For as long as he could remember, Steve had a tight IT band. Mostly he ignored it, but when it interfered with skiing, he’d had enough. That started a cascade of events – three surgeries, and still a knee that was not right. The doc confirmed it. “Someday, you’ll be looking at a total knee replacement,” he said.
Steve thought he’d defied the odds. In fact, he had done so well strengthening his left knee that it was stronger than the right one, but he still didn’t trust it. Then, out of the blue, his back and left knee started hurting. The knee swelled, and he thought, “here we go – this is the beginning of the end.”
To evaluate a knee problem, we never just look at the knee.
Adaptations in the brain and nervous system can be part of the story.
Steve made a physical therapy appointment. After a few visits, he was feeling better. But, just one tweak of the knee reversed the trend. That knee felt fragile and worrisome.
We know that tissues heal. So why was it not getting better? Within 8 weeks of an injury, the tissue has healed. Think of how readily your body heals a cut, or even a broken bone. And while you are healing, pain directs you to alter behavior. Pain protects.
When ALTA PTs evaluate a knee problem, we never just look at the knee. We look at the hip, the ankle, perhaps the lower back, and if the problem is persistent, we also look for adaptations in the brain and nervous system. We’re not talking about brain surgery here, but we are talking sensory integration–a fundamental skill taught in PT school.
When you experience pain, parts of your brain “light up” indicating neural activity in areas that are also used for sense of touch, movement, temperature, etc. When you experience repeated pain in the same area, activating the same parts of the brain, those neurons that fire together wire together. This is called smudging.
Effectively, it can mean that your brain interprets changes in pressure, temperature, or any number of things as pain, and that your nerves are more sensitive to pressure or temperature. It also means that these neurons become less effective at their original task, thereby decreasing the brain’s ability to interpret sensation in that part of the body. The brain’s depiction of your knee becomes imprecise.
These brain patterns created a more painful, sensitive knee for Steve. Luckily, these brain patterns can also be undone.
PTs are not going to order an MRI of your brain to see what’s up. But we do have tests to see if your brain has distorted the representation of your knee. Laterality is the first of many tests we do to assess your brain and nervous system. We assess your ability to tell right from left quickly and accurately. Sounds crazy, but often when people in pain do the test, it’s harder than they expect. Patients are in disbelief. This is crazy, they say.
We tested laterality on Steve. His accuracy was 100% on the right knee and 60% on the left. His homunculus – the part of the brain that registers body sensations – did not have a precise and accurate picture of the knee. If we find a deficit, we can help you fix it. And studies have shown that brain training is really important to decrease pain.
If laterality is A-OK, we move to the next test. Chances are good that if you’ve had pain for a while, your brain has rewired enough to make it hard for the inflammation and sensitivity to normalize. Testing will help your therapist determine what treatments will fix your sensory and nervous system for the best results.
As Steve worked on sensory integration that helped changed the brain patterns, his knee became less susceptible to tweaks. And with fewer flare-ups, Steve stopped thinking of that knee as fragile or problematic – equally important to training his brain away from pain. In no time, Steve returned to his active life.
The really great news is that your brain can change. You can get a more accurate picture of how your knee is really doing. And as your brain changes, the knee becomes less sensitive, less swollen, and more functional.
Over the next few newsletters, we’ll describe all the graded motor imagery that helps us treat your body and your brain to help you get back to a full life.