It was a pleasure to speak at the British Neurotoxin Network conference this week, a meeting for specialists in dystonia who use botulinum toxin as a form of treatment. Held at Keble College in Oxford, the surroundings were perfect for meeting, discussion and the sharing of ideas.
Before dining in the magnificent hall, the audience was entertained by a talk from Dr. Marion on facial expressions, referring to Duchenne, Darwin and the work of Paul Ekman. Much of our communication relies on body language with facial expression revealing much about the emotional state. This is useful to communicate effectively, to demonstrate empathy and to determine threat—i.e. an angry face. Equally, a loss of facial expression due to cosmetic Botox treatment or facial paralysis affects one’s ability to show genuine emotion. A lesser known feature is that we can change our expression to alter our emotion. A simple technique to improve one’s mood is to grip a pencil between your teeth thereby forcing a smile. The feedback from the face to the brain persuades it it sense something good and hence our mood alters.
The focus of my talk was upon the reconceptualisation of pain, looking at whether this process can be considered as a way to progress the rehabilitation of dystonia. The slow move away from a biomedical model to the comprehensive biopsychosocial model has changed both the way we think about and tackle the problem of pain. Understanding that pain is multidimensional (physical, cognitive and emotional) means that there are a number of considerations that are unique to the patient. This makes it key to address the person as much as the condition.
In addition to the tissue based therapies that play role in the treatment of chronic pain, the modern brain based techniques are becoming increasingly recognised as part of a comprehensive programme. Discussing these therapies for pain in the light of what we know about the underlying mechanisms, it has been apparent that they could apply in dystonia and other movement disorders. The cortical reorganisation that we understand in both pain and dystonia is an important focus of a training programme. Graded motor imagery, tactile discrimination training and other brain targeted strategies not only seek to ‘re-organise’ but also to desensitise. Pain is all about a perceived threat by the brain, so any change or learning that reduces the threat can change pain and also movement.
With movement being an expression of who we are, how we are feeling, what we are doing and what we intend to do (we may not realise this fully), when we have difficulty because of pain or a lack of voluntary control, this impacts upon the way we feel. Our movement and posturing interface with the World, so reflect the situation that we are in as much as how we feel about that situation. The bidirectional nature of this interface offers different ways of changing our emotional state and retraining normal movement.
The science based talks focused upon genes (Dr Sean O’Riordan, Consultant Neurologist), cortical reorganisation, the effects of vibration (Dr Richard Grunewald) and deep brain stimulation (Mr Alex Green, Neurosurgeon), all of which are ‘neuroimmune’ lines of thought. Tying this basic science with what we can do therapeutically is a key way in which we can seek to move forward and cultivate new ideas. Clearly we need further research to look at all of these paradigms and develop our knowledge but we are in an excellent position to use some of the existing pain therapies that target the central nervous system to improve body sense and motor control via sensorimotor congruence.
Thanks to Dr Marion and Mondale Events for a great two days.