Neurological

Attention PT’s. Look at this Image. It’s Important. Real Important.

Above is a diagram of the Neuromatrix model of pain.  It was proposed over a decade ago by Dr. Ronald Melzack.  Ever heard of it?  Or him?  Maybe not.  But in school, you likely learned about the gate control theory of pain and somewhere along the way, used the McGill Pain Questionnaire.  Well he also developed these.

So as a PT, what does this model mean to us?  In my opinion, A LOT.  It is a conceptual framework for every one of our patient’s who presents to us with complaints of pain.  Acute pain. Chronic pain.  Dull Pain.  Stabbing Pain.  Neuropathic pain.  You get the point.

Pain is always an output from the brain (specifically the individual regions which make up the “neuromatrix”) based upon many different variables.  Simply the brain’s suspicion that a tissue has the potential for damage, will cause it to react.  TISSUE INJURY IS NOT NECESSARY. This statement is important.  We often search for a “root” cause of our patients pain.  And we often blame tissues.  Heck, we always blame tissues.  Well, research indicates pain is more than mechanical deformation of tissues.  As a profession, we must understand and accept this.  To do so will improve our scientific validity.

The neuromatrix, is a framework made up of cortical areas of the brain which we know to be active when one experiences pain (as well as other processes which cause one to possess a sense of self).  To complicate things, everyones neuromatrix is slightly different (there are some areas that are consistently active though). The reaction of the neuromatrix to stimuli or input described below, results in a conscious, and arguably fantastic, communication response, which is crucial for our safety, well-being and survival.

INPUT to the neuromatrix:

These are on the left side of the image above.  Each of these input is sufficient in causing the neuromatrix to determine that there is a sufficient threat to the body’s tissues, and causes the brain to react. In the latest neuromatrix model, the following inputs can trigger the neuromatrix:

1. Memories of past experiences, attention, meaning and anxiety.

ex. The context of an injury is important.  Imagine a patient that you have treated with chronic whiplash-associated disorder.  They come to therapy and tell you that their drive to therapy caused pain.  Why do you suspect this happened?  Many of us, would suspect that turning the neck to back up or the prolonged driving posture resulted in pain.  But consider the context of the car.  The car itself is a contextual threat to that individuals brain.  The car is what injured them.  The car has meaning.  The brain potentially could be protecting the neck from a threatening environment. And we know the brain can and will do this.

2. Cutaneous, visceral and musculoskeletal inputs

ex. This is the input which all of us learns can cause pain.  Stress and strain to tissue will result in pain.  And it does.  A lot.  But not always.

3. Limbic system and associated homeostatic/stress mechanisms

ex. Emotional, hormonal and stress regulatory systems can also contribute to reaction from the neuromatrix.

One, two or all three types of input can sufficiently cause an output.

So as a PT we must understand that many times, it is more than tissue.  Our patient interactions and their improvement may be due to what you are doing, but the effects may be different than you would suspect.  You’re treatment environment may be warm and inviting (and non-threatening).  The patient may be widowed and your touch to their painful neck is the first human interaction they have had in 3 months.  Your communication skills are pleasant and the patient expects your treatments, which they don’t completely understand, will get them better.  All the therapeutic input which you provide to the neuromatrix, may cause it, to not react.

  1. Iannetti GD, Mouraux A. From the neuromatrix to the pain matrix (and back).Exp Brain Res 2010; 205; 1-12
  2. Moseley GL. A pain neuromatrix approach to patients with chronic pain.Manual Therapy 2003;8:130-140
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Categories: Neurological, Neuromatrix, Pain

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19 replies »

  1. Great stuff Joe and I am going to pass on to colleagues and interns. My biggest question is how do you describe this to the patient? And how do they respond?

    Harrison

    • I have forms which I give to patients on the first day. One is a one-page synopsis on all the contributing variables for pain. Another is an outline of pain coping mechanisms and altering the context in which they experience pain. A third form is a spreadsheet in which they document every time they experienced pain, why they thought they experienced pain and how they coped with it. This allows them to recognize patterns, contexts, feelings, etc. I sit down with every patient and go over these forms at initial evaluation and periodically through treatment. I explain “it’s not in your head” but it “does involve your brain”.

      I also explain that pain is a way in which their brain communicates with them. I tell them that unfortanetly the brain doesn’t do a great job at telling us the degree of injury. So even though you may be in alot of pain, that pain is not predictive of the degree of injury. So, together we need to find ways to show the brain that you can move that body part safely. And I am here to help you with that.

      I tell them that we have learned more about pain over the past decade then we did in the entire 20th century. And this is a good thing because the future of healthcare should be able to manage pain better than it ever has.

  2. Ok great so very detailed. Much more so than I thought. Is this shareable? I understand if not. You can shoot me an email.

    • I will post a follow-up to this by Friday w links to uploaded versions of these forms. I have no reason to not share these. My goal w these posts is to better the profession. I will make available anything I can to do so…

  3. Your description is a well known explanation for the cognitive and emotional factors that may contribute to a chronic pain which may not or minorly be caused by a lasting mechanical deformation. On the other side don’t make the mistake that all pain that exist for a long period is automatically caused by this factors. It still can be only mechanical as I so often find by chronic back and neck pain and headaches and migraine. (Even after 20 yearsor or more). The altered psychological conditions as anger, depression and anxiety are then only the side effects of the chronic pain. In such cases: take the pain and you heal the brain.
    The difficulties lies in the exclusion of the mechanical factors as an MRI is not sensitive enough, thorough mechanical examination and reactions on pain provocation test and mechanical loading can there be more powerfull. I believe you have to be experienced and willing to concentrate your professional skills to one body region to become good enough to understand this to a certain level.
    In cases where the reactions on mechanical testing are unpredictable and unexplainable, pain and other reactions are widespread and oversensitive, mechanical therapy is often unsuccesfull. It is truly (more) often the case in traumatic whiplash injuries. Still I think every patient with a chronic pain has the right to get an thorough mechanical examination first.
    Although I explain the not mechanical patients, the pain model and altered nueromatrix, and stmulate them to move more again, I find it often that it is not helpfull, to better the condtion of the patient. In case of a trauma I think that psychological trauma therapy as EMDR maybe more helpfull and should be done before.

  4. Hi Joseph. Thanks for the info and reminder to discuss all the issues surrounding the neuromatrix for pain perception. I am interested in the forms you use. I noticed you stated you would upload them to this site. Did I miss something or not looking in the right place? I can not find any uploads. If you prefer, please feel free to email me. Thanks again!!

  5. In chronic pain it is the biopsychosocial model you are all referring to and we as physios are at the perfect place to be treating chronic pain and educating our patients. we can use Lorimer Moseley’s explain pain or many other author’s books to explain what is happening to the body because i believe that it is often too bad when the patient has seen at least 10 other clinicians before you and you assume that it is still mechanical when it usually is not after a long time. do you really think that all the physios before you just don’t know it as well as you? Please don’t continue to mob or Mckenzie them any more and use this neuromatrix model and treat them with a biopsychosocial framework. i just taught this in my first class in my pain management course this week. Melzack is still at McGill and a really nice humble man to meet.

    • Lelee I don’t agree. To assumme that every patient after an amount of time wil have a pain that cannot be cured by mechanical therapy is false and is the danger of this theoretical well thought system. In fact 50- 60% from the chronic patients that come to me react very well an relatively quick. Everyone should be aware that his succes percentage firstly depends on the skill to find the right exercise and to motivate and to instruct well (direction, intensity and repetitions). To my own suprise it did not make a difference if the pain was there for 3 months ( already called chronic) 1 year, 10 years or over 20 years. It did not make a difference, how many other therapies they had tried as long as they did not trie exactly what I intended to do. (consequent directional mechanical therapie 6-8 times, a day for 2 weeks to see the first results, this combined with altered loading. I discovered all that by critcal examinating my own results over 2 years. Right, it was not scientific as i did the questioning myself. Right there is no placebo control group. dont’ blame me. I Did the best I could and at least It motivates me to keep going on, feeling that what I do is right. Of course there will be some psychological side effects and even mechanical therapy does not function only in a mechanical way I caal for example the reducing of fear for motion by exercising.There wiil be some placebo too. What count to me and the patient in not how it works but if it works. I asked some patients half a year and a year later and still the firstly good outcomes did not have an recurrence, Others who I did not ask still send me new patients today.
      WIth other the acute and subacute categories it is no surprise the scores were better. Surprising to me was that in the acute group the scores seemed to be all or nothing. So better up to 90-100% or no better at all. Of course this effect can be much explained by natural healing, and therefore my goal of the therapy is to prevent becoming chronic and preventing recurrences in the future.

      So if you don’t have a results with your mechanical therapy you could start blame the biopsychological factors right away, but it still could also because of your skills… The real skill to me is to recognize this an to keep critical to your techniques. Do not forget to ask the patient straight away if he managed to exercise (often) enough to have an effect. Do not forget to let the patient demonstrate how he did his exercise, was it the right intensity, did he really moved to endrange or did he stop when the first discomfonrt came up? When everything is done well and there is no effect you meanwhile get an idea if the which other factors might play a role and if the pain therefore cannot be influenced mechanical. At least in the sixt session this should be clear. It might also be earlier that it is clear. When at least at the 6ht session there is no relevant (more as 30 percent) result I stop. When I found there maybe other factors I trie to explain. Explaining this other factors may help for the understanding and lessen the pain, fear for moving and therefore the disability a bit, it still is not a cure and overall I find the results of these poor. To me biopsychsocial therapy and is not my speciality and should not be the speciality of the physical therapist or physiotherapist (what is in a name). So after the patient understand and accepts the possible other mechanisms I think it is time to call in other medical disciplines.

  6. Koenoverdijk,
    You mentioned that “50- 60% of the chronic patients that come to me react very well an relatively quick” to your mechanical therapy. How do you treat those remaining 40-50%?

    You also feel that “biopsychsocial therapy”..”should not be the speciality of the physical therapist or physiotherapist”. I would have thought that as physiotherapists we deal with pain more than most health professionals and as such we should be making every effort to better understand pain and to strive to treat it as effectively as possible, however this is achieved. I feel that in the context of pain, physiotherapists are best placed to provide “biopsychosocial therapy” and if we are not, we should be. I don’t believe that it is beyond our scope to learn.

    In addition, it shouldn’t be underestimated how much “biopsychosocial therapy” is provided when patients are treated with more traditional manual therapy.

  7. I think it’s great that we are finaaly moving from the hangover of seperating the body from the mind and beginning to draw the two together. I watched a really interesting TED talk on the difference between experience and memory and I have found that this has helped many of my patients.

    The experience of the incident of pain sits in a different and more present area of the brain, it encorprates sensation in the present moment, it is the memory of the pain that gets entwined with emotion, past experience, fears of future experience – and this is where we find fear-avoidence sits and the associated psychosocial elements invovled with that. When working with patients who have a strong memory of a painful episode or incident I like to explain this on a basic level (accepting that i am no expert psychologist) and introduce mindfulness-based practice to allow the patient to access the memory and understand it and accept it.

    Through meditation, body knowledge training and treatment of the mechanical issues of pain that often run side-by-side I have seen nice results and myu patients generally feel they know themselves a little better.

    Is this my role as physiotherapist? absolutely, I think by explaining the pain mechanism as a communicator they learn to read the message rather then run away from it or avoid it. It is important to understand why they are feeling pain and learn how to move the body to respond to this. I don’t feel these are seperate issues, it is all part of drawing the mind and body together in understanding.

    I also try to teach my patients that pain is a symptom, not the cause – and so we monitor the pain but treat the cause – when looking at the mechanical cause especially – as this is what the patient reports the most. it’s a fine line we walk as clinicans and when dealing with persistant pain i dont feel we can escape the psychology of pain memory and fear.

    thank you for the neuromatrix diagram and this interesting topic! Hopefully we will continue to improve our techniques and help the patients we can.

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