Physical therapy patient finds relief after learning the brain’s role in chronic pain

Elizabeth Gangloff

Twelve years ago, Elizabeth Gangloff had surgery to remove part of her colon, and she had endured pain every day after that. But just weeks ago, she began to see relief for the first time, thanks to an innovative approach that addresses biological, psychological and social or “biopsychosocial” factors that influence persistent pain.

Gangloff, a middle school teacher’s assistant, first had surgery to remove her colon in 2004, and she had no lingering pain. But after a second surgery in 2011 to remove the rest of her colon, things were different.

“The day I came home from the hospital, I had pain. It was like I was sitting on a golf ball and my sphincter muscle would spasm,” she said. When she expressed concern, she was told it was probably phantom pain, such as the pain someone experiences after an amputation. “But I had my colon removed in 2004, so why would it happen now?” she thought.

Searching for answers

When the pain didn’t ease, Gangloff was sent to a gynecologist, who did a CT scan. The scan didn’t show anything remarkable. “I kept getting a shrug and being told, ‘Yeah, we’re not sure what’s going on,’” she recalled.

She kept taking over-the-counter pain relievers, but the problem wasn’t getting any better. Though the pain was not continuous, it struck several times a day, taking her breath away and leaving her frozen in place until it passed. This continued for years, affecting her parenting, work and ability to enjoy time with friends and family.

“Part of you just says to suck it up and deal with it. I’ve got kids and a husband and things I’ve got to do,” she explained. “There’s another part that puts off doing things and changes the way you do things. You modify your life to work around it.”

She began to associate certain activities and positions with pain and tried to avoid these apparent triggers: walking up a ramp or stairs, lifting a box or sitting a certain way. At the grocery store, Gangloff would only buy milk if it was conveniently positioned at her shoulder height, because lifting the container from a lower height would trigger too much pain. Once home from shopping, her children brought in any groceries heavier than a loaf of bread so that lifting the bags wouldn’t trigger her muscle spasms.

Her ability to do many typical daily activities had changed, despite using medications. And as a result, her life was slowly threatening to become more and more limited. “I was taking ibuprofen constantly just to get through working or parenting. There were lots of times I said no to things because I knew it was going to hurt,” she said.

Elizabeth Gangloff and Nitin Udhawani.

Finding a new approach

Eventually, she was referred to a pain clinic, although it was for a different problem: nerve-related back pain. After a year or so of treatment for that pain proved unsuccessful, the doctor suggested a nerve block. Before insurance would pay for the block, Gangloff would need to try physical therapy.

That’s when she met Nitin Udhawani, DPT, a physical therapist with Beacon’s outpatient physical therapy program in Three Rivers. She told him about her painful muscle spasms, as well as her back problem.

During her first appointment, Udhawani took her through several body motions. With each movement, he asked about her fear and anxiety levels. They talked at length, discussing what movements and activities she avoided for fear of triggering pain and determining what range of motion was possible without causing muscle spasms.

Udhawani uses motivational interviewing to connect with patients like Gangloff. “A motivational interviewing process helps improve our understanding about fear and about a patient’s thoughts and beliefs about pain and pain perceptions,” he explained.

The technique is designed to empathetically support behavior change, and he also incorporates experiential learning―learning by doing. After her first session, she was able to bend forward with less pain and feel comfortable that she was even capable of bending. After years of chronic pain, that kind of progress can be truly empowering.

As homework, Udhawani asked her to watch a video, which they’d discuss during her next visit. “Videos are a way to reinforce the learning and reinforce her understanding that she is not alone, she is safe to move, she is not broken,” he explained.

Watching such videos also helps patients feel less fragile and vulnerable. They see that they’re not alone; others have had similar experiences and recovered.

Retraining the brain

For Gangloff, pain was being triggered not by physical injury, but by the sensitivity of her brain’s “pain alarm system.” She learned that her brain was anticipating pain and trying to protect her body by sending pain signals at the first sign of any trigger – even when there was no danger of physical injury.

“My brain is overprotective because I’ve been in a pain state for so long,” she said. “When you’re in pain so long, all these little triggers go into your long-term memory.”

For example, Gangloff was unable to squat because it caused too much pain. But she and Udhawani found that a different set of motions that resulted in a similar position brought no discomfort.

Bit by bit, Udhawani would guide Gangloff through movements that challenged her understanding of her body’s capabilities. To help her regain the ability to squat comfortably, he asked her to first lie on a special bed and imagine squatting without pain. He describes this technique as “visual motor imagery,” and it helps to reduce the brain’s oversensitive reactions to a perceived threat.

Gangloff then slowly began exercises. She went from doing the movements while lying flat on a bed to doing them while lying against a tilted bed, and then in a fully standing position. Udhawani explained that progressing in a non-threatening way like this increases the patient’s confidence and reduces fear.

Soon, Gangloff could even do the exercise with added weights. She was retraining her brain as she regained movement in her body.

It’s not unusual for people with persistent pain to have experiences like Gangloff’s. Udhawani says there are a number of common triggers for pain, ranging from fear of movement to negative expectations to excessive worry about their pain. Not understanding imaging results, lack of sleep and even financial stress can all increase a person’s perceptions of pain.

“There is more to pain than tissue injury,” he said. “Pain isn’t always from an injury. Our emotional and psychological experiences are equally (or more) responsible for triggering and modulating one’s pain experience.” This is especially true with persistent pain.

The brain as CEO

Gangloff recalls another video Udhawani recommended. This one featured a construction worker who had stepped on a spike and was screaming with pain. It turned out that the spike had gone between his toes; the pain was his brain’s reaction to seeing the spike passing through his shoe.

“The brain is the CEO in making the decision to produce pain or not,” Udhawani said. “We can have pain even when there is no tissue injury. We can also have injury and have absolutely no pain. Pain and tissue injury are not synonymous, but we like to connect the dots.”

We sometimes connect the dots even when they’re not logical, he says. And we can become so afraid of pain that we move awkwardly or not at all. Further, when we twist our bodies out of alignment to avoid potential discomfort, that can cause popping or clicking that seems to confirm the unhelpful belief that something is really wrong.

“That’s when people get stuck,” he said, emphasizing that the body needs to move in order to be healthy. To break the cycle and overcome chronic pain, Udhawani describes three steps:

1. Challenge our definition of the perception of pain.
2. Find ways to explain to the patient that their body is still strong and can move safely.
3. Take incremental steps forward, with the person’s progression being based on the perceived level of both physical and emotional distress.

As Gangloff learned about the brain’s role in her chronic pain, as well as the effects of anxiety, she was able to recognize her painful muscle spasms for what they were: warnings in anticipation of trouble, not signs of actual damage. Almost miraculously, her pain decreased. Her new understanding of her body’s response to triggers helped with both her back and her muscle spasms.

“Your brain protects you. I’m telling you, my pain has just dissipated,” she explained. “The pain I had several times a day for 12 years has gone away.”