What is Neuroplastic Visualisation for Chronic Pain?

Today I’m going to try and describe the theory behind this neuroplastic technique in my own words (mostly)* in the hopes that someone finds it interesting. Hopefully, nobody finds it useful! Because although that would mean my writing was not in vain, one more person with chronic pain is one too many.

The visualisation I’m doing involves imagining the boundaries of the brain regions that process pain and then making them shrink in your “mind’s eye”. But what are these regions? And how does that help?

There are (at least) sixteen brain regions involved in processing pain

According to Michael Moskowitz, quoted in Norman Doidge’s book, there are many different regions involved in processing a single incident of pain. Without having done my own research to verify these, I won’t go into specifics of which areas he mentions (they all have funny names like ‘hippocampus’). But what is worth knowing is that pain is processed in many parts of the brain.

When not processing pain, these regions do other stuff

When an acute (new and intense) pain signal is generated somewhere in our bodies, those sixteen brain regions light up on brain scans. But in fact, even before the pain signal, those regions are not dormant. They do other stuff too. They just light up even more once the pain signal arrives. Before the interruption, these sub-networks do things like (quoting from Doidge again) “sense pressure, position, vibrations. [They] detect conflict … solve problems [that are presented to them], plan movement sequences, process and retrieve emotional memories. [They] connect emotion with bodily sensations, empathise with others, retrieve autobiographical memories” [1]

And finally, the posterior parietal lobe “processes visual perception [and] internal location of stimuli”. The prefrontal area is involved in “executive function, creativity, intuition, emotional balance”. And the posterior cingulate processes “visuospatial cognition”. [1]

Those last three are where the visualisation comes in.

Chronic pain is neuroplasticity gone wild

When those regions process acute pain, only about five percent of the neurons in each area are dedicated to processing the pain signal, leaving about ninety-five percent to carry out the other important tasks they are involved with.

What Doidge reports is that Moskowitz discovered that in chronic pain, the number of neurons processing pain has grown to between fifteen and twenty-five percent. This leaves a shortfall in the number of neurons that can carry out other jobs.

Essentially, the constant ongoing signals of alarm and damage have rewired the brains of people (like me!) with chronic pain, so that the neural networks no longer function like they used to. That is neuroplasticity — but not in a good way.

Incidentally, to me this seems to explain why those of us with chronic pain can seem to lack concentration or struggle to form sentences, solve problems or recall facts. We may have trouble empathising with others or controlling emotion. Our own brain is being appropriated by excessive signals from our peripheral nerves.

Our posture comes to reflect a defensiveness that is nothing to do with how we feel about the world, but has everything to do with how much finesse and fidelity has been lost in our actual cognitive experience.

Disconnecting is harder than connecting

Making new connections between things in our minds is relatively easy — just repeat it a few times and soon you’ll have no trouble remembering the way to a friend’s house, or how to tie a shoe. But have you ever tried to unlearn something? That’s not so easy. Many of us have nights we’d rather forget 😉 But how many of us have managed to intentionally ditch those unpleasant scenes? Or once we hear a song that we detest and it’s going round in our head, how do you stop it?

That’s essentially what we’re doing with the visualisation technique. We focus our mind and use thoughts themselves (visual images) to literally force our brains into using the neurons for their original purpose — visual perception, internal location of stimuli, creativity, intuition, visuospatial cognition. Visualisation involves all these functions and more. By doing this, we are unlearning a pattern of neural behaviour that has become so ingrained that we were until now unable to break free in any meaningful way, as the neurons became more and more tightly connected. That is why we need to bring such seemingly unreasonable levels of conscious determination to the situation. Relentlessness, as Moskowitz calls it. We must be more relentless than the pain, or else we stand no chance of disconnecting a network that has become progressively more deeply wired over time.

A final point

Eventually, the goal is to use the mind to return our brains largely to the same state they were in before they began producing the experience of chronic pain. When that has been achieved, the visualisation is no longer necessary and we can go about our lives with more normal pain-processing neurology.

We will still receive normal pain signals. The five percent of neurons that are dedicated pain processors will still do their jobs. And the injuries or limitations in our bodies will remain — they will need to be treated in their own way.

An as-yet unanswered question

Although there are sixteen brain regions responsible for processing pain, Moskowitz’s technique only targets three of them. Despite this, anecdotally it seems to have had remarkable success. Why is this? Are these three more central to the experience of pain?

[1] Doidge, Norman. The Brain’s Way of Healing. Penguin Books 2015. pp13-14

  • Note that this is not a systematic scholarly review of the latest research. My list of sources is minuscule. There may well be errors or mistakes compared to the latest neuroscience. I’m just trying to present the basic gist of what I’m doing so people can do their own reading about it if they choose.

Neuroplastic Visualisation for Chronic Pain: Day 7

One week in, and today I have let go of meditation. Anyone who knows me knows what a huge statement that is. I don’t just skip that part of the day though — I still sit down as if I were to meditate. But rather than traditional shamatha-vipashyana, instead I’m reallocating the time for dedicated visualisation. The pain is bound to interrupt a meditation practice of any decent length anyway. I mustn’t let meditation distract me from the technique. I must be more relentless than the pain.

Focused visualisation for a good thirty minutes helps prime the pump. I’ve been unable to sit quietly today at times, despite feeling a pain spike, but I’ve found that I can bring to mind the visualisations even when e.g. in a conversation. It’s a good sign if I can do both at once. To me it seems as if the practice is maybe — just maybe — starting to get a subconscious foothold. Why? Well, I don’t think I can discount the simple fact I’ve been doing it for a week now. But I also attribute it to the focused practice that I began the day with.

The pain relief is also noticeable today, which is welcome, and even better is a sense (whether a sign of neuroplastic change or other side effect) that the relief is lasting longer. Today, whenever I run through the full practice, I get a good few minutes pain-free.

Having said that, I’m still very unsure if I’m doing enough to make permanent change in my neural anatomy. For this reason, I dug deep into my wellbeing fund and ordered a copy of Moskowitz’s Neuroplastic Transformation Workbook (see http://zigzagyogi.com/2016/07/visualization-for-chronic-pain/ for some links to that book and other resources I am using).

I must not fear. Fear is the mind-killer. Fear is the little-death that brings total obliteration. I will face my fear. I will permit it to pass over me and through me. And when it has gone past I will turn the inner eye to see its path. Where the fear has gone there will be nothing. Only I will remain.
Frank Herbert, Dune

Neuroplastic Visualisations for Chronic Pain: Day 6

I have found this the most challenging day so far. I haven’t had a day with this many pain spikes since I started. Because of the frequency of eruptions, the “Relentlessness” aspect of the technique interferes with everything! The only thing I don’t interrupt is yoga teaching — both arriving on time to teach, and the teaching itself. Everything else is fair game — appointments, meetings with friends, housework. When I become aware of a pain spike, I drop everything and focus on the pain maps. Even during mindfulness practice. Normally, meditation gives a cumulative benefit, but I have to let go of it in order to maintain the relentlessness of the neuroplastic technique. I miss it, but need to remember that this is a time-limited thing. The neuroplastic retraining takes 6 — 8 weeks. After that it should no longer be necessary.

Neuroplastics for Chronic Pain: Day 5

This is my fifth day of using Michael Moskowitz’s visualisations for chronic pain. The relaxation response is starting to become ingrained. In Day One I noticed that when I stopped whatever I was doing, closed my eyes and went through all the steps (establishing intention, crafting a visual map of my brain’s pain system, and then shrinking them in my mind’s eye) that I became more calm. In response to this, the pain, always in my peripheral awareness, eased to 1-2/10 and my whole body, but especially neck, shoulders and core, relaxed. Today, it seems all I need to do is start the process, even visualising with my eyes open and the relaxation starts to take place — not, perhaps, to the same degree, but subjectively still very noticeable.

Two things from this. Firstly, an observation and some speculating. On Day One, the relaxation response was so pronounced that, as I said, the pain all but disappeared and this disappearance was accompanied by feelings of freedom and blissful breathing that I’ve hardly experienced all these years since the accident (June 2012). Since then I’ve been able to access this level of pain relief only a half dozen or so times in total across the four days.

Could it be that my body-mind is accustomed to the new level of comfort, and though the relaxation response is actually occurring to the same degree, my experience of relief has faded? Or is there some objective difference between the way I was visualizing and the effect it had on Day One vs the way and effect of subsequent days? Perhaps some inhibitory response has begun taking place alongside the visualisation that wasn’t present on Day One but is now having a dampening effect?

Perhaps (and this seems most likely to me) the newness of the practice and the novelty on Day One stimulated my brain to higher levels of concentration and this, combined with early placebo effects, led to greater temporary relief than in the days since?

Regardless, the practice does not actually rely on achieving a certain level of temporary relief in each session. The aim is to reassign the duties of certain networks of the brain that also happen to process pain input (the posterior parietal lobe and the posterior cingulate as well as the prefrontal area which is involved with creativity). By relentlessly coaxing these systems to work with stimuli other than pain, we make structural changes in these areas so that the neurons are less dedicated to pain processing. So, while I suspect that having a greater sense of temporary relief equates to stronger motivation, deeper concentration and therefore more vivid visualisation and greater engagement of the above brain regions, which we could assume would lead to faster progress, in the long run, repeated effort will still create the desired result — it may just take a week or two longer. Still worth it.

Secondly: a cautionary realization that I must follow the full practice through each time, from setting intention to creating visual maps to shrinking them, and not simply stopping when I feel the realaxation. While that may be tempting, such a method skips the step of engaging the specific brain areas mentioned, so will not lead to the kind of neuroplastic change that this technique is designed to engender. Instead, I’ll become reliant on the temporary relief of relaxation through visualisation, which although real and beneficial, is in the end just like any other form of pain relief in that when stopped, the pain returns.

The ‘I’ in MIRROR stands for Intention and the intention is this: to focus the mind, in order to change the brain.

“Mental efforts help build new circuits and weaken the pain networks.” Norman Doidge, The Brain’s Way of Healing

“If focus is merely on immediate pain control, positive results will be fleeting and frustrating. Immediate pain control is definitely poart of the program, but the real reward is to disconnect excessively wired pain networks and to restore more balanced brain function these pain processing regions of the brain.” Michael Moskowitz, Neuroplastic Transformations Workbook

Visualization for Chronic Pain

I have begun reading The Brain’s Way of Healing by Dr. Norman Doidge. It details case histories in the new medical field of neuroplasticity (the ability of the brain to change itself), and was recommended by my GP at Helios Medical Centre. It appears to be well researched, and is endorsed by neurologists, psychiatrists and physicians from institutions like the University of California, Boston School of Medicine, Harvard Medical School…

Bless Doidge for putting chronic pain as the subject of chapter one.

In that chapter, Doidge reports a way of retraining the pain circuitry in our brains that was discovered by a pain specialist in the United States named Michael Moskowitz. Not wanting to necessarily wait on a copy of Moskowitz’s “Neuroplastic Transformation Workbook” to arrive from Amazon, I will be undertaking that mental rewiring programme at home here in Christchurch, kiwi-style. I will be using as motivation and further study all the blogs and websites I can find of people doing the same. I’ll also be using that single chapter by Doidge, while continuing to inhale the rest of his book. And I’ll write a brief post each day about my findings, and changes or setbacks I notice.

There are likely to be plenty of the latter over the next six to eight weeks, which is the timeframe Dr. Moskowitz suggests before results are truly signs of neuroplastic change, and not just placebo and the result of temporary distractions from the pain. Hopefully I already have some useful experience from my seven-years-since, daily meditations.

Eventually, the visualizations and constant relentless effort of retraining the circuitry should be pretty much unnecessary, and my pain circuitry will have returned more or less to what it was before the chronic feedback cycle set in.

So, the preliminaries.

May all beings be happy. May all beings be free. May all beings share my good fortune.

Days One — 3

I’m currently on Day 5 — here are my brief catchup notes for the previous four days.

Day 1: elated. Probably mostly due to the placebo effect and the simple fact that, when in pain, anything that takes your mind off it is going to have a relaxing effect. Went to the park with my partner and her toddlers. Because of the elation, I probably overdid things. Lots of monkeying around — shoulders and neck!

Day 2: confused about the technique. Setback in terms of pain — possibly caused by trying to keep up with toddlers yesterday! Lots of questions — do I have to interrupt what I’m doing at any time of the day when I feel pain, and visualize? I am in almost constant pain sometimes for hours. Should I continue visualizing all that time? Feeling as though I can’t guarantee I’ll be on time for things if I need to keep stopping all the time. Even visiting friends was tricky today. Don’t seem to be getting any relief from the technique at all today.

Day 3: Moskowitz uses the MIRROR acronym to describe how to apply the technique. The first ‘R’ is for ‘Relentless’. So, in answer to yesterday’s questions — yes. All of that. “Anytime pain intrudes on consciousness”, writes Moskowitz, “it is greeted with visualization.”

Which seems intimidating — and yes, it’s hard to be that consistently motivated. But, reading about the experiences of others helps. Learning about the science behind the technique is motivating for me. And I’m also learning to do the visuals “on the fly” — closing my eyes at red lights to imagine the brain maps. Sometimes the visualization is bringing relief from the pain. Other times, I’m working on accepting that sometimes the visualization will be feeble or feel ineffective.

Day 4: elation returned. Feel emboldened to continue with the technique. Visualizations more vivid. Relaxation more pronounced than last two days. Quite significant relief from the pain if I stay focussed, fades as soon as I stop visualizing though. And still nothing like as much relief as Day One.

There! All caught up. From now on I will post each day separately.

Further Reading

This blog post has a reasonable summary (if you squint past the typos): http://www.lifeinslowmotionblog.com/visualization-chronic-pain-and-neuroplastic-transformation-an-introduction-to-dr-moskowitzs-neuroplastic-pain-management-strategies/

Here is Dr. Moskowitz’s book on Amazon: https://www.amazon.com/Neuroplastic-Transformation-Workbook-Michael-Moskowitz/dp/0615814654?ie=UTF8&keywords=neuroplastic%20transformation&qid=1456245317&ref_=sr_1_1&sr=8-1

And The Brain’s Way of Healing on Norman Doidge’s website: http://www.normandoidge.com/?page_id=1042

What Are Nano Practices?

Nano practices are quick momentary habits that can change your life. I like to experiment with these lean brain-hacking techniques because they punch above their weight for how much time investment is required. Although I do not think they replace a daily formal meditation practice, they do assist us when integrating “on the cushion” insights into daily life, or making use of neuroplasticity to overcome unhelpful patterns of wiring in the central nervous system (brain and spinal cord). Or both.

But taking advantage of nano practices requires persistence at first, while we craft the habit.

How to craft a habit
(this is an aside — you can skip it)

One way to build a good habit is to craft a three-step cycle: trigger -> action -> reward. You choose a trigger (or sometimes our own habit-forming consciousness will choose one for us) and use it as a reminder to perform a certain action, that you then reward yourself for doing. Ideally the action will provide its own reward, but it doesn’t have to.

It takes persistence to start that cycle rolling, and you’ll have to deliberately notice the triggers and decide each time to follow through with the action part. But as we all know, habits build their own momentum — a good thing, in the case of nano practices. Eventually it will establish a virtuous cycle of habit: the more you do it the better it feels and the better it feels the more you do it. But unlike some habits, there’s no Breaking Bad-style drug addiction looming in your life if you take one of these practices on.

Once that cycle is established through persistence, it will form a virtuous spiral that has the potential to rewire the reward circuitry in your brain through neuroplasticity.

Depending on the results you are trying to achieve you may need to graduate from persistence into something more like relentlessness. For example, in February of 2016 I was suddenly and unwillingly cut out of three parallel careers by chronic whiplash pain 1. In July 2016 I cobbled together a home-based neuroplastics intervention based on my own reading and research (I kept a diary of it for 30 days). Although still not capable of full-time work, I’m a lot better off thanks to the habitual nano practice of visualising during pain spikes (which is ongoing and probably will be for the rest of my life). I can work to a “one hour on, one hour off” schedule for most afternoons, which is a huge win compared to where I was at.

But in order to shift the pain to that extent, I had to be more relentless than the pain for about three months before it started to become baked in 2.

Just remember, no matter how much effort it takes to begin with, soon you will not need to work at it. You will automatically ignite a flicker of intention with every little trigger and then engage the practice without question. Like letting out the clutch. What an investment those early efforts are!

Further Reading

One man who wrote a book on habits (literally) is Charles Duhigg, and The New York Times has kindly reviewed his work. He suffers from the usual “motivational talker” oversimplifications, but there is some useful stuff in there.

Although much of James Clear’s content on habits is taken from Charles Duhigg’s book, habits are His Thing and he does a good job of illustrating the repercussions of habit theory. Similar to Charles Duhigg, there is a lot more to habits than what he highlights, but it is very clearly explained for what it does cover (which for both authors is a great deal more than I am, tbf).

  1. I am coping fine thanks, and not looking for sympathy 🙂 Empathy is OK, but do not pity the man who has more time to write than ever before!

  2. {Look, another little clicky balloon}
    Until I get around to writing an Introduction to Neuroplastics for Persistent Pain, the following diary update provides a basic starting point on the technique with some further reading links at the bottom: neuroplastic brain hacking technique for persistent pain.