The drug cabinet in the brain David Butler www.noigroup.com

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

The pain sciences revolution Neuroscience/pain sciences `trendy”

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

The neurone

The ion channel From Bear et al 2001

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

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

Gift 2 – the synapse “only 100 years old”

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

Would this hurt?

An astonishing synapse -the dorsal horn

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

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

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

Key elements of the neuromatrix paradigm Four key points

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

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

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

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

Pain neurosignatures are more related to threat rather than tissue injury

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

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

1. Introduction THREATS PAIN danger PAIN AS OUTPUT

Thoughts are nerve impulses

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

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

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

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

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 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

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

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

2. Therapeutic neuroscience education Pain as epidemic

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

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

Neuroscience/psychology blended style Neuroscience style

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 2006 A psycho educational video used in the emergency department provides effective treatment for whiplash 2006 Spine 31: 1652

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

Neuroscience/psychology blended style Neuroscience style

The twin peaks

CONCLUSION “The brain story” Petrol Link-up 1994

The drug cabinet in the brain David Butler www.noigroup.com Info @noigroup.com