Neurodevelopmental Basis for Chronic Regional Pain Syndrome
In my previous two articles for this journal, (July/August and September 2008 issues),1,2 I presented my neurobiological theories on the etiology of chronic pain syndromes (CPS) and a means of implementing those theories using gait and orthopedic technology. I call this multilevel method of diagnosis "Practical Application of Neuropostural Evaluations," or the P.A.N.E. process for short. In this article, I'll present the first level of evaluation for diagnosing the chronic pain patient.
Theory and Organization of the P.A.N.E. Process
The P.A.N.E. process is organized around developmental and survival priorities. The first three levels in the process are related to neurological functions. Evolution has created both anatomic and functional hierarchies within the central nervous system.3 The various functions of the brain, in turn, are distributed through these developmental layers in specific ways and best described as stratification of functions. The layers are not independent of each other, but work together like the members of a symphony orchestra to give us the incredibly diverse capabilities of our human brain. This functional hierarchy has to be intact for us to operate at our biological and mental best, and it is the first priority to check in matters of chronic illness. I have also concluded that hierarchical organization is not “hard-wired” into the brain, but results from parallel organization and neuronal and synaptic plasticity, which can become disorganized causing severe loss of functional capacity.4 It is my theory that loss of hierarchical order is associated clinically with autonomic dystrophy and functional collapse of basic biological regulating mechanisms.
Dystrophy has been recognized since the Civil War as a severe pain syndrome and which modern pain theory considers is due to loss of central inhibitory mechanisms within the acute pain circuitry.5 However, pain problems are the tip of the iceberg with respect to dystrophy. It is my experience that there is also loss of normal homeostatic adaptability leading to environmental intolerance, altered control of blood flow distribution causing poor exercise tolerance, reduced wound healing, potential collapse of the neuroendocrine and immune systems, and other forms of biological dysfunction beside the pain issues. I believe it is therefore critical to determine whether or not the central hierarchy is intact before embarking on any surgery or therapeutic endeavor. This is another reason why I have made primitive reflex testing the first level in this algorithm. I want to remind the reader that dystrophy is a disorder with a spectrum. Long before a patient shows the classic symptoms, he can be developing the central neurological changes leading to loss of hierarchical control as a precursor to the overt disease. This is the time to find the problem and deal with it, rather than after you have done a major procedure and unanticipated complications ensue.
This article concerns the first priority in the neurological hierarchy: autonomic homeostasis. It is first because, developmentally, the autonomic nervous system is the oldest part of the nervous system.6 To my knowledge, the P.A.N.E. process is the first clinical algorithm designed to evaluate this most basic level of human biology. In testing the associated involuntary, neurological functions, I have found that about 70% of the patients that I see with CPS have neurological dysfunction at this level.
P.A.N.E. Process Considerations
CRPS is fundamentally a neurological condition regardless of what “hurts.” Neurological diagnosis is critical in resolving the associated health issues. In general, western medical neurological diagnosis is inadequate in diagnosing CPS because it is usually limited to finding neuropathy. Western clinicians are caught up in the traditional symptom-directed, pathoanatomic algorithm. One might ask: Where is the pathologic anatomy in fibromyalgia? The traditional Western Medicine algorithm doesn’t work in solving CPS because:
- the CPS patient typically has minimal objective pathology,
- we ignore the incredible “compensatory survival dynamics” inherent in brain processing,7
- standard diagnostic technology (PET, fMRIs, etc.) can not show the status of brain processing, only that it is overactive.3,8-10
Central neural processing is reflexive in 70% of the brain and is affected by “neuritis” of afferent inputs (afferency). Pain is a reflex11 with afferent, central and efferent components. Obviously, a problem is best solved at its source, (e.g., at the keyboard rather than at the printer) yet neuritis is typically not diagnosed.3,11
Since Hughlings Jackson, MD’s pioneering work, brain processing is accepted as following developmental lines. Evolution has created a hierarchy of developmental stages which have to be intact for optimal processing of reflexive functions to occur.12 Chronic states of elevated neural anxiety due to survival stress come at the expense of over-utilization of key neurotransmitters (serotonin, dopamine, nitric oxide, etc.) This explains where the Serotonin has gone in fibromyalgia.8,13,14 What causes these states of metabolic activity? I am proposing that threatened fundamental biological functions—such as bite, balance, breathing, or blindness—activates survival metabolism in the reflexive parts of the brain.15 When these frequently asymptomatic conditions are misdiagnosed (who in our modern world worries about their “bite”?), the chronic stress can lead to depletion of neurotransmitters and set the stage for altered pain processing and altered homeostasis.
Based on my experience with motor reflex testing, I propose that depletion of neurotransmitters drives the brain’s processing back into the primitive developmental layers normally seen only in infancy. I call this “functional regression” and have found that it is reversible if the cause is treated. The problem remains: how does the clinician evaluate the status of reflexive processing in the brain? How does the clinician locate the cause of brain stress, so that it can be addressed? I believe that the P.A.N.E. process being presented in this series of articles is a step forward in answering these questions.
P.A.N.E. Process Overview and Order of Testing
This overview presents the components of P.A.N.E. process and the order in which they are performed. Due to the wide variety of potential causes of chronic pain, this process provides a troubleshooting guide to converge on the underlying problem(s).