Cortical Remapping and Injuries (Redux)

"The gist of this article is that cortical remapping occurs with injuries that are not 100% resolved." - from our archives

Facilitating muscles, "activating" muscles, it is a 2 way street. There is the input into the brain and a corresponding motor output. If you are just "rubbing" out some muscles and get a stronger muscle test afterwards, and that is as far as your thoughts go before you turn your athlete loose, then you may be considered by some to be a stick in the spokes of the bigger system. Simple facilitation without corrective measures or corrective exercises to more permanently remap the optimal pattern may lead to repeated and recurrent pain, problems, re-injury or new injuries, and the like.

As a client adapts to their unresolved, partially resolved (yes, even 95% is unresolved) injury(s) a secondary cascade of neurological changes ensue that often force new cortical remapping. A remapping that is not as fundamentally safe or as sound as the pre-injury mapping yet one that is necessary for protecting further or other injuries. Yet, because it is not the original pristine pattern, it is also one that can begin undercurrents to corrupt other patterns of stability, mobility and movement in cortical and subcortical mappings. Understanding cortical excitability is important, and it can work for you and your client or against you both. It can be used for good or evil.

read on here . . . .

https://thegaitguys.tumblr.com/post/80788172925/activation-cortical-remapping-and-what-you-are

Activation, Cortical Remapping and what you are doing wrong to your people.

We are getting ready to step back into the studio to record podcast 58. We have been touching upon this topic off and on in the last 2 podcasts and we are going back in for more on pod #58 because this stuff is just too important not to beat it to a further pulp.  

The gist of this article is that cortical remapping occurs with injuries that are not 100% resolved. Lots of coaches and trainers out there are trying their hands at muscle “activation” and other new trendy tricks and they are missing the boat and making people worse if they are not doing a good sound clinical history and examination. You can activate any muscles and get what appears to be a miracle response, we can teach a 8 year old how to do activation and get a miracle response, but is it the right response or have you created a temporary compensation for your client (right before you send them into training or competition) ?  Activation is a 2 way street, there is the input into the brain and a corresponding motor output. If you are just rubbing out some muscles and get a stronger muscle test afterwards, and that is as far as your thoughts go before you turn your athlete loose, then you are a liability in the system. Are you part of the problem or part of the solution ?

Here are 2 paragraphs from this brilliant article. This is worth your time. As a client adapts to their unresolved, partially resolved (yes, even 95% is unresolved) injury(s) a secondary cascade of neurological changes ensue that often force new cortical remapping.  A remapping that is not as fundamentally safe or as sound as the pre-injury mapping yet one that is necessary for protecting further or other injuries. Yet, because it is not the original pristine pattern, it is also one that can begin undercurrents to corrupt other patterns of stability, mobility and movement in cortical and subcortical mappings. Understanding cortical excitability is important, and it can work for you and your client or against you both. It can be used for good or evil.  

If after you read these 2 paragraphs taken from the Alan Needle article in LER (link) you think you might be part of the problem or realize that you are not the magician you think you are, then good, you are on the track to self enlightenment and actually helping people.  Go read Alan’s article and breathe deep, ready to absorb and start yourself into understanding that you are really fixing the brain and not always the muscle, and that means you are gonna have to learn about the brain and how it works and more so how it can deceive you and your client and your training, treatments or therapy.

Come join us on The Gait Guys podcast 58 later this week as we delve into this topic deeper and more broadly.

Shawn and Ivo

PS: nice article Dr. Needle. Thank you !

http://lowerextremityreview.com/article/the-brain-a-new-frontier-in-ankle-instability-research

The brain: A new frontier in ankle instability research

http://lowerextremityreview.com/article/the-brain-a-new-frontier-in-ankle-instability-research\

“Recently Wikstrom and Brown proposed a hypothetical cascade of events that would affect an individual’s ability to “cope” following an ankle sprain and provide a rationale for the varying contributors to instability. For an individual starting from a point of normal function, a lateral ankle sprain will trigger a consistent pattern of changes to the joint from the inflammatory process. Swelling will increase pressure on the joint’s mechanoreceptors, and pain will contribute to inhibition of the reflexes to the joint (arthrogenic inhibition). Together, this means patients will have difficulty sensing the joint and subsequently stabilizing it while excessive mechanical laxity will increase this loss of stability.19

Inflammatory changes may be similar across all patients; however, as symptoms remain and the patient adapts after his or her injury, a secondary cascade of neurological changes may occur that may include cortical remapping. In some patients, these adaptations may be beneficial and serve to protect the joint from further injury. Other patients may maladapt, as sensorimotor reorganization changes the nervous system’s perception of the joint. Variable amounts of laxity, proprioception, and cortical excitability exist throughout populations of healthy, previously injured, and functionally unstable joints. Where these populations diverge may be related to how each is scaled relative to the others. For instance, a joint with greater amounts of laxity may have higher proprioception and excitability to aid in stabilizing the joint, but following injury, these factors may become decoupled, leading to errors in movement and coordination.19”  -Alan Needle, PhD

Remapping the Cortex: How Rehab Exercise does it.

Below are two studies that we recently incorporated into 2 neurologic gait cases during one of our global teleseminars on www.onlineCE.com.  You can find that lecture there in a few weeks but we have dozens of our other presentations available there presently. 

Injury to a body part starts a reorganization of the brain cortex. We know this occurs from a plethora of studies but most of them are based on injury induced changes and not from treatment-induced means.  These studies support the treatment induced changes that occur in the central nervous system, and they are profound and give us comfort and validity in our work. The findings of these studies should not be a shock to you if you are in the work of manual therapy and rehab. 

The one study used transcranial magnetic stimulation to map the cortical motor output area of a hand muscles on both sides in 13 stroke patients in the chronic stage of their illness before and after a 12-day-period of constraint-induced movement therapy.

What they found was “post treatment the muscle output area size in the affected hemisphere was significantly enlarged, corresponding to a greatly improved motor performance of the paretic limb”. As the study showed, this suggested a recruitment of adjacent brain areas. Even at 6 month follow up examinations “the motor performance remained at a high level, whereas the cortical area sizes in the 2 hemispheres became almost identical, representing a return of the balance of excitability between the 2 hemispheres toward a normal condition.”

The second study (2) looked at limb immobilization in 10 right-handed subjects with right upper extremity injury that required at least 14 days of limb immobilization. Subjects underwent 2 MRI examinations post injury, 48 hours and 16 days post immobilization. Cortical thickness of sensorimotor regions and FA of the corticospinal tracts was measured.  The findings showed “a decrease in cortical thickness in the left primary motor and somatosensory area as well as a decrease in FA in the left corticospinal tract. In addition, the motor skill of the left (noninjured) hand improved and is related to increased cortical thickness and FA in the right motor cortex.”

These studies suggest the findings are associated with skill transfer from the right to the left hand. It was suggested that immobilization induces rapid reorganization of the sensorimotor system. 

Rehab works, but everyone here on The Gait Guys already knew that. It is just nice to know the specifics of “how”.  

Please go to these articles and get the specifics for yourself. Don’t take our word for it ! 

references:

1. Stroke. 2000 Jun;31(6):1210-6.Treatment-induced cortical reorganization after stroke in humans. Liepert J1, Bauder H, Wolfgang HR, Miltner WH, Taub E, Weiller C.

2. Langer N, et al “Effects of limb immobilization on brain plasticity"Neurology 2012; 78: 182–188.

Things may not always be how they appear.

What can you notice about all these kids that you may not have noticed before?

Look north for a moment. What do you notice about all the kids with a head tilt? We are talking about girl in pink on viewers left, gentleman in red 2nd from left, blue shirt all the way on viewers right. Notice how the posture of the 2 on the left are very similar and the one on the right is the mirror image?

What can be said about the rest of their body posture? Can you see how the body is trying to move so that the eyes can be parallel with the horizon? This is part of a vestibulo cerebellar reflex. The system is designed to try and keep the eyes parallel with the horizon. The semicircular canals (see above), located medial to your ears, sense linear and angular acceleration. These structures feed head position information to the cerebellum which then forwards it to the vestibular nucleii, which sends messages down the vestibulo spinal tract and up the medial longitudinal fasiculus to adjust the body position and eye position accordingly. 

Can you see how when we add another parameter to the postural position (in this case, running; yes, it may be staged, but the reflex persists despite that. Neurology does not lie), that there can be a compensation that you may not have expected?

What if one of these 3 (or all three) kids had neck pain. Can you see how it may not be coming from the neck. What do you think happens with cortical (re)mapping over many years of a compensation like this? Hmmm. Makes you think, eh?

Ivo and Shawn. The Gait Guys. Taking you a little further down the rabbit hole, each and every post.