NOI Notes

Reaching everyone through a blog isn't easy. So for about 6 months now I've been writing a monthly newsletter along with my noigroup team which discusses lots of different topics - making them relevant to both the patient and clinician.

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The newsletter comes out each month and is stored away afterwards in the archive of NOI NOTES if you're interested in some of the previous topics.

Calming therapeutic neuroscience narrative 2. “Zings and zaps from nerves”.

There are many odd pains and sensations that people experience where the strangeness may evoke more stress and maybe even more pain. A fairly common one is where damaged peripheral nerves “fire” at odd times. This is a feature of abnormal impulse generation in nerves, researched extensively by Patrick Wall, Marshall Devor and colleagues.

It seems to happen when a nerve is mechanically stretched or pinched though not every time, which makes it more stressful when it happens. A common one is when a person puts their neck back and they get a shock like zing. Sometimes people get a zap in the front of their hip when they walk and clinicians who examine the physical health of nerves in patients will be aware of the occasional sharp zings when they perform assessment techniques such as a Straight Leg Raise or Upper Limb Neurodynamic Test.

Noone likes zings and zaps and if it happens a few times, it is only natural that the person will avoid that movement and change their posture. In most cases, zings and zaps are not serious indicators of disease or serious trauma and with some explanation and some exercise of neighbouring tissues, the zings and zaps may well just go.

“Its just your body reporting in” may help some.

But what about the muscles and joints?

Thankyou for your emails about “words that hurt”. A continuing discussion and a source of angst for some readers is the role of body tissues in a chronic pain state. The discussion on “words that hurt” may suggest that we think 'its all in the brain'. This is not true. Many chronic pain states (eg rheumatoid arthritis, severe trauma) are constructed with very significant contributions from body structures such as joints and muscles. However the key thing is that bodily damage or changes do not necessarily have to contribute to pain production. The ‘degeneration' reported on the X-ray simply does not have to hurt.

In cases of chronic pain where tests such as imaging, blood tests, and physical examination finds little to report, yet pain persists, it is quite possible that a process of central sensitisation exists – a very real, physical and increasingly understood process based on synaptic activity in the spinal cord and brain. It is the representation of the structures in the brain, rather than the actual tissues which are at fault.

However, in this state, while the tissues have been through an appropriate healing time, they can still contribute in the following ways:

• by being unhealthy, unfit, weak, unused and sensitive. But remember they have been through their healing stage of inflammation, cell proliferations, remodeling and repair, thus they can’t heal again, but they can get healthier and 'fitter'.

• by being the recipients of the brain’s attempts to help out what it perceives are the problem areas by increased levels of stress chemicals, tight muscles and inflammation.

Every human pain state is constructed by varying contributions of the body tissues, the representation of the tissues in the brain and the stress systems called upon to defend the injured tissues or the brain’s perception of the injury.

Words that hurt - Part 2

Thankyou for all the responses to the previous blog about painful words and phrases. There is no shortage of them and the context they are used in can enhance the nastiness of them.

“Degeneration” comes up a lot, probably due to its frequent use in radiological reports and so does “crumbling”, reminding one responder of an oxo cube. “Permanent” was another and a patient got “all seized up, be very careful” recently from a surgeon who should have known better. I can’t help smiling when a patient says “its bone on bone in there” or throws the thick package of imaging studies on the bed, saying “there it is”.

Different professional groups have different harmful words "your child's membranes are strained" and "there is a severe compression of the base of your skull" were sent by a therapist experienced with craniosacral techniques. Equally, any benefits from the current manual therapy focus on spinal instability could be negated depending on how a person views the word “instability”.

Most clinicians have heard these and other terms (even “slipped disc” is still around) and are realizing the impact of the language.

Reflect….. say a person is told they have “a degenerate L4 disc pressing on a nerve root and the thecal sac”. They will repeat that phrase many times and internalise it even many more times. Googling “thecal sac” will reveal that the problem is close to the spinal cord and notions of paraplegia may emerge.

When we can conceptualise that the “degenerate L 4……” phrase is a brain construction held in motor, perceptual, emotional, planning and other brain areas, we may realize that it is not much different to how a learned limp is held in the brain. Just as most therapists would try and reduce the limp, a search for new, variable and more positive language is therapeutic. Or even better, could the health community avoid the exaggeration, crazy metaphors and even lies at first encounter ?.

Please send your thoughts

Phantom pain – the great leveler

Some time ago, one of my undergraduate pain science students came up to me after a lecture on phantom limb pain and said “but it is not real pain is it?”

Hopefully later lectures fixed the misconception and you wouldn’t want to tell the amputee that its not real pain!

Phantom pain is worth reflecting on from time to time. If there was a surgeon mad enough to perform a ‘lumbarspinectomy’ for chronic low back pain, the glaring evidence is that the pain would still be there in the hole in the back and made worse by stress and movements. Yet we jiggle and zap it, poke needles into the area and take medications which are supposed to find their way to the area and pathological process in the spine.

Clinicians should tell the patient about phantom pains. It provides a gateway to education about the role of the brain in pain. And it is worth remembering that many soldiers who returned from world war two with amputations and pain were told that it is impossible to have pain in fresh air.

Tell us your phantom stories…

Image from Butler DS, Moseley GL, 2003 Explain Pain, NOI Publications, Adelaide

Calming therapeutic neuroscience narratives – mirror pains

Now there is a novel title! A part of “Explain Pain” in the clinic is to give meaning to the patient’s symptoms. By providing meaning and explanation, the “threat value” of the symptom is usually reduced, thus reducing engagement of coping systems such as the sympathetic, immune, endocrine, motor and pain systems.

One of the joys of reading clinical neuroscience is the discovery of explanation. Let me give you one example:

Mirror pains – the once perplexing state where the same pain (area and nature) is experienced in the other limb has been shown to have an immune system basis (Milligan, Twining et al. 2003). In the past, I tried to make up explanations for patients, such as that it was new or different use of the limb, but for me (and surely the patient) it was always unconvincing. And imagine the patient’s distress and fear that their problem was now spreading and seemingly out of control.

The research by Milligan’s group showed that if immune activating compounds are injected around rat sciatic nerve, ipsilateral allodynia can be observed. If more compound is injected, then the allodynia is bilateral. This response is rapidly reversed by glial metabolic inhibitors. Glia are one source of the proinflammatory cytokines such as Interleukin 1 &6 and TNF which appear to underpin the mirror pains.

My narrative may be something along the lines of “mirror pains are quite common and we are now beginning to understand them. Your brain has calculated that due to all the circumstances around your injury (eg no explanations, failed treatment to date, work pressure etc etc) that you need a bit more sensitivity, a bit more protection, so it has done a really good job and made pain on both sides. Don’t worry when we can get you in control of this, your brain will realise that it doesn’t need to make so much pain………..”

More calming therapeutic narratives in later blogs.

Milligan, E. D., C. Twining, et al. (2003). "Spinal glia and proinflammatory cytokines mediate mirror-image neuropathic pain in rats." The Journal of Neuroscience 23: 1036-1040.

Words that hurt

There is a rhyme from school that we all know. “Sticks and stones will break your bones but words will never hurt you”. I recall getting in a schoolyard fight and being called a I don’t recall any pain from the fight but I still remember being called a fat pig and to this day, I know the person who called me that. This is Cartesian dualism in the playground – the split of brain and body. Words do hurt.

Experienced clinicians will know of many words that hurt. They come from imaging reports (e.g. rupture, compression of thecal sac, degeneration, arthritic) they come from all clinicians ("you have the back of a 60 year old", "you’ll be in a wheelchair"

"you have the back of an 80 year old", "its slipped out") and it comes from the internet, neighbours and friends.

Some therapists have plastic models of the lumbar spine including ones with a plastic disc with a big red bulge on it – its quite scary and disc bulges are not like that, nor do they have to hurt.

These words and phrases hurt. They lift awareness of the painful part and strongly suggest that there is still damage and disease. This raises the levels of stress chemicals in the body such as adrenaline and cortisol which may make the sore area even more sensitive.

I would be grateful if readers could send me example of words that hurt. Send them to b1@noigroup.info.