Sunday, November 18, 2007

Structure vs. Function - Part III

Why this debate should matter to you - the therapist and the patient.

The search for structural faults that are causing pain is still going on.
And it'll continue to do so.
I think it has do do with basic human psychology - we have this need to put labels on everything we see. Our brains want easy explanations - all the time.
Our brains produce visual (and other) illusions because they are hardwired to resolve every computational problem they encounter.

They are not computers running Windows; they can't just crash - they have to continue functioning - even if that means finding patterns in meaningless noise (pareidolia, conspiracy theories, astrology).

So where do you - the patient come in?
Well - your expectations are shaped by this mechanism. You want answers when you consult a health care professional. And those answers better fit your view of the world - or else!

Structural faults like ruptured discs, degenerated vertebrae, pulled muscles are easy to put a finger on - just think of an MRI scan that shows a bulging disc. What's easier then to show you - the patient in pain - that picture and explaining that that bulge causes all your problems. And since an operation could clear that right up you could be pain free again in a week or so.
It's convenient, easy, convincing - and even fits the symptoms sometimes.

Now compare this to a more functional explanation - with or without the scan if you like.
The doctor would explain to you that yes - there is a bulge - but it could be an old one you've had for a year already (without symptoms) - and that the reason you are in pain now is that your brain "has decided" to produce a painful sensation because of some factor that could be biological, social, psychological or all three.

His advice is to keep active, distract yourself as much as possible and adjust your daily life accordingly and check back in one or two weeks if things don't get worse.

Which would you rather pick?
Exactly - option one is simple the better sounding one. Until you had the operation of course and the pain is still there.

That's not to say that all operations are for nothing. But even orthopedic surgeons have started to admit over the past few years that the outcomes weren't that great in cases where the main reason for an operation was pain as a symptom.
Long term studies show that the outcome over the long run is even the same compared to conservative care.
This goes for spinal surgery and other kinds too (think osteoarthritis of the knee).

Pain - like it or not - is in your brain!
It always is - and always will be. It's an emotion like anger, fear, love and all the others. And like all the others it's being put together according to the circumstances you find yourself in.

So if you change the context - you can change the pain - your pain.

Some methods and influencing factors I already have described in my Pain for Dummies Series.

Here are a few more:

- Kinesiotape: How does it work? It's all about low-level cutaneous neural system input - or "grooming" as it's known in primate circles. Have you ever seen chimpanzees grooming each other? That's what kinesiotape does. And if you can honestly say that you wouldn't like to be groomed for a few hours each day you are a liar!

- Feldenkrais: that guy was a genius. Simply brilliant! He recognized that the brain is plastic and likes to learn. That's what happens when you do those exercises - your body learns how to move more efficiently. It's all about feedback and re-programming better motor patterns. When I say Feldenkrais I also mean all the other offshoots his work created: Somatics (faster, shorter - equally cool), Alexander Technique, Rolfing, Yoga, ...
And of course - when you try new movements you have to concentrate a lot - distracting yourself - again.

- Meditation: training how to calm "the mind" - to get the same level of control over your "mental muscles" as over the ones you exercise in the gym.

Atmospheric Re-entry

- Feedback therapies: Mirror Box for CRPS, Phantom Limb Pain and the like. Tactile input for parts of your body you can't see - like our back. And auditory training for tinnitus.

- Redcord: we use this device in our clinic and I have to say it's phenomenal! There simply is no faster way to re-program motor patterns.

- Motor imagery: works. Close your eyes and work out at the same time. Mentally rehearse things that you have to do every day and try to make them more efficient.

- Neuromatrix training: read the blogs - mine, David's and Diane's.

- Educate yourself: the 20th century is over. The expansion of the Internet puts the worlds knowledge at your fingertips (otherwise you wouldn't be reading this!). The more you know about yourself the better off you are.

- Give back: there's nothing like sharing what you have learned or experienced with the rest of the world. By putting your thoughts into words you go over the experiences again - putting them into proper perspective. The only thing you can do wrong is not doing it.


dermoneuromodulator said...

Hi Neurotopian,
Can you tell me how the redcord slings feel? What they are made from? Do they 'grip' the skin somehow or are they just regular canvas type material?

Matthias Weinberger said...

I'd say canvas is close. But think more in terms of "plastic canvas" - I guess they put some special coating over the material to make it more resistant to everyday use.

jeisea said...

I just discovered your fantastic blog is in English. Thank you so much for this. I'll be reading all your posts.

I notice here you mention mirror therapy for crps. I have crps and I know MVF does work. I also recently discovered that it works for other pain very well. I treated what I thought was a single sided face/head problem with a hinged twin makeup mirror. It got rid of the pain very effectively but when I stopped the pain returned. I kept this up for a few months and only ended up going to a dentist just in case it was something else causing the pain. Turned out to be an abscess and as I neglected it so long I lost a tooth. Mirror therapy is very effective for pain other than CRPS. I now know if the pain returns as soon as I stop MVF then I need to look for another cause.

I've been using mirror therapy for over 12 months now with fantastic results. From intractable whole body pain, I can now identify pain from other causes and identify mechanical issues and address these. I think I am winning the battle. It is thanks to the help and advice of therapists and researchers such as yourself. ( I do remember you said once you are not interested in research). You have helped me understand the new brain science, in particular the need to keep the experiences fresh and interesting. To that end I have supported MVF with laser acupuncture, meditation, aromatherapy etc.

What you suggest works. It's drug free and non invasive. I thank you so much.

I would like your permission to place a link to your blog on mine and highlight some of your posts.

Matthias Weinberger said...

Hi Jan!

Good to hear from you again.
Yes - I decided to write most of my posts in English after all.
I will continue switching between German and English however. ;-)

I've just finished writing the drafts for an eight-part series about Mirror Box Therapy which will start in the next few days.

Personal experiences like yours are incredibly valuable to me because only the person who has the pain can tell me and others what works best. So keep the comments coming.

I will include a resource page in the Mirror Therapy series and will mention your blog too.

Feel free to link to my articles as much as your heart desires! ;-)
Between us and others who are networking and sharing I'll bet we will be able to beat chronic pain in no time. ;-)

jeisea said...

Hi Matthias
Thank you for encouraging me to share. You may not be aware that we voted in a new government this weekend. I am so confident of the decency and commitment to change of this government that I intent to begin with my local member and work my way up to the new (to be decided) minister for health and possibly Kevin Rudd, the new Prime Minister. I got an email from David Butler in which he says money is not provided for research into mirror therapy. No profit in it. The potential saving in suffering but also in economics is massive. As you've said in one of these posts, it is virtually free and a person can do it themselves at home with any or a variety of mirrors.

I don't want to go to my local member just with a suggestion. I want to show the science and present my case compellingly. To that end I am hoping I may put something together and perhaps run it by you.

The reason for research I feel is not to prove that it works. Mirror therapy does work without question. However I am aware of therapists who have been to conferences and still come away unconvinced. I have seen others who think that "it works for some". People who are so rigid in their thinking that they need to see the undeniable scientific proof. I want our government to fund the research to get the proof and then more for education.

Again thank you for telling it like it is in this blog. It is a refreshing and inspiring read. Oh and I love your artwork.


Matthias Weinberger said...

I will start my series on Mirror Box Therapy soon and there will be one posting that consists of links to websites, videos,.. - I will also put the most relevant articles in there. Feel free to use that in your presentation!

The more people know about this stuff the better.

I'm also thinking about contacting the people at Walter Reed to get some more inside information.

By the way: some more great pictures are on their way as I have several photoshoots lined up!

Anoop said...

Great blog.

I come from a sports background and was really intersted in your injury comment and how you have to stregthen the tissue, but more importantly, retrain the movement and propiorecption.

I would love to hear a practical example of how you would reeducate after an ankle injury for ex or a hamstring injury.

Also, if you noticed, in Butlers book he talks about how reccurence of injury whichis really interestin.Butler talks abt how reccurent pain are often protective. He says " if you have reccurent pain for many years, each reccurence does not mean you have reinjured that muscle, joint, or nerve. It makes more sense scientifically to conclude that recurrences occur because some cue or set of cues has been sufficient to activate the virtual representation of the old injury".


Matthias Weinberger said...

"I would love to hear a practical example of how you would reeducate after an ankle injury for ex or a hamstring injury."

Well - as soon as full weightbearing is possible we start out with walking on level surfaces - forwards, backwards, sidestepping, etc. - after a while we introduce unstable surfaces.

If the patient can handle that we start jumping - first unto a stable surface again - and progress to unstable surfaces.

Once the patient is able to do that we add distractions - throwing a ball for example during the jumping.

I guess there are a thousand different ways to do this - but as a lot of studies suggest injury prevention (especially in contact sports) requires coordination and proprioception. The American Journal of Sports Medicine and others have published studies where they introduced proprioceptive training and the injury rates went down dramatically.

For hamstrings I find eccentric exercises to be the most beneficial to re-train motor control. Progression is done by varying the speed of the exercise.

Yep - David is spot on in my opinion. That's why when you have the flu for example you didn't hurt your back again - the "memory" of the old injury just comes back.
I will post about this one day.