Change Your Brain, Change Your Joints

Your brain may hold a new key to unlocking the secret of restoring and preserving joint health.

This is based on the exciting and emerging field dealing with brain plasticity (plasticity = capacity to change). To understand why doctors are now looking to the brain to accelerate healing in places like the joints, we have to explore a few important ideas that emerged in work with athletes and amputees.

Dr. Ramachandran, a professor of neuroscience at UCLA, was trying to understand phantom limb pain in people who had lost an arm or a leg. These individuals frequently experienced tremendous pain in a limb that was no longer there. They typically experienced the pain as though it was occurring in their missing hand or their missing foot.

Through many years of research, Dr. Ramachandran discovered that the body maps representing the missing limb within the brain, behaved as though the limb was still there. They also behaved as though the limb was still in pain. It became clear to him that neurological circuits for pain were set up that did not go quiet just because the limb was no longer there.

This new view of a highly changeable brain that remained linked to damaged or missing limbs led to entirely new treatments for stroke, for people with amputated limbs, and with other conditions.

Here is how this work may apply to joints. Much like the brain can continue to send out pain signals related to a missing limb, we believe the brain can also set up pain loops in limbs or joints that have been painful or injured for a long period of time. It might look something like this. A neurological circuit is established from an osteoarthritic knee to the spinal cord, to end in the brain. This loop has been communicating with the brain for many years. The brain has been trying to limit potentially damaging activity in the joint, so these signals are set up as a form of protection—a kind of splinting, if you will.

Using the techniques not so different from those used with stroke or amputees, we believe it is possible to quiet the pain signals being sent from the brain telling you that your joint is in pain. There are two reasons to do this. The first is as an obvious means to lessen the pain. Second, if you wish to become more physically active, it may be helpful to first “convince” the brain that the joint is able to function with less pain when you move it. If the brain can be convinced of this (at least to some degree), then the pain signals might quiet and you can become more physically active, to where you are able to fundamentally change your joint stability and health.

So how do we fool the brain into thinking the joint is moving without pain? There are several ways, but we’ll focus on two of them:

Mirror work
Motor imagery

Mirror Work

Imagine yourself putting the palm of your right hand down on the table and setting a mirror where your left hand might be. If you looked at the reflection of your right hand in the mirror, it would look like you were seeing your left hand. Dr. Ramachandran did this with his patients. He had them, for example, place the “good” hand in a box with a mirror aligned so that the reflection of the good hand looked like the “damaged” or “injured” hand. Movement of the good hand made it appear (in the mirror) as though the opposite hand was moving. This, of course, was occurring without pain. The subject was asked to daily exercise the good hand, while watching the reflection in the mirror. Watching the reflection convinced the brain that it was the injured hand that was moving and that it no longer hurt to do such movements. In follow up, it turned out that the neural circuits set up for pain in the injured hand had been quieted.

[INSERT GRAPHIC OF MIRROR BOX]

Motor Imagery

There are two basic forms of imagery with which doctors often work. One is visual imagery and the other is motor imagery. Visual imagery is when you visualize a dog running, a hot air balloon drifting, or the scenery passing by as you drive in your car. You are basically imagining an activity with you as the observer. Motor imagery is when you visualize yourself actually doing something. If you visualize yourself skiing, shooting a basketball, or playing with your dog you are using motor imagery--you are the doer, not the observer.

There is a tremendous difference between the two, as motor imagery has been associated with significantly improved performance among athletes and significant gains in treatment of injury.

In our approach to using your brain to support joint health, you can use motor imagery in an attempt to rewire the brain/body maps and quiet the pain signals. It can be done by visualizing yourself, say, flexing your painful knee repeatedly. As you do this visualization, you are not actually moving your knee, but your brain is convinced that your knee is moving freely, without stiffness, and without pain. As the brain grows accustomed to this joint being able to move freely, it will slowly rewire the maps, so that pain is no longer the dominant signal associated with movement. This is the theory, with a growing body of evidence in support of the theory.

For someone with mild joint pain, this can have a surprising impact. While this alone is generally not sufficient to remove a cascade of pain signals from longstanding pain, it serves one important purpose. It can lessen the pain signals in such a way that beginning a necessary exercise program can be done with more confidence and less discomfort. Again, through motor imagery, we are trying to fool the brain into thinking that the joint does not hurt when it is moved. After a short time, you will engage in strengthening exercises with the aim that a stronger more mobile joint with less pain will be the outcome.

Why We're Hopeful About Motor Imagery

The idea that motor imagery (visualizing oneself doing an activity) might rework some brain maps and restore function in a painful joint has generated a lot of excitement. All of the specifics are not fully understood. But the technique has begun to show tremendous promise. For this reason, we have incorporated motor imagery into our osteoarthritis support program. While all the evidence is not yet in, we feel the evidence is compelling enough that those who wish to try the technique should have the option to do so.

Below is a bulleted summary of some studies showing benefits of motor imagery in a variety of pain conditions.

Motor vs. visual imagery: Several studies have shown that visualizing oneself doing an acitivity is more productive than visualizing someone else doing the activity. Visualizing oneself doing the activity seems to activate more of the motor (motion) part of the brain, more like actually doing the activity. Visualizing someone else doing an activity seems to activate the visual part of the brain. [Guillot, A, Collet, C, Nguyen, VA, et al. Brain activity during visual versus kinesthetic imagery: An fMRI study. Hum Brain Mapp 2008;Sept 25.]
Mirror feedback: Use of a mirror in which the heatlhy limb is practicing movement while the individual watches the reflection in a mirror, has an affect on pain from a phantom limb or a paralyzed limb. Those using the mirror visual feedback had significant reduction in pain intensity, especially deep pain. [Sumitani, M, Miyauchi, S, McCabe, CS, et al. Mirror visual feedback alleviates deafferentation pain, depending on qualitative aspects of the pain: a preliminary report. Rheum (Oxford) 2008;47(7):1038-43.]
Complex Regional Pain: People with complex regional pain syndrome were asked to do motor imagery and mirror movements. They were compared with those using physical therapy and regular medical care. Those doing motor imagery experienced significant improvement in pain, function and disability. Improvment was still noted after six months. [Moseley, GL. Graded motor imagery for pathologic pain: a randomized controlled trial. Neurology 2006;67(12):2129-34.]
Home-based motor imagery: People who had their walking affected by stroke were trained in motor imagery and then asked to perform motor imagery 3 days a week for six weeks. Their walking speed increased by 40 percent, with an overall improvement in their gate and their physical function. [Dunsky, A, Dickstein, R, Marcovitz, E, Levy, S, Deutsch, J. Home-based motor imagery training for gait rehabilitation of people with chronic poststroke hemiparesis. Arch Phys Med Rehab 2008;89(8):1580-8.]
Motor imagery improves muscle nerve conduction: Doctors have tried to understand how imagery might actually affect muscle behavior. The participants were asked to visualize lifting a dumbell of varying weights (motor imagery). Electromyographic (EMG) measurements were taken of the muscles. Motor imagery was found to activate the muscles, while there was no muscle electrical activity in a resting state without imagery. The doctors observed that, during the motor imagery, the EMG patterns corresponding to each type of muscle contraction remained similar to those observed during actual muscle movement. [Lebon, F, Rouffet, D, Collet, C, Guillot, A. Modulation of EMG power spectrum frequency during motor imagery. Neurosci Lett 2008;435(3):181-5.]

The exitement surrounding motor imagery can be further illustrated by one final study we'll mention. Dr. Jennifer Stevens at the College of William and Mary brought five patients into her laboratory who had suffered a stroke that affected use of their hands. She sat each person in front of a computer. Both hands were placed on the table in front of them, with the palms facing down. Each person then watched a short movie clip of a person making twisting movements with a wrist. The people were then asked to close their eyes and imagine themselves making those movements (motor imagery). This was repeated: watching the movie, motor imagery of moving their wrist, watching the movie, motor imagery, and so on. They did this for twenty five minutes a day for one month. In addition, each person used a mirror box, where she (he) put her good hand in a mirror box and moved it ,while she watched the reflection of the movement in the mirror. The reflection would look to her like the impaired hand was moving, supposedly convincing the brain that the impaired hand was being moved successfully.

This group of five people were compared to 5 people with a similar condition who underwent traditional occupational therapy. Remarkably, both groups made similar improvements. This is really quite astonishing. That reworking the brain maps through motor imagery and use of a mirror can actually retrain the brain toward recovery function in a damaged limb and that the outcome would be comparable to someone using physical therapy. [Blakeslee, S, Blakeslee, M. The Body Has a Mind of Its Own. New York: Random House, 2008:96-7.]

Most studies with motor imagery have shown benefit. However, there are a small number of studies in which people with a difficult condition called complex regional pain syndrom have experienced some worsening. Results could have been due to people's expectation that even visualizing movement might be painful. In other words, after many years of chronic pain, the individuals had likely become so conditioned that any movement (even imagined movement) might lead to the expectation that pain would set in. None of these studies are in osteoarthritis, so it is unclear whether this is likely to be the case with joint pain. If you decide to attempt motor imagery in an effort the improve your joint health, pay attention to how you feel. If you feel worse from the activity, it would be wise to cease the imagery exercises.

[Mosely, GL, Zalucki, N, Birklein, F, et al. Thinking about movement hurts: the effect of motor imagery on pain and swelling in people with chronic arm pain. Arthr Rheum 2008;59(5):623-31.]

The Promising Future of Motor Imagery

We've explored just a tiny slice of the motor imagery research. This evidence is already changing how doctors have been able to help people who have suffered from amputation, stroke, brain injury, and other conditions. While many refinements will happen to improve these methods, it is already clear that the basic concept has added profound benefits to people with severe conditions.

The Insulite System for Healthy Joints has a motor imagery component built in, for those who wish to take advantage of this emerging approach. While the method has not been widely studied in arthritis, we believe the fundamental principles apply to joints, as well. This approach can be used to support improved movement in the major joints that tend to be involved in osteoarthritis, including the ankle, knee, hip, spine, wrist, and hand. If you suffer from joint pain that is not true arthritis, motor imagery may still offer a helpful tool to support and maintain healthy joints as you age.