Mskspot is hungry for exploring the latest research and its starting with a post where I think most therapists are troubled with...CHRONIC PAIN
A recent research paper by Pelletier et al. (2015) [1] discussed the issue of neuroplasticity in the CNS and how this might correlate into the rehabilitation of chronic MSK conditions.
We know that traditional intervetions are lacking the ability to successivelly address chronic MSD symptoms [2]. Effects of the above treatment type are only valuable in the short term. Consequently they cannot target the above population, resulting in perpetuation of their problems and lower life quality.
Chronic MSD might be related with hyperalgesic, allodynic and other altered sensations. However, hyperalgesia is a normal responce of the injured tissue where it protects itself from further damage [3]. According to Woolf, JC. this is a responce related to the structural-pathology paradigm and where traditional interventions are more valuable. Consequently, we need better interventions to improve chronic symptoms.
Cortical reorganisation in the S1 is reported in patients with Phantom Limb pain (PLP), Chronic Lower Back pain (CLBP), Complex Regional Pain Syndrome (CRPS) and many more [4-7]. Distortions of body image and perceptual changes have also been reported in the above studies in which the changes involved abnormal size, shape, swelling and position. Nevertheless, perceptual changes may arise not only from an abnormal sensory modulation but from conflicting motor and sensory inputs as well [8]. Perceptual changes might have functional implications. That might occur when there is not an agreement between sensory and motor input which might lead to increased pain responces and sensory disruptions [9].
It is important to mention that modulation of the shape / size of a limb (Visual distortion) might produce better results in tactile acuity and pain [10,11].
What is also very interesting to mention is that motor skill learning exercises and not traditional exercise programmes might generate better results. That is evident in a study in where there was a reinstatement within the cortical representation of the M1 as well as an improved EMG activation pattern (multifidus, transverse abdominis, iliocostalis lumborum) in individuals with Chronic Low Back Pain. [12-14]. However, repetition should occur in skilled movement patterns since repetitions in any un-skilled movement does not lead to neuroplastic alterations in the M1 [15].
We also know that nociceptive / neuropathic stimuli, altered cutaneous and proprioceptive input can affect sensorimotor organisation in the CNS which in turn affect perception, pain, and motor control. However if the above changes remain for too long then they can lead to permanent adaptations to the peripheral msk structures [16].
Prolonged use of the affected area might lead to a vicious cycle where immobility, cortical representation and atrophic changes strengthen each other [1].
Can't we deal better with chronic pain ? Which intervention and how can we use it best to improve overall function ? Does it work for all chronic conditions ?
Food for thought...
[1] Pelletier,R., Higgins.J., and Bourbonnais, D. (2015) Is neuroplasticity in the central nervous system the missing link to our understanding of chronic musculoskeletal disorders? BMC Musculoskeletal Disorders (2015) 16:25
[2] Wand BM, Parkitny L, O’Connell NE, Luomajoki H, McAuley JH, Thacker M, et al. Cortical changes in chronic low back pain: current state of the art and implications for clinical practice. Man Ther. 2011;16:15–20.
[3] Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011;152:S2–15.
[4] Moseley GL, Parsons TJ, Spence C. Visual distortion of a limb modulates the
pain and swelling evoked by movement. Curr Biol. 2008;18:R1047–8.
[5] Mancini F, Longo MR, Kammers MP, Haggard P. Visual distortion of body size modulates pain perception. Psychol Sci. 2011;22:325–30.
[6] Bray H, Moseley GL. Disrupted working body schema of the trunk in people with back pain. Br J Sports Med. 2011;45:168–73.
[7] Moseley GL, Flor H. Targeting cortical representations in the treatment of chronic pain a review. Neurorehabil Neural Repair. 2012;26:646–52.
[8] Bailey J, Nelson S, Lewis J, McCabe CS. Imaging and clinical evidence of sensorimotor problems in CRPS: utilizing novel treatment approaches. Journal of Neuroimmune Pharmacology. 2012;8:564–75.
[9] McCabe C, Haigh R, Halligan P, Blake D. Simulating sensory–motor incongruence in healthy volunteers: implications for a cortical model of pain. Rheumatology. 2005;44:509–16.
[10] Preston C, Newport R. Analgesic effects of multisensory illusions in osteoarthritis. Rheumatology. 2011;50:2314–5.
[11] Osumi M, Imai R, Ueta K, Nakano H, Nobusako S, Morioka S. Factors associated with the modulation of pain by visual distortion of body size. Front Hum Neurosci. 2014;8:1–9.
[12] Danneels L, Coorevits P, Cools A, Vanderstaeten G, Cambier D, Witvrouw E, et al. Differences in electromyographic activity in the multifidus muscle and the iliocostalis lumborum between healthy subjects and patients with sub-acute and chronic low back pain. Eur Spine J. 2002;11:13–9.
[13] Sihvonen T, Lindgren K, Airaksinen O, Manninen H. Movement disturbances of the lumbar spine and abnormal muscle electromyographic findings in recurrent low back pain. Spine. 1997;22:289–95.
[14] Tsao H, Druitt TR, Schollum TM, Hodges PW. Motor training of the lumbar paraspinal muscles induces immediate changes in motor coordination in patients with recurrent low back pain. J Pain. 2010;11:1120–8.
[15] Remple M, Bruneau R, VandenBerg P, Goertzen C, Kleim J. Sensitivity of cortical movement representations to motor experience: evidence that skilled learning but not strength training induces cortical reorganisation. Behav Brain Res. 2001;123:133–41.
[16] Mansour A, Farmer M, Baliki M, Apkarian AV. Chronic pain: the role of learning and brain plasticity. Restor Neurol Neurosci. 2014;32:129–39.
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