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. 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
1. 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
1.
Multiple brain areas ignite together creating
neurosignatures
2. The specific tissue injured may
not matter for a pain
neurosignature
Pain neurosignatures are
more related to threat
rather than tissue injury
1. Introduction
PAIN
PAIN AS
INPUT
1. Introduction
PAIN
PAIN AS
INPUT
1. Introduction
THREATS
PAIN
PAIN AS
OUTPUT
Thoughts are
nerve impulses
Key elements of the neuromatrix
paradigm
1.
2.
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
1.
2.
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
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
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