“When I'm not working, I go to the mountains with people who have chronic pain and we do activities in nature.” Talking to Mayte Serrat is about enthusiasm, a vocation for health and a passion for research. She is a doctor, physiotherapist and psychologist, and also coordinates the Physical Exercise and Psychosocial Approach Working Group of the Catalan Pain Society of the Academy of Medical Sciences of Catalonia. In addition, she is the principal investigator of fibrowalk therapy at the Vall d'Hebron Hospital, “the first effective therapy against fibromyalgia,” as she explains. A therapy that reeducates the brain to fight persistent pain.
In this reference center, Vall d'Hebron, Serrat is responsible for the group therapy of the Expert Unit in Central Sensitization Syndromes. He researches neuroscience in addressing chronic pain and nature activity therapy, in addition to presiding over the NGO CIM Project, the Inclusive Mountain Club. Now Serrat has just received the Physiotherapist of the Year award from the College of Physiotherapists of Catalonia.
What scientific evidence is there that pain can be reduced by training the brain?
We have six articles published in journals of maximum impact, with studies carried out between 3,000 and 6,000 people, which demonstrate the effectiveness of fibrowalk to treat fibromyalgia, but it is the same treatment for any type of chronic or persistent pain. Other researchers call Pain Reprocessing Therapy (DRT), but the basis of all this is the same, the neuroscience of pain. The 2021 Nobel Prize in medicine was given to David Julius and Ardem Patapoutian for the discovery that pain is in the brain.
How many years have you been researching the topic and what have you found?
It has been researched for more than twenty years, and more and more studies are coming out that reaffirm it: pain is not in the body, it is in the brain. Many medical books talk about pain pathways and it is a mistake because they do not exist. The pain does not run through your body. They are nociception pathways, pain activation mechanisms. If your brain believes that you may be in danger and that you may suffer physical harm, it will generate pain; If you think not, it does not generate pain.
There are people in pain who do not suffer any physical damage...
We have cases of people without physical damage or who in terms of investigation we are not able to quantify. The most obvious case is fibromyalgia: medical tests show that everything is fine, but the person is in unbearable pain. There is also the opposite case, you can have great physical damage and not perceive pain. In the case of amputees: they have a “phantom limb”, they feel pain in a part of the body that does not exist, that they do not have. “My right arm has been amputated and my right hand hurts”... This happens because the pain is in an area of the brain.
At what point are we in the application of therapies based on pain neuroscience? Are they already used in treatments?
We are in full effervescence. I am in 22 work groups: in the Catalan Pain Society, in the Spanish Pain Society, in the Spanish Multidisciplinary Pain Society, the professional associations of psychology and physiotherapy, the CAMFiC (Catalan Society of Family and Community Medicine), etc. . It has been applied in consultations for a few years now, and now it is beginning to be heard a lot, it is known that it is necessary to provide education in the neuroscience of pain.
What pain is it being used for?
For persistent chronic pain with altered central sensitivity. It is also applicable to acute pain, and in fact it is knowledge that we should all have to serve as prevention. If you come with a sprained ankle, I will not apply the neuroscience of pain to you, but it can serve to predict possible chronic pain in that ankle. In fact, pain neuroscience education should be explained to children in schools: knowing that pain is in the brain and that there are many factors that influence it can help you prevent persistent pain.
Give examples of pain that can be treated in this way…
Fibromyalgia can be treated but also neck pain, low back pain, back pain, migraine... But it is not for everything. If there is impingement and neuropathic pain, obviously the first intervention will not be to do education in pain neuroscience. You will have to see what happens there, what physical damage there is and if there are physical therapy tools to rehabilitate. We are talking about something else: a pain that lasts more than a year, that has become persistent. In these cases, education in the neuroscience of pain serves as a complement to the treatment you must receive.
Pain, you say, depends on many factors...
If on a happy day at the beach you get a cut on the sole of your foot, you probably won't give it much importance. If on another occasion you have a bad day, you have argued with your partner, that same cut will hurt you much more. And you are the same person and the same cut. The pain is not proportional to the amount of physical damage. Nociception, the possibility of harm, is neither necessary nor sufficient: you can have physical harm and not feel pain, and also the other way around.
What are the factors that determine whether we will feel pain or not?
Learning and previous experiences: if I know that I have sprained my ankle, but my recovery has gone very well, if I have another one later, it is likely that I will face the sprain with very good expectations. This will determine the amount and intensity of pain. More factors? The sprain will not do the same damage if I do it when I am about to go on vacation for a trip that has cost me a lot of money as if I do it when I have to go to a place where I don't feel like going, and I may even put the excuse sprain.
Also talk about social and cultural factors, for example?
In African culture, fifteen-year-old boys are put in a circle and the skin of their penis is cut, they are circumcised. There it is natural, it is a sign that they have become men, that they are warriors... If we try to do this to the boys of La Garriga, in Catalonia, we will see what damage it does to them!
Cognitions, spiritual factors, emotions... everything affects pain, how?
The fact that you understand that this pain will not injure you if there is no physical damage makes you calmer, and the brain does not activate the pain program. The more alert and scared the brain is, the more pain we will feel. If the brain feels very threatened, I will be in pain. If we can change thoughts through behavioral techniques, the brain will deactivate the pain program. There are people with fibromyalgia who explain that before learning about these therapies they did not want to get out of bed because they were in so much pain that they feared their body would break.
If we have pain, should we stop what we are doing?
This is an erroneous guideline given in medical consultations: if you have pain, don't move. When you do recovery, sometimes they tell you: “when you start to feel pain, stop.” Noooo! You are proving the brain right! A thorough evaluation of the injury must be performed and a therapeutic exercise regimen that is not based on pain should be implemented. What we want is the opposite, to teach the brain that you can do something without feeling pain, which is why a progressive and gradual exercise regimen is necessary.
But we don't feel pain because we want to, it is not consciously generated, right?
No, the person does not generate it because they want to, it is unconscious, involuntary.
Pain has two missions, it says... which ones?
The first is the perception of threat, warning you that there is a danger. The second, more important, is that you take an action. Have you come home with a bruise and don't know how you got it? Why hasn't the brain made you aware that you had damage? Because you probably did it in a state of stress, while doing other things, and the brain considered that the task you were doing was more crucial than giving you pain to make you stop: you didn't need to be aware of that.
What do we do to change the perception of pain? What specific tools do we have to reeducate the brain?
The 2020 Delphi study, by Louise Sharpe, is an international consensus research that concludes that to address any type of persistent pain there are three pillars: education, therapeutic exercise and a psychological approach. They are the bases of any treatment.
First, pain neuroscience education… What does it mean? What does it consist of?
Simply being informed of what I am explaining is part of the treatment. If you know how it works, you can reduce the perception of threat.
Secondly, there is therapeutic exercise, what type?
As physiotherapists we will prescribe exercises and movements not for having physical benefit, but for re-educating the brain. That is, establishing a base level and a progression to re-educate the brain so that it understands that it can do the movements without breaking anything, avoiding kinesiophobia, the phobia of movement when you have an injury, which is a vicious circle: You don't move because you are in pain, and you are in pain because you don't move.
Moving even though there is pain is necessary... What if we can't?
Confronting pain with movement is necessary, and if you cannot move, imagining that you are moving will help you. People with spinal cord injuries have walked again thanks to virtual reality therapy, because they have given the order to the brain that they can do so, giving a visual stimulus: this is neuroplasticity.
Thirdly, there is the psychological approach. In what sense?
Cognitive-behavioral therapy is the one that has shown the greatest benefit. Helps cognitive restructuring, changing thinking. When you have pain you will naturally think “this pain kills me, it doesn't let me do anything”, negative thoughts because the pain is ruining your life. This is practically inevitable.
But when we give you tools to identify thoughts with mindfulness, we are offering you a strategy to realize what you are thinking. To begin with, you must be aware of negative thoughts; Then you have to learn to change it for a safer one (it should not be called more positive). We must create security contexts to avoid the brain's alert. The more secure the person is, the more likely the brain will decide that the brain is not necessary.
An example of safety context to avoid pain?
Have you never heard people say that when they go to town their knee no longer hurts? Your brain, for reasons unknown to us, interprets that this area is safe for you, and does not cause pain. If it were a matter of the weather, everyone who is in pain should go to that town! But no, this doesn't work.
How long do these therapies take to be effective?
They are not easy or immediate, they involve a process. There is a moment when the pain decreases much faster, because the brain has already learned, and the recovery is faster each time. In our studies, 70% of people, after three months, have a reduction of more than 20% in symptoms. There are 10% of people with a reduction of more than 70% in symptoms. They are results of people with fibromyalgia.
Is all this being applied to primary care? Is it being disclosed so that it is known?
Many working groups are being held. This year, physiotherapists and 'Emotional Wellbeing References' have joined primary care, and the indications from the Health authorities are to create groups to treat chronic pain. Much of it is training in the neuroscience of pain.
And what do you do in nature, in the mountains, with the non-profit entity CIM Project, which you chair and which has just been recognized by the College of Physiotherapists of Catalonia?
We do techniques with people with chronic pain so that they continue to improve. It's a club for anyone with a disability or diversity. In 2024 I'm going to Everest Base Camp with 67 people! Before that we will go out to the mountains for everyone who wants to participate. We want to be a model of inclusion, what society should be, and enhance people's capabilities.
In my doctoral thesis I did the same therapy that I do in the hospital (Vall d'Hebron) abroad, in the Parc del Cargol in Barcelona. I got better results. Being under a pine tree has physical and psychological benefits, spending half an hour in a park, even in the city, provides many benefits. I have gone to Aconcagua, Montblanc, Kilimanjaro, expeditions to Everest... And now I have united my passions: pain re-education can be done in nature.
