Exercise for the modulation of pain – Four pictures

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Four educational cartoon images in A3 format about how physical activity is effective pain / pain modulation. The pictures show how various chemical processes in the nervous system and the brain inhibits pain.

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Frame the drawings and put them on the wall in your clinic. Preferably in an area where there is not much going on. In a quiet area, where the patient can look at the drawings not being disturbed. Now the person can observe the drawing(s) and reflect on what the drawing is saying. The person is mirroring her/himself in the drawing, maybe recognizing him/herself. When the patient start to talk about how he/she interpret the information from the drawing, you can add information to what the person is telling you. Instead of explaining, it is better to guide the patient. This biopsychosocial form of communication will help you minimizing the problem of stigmatization. When you purchase these drawings (A3 format) you will also receive a pdf with a picture of each drawing with an explanatory text that you can print and give to your patient. In this way you can use the drawings as a treatment tool combining it with other methods/techniques you apply helping patients in pain.

Picture 1 – Opening the chemist shop in the brain can change your pain

01It is fascinating that we through evolution have developped different mechanisms in our central nervous system that produce different hormones and neurotrasmittor substances having positive effects on your mood and cognitive functions. These substances, also named endogenous neuropeptides, have also a pain relieving effect similar to morphine. We are talking about endorphins, oxytocin, dopamin, serotonin, cortisol, adrenalin and noradrenaline. Graded exercise therapy is an excellent method to activate the chemist shop. Physical activity activates a chain of hormonal reactions in the endocrine system where cortisol has an important function in pain modualtion.

Picture 2 – Pain modualtion is chemical reactions in different areas of the brain

02Research has shown that endorphins attach to three different areas of the brain; 1) Orbitofrontal Cortex, Insula and Anterior Zingulate Cortex. These brain areas are connceted to the limbic system involved in cognitive functions and feelings. When endorphins attach to these brain areas you feel less pain, you look more positively on life and you become more proactive solving problems, compared to being passive and depressed.

Picture 3 – The descending pain inhibiting system


Pain modulation involves cortical and spinal inhibition of nociceptive input. Nerveimpulses from the exercising muscles travel to the spinal cord where different chemical reactions occur in an interneuron. At the same time different areas of the brain is activated initiating a descending pain inhibiting effect acting on the posterior horns in the spinal cord. Even though nerveimpulses from mechanoreceptors fro the periphery have a pain modulating effect, the regulation of pain is a top-bottom system. In addition to this, expectation effects like postive (placebo) and negative (nocebo) expectations influence nociceptive regulation. If the exercise therapy is casuing anxiety and fear, nociceptive input will incerase and you may experience more pain. Thus, the exercise therapy has to be graded according to what you can tolerate, preferably performed painfree or close to painfree, not causing anxiety or fear.

Picture 4 – “Exercise is stress, but positive stress

04When you exercise you activate the same stress axis as when you experience pain. The big difference is that the stress exercising is causing, is a positve form of stress. This form of stress opens up the chemist shop. In contrast, pain can close the chemist shop. Exercise activates the hypothalamus – pituitary – adrenal axis, or the so-called H-P-A axis in a “positive way”, where all the different hormones produced have important effects keeping you healthy. The activation of the hypothalamus results in a release of corticoreleasing hormone , and the Pituitary gland releases Adrenocorticotrophic Releasing Hormone into the blood travelling to the Adrenal gland. Here cortisol is released into the circulation to the liver and working muscles where glycogen is used as energy for the working muscles. The muscle, also being an endocrine organ, produces mykines believed to have antiinflammatory effects. To achieve all these postive effects you have to
exercise 45 to 60 minutes at least every second day,
preferably every day.

When all this is said, you can only start exercising with an exercise dosage which is tolerable not causing anxiety and fear. This may only be of 5-10 minutes duration. As your tolerance for loading your body improves, you increase the time exercising accordingly. This is not easy and you need support from your loved ones.

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