The drug cabinet in the brain

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

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. 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. 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) Neuroreport9: 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 2006 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 www.noigroup.com Info @noigroup.com