Thursday, October 25, 2012

Spine meets Brain - a love story

So is your love story one of harmony and balance or is it like Wuthering Heights and totally dysfunctional?

People with pain don't think about anything else but the pain so talking about brains when you first meet is not a good idea.  However while the spinal joints and their components do tear, swell and hurt the research is mounting that tells a story of the complex sensorymotor relationship between the spine and the brain and what happens to each when things don't work.  Moreover research tells the story that physically based treatments work primarily because of the effect they have on the way the brain senses or feels the spine and it's movements.

The brain moves the spine and in turn receives feedback about movement, pressure, pain and a myriad other things.  Both change in response to each other.  They improve together and decline together.  People with long term spinal pain demonstrate muscle wasting on the side of injury, poor local joint control, poor postural control, poor pain control and changes in parts of the brain concerned with emotions and thinking and autonomic changes.  The autonomic system is housed in the brainstem along with the mechanisms which are sensing and controlling the spine, balance (orientation) and posture.  They are both housed there because they talk to each other ALOT.

This is why a common presentation would be 'chronic neck/shoulder pain and stiffness, headache, head tilt, postural instability (disorientation), feeling 'out of it', trouble focusing, unable to follow a moving target without swaying, and the list can go on.  Many of these findings change with application of physically based treatments and studies are suggesting that these findings precede pain.  That's saying that in chronic cases the brain gets things wrong BEFORE a person experiences pain.

What do we mean by 'wrong'?  A person should stand upright, level and be stable but typically many chronic spine patients are crooked, unlevel and unstable.  So when treating people we look at pain control and changes in body orientation as well as another indicator of improvement.

Monday, October 22, 2012

Exercises for spinal pain - What's the use?

The following is borrowed from Matthew Long at Clinical Development International (CDI) where you'll find the full article and it's references.

Quite a few large studies investigating the effectiveness of different exercises for chronic low back pain (cLBP) have come up with apparently confusing results.  As a group these exercises are directed at specific functional weaknesses in the core muscles which act as a dynamic 'girdle' to support the lower spine and pelvis.  Do these exercises work?

The answer is no. The answer is also yes and it's not always for the reasons we think.

Generally people report subjective improvement with exercise but some report reduced pain even when there is no real change in muscle recruitment and vice versa; others display improved muscle tone but don't report a reduction in pain.  Pilates and core stability clinics have gone through a phase of being the next panacea for cLBP sufferers but it's not backed up by research.  What's going on?

One problem is that cLBP isn't a diagnosis so people experiencing cLBP do not share exactly the same problems.   A one size fits all approach is a big issue with cLBP studies as they do not target specific conditions.  However there is still useful information to be gleaned. 

Chronic pain (lasting past an expected healing time) is produced by the brain.  It's a kind of memory of the injury and the brain becomes hypersensitive to normal movement.  The brain can act as a thermostat lowering the threshold or required intensity of sensations from joint movement and give the perception of pain during normal movement.  After all the function of pain is to stop you from injuring yourself but if the injury is in the past......  It's thought to be a normal protective mechanism which can get out of hand.  People with cLBP have displayed reduced cortical or grey brain matter so it appears that chronic pain actually results in brain atrophy.

'Move it or lose it' makes even more sense these days than it did before.  Overall ANY movement or exercise which the patient undertakes and enjoys or is otherwise motivated to perform has the ability to improve both joint mechanics and the way the brain 'feels' or perceives the joint structures.

It's important for patients to understand that moving is what we are primarily evolved to do and the lack of it leads to body AND brain wasting.

Conversely chronic neck pain (cNP) is a little different with improvements in neck muscle function coinciding with reduced pain both in the neck region and interestingly in distant areas like the lower leg (so like cLBP cNP also appears to have a 'thermostat' component).