Wednesday, February 22, 2012

New treatment encounter V

New treatment encounter I
New treatment encounter II
New treatment encounter III
New treatment encounter IV
New treatment encounter VI

I decided to add one more post to this series, to illustrate a few of the key ideas I use to help a new patient develop new cognitions regarding pain.

In Part I I described talking to the patient about the nervous system as a whole. This post could be labelled Part Ia.
But it's OK that it's Part V.

I draw ridiculous pictures very fast to show people what I'm talking about, usually scritchy little things on a piece of paper with a ball point pen. I made a series of drawings in photoshop, using more than one colour, to bring here. I'll go through them one at a time.

1. So, first I draw a brain with a little ponytail of a spinal cord hanging down. I tell them, let's say this is your brain, and spinal cord hanging down inside your spine. It's called the central nervous system.

2. Then I add nerves sticking out of the spinal cord. I tell them, these are your 72 kilometers of nerves, your brain's "feelers", going everywhere and doing everything, and reporting back to the central nervous system. Collectively this is called the peripheral nervous system.

3. All around the nervous system is a physicality, with its layer of skin the brain is very interested in. (Yeah, this picture usually does end up looking sort of like a gingerbread cookie.)

4. I tell them, most of the front part is the human part.

5. But all vertebrates have a "critter brain". The critter part is old, the part that runs everything and keeps us alive. It's like a big loyal dog. It's been around a lot longer than the human part, and it will take over if it feels threatened. This is the part that has become a bit freaked out, the part that we have to learn how to deal with, teach, train, impress, reassure, help work more appropriately again. It's trainable, like a dog. It needs a job, like a dog. So, how do you deal with it? Same way you might deal with a real dog, probably, that you could see was scared or misbehaved. You would try to understand it, try not to scare it or spook it, but observe it, remain calm around it, try to figure out what it needed and provide it with that, be around but give it space, wait for it to trust you, wait for it to wag it's tail and come over to lick your hand and roll on its back. 
This usually helps patients get started thinking - everyone (mostly) likes dogs, likes to think they would know how to relate to one, rescue it from a neglectful owner. Here is this misunderstood "creature" right inside them that they can immediately do something about. The important part of this metaphor is two-fold: people will often be more willing to take a project looking after somebody or something "else" before they'll take on looking after themselves. Even if that "other" is right inside them. Second, they realize right away that were this true, they would need to learn how to relate to other creature pretty fast if they want to live comfortably again. There are some ways this story makes no sense, but in terms of motivation, it's usually an idea that can help people move out of seeing themselves in a victim role into a caretaker role. I think that's what is the most important thing - stewardship of one's own nervous system, taking responsibility, seizing the locus of control. 

Exteroceptive input via skin
ascends through fast dorsal columns,
bypasses dorsal horn/spinothalamic tracts

6. To further the metaphor, my job becomes helping people get their "dog" back under control; the first step is to learn how to be the alpha dog to the inner dog, and help "owners to better understand how to see the world through a dog's eyes." I.e., help people learn to gain some control of, or at least, emotional distance from, their own critter brain. One thing real dogs respond to, crave even, is physical contact. So, manual therapy has a role here. I explain to the patient that I can provide their human brain with some sensory input that will be exteroceptive, in through their skin, that it's important that it NOT hurt; because it will not hurt, it will go straight through the critter brain without stopping, all the way to the human brain, where maps of the body are stored. This will make the human brain start to go to work influencing, in a good way, the critter brain, from the top down. Not that the critter brain won't know someone is touching its organism - the one thing that both brains have, and use in common, is the peripheral nervous system - but the contact won't be uncomfortably nociceptive.
Patient learns to detach from feeling helpless and watch events unfold calmly
7. Their job will be to allow stuff to happen. What they feel in their nervous system will be their own human brain getting out of the way, becoming an observer, and letting their critter brain self-regulate and change its behaviour. This is known as "descending modulation." 

The critter brain is thus deliberately placed between two coordinated forces: 
A) On the one hand, it can "feel" that something touches its organism directly. This will mildly threaten it, or at least get its attention such that it will need to check for any potential threat. Recall in Part IV, the diagram of the internal regulation system, and the descending modulation system parts of the nervous system. That's what we're talking about when we think "critter brain", including insular cortex and anterior cingulate cortex, which develop much earlier in life than the prefrontal "human" brain bits. We need to get the critter brain's attention, bearing in mind that it's already so adept at nocicepting, firing up a barrage of upregulated nociceptive stimuli, that we don't need to give it any more of that - just touching it will get its attention enough to get it to check out the novel stimulus. 
B) Meanwhile, at the same time, it has a calm human brain now engaging with it from upstairs, at the other end, watching it, expecting different behaviour now, not reacting the way it used to. 

These two things together are enough of a new situation that it will be stimulated to adapt. Provided it's a normal intact nervous system that only has a behaviour glitch, it will be a fast learner. 

With good preparation, a patient can be taught how to think about things differently, step outside the problem, observe it in a more detached way, be interested in it in a different way, not "How do I escape from my own body that has betrayed me in this awful way?" but rather, "Ah, I see - I've been treating my own nervous system all wrong! To have to have a better relationship with it, I have to take charge - I get it now. Very interesting! I think I can take it from here. :-) " 

The patient still needs to be made aware of all the usual stuff, how to avoid getting stuck in the same place again, to move (motion is lotion, "dogs" need exercise), strategies for self management, all that. But the big piece is that they'll be motivated from inside - they'll end up with locus of control. 

One last thing - if this didn't start to happen inside a couple or three visits, I'd suspect that the patient and I were not a good therapeutic fit, and would not want to continue to take their money. I would teach them all about the neuromatrix model, and let them go away to think about things for awhile, with the option to come back if they had some new insight, but I would not provide them with more manual treatment that was clearly not landing anywhere in their brain such that their brain could produce different output. 

LINK to WCPT 2011 slide show presentation, 90 minutes: TEACHING PEOPLE ABOUT PAIN; Moseley, Butler, Louwe, Thacker

Out-thinking Pain: How the Mind can Control Pain with Catherine Bushnell, video, about an hour.


Anonymous said...


Anonymous said...

Fantastic. Thank you.

MinkiKimSI said...

Hi Diane,

I love the dog metaphor. Matter of fact, I think I might steal this as part of my pain reconceptualization portion of my intakes.

Also, I've been wondering how I can best describe the nervous system and biology of pain to clients without their eyes glazing over. I like the series of drawings you provided. Visual aids are often helpful.