NOI Group - Pain, Plasticity, and Rehabilitation

The latest NOIgroup (Neuro Orthopedic Group) newsletter includes some great clinical reviews of Graded Motor Imagery work out in the clinics.

http://noinotes.wordpress.com/2012/10/24/learning-from-the-shadows/

Also, have a look at this 2-day seminar/workshop being hosted by NOI (Brendan Haslam, David Butler) in Melbourne this November.

http://www.noigroup.com/documents/noi_ppr_course_flyer_bh_2012.pdf


This lecture, practical and interactive course is about developing management strategies for the neurological patient with pain. It will help you to understand how the pain system works, the notion of pain as an output, and how this fits with neurological diagnoses/conditions. The relationship of pain to other homeostatic and response systems such as the immune and endocrine systems, cognitions and language will be introduced.

We know from research that neurological populations (such as Stroke, Spinal Cord Injury, Parkinson’s Disease and Multiple Sclerosis) experience higher incidences of chronic pain than that of the neurologically intact population. The addition of pain compounds the already disabling effects of the neurological condition, 
causing greater functional difficulties in task performance. Despite this, clinical guidelines remain consistently vague with regards to recommendations as to how to address this significant problem, and it is too often neglected in patient care.

This course will cover assessment and management strategies for this population, utilising strategies such as graded motor imagery, sensory retraining, neuroscience education and neurodynamics. You will learn how to utilise these strategies to influence pain and other outputs as appropriate, develop ideas of progression, and, importantly, learn how these fit within the rehabilitation model utilised in neurological rehabilitation, in both the acute and long-term setting.

Course aims
1. To introduce the concept of pain as one of many output systems that may be perturbed in neurological patients.
2. To expand the clinical framework of neurological rehabilitation to incorporate pain rehabilitation, via the paradigms of neuromatrix and pain mechanisms.
3. To reconceptualise pain in terms of modern neuroscience and philosophy.
4. To introduce an array of established and novel treatment strategies targeting the neurological patient with pain, based on clinical reasoning and evidence from clinical trials and neurobiology.
5. To introduce the role of education in effective pain treatment, based on current research.

Course Programme – Day 1
• Pain in the Neurological Population: incidence, classification and impact
• Biopsychosocialism and use of paradigms
• The output and homeostatic pain mechanisms
• Nociceptive, Neuropathic and Neuroplastic Pain: What does it all mean?
• Making sense of Peripheral and Central Sensitization

Course Programme – Day 2
• Graded Motor Imagery: “Sliding under the radar”
• Therapeutic Neuroscience Education: “Taking the threat out of pain”
• Facilitating Representational Change 1: Utilisation of Sensory Retraining in treating pain 
• Facilitating Representational Change 2: Incorporating Neurodynamics into Sensory Retraining to influence outputs

All I can say is that I want to be at the next one of these that is run, and I hope someone else reading this might want to go too.  

Review of Conference with Moseley and Hodges on Pain and Motor Control

A great post by Todd Hargrove on a talk by Lorimer Moseley he recently went to in Portland.
http://www.bettermovement.org/2012/review-of-conference-with-moseley-and-hodges-on-pain-and-motor-control/

A short excerpt...
Before the brain creates pain on the basis of nociception, it will essentially ask a key question: how dangerous is this really? To answer that question, it will consider many different kinds of inputs, which can be divided into four basic categories:

1. proprioception (information from joints, muscles, tendons and skin about the positions and movements of the body parts)

2. interoception (information from nociceptors about the thermal, mechanical and chemical condition of the tissues)

3. exteroception (the five senses)

4. cognition (knowledge, memory, feelings, perceptions, belief, logic, attention, expectation, etc.)

If the brain processes the different inputs and concludes that some form of protective action is necessary, it can choose between several different kinds of protective outputs, such as pain, immune responses (e.g inflammation) or protective movements such as flinching, limping, muscle guarding, stiffness and other motor control changes. (Now which kind of protective output would you rather have, movement or pain?)

One important point to consider is that any output will almost immediately become a new input into the system. For example, a protective movement will modify the proprioceptive and exteroceptive inputs to the brain. Pain will create new thoughts, feelings and knowledge about dangers to the body. Inflammation will sensitize nociceptors. And so new outputs are created which then immediately become inputs again.

The point is that this is an incredibly complex and dynamic system that loops back on itself every second in an unpredictable and inherently personal and individualized manner.

Our Words Can Really HURT

Following from the last post...
Lately I have really been thinking hard about what David Butler, PT has been speaking of for a long while now.  The idea of therapists' crucial role as linguists - how we speak to our patients and how we speak to each other.  Our words are essential tools in educating and providing therapeutic value.  Thoughts are nerve impulses that affect the neurochemistry  within our nervous system.  The words we use affect how our patient's think/believe/feel about their pain states. 

http://forwardthinkingpt.com/2012/10/18/our-words-can-really-hurt/

The Problem with MRI's

An excellent post from the Better Movement (Todd Hargrove) blog.

http://www.bettermovement.org/2012/the-trouble-with-mris-and-my-brother/

Though undoubtedly an important diagnostic/imaging technique that can be useful...

"many studies have shown that almost no matter where you point an MRI on a body, you can find something wrong there, even parts that are completely free of pain."

"many doctors assign too much importance to abnormal findings on an MRI. There are several recent articles discussing this."

"the problem is that ”finding out what is in going on the tissues” can really scare people about the condition of their body, which can make pain and disability worse. "

Very important for patients and therapists to think about, huh.

"MRIs are obviously useful and sometimes completely necessary tools that can be used to accomplish a great many good things. But like any tool, they can be abused, and it seems that there is currently an epidemic of MRI abuse."

The Amazing World of Psychiatry: A Psychiatry Blog

Well,  just when you think you have too much interesting material to read, along comes another great blog...

http://theamazingworldofpsychiatry.wordpress.com/

A recent post ("Building a Model of the Insular Cortex") gets into the features and facets of our insular cortex, the part of the brain that is involved in integrating sensory information as well as appearing to play a significant role in emotions.

http://theamazingworldofpsychiatry.wordpress.com/2012/10/15/building-a-model-of-the-insular-cortex-part-2/

Manual Therapy in a Neuroplastic World

An excellent summary of David Butler's concepts ("Manual Therapy in a Neuroplastic World"), written by Erson Religioso III, on his blog...

http://www.themanualtherapist.com/2012/10/manual-therapy-in-neuroplastic-world.html

Very much worth reading through.

Explaining the idea of a manual therapist being a:
1) biopsychosocialist
2) brain reinhibitor and sculptor
3) immunotherapist
4) linguist

As always, read on...