lot of time testing and training receptors. Receptors have to have a way to get information from the periphery to the spinal cord, and that is going to be through the peripheral nerves. Later on, we’re going to show you some of the exercises that Tony already demonstrated, where we may need specific mobility drills, or flossing drills, or what we call slacking or tensioning drills for peripheral nerves, because they can be a roadblock for signals to get to the brain for processing.
After the peripheral nerve, then we have to go into the spinal cord itself. From the spinal cord, we then move up into the brain, and we’re now to the back bottom part of the brain, which is the cerebellum, which we’ve been discussing. We have the brainstem. It’s where the PMRF lives and the lot of other very important things up in the mid brain that we’re going to look at when we get into vision. We have the thalamus, which is a switchboard operator for the brain, which kind of makes decisions about what goes to the cortex, what gets ignored. We have the insula, which is the home of interoception, which we were talking about in the early stages when we were talking about inputs. And then, finally, we have the cortex, which we looked at a little bit. We talked about the occipital lobe, the temporal, parietal, and frontal lobe. So the basic thing that I’m trying to get you to understand here is that the answer to anyone’s threat lies somewhere in this anatomy.
So a neurologically designed training system over time would make us an expert in receptors, peripheral nerves, the spinal cord, different parts of the brain, cerebellum, brainstem, thalamus, insula, and the cortex. And what being an expert in those systems means, knowing how to assess those areas, knowing what functions lie there, and how to stimulate and inhibit those areas. So all of Z-Health kind of is encapsulated in this one slide. This is what we do, this is what we spend the 12 courses in our curriculum making you an expert at. The reason that we do that is because problems in any one of those anatomical areas can manifest as threat. And when it manifest as threat, ultimately, it may be a driver of pain, or in a more healthy person, It can be a driver of improved performance when we give it the right stimulation.
So, this is the kind of Z-Health approach in a nutshell. I hope that this has made sense to you with regards to kind of how we approach pain, and ultimately, how we’ve built a system to deal with this whole idea of threat, threat modulation, and the threat bucket. All right, so we’re going to take a little break and we’re going to be back, and we’re going to start diving quite deeply into our first input system, which is going to be the visual system. So rest your eyes on the break, ’cause we have a lot of work to do.