Tactile Chicken Soup for the Brain: 2-pt discrimination

REORGANIZE, SHARPEN, AND HONE THE BODY SCHEMA
This guy has nothing to do with that statement, but looks like someone who might say that...
This guy has nothing to do with that statement, but looks like someone who might say that…
Today’s blog will discuss some interesting research on cortico-somatosensory reorganization, and its implication to pain patients and the art of physical therapy as a whole.

One factor that can feel unsettling is summarizing or justifying treatment with a much more complex explanation of mechanism,  in part due to patient education, though as practitioners we just have to accept that humans are complex and continue to strive to find meaningful variables, explanations, and interactions that promote proper beliefs on behalf of the patient regarding their condition.

The Practitioner may want do delve into a deep understanding of treatment interaction, mechanism of effect to interface (tissue being “treated”), application of treatment and education, all for the purpose of building a proper framework. From patient perspective however, I believe simple is better: we can choose to communicate concepts of the body recovering to its normal state (ie getting rid of pain or restoring function) to patients in a way that borders the conversation between two laboratory physiologists students prepping for an exam, to explanations that are tangible to the patient (though may seem trite).

This can be a particular area of struggle for myself when internalizing the way a patient presents, then externalizing it verbally in terms of approach to explanation of symptoms, treatment, patient buy-in, adding a bio component that is meaningful as well as psychosocial component that is tangible and meaningful. Beyond that, there can be many other intended influences passed upon the patient that don’t necessarily warrant an explanation (maximize placebo effect while setting realistic expectations and practice good listening and empathy skills with explanations that don’t dismiss or belittle patient concerns).

We do this all the time, decide what to verbalize and what not to; some of it is subconscious. We don’t start an evaluation by saying“research shows that good eye contact and listening when talking to people in pain during their initial sessions is predicative of a good outcome” then sit watching the patient and nod… but with all the information on a persons response to treatment elucidated by placebo studies, psychosocial studies, and pain science in general we have a lot to choose from in terms of what to and what not to verbalize.

Which brings me to the topic of a smudged homunculus…

I like to reference the studies by Moseley, as well as Louw, that discusses 2-point discrimination deficit in CLBP patients, when I find a reasonable time to do so with patients.

I think a meaningful way of getting some rather interesting and hopeful research across to a patient in pain may be something like this:

When were experiencing pain, we start to move and act differently than before.  Initially this may be proper and important, as we want to protect the possible tissue injury, though if our body continues to react, move, and live as if injured it can become habituated.  We all have an internal map of our bodies in our brain,  and research shows that people with persistent pain start to recognize the part of the map representing the painful body part less. This results in improper interpretation of information getting to the brain, and affects what you feel as pain and how you move that area.

 A recent research study looked at sensation awareness in lower back pain patients, and they found that the people in pain had difficulty discerning how many pins were poking them, where they were and how far apart they were. The also found that they could train this over a few months, and the people had a significant reduction in pain once as they became better at noting the accuracy of the pin prick.

Most interestingly, the people only improved if they were asked to scrutinize the sensations and report what they were feeling (placing pins into the back and creating a stimulus without having the patient consciously focus on what and how they were feeling it had no benefit).

Although verbose, choosing to convey this info to the patient may be relevant for a few reasons:

·      It validates that in persistent pain patients something could be “wrong” or “amiss” for the patient, without describing damaged joints or tissues

·      It demonstrates that changes can be made, and points the periscope at the tip of the iceberg that there is more to getting better than “fixing the joint with a technique”

·      It shows the possible importance of awareness to the patient, that some portion of them improving will be pending on them making their exercises (or manual therapy) meaningful and not just “something done to their body”.

·      It opens up a window for more questions from the patient, if THEY want to learn more about it! (spouting intricacies of pain being an output may inhibit relations if poorly administered)

So back to practitioner framework, why is the research of impaired 2-point discrimination important? We know that somatosensory organization of the brain changes (maladaptive) when there is dysfunction (this is seen in not only pain, but post stroke). Loss of limb leads to invasion on the severed limb’s representation by surrounding area representations. It abides by the “use it or loose it” principle. That’s right, neuroplasticity can be for better or worse. Further, when we acquire a skill, these (adaptive) changes are reason for our performance and retention of that skill (why a professional violinist may have a differently organized map of the fingers). In the Motor cortex, neural density and cortical matter is correlated with the importance and use of that area!  It can be “sharpened” and adapt by training, just like it can be “dulled” by non-use and habituated pain behavior.

The Motor cortex gets info/inputs from the somatosensory cortex and digests it in order to coordinate an output of motor control. Thus disturbances in output (how we move) are related to altered input from the somatosensory cortex. Though alleviating pain doesn’t necessarily mean the output of motor function, fluidity of movement, and movement options restore automatically. This is why functional movement based exercise is important, and in particular, perhaps awareness to movement. And the “functional” (although this term can be annoying) is important in that in order to be a catalyst towards a cortical reorganization change, it needs to be meaningful to the patient.

*as a side note, what annoys me with “everything must be functional” is that there needs to be a starting point with every patient; if their current function is maladaptive then replicating a functional exercise component may be difficult. Giving some form of input (maybe its an isometric, maybe just some simple pelvic rocking) may be a good starting point to build upon the awareness and ability, while educating the start slow and build concepts of graded exposure.

Although I know little of “Feldenkrais” physical therapy, I imagine part mechanisms of their success is due to this remapping that takes place, as they are “feeding” the brain with lots of slow and thoughtful inputs through movement. I still think an explanation is warranted on why the person should pay attention to the movement, as if not, the person is just knowing that “every 2 hours I need to do a pelvic clock, that’s supposed to make me better”…

I like how Tim Flynn and Emilio Puentedura discuss manual therapy in a recent publication discussing manual therapy and some of the paradigm shifts concerning “mechanism of treatment” (just because it “works” doesn’t mean that the specific treatment was the “fix”)

·      “There is very little evidence that manual therapy performed under anesthesia is effective for CLBP and perhaps this is because we need to “manipulate”the brain, and not just the joints and other peripheral tissues, to bring about a change in the pain experience”…

·      Current evidence suggests that these representational body maps are dynamically maintained in the brain (neuroplasticity) and are negatively influenced by neglect, decreased movement, and pain

·      They touch on that part of skilled MT is certainly feeding inputs, as in “do you feel this part of your spinous process here, whats it feel like with this motion? Is this painful? Can you feel a slight stretch here?


These “techniques” can certainly be beneficial, but were continuing to consider lots of different reasons for their efficacy.  Physical therapists like Jason Silvernail have been talking about this for many years, in what he at one point titled “crossing the chasm” when speaking of some of the reconceptualization for what our treatment is doing. Finding ways to communicate these concepts isn’t always easy (with both patients and fellow PTs), but if you’re at all a curious PT its impossible to ignore.

Although the aforementioned study discusses sensory input via pin prick, the body is experiencing sensory input via movement all the time. The take home to me is that under the influence of altered inputs feeding a cycle of altered outputs, we are more hopeful of changing this if we add awareness and discrimination to our inputs: be it exercise our MT. Visual feedback may be one way being able to constantly re-scrutinize positional awareness, test and train. In this sense, we’re giving more information, which may change processing in hopes to achieve an overall more adaptive system.

MG.blog.pic.2ptouch.png
-Tal Blair, DPT

References:

Moseley et al. Tactile discrimination, but not tactile stimulation alone, reduces chronic limb pain. Pain 137 (2008) 600–608

Catley et al. Is Tactile Acuity Altered in People With Chronic Pain? A Systematic Review and Meta-analysis. The Journal of Pain, Vol 15, No 10 (October), 2014: pp 985-1000

Louw A, Farrell K, Wettach L, Uhl J, Majkowski K, Wedling M 2015 Immediate effects of sensory discrimination for chronic low back pain: A case series. New Zealand Journal of

Physiotherapy 43(2): 58–63.
Flynn et al. Combining manual therapy with pain neuroscience education in the treatment of chronic low back pain: A narrative review. Physiotherapy Theory and Practice · June 2016

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Defective imitation of finger configurations in patients with damage in the right or left hemispheres:

The aim of this study was to explore the mechanism underlying the imitation of finger gestures, we devised a simple imitation task in which the patients were instructed to replicate finger configurations in two conditions: one in which they could see their hand (visual feedback: VF) and one in which they could not see their hand (non-visual feedback: NVF). Patients with left brain damage (LBD) or right brain damage (RBD), respectively, were categorized into two groups based on their scores on the imitation task in the NVF condition: the impaired imitation groups (I-LBD and I-RBD) who failed two or more of the five patterns and the control groups (C-LBD and C-RBD) who made one or no errors. We also measured the movement-production times for imitation. The I-RBD group performed significantly worse than the C-RBD group even in the VF condition. In contrast, the I-LBD group was selectively impaired in the NVF condition. The I-LBD group performed the imitations at a significantly slower rate than the C-LBD group in both the VF and NVF conditions.

These results suggest that impaired imitation in patients with LBD is partly due to an abnormal integration of visual and somatosensory information based on the task specificity of the NVF condition.

Re-Sensitization is where it’s at

Unless you’ve been under a rock as a clinician, the term ‘central sensitization’ should be in your vocabulary.  It has gained popularity through the cycle of pain science, especially over the past 5-10 years.  Even though it appears central sensitization is new and sexy, it is not a modern term, and to my knowledge, the seminal paper on it by Dr. Woolfe goes all of the way back to 1983. Much change and marketing has happened in this 33 year span, but even still, the thought process of this term has been around for centuries.

You can find 6 ways to Sunday to explain this phenomenon to your patients, which I do using my “Pain Cartesian Scale (here too).  I encourage you to find the best way to translate this to your patients in the context they need to understand.  My colleague and friend, Dr. Matt Dancigers, explains this better than anyone else I know.  I highly recommend reading his blog.
Nevertheless, I find the explanation of central sensitization to be somewhat limiting to achieving better outcomes for my patients.  Don’t get me wrong, it does help, but not an extraordinary game changer.  What I find works better in clinical practice is the term, “Re-sensitization”.  This is an ad-on to central sensitization and of course has to go alongside it in your education, but seems to be more of a heavy hitter in regards to applicability for the individual—especially after he/she has felt results and gained your trust.
In a nutshell, the way I assimilate Re-sensitization to patients is one they understand—it is an exacerbation of symptoms.  We all know this happens for any condition, but especially chronic pain.  I translate the importance of a healthy diet, stress reduction and general exercise, of ways to reduce re-sensitization—-this is a multi system issue (endocrine, metabolic, cardiovascular, etc) and not just musculoskeletal.  But for the main purpose of my point in this post, I recommend  focusing on a specific HEP based off of what worked for the patient under a course of care.
In some individuals, a general exercise program at a gym may just do it.  But what I find, and I’m sure many of you, is that you need something specific for the area/region that seems to be the one that is picked at the most.  It could be a neural glide, self-mobilization, myofascial ischaemic compression, etc etc—-but your job, and what I get most out of the umbrella term of sensitization, is to find and prescribe what works with the upmost confidence and highest power to desensitize the system to prevent re-sensitization.
It works like this: Peripheral sensitization leads to Central sensitization—-we can ramp down this entire system (and local region) through our interventions—-but then Re-sensitization occurs over a course of Time—this is where intervention is needed again—by either specific HEP and or Therapist Treatment.
resensitization
It is challenging to put more concepts into words and make it applicable to your setting, approach, and patient type.  But, I do hope you are learning more about central sensitization and now the phrase re-sensitization—which has been successful for me in the science of pain.  It also helps me establish a wellness program and principle of coming back to me vs medication/physician/surgeon if exacerbation occur as an overall successful business plan.
As an added bonus for reading my blog,, I am offering a FREE, 30 min, E-mentorship session for anyone who feels they would like more information on re-sensitization, but also mentorship and guidance on complicated cases.  Just email me at harrisonvaughanpt@gmail.com with “re-sensitization” in subject line. You may just find it to be beneficial and would like to go through a mentoring process. Feel free to contact me for more information and read about the Program more on my E-mentorship page.
As always, looking forward to your input. 
You can see original post and all prior posts at http://intouchpt.wordpress.com
Harrison Vaughan, PT, DPT, OCS, Dip. Osteopractic, FAAOMPT

Dr. Harrison N. Vaughan, PT, FAAOMPT is author of a In Touch PT blog, provides in-home and office physical therapy treatmentsconsultation and e-mentorship opportunities for clinicians atwww.painandspinespecialist.com.   He is also CEO of Integrative Clinical Concepts (ICC) at www.iccseminars.com.  You can best reach him at harrisonvaughanpt@gmail.com 
Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic…

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Pressures and Oscillation Frequencies Generated by Bubble-Positive Expiratory Pressure Devices.

Positive expiratory pressure (PEP) devices are used to assist with airway clearance. Little is known about the therapist-made or commercially available bubble-PEP devices. The aim of this study was to determine the end-expiratory pressures (cm H2O) and oscillation frequencies (Hz) generated when a range of flows were applied to the therapist-made bubble-PEP devices (Bubble-PEP-3cm and Bubble-PEP-0cm) and commercial bubble-PEP devices (AguaPEP, Hydrapep, and Therabubble).

This was a bench-top experimental study using a compressed air source, flow rotameter (flows of 5, 10, 15, 20, and 25 L/min), and pressure transducer. Data were collected using a data acquisition device with PhysioDAQxs software and analyzed with Breathalyser software to determine the pressures and oscillation frequencies generated by 5 bubble-PEP devices. Each flow was constant for a 30-s measurement period, and measurements were repeated in triplicate. The 5 devices were: a therapist-made Bubble-PEP-3cm device (filled with 13 cm of water, tubing resting 3 cm from the base of the container); the therapist-made Bubble-PEP-0cm (filled with 10 cm of water, tubing resting at the base of the container); and the AguaPEP, Hydrapep, and Therabubble devices with water to the 10 cm mark on the containers.

Bubble-PEP-3cm maintained the most stable pressure throughout the range of flows tested. All devices investigated produced similar oscillation frequencies.

Feasibility and Safety of a Virtual Reality Dodgeball Intervention for Chronic Low Back Pain

Whereas the fear-avoidance model of chronic low back pain (CLBP) posits a generic avoidance of movement that is perceived as threatening, we have repeatedly shown that individuals with high fear and CLBP specifically avoid flexion of the lumbar spine. Accordingly, the authors developed a virtual dodgeball intervention designed to elicit graded increases in lumbar spine flexion while reducing expectations of fear and harm by engaging participants in a competitive game that is entertaining and distracting.

They recruited 52 participants (48% female) with CLBP and high fear of movement and randomized them to either a game group (n = 26) or a control group (n = 26). All participants completed a pregame baseline and a follow-up assessment (4-6 days later) of lumbar spine motion and expectations of pain and harm during standardized reaches to high (easier), middle, and low (hardest to reach) targets. For 3 consecutive days, participants in the game group completed 15 minutes of virtual dodgeball between baseline and follow-up.

For the standardized reaching tests, there were no significant effects of group on changes in lumbar spine flexion, expected pain, or expected harm. However, virtual dodgeball was effective at increasing lumbar flexion within and across gameplay sessions. Participants reported strong positive endorsement of the game, no increases in medication use, pain, or disability, and no adverse events.

Although these findings indicate that very brief exposure to this game did not translate to significant changes outside the game environment, this was not surprising because graded exposure therapy for fear of movement among individuals with low back pain typically last 8 to 12 sessions. Because of the demonstration of safety, feasibility, and ability to encourage lumbar flexion within gameplay, these findings provide support for a clinical trial wherein the treatment dose is more consistent with traditional graded exposure approaches to CLBP.

This study of a virtual reality dodgeball intervention provides evidence of feasibility, safety, and utility to encourage lumbar spine flexion among individuals with CLBP and high fear of movement.

Untold Physio Stories S4:E4 – A Tale of 2 95 Year Olds

Download file | Play in new window | Duration: 11:15 | Size: 25.77M
How often do you work with 95 year old patients in your practice? Listen in to how differently two 95 year olds present to physical therapy.

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Untold Physio Stories is sponsored by the EDGE Mobility System, featuring the EDGE Mobility Tool for IASTM, EDGE Mobility Bands, webinars, ebooks, Pain Science Education products and more! Check it out at edgemobilitysystem.com .  Be sure to also connect with Dr. Erson Religioso at Modern Manual Therapy and Jason Shane at Shane Physiotherapy.
Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic…

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Timing of hypertonic saline inhalation for cystic fibrosis.

Inhalation of hypertonic saline improves sputum rheology, accelerates mucociliary clearance and improves clinical outcomes of people with cystic fibrosis. The objective of this review was to determine whether the timing of hypertonic saline inhalation (in relation to airway clearance techniques or in relation to time of day) has an impact on its clinical efficacy in people with cystic fibrosis.

The team identified relevant randomised and quasi-randomised controlled trials from the Cochrane Cystic Fibrosis Trials Register, the Physiotherapy Evidence Database (PEDro), and international cystic fibrosis conference proceedings.Date of the last search of the Cochrane Cystic Fibrosis and Genetic Disorders Group’s Cystic Fibrosis Trials Register: 19 December 2016. Any trial of hypertonic saline in people with cystic fibrosis where timing of inhalation was the randomised element in the study protocol with either: inhalation up to six hours before airway clearance techniques compared to inhalation during airway clearance techniques compared to inhalation up to six hours after airway clearance techniques; or morning compared to evening inhalation with any definition provided by the author.

The searches identified 97 trial reports which represented 46 studies, of which two studies (providing data on 63 participants) met our inclusion criteria. Both studies used a cross-over design. Both studies had low risk of all types of bias except the participants and the therapists who applied the treatments were not blinded. Intervention periods ranged from one treatment to three treatments in one day. The effects of the various regimens on lung function were non-significant. Satisfaction was rated significantly lower on a 100-mm scale when hypertonic saline was inhaled after the airway clearance techniques: mean differences 20.38 mm (95% confidence interval 12.10 to 28.66) compared to before airway clearance techniques and 14.80 mm (95% confidence interval 5.70 to 23.90) compared to during the techniques. Perceived effectiveness showed similar significant results. Other outcomes were unaffected by the timing regimen used. No trials compared morning versus evening inhalation of hypertonic saline.

People with cystic fibrosis could be encouraged to inhale hypertonic saline before or during airway clearance techniques to maximise perceived efficacy and satisfaction, even though these timing regimens may not have any better effect on lung function than inhalation after airway clearance techniques. Given the long-term efficacy of hypertonic saline has only been established for twice-daily inhalations, clinicians should advise patients to inhale hypertonic saline twice daily. However, if only one dose per day is tolerated, the time of day at which it is inhaled could be based on convenience or tolerability until evidence comparing these regimens is available.