Practical Case Management

Fred Clary, DC1752 Lexington AveRoseville, MN 55113651-487-5950drfredclary@yahoo.com

Taking a different perspective

Neurology Milestones or Dead Dogmas

Before late 1990’s, brain tissue can not heal After 2001, the brain is highly plastic, continually adapting and

modifying throughout adult life Before 2002, the thalamus is a midbrain afferent relay

structure After 2002, the thalamus regulates the quantity and quality of

information reaching the cortex and modifies the information before its final destination

Before 2000, no adult stem cells exist in the CNS After 2000, adult stems cells found, they are numerous and

act as glia cells when not regenerating circuits

Neuroplasticity-Does it matter?

Neuroplasticity is a fundamental issue that supports the scientific basis for treatment of brain injury and functional movement disorders with goal-directed experiential therapeutic programs in the context of rehabilitation approaches to the functional consequences of the injury.

The adult brain is not "hard-wired" with fixed and immutable neuronal circuits. There are many instances of cortical and subcortical (thalamic!) rewiring of neuronal circuits in response to training as well as in response to injury. There is solid evidence that neurogenesis, the formation of new nerve cells, occurs in the adult, mammalian brain--and such changes can persist well into old age.

There is now ample evidence for the active, experience-dependent re-organization of the synaptic networks of the brain involving multiple inter-related structures including the cerebral cortex

Neuroplasticity- Say that Again!

Neuroplasticity: The brain's ability to reorganize itself by forming new neural connections throughout life. Neuroplasticity allows the neurons (nerve cells) in the brain to compensate for injury and disease and to adjust their activities in response to new situations or to changes in their environment.

Brain reorganization takes place by mechanisms such as "axonal sprouting" in which undamaged axons grow new nerve endings to reconnect neurons whose links were injured or severed. Undamaged axons can also sprout nerve endings and connect with other undamaged nerve cells, forming new neural pathways to accomplish a needed function.

For example, if one hemisphere of the brain is damaged, the intact hemisphere may take over some of its functions. The brain compensates for damage in effect by reorganizing and forming new connections between intact neurons. In order to reconnect, the neurons need to be stimulated through activity.

Neuroplasticity sometimes may also contribute to impairment. For example, people who are deaf may suffer from a continual ringing in their ears (tinnitus), the result of the rewiring of brain cells starved for sound. For neurons to form beneficial connections, they must be correctly stimulated.

Simply put the brain compensates, the patient learns to be well or be sick!

Its Biology (Evolutionary Biology). Not Opinions…

not all neural plasticity is beneficial The brain is driven by efficiency, so if a

bad signal (program) continues to run the brain simply becomes plastic and saves resources

Less input is requires to get the same output (result) whether its physiological or pathological…

Chronic Pain

As a nociceptive circuit continues to run, the CNS, in order to save resources, will make this signal more efficient…this can lead to Fibro, Chronic Pain Disorders, etc…

Nociception is just one of many modalities under the influence of neuroplasticity, motor programs are just as resourceful…

Pain is noted as being a "dark side" of neuroplasticity. But, if the brain can learn its way into pain, it can learn its way back out.

Popular Lit????

They even spelled Thalamus Correctly!!!

Thalamic Integration & Summation

Thalamic Summation: All Sensory Afferent Information is Summated in the Thalamus

Thalamic Integration: All Sensory Afferent Information is integrated in the thalamus

Cortical Firing: Cortical Firing is dependant Upon Thalamic Summation & Thalamic Integration

A Review

Receptor Driven

We are receptor driven Everything we do to a patient changes

the firing of their receptors If you are stuck (restriction, movement

asymmetries) , you are destined to fire the same population of receptors

Processing Constraints

The midbrain must make decisions on what afferentation, receptor inputs are allowed to the cortex for firing

These many inputs lead to an efficient output

If one or more inputs are changed, the output is changed

Even Motor Programs are now thought to have a final pass or ‘flavoring’ from the thalamus before output

It’s the Cook in the Kitchen that determines the meal’s elegance.

Lack of proper proprioception leads to aberrant local and global movement patterns (dysponesis)

Improper sensory integration leads to inefficient/ imbalanced efferent yield, local/global efferent dysfunction, disability, disease states, symptoms and loss of human potential

Aberrant local and global movement patterns habituate (pathological neuroplasticity) unless modified, attenuated and eliminated from the input side.

Physiological filtering and through the through the thalamus is one therapeutic window in which we can reach the CNS.

It’s the Thalamus? Come On

Because of the structural and cellular neurophysiological constraints , the thalamus interprets global movement, stabilization and multi-joint movements over an isolated joint movement –Its sees Patterns…CPGS!

That neg. MRI, chronic shoulder pain & dysfunction just might be an ankle problem!

Why Does the Thalamus See Patterns –The Importance of Metabolic Efficiency of

Neural Processing

Each movement places local and global demands on energy…the region of the body that demands the highest attention for energy resourcefulness is the CNS… Approximately 50-80% of the mammalian brain's energy use appears to be due to neural signaling…The brain uses 20% (up to 50% in children) of the body’s resting metabolic energy…

Neural processing is metabolically expensive. These metabolic demands could be large enough to influence the design, function and evolution of brains and behavior. If metabolic energy is limiting, then neurons, neural codes and neural circuits will have evolved to reduce metabolic demands. Metabolic efficiency can profoundly influence neural coding. The minimization of metabolic cost promotes the distribution of signals over a population of weakly active cells.

The brain will always choose the most efficient firing pattern the saves resources (energy) in the CNS in the NOW…whether that movement pattern is in the long term interest of the organism or not…the brain must be changed (made efficient) in programs that lead to long term efficiency for the organism as a whole…

The Hungry CNS Rules…Say that again…

The brain is one of the most energy-expensive tissues in the body, as it uses large amounts of metabolic energy for information processing. Because of this, neural codes are constrained not only by a combination of structural and functional requirements, but also by energy demands

All Effective Rehab is Brain Rehab!

Neurophysiological Partitioning: since the CNS controls and regulates all physiological process of the human body, these optimizations must occur at the microscopic cellular level in the nervous system first.

All these changes can be explained by considering the process of energy efficiency of neural communication and neural processing. Energy (available ATP) is finite. It is reasonable to assume that the limiting factor for this energy efficiency optimization process is the use of available ATP. Thus, to optimize neurological programs, the CNS will shunt and mobilize ATP to the areas of greatest physiological need in the CNS.

Synergistic Neurophysiological Efficiency: Over time, all neural processing moves to the most energy efficient state. Neuroplasticity is driven by long term efficiency of the information processing NOT the long term survival needs of the individual.

Neuronal communication and computation are efficient when considered in the dual (synergistic) context of energy and information rather the either context alone.

It’s the Patterning!

Organisms must adapt their behavior to meet the needs of their internal and external environments. Central pattern generators, as part of the neural circuitry of an organism, can be modulated to adapt to the organism's needs and surroundings. Three roles of modulation have been found for CPG circuits:

Modulation in CPG as Part of Normal Activity –GET Efficient!!!

Modulation Changes the Functional Configuration of CPGs to Produce Different Motor Outputs –You can change the movement by a variety of inputs!

Modulation Alters CPG Neuron Complement by Switching Neurons Between Networks and Fusing Formerly Separate Networks into Larger Entities –CROSS Training!!!!

Life is all about choices…

In all of its functions, the brain seeks optimum efficiency, or the path of least resistance. If one particular function is not accessible, the brain will automatically go on to the next most efficient process for doing that particular task. If the second task is not available, it will go on to the third or the fourth most efficient way. Because each alternative process is less efficient, it becomes more stressful and energy expensive.

The brain will keep searching for an appropriate processing method, until eventually the activity may become so subconsciously stressful (energy greedy) that the person will choose to give up trying to do the task altogether. If it is a conscious activity, the individual will give up the fatiguing activity. If the process is unconscious, the individual will decrease the energy partitioning to that process, making this unconscious activity minimized, nonfunctional or detrimental to the whole, depending on where the process is located in the physiological hierarchy.

Big Words…Big Concepts

Neurophysiological Partitioning: since the CNS controls and regulates all physiological process of the human body, these optimizations must occur at the microscopic cellular level in the nervous system first.

All these changes can be explained by considering the process of energy efficiency of neural communication and neural processing. Energy (available ATP) is finite. It is reasonable to assume that the limiting factor for this energy efficiency optimization process is the use of available ATP. Thus, to optimize neurological programs, the CNS will shunt and mobilize ATP to the areas of greatest physiological need in the CNS.

Synergistic Neurophysiological Efficiency: Over time, all neural processing moves to the most energy efficient state. Neuroplasticity is driven by long term efficiency of the information processing NOT the long term survival needs of the individual.

Neuronal communication and computation are efficient when considered in the dual (synergistic) context of energy and information rather the either context alone.

It’s the Pattern that is seen not the delt…

Although the theory of central pattern generation calls for basic rhythmicity and patterning to be centrally generated, CPGs can respond to sensory feedback to alter the patterning in behaviorally appropriate ways. Alteration of the pattern is difficult because feedback received during only one phase may require changed movement in the other parts of the patterned cycle to preserve certain coordination relationships.

For example, walking with a pebble in the right shoe will alter the entire gait, even though the stimulus is only present while standing on the right foot. Even during the time when the left foot is down and the sensory feedback is inactive, action is taken to prolong the right leg swing and extend the time on the left foot, leading to limping. This effect could be due to widespread and long-lasting effects of the sensory feedback on the CPG or due to short-term effects on a few neurons that in turn modulate nearby neurons and spread the feedback through the entire CPG in that way.

WE have a window to all movements once we recognize it…IF the program exists in the first place…

Am J Orthop. 2003 Jul;32(7):330-6.

Peripheral and central nervous system mechanisms of joint protection.

O'Connor BL, Vilensky JA.

Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, Indiana, USA.

Although there are many risk factors (such as age, family history, and obesity) associated with the development of osteoarthritis (OA), only trauma is known to cause OA.

The neuromuscular system controls the amount and kind of movement occurring at a joint, so it is this system that is ultimately responsible for ensuring that joint tissues are not damaged to the point of developing OA during normal day-to-day activities.

In the present paper, we review and critically evaluate some of the current concepts of the role of peripheral and central nervous system mechanisms that might protect joints from excessive excursion and joint tissues from excessive loading and OA.

We conclude that a neuromuscular protective model based on central pattern generators (CPGs--subconscious motor programs) can best reconcile much heretofore ambiguous information pertaining to the development and progression of OA in stable and unstable joints.

Movement- a beautiful symphony

Reality in a Nutshell –Sensory Motor

Movement- a beautiful symphony Clin Orthop. 2003 Apr;(409):53-60.

  Neuromuscular training and injury prevention in sports.

Etty Griffin LY.

Exercises that help develop neuromuscular control and increase functional joint stability are critical in conditioning and rehabilitation programs designed for injury prevention in sports. Information regarding joint movement and joint position provided by mechanoreceptors in the skin, muscles, tendons, ligaments, and joints combine with input from the vestibular and visual systems to maintain balance.

Insufficient neurological input or improperly processing that input at the spinal, brain stem, or cognitive centers can lead to an inadequate response by the motor system resulting in an injury. Therefore, it is important to include drills that enhance neuromuscular control into traditional training, conditioning, and rehabilitation programs for sports.

Clin Orthop. 2002 Jul;(400):98-104.  

Sensorimotor deficits contributing to glenohumeral instability.Myers JB, Lephart SM.

The conventional perspective has been that capsuloligamentous structures act as a mechanical restraint to humeral translation at the shoulder. Although this is true, the capsuloligamentous structures also have a sensorimotor influence on the musculoskeletal system, providing stability at the shoulder. The purpose of the current study was to discuss the sensorimotor role that the capsuloligamentous structures play in providing stability, how these mechanisms are disrupted with glenohumeral instability, and how surgical intervention restores such mechanisms.

Proprioceptive information transmitted from the mechanoreceptors embedded within the capsuloligamentous structures influence the coordinated motor patterns, reflex activity, and joint stiffness to provide enhanced joint stability.

The capsuloligamentous injury that occurs with shoulder instability not only affects mechanical restraint, but also alters this proprioceptive input to the central nervous system. As a result of these deficits in proprioception, alterations in reflex activity and motor programs as evident by muscle firing pattern alterations manifested.

Neuroplasticity & Rehab

Four fundamentals had to be in place for gaining positive rehabilitative control, "harnessing" this ordinary activity the brain does all the time anyway:

1. The focus, the inner attention, has to be on the process of learning the action, (the process) not the desired action itself.

2. The heart has to be in good shape. Cardiovascular capacity needs to be there. The brain needs lots of oxygen when it's in learning mode. Deep breathing can help.

3. Rehabilitation must be incremental, and just a little bit taxing. (Does this not sound just like any form of "exercise"?) The brain will build itself best on a sense of consistent accomplishment.

4. The desired goal needs to be interesting.

Tenets of Neuroplasticity in Physical Rehabilitation

Seven tenets of neuroplasticity:

1. Change can occur only when the brain is in the mood: alert, on the ball, ready for action.

2. Change strengthens connections between neurons engaged at the same time. The brain builds on its successes.

3. "Neurons that fire together wire together" (-Donald Hebb, psychologist from McGill Uni. Montreal) This helps the brain get better at its predictive capacity. Associations can be made more easily.

4. Initial changes are just temporary. While the brain can learn through impact (a powerful experience), usually it learns through lots of repetition.

5. Brain plasticity is a two-way street; it can change itself in positive or in negative directions. E.g., chronic pain, bad habits

6. Memory is crucial for learning. Where you put your attention is important. Practicing something while distracted won't help the brain change.

7. Motivation is a key factor.

Goal of Rehabilitation

Goal of Rehabilitation is to stabilize the joint& increase efficiency of movement

It’s Just not about : Increasing Range of Motion,Increasing Global Movement Strength (Non-Functional)General Re-Conditioning of Major Movers It’s About: Re-Training Proprioception / motor pathways , Re-training inter muscular

coordination (firing patterns & processing), Decreasing Pathological Neuroplasticity, Increasing End Range Strength in the vulnerable joint complex

Food for Thought

Isokinetics Isometrics Isotonics Eccentrics Concentrics Q: What is Reality? Q: What is the Environment Q: How Do People Get Injured (Besides Gun

Shot)? WEAK LINK in the Kinetic Chain or Misfiring during a movement pattern or End Range Strength

So What Does This Look Like

In Chronic, Long Term Cases…Every player in the movement symphony must be assessed…

The obvious area of dysfunction may not be the primary area…even though it may ‘appear’ to present with the greatest dysfunction…

Examples-After your usual workup then think….

Gait- Upper Extremity Dysfunction leading to LE dysfunction, visa versa

Chronic Shoulder Instability- Look at Core & LE

Chronic Hip- ankle or shoulder issue

Rehab Nuggets

End Range Strength 360-degree Stability & Firing Firing Patterns & Ordering Balance & Attenuation of GRF

Thoughts

Rehabilitation must be: Active Simple User Friendly Habitual

Parting Big Words…a theory backed by more research &

biology than our current paradigm

Physiopathology – clinicians have long been aware of structural pathology and the ability of these anatomical or biochemical abnormalities to produce malfunction. Malfunctions produced in this manner are termed pathophysiology by the health care community. Malfunction resulting from processing or signaling errors within the circuitry of nervous system is termed physiopathology. Because of the presence of both inborn and acquired neuronal interconnections (acquired because of efficiency driven neuroplasticity), processing and signaling errors can be produced and maintained.

Signals traveling along sensory afferent pathways and entering various neuronal circuits within the CNS or signals in from the PNS but entering the CNS will affect individuals differently. They can also affect the same individual differently on different occasions. In the presence of one set of variables, a migraine headache develops. With another set of variables, gastrointestinal or cardiac malfunction of one form occurs. In the presence of still another set of variables, the individual becomes chronically fatigued or clinically depressed. Acute or chronic anxiety, mental illness and amplified pain are a common result. Alterations in endocrine function can also occur. All of these consequences result from sub-cortical processing errors (signaling malfunction) that affect physiological mechanisms in a manner detrimental to the organism. In this paradigm, inappropriate emotions or amplified bodily pain or a diagnosable disease is just a symptom from processing and signaling errors and is not the primary diagnosis. Physiopathology causes Dysponesis. The disease or dysfunction is a result not the cause.

Physiopathology (Nervous System processing errors) can accompany structural pathology and it can also exist alone and be the sole cause of a given patient’s symptoms.

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