Exploring the mind-body connection in controlling spinal cord injury-related neuropathic pain
Ann Van de Winckel, PhD, MSPT, PT, is fascinated by the mind-body connection. Two studies that her Brain Body Mind Lab is currently conducting are related to how the mind-body connection can be used to effectively combat neuropathic pain from spinal cord injury (SCI).
One study focuses on the use of cognitive multisensory rehabilitation (CMR), which incorporates conscious perception of body positions and movements during (multi)sensory discrimination exercises. The other study investigates the use of Qigong — a traditional Chinese medicine healing method of coordinated body-posture and movement, breathing, and meditation. Each study takes a slightly different path to achieve the outcome of reducing or eliminating neuropathic pain.
“In the brain,” Dr. Van de Winckel explained, “there is an area called the multimodal integration network. It receives all the signals from all the senses that your body uses and integrates these signals to help create your body awareness – where your body parts are in conjunction with each other. This network then sends information to another part of the brain called the posterior parietal cortex [PPC], which helps you understand where your body is in space so it can guide you correctly when you move.”
Two brain areas within the multimodal integration network play a key role in pain perception. When the spinal cord is injured, sensory information that goes from the body to the brain is either absent or altered, according to Dr. Van de Winckel (pictured at left). “When the altered signals arrive in these areas of the brain, they are different from what the brain is expecting to receive, which creates a disconnect. It’s like when your radio isn’t working and you turn up the volume to hear it better. That is when the pain happens – the brain is cranking up the volume to better deal with the signals it is receiving.”
In both these research studies, the goal is to restore the participant’s body awareness by correcting the disconnect between what the brain expects to receive and what it actually receives. “We believe that doing so helps reduce pain,” said Dr. Van de Winckel.
Cognitive multisensory rehabilitation study
Dr. Van de Winckel is partnering on this study with Rehabilitation Department Head Leslie Morse, DO. They are actively seeking candidates for the study – adults with spinal cord injury whose legs are paralyzed (paraplegic) and who have neuropathic pain. There is also a control group of age- and sex-matched healthy adults, but this group is fully populated.
Study participants are randomized into two groups – one group starts with six weeks of one-on-one, in-person cognitive multisensory rehabilitation (3 times a week for 45 minutes) and then stays 6 weeks at home; the other group starts with 6 weeks at home and then receives the in-person therapy for 6 weeks. “During those six-week periods at home or during the therapy period, we call them every week to ask about their pain, medications, and what happened during the week that influenced their pain,” said Dr. Van de Winckel. “Before and after the six-week period, they get a Zoom questionnaire and an MRI, so in total, participants get three MRI scans and complete three Zoom questionnaires.”
In the MRI scanner, participants will complete some tasks while their brains are being imaged. “They will be asked to locate where the worst pain is in their body and to envision the feeling when they’re moving a limb that is painful,” said Dr. Van de Winckel. “They then watch a short video of a Qigong movement, rest for several seconds, and then visualize that movement without actually moving. The important areas of the brain we discussed before are activated during these tasks.”
How does CMR therapy work?
If you were meeting in-person with a CMR-certified therapist, a typical exercise would involve the therapist sitting near you. The therapist will guide you so that you regain awareness of where your legs and trunk are in space and how the legs and the trunk relate to each other.
Dr. Van de Winckel describes one of those exercises that helps achieve that. “The participant is sitting on the treatment table and the therapist covers their lap so that they can only see the top of their upper legs,” she said. “The therapist is sitting on the floor, in front of the participant and asks, ‘If I stretch my arm out, can I reach your leg and if so, what part of your leg am I touching?’ To answer the question, the participant must understand the relationship between the arm of the therapist and their own leg. They must also understand how much space their legs occupy. When this awareness is restored, the therapist will also use exercises to increase sensation and even, in some situations, help the participant regain some movement. After six weeks of this type of therapy, I have seen people not only reduce their neuropathic pain and increase awareness of where their legs are in space, but also recover sensory function and to some extent, motor function.”
Ideal candidates for this study are adults with spinal cord injury (paraplegia or quadriplegia). This study is completely remote and thus accessible for participants who do not live in Minnesota. All participants will start with an introductory Qigong class on Zoom. “Then the participants will use an online video to follow the qigong exercises for 12 weeks, 3 times a week,” said Dr. Van de Winckel. “They are free to choose the place and time of day when they do the video, as long as they do it at least three times a week. For any movement that the participant cannot do, they are told to imagine the feeling in their body as if they’re doing it. We found through imaging that brain areas activate in the same way when you imagine the feeling of doing the movement as when you actually move. This means that this treatment is accessible to people who cannot move their limbs.”
Participants will also be called every week to be asked about their pain, medications, and what happened during the week that influenced their pain. “We will do Zoom questionnaires at three time points: before and after the Qigong training and again eight weeks afterward when they are not training but just going about their days,” explained Dr. Van de Winckel. “The final eight weeks are meant to see how long the reduction in pain lasts after training is completed.”
Adults with chronic low back pain went through a similar Qigong training in another study led by Dr. Van de Winckel. She and her team saw changes in the aforementioned parts of the brain afterward and their pain was reduced.