Is specialisation healthy in a neuroplastic world?
I don’t think so! There has been an increasing shift in Australia in recent years towards specialisation within the physiotherapy profession. While this may have many positives for healthcare in general, I think we need to be very careful that it does not come at a cost of denying or ignoring research and clinical findings in other areas that complement our own practice.
Rene Descartes lives! The neuro/orthopaedic dualism persists – what is orthopaedics missing?
The rapidly changing world of pain science is now encouraging the traditional “orthopaedic world” to embrace neuroplasticity. Many dinosaurs remain of course, but new treatment strategies such as graded motor imagery, tactile acuity training, even brain function discussions are becoming more common place in the “orthopaedic world”. These strategies have emerged from the “neurological world” . But have we gone far enough? What else is there in neurology practice that could be taken up in orthopaedic practice? Neurology is all about functional restoration and I often wonder if manual therapy sometimes gets lost in its own detail. We should be better at promoting quality, efficient movement that is challenging but not threatening. How many of us feel confident putting hands on to provide new movement experiences in functional tasks such as gait, rolling and sit-to-stand? Yet these are common tasks that our patients report as pain-provoking.
Similarly, what could neurology be missing? Oddly it is pain!
Has the neurological world that brought us imagery, facilitation of quality efficient movement, motor learning and sensory training, kept up with developments of knowledge of states such as peripheral and central sensitisation? Pain is one of many outputs that can be perturbed in any condition, and this is particularly so in neurological states, where there is documented evidence of high prevalence of pain, but that interestingly this pain is delayed in its onset post event and develops further over time, suggesting there is more at play than purely structure (Borsook 2012). Essentially neurology has denied, and still denies, the prevalence and impact of pain in states such as MS, stroke, and Parkinson’s. In Parkinson’s disease for example, it is pain more than the motor changes which affect quality of life.
Much Neuroscience gets lost
Earlier this year I participated in an initiative in Melbourne titled “Advancing the Science of Rehabilitation: Translating Neuroscience and Rehabilitation into Everyday Life” which consisted of a mix of invited clinical researchers and basic scientists (not my favourite term) from the Asia Pacific region. A common discussion point was that when neuroscience research was presented to the wider clinical audience, the response was often “This stuff is really interesting to know, but how does it help me treat my patients?” It’s no different to 25 years ago when phantom limb was regarded as medical curiosity – “Interesting but what do I do next?”
Let’s get married – or at least engaged
I think that Orthopaedic and Neurology based clinicians (wouldn’t it be nice if we married) need to chat more. Here is just one example of science that should unite us and be up for discussion – what is the place of increased maturation rates of adult neurones from stem cells in response to demands such as exercise and environmental enrichment?
Doing something about it
We are trying to make links in the NOI Pain, Plasticity and Rehabilitation courses where we look at pain in neurological diseases, and try to incorporate the best from Orthopaedics, Pain science and Neurology. Nothing is more pleasing than when we hear of a participant from an orthopaedic background say ”I think I will take on a few patients with stroke/MS or spinal cord injury associated pain and give it a go”. Or when someone from a neurological background realises the epidemic of pain in neurological patients and that something can be done about it.
While it is impossible for any of us to stay up to date with everything, it is worth journeying out of our comfort zone (or safe place) on occasions to challenge our own learning and beliefs.
– Brendon Haslam
www.noigroup.com
Borsook D. Neurological diseases and pain. Brain: a journal of neurology. 2012;135(Pt 2):320-44.
Very well put. Lets not forget that it is the patient that attends our clinics, presenting commonly with pain, suffering and functional disability, and not their underlying pathology. If we approach our work from this angle then we should be able to offer something for everyone with or without todays knowledge. This brings us back to the core skills of our profession and David’s question of ” What is it that I offer that helps this patient. Is it my knowledge or me”. Of course the answer is both and………
The divided fields of neurology and psychiatry stand out as examples/problems of specialisation . The neurone is the essential element of both groups yet they hardly mix. Descartes would be proud of his lingering power. Few psychiatrists have contributed to our knowledge of pain (Issy Pilowsky was an exception) and neither have neurologists (Goran Lundborg is an example of an exception). It took a new profession in pain medicine to get things going but its been a clumsy process.
I am hoping the rehab professions don’t make the same mistake.
David Butler