Slide 1

Pain is in the Brain: Understanding the origins of acquired mechanical deformation and its treatment by manual therapy. This presentation will discuss the origins of pain and two neuroscience based therapeutic approaches for people experiencing pain. The principle concepts to understand for these treatment rationales are: Pain is an output of the brain, and is produced when the brain determines that tissues of the body are in or potentially in danger. Pain is a product of the activation of a neuromatrix signature of a multisystem output unique to the painful person. The approach of these therapies is to reduce inputs that infer tissue in danger, and support the ongoing correction of the pain output. In simplified terms; our goal is to de -threaten the news of difference. (Cocks T, 2011)

Slide 2

Elaine Scarry quotes American poet and pain sufferer Emily Dickinson (1830 - 1886) to emphasize the difficulty of finding language sufficient enough to express the experience of pain. Says Scarry; Physical pain unmakes us; the nature of creativity can re-make us. Pain is unpleasant and no one wants it, but it is an essential part of life. It is normal, protecting us and warning us of danger. (Body in Pain Oxford University Press 1987) People in pain can cry, use quick expressions, gesture and symbolize their pain to solicit help and support in a situation of danger or threat. They involve the hearer and do not allow them the chance of avoiding solidarity. (The Language of Pain, Konrad Ehlich 1985) David Biro author of the book The Language of Pain speaks of Elaine Scarrys work, Scarry starts out with two main premises. Number one, that pain is not merely indescribable but that it actively destroys language, reducing the sufferer to a state before language, to primal screams. The second premise is that pain radically separates the sufferer from the observer of pain. For the sufferer, pain is the prototype of certainty theres no way to doubt that you have pain.

Slide 3

In the SomaSimple essay Consilience, Barrett Dorko wrote; Pain is an output of the brain. Few claims in science are accepted as final, but as evidence piles upon evidence and theories interlock more firmly, certain bodies of knowledge are questioned less often than others. These ascend a scale of credibility from: interesting to suggestive to persuasive to compelling. And given enough time thereafter, obvious. Paraphrased from E.O. Wilsons Consilience: The Unity of Knowledge Lets go from interesting to obvious.

Slide 4

Through metaphor we can traverse doubt and empathize with the certainty of the patients pain. Patients want to know they have been heard and believed. When it is understood that pain is an output of the brain, therapy becomes patient centered. The patient drives the resolution process and the therapist becomes an interactor.

Slide 5

Descartes theorized particles entered tissue pores where nerve tubes filled with threads terminated. Specific threads transmitted the pain to the brain like a bell puller. For centuries pain was thought of as a symptom of disease or correlated with injury and cause. Pain was an input. The twentieth century saw medical advances that allowed for better pain research. Melzack and Wall proposed in 1965 that the dorsal horn of the spinal cord acted like a gate. Flow of various impulses from the peripheral nerves was modulated through three systems to the central nervous system. They also suggested that the amount and quality of pain perceived was determined by many physiologic and psychological variables. Pain is an output.

Slide 6

In 1999 Dr. Melzack published From the gate to the neuromatrix. The Neuromatrix Theory of Pain proposes that; pain is a multidimensional experience produced by characteristic patterns of nerve impulses generated by a widely distributed neural network the body-self neuromatrix in the brain. From the SomaSimple Moderators Consensus on Pain: 1. Pain is a category of complex experiences, not a single sensation produced by a single stimulus. 2. Nociception (warning signals from body tissues) is neither necessary nor sufficient to produce pain. In other words, pain can occur in the absence of tissue damage. 3. A pain experience may be induced or amplified by both actual and potential threats. 4. A pain experience may involve a composite of sensory, motor, autonomic, endocrine, immune, cognitive, affective and behavioural components. Context and meaning are paramount in determining the eventual output response. 5. The brain maps peripheral and central neural processing into each of these components at multiple levels. Therapeutic input at a single level may be sufficient to resolve a threat response. 6. Manual and movement therapies may affect peripheral and central neural processes at
6

various stages: - transduction of nociception at peripheral sensory receptors - transmission of nociception in the peripheral nervous system - transmission of nociception in the central nervous system - processing and modulation in the brain 7. Therapies that are most likely to be successful are those that address unhelpful cognitions and fear concerning the meaning of pain, introduce movement in a non-threatening internal and external context, and/or convince the brain that the threat has been resolved. 8. The corrective physiological mechanisms responsible for resolution are inherent. A therapist need only provide an appropriate environment for their expression. 9. Tissue length, form or symmetry, are poor predictors of pain. The forces applied during common manual treatments for pain generally lack the necessary magnitude and specificity to achieve enduring changes in tissue length, form or symmetry. Where such mechanical effects are possible, the clinical relevance to pain is yet to be established. The predominant effects of manual therapy may be more plausibly regarded as the result of reflexive neurophysiological responses. 10. Conditioning for the purposes of fitness and function or to promote general circulation or exercise-induced analgesia can be performed concurrently but points 6 and 9 above should remain salient.

Slide 7

Dr. Ron Melzack

Dr. Lorimer Moseley

Dr. V.S. Ramachandran

Diane Jacobs PT

Barrett Dorko PT

David Butler PT

The neuroscientists and manual therapists of pain. Ron Melzack: Neuromatrix of Pain. Lorimer Moseley: Pain education, Rubber hand. Ramachandran: Phantom pain, Synaesthesia. Diane Jacobs: Dermoneuromodulation. Barrett Dorko: Simple Contact, Ideomotion David Butler: The sensitive nervous system, Neurodynamics.

Slide 8

The actual mainstream paradigm for manual physical therapy in the treatment of pain mostly relies on a biomechanical model. F. Wellens (2010)

Biomechanical model for pain

Neurophysiological model of pain

As manual therapists we are most able to help patients resolve pain originating from mechanical deformation and chemical irritation by encouraging movement that decreases threat signals. We must integrate knowledge of neuroscience, endocrinology, immunology as well as biomechanical contributions of the physiology of pain if we are to succeed in threat resolution.

Slide 9

Immune contribution to pain

Endocrine contribution to Pain

Vascular

Lymphatic

Signs of adverse neural dynamics are : increased sympathetic tone (apical breathing), reduced range of motion (defense), reported pain, fatigue, and edematous, cool limbs. Diamond and Tracey in Mapping the Immunological Homunculus conclude, It is interesting to consider that in addition to defending the host from infection, the immune system functions as a sensory organ that transmits information in real time to the central nervous system about the tissue response to injury and infection. This presents important possibilities for understanding fundamental mechanisms that maintain physiological homeostasis. Progress in this field is all but certain to reveal the identity of other circuits that reflexively regulate the immune system and to produce maps that will guide understanding of the neurological basis of immunity and physiology. (Diamond B, Tracey KJ Mapping the immunological homunculus PNAS 2011.)

10

Slide 10

The maps for body-self. These maps are malleable and do change depending on use. They are particularly susceptible to change caused by chronic pain. Lorimer Moseleys work on visual cues and pain, limb lateralization and graded motor imagery work are based on these somatosensory and motor cortex maps. Antonio Damasio said in the book Descartes Error, Were it not for the possibility of sensing body states that are inherently ordained to be painful or pleasurable, there would be no suffering or bliss, no longing or mercy, no tragedy or glory in the human condition."

11

Slide 11

The brain possesses instinctive mechanisms for the resolution of danger signals: withdraw, protection, and resolution. It can ignore or over-ride danger signals in situations of extreme peril, by inhibiting pain output through descending modulation conducted mainly by the noradrenergic, serotonergic, and opioidergic systems (Neuroanatomy Research Advances, 2010), cognitive behavior modification, and movement.

12

Slide 12

Moseley 2007

In Reconceptualizing Pain, Moseley argues that the biology of pain is never really straightforward, even when it appears to be. It is proposed that understanding what is currently known about the biology of pain requires a reconceptualization of what pain actually is, and how it serves our livelihood. There are four key points: (i) that pain does not provide a measure of the state of the tissues; (ii) that pain is modulated by many factors from across somatic, psychological and social domains; (iii) that the relationship between pain and the state of the tissues becomes less predictable as pain persists; and (iv) that pain can be conceptualized as a conscious correlate of the implicit perception that tissue is in danger. It is now known that as nociception and pain persist, the neuronal mechanisms involved in both become more sensitive, which means that the relationship between pain and the state of the tissues becomes weaker and less predictable. Moseley 2007

13

Slide 13

Central nervous system and peripheral nerves carefully dissected out. This brain is most metabolically demanding organ in the body 2% of body weight but 20% of O2 use and high glucose demand which can cause everything from confusion to convulsions if it drops too low. This is the narrator stripped of the story. When we interact with another human being it is this delicate, complex system that we wish to observe. The CNS has a lot to teach the manual therapist who cares to understand it.

14

Slide 14

Nociception literally means danger reception. Nociceptive neurons each have a repertoire of different functional phenotypes *chemical, thermal, or mechanical+ that are elicited by different tissue conditions. Those conditions include the various stages and intensities of inflammation, neuropathic injuries and metabolic disease, or regeneration and healing to provide optimal neural functions and tissue integrations for each of those conditions (Bonica 2001). Mechanical deformation and compression alters the nerve impulse by slowing it or stopping it. This can be interpreted as a danger signal but it is not pain until the brain says it is.

15

Slide 15

The Sensitive Nervous System: David Butler PT, Clinical Neurodynamics: Michael Shacklock PT
Photo: Dr. Alf Breig

This is a macro view demonstrating the increased neural tissue tension Dr. Alf Breig found during cadaver studies. The clinical implications of adverse neural tension can be a worsening of symptoms. In 2008 Barrett Dorko wrote; Self-correction as expressed in ideomotor activity is inherent to life, not just to those moments we experience as painful. In my experience, the speed is commonly quite slow and the direction and range unrelated to the relief gained. It follows that we should remember that pains intensity or persistence secondary to an abnormal neurodynamic is unrelated to the amount of nervous tissue recruited or the direction of the strain.

16

Slide 16

Dermo is through the skin. Neuro pertains to neurology. Modulation is the process of varying properties or conditions. The DNM system concentrates on the cutaneous nerves. All treatment concepts that apply to peripheral nervous tissue in the skin also apply to the larger nerves and the spinal cord. (Jacobs, 2007)

17

Slide 17

The skin is the brain exposed. Derived from the embryonic ectoderm, the skin is the largest sensory organ of the body. Why skin stretch? DNM addresses mechanical deformation in the cutaneous nerves, helps reduce threat signals to the brain through non-nociceptive pathways, addresses defense resulting from the protective phase of pain experience, and elicits the characteristics of correction through descending neural modulation by delivering lateral stretch and novel stimuli.

18

Slide 18

Images: Diane Jacobs PT Dermoneuromodulation Manual (2007)

Vancouver physiotherapist Diane Jacobs wrote the DNM manual in 2007. She has since shared it with many therapists all over the world. From Grays Anatomy, The skin forms a self-renewing and self-repairing interface between the body and its environment, and is a major site of intercommunication in both directions between the two. Can this be overstated? I don't think so. In a treatment encounter, WE are the environment that the patient's skin is trying to communicate with. We should make an effort to listen. (Jacobs 2006)

19

Slide 19

Photo: Diane Jacobs PT Used with permission

The next three slides demonstrates sub-cutaneous innervation of the arm and forearm. Diane painstakingly dyed the nerves black to make them more visible.

20

Slide 20

Photo: Diane Jacobs PT Used with permission

The cutaneous nerves are often lost when the skin is removed to reveal the muscles. Diane took pains to discover the orientation of the sub-cutaneous skin ligaments that the nerves move through to reach the surface of the skin.

21

Slide 21

Photo: Diane Jacobs PT Used with permission

Diane writes in the DNM manual that the treatment rational for DNM includes providing the nervous system with novel stimuli to assist its *the CNS+ function, an approach consistent with neruodynamic theory and the pain neuromatrix. I think a good case could be made that all forms of manual therapy are neuromodulatory in their effects, and since no one takes the skin off a patient prior to treatment, all manual therapies are dermo as well.

22

Slide 22

Source: Kahle, Color Atlas of Human Anatomy, Vol. 3 2003 Thieme

Target areas that contain high distributions of cutaneous innervation are ideal for DNM. Some patients are hypersensitive and working in zones peripheral to reported area of palpated tenderness is effective in reducing threat signals remotely.

23

Slide 23

Diane Jacobs PT 2010 Used by Permission

Ruffini Endings: Discovered by Angelo Ruffini, 1891 first written up in 1894 19% of ALL fibers are slow adapting Type II, attached to Ruffini endings (Melzack, Wall), elongated spindle shaped (Purves 2001) Found in the dermis of thin hairy skin (Purves) Respond with indent pressure of 200 micra (Melzack, Wall), have a wide receptive field (Encyclopedia of the Human Brain) Function as dermal stretch receptors: fire continuously to lateral stretch of the skin, exhibit directional preference (Melzack, Wall 1996 and Johansson, Vallbo 1979) Contribute to proprioception (Proske, Gandevia 2009) ARE NOT NOCICEPTIVE

24

Slide 24

Drawing: Diane Jacobs PT Used with permission

The following two slides demonstrate the balloon technique used to perform DNM as drawn by Diane. Lateral traction in the skin is preferred over downward grasping pressure.

25

Slide 25

Drawing: Diane Jacobs PT Used with permission

Part two of Dianes balloon technique notes. Sometimes it is prudent to work at a distance from the tender areas. DNM shares with Simple Contact the characteristics of correction. As the threat reduces nerves get oxygen and nutrients, deformation and defense are decreased, and warming, ease, softening and surprise are revealed.

26

Slide 26

Drawing: Diane Jacobs PT Used with permission

Demonstration of the principals of the balloon technique with a balloon. Another exercise is to have more than one therapist, each holding a hand on theirs and the others balloons to experiencing the simulated sensations of tissue movement. Another way to describe the action is like gathering a handful of sand with your fingers open.

27

Slide 27

Barrett Dorko PT quote: The novelist and poet John Updike wrote of pains ability to isolate us: Pain shows us what seriousness isAnd shows us too, how those around us cannot get in; they cannot share our being.

In short, people in pain are alone in some way, and, if the pain is chronic, they might even get the sense that they have been cast away, and cannot find help anyplace but within themselves.
Ironically, as the social commentator Ivan Illich observes, Our personal experience of pain is now shaped by the therapeutic program designed to destroy it. If this is true, and I believe it is, the time and conditions necessary to learn what pain might teach us, what it might ask us to create, are rarely present in a typical therapy setting.

SIMPLE CONTACT: Simplifying Manual Therapy Simple Contact is: Therapeutic technique that elicits the expression of ideomotor movement and the characteristics of correction.

28

Slide 28

The Neuromatrix Simplified

Lets take a step back and return to the neuromatrix before examining Simple Contact. Mechanical Pain Science: Contemporary pain theory as advanced by Melzack and Wall holds that movement and pain are inextricably linked as two cortical outputs of the same multisystem process. Professor Wall has suggested that pain needs to be resolved through an appropriate motor response, in the context of this same neuromatrix theory. This motor output, Wall suggests, should come from an instinctive source, as part of the neurophysiological mechanism for pain resolution. In fact, according to Wall, pain has a corresponding motor response needed for proper resolution. Once the brain decides that there is tissue in danger, something need to be done. Remember that the brains opinion regarding the presence of danger might be erroneous. (Dorko 2009)

29

Slide 29

The Need State

Barrett Dorko PT: Patrick Wall says that pain may be likened to a "need" state, like hunger, or thirst. They motivate us to eat or drink; consummatory acts that, theoretically, would be most appropriately performed instinctively - not that the culture encourages that. Of course, eating and drinking wont alter pain; movement will. Wall states that there are three instinctive responses to danger signals. These are what we must consume or the sensation and posture will remain. These occur in sequence Withdrawal, Protection, Resolution. They are active movements and, being instinctive, nonconsciously directed. It appears that we most commonly see the patient paused in the second stage. The last stage of correction, what Wall calls resolution, is commonly inhibited prior to its full expression by misinterpretation, coercion, the judgment of others, the fear within the patient, insistence that we pose and posture whenever possible and a lack of interoception. Therapists can change all of that.

We change by permitting. The position doesn't matter; what counts more, by my reckoning, is that the patient is free to move. Perhaps sitting or standing, but ask them what they would prefer; after all, we do an awful lot of ordering patients around into positions - it makes a pleasant change that they can choose for themselves. (Nari Strange, Soma Simple 2006) Ideomotion can be described as instinctive, automatic expressions directly coupling dominant mental representations to action without intermediary volition. Ideomotor theory suggests that motor patterns can be automatically and intimately associated with their internal and external sensory effects, and will occur in the absence of any other cognitive representation or efferent motor command. Although ideomotion has been commonly associated with non-volitional movements, ideomotor theory also provides a compelling explanation for the generation of goal-oriented voluntary actions. During ideomotor movements the sensory effects, such as the kinaesthetic and interoceptive sensations that may accompany each movement, are directly coupled with the generation of the movement itself . Thus a kinaesthetic representation of a position that may be associated with reduced pain sensation, or stretch of a stiffened tissue, will be automatically coupled to the movement that produces the represented sensation. (Luke Rickards et al. 2007)

30

Slide 30

Photos 1-4: Barrett Dorko PT Used with permission

Every position has its advantages and disadvantages and I swear I don't work with my patients in any sort of sequence. It's also important to remember that the characteristics of correction take precedence over the movement you can easily see. (Dorko SomaSimple 2006) I also found very early on that a lot of explanation is not necessary to illicit the movement, although it may be useful later on. (Rickards Soma Simple 2006) Belly Ball, In that moment before he releases it our eyes meet and I feel it again. Something passes between us and its not the ball. He has a manner and way of looking at things that all of my other holders dont quite have. (Dorko 2011) What it looks like, Ive gone to where the patient spends his day in his chair. There he deals with discomfort altered by position and that tiny bit of history is all I need to begin. (Dorko 2011) Vermeer: Even my most beautiful days sometimes seemed to me like the Vermeer painting of the town of Delft on a summer afternoon, where, above the still spires and shimmering river, the clouds hang oppressively low, and gloom and mortality press. (The Pain Chronicles, Melanie Thernstrom) Magic isnt actually about making things appear, its about removing a secret cover. Then I show them the cover and how I remove it. I say, Theres a stronger, safer and more confident walker in you, and together were going to uncover them. Let me show you how. (Dorko 2010)

31

Slide 31

"I thought, the way you solve a problem in biology is you solve its simplest representation. (Eric Kandel, Nobel Prize winner) Frederick Nietzsche said, To trace something unknown back to something known is alleviating, soothing, gratifying and moreover a feeling of power. Danger, disquiet, anxiety attend the unknown-the first instinct is to eliminate these distressing states. First principle: any explanation is better than noneThe cause-creating drive is thus conditioned and excited by the feeling of fear

32

Slide 32

Barrett calls these questions The Vitals of Pain. This is the name he gave to five aspects of the patients presentation that he feels are essential to know and understand in order to proceed with evaluation and care. Visual metaphors have the power to bridge understanding where none exists or when there is a difficulty of language. The five questions were developed to timely seek concise relevant and information on the status of the sympathetic nervous system. The sympathetic system revealing the characteristics of adverse neural tension or defense most likely correctable through instinctive movement.

33

Slide 33

Barrett wrote in the essay Beaten on the Drum, These days I try to land on my patients as if I were a bird, and they the ocean. Im not kidding. They are driven to a wide range of expressive movement by an internal weather they both create and endure. I navigate as I can, but once I touch, the manual therapy is pretty much over and the active movement therapy becomes increasingly dominant. From The Matrix and Me Barrett said, I offer my students an arresting and perhaps startling vision of normal function, principally by introducing them to ideomotor movement. Having never before seen this, the therapist is suddenly confronted with a world of therapeutically useful movement they hadnt known existed. Once shown how to elicit it, they find that alterations in painful function may rapidly and unexpectedly occur without any real effort on the part of the patient or therapist (Ive watched this happen in my clinic and at workshops for over twenty years so I say this with a great deal of confidence). Faced with this, many therapists are initially confused and then thrilled with their newfound skills, to say nothing of what theyve just discovered about their patients ability to improve.

34

Slide 34

Barrett from the essay On the day that one of Andy's men died; I speak to my classes about something our patients are hiding just beneath their surface. This is a motion that will help them but at the same time makes them conspicuous. If they are hesitant to express it maybe we need to understand that this is not only because of the way our culture looks upon it but also that evolutionary forces have driven them to hide it. In my experience, therapists arent any less affected by this, and when I ask them to speak aloud before others they typically become as still as a tree sloth in the Amazon. Theres survival in this, but I rather doubt theres much health.

35

Slide 35

It has been my journey since I was in school to understand pain and I am still learning. My personal story is a friend with a brain injury and a desire to help her overcome chronic pain. The generosity and compassion of the contributors at SomaSimple have shared most what you have learned here today. It is my hope you will be intrigued and spurred to learn more so you may turn complicated to complex and simplistic to simplicity as you interact with your patients.

36

Slide 36

Conclusion: what resolution looks like.

The bottom line is that we have to be exceptionally imaginative when it comes to pain or else it will remain incommunicable and invisible, not only for the sufferer but also for friends and doctors trying to help. (David Biro, The Language of Pain, 2010)

37

Slide 37

Scarry Elaine, The Body in Pain, Oxford University Press 1987 Ehlich Konrad, The Language of Pain, Theoretical Medicine 6 (1985) pp. 177187 Moseley G. Lorimer, Reconceptualizing pain according to modern pain science Physical Therapy Reviews, Vol. 12, No. 3. (September 2007), pp. 169-178. Cocks Tom, Body in Motion, 2011 Bonica Management of Pain, Lippincott Williams & Wilkins; Fourth edition 2009 Wellens F, The traditional mechanistic paradigm in the teaching and practice of manual therapy : Time for a reality check. Diamond B, Tracey KJ, Mapping the immunological homunculus PNAS 2011 Damasio Antonio, Descartes Error, Harper Collins 1995 Neuroanatomy Research Advances (Neuroanatomy Research at the Leading Edge) Nova Science Publishers Inc., 2011 Moseley G. Lorimer, Reconceptualizing pain according to modern pain science Physical Therapy Reviews, Vol. 12, No. 3. (September 2007), pp. 169-178. Bonica's Management of Pain, 4th Lippincott Williams & Wilkins, 2010 Melzack Ron, Pain and the Neuromatrix in the Brain, Journal of Dental Education, Volume 65, No. 12 2001 Moseley G. L., A pain neuromatrix approach to patients with chronic pain, Manual Therapy (2003) 8(3), 130140.

References: For further reading visit http://www.somasimple.com

38

Slide 38

Melzack Ron, Pain and the Neuromatrix in the Brain, Journal of Dental Education, Volume 65, No. 12 2001 Moseley G. L., A pain neuromatrix approach to patients with chronic pain, Manual Therapy (2003) 8(3), 130140. McCarthy Sam, Rickards Luke D., Lucas Nicholas, Using the concept of ideomotor therapy in the treatment of a patient with chronic neck pain: A single system research design, International Journal of Osteopathic Medicine 10 (2007) Wand Benedict M., OConnell Neil E., Di Pietro Flavia, Bulsara Max, Managing Chronic Nonspecific Low Back Pain With a Sensorimotor Retraining Approach: An Exploratory Multiple-Baseline Study of 3 Participants, Physical Therapy Volume 91 Number 4 April 2011 Nijs Jo, Van Houdenhove Boudewijn, Oostendorp Rob A.B., Recognition of central sensitization in patients with musculoskeletal pain: Application of pain neurophysiology in manual therapy practice, Manual Therapy (2010) Jacobs Diane Canadian Physiotherapist, http://humanantigravitysuit.blogspot.com/ Dorko Barrett American Physiotherapist, http://www.barrettdorko.com Henderson Roderick Pain and Orthopedic Physical Therapy 2011 Lewis Jennifer S., et al. Wherever Is My Arm? Impaired Upper Limb Position Accuracy in Complex Regional Pain Syndrome. In PAIN. June 2010. Vol. 149. No. 3. Pp. 463-469. Biro David, The Language of Pain, WW Norton, 2009

References:

39