fencing

Nerdy, Sciency Stuff


The past three weeks have been a swirl of joyous, passionate neuro-nerdy stuff! And yes, it’s absolutely possible to call neuroscience joyous and passionate (just ask David Butler and the NOI crew).

What have I learned?

Let’s begin with the obvious: pain is an output of the brain.  What does that mean? It means that unless the parts of the brain involved in deciding what we need to know about decide we need to know about a threat – we won’t experience that unpleasant sensory and emotional experience  we call pain.  Pain is a complete biopsychosocial phenomenon.  Our experience of OUCH! or YEEEOWW! is absolutely determined by a judgement call made by our brain, and the basis for that judgement call is on the degree of threat we are facing.  If we’re purposively allowing someone to etch a design into our body, we’ll experience a sensation, but most people who have a tattoo say that it’s not painful.  It might be different if we were being held down against our will, and someone is etching an abusive word onto our flesh – the context would be different and we’d view it as a real threat to who we are.

Neuroscience, and especially studies using fMRI, has been able to unravel some of that fringe stuff that lies between “psychosocial” and “biological”.  It’s a research paradigm that has much to offer because it’s uncovering how the structures in our brains respond to both internal and external events.  Yes, thinking can make something happen.

There are limitations, though, and it was refreshing to hear this often throughout the two conferences I’ve attended.

An MRI is a big, noisy machine. People have to lie down and be still during imaging. There is not a lot of room in the machine. Images only show how blood flows to various regions of the brain. It’s not available to many people. They’re expensive! The results require interpretation (but what testing doesn’t require interpretation?!).

What this means to me is to interpret findings somewhat cautiously.  These studies don’t examine the situations and contexts of the people I work with.  Many of the studies use acute pain research protocols – things like thermal stimulation, cold pressor, capsaicin. The people being studied are often young, healthy volunteers – often undergraduate students. The experiments are short-lived, and they have an end in sight for the volunteers.  People can’t move about, or do the activities over time.  The context is different from everyday living.

At the same time, the experiments begin to uncover information about how our brains function – and maybe we can take the findings and begin to study correlates in the real world.  I think this is much of what the Body in Mind group do.

One of the problems, and criticisms, of translating neuroscientific research into the clinic (and probably one of the reasons occupational therapy suffers from a low profile in health) is that the real world is a messy, joyous, passionate, grim, untidy place.

People are made up of their biology but modified by experience and context and opportunity and restriction.  People bring this context into their treatment environment.  And the treatment environment is also a context, and so are we as clinicians.  It’s unsurprising that some of what can be demonstrated in neat, controlled, rigorous clinical trials just can’t be replicated with the people we see, in the world we live in, and in the activities and communities people are in.

This is where joining the dots between scientific methodologies is needed.  Bringing together the artificial research methodologies used in fMRI and randomised controlled trials (double-blind, placebo) where standardisation and unformity are underlying assumptions – and the qualitative, individual, quirky and idiosyncratic methodologies that assume that my reality is mine alone, and that it’s impossible to ever really experience it the way I do.

Both methodologies have application. Both contribute to our understanding of how people and our world work.  And somehow, our theory-building (which is simply a way to provide a metaphor so we can share understanding) needs to pull the multiple strands of knowledge together so that I, as a clinician, can work out how to help my fellow human.

What am I saying here?

Nerdy, sciency stuff is probably what I, as a clinician and researcher and teacher, need to immerse myself in.  My passion is to help clinicians who maybe don’t enjoy this stuff, maybe don’t have the time to learn this stuff, maybe don’t think this stuff has direct relevance to what they do, gain access to the implications of research.  Not a theory of everything (or this)- but a practical translation of nerdy, sciency stuff into what a clinician might do.

There. I think I’ve summarised my current reflections on all that neuroscientific goodness that has nourished my neurones. I’d love your comments! And don’t forget, you can subscribe, join me on Facebook, or introduce yourself.

6 comments

  1. I cam accross this on an ‘inspirational quotes’ website: “If you don’t pay appropriate attention to what has your attention, it will take more of your attention than it deserves.” (David Allen) I have to confess I don’t know who David Allen is – but it made me think does this some up a lot of pain management (the key bit here being ‘appropriate’ attention).

  2. How do you feel ACT sits with the “Pain is what we experience as the output of a threat detection system”? We currently work the latter message and try to embed that thought to facilitate top down inhibition of nociception. Then move on to ACT for living with the distress that having an over sensitised threat detection system causes. Meanwhile we steadily lead towards mindfullness and the benefits we feel that gives (I suspect it is left insula activation) but it ties into ACT or compassionate self approaches nicely.
    My issue is that rehabing people to a level that does not trigger the alarm from the threat detection system feels a bit like re-inforcing experiential avoidance. It re-inforces a level of vigilance I am slightly uncomfortable with. Our outcomes show a slight rise in anxiety scores and avoidance but an increase in QoL measures that is clinically significant. Dilemma.
    Kind thoughts,
    Ste5e

    1. Hi Steve,
      Yes, I completely understand where you’re coming from, and I have a good deal of empathy with your dilemma because I’m in the same space!
      I wonder if the definition of pain as an output of a threat detection system is actually as accurate as we’d like it. My reasoning is that in my PhD research I’m looking at people who cope well with pain and don’t seek treatment for pain per se despite having ankylosing spondylitis, rheumatoid arthritis or osteoarthritis. These people self identify as coping well, are all working, and have had painful conditions for years without letting it stop them. They still experience pain, but don’t experience distress. From some of the work by Irene Tracey et al, I wonder if the so-called “motivational-affective” pathways are only activated in the event of the stimulus being perceived as threatening, and that perception has to be modified by cognitions, past learning (including social learning as well as experiential), while the sensory-discriminative and cognitive-evaluative pathways remain active. If we’re modifying the threat value we probably do so by modifying both the motivational-affective and cognitive-evaluative pathways, so perhaps both are complementary? I’m not sure!
      Personally, I’ve preferred to use the exposure-based approach where the anxiety levels is raised so that habituation can occur and the threat value of the pain is reduced. And in this process I use mindfulness so people can experience what is happening in the NOW rather than anticipate what might happen later.
      I’d love to hear your thoughts on this!
      cheers
      Bronnie

      1. Hi Bronny,
        The ‘threat detection system’ is of course a soundbite simplification to lodge in the prefrontals of our patients. And we hope it offers an alternative thought to ‘pain is damage’ which is more workable.
        I am fascinated by your research choice – it is an area where we have a huge amount to learn from – the control group of people who have ‘painful’ conditions but not a level of distress that gets in the way of life. These are the people we never get to see. The non-catastrophisers, the non-fear-avoidant, the confronters, the copers. We have a lot to learn.
        I have wondered whether this is innate not learned. Whether there is a bell curve of pain sensitivity and if you are at the high end then you are going to be a candidate for persisting pain and if you are on the low end then you can be stoic and a coper. Of course then society layers on stigmatising value judgements of strong and weak and away we sail. Our observations are all post hoc.
        I suspect this innate background ability to experience pain non-threateningly is heavily modifiable in childhood but mostly for the worst by childhood trauma of the psychological types. Then it is open to the harsh words of the medical model to potentially undermine people self-caring efficacy.
        A genetic basis modified by early life experience and the balance of top down facilitation or inhibition depending on what exposure you have to different memes.
        Big respect to Tracey et al. I have brushed against her stuff whilst following F. Benedetti’s work on placebo and the interaction of doctor and patient but I have always wanted to read more of her work.
        Also I love the way your clinical reasoning is coming out of the neuromatrix – I am not quite there yet yet. I appreciate it but am not fluent in interpreting it into clinical language.
        I too come from an exposure based treatment background and I currently like the analogy of the ‘rescue dog’ for the patients nervous system. The dog has had experiences that cause it to respond in ways that are exagerrated and unhelpful to stimuli it percieves as threatening because past experience has taught it that there is a risk of harm. The new owner can rehab the dog by taking a patient and compassionate approach and graded the level of threat to that which does not scare the dog. Over time the threat level can be raised – faster, greater amplitude, challenging context. It is a nice analogy because people are often kinder to dogs than they are to themselves!
        Great to chat and kind thoughts,
        Steve

  3. Oh yes, mindfulness. A very busy field right now and I am not so up to date. I remain to be convinced that there is more to it than the benefits of deep breathing with its left insula activating capabilities – Bud Craig. No doubt a consensus will emerge about the hippocampal and ACC changes and whether they are clinically significant.
    I have been using Pilates with my graded exposure approaches for a long time. I no longer believe it is ‘special’ and I down play a lot of its mystique but I do emphasise the breath control elements because I suspect they carry over the benefits of deep breathing and some elements of a meditative approach to exercise.
    Still learning. And so I am taking formal mindfulness training soon.
    Steve

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s