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How Heart Rate Variability Biofeedback Can Help Chronic Pain

Publication date: 18 July 2012

In my last post I wrote about a recent seminar given by Richard Gevirtz in London. In this post I want to write about a fascinating theory of chronic pain he presented. More specifically it's a theory of myofascial pain - a kind of pain felt over certain areas of the body including back pain, shoulder pain and some tension headaches.

In many of these cases there is a combination of trigger points and referred pain. Trigger points are very small but exquisitely sensitive areas of muscle. (The term was coined by a doctor - Janet Travell - but it's fair to say that her work is not widely known in mainstream health services.) Referred pain means pain felt in a certain area but the actual source of the pain signal is elsewhere - the brain in some sense misinterprets the pain signal.

Gevirtz's starting point is a puzzling finding: patients say that their muscles feel very tense, and they can even feel hard and tight to the doctor, yet when you measure the tension in the muscle using standard surface EMG no tension is found. EMG actually measures electrical activity in musculo-skeletal nerves which control muscle tension, but Gevirtz realised there is another kind of nerve input to muscles that he believes is key to myofacial pain. He came across a research paper which reported that the sympathetic nervous system (SNS) innervates small structures within muscles called spindles. The SNS is a quite different branch of the nervous system than musculo-skeletal nerves - it's more associated with stress and automatic body responses, as I described in my earlier post.

Muscle spindles help us to sense what our muscles are doing. They are enclosed in capsules. Gevirtz thinks that excessive SNS input to muscle spindles causes pressure to build within this capsule, resulting in pain. He asserts that trigger points are these swollen muscle spindles, and offered us some pretty convincing evidence when he showed us a video of EMG recorded from a needle inserted into a spindle. We saw that everyday stress made this muscle spindle EMG go wild, while a neighbouring needle embedded in ordinary muscle showed nothing.

Normally when you tell people who are suffering chronic pain that it is simply a matter of stress, they don't like it at all. It's as though you're telling them their pain is just imagined, not real. They can't accept that their beliefs, thoughts and behaviours could cause their pain. To a large extent, they are right - their pain is real.

With Gevirtz's account, we can give such people a convincing story that stress has a real physical effect on their muscles, that leads to pain. And this belief has a big effect - they are much more likely to help themselves. Research demonstrates that even understanding on its own has a dramatic effect on outcome.

The kind of stress that causes this kind of problem is just everyday - nothing major. It's persistent low-level worry that does it. This leads to prolonged withdrawal of vagal activity (described in my last post). Of course not everyone who worries, develops chronic pain - showing that autonomic nervous system responses are an individual matter, not the monolithic actions they were once thought to be.

Gevirtz in his clinical work uses a combination of Heart Rate Variability (HRV) biofeedback training and physical therapies which work directly on muscle spindles. HRV biofeedback works by re-establishing the vagal input needed to release the muscles from their chronic sympathetic activation. He appears to be having a lot of success.

While not all chronic pain fits this model, Gevirtz's work is certainly a very promising development.

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