The drug cabinet in The drug cabinet in the brainthe brain

David Butler

www.noigroup.com

• present some extraordinary gifts of neuroscience to rehabilitation

• introduce therapeutic neuroscience education as a new evidence based management tool

Aims

The pain sciences The pain sciences revolutionrevolution

Neuroscience/pain sciences Neuroscience/pain sciences `trendy”`trendy”

Gift 1 – the ion channelGift 1 – the ion channel

“the molecular targets of rehab”

The neurone

The ion The ion channelchannel

From Bear et al 2001

“DNA makes messenger RNA. Messenger RNA` makes proteins and proteins make us”

– Open or closedOpen or closed

– Many different Many different kinds of sensorskinds of sensors

– Live for two days, Live for two days, like butterflieslike butterflies

– Reflect your Reflect your perceived needsperceived needs

From Bear et al 2001

Your molecular biology degree ……..

Gift 2 – the Gift 2 – the synapsesynapse

“only 100 years old”

Rejoice in your neurones and Rejoice in your neurones and synapsessynapses

•100 billion neurones100 billion neurones• Up to 100,000 Up to 100,000 connections eachconnections each• More possible More possible

connections than connections than particles in the particles in the

universeuniverse• Baby makes 3 Baby makes 3

million synapses per million synapses per secondsecond

• 200,000 km of 200,000 km of cabling in the braincabling in the brain

From: Neuron 10 (1993) Front Cover

Would this hurt?

An astonishing synapse -the dorsal horn

Gift 3 – The neuromatrix Gift 3 – The neuromatrix paradigmparadigm

• Melzack’s neuromatrixMelzack’s neuromatrix• representationrepresentation

• Maps in the brainMaps in the brain• The virtual bodyThe virtual body

• Schema – “body of knowledge”Schema – “body of knowledge”

“about 12 years old”

Reflect on the phantom

Butler DS, Moseley GL Explain Pain 2003

The outer skin homunculus (map, /representation in the brain)

Key elements of the Key elements of the neuromatrix paradigmneuromatrix paradigm

Four key points

Key elements of the Key elements of the neuromatrix paradigmneuromatrix paradigm

1.1. Many bits of brain get turned Many bits of brain get turned on togetheron together

Courtesy Lozza

The brain activity which occurs when a person suffering chronic pain experiences pain during an attempt at an abdominal contraction

Butler DS, Moseley GL 2003 Explain Pain

A possible pain or movement neurosignature

Note:

•No one “hub”

•Common but will vary

•Turned on together

Key elements of the Key elements of the neuromatrix paradigmneuromatrix paradigm

1.1. Multiple brain areas ignite together creating Multiple brain areas ignite together creating neurosignaturesneurosignatures

2.2. The specific tissue injured The specific tissue injured may not matter for a pain may not matter for a pain

neurosignatureneurosignature

Pain neurosignatures are more related to threat rather than tissue injury

PAIN

Damage

and pain

1. Introduction

+ emotions

PAIN AS INPUT

PAIN

Damage

and pain

1. Introduction

+ emotions

PAIN AS INPUT

PAIN

danger

1. Introduction

THREATS

PAIN AS OUTPUT

Thoughts are Thoughts are nerve impulsesnerve impulses

Key elements of the Key elements of the neuromatrix paradigmneuromatrix paradigm

1.1. Multiple brain areas ignite together creating Multiple brain areas ignite together creating pain representationspain representations

2.2. The specific tissue injured may not matter for a The specific tissue injured may not matter for a pain matrixpain matrix

3. Pain representations are 3. Pain representations are easily modifiedeasily modified

The neurosignature can be easily modified:

turned up

turned down

ignited by numerous stimuli including mirror neurones

Key elements of the Key elements of the neuromatrix paradigmneuromatrix paradigm

1.1. Multiple brain areas ignite together creating Multiple brain areas ignite together creating neurosignaturesneurosignatures

2.2. The specific tissue injured may not matter for a The specific tissue injured may not matter for a pain matrixpain matrix

3. Representations are easily modified3. Representations are easily modified

4. Representation smudging4. Representation smudging

Smudging/brain change are Smudging/brain change are normal – reflects the “need” of normal – reflects the “need” of

the individualthe individual

• Occurs as a normal Occurs as a normal part of life (musicians, part of life (musicians, blind persons, breast blind persons, breast

feeding mice)feeding mice)• ie the “self ie the “self

constructing” brainconstructing” braineg. Elbert T et al (1998) Neuroreport 9: 3571

Smudging and injury states

•Phantom limb stories

•The more chronic and painful a problem is – the more the brain neurosignature is smudged

•“Web fingers”

•On computers – hands grow big and shoulders fade

Some listeners may be interested in the feet as erogenous zones

More neuromatrix/smudging More neuromatrix/smudging giftsgifts

Web four fingers, smudging noted Web four fingers, smudging noted after 30 mins, lasts 2 hours if webbed after 30 mins, lasts 2 hours if webbed

for 5 hoursfor 5 hours How about the toes?How about the toes?

Motor as well as sensoryMotor as well as sensory Immune based – makes sense to Immune based – makes sense to

spread pain or revert to gross spread pain or revert to gross movements when the brain thinks you movements when the brain thinks you

are in troubleare in trouble

Stavrinou et al 2006 Cerebral Cortex

The immune bufferring The immune bufferring behavioursbehaviours

  Ability to develop coping skillsAbility to develop coping skills

Perception of stressorPerception of stressorSocial interactionsSocial interactions

Belief systemsBelief systemsExerciseExerciseHumourHumourIntimacyIntimacy

DietDiet Rabin BS 1999 Stress, Immune Function and Health, Wiley-Liss, New York

So what can we take from So what can we take from these giftsthese gifts

1. The obvious – the role of early 1. The obvious – the role of early movement and return to movement and return to

functionfunction

2. Therapeutic neuroscience 2. Therapeutic neuroscience educationeducation

Pain as epidemic

Structure Structure specific style specific style – “school for – “school for

bravery”bravery”

Does not work. Bombardier C et al 1997 Cochrane Collab

Review 22: 837

Psychology booklet basedPsychology booklet based

e.g. McClune T et al 2003 Emergency Medicine Journal 20: 514

Neuroscience/psychology Neuroscience/psychology blended styleblended style

Neuroscience styleNeuroscience style

Neuroscience style education is Neuroscience style education is effectiveeffective

Increase pain theshholds during physical tasks Increase pain theshholds during physical tasks Moseley GL et al 2004 An RCT of intensive neurophysiology education in Moseley GL et al 2004 An RCT of intensive neurophysiology education in

chronic low back pain Clin J Pain 20:324chronic low back pain Clin J Pain 20:324

Reduces unhelpful pain related beliefs and Reduces unhelpful pain related beliefs and attitudes, improves exercise outcomesattitudes, improves exercise outcomes

Moseley GL 2004 Evidence for a direct relationship between cognitive Moseley GL 2004 Evidence for a direct relationship between cognitive and physical change during an education intervention in people with and physical change during an education intervention in people with

chronic low back pain. Eur J Pain 8: 39chronic low back pain. Eur J Pain 8: 39

Helps in acute pain statesHelps in acute pain statesOliviera A et al 2006 A psycho educational video used in the Oliviera A et al 2006 A psycho educational video used in the

emergency department provides effective treatment for emergency department provides effective treatment for whiplash 2006 Spine 31: 1652 whiplash 2006 Spine 31: 1652

Pain states in once “mad” Pain states in once “mad” people now easily explainablepeople now easily explainable

Mirror pains – an immune responseMirror pains – an immune response

Non zonal spread of pain – smudgingNon zonal spread of pain – smudging

Delayed onset post injury – peripheral nerve Delayed onset post injury – peripheral nerve responsesresponses

Associated gut, libido, slow healing, Associated gut, libido, slow healing, memory loss – hypercortisolismmemory loss – hypercortisolism

Night pain – peripheral nerveNight pain – peripheral nerve

Reoccurrence post injury – normal brain Reoccurrence post injury – normal brain based survival responsebased survival response

Neuroscience/psychology Neuroscience/psychology blended styleblended style

Neuroscience styleNeuroscience style

The twin peaks

“The brain story” Petrol Link-up 1994

CONCLUSION

The drug cabinet in The drug cabinet in the brainthe brain

David Butler

www.noigroup.com

Info @noigroup.com