1. The drug cabinet in the brain
David Butler

2. Aims
present some extraordinary gifts of neuroscience to rehabilitation
introduce therapeutic neuroscience education as a new evidence based management tool

3. The pain sciences revolution
Neuroscience/pain sciences `trendy”

4. Gift 1 – the ion channel
“the molecular targets of rehab”

5. The neurone

6. The ion channel
From Bear et al 2001

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

8. 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

9. Gift 2 – the synapse
“only 100 years old”

10. 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

11. Would this hurt?

12. An astonishing synapse -the dorsal horn

13. Gift 3 – The neuromatrix paradigm
“about 12 years old”
Melzack’s neuromatrix
representation
Maps in the brain
The virtual body
Schema – “body of knowledge”

14. Reflect on the phantom
Butler DS, Moseley GL Explain Pain 2003

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

17. Key elements of the neuromatrix paradigm
Four key points

18. Key elements of the neuromatrix paradigm
Many bits of brain get turned on together

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

20. A possible pain or movement neurosignature
Note:
No one “hub”
Common but will vary
Turned on together
Butler DS, Moseley GL 2003 Explain Pain

21. Key elements of the neuromatrix paradigm
Multiple brain areas ignite together creating neurosignatures
The specific tissue injured may not matter for a pain neurosignature

22. Pain neurosignatures are more related to threat rather than tissue injury

23. 1. Introduction
+ emotions
PAIN
PAIN AS INPUT
Damage and pain

24. 1. Introduction
+ emotions
PAIN
PAIN AS INPUT
Damage and pain

25. 1. Introduction
THREATS
PAIN
danger
PAIN AS OUTPUT

26. Thoughts are nerve impulses

27. 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

28. The neurosignature can be easily modified:
turned up
turned down
ignited by numerous stimuli including mirror neurones

30. 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

32. 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

33. 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

34. Some listeners may be interested in the feet as erogenous zones

35. 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

36. 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

37. So what can we take from these gifts
1. The obvious – the role of early movement and return to function

38. 2. Therapeutic neuroscience education
Pain as epidemic

39. Structure specific style – “school for bravery”
Does not work. Bombardier C et al 1997 Cochrane Collab
Review 22: 837

40. Psychology booklet based
e.g. McClune T et al 2003 Emergency Medicine Journal 20: 514

41. Neuroscience/psychology blended style
Neuroscience style

42. 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

43. 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

44. Neuroscience/psychology blended style
Neuroscience style

45. The twin peaks

46. CONCLUSION
“The brain story” Petrol Link-up 1994

47. The drug cabinet in the brain
David Butler