Part I (here) of this blog series considered neuroplastic cortical changes known as brain map smudging. Primary somatosensory cortex (S1- homunculus) smudging is a potential biological and physiological change that can occur with any injury or bout of pain. Simply stated, the brain’s sensory cortex develops an altered appreciation of the location and awareness of a represented body part. Many view these cortex changes as protective responses of the brain from a perceived threat. Fundamentally, smudging is a complex phenomenon, without a definitive causation, and will take future study to better appreciate the details.
Despite the need for future study, there are some subjective clinical signs that may point to the presence of brain map smudging. This blog will explore potential subjective presentations that suggest smudging is present, and further, point to non-traditional assessment and treatment for answers.
Hearing the “Unusual”
How many times have you heard a patient in the clinic say some variation of the below subjective statements?
“I don’t trust my knee on stairs” “my right side does not feel like my left side”
“when I walk I am not sure of my hip” “my legs feel different lengths”
“my shoulder feels strange like I can’t control it” “it does not feel coordinated”
“it looks weird to me” “my lower back does not feel like it is mine”
“it is snapping, popping, and clicking now” “it feels swollen”
“my foot is not moving right and feels like it turns in” “it feels wobbly and shaky”
“thinking of movement causes my pain”
“I can’t image how bad it would hurt to do it”
“my pain has a mind of its own” “it hurts my back to watch someone lift”
“there is no way I can bend over and touch my toes, my back is too unstable”
“sometimes my knee feels like it is not there to support me”
“my pain jumps from my knee, to my ankle, to my calf, and then back to my knee”
You take note and objectively test aspects of these subjective statements. You provide a comprehensive examination for stability, motion, strength, neuro, girth, balance, end-feels, etc. However, after a thorough objective exam nothing valuable is found to support these type of statements. In fact, many of your findings may be within normal limits. The patient may have a lot pain and functional limitations, but for the most part the exam is clean.
Through it all the patient is still convinced of what he or she feels, and these types of statements now become “unusual” because they no longer fit a known clinical picture. You are stuck with the Subjective not matching the Objective! It is not supposed to work that way.
My early training and thinking led me to one of three conclusions:
- Focus on exercise for stability, balance, proprioceptive training to enhance motor control, despite finding that were WNL, because the patient is still complaining of the problem.
- Mobilize and/or manipulate it to make it move better
- Put those comments on the mental back burner, thinking “this patient statement is a bit strange and this kind of complaint will get better when the pain is gone and we perform strengthening, flexibility, etc.”
What do you do with these types of statements and findings?
When I came to the realization that what a patient tells me is always true to him or her, and he/she is doing his/her best to tell me what he/she is experiencing, it motivated me to consider alternative explanations for the reality of these statements. Neuroscience has taught me that these “unusual” statements may, in fact, be related to cortical brain map smudging. Neuroscience is further teaching us to seek answers for these “unusual” statements from Graded Motor Imagery (GMI) assessments and treatments.
GMI was initially developed to treat the most challenging pain states on earth; complex regional pain syndrome and phantom limb pain. Though current studies (here) suggest GMI may be beneficial as part of a multimodal treatment applied regularly in the clinic.
Identifying people with S1 smudging, using GMI, may be a huge clinical change for any therapist treating patients in pain; especially when hearing complaints that do not add up clinically. Understanding GMI assessments and treatments has forced me to reconsider “unusual” patient statements as potential cortical smudging. It has challenged me to dig a bit deeper and consider novel alternative treatments that target the S1 homunculus to provide answers. The truth of these “unusual” subjective statements is your patient may be describing, and asking for, a very specific regimen of treatment.
Your patient may be asking, “O body part, where art thou?”
The next blog will take a look at the principles and concepts of GMI for daily clinical use.
I would love to hear your thoughts on this blog and any “unusual” subjective comments you hear in the clinic.