Archive for the ‘2012’ Category

Missing out at Christmas

December 20, 2012

I guess we can broadly and boldly say that rehabilitation professions are making some headway with pain states that are broadly categorised as ‘musculoskeletal’ – the backs, the necks, the shoulders and other bits. And recently, since an awareness of the potential of brain changes gave a green light to researchers and some ‘withit’ clinicians, there appears to be some headway into better management for neuropathic pain states such as brachial plexus tears, complex regional pain syndrome and phantom limb pain. But a massive group is still suffering, missing out – and their pains are not yet even on the radar of researchers and clinicians…

Who is missing out?
There are two main groups – those with neurological disease and trauma such as stroke and a group we can broadly identify by anatomy such as pelvic pain. Please spend a moment to review these sorry stats:

Stroke hurts in many ways – experiencing pain that interferes with daily life is one way. Pain in stroke patients is reported as high as 53% and there is an incidence of CRPS in 23% of the stroke population (Cacchio et al 2009). ‘Novel’ pain (ie., excluding those that had pain prior to the stroke) was found in 39% of stroke patients (Kilt et al 2011), suggesting essentially that stroke can cause pain. Remember that nearly 3% of the population will have a stroke.

In spinal cord injury, at least 80% experience chronic pain, many regarded as severe. Parkinsons’ disease is particularly painful – prevalence levels are reported as high as 83%, yet only 34% are on any analgesic medication. This pain is worse in females and has no association with age, or disease duration. In multiple sclerosis, pain prevalence is reported as high as 86%. Intensity ratings of 5/10 are common (Khan & Pallant 2007). Alzheimers hurts in 57%, so does Guillaine Barre (up to 89%), HIV/AIDS (up to 90%) and leprosy (50%) though the conventional wisdom is that leprosy should not hurt. See (Boorsook 2012) for a summary.

Researchers and clinicians appear to avoid certain body parts, in particular pelvic pain and also face pain. Pelvic pain in particular is hardly on the research radar. Endometriosis alone costs Australia at least 6 billion dollars per year and figures always hide the human burden. (Bush et al 2011)

What can we learn already?
I heard only last week from a physio colleague in regard to stroke treatment “we don’t worry too much about pain, we have to get them functional”. I guess if you don’t worry too much about it, then you won’t be aware of how much a feature of life it is in these groups.

But ponder – post stroke, Parkinson’s and other neurological injuries and disease once again informs us/forces us to understand how much pain is a brain construction – there is no injury to tissue structure in these problems. And in MS, the level of demyelination does not relate to the amount of pain. It’s sort of the same as in ‘musculoskeletal pain’ where the amount of arthritic change or disc pathology rarely relates to the level of pain. The only good thing is that it should be easier to provide therapeutic neuroscience education and talk about the brain in pain as there is no tissue injury.

And ponder too, how linear thinking hampers rational clinical pain engagement. Most people, including researchers think about the effect of pain on motor function as if it were linear yet the pain construction in the brain is in parallel with the motor construction, ie., the brain bits involved overlap. Pain treatment on the grounds it should help motor outcomes seems obvious. Pain is just forgotten – in MS, those with pain are more likely to be unemployed; in nearly 20% of spinal cord injured patients, pain was the factor limiting return to work, not their neurological disability.

What can we do about it?
In our very own small way, we are planning to do something. We have had our first course in neurological disease and pain last month and introduced therapies such as graded motor imagery and therapeutic neuroscience education for these once untouched neuropathic pains. There are more courses planned in Australia and later for overseas. We are well on the way in planning for pelvic pain courses under neuroimmune refreshed biopsychosocial thinking. And we will fund imagery studies on face pain, pelvic pain and therapeutic neuroscience education for stroke pain, but I think we can all start by listing awareness on groups that are missing out on the very first stage of treatment – “an understanding of why I hurt”. Tell us who you think is missing out.

See you in 2013.

And by the way, thank you so much for all your great feedback from the NOI 2012 conference. With over 600 turning up it was an affirmation that we are on the right track with our teaching.

November NOI Notes submission winner…
Last month we asked for ‘stories from the shadows’ – a story that makes us reflect the deepest on “what is going on here”. The winner’s story of a complex patient state is not able to be published, however, their entry did win them a copy of The Graded Motor Imagery Handbook. Well done Adrian from Warrnambool!

Search for and enquire about new courses here.

References

  1. Bermejo PE, Oreja-Guevara C, Diez-Tejedor E. Pain in multiple sclerosis: prevalence, mechanisms, types and treatment.  Rev Neurol 2010; 50:101-8.
  2. Boorsook, D. (2012). “Neurological diseases and pain.” Brain 135: 320-344.
  3. Bush P, Evans S, Vancaille, T. The $6 billion dollar woman and the $600 million dollar girl. The Pelvic pain report. http://www.fpm.anzca.edu.au/Pelvic_Pain_Report_RFS.pdf
  4. Cacchio A, D. B. E., Necozione S, di Orio F, Santilli V. (2009). “Mirror therapy for complex regional pain syndrome type 1 and stroke ” N Engl J Med 361: 634-636
  5. Khan F and Pallant J. Chronic pain in multiple sclerosis: prevalence, characteristics and impact on quality of life in an Australian community cohort.  Journal of Pain 2007: 8: 614-623.
  6. Kilt H, finnerup NB, Overvad K, Andersen G, Jensen TS. Pain following stroke: a population-based follow up study.  PLoS ONE 6(11): e27607.doi:10.1371/journal.pone.0027607

El Administrao
For new readers: if you would like to continue to receive newsletter updates from us you can sign up for the noi notes – this way you can ensure that your notes go to the right place and that you receive regular, and hopefully interesting information that is pertinent to your profession or interests.

You can also follow this newsletter on the NOI notes archive, and update your profile by logging in to noigroup.com to keep in touch. If you no longer wish to receive information from us please let us know by email with UNSUBSCRIBE as the subject.

That’s all for now. Please stay in touch and we look forward to seeing or hearing from you in the near future!

Cheers and Merry Christmas, from the noisy noisters!

19 North Street
Adelaide, SA 5000 Australia
T: +61 (0)8 8211 6388
F: +61 (0)8 8211 8909
E: info@noigroup.com
W: www.noigroup.com

Learning from the shadows

October 24, 2012
When clinicians go about their daily practice, they will often hear odd complaints and encounter weird findings and anomalies. Most are forgotten but sometimes the findings happen again and again and may well become researchable. For example, many patients with chronic pain complain of sensitivity to cold and following research, cold sensitivity is now an established part of the pattern of central sensitisation. We call this “learning from the shadows” [1] i.e. knowledge hidden in the clinical darkness which makes its way out of the shadows via good clinical behaviours  and which can eventually be put to scientific scrutiny. This is a great example of developing clinical practices driving new research, and complements the other direction of research driving clinical practice.NOI as astonishing anecdote central
At NOI we get about 30 GMI associated requests for help with patients every week, and it allows us to collect a rich narrative about what is happening “out there”, especially in the area of left right discrimination. It’s quite exciting as it often includes success stories such as the person who had severe pain after an eye was surgically removed – left right discrimination tasks hurt , she had to start with the foot and eventually could do ‘vanilla’ hands as her pain eased right back.

Other stories include: consistent loss of left right discrimination in dyslexia, the rare freak-outs when a person with a severely painful and dysfunctional right hand is asked whether a picture of a right hand is left or right, instant reversal of left right discrimination scores in a day, but still some who won’t change, the regular loss of left right discrimination and difficulty imagining movement in osteoarthritic knees. Some stories engender a sense of awe – we have had repeated narrative about spread of pain post whiplash treated with spinal left right discrimination (perhaps keeping central sensitisation in check?) and of young people with CRPS whose left right discrimination scores flipped while attempts at painful desensitisation were made (they seem to think the left is the right and vice versa – a powerful attempt at protection?).

GMI and neurological damage
We are hearing more regular anecdotes from therapists and patients with injured or diseased nervous systems and also how the GMI process can be integrated into management.

Here is an anecdote from NOI instructor Brendon Haslam:

I was recently referred a man who was 4/52 post surgery from removal of a meningioma, following an 8 month history of worsening leg weakness and numbness.  He had previously been a very keen tennis player and runner.  At his first appointment, he walked in reporting feelings of poor hip control both in stepping and stance.  He had no active left dorsiflexion or toe extensors, and said he had the feeling of a ‘flicker’ of calf activity in the past week.  His surgeon had told him he was confident in the results of the surgery. Reassured by this, he saw any improvements as a bonus, but was understandably keen to get to the highest functioning level possible.

He described having weird feelings in his foot, a mild lack of ownership (“it’s just not quite right”), but denied having any pain. We discussed the notion of utilising GMI in addition to use of hands on facilitatory techniques to try and gain extra awareness of movement. He was happy to try anything, and followed the reasoning explained to him about how GMI could help. We initially used Recognise Online (vanilla feet) with good results within the session, scoring >90% accuracy and reaction times just over 1 second after initial trial ‘learning’ run.  Feeling confident with such good Recognise results, we then went straight to mirror therapy (using an upright mirror in sitting). Instantly he felt a sense of ownership of the reflected image of his leg and foot, and got very excited at this. Starting with some basic PF/DF, he felt as if was getting some activation left foot and calf, and noted flickers of tib ant and antigravity calf were visible within a couple of minutes. He then rested, and repeated the task, with further improvements with some slight antigravity dorsiflexion/inv (but no toe extension). We then took the mirror away so he could see the active movement he was now performing.  He was blown away by this and keen to keep going.

The session then changed tact a little bit to try and get some more unilateral movement without relying on the mirror or the good leg, and so utilised some PNF lower limb patterns in supine, with a further increase in active movement throughout leg, and the distal component coming in repeatedly. This was progressed into free active patterns (with no operator) on the plinth, with the mirror on the affected side (at the side of the plinth) so he could see the active movement occurring at all areas (trying to get visual reinforcement for extra sensory input, as well as the feel good factor).

At the end of the session, I discussed the option of setting up a home upright mirror to enable him to recreate the movements performed at home, in addition to some easy visualization activities to perform during the day.

He returned 5 days later feeling great. He had not only consolidated his active movement gains, but progressed them. He was able to consistently recruit dorsiflexion (inversion biased), and had even tried some gentle hits of tennis!  Within this second session, he was able to recruit toe extensors (gt toe> others) with firing of EDB as well. He reported increased balance skills and confidence, doing more outdoors and genuinely excited about where he’s going. He then asked the question “why wasn’t this started sooner?” and informed me that he is thinking of flying overseas in a few weeks providing he gets the okay from his surgeon! I’m due to see him again today for his third session, and can’t wait to see where it goes. Clearly there has been that underlying potential there for a while, it was just a matter of finding the right ‘switch’ to create an opportunity to tap into it.”

More please!
We are expecting more stories, especially as we are about to begin a new course called Pain, Plasticity and Rehabilitation where we introduce GMI strategies to the neurologically damaged patients. Chronic  pain is common and attempts to treat it are often not attempted.

Keep the ‘stories from the shadows’ coming in. We will give a copy of The Graded Motor Imagery Handbook to the story that makes us reflect the deepest on “what is going on here”. Submit your story to info@noigroup.com 
Search for and enquire about NOI courses here 

 

References

  1. diSessa, A.A., A bird’s-eye view of the “pieces” vs “coherence” controversy., in International Handbook on Research on Conceptual  Change S. Vosniadou, Editor. 2008, Routledge: New York.
  2. Moseley, G.L., et al., The Graded Motor Imagery Handbook 2012, Adelaide: Noigroup.

Recent conferences

A big hooroo and thank you to the people who visited the NOI stands at IFOMT2012, Quebec City, Canada, and also the AHTA conference in hometown Adelaide.

El Administrao
For new readers: if you would like to continue to receive newsletter updates from us you can sign up for the noi notes – this way you can ensure that your notes go to the right place and that you receive regular, and hopefully interesting information that is pertinent to your profession or interests.

You can also follow this newsletter on the NOI notes archive, and update your profile by logging in to www.noigroup.com to keep in touch. If you no longer wish to receive information from us please let us know by email with UNSUBSCRIBE as the subject.

That’s all for now. Please stay in touch and we look forward to seeing or hearing from you in the near future!

Cheers, from noigroup team

19 North Street
Adelaide, SA 5000 Australia
T: +61 (0)8 8211 6388
F: +61 (0)8 8211 8909
E: info@noigroup.com
W: www.noigroup.com

Left and Right – take care with the hype

July 12, 2012

As producers of the materials and investors in some of the research behind Graded Motor Imagery, it is our hope that users will utilise it as well as possible. Questions from patients and clinicians pour in daily, although The Graded Motor Imagery Handbook has eased some of the pressure. These Notes look at the most common questions and issues around stage 1 of GMI – left right discrimination. The main reference for all the answers is The GMI Handbook and particularly research by Sarah Wallwork and Jane Bowering at the University of South Australia and Lorimer Moseley at numerous institutions.

First – Left right discrimination – what is it?
Left right discrimination (LRD) or ‘laterality’ is the ability to identify an image of a body part as left or right or in the case of the spine, to identify if the person in the image is turning (leaning/rotating) to the left or right side.

Is this a left or right hand?  
Is this person turning (leaning/rotating) to the left or right?  

LRD is known to be altered in a number of neuropathic pain states such as CRPS and phantom pain and we have repeated anecdotal evidence of left right discrimination changes in a variety of states ranging from post spinal cord injury pain, fibromyalgia, carpal tunnel syndrome, limb immobilisation and dyslexia. We would not be surprised to observe changes in any neuropathic pain state nor would we be surprised if left right discrimination ability was intact.

See the section on ‘tools’ below for information about getting a free Recognise trial and low cost downloads of the Recognise Apps (hands or feet) for the next 5 days.

“What is normal?”
Everyone asks us this. I am not sure I know what a normal human being is, but here are a few suggestions from the studies so far.
Our broad suggestions for normal responses to a left right discrimination test are:

  • Accuracy of 80% and above, but why not aim for more!
  • A speed of 1.6 seconds +/- 0.5sec appears quite normal for necks and backs. Hands and feet are a little slower with an average speed of 2 seconds +/- 0.5 seconds
  • Accuracies and response times should be reasonably equal left and right
  • The above figures should be quite stable, i.e. they don’t fade out with stress and are consistent for at least a week.
  • A judgement will also be needed on the personal relevancy of the responses. For example, minor left right discrimination changes may not be so relevant in a person who has a severe pain related incapacity, whereas they may be more relevant in a person with a much more minor problem. This is a clinical reasoning judgement.

“But it’s not working – the scores don’t seem to change!!”
Now that is a good question. You may need to remember that you may have a patient with unrelenting neuropathic pain for 10 years, untouched by any therapy who can’t begin to comprehend that the problem may be in their brain. Give 1 in 10 of such a patient significant relief and you will be doing better than the most powerful drugs on the market.

My typical advice for when LRD scores no longer improve:

  • Has it been done enough? (might need up to 2 hours a day)
  • Has it been done for long enough? (might need weeks or months)
  • Has it been done in different contexts and with different tools? (use the online program, flashcards, apps, magazines, photo albums in safe and non-safe places and in different moods)
  • Is it being done properly? (a quick but relaxed and automatic decision)
  • Has it been embedded in a favourable education context? (can they engage their brains or is it off limits?)
  • Is there an existing brain injury? (perhaps it was never going to change much)

“My patient is faster on the sore side”
Maybe your patient is a rabbit? In acute experimental states, it has been noted that participants are faster on the sore side. That kind of makes sense if you want to protect a sore part you can make an evaluative bias. In a chronic state – whenever that is (is it a few weeks or a few months?) – it appears that they get slower. It’s one of those things – all output systems seem to vary over time as the self seeks homeostasis.

“Does being left or right handed make a difference to scores?”
No, there is nothing special about being a leftie.

“Does age make a difference?”
No, we oldies are pretty slick. Nor is there any gender effect and I guess you wouldn’t expect there to be.

Why are there rotated images?
We have had a few queries about the rotated images. The reason for rotation is to push the brain that little bit more. An image which is upside down (rotated by 180 degrees) will always take longer, or is more difficult, to judge as left or right than if it was upright or on its side.

Some of the GMI tools available
There are always plenty of GMI tools at your fingertips. Run through your Facebook photos or dust off the albums and pick out all the left hands. Use a magazine to do the same. Try turning it upside down!

We have also built some easy to use and accessible tools. Recognise is the computer program and anybody can sign up for a free 5 login trial to test their LRD or do motor imagery exercises.

Apps are available as ‘Recognise hands’ and ‘Recognise feet’ for iPhones and Androids. Go to the iTunes App store (iPhones) or Google Play (Androids) to get the App for an unusually low price over the next 5 days! This offer ends July 18, 2012.

Flash cards are available as sets of 48 pictures (24 lefts and 24 rights) in Hands, Feet, Necks, Shoulders and Backs. Play games like ‘fish’, ‘snap’ or ‘memory’. Build a fear hierarchy based on the different postures and work through them gradually.

The NOI Mirror Box is also useful for progression through the stages in GMI.

Write to us
We love hearing about any experiences you’ve had (good or bad) using GMI. Your feedback helps us to direct research, develop tools and share anecdotes. Get in touch on recognise@noigroup.com.

Links
What is patient empowerment?
How a bee’s brain can change with new tasks
New findings: Blaming the brain for chronic pain
The Pain Toolkit
Does evidence support physiotherapy […] in CRPS-1. A systematic review, 2009.

Hot NOI courses in the next 2 months!
14 – 15 Jul Mobilisation of the Nervous System, London, UK
16 – 17 Jul Mobilisation of the Nervous System, Derby, UK
27 – 28 Jul Schmerzen Verstehen, Burgau, DE
5 – 6 Aug Schmerzen Verstehen, Bremen, DE
18 – 20 Aug Das Sensitive Nervensystem, Hamburg, DE
18 – 19 Aug Mobilisation of the Nervous System, Jaipur, IN
25 – 26 Aug Mobilisation of the Nervous System, Pune, IN
8 – 9 Sep Explain Pain, Chicago IL, US
14 Sep Graded Motor Imagery, Arnhem, NL
15 – 16 Sep Explain Pain, *CLOSED COURSE**, US
15 – 16 Sep Schmerzen Verstehen, Bremen, DE
15 – 17 Sep Mobilisation des Nervensystems, Zurzach, CH

Search for and enquire about NOI courses here

Body love and GMI

June 6, 2012

Those who came to the recent NOI neuroscience festival in Adelaide will have noted more education and research devoted to Graded Motor Imagery. The Graded Motor Imagery Handbook[1] is now available. Due to popular demand, the next two NOI Notes are devoted to the topic of Graded Motor Imagery from the clinical viewpoint.

Graded Motor Imagery as a toddler
Lorimer and I have always been very wary of clinical implementations of GMI. We used to call it embryonic for years. It is increasingly becoming popular and we want it to be done as best as you can. This means using clinical reasoning to tailor it for individual patients (no recipe books here!), linking it to education, making it a part of a package that deals where possible with all relevant contributing issues to a person’s problem and being prepared to grade, adapt and move along the scale of therapies in GMI (see Figure 1 below from The Graded Motor Imagery Handbook which shows where GMI ‘sits’ in overall management). It’s no magic cure – it’s hard work in a patient group with problems that, in many cases, are harder to treat than some cancers.

Figure 1: GMI as part of an overall rehabilitation process

Part of the growing up process of a proposed treatment strategy is to see what pain states may benefit and to keep an eye on what is happening in basic sciences. While the relevance of Graded Motor Imagery in neuropathic pain states such as CRPS is supported[2], what about other pain states, including some that may be “not so neuropathic”?

How scientific is that categorisation!!! But the clinicians will know what I am referring to.

Post ankle fracture stiffness – is it all in the ankle?
A friend of mine asked me to see her husband. He had fractured/dislocated his left ankle 5 weeks previous. The ankle had been internally fixated and he had been given a moonboot and told not to weight-bear. Little information was provided post-surgery and he had the moonboot on all day and night, even the same post-surgical dressings. He said the ankle was going red – it was super stiff and with a history of RA. He was very concerned about the future. Notably, he said “he didn’t like the foot, especially with screws in it?” and “it didn’t feel like his”.

The ankle was very stiff but my original fears of CRPS were quickly dispelled. This of course is basic rehabilitation – start weight-bearing, graduated stretching and strengthening, balance and education. But I also tested the speed and accuracy of left/right foot discrimination via Recognise.

Anybody can sign up for a free 5 login trial account to test left/right discrimination at http://noigroup.com/recognise/createaccount.

There were differences. He was inaccurate identifying left feet compared to the right and generally slow (around 3 seconds – ‘normals’ are around 2 seconds). With practice (around 150 tests over 6 days) they resolved quickly (left accuracy = right, and times were 2 seconds and under). This is a glorious anecdote of course – there may have been regression to the mean (extreme variations are inevitably followed by average variations), there may have been the effects of multiple treatments – perhaps just getting going and using the foot is enough to restore any left/right discrimination issues, and we all probably suffer a bit of confirmation bias as we look for what we want to believe. But the questions raised from this anecdote include:

  • Is there a place for exercise of neurosignatures of immobilised parts?
  • Could it offer some protection against CRPS?
  • Are clues such as “my foot doesn’t feel like mine” indicative of changes of representation in the brain?

Figure 2: Results in Accuracy and Speed from Recognise
As you can see the general accuracy improved but still there was far more 100% results compared with the left foot and there was a general decrease in speed of recognition. The speed results at the end of 6 days are regarded as normal.

Love and the foot
I took something else from the clinical encounter. My friend who is very perceptive said to me as I left after the second visit “you just got him to love his foot again didn’t you?” Well, love wasn’t something I had planned with his foot (still in its original dressing) but I reflected on what was essentially a basic treatment focussing on an unloved body part with its laterality not quite discriminated in the brain suggesting foot representational changes in the brain.

I can go with the notion of ‘loving the foot’ as a broad direction to reintegrate/restore brain representation of the part. The integrative activity of multiple sensory inputs such as vision, motor, touch and proprioception plus the ‘welcoming back’ emotions and cognitions would seem enough to activate micro and macroglia keeping an eye on and re-embellishing the synapses which truly belong to the best functioning foot for that person. Mind you, the neuroscientists don’t quite say this directly (yet) but you feel as though they are itching to! Check out one of a number of reviews on the immune system and plasticity[3].

Suggestions for clinicians
We enjoy and learn from feedback about graded motor imagery. We call it ‘learning from the shadows'[1] – contact us at recognise@noigroup.com if you’ve had similar findings with Recognise testing.

The online Recognise software is free for anybody to use as a trial for 5 logins, so give it a go in a pain state. If you get these Notes you’re already a member so use your Noigroup membership email and password to sign in at http://www.noigroup.com/recognise or to set up a new account, go to http://www.noigroup.com/recognise/createaccount.

Next month we will take a closer look at left/right discrimination. – David

References
1. Moseley, G.L., et al., The Graded Motor Imagery Handbook 2012, Adelaide: Noigroup.
2. Moseley, G.L., Graded motor imagery for pathologic pain. Neurology, 2006. 67: p. 1-6.
3. Yirmiya, R. and T. Goshen, Immune modulation of learning, memory, neural plasticity and neurogenesis Brain, behaviour and immunity, 2011. 25: p. 181-213.

A bit more reading
Here is a brilliant article by Jonah Lehrer, published in The New Yorker in 2010, about The Decline Effect.

Last Notes on Brain Food
Download the bite sized recipe book from our last edition, Brain Food. Congratulations to Ewa from Australia for your delicious, simple, fresh and healthy grilled piece of oily fish. In keeping with the NOI philosophy, we loved the adaptability of the ‘recipe’ as much as the healthy ingredients suggested. You now have a copy of Explain Pain and a box of Haighs dark chocolate coming your way in the post.

12 Recipes from around the world [PDF]

…A grilled piece of an oily fish such as salmon or tuna, a side of fresh green salad (preferably straight out of the garden), dressed with parsley, raspberries and avocado dressed with a good cold pressed olive oil and balsamic vinaigrette on top, with a side of some whole grain such as brown rice/quinoa/barley for the hungry person, this could have some very lightly toasted slithered almonds and walnuts mixed through with a light drizzle of olive oil again.

Fish / Salad greens (from the garden) / Parsley / Raspberries / Avocado / Good olive oil & balsamic / Whole grains (brown rice/quinoa/barley) / Toasted almonds and walnuts

El Administrao
For new readers: if you would like to continue to receive newsletter updates from us you can sign up for the noi notes – this way you can ensure that your notes go to the right place and that you receive regular, and hopefully interesting information that is pertinent to your profession or interests.

You can also follow this newsletter on the NOI notes archive, and update your profile by logging in to http://www.noigroup.com to keep in touch.

That’s all for now. Please stay in touch and we look forward to seeing or hearing from you in the near future!

Cheers from the Noigroup team

NOI Notes on Brain Food

February 8, 2012

Bacon and egg icecream
When master chef Heston Blumethal first made bacon and egg icecream at his restaurant, The Fat Duck, in the UK it was apparently pleasant, but not really that “baconny” or “eggy”. However, when a piece of crispy fried bread was added to the plate, the bacon and egg flavours really emerged. The bread didn’t add much flavour but the bacon flavour must have been lifted by the bread providing a awareness of crispy texture [1]. There are many similar examples; oysters taste better if you hear waves, you can believe that an old potato chip is fresher if you change the crunch sound through headphones when you eat it. Those who like strong coffee will drink more if they are under strong lighting, but if you like weak coffee you will drink more under dim lighting (See Spence [1] for a fascinating review).

What this is saying of course is that our sensory perceptions rely on many senses. Those who wear glasses think that they hear better when they wear their glasses; you smell different things when you sniff red or white wine – but even experts smell red wine characteristics in white wine coloured red! [2]. What has it got to do with rehabilitation and pain?

Slippery prawns, silky tofu
It is not only smell, vision, sound, and sometimes touch (oh the sensual texture of a silky tofu!, the slippery fresh firm prawn being peeled!) which contribute to taste perception, it’s also the environment – time of day, dining companions, candle, tablecloth etc. We can actually be quite biopsychosocial when it comes to working out what constructs the brain output of taste! Taste, like pain, is not solely an input as is often taught – it is a multimodal output constructed by taste neurosignatures. (You can have taste perceptions without anything in your mouth). We can learn a lot about how the brain works by contemplating neurogastonomy – the topic of a plenary lecture by Professor Charles Spence from Oxford University at the NOI 2012 conference. It should also make us take a closer look at how pain is constructed in the brain.

The act of eating and brain health
The very act of eating not only refuels the most energy hungry organ in the body, it stimulates the mind in a number of ways. For example, eating and thinking of eating produces gut peptides such as insulin and leptin (a la Ivan Pavlov), helpful in digestion of course but which are also known to influence cognitive processes and have direct effects on plasticity [3]. It would seem that a healthy variety of sensory inputs while eating could enhance the beneficial brain effects to the point where any of the senses can stimulate healthy neurochemistry – ah…. just looking at a ripe crunchy apple makes me feel and think better. My conversation over dinner is always better with a candle lit and especially with certain people.

But food can also be used in other ways…

Feed your synapses
We are now more and more aware that the nutrients in some foods can alter brain function, specifically cognition and mood. There has been some pop-science around but good evidence is emerging. The Omega-3 fatty acids that we source in our diets (in fish especially salmon, walnuts, kiwi fruits) and don’t produce ourselves, are important cell membrane components and enhance neuroplasticity. Examples of other nutrients which have shown beneficial effects on brain function include Vitamins B, D and E, turmeric, calcium and zinc (eat your oysters!), choline (in eggs, chicken, veal and turkey) and the natural sugars produced in plants. However, excessive calorie intake may limit any benefits and saturated fats can promote cognitive decline. Beneficial cognitive effects are enhanced by exercise. If we are into education about sensitivity, then all rehab groups should be taking this information to the public. See Gómez-Pinilla (2008) for a review.

There is more..

Food and Pacing
A clever psychologist I know told me how you could use food in pacing. She told me about an elderly Greek lady with chronic upper body pain where a therapist insisted that hydrotherapy would help, despite the fact that the patient hated water. However, with a goal of cooking a meal for a special event and planning and executing all the cooking over a week, breaking down the activities, she achieved what she thought was impossible and had significant pain relief. And the cooking gets them moving more, out more (shopping) and interacting with more people. If it’s graded, your nerves will love all the physical exercise as well.

Fabulous plasticity enhancing food at the NOI conference
Food has a high profile at the NOI 2012 conference with lunchtime activities and workshops on all three days. The conference dinner will be a beauty with South Aussie specialities, enhanced by sensory input such as music and stunning acts. There will be food tastings in the exhibition hall, and a bit of trickery using food to show you how important all the senses are. Our conference is linked to the Tasting Australia Festival which is in Adelaide this year. We have a special workshop on food and pain. Ian Parmenter, well known to Australians for the cooking show ‘Consuming Passions’ discusses pain and hospital food; ‘at-the-coalface psychologist’, Maria Polymeneas talks about using food for pacing activity; Talitha Best from the University of South Australia discusses the recent evidence on nutrition and cognition and Charles Spence from Oxford University discusses multimodal integration and taste.

We think a powerful message from food is that many ‘things’ can be used to treat pain, for example, movement, art, dance, work and food. (Awesome art exhibition at the conference). Take a sidestep for a moment: we are suggesting that the most successful meal for body and brain is one that not only has the best nutrients but one that includes maximal integration of the senses for that place and time. The lessons of taste tell us that an injured worker should ideally return to work with effective multimodal integration – being able to integrate all the smells, noises, visual, touch, emotional and contextual inputs of the workplace without kicking off pain and stress responses. Let’s eat!

 

References
1. Spence, C., The multisensory perception of flavour. The Psychologist, 2010. 23: p. 3-4.
2. Morrot, G., F. Brochet, and D. Dubourdieu, The Color of Odors Brain and Language, 2001. 79: p. 309-320.
3. Gómez-Pinilla, F., Brain foods: the effect of nutrients on brain function. Nature Reviews Neuroscience, 2008. 9: p. 568-578.

Links
From the US and know somebody about to undergo low back surgery?
Are you a Physio? Have you seen this petition yet?

Moseley, Butler, Thacker, Louw: Teaching people about pain. 90 mins with slides.
NOI 2012 Conference Programme
IFOMPT Conference, Montreal, Sept-Oct 2012
Skiing: Legs of steel
Getting over skiing injuries