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Neuroplasticity: Transforming the brain


Neuroplasticity is a concept that’s taken the world by storm over the past years – take a look at this Google graph of the growth in searches for the term!Capture

 

The idea behind using the brain’s ongoing neuroplasticity is that we can influence the connections between neurones by doing and thinking differently. Great idea, and definitely one we can use. There have been many discussions about how much we can influence plasticity – or not (this post refers to education and neuroplasticity, this to an old discussion about Norman Doidge’s book – and some of the points that have been omitted). Whatever the real situation, there’s no doubt that our brains do continue developing, forming and reforming connections between synapses and generally responding to our world and the interactions we have with our world via our bodies.

Pain researchers have been particularly enraptured by the idea that the brain can develop new connections, driven it seems by a greater understanding that our experience of pain is an integration of information from the body, modulated at every step of the way by both ascending and descending influences, right until that information is processed by various parts of our brain and, in combination with past experience, expectations, beliefs, predictions for the future, current goals and priorities and in our sociocultural context, produces what we know as pain. Long, long sentence – but you know what I mean!

So, the reasoning seems to go, if pain is an output of our nociceptive system and produced via all these interactions, then neuroplasticity should mean painful experiences can be reversed using the same principles. And yes! Lo and behold! In some cases this happens – vis all the research produced by Moseley and crew in Adelaide, and promoted by the NOI group, and others.

While Lorimer’s group has produced probably the most consistent body of work in relation to therapy based on neuroplasticity, with NOI promoting many of these approaches, it’s not the only group to do so.  Today I’m taking a look at Michael Moskowitz and Marla Golden’ book Neuroplastic Transformation: Your brain on pain, and the accompanying website.

I’ve been asked to take a look at this by a follower, and it’s been an interesting and fun project to work on.

The book is a spiral bound, colour printed A4 sized book with large print (yay!) and gorgeous illustrations of brain sections and neurones and other beautiful diagrams relevant to understanding the brain. The principles underpinning the book are that if we can understand a bit more about the brain, we can harness the functions so we can train our brain to be a little more settled and out of pain. The three neuroplastic rules are: What is fired is wired; What you don’t use you lose; When you make them you break them; when you break them you make them.  The premise is that it’s possible to reverse the changes that occur when a person is experiencing persistent pain – “treathment that uses the basic principles of neuroplasticity to change the brain pathways back to normal function and anatomy”. The authors discuss using thoughts, images, sensations, memories, soothing emotions, movements and beliefs to modify the experience.

The process of treatment involves four phases: Rescue, Adjustment, Functionality and Transformation, or RAFT. Rescue involves generating hope that pain can be changed by providing information about neuroplasticity, and developing a partnership between clinician and person living with pain. Adjustment involves “stabilising” the pain disorder – using a multi-modal approach including medications, injections, and psychosocial treatments to increase activities while reducing pain – emphasising that adjusting to the pain disorder is not the end goal. Functionality involves the person, every time he or she experiences pain, challenging the experience with non-painful stimuli. In other words, every time the person becomes aware of his or her pain, they need to use thoughts, beliefs, images, sensations, movements and emotions to “reverse the neuroplastic processes that cause persistent pain”. Finally, Transformation involves using the experience of overcoming pain to establish new ways to give pleasure.

What I like about this approach is that it is explained and illustrated very well, using up-to-date information and illustrations. It strongly supports self-management or the person being as much part of the treatment as any clinician. That’s good – because, as any of us who have ever tried to change a habit know very well, change is hard! And that’s probably one of the three main concerns I have about employing this approach as a core pain treatment.

My concerns:

  1. Reversing or altering cortical pathways is truly difficult – and it’s perhaps not possible to completely reverse, especially if the problem has been present for a long time. Here’s why: can anyone remember learning to ride a bike? Remember all that falling off, the wobbling, the stopping and starting, the weaving all over the place? How many hours did it take to learn to do that successfully, smoothly and to the point where you were safe to ride in traffic? Now, for some of you, it will have been YEARS since you jumped on a bike. Do you forget how to ride? No. You might wobble a bit, but you don’t actually forget. Similarly, in phobic states, pathways associated with avoiding the feared stimulus remain “wired together” even when new pathways associated with approaching the stimulus are developed. What this means is that it’s possible for a spider phobic to remain somewhat jumpy around a spider even after treatment has reduced the screaming heebie-jeebies. When we think about pain and the myriad associations between the experience, context, interoception (internal body feeling-sense), memories, emotions, language, treatment visits, investigations – there are so many connections that become wired together as a result of experiencing persistent pain that to completely reverse it is an almighty monumental challenge requiring hours or dedicated practice.
  2. While the principles of a neuroplastic approach are well-known, there are some differences in the approach depicted in this book that I’m not aware of being tested formally in pain research. For example, while it’s nice to have a pleasant smell or memory brought to mind, I’m not aware of studies showing that doing this changes memory for pain (or pain intensity). I may well be wrong about this and I’d love someone even more geeky than me to bring some studies to my attention.
  3. My third reservation relates to the well-established research showing that persistent pain is not easily changed, and meanwhile, in the pursuit of pain reduction, many people lose out on good things in life. While people are sitting in waiting rooms, spending time with therapists, monitoring and checking on pain intensity, it becomes very difficult to carry on with valued actions. There are many ways to make space to have your pain and live as well. This doesn’t mean you need to give up hope of pain reduction, but it does mean the focus moves from this as a life focus and on to the things that make life of any kind worthwhile. Maybe the two approaches can go hand in hand, but to my mind the very intensive nature of the approach within this book means that attention must be shifted away from valued actions and towards doing the things that this book argues will reverse pain.

Overall I like the approach within this book – I like that it’s person-centred, positive, uses underlying principles and encourages the person to be actively involved in his or her treatment. There’s no way you can be a passive recipient with this approach! I would love to see some more in-depth study of the effects of this treatment, even in a series of single-subject experiments. I think it could be very helpful, but I’m a little concerned at the focus on pain reduction as the primary goal, and the time and energy this approach demands.

11 comments

  1. I don’t agree with Bronnie. She is biased I think with her own persistent pain…. I like a lot of her ideas but I don’t like her self limiting beliefs in normalizing the pain system

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    1. Hi Carolyn, thanks for taking the time to comment. I’m comfortable with people having differing views on what to do about persistent pain – that’s what a forum like a blog is all about. Have a go at the neuroplasticity approach and let me know how it goes for you. I’d really love to hear if it works out, anything that helps has to be good, providing you weigh up the good and not so good for yourself and from your own perspective.
      cheers
      Bronnie

  2. well stated review – to add a couple of things – it is beyond belief that the authors do not offer this book as an ebook, when people in pain often do not have much money and this is not a particularly expensive task, AND the book is printed heavy paper making it expensive!
    and the vast number of suggestions without any framework to help diminish being overwhelmed with how to put all the information and suggested techniques together makes the book more academic than self-help.

    All in all, this has some great suggestions based on research, and others guided by patient experiences – I hope that clinicians will read this

    And with the discussion of anandamide as a neuropeptide involved in pain modulation, those with a background in Sanskrit will be pleased.

    1. LOL Love that last point Neil! Yes I think giving a framework would really help, and I also think people should be warned that it’s incredibly hard work, takes considerable commitment, and because we don’t know the outcomes (I can’t find any studies on it – unless you have?) it’s really a tall ask for people to do, especially without clinician support. Wouldn’t it be cool to have it as a structured online programme? Now THAT would be fabulous!
      Thanks for dropping by Neil, always cool to know you’re around (ps I may be in Vancouver again at the end of the year – we must catch up!).

  3. Thanks, Bronnie, for your thoughtful review of a frontier. I’ve sent it to the authors. I’m setting up a workshop with one of their associates here in Boulder and we’ll see how it goes.

    1. How exciting Charles! So looking forward to finding out how you find it. I’d love to talk with the authors, they’ve hit upon some really useful strategies – and I love that it’s science-based. Next step is to see whether it can be pulled into a self-management programme for head-to-head testing with other similar approaches. I’d love to see it!

  4. Very interesting – thanks for bringing new approaches to pain rehab to our attention.

    As much as I agree with the patient-centered focus and clinical application of new science, I also think it is important to stress that these new theories (that we are changing our brains in a deliberate or ‘better’ way) should be considered as only that: Theories. What we observe in our patients when we apply these (or any other theory or technique that work wonders) is not the verification of these theories.

    Having said that, I always believe that if the clinical bits make sense without the ‘sciency’ explanations, you could be well of giving it a go… But not just because it sounds persuasive.
    What I don’t find in your review (and thus don’t know how they handle) is outcome measurements.

    Giving my position on the (lack of) linear understanding of brain activity and lived life of a person, I think that any theory must be coupled with objective and subjective measures of relevant outcomes (from the patients perspective), before it should be systematically used in clinical practice: Theorizing what may work, but not how we can decide if it has had the wanted effect, is insufficient.

    And some final skepticism: If what they say about science (on their website) is truly more than just a theory, do they also embrace the use biomarkers (e.g. serum, biopsies or QST) to reliably assess the individual patient’s outcome? Or should we – as I assume both of us would prefer – stick to patient related, functional and observable or self-reported outcomes?
    I feel confident that non of your readers would be ready to devote themselves to biomarkers just yet, and that leads me to the “so-what” question in relation to all the science applied to support this (and other) theories. And even more so, how is the theory epistemological different from pre-2000-theories of structural alignment and dynamic muscle stability? Are they just replacing joints with synapses and movements with neurotransmitters? Or is there a better validity to their theory?

    To sum up, I believe that outcomes more than ‘the latest’ in neuro-research should guide clinical practice.

    1. The reason there’s nothing on outcomes is because there’s nothing I could find on outcomes! Which is partly my point: if a new! improved! treatment emerges, I’d like to see something about how well it works, who it works best for, and what conditions it’s useful in – and while a theoretically-derived treatment should be more effective than whatever is to hand, it ain’t necessarily so (as we know from all the work on core strengthening for low back pain, and many of the surgical and ablative techniques). This is one reason I’ve encouraged a couple of the commentators to take a look at the approach and decide for themselves whether they want to invest the time and energy into the approach – and then to let me know how it goes for them. Two swallows do not a summer make, but that’s two more swallows than I can see right now. Thanks for taking the time to comment, always a pleasure to see you around!

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