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.

A couple of geeky websites!

I just thought I’d post a couple of websites I’ve found over the past couple of days – using StumbleUpon. If you haven’t tried StumbleUpon, and you find yourself at a loose end, or just feel like ‘browsing’ the internet instead of watching TV, try it! Full of cool sites that show up randomly, or you can guide it by adding keywords for the areas you’re interested in.

Brain Explorer is a site put together by Lundbeck Institute. It has a wide range of information, but the bits I liked the most were the Brain Atlas section, and the gallery. Lots of great images, and relatively simple explanations.

Science Daily has a wealth of newsworthy links and posts. Headings of ‘Health & Medicine’, ‘Mind & Brain’, ‘Plants & Animals’, ‘Earth & Climate’ and more – videos, articles and images. Great reading, you can spend a long time on this site!

Zack Lynch blogs about Neurotechnology on Brain Waves. He lists a bunch of quite technical blogs that he regularly visits, as well as some links that are well worth browsing on Neuroresources. Latest blog entries include the Allen Spinal Cord Altas, What’s your Brain Age?, and a great video by Jill Bolte Taylor. Worth a visit!

And my final link for today – Changing Minds is a huge site with a whole bunch of information and links to factors that influence change. From Argument to Brand Management, Theories and Techniques, this site has plenty to keep you interested, especially if you’re curious about how to help people change. Definitely one to bookmark.

I hope you have a moment or two to spend perusing the links – they’re fun and you can spend lots of time just locating information, for the true information junkie like me!!

Advances in the science of acupuncture

Acupuncture has been used in China for thousands of years – it’s one of the first ‘alternative’ treatments requested by patients experiencing persistent pain, and one that has been receiving increasing attention from the scientific community as neurobiological research progresses.

This paper by Wang, Kain & White provides an overview of the state of play for acupuncture and analgesia. As a result of this I’m taking another look at acupuncture as a potential modality for people with chronic pain – with a few proviso’s!!

What’s the evidence?
Traditional Chinese acupuncture is a philosophy that focuses more on prevention than treatment of illnesses. The ancient Chinese believed that Qi flows through a network of channels called meridians, which bring Qi from the internal organs to the skin surface. Along these meridians there are acupuncture points that can be stimulated to correct the imbalance and restore the body to normal health.

Western theories are primarily based on the presumption that acupuncture induces signals in afferent nerves that modulate spinal signal transmission and pain perception in the brain.

Over the last decade, advanced imaging technologies have been introduced, including positron emission tomography (PET), single-proton emission computer tomography (SPECT), and functional magnetic resonance imaging (fMRI). These imaging technologies have made it possible to noninvasively visualize the anatomic and functional effects of acupuncture stimulation in the human brain.

PET scanning found that only acupuncture stimulation at LI4 with De Qi sensation activated the hypothalamus – sham or needling in ‘incorrect’ positions didn’t.
In another study, during a PET scanning sequence Biella et al. found that acupuncture, but not sham treatment, activated the left anterior cingulum, superior frontal gyrus, bilateral cerebellum, and insula, as well as the right medial and inferior frontal gyri. These are the same areas activated by acute and chronic pain.

However, just in case you thought it was ‘simple’ – the anticipation and belief of a patient might also affect the level of therapeutic outcome. This has been specifically examined, and findings from Pariente et al. identified that both true and sham acupuncture activated the right dorsolateral prefrontal cortex, anterior cingulated cortex, and midbrain, however only true acupuncture caused a greater activation in insula ipsilateral to the site of stimulation.

SPECT and fMRI studies have also been conducted, with similar findings – only true acupuncture produced activation of specific areas of the cortex that are apparently involved in pain perception.

Physiological and imaging studies are providing insight into the neurophysiological mechanism of acupuncture analgesia. Recent data suggest that acupuncture triggers a sequence of events involving the release of endogenous opioid-like substances, including enkephalin, [beta]-endorphin, and endomorphin, that modulate pain signals processed along the pathway. Imaging studies demonstrate that the limbic system plays an important role in acupuncture-induced analgesia.

Now just because I can, I invite you to consider the place of placebo, or as Dan Moerman calls it ‘meaning response’.
Unless really good randomisation and double blinding (the patient and the assessor are ALL unaware of whether the procedure is ‘real’ or ‘placebo’) we will run into the effect of having treatment (of any kind) can have on an individual. And especially in the case of acupuncture where the practitioner can never be blinded to whether the procedure is ‘real’ or ‘sham’, inadvertent changes of nonverbal (and at times verbal) behaviour can and will be conveyed.

So…. a very fruitful area of study, methinks.

Oh and another concern I have with acupuncture, as I do for any procedure that involves another person rather than self management for a chronic health condition – acupuncture is usually done by someone to someone. The very process of attending a practitioner is a form of pain or illness behaviour. This action by definition means the person has:

  1. identified that they want help
  2. need to ask someone else to help them
  3. can’t manage by themselves

This means the person will inevitably relinquish a degree of self efficacy (confidence that they can manage their problem by themselves and out of their own efforts) to the actions of another person.

As someone who likes my independence, I’m not sure that I want that.

If you’re curious to learn more, trying searching under the term ‘acupuncture’ and ‘chronic pain’, and seeing what comes up. I visited Cochrane Collaboration and found a couple of older reviews of acupuncture, none of them particularly able to identify strong support for its use.
I also visited the Bandolier Oxford Pain Site, and searched under ‘acupuncture’ – again I couldn’t find much support, and most articles were out-dated.

My question is: if fMRI and other studies are demonstrating significant changes in blood flow etc, are they truly controlling for ‘meaning response’, ‘treatment effects’, inadvertent communication of expectations by the practitioner etc, or is this confounding these results?  And if it is a ‘meaning response’ – how can we integrate this into our practice?

Dan’s book, by the way, Meaning, Medicine and the Placebo Effect is a really GREAT read – with some good info on pain as well as health care and the sociology of ill health. Good stuff!

If you’ve enjoyed this post, want to know more, want to keep reading – don’t forget you can subscribe using the RSS feed – and do drop me a line! I love mail, and am very happy to reply (even if we don’t agree!!).