Tip Targeting Cortical Representations in the Treatment of Chronic Pain

[marcel]

Targeting Cortical Representations in the Treatment of Chronic Pain:
Mosely and Flor. 2012

Abstract
Recent neuroscientific evidence has confirmed the important role of cognitive and behavioral factors in the development and treatment of chronic pain. Neuropathic and musculoskeletal pain are associated with substantial reorganization of the primary somatosensory and motor cortices as well as regions such as the anterior cingulate cortex and insula. What is more, in patients with chronic low back pain and fibromyalgia, the amount of reorganizational change increases with chronicity; in phantom limb pain and other neuropathic pain syndromes, cortical reorganization correlates with the magnitude of pain. These findings have implications for both our understanding of chronic pain and its prevention and treatment. For example, central alterations may be viewed as pain memories that modulate the processing of both noxious and nonnoxious input to the somatosensory system and outputs of the motor and other response systems. The cortical plasticity that is clearly important in chronic pain states also offers potential targets for rehabilitation. The authors review the cortical changes that are associated with chronic pain and the therapeutic approaches that have been shown to normalize representational changes and decrease pain and discuss future directions to train the brain to reduce chronic pain.

Keywords
rehabilitation, motor imagery, sensory discrimination, cognitive-behavioral

[Sheffphysio]

the paper is available on the BIM site. Every PT should read. About 0.1% will

[ste5e]

Ever the optimist Dave!

[bernard]

For those who do not want to search it:

[Greg Lehman]

In my transition from mesoderm to ectoderm I am still uncertain about terminology and the science it stems from. For example, Lorimer writes in the abstract above:

Neuropathic and musculoskeletal pain are associated with substantial reorganization of the primary somatosensory and motor cortices as well as regions such as the anterior cingulate cortex and insula

From reading this board many seem to suggest that there is no such thing as "musculoskeletal pain". Is this use inappropriate?

Thanks,

Greg

[Diane]

I can't imagine he would a) write that himself, or b) let it go by without at least some question. But he's a co-author, not the sole author, so he might have had to acquiesce.

[Jon Newman]

Originally Posted by glehman

From reading this board many seem to suggest that there is no such thing as "musculoskeletal pain". Is this use inappropriate?

Thanks,

Greg

Hi Greg,

Sometimes it's tough to tell if people agree whether there is such a thing as _______ unless we have some reference for what the person using the term means by it. Do you have a definition of "musculoskeletal pain" and, even better, a source for the definition?

[zimney3pt]

Greg there is this paper: Teaching People about pain: Why do we keep beating around the bush by Lorimer, in which he was the sole author that speaks a little to that.

[Greg Lehman]

Hi Jon,

You wrote,

Sometimes it's tough to tell if people agree whether there is such a thing as _______ unless we have some reference for what the person using the term means by it. Do you have a definition of "musculoskeletal pain" and, even better, a source for the definition?

I dont have a definition for musculoskeletal pain as i was not using the term. What my definition is certainly less important than the what Lorimer Moseley views to be msk and neuropathic pain. I just thought this was interesting. Lorimer Moselely was using the term in a manner that seems inconsistent with both the article that Kory recommnded and with many of the posts on this site, particlarly this thread "different types of pain". While he did not define the term in the abstract above he certainly used the term and also juxtaposed the term with "neuropathic pain". This suggests to me that he sees them as somehow different or has no issue with ascribing a tissue to the brains pain output (maybe). Unless, as Diane suggests, that he would have had to acquiesce to the wishes of a second author or that he did not write that himself. If Diane is correct, then there are other intersting issues related to authorship in addition to terminology.

Greg

Ps excuse the typos this is written on an ipad and i dare not risk correcting things for fear of losing things

[Jon Newman]

I see. Linguistic consistency can be a challenge. In this context my interpretation is that "musculoskeletal pain" is the same as "nociceptive pain" while simultaneously referencing the mesodermal bedding in which the nociceptors of the nociceptive neurons lie.

But contacting the authors for clarification is always your best bet.

[Greg Lehman]

Thanks Jon,

I like that explanation. I guess my point would be that perhaps it is not such a terrible thing or even a misnomer to label something as musculoskeletal pain then and that such use would still be consistent with what is known about pain science. I would still wager that this is still a contentious usage amongst many here.

Greg

[Diane]

Talk about targeting cortical representations... check out the webinar (about an hour) by Catherine Bushnell.

[Jon Newman]

Originally Posted by glehman

Thanks Jon,

I like that explanation. I guess my point would be that perhaps it is not such a terrible thing or even a misnomer to label something as musculoskeletal pain then and that such use would still be consistent with what is known about pain science. I would still wager that this is still a contentious usage amongst many here.

Greg

I think the shortcut is more likely to import the issues associated with conflating the status of a mesodermal tissue with pain. I understand the desire for a short, quick, way of describing "musculoskeletal pain". I see few drawbacks in being more thorough except for the time it takes. I wouldn't describe it to patients as I did here unless I'm working with someone like me.

[Frédéric]

About msk pain. I think there is nothing wrong with using the terminology as long as we know that it's a short for : pain experienced secondary to incoming nociception arising in _________ (your msk structure of choice).

It's usefull to differenciated it from neuropathic pain which would be secondary to a nerve pathology or nociception arising from the signaling nervous tissues themselves.

[Diane]

Originally Posted by Frédéric

About msk pain. I think there is nothing wrong with using the terminology as long as we know that it's a short for : pain experienced secondary to incoming nociception arising in _________ (your msk structure of choice).

It's usefull to differenciated it from neuropathic pain which would be secondary to a nerve pathology or nociception arising from the signaling nervous tissues themselves.

I'd be more comfortable if it were "body part" or "region" of choice, to make it clear it's not specific to any kind of "tissue" type, hard or soft.

[Frédéric]

Agreed!

[Diane]

Although, tissue is implicit in the very term, "musculo" (i.e., muscle) and "skeletal" (i.e., bone&joint), so there you go. Back to square one.

[Barrett Dorko]

Suppose we were to use the term "physicality of pain." We kow that it must be neurogenic because all pain is. Affecting that with context and movement then becomes our job.

I don't think it would hurt (pun intended) to say, "Iron bars and concrete walls do not a prison make - but they sure do help" when speaking of the necessity of nociception as a significant contributing factor on the left side of the matrix. We can't know whether or not movement in the directions we'd prefer would help, but we can assume it's a decent idea when approached appropriately.

[Frédéric]

Originally Posted by Diane

Although, tissue is implicit in the very term, "musculo" (i.e., muscle) and "skeletal" (i.e., bone&joint), so there you go. Back to square one.

I see your point but I would'nt go as far as saying tissues are unrelated to pain. I don't see anything wrong with saying that pain can be related to something happening in tissues because it can. Just like a painful experience can be unrelated to what is happeningin tissues like in what we call compassion pain or phantom limb pain. Thus, it's usefull to add a qualificative word - noun- to complement the pain - verb - .

That doesn't mean that every pain that people qualify as msk pain really/mostly happens secondary to nociception incoming from msk tissues as some seem to imply. It is thus usefull to be clear about these kind of things so that people don't misunderstand what we mean. That's why I have nothing against the use of the word msk pain by Moseley and Flor. He's been clear about what pain is before. And we know Flor's position on that is pretty much like Moseley's by reading the rest of her published materials.

I personnaly think putting to much emphasis on the semantic of the use of _______ pain might take some readers astray from the greater picture by creating some disagreements that get in the way of the transmission and subsequent acceptation of the core message. But obviously, our respective tolerance to langage shorthcuts aren't exactly the same and I can understand why this issue might be more sensitive for some while it's less for me.

[Greg Lehman]

If nociception is neither necessary nor sufficient for the output of pain what factors from the neuromatrix are necessary, sufficient or both for pain. Do we know this? More important, is this even useful to think about?

Greg

[Frédéric]

Originally Posted by glehman

If nociception is neither necessary nor sufficient for the output of pain what factors from the neuromatrix are necessary, sufficient or both for pain. Do we know this? More important, is this even useful to think about?

Greg

The perception of threat.