Transcript

Tim Beames (00:01.868)
Hello and welcome to another pain podcast. I'm the host Tim Beames and I'm joined by Bart Van Buchem So today we thought we'd explore the idea and the co-occurrence of movement and movement disorders with pain. And we wanted to use two conditions that I think both of us are fairly familiar with. So

I've worked a lot with patients who experience complex regional pain syndrome, but you've worked a lot with functional neurological disorders. And I mean, what's interesting for both of those conditions, like from my perspective, is how significantly movement can be impaired. And, and that there often is a

co-occurrence or a relationship with pain as well. and it may kind of make sense as well. Like if movement is painful, why do I want to move? But I think it's a little bit more complex than that. So, I wonder whether we could start then by, I mean, maybe first of all, I think there's a sort of misattribution of

movement or muscles to pain by a lot of people. it's all, so what I, what I often hear or what I see is people attributing the muscle as the cause of the problem, you know, it's because I've got a tight this or a loose that or an overactive this or that there's a trigger point here or whatever it might be. And, and, and I don't

see movement and movement disorders and the relationship of pain necessarily following that, although that may be a part of what you observe or you measure within that person. What's your thoughts there on that sort of countering some of the, I don't know whether it's countering or just creating a different viewpoint of how the movement system and the muscular system relates to

Bart Van Buchem (02:16.271)
Hmm.

Tim Beames (02:30.392)
to pain.

Bart Van Buchem (02:31.662)
Well, that's a great question. think that that's a debate that has been going forever, I guess. And one of the most compelling differences that I've ever found, to be honest, is that you can't have pain without noticing it, but you can have a movement impairment without noticing it. Do I express this in a way that it's just everything, right? So

It makes me think, right, so you could say this is a, you can, unconsciously, you, any consciousness, you could have a movement disorder. This happens all the time. People may have changed their movement and they may sort of dragging their feet or, unable to do so. And they may notice it by they, they are pointed at making it consciously. So, or sort of driving your attention towards makes you.

noticing it very well. if you very, once you notice it, it's very hard not to notice it, right? Although within FND, I would say they've seen some some very interesting movement disorders that sort of you feel like when you see it, you would would definitely argue that, well, it's hard not noticing it. But some people don't, to be honest. With pain, which is typically inexperience.

And it will be very hard as an observer to whether a person is in pain or not. Some people can actually act like it doesn't change behavior because from my background as a physiotherapist or I would any type of paramedic or so any kind of, of, let's say allied health profession would be sort of observing and basically saying, well, the first thing we do notice is that movement have changed.

over the course and it may or may not relate it to a pain problem. And like you said, the condition of complex regional pain syndrome, which will be from a functional neurological point of view, will be the functional dystonia. And that might be painful or maybe not that painful, but most of the dystonias are not comfortable. So there will be painful.

Bart Van Buchem (04:56.388)
They seem to correlate quite well. that's where I can see, can't see that all the, let's say all the types of conditions that we notice as a painful condition may have involve a movement disorder or the other way around. So I think we have to be cautious there, but I think the starting point is what I said. There is a massive difference where I can see you can't send there the same.

But they do share features very strongly, depending on the person. And I think one of the things for having a, let's say the, diagnosis of CRPS is also based on part of it is a movement disorder. Otherwise you wouldn't get to the Budapest criteria that are sort of ticking off the boxes. So you need some kind of sort of.

Tim Beames (05:29.036)
Hmm, yeah.

Bart Van Buchem (05:55.93)
that's a position that would sort of create the likelihood of this diagnosis. Without this, it's getting less likely that this is a diagnosis. So I think this is a nice debate, but I think we've covered this before. This is also an academic discussion and maybe for clinicians to sort of address it whether it's is or not, but in the end,

Tim Beames (06:18.679)
Mm.

Bart Van Buchem (06:25.016)
I would consider my patient would be, so what's the problem? What is it what we can do about it instead of trying to, whether it's a neurological problem or it's like a pain condition problem, and that could go forever.

Tim Beames (06:28.152)
Yeah.

Tim Beames (06:36.866)
Mm.

Yeah, yeah, yeah. So here's what I'm thinking. I'm thinking if we reframe movement and the relationship of movement and the motor system, then that actually gives us a little bit of a better way of integrating the therapeutic approaches that we could offer to people who have either FND or CRPS. hear me out and see what you think.

But my position of thinking about the motor system is it's a predictive system. in other words, imagine someone throws you a ball, you're predicting where the ball is going to the trajectory of the ball is going and you move your body to get into that predicted position.

That might be a sort of typical thing if you're walking up the stairs or walking down the stairs It's a funny thing isn't it because most of the time you completely unaware of it very very occasionally you that predictive Capacity that you have just goes a bit awry So you might think that's an extra step to come and there isn't and and then that brings us into our awareness of going wow, isn't it amazing we we go around so much of our life predicting out what the consequences of our actions are going to be

Bart Van Buchem (08:01.646)
Hmm.

Tim Beames (08:03.214)
And the reason I'm saying that is both of the conditions I'm thinking have in their relationship with pain is that the movement is affected from, if you want, a top-down perspective, a predictive perspective. So for CRPS, for instance, we know that there can be shifts and changes in the

cortical representation of your movement, assemblies and maps, cetera. But a part of it is just the nature of the expectation of when I move, I'm going to be in pain. And CRPS is characterized with really severe and intense pain. So if you know that you're going to be in pain, what can you do about it? And we have this repertoire of

of behaviours that help us to avoid, reduce pain or maybe alleviate pain. And usually those involved some form of movement within that.

Bart Van Buchem (09:16.432)
Yeah. So what you're saying, and I think that's where we agree on this is just have trying to avoid the movement is causing pain. It's not a sequence that first the movement disrupted or getting in trouble. And therefore the pain we, you actually say, no, there's a top down, there's a prediction of pain and movement. That's what these adaptation or movement changes occur at the same time.

Tim Beames (09:45.752)
Yeah.

Bart Van Buchem (09:45.932)
same reason probably, not necessarily in a positive way, that's pretty radical, Tim, saying that the movement is not causing the pain.

Tim Beames (09:48.526)
Yeah

Tim Beames (09:59.348)
It is pretty radical, isn't it? But I'm more like there is a complexity there for me is that that might be a part of how things come about. that's not alone because then you're met with the sensory evidence of what moving differently and what's going on in your body.

does to meeting those predictions and the CRPS and FND are beautiful examples where we have aberrant changes within the body that probably do a brilliant job of reinforcing that something is wrong there. So CRPS is a lovely example where you have quite visible signs of sometimes swelling, hair, nail growth changes, colour changes of the skin.

temperature changes. So you can have a range of trophic autonomic changes that are going alongside this predictive change. And part of that are probably sort of, in some ways, tied to that predictive and behavioral response of, you know, there is a problem here, there's trouble here, there's protection needed. Yeah.

Bart Van Buchem (11:18.734)
Yeah, yeah, this is where probably the overlap again, is massive. may. Sometimes it's from my case histories that I can remember of that many people would say it started. Sometimes it starts just with pain. This is the first symptom. But there are others that it started with a movement disorder. I would say they started with this dystonia, this inverted foot, for example.

this, this, this, I would say the position, the position of the foot or during walking, wasn't necessarily painful in the beginning. And it started to become painful after a while that may sort of feed into the idea that the movement problem caused a pain problem. But I want to just to highlight this. It's probably harder to, to, address or to treat a

pain in generally, then you can actually treat movement because this is something we can objective. We can see it happening. Changing movement is, is pretty much straightforward. You can see what's happening and you can see the result. It's the exposure of changing movement. And therefore the result is, I would say that that's,

I would say, I would say straightforward, it's easy to see what's happening and from the experience of the patient. So, so my view is my experience in general is that I, I do when I need to choose whether a person is in pain and does have a movement disorder, I might starting to see if I can change the experience of pain by changing the movement. Any thoughts on that? Because this is a, because the other way, so just take away the pain and that will be the common from your patient.

change the pain and I will be walking normally and I'll be alright again. Is that true?

Tim Beames (13:20.994)
Yeah, yeah. Could it be? It could be. It could be. Yeah, so yeah, I think so that brings us, think really nicely to where we wanted to go, which was sort of how therapy relates to movement and pain. And I absolutely agree with you, like you could change movement and by changing movement, change the experience. By changing the experience, you can start updating the predictions.

Bart Van Buchem (13:26.266)
Could be, yeah.

Tim Beames (13:50.51)
So absolutely, I agree with you. That would be one way of doing it. The other would be somehow changing the prediction that will help to change the movement or the behavior relating to that as well. my, like where you start, I think is a preference based on both.

you know, the evidence that you have in front of you with that person, but also partly it's that person's evidence as well. So one of the things that I've found challenging over the years, and I wonder whether this has been the same for you with FND, is that if you're saying to someone with CRPS, there's a huge part of what's maintaining this in terms of if you want glitches in the brain, as John Stone called it, wasn't it?

Bart Van Buchem (14:46.064)
Yeah.

Tim Beames (14:47.65)
But we, but, therefore the treatment approach, we could focus on, on helping to, if you want, re-educate the brain and re-educate some of those predictions that you're issuing. And some people that, that they're totally on board with that, they're switched on, that sounds great. But I would say probably half of the people that you introduce that as a concept, absolutely not. So having...

you're having a flexible approach, I think is important.

Bart Van Buchem (15:20.964)
Hmm. Yeah. Totally agree there. You can't go. There's no, there's no one way. There's no Tennessee on this. I guess that, that where the, say if you want to change predictions, so how would it look like, right? How would a positive response? and from, from the FND experience is that there can be quite

obvious and radical from my experience. showing or demonstrating that you can actually move, let's say, better with a positive experience that would have, what could impact the cause of recovery massively.

So let's say if you have a turning point in therapy and that could even happen on the first session, to be honest, this is, this is what I would say. This is, where I'm going just typically ongoing pain states compared to, to F and D states that are there for a while. If you can create this, this experience with people walking backwards or changing their posture or changing the way they have been doing, even distracting them and being able.

to have a positive movement experience that would shape the next phase. And I've rarely seen anything that happens so fast in like Evendeet and in other conditions, because it's sort of, it feels like people are like, this is what it used to be. This is how it should be. And now it feels normal. It feels owning it. So that you can see the sense of agency of that body part and using

And doing that movement by yourself is radically changing. And therefore it has an impact, right? And therefore people take it home. They're going to practice it and going to do it more and more. And they seem to be quite successful. And because it's so obvious, you can record it on video. You can show it. People feel it, especially when they're feeling it. This is where the changes and because it's, and this is typically something where I, my experience is that where the

Bart Van Buchem (17:44.654)
There is not too much pain, whereas if pain is not the most dominant, it's much easier. If there is pain, I can see there is, like say that the impact might be smaller in my, in my experience because it seemed to be distracting people, making people it's, it's fatigue. It's, it's distracting in a way. the learning process of changing movement and the disorders that

go along with it is pretty, yeah, it's pretty on, right? So it's a big deal in that sense. So I would see FND without pain is much more, it's probably easier to treat than FND with pain. And that will come to the CRPS condition because there's no CRPS without pain. that will be, that's quite interesting, right? I found that

Tim Beames (18:30.446)
Yeah.

Bart Van Buchem (18:42.52)
Also, whether I would consider, it like successful treatment is probably being driven by pain or the absence of pain as part of them. That's what my observations are.

Tim Beames (18:56.012)
Yeah, interesting. Can I then ask if we're so with this feels like a feels like a bit of a debate in a way, but how important do you feel bringing awareness is to being able to change the movement, behaviour and pattern? Do you make a thing of

bringing someone into the felt experience or showing them either by the mirrors or videoing them or getting them to really critique and analyse the experience and the feel and the movement. How important is that for you?

Bart Van Buchem (19:42.97)
Yeah, I-I-

depending on it's safe, whether people are, you don't want to frighten up people, right? So it's like, if it's very, I would say if it's changing, people do, you do have a, like you said, there is a prediction of how you think you move and how it really does. the feeling and objectifying what it is, especially when it's doing better than people feel, I think it's massively important to show them that actually

You could say in, in other terms, you could say your brain is sort of, is sort of mixing up things a bit. Now it makes it worse. It's like standing in front of a mirror that is curved. It makes you better or smaller or longer or taller or more funny. And that's how our perception is. So I think introducing people to the notion of perception is quite important. And I think there in our eyes, particularly seeing it has a massive impact. As we know, it's.

Vision is quite dominant in terms of our senses and you can, you can sort of add some smells and some other stuff, I think vision is quite dominant and therefore extremely usable and extremely helpful because we can use mirrors and we can do it in a, in a gradually, can do it gradually exposing people that to that little notions of, of how you.

consciously see, watch, and also feel it. Because I don't think we, it may look better, but it can feel horrible. Right? And I think that's something we have to not to be judgmental to towards the notion of, right, this is the right movement. This is the right posture, but changing it and asking for their experience. And therefore it may correlate that it

Bart Van Buchem (21:42.184)
I would, I could consider that if it looks comfortable, then it's very likely that it will be because you will look the sign. can see their, you can see their Grimms and you can see the people how they do it. If people relax, you can see their body language is telling you that, right? That's no rocket science. This is how we are trained. And I would definitely say, well, this looks more comfortable. that, does it feel like that? People would often say, well, actually it is. It's much more comfortable.

than it was before. how can we sort of integrate that, right? And using it.

Tim Beames (22:15.34)
Yeah, I mean that's so interesting you say that because there's such a push for many people with CRPS, you know, you've lost movement, you know, let's get it back and it's almost like, and there are treatments, the Macedonian approach for instance is like, you know, deliberate and careful in some ways.

Bart Van Buchem (22:38.415)
Hmm.

Tim Beames (22:38.658)
but to push movement, like really regain it and ignore if it's painful. Yes, it's painful. So what is going to be painful kind of thing. And there is a population where that can be effective. But what I'm hearing from you and I side definitely is I would rather look for where comfort comes and explore comfort in movement and reinforce that and spend.

Bart Van Buchem (23:04.837)
Yeah

Tim Beames (23:05.568)
and spend some time on it as well. Like really feel it, see it, do it.

Bart Van Buchem (23:12.834)
Absolutely. Yeah. And it's so interesting where I think that one of the, these are overlaps, which you'll see, for example, in tremors, when people in CRPS may have tremors here and there, and, they seem to behave very similar to functional tremors without pain. But even for a person in pain with a tremor, if it's uncontrolled, you don't know how to control it. And you find a way of actually controlling it by using entrainment or distraction and showing it or feeling it.

It gives you the sense of agency again. And I think this is something that is common in both, in, in both conditions that, that whether they are different or not, you will, people will say, I lost my limb. It's not there. It's not mine. don't, I can feel it and I can only feel the pain and not the rest of the body. loss of agency is a key feature in both and just thinking about.

Right? How can I change or how can I give people sense of agency? And I think that's something so much so, so the research is very compelling there. we lost, if we're losing sense of agency, it's generally not a positive thing. We don't on a longer term, it's not helpful. Maybe on the short term it may, because it's a sort of response, like a stress response that drives that.

makes you feel don't having a body sort of makes you surviving. But in the longer term, it's getting you in trouble. And I think this slowly getting gradually getting back to a sense of agency, even if it's only having a foot or a toe or whatever, that could be something where we can start having some positive impact. And this is where we can learn where, where that's where my learning curve, I feel much more confident.

in treating CRPS since I've been diving into the details of FND. Because it seems to be the FND without pain seems to be like I said, a slightly less complicated case compared to the CRPS with pain where actually you can see both and it's very challenging, but you need to find what is actually what I'm trying to do. If you're not focusing on the pain, but on the movement, trying to make some difference.

Bart Van Buchem (25:37.594)
And that's quite amazing because you can, one session could make a huge difference in person's life, returning some sense of agency. It's amazing, isn't it? Yeah.

Tim Beames (25:48.45)
Yeah, yeah, I feel like we've got another three or four episodes to go through.

Bart Van Buchem (25:53.54)
Well, that's a good thing. We're going to cover F &D pretty heavily in the near future. So hang in there. I would say to all the listeners. So we're going to.

Tim Beames (26:02.318)
I think we need a deep dive here, don't we? Yeah, and okay, so I'm afraid we're running out of time, but let me see if I can summarize a bit of what we went through. So our initial thoughts were around the relationship of movement and pain and the coexistence, co-occurrence of them and how tightly intertwined they were.

Bart Van Buchem (26:05.188)
Deep, deep, dive. Yeah.

Tim Beames (26:29.208)
What was interesting, and so we took two conditions that we're familiar with is complex regional pain syndrome and FND. But what I'm hearing from you as we go through that discussion is there's, it's almost like there's a sort of, there are different profiles within an FND population and you might have more or less pain and with more pain actually there is complexity around movement and how we offer that back and bring someone back into their body.

But a sort of initial discussion that we had was the importance of not seeing the muscle so much as a problem, but understanding the movement system as a predictive system. And by understanding the prediction based on the experiences and also the evidence that they have in their bodies, then it sort of informs us into two directions. It informs us that we could take an approach where we're trying to

change and alter the prediction, bringing it into something that means that there'll be more comfort, a prediction of comfort if you want, or prediction of accurate movement, or prediction of a steady limb, or prediction that that is my body, you know, I'm whole again. And then we have the other side, if you want, although I don't see them as two separate things, but the other would be to work on creating and giving back.

Bart Van Buchem (27:35.855)
Yep.

Tim Beames (27:58.784)
movement and giving someone the felt sense or the visual sense the feedback of movement and the comfort in movement.

And we are sort of, I feel like we're left with a few sort of questions here is the deeper nature of how important would it be to be conscious of making those changes and seeing those changes? And would there be a population with FND where actually bringing attention to those changes might actually escalate symptoms and therefore we need to sort of be a bit more cautious of that and...

Bart Van Buchem (28:10.832)
That's.

Tim Beames (28:38.752)
And might there be a population with CRPS, for instance, where in fact we do push into pain and I don't want to say ignore it because it goes against my sort of feelings of what we should do ethically and morally to people. there might be merit for some people where we're actually pushing into something. And I'm not sure we know that yet, or I certainly don't know that yet.

Bart Van Buchem (28:39.717)
you

Bart Van Buchem (28:59.182)
Yeah, yeah.

Bart Van Buchem (29:05.112)
No, and I like the idea of these concepts are so because this in this area, it seems to be more likely that people are sort of using different concepts of treating, let's say you're using prediction prediction errors and, and the Bayesian models, because the old models doesn't fit, don't fit, right? They don't help us the original. And actually, they do help us here.

And I would say just turn it around. can, if we can do it with FND and CRPS and these types of conditions, which is very like neuromusculatal, like this combination, I would say this is, this is absolutely the perfect place where we can sort of create this, this experience or this can be experiential and trying to learn from this, how are we going to move this back to, say, let's say what we would usually call musculoskeletal issues. And

actually to treat them as a neuromusculoidal issue, using that framework at least, and integrating newer and probably more valid models for treatment and for human experiences and recovery. And that's what the research is also saying that, but we're not there yet. So we need so much more. I would definitely say if you dive in this area, you'll be much more confident in treating, let's say,

I would say, radicular pain syndromes in general, because it gives you a whole lot of new options as a therapist or as a doctor. So definitely recommendable. If you want to have a little read on this discussion on the CRPS and FND debate, there is a paper that you can download. It's from Stoyan Popkirov. He's one of John Stone's group.

2018. It's been published in Neurology, General Neurology, which will be a nice overview of this discussion. So have a look, go to the internet and find the paper and you'll be having a little dive in this debate.

Tim Beames (31:22.636)
Lovely, thanks for that. well, that's the end of this episode. So if you like what you hear, then please give us a like, share it, tell everybody about it. Come and join us over at lepubscientifique.com as well. And see you all soon.

Bart Van Buchem (31:39.574)
you soon. Thank you for listening. Ciao.