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The drug cabinet in the brain
David Butler
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Aims present some extraordinary gifts of neuroscience to rehabilitation introduce therapeutic neuroscience education as a new evidence based management tool
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The pain sciences revolution
Neuroscience/pain sciences `trendy”
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Gift 1 – the ion channel “the molecular targets of rehab”
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The neurone
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The ion channel From Bear et al 2001
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“DNA makes messenger RNA
“DNA makes messenger RNA. Messenger RNA` makes proteins and proteins make us”
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Your molecular biology degree ……..
Open or closed Many different kinds of sensors Live for two days, like butterflies Reflect your perceived needs From Bear et al 2001
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Gift 2 – the synapse “only 100 years old”
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Rejoice in your neurones and synapses
100 billion neurones Up to 100,000 connections each More possible connections than particles in the universe Baby makes 3 million synapses per second 200,000 km of cabling in the brain From: Neuron 10 (1993) Front Cover
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Would this hurt?
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An astonishing synapse -the dorsal horn
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Gift 3 – The neuromatrix paradigm
“about 12 years old” Melzack’s neuromatrix representation Maps in the brain The virtual body Schema – “body of knowledge”
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Reflect on the phantom Butler DS, Moseley GL Explain Pain 2003
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The outer skin homunculus (map, /representation in the brain)
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Key elements of the neuromatrix paradigm
Four key points
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Key elements of the neuromatrix paradigm
Many bits of brain get turned on together
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The brain activity which occurs when a person suffering chronic pain experiences pain during an attempt at an abdominal contraction Courtesy Lozza
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A possible pain or movement neurosignature
Note: No one “hub” Common but will vary Turned on together Butler DS, Moseley GL 2003 Explain Pain
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Key elements of the neuromatrix paradigm
Multiple brain areas ignite together creating neurosignatures The specific tissue injured may not matter for a pain neurosignature
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Pain neurosignatures are more related to threat rather than tissue injury
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1. Introduction + emotions PAIN PAIN AS INPUT Damage and pain
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1. Introduction + emotions PAIN PAIN AS INPUT Damage and pain
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1. Introduction THREATS PAIN danger PAIN AS OUTPUT
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Thoughts are nerve impulses
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Key elements of the neuromatrix paradigm
Multiple brain areas ignite together creating pain representations The specific tissue injured may not matter for a pain matrix 3. Pain representations are easily modified
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The neurosignature can be easily modified:
turned up turned down ignited by numerous stimuli including mirror neurones
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Key elements of the neuromatrix paradigm
Multiple brain areas ignite together creating neurosignatures The specific tissue injured may not matter for a pain matrix 3. Representations are easily modified 4. Representation smudging
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ie the “self constructing” brain
Smudging/brain change are normal – reflects the “need” of the individual Occurs as a normal part of life (musicians, blind persons, breast feeding mice) ie the “self constructing” brain eg. Elbert T et al (1998) Neuroreport 9: 3571
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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
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Some listeners may be interested in the feet as erogenous zones
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More neuromatrix/smudging gifts
Web four fingers, smudging noted after 30 mins, lasts 2 hours if webbed for 5 hours How about the toes? Motor as well as sensory Immune based – makes sense to spread pain or revert to gross movements when the brain thinks you are in trouble Stavrinou et al 2006 Cerebral Cortex
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The immune bufferring behaviours
Ability to develop coping skills Perception of stressor Social interactions Belief systems Exercise Humour Intimacy Diet Rabin BS 1999 Stress, Immune Function and Health, Wiley-Liss, New York
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So what can we take from these gifts
1. The obvious – the role of early movement and return to function
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2. Therapeutic neuroscience education
Pain as epidemic
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Structure specific style – “school for bravery”
Does not work. Bombardier C et al 1997 Cochrane Collab Review 22: 837
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Psychology booklet based
e.g. McClune T et al 2003 Emergency Medicine Journal 20: 514
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Neuroscience/psychology blended style
Neuroscience style
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Neuroscience style education is effective
Increase pain theshholds during physical tasks Moseley GL et al 2004 An RCT of intensive neurophysiology education in chronic low back pain Clin J Pain 20:324 Reduces unhelpful pain related beliefs and attitudes, improves exercise outcomes Moseley GL 2004 Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. Eur J Pain 8: 39 Helps in acute pain states Oliviera A et al A psycho educational video used in the emergency department provides effective treatment for whiplash 2006 Spine 31: 1652
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Pain states in once “mad” people now easily explainable
Mirror pains – an immune response Non zonal spread of pain – smudging Delayed onset post injury – peripheral nerve responses Associated gut, libido, slow healing, memory loss – hypercortisolism Night pain – peripheral nerve Reoccurrence post injury – normal brain based survival response
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Neuroscience/psychology blended style
Neuroscience style
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The twin peaks
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CONCLUSION “The brain story” Petrol Link-up 1994
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The drug cabinet in the brain
David Butler
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