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Full Course Details: Public course page
Learn more about our guest: Irvin Eisenberg, MOT
Agenda
Intro (5 minutes)
Breakdown and analysis of journal article (5 minutes)
- 00:00:00 Intro to Pain and OT
- 00:01:00 OT Potential Podcast Intro
- 00:02:27 Intro to Chronic Pain
- 00:03:02 Problems with Classical Understandings of Pain
- 00:03:47 Intent of this Article
- 00:04:10 The Distributed Processing of Nociceptive Information with the Spinal Cord
- 00:05:45 The Distributed Processing of Nociceptive Information with the Brain
- 00:07:36 Distributed Treatment
- 00:09:12 Article Conclusion
Discussion on practical implications for OTs (50 minutes)
- 00:10:11 Intro to Irvin Eisenberg
- 00:15:56 Opening his Own OT practice
- 00:20:11 Impressions of the Article
- 00:28:28 Talking about Pain with Clients
- 00:34:48 Story about the Tremendous Power of the Brain to Regulate Pain
- 00:39:01 Go-to Assessments for Pain
- 00:45:43 Irvin’s Holistic Approach to Pain
- 00:58:43 Advice for OTs who are Interested in Starting a Pain Private Practice
- 01:00:25 Final Thoughts
Supplemental Materials
- Role of occupational therapy in pain management
- The effect of occupational engagement on lifestyle in adults living with chronic pain: A systematic review and meta-analysis
- Why You Hurt- Education from Adriaan Louw
- Centralized Sensitization Inventory
Article Review
Read Full Text: The Distributed Nociceptive System: A Framework for Understanding Pain
Journal: Trends in neurosciences
Year Published: 2020
Ranked 100th on our 2019-2023 list of the 100 Most Influential OT Journal Articles
I once heard a neuroscientist say:
Many of our frameworks end up being wrong—because the body is more complicated than we ever imagined.
Pain science perfectly illustrates this. We are living in an era where new frameworks are being written—because classical understandings of pain have not only been inadequate, but have also led to ineffective (and even harmful) treatment.
Today, we look at a new framework for understanding pain.
And, it brings good news for OT.
The authors argue that because chronic pain is such a complex condition, it requires the kind of holistic treatment inherent to OT and PT.
To help us unpack what this all means for your daily OT practice, we are excited to welcome to the podcast Irvin Eisenberg, owner of Resilience Occupational Therapy, where he helps members of his community manage their pain.
Big-picture introduction to chronic pain
Chronic pain affects more than 30% of the global population—making it the leading cause of disability worldwide.
Part of the reason chronic pain remains so widespread and debilitating is that our understanding of the systems behind it is sharply limited.
We still can’t fully explain the central nervous system mechanisms that process potentially noxious information into our subjective experience of pain.
The article refers to this process as the “nociceptive system.”
The problem with our classical understanding of chronic pain
Focusing on single neurons, single molecules, or single brain regions has left us with an incomplete understanding of pain—thus rendering our efforts to develop new pain treatments largely unsuccessful.
Many of these efforts have revolved around pharmaceuticals. In short, we’ve been looking for a pain-busting miracle drug.
But medications for chronic pain are startlingly ineffective—and new drugs often fail to outperform a placebo.
Meanwhile, more effective and holistic therapies for chronic pain—like OT and PT—are underutilized and under-reimbursed.
What is the intent of this article?
In this article, leading pain scientist Robert Coghil, PhD, lays out a framework for understanding pain. He calls it the Distributed Nociceptive System.
Full disclosure: There is a ton of complicated science here, so I am going to stay focused on the big-picture takeaways.
The distributed processing of nociceptive information with the spinal cord
Recent research now indicates that the spinal cord BY ITSELF has the ability to:
- Encode multiple dimensions of sensory information, like intensity and location.
- Formulate complex motor responses to noxious stimuli.
Historically, we’ve been taught that the dorsal horns of the spinal cord are engaged in sensory processing, whereas the ventral horns are engaged in motor processing. I even found a graphic that reinforces this understanding:
We now know this to be untrue; pain processing actually is distributed across both the ventral and dorsal horns.
Additionally, nociceptive input historically has been ascribed to laminae 1-5. This also has been labeled untrue. Nociceptive processing is distributed across multiple laminae.
In short, processing can take place at multiple locations along the spinal cord—making the signal extremely hard to disrupt.
Unfortunately, these classical tenets of pain have led doctors to surgically cut the spinal cord in order to alleviate chronic pain—only to have their patients’ pain return. The theory here is that over time, an alternative pain pathway becomes engaged.
The distributed processing of nociceptive information with the brain
In the brain, the story is the same. We are discovering redundancy upon redundancy, ultimately ensuring that pain information is processed—even when one tract or large portion of the brain is damaged.
For example, classical views of pain once associated sensory processing to the lateral nuclei of the thalamus—and motivational processing to the medial nuclei. We now know that both of these brain sections have the ability to process pain.
Part of what we now know about pain processing comes from more advanced science around particular brain regions. But, we’ve also added to our knowledge by studying cases where specific brain regions are injured—yet somehow, pain persists.
In what the author calls a horrific example of the resiliency of pain, he describes the case of a patient who had facial pain following shingles. Surgery was performed to:
- Resect the sensory root of the trigeminal nerve;
- Excise the contralateral somatosensory cortex for the face;
- Excise the ipsilateral somatosensory cortex for the face; and
- Excise the bilateral prefrontal cortex.
Basically, anything that might carry the pain signal was removed—and yet, the pain remained.
This all leads to the central tenet of this new pain framework:
The extraction and utilization of nociceptive information is a process that can be accomplished separately and largely independently by multiple sites within the central nervous system.
Pain: a Distributed Problem Calling for a Distributed Treatment
We now can see why surgery often fails to disrupt pain.
We can also see why medication targeting a single neurotransmitter or neuromodulator is so ineffective.
There is a clear need for treatments that target distributed systems. Luckily, they do exist—they are simply underutilized. The author highlights two main categories of such treatment:
Multidisciplinary treatments incorporating cognitive behavioral therapy
Emerging evidence indicates that multidisciplinary teams who incorporate cognitive behavioral therapy into treatment can substantially alter pain by targeting multiple brain areas.
Specifically, combined cognitive behavioral, physical, and occupational therapy has been shown to decrease connectivity of the left amygdala with the:
- Prefrontal cortex
- Motor cortex
- Cingulate cortex
- Anterior insula
Mindfulness meditation
Compared to a topically applied placebo cream, meditation has been shown to produce greater reduction in both pain intensity and pain unpleasantness. It also demonstrated a distinct pattern of deactivation in the cingulate cortex.
Conclusion
Extraction and utilization of nociceptive information can occur at lower levels of the nervous system—and across multiple, distinct brain regions.
This framework helps explain why the nociceptive system is so resilient—and thus, difficult to disrupt.
We still rely far too heavily on focal pharmacological modalities. And, we fail to capitalize on the tremendous power of the brain to regulate pain.
Bottom line: There is a critical need for more multimodal treatments aimed at addressing both chronic and acute pain.
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