Dr Wayne Kampers | Harley Street Psychiatrist | Private Harley Psychiatrist | Harley Street Psychiatry

Pain Edition 2023

The Masters Series Pain Edition
We've all experienced physical pain, and we all know what the universal agony of grief, isolation, and shame is like. Draining, paralyzing, and overwhelming, pain leaves us feeling powerless and unable to cope as new emotional and physical wounds open and aggravate historical injuries in a seemingly uncontrollable tailspin.

What can seem even harder is trying to help someone else in that state find hope, both in a professional and a personal context. But, armed with the right knowledge, it's possible and we can contribute to helping our friends, clients, and selves out of suffering.

In previous editions, we learned that unresolved trauma manifests in our bodies, but we haven't fully explored the impact that has on our present. The relationship between trauma, mental anguish, and chronic pain is well established. One in five of adults live with chronic pain, with traumatized individuals being twice as likely than the general population to experience this.

In The Master Series: Pain Edition, we will explore how pain connects with trauma and learn what we can do to address that relationship through our practice. Join us as we calculate the cost of pain on our mental health, consider the relationship between the pain we feel and the legacy of our past, and explore vital healing methods, techniques, and practices we can use to move towards a pain-free future.

Day 1

Transforming Pain into Power: Harnessing the Power of Neuroplasticity

Dr. Wayne Kampers

Learn about the science behind neuroplasticity and how it can be used to overcome chronic persistent pain. Drawing on his extensive knowledge and experience as a psychiatric consultant, Dr. Kampers will provide you with the tools you need to harness the power of neuroplasticity for healing.

Whether you are dealing with chronic pain yourself or working with clients who are, this workshop will provide you with the knowledge and skills you need to effectively use neuroplasticity as a powerful tool for healing.

Learning Objectives

• Understand the science behind neuroplasticity and how it relates to chronic persistent pain.
  
• Learn about the role of mindset in pain management and how it can be used to harness the power of neuroplasticity.
  
• Develop effective strategies for using neuroplasticity to transform pain into empowerment.
  

Transcript of my presentation

Hi everyone.

Welcome and thank you so much for joining this fifth Masters Series edition, the Pain Edition

I will be one of your speakers for this edition and I'll also be the moderator for the other speakers. So, I want to thank you all for connecting with us wherever you are.

And it's really my hope and aim that after this edition that you will leave with a much great understanding of the profound and deep relationship and connection between trauma, addiction and chronic pain and how they relate it to shame and guilt and how in the process of that there is fracturing of the imagination.

I'd like to really thank the organizers for asking me to be part of this edition. I really am humbled and grateful for many reasons. I'm passionate about chronic pain myself and it's really fantastic to be given this opportunity. It's very interesting, I was talking to one of the organizers earlier and just telling them about six degrees of separation and a sliding door moment that happened with me as to how it came about that I was invited to take part in this Pain Edition.

Last September, I was asked to present at a trauma conference in London and I'd been asked earlier on in the year and I was under the assumption that I was going to be talking about pain at this trauma conference and I think it was about a week before it took place, they asked me for my slides and so I said to them, "I'll have them to you in a couple of days." And then they said, "And this is the topic that you're speaking on," and the topic was something completely different to what I was supposed to be speaking on.

It turned out I had to present on the pharmacology of PTSD. I had to talk for an hour on the pharmacology of PTSD. And for those of you who know anything about the pharmacology of PTSD, it's pretty hard to talk for an hour about it because the pharmacology of PTSD is not great. So, anyway, I almost thought of myself, I don't know if I want to do this. And that sliding door moment where I thought to myself do it. And so, I did it. I decided not to bail. And so, I went to this conference and presented on the pharmacology of PTSD and it was at that conference that one of the organizers of this conference, Araminta, approached me and asked me if I would be interested in talking. I said, "Of course I would. I'd love to."

Interesting at that same conference was another therapist who I hadn't seen for years because of COVID and I was speaking to her about this and so she's the one that me with Dr. Isaac Mathai who I contacted and he also agreed to be part of this. That same week, a patient of mine who is well, and I don't see her, probably see her every six months. She came to see me and she said to me, "I was visiting a friend of mine in LA and I mentioned to my friend your interest in pain and so she'd like to connect with you."

That is how I managed to end up connecting with Catherine Oxenberg. And obviously I'm interviewing Catherine later and Catherine's connected with Gita via her foundation and Gita's presenting later on today. And when I'm speaking to Catherine, she also talks a lot about the Curable App, which I'll mention later. And of course, Les Aria who's speaking tomorrow, he was in inextricably involved with the Curable App. So, it's strange how things happen and how it's all connected.

I just thought I'd share that story with you first. So, everything in life I believe is about relationships, about communication and about connection. And every human problem is related to problems in these areas including the relationship with pain. And I think could it be good just to reflect on the previous four editions that have happened before and how important they are leading up to us speaking about chronic pain today and how they really laid the foundation and mapped out the journey of the destination to talk about chronic pain today.

Let's back and look at the first edition, The Trauma Edition, and see how developmental trauma and attachment systems affect the processing of traumatic experiences, how it affects brain circuitry, in terms of social engagement systems, the social engagement system template that was presented by polyvagal theory and the link with sociality and autonomic regulation and dysregulation are that in terms of the fight, flight or freeze response really determines what happens in not only trauma but also in addiction. We introduced the concept of the amygdala hijack where the amygdala just really takes over and is running the show so that your prefrontal cortex and your smart part of your brain has to take a backseat. And the really importance as well of somatic experiencing and the trauma framework was introduced in that first edition as well, highlighting the real importance of the clinical tools that we need to develop to address these real fixed physiological states where both our minds and our bodies are stuck.

The Imagination Edition was really interesting because got to understand addiction and the source of addictions in early childhood environment, the neurobiology of the brain's reward pathways and the emotional patterns that lead to addiction and how they become wired into the unconscious brain. And we introduce them to the role of psychedelics and obviously later on today we're going to speak about psychedelics. And in that edition, it was really the neurochemical processes of addiction reflecting on ketamine, psilocybin, MDMA and there are so many trials going on with these medications.

In my clinical practice, I've successfully treated a lot of people with ketamine and that's the only one that's licensed in the UK at the moment. But on the horizon, psilocybin and MDMA are going to be very exciting. As part of my practice, I do pharmacogenetic testing and I was speaking to a geneticist yesterday who is based in America. She mentioned to me two new drugs that are actually being trialled in the states at the moment. But those are the first two new drugs I think that really have been manufactured in the last couple of decades. There has not been any new medications in psychiatry for a very, very long time, which is why I think the whole field of psychedelics and micro dosing are going to play an integral part in the treatment of many psychiatric conditions moving forward.

If we reflect really on The Connection Edition, there we really learned about the power of self-compassion and connection, what happens in disconnection, the role of trauma in addiction was highlighted again and we learned about the importance of the self and self-identity, interpersonal connection, interconnection and intraconnection, which will be addressed this weekend as well.

In The Shame Edition, the whole concept of generational shame and the collective legacy burdens that underpin race and class and gender and how it impacts us, not only individually but relationally and systemically, and internal family system techniques was introduced there, which is such a key part of looking at trauma and addiction and at chronic pain.

And also, really the importance of the healing power of intimacy from shame to connection and again the focus on the sensorimotor psychotherapy approach and the relational nature of shame and the role of the body in healing shame and how one needs to work somatically with parts of the self in terms of healing shame, which all leads us to what we are going to be talking about today, which is Chronic Pain


Let's talk about chronic pain. This is a global problem. It is estimated 20% of the world's population, that's one and a half billion people, suffering with chronic pain. Up to 50% of old adults, up to 10% of children, adolescents, those numbers are just absolutely staggering. There's no doubt that we are in the midst of a chronic pain epidemic. It is the single greatest leading cause of disability worldwide. It's a major contributor to healthcare costs in so many countries, major contributor to lost productivity, disability payments, and on an individual level the amount of suffering that it causes for individuals and their families.

Chronic back pain is probably the commonest chronic pain that people suffer with. It's deemed to be non-specific in up to 95% of cases. And there's still real uncertainty regarding what the most effective treatment for back pain is. Back pain is the single leading cause of disability worldwide.

I have myself suffered from and fortunately recovered from back pain. And I think that the reason my back pain was such a problem is because pretty much anybody who has X-ray from about the age of 18 or 19, is going to already start showing degenerative changes within their spines and bulging discs.

And my X-ray was not really a pretty sight. Degenerative changes. Various prolapsed herniated lumbar discs.

The analogy of as you get older and you get grey hair and you get wrinkles, that's exactly what's happening to your spine as well. It's also getting the equivalent of grey hairs and getting old, but that doesn't necessarily mean that it is the cause of your back pain.

Later on, I discuss the differentiating clues are of neuroplastic pain. I ticked all clues.

The huge consequence of chronic pain is the subsequent iatrogenic opioid addiction that the world is having to deal with. Iatrogenic obviously meaning that it's caused by the medical profession who are prescribing medications in order to try and help people with chronic severe pain.

Unfortunately, with chronic pain of this nature, neither interventions nor medications are helping. So, they end up on stronger and stronger and medication and eventually end up on opioids and become addicted to them.

Speaking from personal experience, I had reached the stage where my pain was that severe, I was one short of actually going onto opioids, onto a fentanyl patch. Thankfully that never happened. But it's not difficult to see how and why it happens and then the problems that one has.

Because now you're not only dealing with opioid addiction but worsening pain because the opioids are not actually helping their pain. And certainly, when one looks at pain recovery for somebody, you very often have to manage the opioid addiction concomitantly. And in my own experience with my own patients, there's often a very heavy investment in the opioids and not wanting to come off them; very often you have to address that as a separate entity.

And if we look back historically chronic pain conditions, it's been a real problem because there are such vague and ambiguous terms that have referred to chronic pain, nonspecific, somatoform, functional and all with real obscure aetiology and pathophysiology. And it's been a problem for so many decades. So, over the last couple of years there's been the working groups that have been really concentrating on this.

So chronic pain was reclassified in the ICD-11, which is the International Classification of Disease, it's the European equivalent of the DSM Diagnostic and Statistical Manual. I think it's DSMs fifth version now. So, the ICD-11 is the latest version of this and became effective in January of last year, of 2022. And this was a collective collaboration between the World Health Organization and the International Association for the Study of Pain, the IASP, who designated and reclassified all of these conditions into Chronic Primary Pain conditions and chronic secondary pain conditions.

In the chronic primary pain conditions, which is what we are going to be talking about this weekend, the pain itself is considered to really be the disease and distinguished systematically from chronic secondary pain conditions where pain is a symptom of another condition.

And certainly, this new definition of chronic primary pain has been an important step and has neutralized the misleading dichotomy that has existed for such a long time between somatic and mental disorders. It also includes important components to it of emotional distress and of functional disability.

So, in the new ICD-11, chronic pain is defined as primary if pain persists or recurs for more than three months or secondary to other causes. The whole concept of primary pain is it's a new concept and really has been informed by the latest public scientific and clinical evidence-based research. A lot of it has come from functional magnetic resonance imaging research and pain processing therapy research.

And Les Aria will talk about pain reprocessing therapy tomorrow and I'm hoping, which I'm assuming he will, he'll talk a little about the real advances in terms of the Boulder trial, which has been such a huge landmark in us understanding chronic primary pain conditions.

So fundamentally, chronic primary pain is where the primary pain is the problem as not secondary to any disease or pathology of the body. No structural abnormality is identified that can explain that pain. If you recall back to phantom limb pain, it's that type of pain really where the brain just continues to fire on pain pathways, even though there's no longer a limb there. And this pain basically becomes self-reinforcing, self-perpetuating. Virtually takes on a life of its own due to the changes in the brain pathways.

If we just look at the six major causes of the chronic secondary pain syndrome. So, we can understand the difference. This is pain that is related to an organic cause:

• Secondary to cancer or its treatment
  
• Post-surgical or post-traumatic pain
  
• Neuropathic pain, which is really damage to the peripheral or central nervous system
  
• Secondary headaches
  
• Secondary visceral pains
  
  • An example there would be something like pancreatitis
    
• Secondary musculoskeletal pains
  
  • Something like osteoarthritis.
    

When you look then at the Chronic Primary Pain categories, they really have differentiated these by organ systems all as a general category.

• Chronic, widespread pain
  
  • That's where fibromyalgia fits and complex regional pain syndrome, CRPS.
    
  • These are two conditions that so many people suffer from and that's a category that they would fit into.
    

Then we literally go top down, okay?

• Chronic primary headaches or a facial pain and those are people who present with chronic migraine, chronic tension type headaches and various other things in the head and neck.
  

Moving a bit further down, you have

• Chronic visceral primary pain
  
  • Irritable Bowel Syndrome (IBS) would go into that category
    
  • As would chronic primary chest pain, chronic primary epigastric pain, abdominal pain, bladder pain, and the chronic pelvic pain that we see in both men and women, and obviously more commonly in women a problem.
    
• Chronic pelvic pain in women without an identifiable cause is common.
  

And then we get down to the

• Chronic primary musculoskeletal pain
  
  • This is really the back ache and chronic lower back pain, which is, as I mentioned earlier, the biggest problem and the poorest outcomes in terms of interventions for people who have got chronic primary lower back pain who go and see their doctors and it's identified as a disc or something that is seen on a scan and treated very often to surgery.
    
  • And we know from the results of surgeon Dr David Hanscom who is the expert on this area.
    
  • And when you hear what he says and when you read what he's written in terms of his path, it's amazing what happened to him and how he changed his career as a result of that.
    
  • And what enormous contribution he is now giving to the pain with all the fantastic work that he and many of his colleagues are doing.
    

The ICD 11 also details specifiers:

• How severe, how bad,
  
• How interfering with your activities of daily living
  
• The course of it
  
• The effects
  
• How does it make you think?
  
• How does it make you feel?
  
• What does it make you do?
  
• What does it make you not do?
  

All of these are just various ways of describing how negative and how devastating the pain is to a person's life.

In the medical world when anything is diagnosed as Primary, the other terms that are used in this category are

• Idiopathic
  
• Essential
  
• Functional
  
• Agnogenic
  

And these literally mean any disease with an unknown cause or mechanism that is apparently spontaneous in origin.

The Greek word for idiopathic, patho is suffering and literally translates into one's own suffering, a disease of its own kind

So even though this has been put in place by the ICD-11, it still leaves us with, well, these people have got Chronic Primary Pain often over years and years duration and we don't know what the cause is.

So, this whole series is about looking at this and we actually do know what the cause is. And are there things that we can look at to see how we can help these people out of chronic pain?

Many of us have been in our own chronic pain journeys ourselves and we have realized that there is a cause.

To further complicate matters, secondary pain is described as nociceptive pain, which means tissue damage or neuropathic pain, which is nervous system damage.

And then as far as primary pain goes, this is where it gets really messy.

So neuroplastic pain, neural pathway pain, nociplastic pain, chronic primary pain are all the same thing. And all underpinned really by another term,
central sensitization.

All of these are chronic primary pain, just not secondary. So not secondary to any cause.

And the ICD-11 really introduced this concept of nociplastic pain

I think that many people are still familiar with the word neuroplastic pain and certainly in Pain Reprocessing Therapy, that's the term that's used. For the purpose of the rest of our discussion, I'm just going to use the word neuroplastic pain so that everybody understands what I'm talking about.

This is the type of pain we are talking about. So, it's pretty much Chronic Primary Pain for which there's no identified structural cause

And the majority of chronic primary pain, chronic persistent pain, is neuroplastic pain

Neuroplastic pain, is in essence a maladaptive learned phenomenon, an unhelpful habit that the brain has learned.

The good thing is that because it's an unhelpful habit that has been learned, it's an unhelpful habit that can also be unlearned.

So neuroplastic pain really is a false alarm. It's pain that is caused by learned neural pathways in the brain and not due to ongoing structural damage or disease in the body and that's a very important point to make. The brain in essence is misinterpreting safe signals from the body as if they were dangerous. And as a result, produces neuroplastic pain or other medical unexplained symptoms.

There is a long list of medically unexplained symptoms that falls into this category. We're just going to be talking about pain today, but if you look at the PPDA website, which captures all of this very, very nicely, they describe a list of symptoms that literally it goes from tinnitus to visual stuff. I wouldn't be able to rattle off the list by myself, but neuroplastic symptoms can be anything. And any symptom that is medically unexplained that has been investigated by a doctor or doctors and they can't find a cause and that is persisting for more than three months, one really needs to consider whether or not this is a neuroplastic symptom.


So, let's just talk more about neuroplastic pain.

There are four main ways that neuroplastic pain can develop.

Firstly, a person can have an actual structural injury that is since healed and neuroplastic pain can actually follow a structural injury. What we do know about the body is everything the body heals. Everything has a healing time. And so, if you lacerate your finger, skin healing time is two to four weeks. If you damage a muscle, it's anywhere between one and six weeks. You break a bone, anywhere between four and 12 weeks. Tendons probably up to about 12 weeks. Ligaments a bit longer, possibly up to about 16 weeks. All things heal. The body heals them within that timeframe. There are some spinal discs that
maybe take a bit longer, possibly up to six months per se. But anything that's persisting after a period of six months, you really need to ask the question is why is this person still feeling this pain? And what we do know is that the single greatest factor that fuels pain is the fear factor. The fear factor that then becomes amplified and maintained well past healing time.


So, the second one is where there's actually no injury, but there's a perception that there's an injury or there's a perception that there's structurally something wrong with the body. And once that perception happens, the fear factor can fuel that and amplify it. And then that just gets maintained. And the
primary fear of all people in chronic pain is that there must be something structurally wrong with their body to be causing pain of the severity. And that's why so many visits to the doctor and so many investigations and so many different treatments.

And Catherine and I are going to talk about her experience and I think her experience, and I'll mirror my own experience in terms of the pathways, in terms of what happens when you do suffer with pain and you go and go to the doctor. So that's the second cause.

The third cause is chronic pain can be precipitated in childhood, in adolescence and in adulthood by any adverse or stressful or traumatic experience originating as early as childhood. And what we've learned is that it doesn't need to have been a major trauma. We are obviously familiar with the ACE studies and again, Catherine and I will talk about that, but I treat and see so many people who aren't able to identify a major single event trauma in their life, sometimes even aren't able to identify relational trauma that would constitute a diagnosis of complex PTSD. The difference between PTSD and complex PTSD, I'm not going to really discuss these in this meeting, but people don't have to have had those sorts of trauma and often people have had major traumas in their life and don't go on to develop pain. But that's just the point to make is I do see quite a few people in my own practice that when I do a very detailed trauma history on them, often we can't find any specific thing. But of course, that may be something in the subconscious that hasn't yet been accessed and I'll talk about that a bit later.

And so, then the fourth way that neuroplastic pain can develop is just an insidious onset. There's no definitive acute injury, no perceived injury and no obvious adverse, stressful or traumatic experience that one can identify and people develop pain. And in this group of the insidious development of neuroplastic pain, of course it can happen in all of the groups, but in this group personality traits may play a major role.

And I'll talk in more in detail of personality traits. But these are personality traits that people who are people pleasers, who are prone to self-criticism, who put enormous amount of pressure on themselves, people who have positive traits that end up being not so positive for themselves. Conscientious people, people pleasing, perfectionists might be prone to anxiety. Their brains are constantly on high alert feeling like they're emotionally in danger. And of course, when the brain does feel emotionally in danger, it can not only trigger, but it can also maintain pain.

So how do you know if somebody's pain is neuroplastic? There's certain neuroplastic clues in terms of just identifying neuroplastic pain. As I mentioned before, anything that is not related to an identifiable or a confirmed organ disease or structural damage, no organic cause. The whole medically unexplained symptoms or symptoms that really don't do well with treatment. They've been offered treatment and have only had partial or temporary relief. These are people that frequent visits the doctors and often be told after many, many investigations and many things that your symptoms are all about stress or your symptoms are all in your head.

And of course, that is the very, very last thing people want to hear because they're suffering. The pain is 100% real for them. And less understanding, the irony is that in fact the pain that they're experiencing is being generated from their brains, but to give the analogy, it's all in your head I suppose it's medical gaslighting if anything.

But those are the types of things that are presenting to doctors all the time. And I think for many doctors, possibly people with chronic medically unexplained symptoms become their heart sink patients because they want to help and their patients get subjected to enormous number of investigations and so much medication and the doctor doesn't feel like they're actually getting anywhere and the patient doesn't feel like they're getting anywhere. So, it ends up being a little bit of a catch-22 situation. So that group of people, medically unexplained symptoms. Symptoms that can begin with a physical precipitation, no actual obvious injury, no obvious trigger that's causing it. Symptoms that persist, as I said, much longer than the expected healing time. They can be symmetrical, both sides, or they can be asymmetrical but don't make anatomical sense.

So, one half of the body on one side, one half of the body on other side, that doesn't make anatomical sense in terms of where it'd be mapped in the brain. And certainly, when I talk about my own symptoms, the thing that was a key for me, I obviously had medical knowledge, but in terms of my pain, it didn't make anatomical sense. The pain I had didn't match the dermatome, the disc didn't match the dermatome. So that was something that always worried me is that why is this not making anatomical sense?

Pain that spreads over time to different areas of the body, that radiates to opposite side of the body or just that doesn't make sense. So that occurs in different body parts, multiple symptoms that have different qualities, that maybe associate with headache or bloating.

Qualities like tingling or electric shock or burning or numbness or hot or cold. All of these symptoms should really point a person towards, could this be neuroplastic pain? They're inconsistent. The pain migrates. Can be less intense, even within a day. Can occur upon awakening. Can occur while asleep. They can occur after exercise. Can occur when stress happens or even when people are thinking about stress. And tend to perhaps be at their minimum when they've got other distracting activities, okay? And symptoms that seem to be triggered. And the key really is that can be triggered by anything. They can be triggered by food smells, by sounds, by lights, by computer screens, menstrual periods, changes in the weather, anticipation of stress or actual stress. Even imagining engaging in a pain triggering activity such as bending over, if they believe they've got an injured back, turning the neck, sitting or standing. So many people will attribute the onset of their pain to something innocuous they did. I was just bending over, I was just picking up, and my back went and that's what actually caused the injury. When I speak to Catherine, I'll detail to you how a seemingly innocuous event, the same thing happened to me.

So those are really the things that you need to be looking at in terms of thinking it could this be neuroplastic pain? Always we need to have a look at does a person have a history of chronic stress or depression or anxiety or underlying untreated PTSD? Have a careful look to see if a person has a history of any adverse childhood experiences or childhood adversity. And these are all the sorts of things that will give you the clues.

Invariably there will be some form of trauma, psychologically emotional trauma that has resulted in what causes this chronic pain syndrome, which at the end of the day is basically corticolimbic system dysfunction. It's all about limbic system dysfunction. And I'll talk a little bit more about that.

Before we have a little bit of a break, I'd just like to just concentrate a little bit on people's personalities in terms of being able to recognize which people will develop neuroplastic pain. I mentioned a couple of personality traits earlier, but this is really key because very often people that have these personality traits are the types of people that maybe repress their emotions and it's the repressed emotions that invariably end up triggering neuroplastic pain.

Now, as I mentioned, things that are very positive in the workplace and very positive in terms of so many aspects of people's life. Perfectionists who are detail orientated, extremely organized, highly conscientious, try to accomplish too many things, very critical of themselves, hold themselves to
extremely sometimes impossibly high standards, overly responsible, overly conscientious, sometimes a little bit control orientated. Stoic people who just hold in their emotions, have difficulty opening up to people in expressing their emotions. They put the needs of other people before themselves and they
will routinely change their plans to satisfy the needs or schedule the needs of others, and try to be peacemakers in so many situations. Some of them might have quite legalistic tendencies, like to be right, my way or the highway approach. On the other hand, they might also be quite hypervigilant, anxious people, may have dependency traits, may have low self-esteem traits and may have some hostility or aggressive traits as well.

Fundamentally, these are people who ignore their own needs and repress their feelings, they repress their emotions. And so, over a long period of time their emotional and their physical needs often remain unmet. They never voice their real true feelings and that may be associated with deep-seated feelings of inadequacy or low self-worth, doesn't have to be, but all of these personality traits are negative to the self and these individuals can become quite harm avoidant. And this harm avoidance reflects a tendency to develop condition fear responses. And that explains the pain that they end up experiencing and just get caught in this vicious, vicious cycle of fear and avoidance, fear and avoidance and suffering. So certainly, in my clinical practice I do see a lot of very successful businessmen who reflect this exact profile in some form or other and are very successful in their jobs but end up being not successful in their lives because they get struck down by chronic pain.


So, pain is a survival technique, it's there in an attempt to protect us. We need to experience pain for survival. What most people don't probably realize is there's no such thing as pain receptors. All we have in our body are things called nociceptors, which pick up change. So, let's say for example, you're in the kitchen making dinner and you cut your finger with a knife. A signal gets sent immediately, so quickly up to your brain, and your brain sees blood, it processes all the information, it puts all the information together and it has to make a decision, what am I going to do?

So, it sends a pain signal straight back down to your finger and you experience the pain and you say, "I've got to do something about this." So, you put a pressure bandage on. If it's serious you go to A&E and you get it stitched and get stitched up. And once it's stitched up, unless there ends up being an infection or inflammation, the pain disappears or goes away because the brain now feels it's safe. And so no longer needs to send you that signal.

And then as we know skin healing times is two to four weeks later, that heals but the pain disappears the minute the brain perceives that it's safe. Imagine when people go on skiing trips and adults go skiing for the first time and have a fall on the ski slope and they sustain a fracture of their femur. Awful, awful injury, incredibly painful. And they get air ambulance out and end up having surgery and massive fractured femur, huge bone in the leg and they get it pinned and put together and immobilized. And can you just imagine they've got a broken shattered bone inside their leg but the minute it's surgically fixed, even though it's still very badly damaged, very badly broken inside, there's no longer any pain.

The legs immobilized because the brain says this is now safe. And the minute the brain deems that something is safe, it removes the pain. So, pain in acute injuries is there as a survival technique. And the type of pain we're talking about, chronic pain, the pain maps in our brains, they get damaged. And us warning signal, our fire alarms in our brain are just now firing off consistently, making us believe that there's a problem in our body when in fact it's just our brain, our pain system just continues firing long after the body has healed. It's almost like the acute pain that we had develops an afterlife that's in the case of injury or that your chronic pain develops a life without any acute injury. It's key to understand. And what I'm trying to say is that, and this is what people often don't realize is that all pain, whether it's due to an acute injury or whether it is current, all pain is determined is by the brain. And how much pain we feel is determined in significant parts in our brains by our past experience of pain, our psychology, how serious we think the injury is and what our whole perception of the pain experiences.

So, let's just talk a little bit now about what neuroplastic change is. Because neuroplastic change is key in terms of what happens in pain, what happens in the brain and also is key in terms of how we recover from chronic pain. So, neuroplasticity, we used to think that our brains were hardwired, what you were given was it and that you couldn't change your brain. But we now know that that's not true. Through quantum physics and functional imaging and advances in science, we know that the brain can change dynamically, it can change its structure, it can change chemically, it changes functionally.

And neuroplasticity represents that. It's the property of the brain that enables it to adapt and reorganize its own structure and functioning in responses to changes in the environment and in response to changes in mental experience as well. In response to thoughts, in response to emotions and in response to behaviours. And neuroplastic change really is responsible for all the habits we have, both good and bad, helpful ones and harmful ones. It's this flexible wiring capability of our brains that enables us to grow and to change and to heal or not. And when I say or not, there's a negative side to neuroplasticity as well. And the negative side of neuroplasticity is really if you look at addictions and harmful and addictive habits, be its substances or activities or toxic relationships, that can create a very negative neuroplastic change in the brain. And those can all become deeply ingrained habits. And if you think about addiction and being stuck in toxic relationships or having a process addiction or addiction to anything that is in any way destructive or harmful to yourself, you can be stuck in that position for years until you create the neuroplastic change.

Because for all intents and purposes, your brain may actually feel that that is a safe place to be and doesn't know better, doesn't know how to shift out of out of those deeply ingrained neural pathways. Positive neuroplasticity is where neuroplastic change can happen in our brain and you can have positive shifts and transformations on every level. And this is really, really the key in terms of how we address treating people who have chronic primary pain. We really need to rewire our neural networks chemically, electrically, behaviourally, psychologically, relationally. Every single aspect needs to be rewired. We need to create new neural networks in us brains.

On a day-to-day basis, 95% of our thoughts, of our beliefs, of our emotions, of our habits are all experienced and guided by our subconscious brains. Parts of our brains we are unaware of. 95% of that is guided by our subconscious brains. Our conscious brains, that 5%, is just constantly focused on creating the perceptual image of our reality. And it really is about understanding that and realizing that in order to change our habits, we have to understand what's going on in the subconscious brain, become aware of it and know how to access it, and what to do about it.

So neuroplastic change has to be a dynamic process, A dynamic process physiologically and physically. And it's really what we do and our interactions with ourselves and interactions with our environment that facilitates reorganizing of brain connections in response to what our changing needs are. Rewiring neural circuits are the only way that we can shift from being in chronic pain to not being in chronic pain. This whole concept is known as wiring and rewiring.

This is known as Hebb's Law. But interestingly, if you go back in history and look at the psychoanalysis of neuroplastic therapy as described by Hebb, neurons that wire together fire together. Actually, it was originally proposed by Freud back in 1888 I think it was. And what Freud stated is that when two neurons fire simultaneously, this firing facilitates their ongoing association. He called it the Law of Association by Simultaneity.
And that really forms a basis of what he did in psychoanalysis with free association, a patient would lie on the couch and Freud would be behind him.

In the slide presentation that I've prepared for all of the participants, you'll see quite a few slides towards the end, which shows that Freud, long before we had neuroimaging and long before we had advances in quantum physics and that, Freud was talking about so many of these things already and talking about what was going on in these subconscious and repressed emotions. And he was a huge contributor to psychiatry. And I think when you go back and see what he was actually talking about, information is actually, it's all there. I find that quite fascinating that we're in 2023 and Freud was talking about this hundreds of years ago.

So, the next question is, well, okay, we know all of this, so how do we do it? And this whole concept of neuroplasticity, which we know is essential for normal brain development and it helps create functional brain circuits that are required on basis of learning. It's how you learn new skills.

The greatest neuroplastic change is learning a new language, playing a musical instrument and interestingly traveling, creates this neuroplastic change.
Unfortunately just going on holiday doesn't create neuroplastic change. If only it did, we could all just pack up and go on holiday. I think it's more about new experiences and stimulating new pathways and possibly learning a lot of new things. So, it's that concept of traveling that I think is referred to.

The younger you are, the easier it is for neuroplastic change. Young brains are much better at learning and adaptation, but it doesn't negate the fact that it can't happen as you get older. There is still a huge amount of neuroplastic capability in adult age as well. But in order to achieve neuroplasticity, there are absolutely fundamental principles which underpin positive neuroplastic change in the brain. There has to be focused attention. So, you really have to be interested in what you're doing and there has to be consistent and repeated engagement with the same task. It has to be coupled with determination. It has to be coupled with hard work, with motivation and doing all of this maintaining brain health.

The best analogy I can give you is to think about if you wanted to make an enormous change in terms of sport or you wanted to run a marathon or you wanted to achieve lifting certain weights in the gym or you want to achieve anything in that. If you just think about focused attention, consistent and repeated engagement, determination, hard work, motivation and overall brain health, that's how you achieve it in that arena. It's no different. It's no different in this arena.

The opposite has exactly the same effect. If people are disengaged, inattentive, distracted, lazy, nothing happens. Okay? So, all of the previous things you would call neuroplastic on switches, all of those are what are called neuroplastic off switches. So, in terms of wanting to address where the problem is, everything is occurring in the limbic lobe. Okay? Limbic lobe dysfunction is what the result is in terms of what causes chronic pain.

And all of the interventions are focused really on resetting the limbic system, be it trauma, be it addiction, be it chronic pain, resetting the limbic system has to be the key component of that. And so, neuroplasticity is really an activity driven process, okay? It's something that has to be practiced on a daily basis in order for those neural pathways to be developed and to be strengthened.

So, this plasticity-based learning has to be consistent. There has to be consistent internal mental rehearsal. And because we know that every thought we have, every feeling and every action, we actually, are engaging and triggering thousands of neurons that join together, that form these neural
networks. And the more we engage in these, the greater chance we have of effecting change in a positive way.

In the same ways in a negative way, they've looked at scans of people who suffer with OCD and can see how the obsessional thoughts and obsessional thinking lights up certain parts of the brain. And to some extent, if you draw the analogy that what you're trying to do is you're trying to create new neural networks, you're not trying to correct old ones, trying to correct old ones just often reinforces those old ones, it's about creating new neural networks.

The analogy I give to my patients is an I'll talk about self-care routines because this is where it starts is if you've got a default setting neural pathway that's not serving you, be it a neural pathway, that is the pathway that drives anxiety, that drives addiction or that's driving chronic pain, you don't try and fix those pathways. You need to create new neural networks and new neural pathways and wire them together, almost create like a new neural super highway.

And give the analogy of saying think about a chandelier, all those bulbs on, okay? And every time you are creating a new neural pathway, you're switching a bulb on in that chandelier and you want to get that chandelier all the lights on, and that's the chandelier you want to be operating on. That becomes your new neural pathway, not your old default set pathway. You want to switch this on and switch it on all the time in terms of creating the change.

The reason why everything needs to be focused on the limbic system is because when you look at the whole concept of polyvagal theory that's been covered in previous editions, really in terms of the balance between the parasympathetic nervous system and the sympathetic nervous system. The sympathetic nervous system is your fight, flight, freeze, nervous system. You need that for survival and it kicks in when you need it. All right? And when you don't need it, you go into your parasympathetic state, which is connection, growth, sleep, recuperation.

Problem we have is this, we live in a dysregulated world. We live in a world that bombards us with so much negative information and so much negative energy that our limbic systems have become dysregulated. We have dysregulated limbic systems living in a dysregulated world, okay? It's quite hard to change a dysregulated world, but we can change our dysregulated nervous systems and that's where we have to focus on.

It would be great if we could change some aspects of our dysregulated world but for the purposes of dealing and helping people with chronic pain, you have to focus in on the limbic system. And so, your brain remembers. So, any learning driven neuroplastic changes that you are making, your brain will
remember your best efforts and it'll make that small change. And if you do that incrementally and consistently, slow progressive improvement will start.

I often say to people who are recovering from addiction, they might be working the 12 steps, but one of the things that is key in addiction is to attend 90 meetings in 90 days. And I often ask people, "What are you actually doing there? What does that mean? Why is it so important?" Because the recovery's always better in people who are able to attend those 90 meetings in the first 90 days. You think about it, really, they are reinforcing neuroplastic change and creating a new neural network and new habits in terms of that positivity. And I think often if people know why they're doing what they're doing, they're more likely to do it and especially if they're starting see results.

So neuroplastic change is really where things are at. And so, all self-care routines need to focus on switching on as many of the neuroplastic on switches as possible, specifically intended to calm down the nervous system and specifically intended to calm down the limbic system. Okay?

Neuroplasticity of thoughts is crucial as well. I think at one stage it was thought that we had something like 70,000 thoughts per day. When I last researched this, I think it's probably closer to 6,000 thoughts per day. But what the research does show is that of those 6,000 thoughts we have a day, probably 95% of them are repetitive and 80% are negative. So, in terms of neuroplastic change, you have to intentionally change your thoughts on a consistent basis in order to create stable new neural connections. You have to strengthen those neural connections so that you can actually create the change.

So, I'll talk to you a little bit about self-care routines because that's really in terms of where neuroplastic changes and how do you put neuroplastic change into action? I ask everybody the question when I'm talking about self-care routines. First of all, I'll ask people, do you have a self-care routine? And most people don't actually have a self-care routine.

I said to people, "What is the first thing that the vast majority of people do? The very first thing when they wake up in the morning?" Probably the whole planet or the majority of the planet, the first thing they do really is this, they're on their mobile phones. And of course, mobile phones in terms of wanting to create positive neuroplastic change in the brain, your self-care routine has to start with a digital detox. Not going on that phone for however long your self-care routine takes, half an hour, an hour. Because everything that you look at on that phone, it'll tend to be an email or a message or a WhatsApp or social media platform or the news. All of those sorts of things are not good in terms of calming a nervous system down. The aim is really to calm the nervous system down.

There has been research done in terms of seeing what are the things that really do promote longevity and people living a long life? And a key there is to have an anti-inflammatory approach to everything. Anti-inflammatory, positive neuroplastic approach to everything.

So, what do I mean by anti-inflammatory? What we now know is that anti-inflammatory doesn't just apply to inflammation of tissues and the bones, okay? In terms of what is inflammatory to the brain, the brain releases substances, sets off a cytokine system and that cytokine system is inflammatory to the brain even with things that you don't think that it is.

So, what I'm trying to get at is that your immune system can also get fired up by neuroplastic off switches, okay? Your immune system is there to protect you as well. So, when your immune system has to deal with an infection, it mobilizes all of its T-cells, it mobilizes cytokines and creates the inflammatory response so that it can deal with the threat, it can deal with the infection, it can deal with what it needs to deal with.

Turns out that any mental threats are also inflammatory processes that the same process can happen, except that with mental processes, those are far harder to escape in terms of the effect of your immune system and your cytokine system and you end up having a sustained inflammatory response and that can really form the basis of chronic pain and also of chronic mental and physical disease is all thought to be due to chronic inflammation of the cytokine system and the immune system.

And so, we really need to be thinking about an anti-inflammatory way of eating, an anti-inflammatory way of thinking, an anti-inflammatory way of being, okay? Anti-inflammatory way of eating, I'm not an expert nutritionist, but in its basics, anything that is mostly plant-based and not processed is anti-inflammatory way of a nutritional approach.

In terms of what is toxic to the nervous system. If you just think about social media, inflammatory things to our limbic system are the use of too many mobile phones for watching the news, violent games, violent movies, all of these sorts of things are actually inflammatory to our brain. And so, in the process of recovering, all of these things need to be addressed as well.

So, let's just go back to self-care routines. So, self-care routine has to start each day in the same way away from your mobile phone. Digital detox is the way to start it and then is to try and switch on as many neuroplastic on switches as possible. And a lot of people will be talking about this over the weekend. That daily morning routine is the calm before the storm of life, the calm before our dysregulated world that we are going into. You have to have a system and an approach that calms your nervous system, starting with a digital detox from your phone, not watching the news, not watching violent shows, not overstimulating your brain through that.

Then it's really about what other ways can we look at in terms of calming nervous system? And all of the medicines and breathing exercises, all of the mindfulness meditations, all of the things that calm down the nervous system, affirmations and gratitude. There's a list of so many things that you can do and you have to bespoke those to yourself. If you look at The Miracle Morning by Hal Elrod, it gives you a template of what you can do in order to start with a neuroplastic on switch routine every day.

There's one last thing I just want to talk about in terms of neuroplasticity. And this is the real concept of things that in terms of all of the pain patients that I have, is the concept of something called expressive writing. Expressive writing, I think is an absolutely wonderful tool, and there's been a lot of research into expressive writing.

Pennebaker is the cornerstone of this, and he's done extensive research on this. John Sarno, who was a huge contributor to what we understand now about chronic pain, in his book called The Divided Mind, he talks about something called the reservoir of rage. And the reservoir of rage, it's like being in a prison with lots of unsavoury characters trying to break out. These are in our internal reservoir of rage.

These are people that they're too dangerous to enter from the subconscious mind into the conscious minds. They just remain. They remain repressed in our subconscious unconscious mind.

And they remain there because we repress so many of our emotions. Because if we express them or show them, you could almost think of yourself as losing it with a loved person or someone close to you. And so, we repress these because we are not only safeguarding ourselves, but also safeguarding other people from hurting them by saying something that we want to say that is deeply unkind or unpleasant.

And that may be socially acceptable in any situation. So, what we do is we just repress, we repress, repress all of these emotions into our reservoir of rage, almost like a pressure cooker. And these really are unconscious, repressed emotions. Could be viewed in a way even they're stored trauma. And we need to release these repressed emotions in order to heal, in order to deal with our pain, in order to move from our chronic pain state.

Because the reservoir of rage tries to inform our conscious minds of just how scared and stuck, we are. And our conscious mind just keeps on pushing them back. So, our subconscious minds then says, "Well, no. What messages can I send to you that you're going to take notice of?" And of course,
pain is the message they can send and everybody responds to pain. Nobody ignores pain. And particularly when it's pain that's that severe.

And that neuroplastic pain that we are experiencing really diverts us from experiencing our internal emotional world, our emotional pain. And this is why expressive writing is so important. Expressive writing is about accessing our subconscious mind and being able to dive deep into our thoughts, our opinions, our emotions rooted in memories and trauma.

There may not be major trauma, that major trauma might have been dealt with via therapy, but expressive writing is certainly a way to process those feelings that are deep in the unconscious, that our brains won't allow to come into the conscious thing because of the reason that we might deeply offend people or it might be socially unacceptable the thing that we do. So expensive writing, here's how it works. You don't tend to prepare for this. There's a guide as to lists you can use, but there's no real thinking ahead. It's something that you just sit down and you do.

It needs to be spontaneous and all the writing that you do is completely confidential. There's no sharing of the content of the writing. And you really do write in a stream of consciousness, free flow writing, coming from your gut and from your heart. You shouldn't edit your thoughts; you shouldn't edit your feelings.

You really, really want to go deep and explore your deepest emotions and thoughts, those darkest secrets that you don't want any other person to know or that you don't want to discuss with anybody. They can be about anger, shame, guilt, past or present, about anyone or about anything. They can go back to your childhood. They can be about adult experiences. They can be in the here and now. They can be about anything. It literally is that you are diving really deep and getting all of those deep-seated emotions out.

Consistency is the key. 20 minutes every day, but here's the real key. The minute the 20 minutes is up, you do not read what you have written down, okay? You are not examining your thoughts. You tear that piece of paper up immediately and you destroy that piece of paper immediately. It's not for you to read and it's not for anybody else to read. This is not journaling. This is not keeping a diary. This is not examining a thought dialogue.

This is about separating your repressed thoughts and emotions that are trapped in your unconscious mind because fundamentally you are not your thoughts. And by doing this, one can start the healing process. You are accessing so many of those deep-seated repressed emotions that are fuelling your pain.

You want to access that raw, unfiltered truth about how you feel. You don't want to sense yourself. Things that are shameful, that are scary, that are ugly. Imagine yourself as a kid almost having a tantrum, getting it all out. Okay. Often been described as a word vomit onto a page. Another description I've heard, which is quite graphic, is you've got a bad cold, you literally are blowing your nose into that handkerchief or that tissue. You're not going to go and look at it afterwards. You literally are just going to get rid of it. You don't even want to be associated with it, you're taking all of those real deep-seated things and you're getting an art into your conscious mind.

And gradually what will happen is your brain will start to learn that it's okay to have these feelings. Your brain will start to learn that it's okay to feel these things. You're accessing deep-seated emotions and repressed emotions and very often straight after doing the expressive writing, people might want to engage in some self-compassion meditation just to calm their nervous system down or might want to do some guided visualization.

It's such a key part of recovery and the regular practice of this is a huge neuroplastic on switch. So, all of the things that are I've spoken about really are the neuroplastic on switches. And any person that is going to be recovering from chronic pain has to start their day with the self-care routine that focuses in on calming down the limbic system, calming down the nervous system that has become dysregulated and that it's in a dysregulated world.

And finally, the last thing I really want to say about neuroplastic change is all of these things that are spoken about, all the neural networks that wire together and fire together to create the new neural super highway in your brain, the new chandelier, the thing that is the most important though is the neuroplastic change that has to happen with your thinking.

That is the thing that is the game changer. That people who are able to change the way that they think, not only about their pain but the way they think about life in general, are the ones that can make progress. That is not a passive process either. One has to go from an unintentional way of thinking.

An unintentional way of thinking is starting your day every day with somebody else telling you what you must think, your mobile phone, to an intentional way of thinking. That you are intentionally starting your day every day in a way that is self-serving.

The principles of so many religions, Buddhism and Christianity and other religions is you can't serve others until you've served yourself. And self-care routines are all about serving yourself and getting yourself emotionally regulated and getting yourself into a good head space so you can deal with the dysregulated world. The world outside is going to carry on in its dysregulated way. And the only way that people can recover from their pain is to very first start calming down their nervous system is absolutely crucial. And obviously as part of the neuroplastic change in thought processes, the thing that holds people strongest in their pain is really their belief. Their belief about what their pain is.

And the education side of getting people to understand the concept of neuroplastic pain is that their brain's made a mistake and is giving them a false alarm and that actually there's nothing wrong with their bodies is absolutely crucial. Because by doing that, people can say, "There's nothing wrong with my body. I can start exercising again." And that's encouraged. That's another neuroplastic on switch, movement and exercising. So, all of these things in terms of self-care routines, and I only just touched on them, there's so much we could talk about in terms of self-care routines that are anti-inflammatory, neuroplastic on switches. That in itself it's a little mini conference on its own.

So, I've been talking for a long time now and I hope that everybody that's watching has got an understanding really of what neuroplastic pain is and what chronic pain is, and that you all have an understanding of why this has happened. Our brains have made a mistake. Our brains have become super sensitized. Our brains are sending us the wrong message. They're trying to protect us. Our brains are doing their best to protect us.

And those people who do suffer with chronic pain have nothing structurally wrong with their bodies. And that is such a positive thing. That gives people hope. Everybody who suffers with chronic pain really wants hope. And there is hope when they know there's not anything structurally wrong with their
bodies.

Thank-you.