The Body Image Project - Part 1: Overview

If you rehabilitate movement or treat pain you should know this

Background

Following The Learning Project, I embarked on a mission to develop a clinical prediction rule for the diagnosis of widespread central sensitization. You have to appreciate that several years ago, central sensitization was understood to be something different than it is now (Smart 2010). Now it seems to be anything that isn't 100% mechanical (segue into The Central Pain Project). This used multiple laboratory measures of sensory hypersensitivity on 8 bodily regions (left and right: lower cervical, lower lumbar, lower upper arm and mid upper lower limb), and compared them to 36 variables. Since the measures of sensory hypersensitivity are self report, I used the flexor withdrawal reflex as part of the validation. Then a funny thing happened.

During the pilot work, there were people who clearly sounded like they had central sensitization, but clearly did not! Very atypical pain patterns, non mechanical, unable to localized a tissue on physical assessment (e.g. no pain provocation tests were positive).

At the same time there were enough people that had come through The Learning Project to start looking at the characteristics of the false negatives on the Motor Control Abilities Questionnaire (MCAQ) (a tool I developed to screen for the ability to learn specific motor control exercises). Then something fairly obvious happened.  Many of the people who were sort of false negative on the pilot of the central sensitization clinical prediction rule were also the false negatives on the MCAQ. Obviously this was meaningful. So I took a hard and deep look at this group.

Some interesting findings

• More than 50% were accountants, engineers, mathematicians, physicists, book keepers (note the study with the association between parents being engineers or accountants and autism)
• Altered developmental milestones
• History of birth trauma
•  Ambidextrous or mixed dominance (note association with various psychiatric illnesses such as personality disorders, suicide, anxiety)

After some deep thinking, reading and observation, the hypothesis of a midline deficit was born. I developed screening tests to challenge midline. A look at the previous notes of this group identified that they could not grasp the concept of the visualization strategies. A discussion with my sister revealed that the inability to perform motor imagery is a type of learning difficulty. We should not take that for granted (segue into the Motor Imagery Project).

There was a need to be able to screen these people. An existing motor imagery questionnaire was modified and a study was done on body image drawing (adapted from Lorimer Moseley 2008). The diagnostic accuracy was highly sensitive, but not very specific. This was OK though because the preliminary clinical prediction rule for central sensitization was great so you can use them together. This was the same for the physical assessment. These people were not great (huge variability, but all failed) at the tests designed to challenge midline. Now that this group could be identified I named the pain mechanism "Body Image Pain" since they could not perform motor imagery of their body.

Now there was a need to rehabilitate these people. It seemed so logical that there would be a natural way to develop your midline. The neurodevelopmental process, specifically rolling and crawling seemed like obvious choices. The problem was, they were not very good at it and many did not respond (a few did though).

A closer look at this revealed that the movements needed to develop into rolling and crawling were mostly primitive reflexes stimulated by the vestibular system. So the process of using the primitive reflexes to learn the neurodevelopmental basics was used. More success. Something was missing. Some time looking at infants learning to roll and crawl sent it home. (1) There were pre-segmental rolling primitive reflexes & (2) Rolling needed to be more specific.

A few comments on the rolling and crawling described by other groups in the literature:

·         The rolling process as described for adults is not the same as described for infants

·         When the correct pattern is used, these patients with "Body Image Pain" get immediate long lasting relief.

This convinced me that just like other exercises (like core stiffness), the more specific you are, the better the result so rolling has a pattern and this pattern needs to be specifically learned.

Summary

Pain is complex. The concept of central sensitization revolutionized things. But there is a need to sub-classify further. So now the general category should be Central pain with two sub-groups: central sensitization and Body Image Pain. We can now identify it from the history, screen it with self report tools, use a physical assessment and quite easily rehabilitate it. We now know much more about midline and body image. Keep checking in to find out more. 

Sean GT Gibbons BSc (Hons) PT, MSc Ergonomics, PhD (c), MCPA

Gibbons SGT 2016 Is neurocognitive function associated with the ability to perform motor imagery in adults with musculoskeletal pain? A retrospective case control study. Proceedings of: “Cognitive Vitality”  The CAPM&R 64^th Annual Scientific Meeting. May 25-29, London, Ontario. Journal of Rehabilitation Medicine

Gibbons SGT 2016 Are a battery of obstetric and neurodevelopmental variables are associated with a subgroup of fibromyalgia and un-classified pain patients. A retrospective case control study. Proceedings of: “Cognitive Vitality”  The CAPM&R 64^th Annual Scientific Meeting. May 25-29, London, Ontario. Journal of Rehabilitation Medicine

Gibbons SGT 2016 Should central pain be sub-classified? A hypothesis of Musculoskeletal Body Image Pain - initial insights into diagnostic criteria. Proceedings of "Expanding Horizons": The 11^th International Conference of IFOMT. July 4-8; Glasgow, Scotland

Gibbons SGT 2014 Sub-classification, diagnosis and rehabilitation of musculoskeletal body image disorders. 62nd Annual Scientific Meeting of the Canadian Association of Physical Medicine and Rehabilitation. St. John's, June 18-21

Gibbons SGT 2012 Facilitating neuroplasticity for pain, movement and function.  Manitoba Physiotherapy Association. April 13; Winnipeg, Manitoba

 

Gibbons SGT 2010 The development, initial reliability and construct validity of the motor control abilities questionnaire. Proceedings of: The 7^th Interdisciplinary World Congress on Low Back Pain. November 9-12; Los Angeles, US

Gibbons SGT 2010 Benefits and limitations with specific motor control rehabilitation Proceedings of: ECT 2010 - “Neurological concepts and impact of manual therapy on pain”, Sept 23-25; Antwerp, Belgium

Gibbons SGT 2010 What does chronic pain have in common with learning difficulties?  Proceedings of: Neurodynamics & The Neuromatrix Conference. April 15-17; Nottingham, England

Gibbons SGT 2010 Influence of cognitive learning factors on psychosocial factors and central sensitization. Proceedings of: Neurodynamics & The Neuromatrix Conference. April 15-17; Nottingham, England

Moseley GL I can't find it! Distorted body image and tactile dysfunction in patients with chronic back pain. Pain. 2008 Nov 15;140(1):239-43. doi: 10.1016/j.pain.2008.08.001.

Smart KM, Blake C, Staines A, Doody C. Clinical indicators of 'nociceptive', 'peripheral neuropathic' and 'central' mechanisms of musculoskeletal pain. A Delphi survey of expert clinicians. Man Ther. 2010 Feb;15(1):80-7. doi: 10.1016/j.math.2009.07.005.