Skin: not as superficial as you think

A human foetus can do it, as can a newt, even a starfish has got it nailed; yet when it comes to you and I, regeneration is a struggle. That is not to say we can’t repair ourselves, we do so but the end result – a scar – can have a profound effect on the physical and psychological aspects of sufferer.

Fiona Wood strives to change this. World renowned for her work with burns victims, she graced the recent NOI conference with her seminal ideas on tissue healing that were far from skin deep, enticingly asking: ‘can we think ourselves whole?’

Following her fantastic delivery, I thought, ‘wow’:

  • Skin, you are rad
  • Brain, you are happening

And ‘gosh’:

  • You two should never be separated

It has become second nature to think about our body as being represented in the brain, indeed, it is a difficult place to leave once you have arrived (a bit like Adelaide really). Yet, paramount to the maintenance of the sensory homunculus is the afferent information that we receive from the body surface: our skin.

Without our skin who would we be? Beyond its function as a peripheral barrier, skin serves to create an interface that dictates our ‘self’ in relation to others. This quality is compromised in the face of burns.

Whilst tackling the key requirements for successful wound healing, recently revolutionising the way in which skin grafts are applied with ‘spray on skin’ (ReCell®), Fiona Wood has postulated that burns management needs to go beyond the surface and address the scar that is not visible to the naked eye.

Research has demonstrated that not only are there sensory function and neuroanatomical changes at the site of tissue scaring, there are changes present at uninjured areas peripheral to the wound (Anderson et al, 2010; Hamed et al, 2011). It is therefore suggested that beyond the superficial wound lies a broader, systemic response to burns injury that intertwines the periphery and central components of the body-subject (Merleau-Ponty, 1962). This is a concept that is not unfamiliar, certainly a chronic pain picture, with its high prevalence following burns, is an appropriate adjunct here. In this light it seems plausible that plastic changes occur within the CNS following burns injury, moulding the 3D representation we hold of our ‘self’. Like in chronic pain, could this alter the way we predict and evaluate widespread afferent and efferent signals in the presence of scaring? A concept that could help us further understand the reduced functionality associated with scaring.

In order to promote skin healing, moving away from repair towards regeneration, the relationship between the CNS and the periphery cannot be ignored. Should we therefore be looking to maintain the sensory representation of wounds from the outset? Should we discourage the masking of affected body parts that removes important visual feedback? Indeed, should we be applying techniques commonly associated with chronic pain rehabilitation to acute burns victims?

Again refuting Descartes, the need to inexplicably tie the body with the brain is a point null and void- they are one and the same. Whether addressing pain or the creation of scarless healing, the body-subject seems never to work in isolation and we should therefore treat it accordingly.

Abby Tabor

Abby 150x150 Skin: not as superficial as you thinkAbby has a very posh English accent, and clearly doesn’t like granola bars.  What brought Abby out to Oz? Abby first got an inkling for what pain really was after listening to Mick Thacker during her undergraduate degree at King’s College London. It was his inspiration, along with a certain Moseley style Explain Pain experience that led her to the other side of the world to delve deeper into the world of pain.
She finally agreed to return to the UK, on one condition, that they would let her come back to the land down under to do part of her PhD. Still in the early days of research she is nurturing a nice little coffee habit and asking a lot about how philosophy can fit into our understanding of pain.

References:

Anderson, J., Zorbas, J., Phillips, J., Harrison, J., Dawson, L., Bolt, S., Rea, S., Klatte, J., Paus, R., Zhu, B., Giles, N., Drummond, P., Wood, F., & Fear, M. (2010). Systemic Decreases in Cutaneous Innervation after Burn Injury Journal of Investigative Dermatology, 130 (7), 1948-1951 DOI: 10.1038/jid.2010.47

Hamed, K., Giles, N., Anderson, J., Phillips, J., Dawson, L., Drummond, P., Wallace, H., Wood, F., Rea, S., & Fear, M. (2011). Changes in cutaneous innervation in patients with chronic pain after burns Burns, 37 (4), 631-637 DOI: 10.1016/j.burns.2010.11.010

Hyakusoku H et al. (2010) Recell. Color Atlas of Burn Reconstructive Surgery. Ch 6

Merleau-Ponty M(1962) Phenomenology of Perception, trans. Smith, London: Routledge and Kegan Paul

Comments

  1. John Quintner says:

    Abby, please explain exactly what you mean by “the body-subject seems never to work in isolation and we should therefore treat it accordingly.”

    [Reply]

    Abby Reply:

    Hi John,
    My intention with this closing remark was to illustrate that we cannot separate ourselves into brains and bodies, furthermore we can not separate ourselves from our surrounding environment. They are intertwined, so that each experience propagates the next.
    The body-subject was a term I came across in Merleau-Ponty’s work, in which he used it to move away from dualism, I admit to being a philosophy novice, but for me it demonstrates an important point in relation to pain. If some one experiences pain, it may be said that they are in a particular state or position, which in turn affects the way they interact with their environment as well as potentially shaping the way they see their environment in the first place.
    Treatment wise, I think it pulls us away slightly from putting the brain on a pedestal and getting us to address pain from a more body-centric position (not in a Cartesian fashion), one that incorporates brain, body and environment united.

    I hope this helps to explain, let me know if this has missed the mark.
    Cheers,
    Abby

    [Reply]

  2. Alex Chisholm says:

    Thank you so much for this post! I have worked with burns for two decades, and strongly believe that chronic pain in ‘healed’ burn tissue/scar might be connected to changes in CNS, as well as peripheral changes. Many old burn patients, with large TBSA, have chronic pain. Our Doctor, however, told me that this was not possible, that I had entirely missed the boat and that I had no idea of what was happening. Essentially that I was nuts to think there might be a connection. So I am very grateful to see that perhaps I have not entirely missed the boat!

    [Reply]

  3. Dave Moffitt says:

    Great article. I will use it to open school
    Students up to the wonderful interplay that is our various body bits.

    [Reply]

  4. hi abbey,
    i’m wondering if you’ve come across anything for EB (Epidermolysis Bullosa) sufferers. i have a dear godson with the condition and always have my ears ready for any break throughs or coping strategies.
    cheers
    soula

    [Reply]

    Abby Reply:

    Hi Soula,

    I am afraid I have very little knowledge specific to EB. There seems to be quite an emphasis on techniques that minimise anxiety and the threat value of particular everyday tasks that tend to be painful (eg, bath time and dressing changes). I came across an interesting paper (Pain Management in Epidermolysis Bullosa. Goldschieder and Lucky) that may offer a bit more depth to this.

    In line with the above, I wonder whether graded motor imagery may offer a treatment avenue, promoting pain-free movement and self awareness. I couldn’t find any evidence for this though.

    Sorry that I don’t have more to add, I will keep a lookout for any further info.

    Best wishes to you and your godson,

    Abby

    [Reply]

  5. John Quintner says:

    Abby, I suggest you read our 2008 paper – Pain Medicine and its Models: helping or hindering? You can download it from the Painaustralia website, under Health Care Professionals & Research from Australia. To escape dualistic thinking is easier said than done! I believe we have done so in our 2011 paper – An evolutionary stress-response hypothesis for Chronic Widespread Pain (Fibromylagia Syndrome). You be the judge!

    [Reply]

  6. John Quintner says:

    Abby, additional thoughts. Taking a biogenic systems approach to living organisms may be useful. Within living systems there exist a myriad of sub-systems, each of which contains sub-sub-systems etc. What properties they share in common could well be self-organization, autopoiesis (self-creation) and negentropy (they gain in energy). Importantly, living systems appear to have an over-arching property – that of self-referentiality (they make their own rules). Cognition can be defined as the means by which the organism makes its way in the world. This approach complements our traditional anthropogenic view of the world, but it does also enable us to transcend body/mind dualistic thinking about pain issues, in which we are hopelessly enmeshed. It has taken me many years to get my head around this stuff. Does this help? I am indebted to Dr Pamela Lyon for the above insights.

    [Reply]

    Abby Reply:

    Hi John,

    Many thanks for your comments and really informative links. I am making my way through Dr Pamela Lyon’s paper at the moment, extremely interesting. It will provide some great talking points for Mick and I, I’m sure.

    Kind Regards,

    Abby

    [Reply]

  7. Dr Mick Thacker says:

    Hi Abby
    Great post and some essential comments made in your responses and those of John. Making sense of philosophical constructs is difficult and useless unless they make biological sense. Maybe we should finally cease to use the terms peripheral and central? They make no biological, anatomical or philosophical sense !
    Mick
    (PS lets have coffee and philosophise this week!)

    [Reply]

  8. John Quintner says:

    Could we be witnessing a Kuhnian paradigm shift in pain theory? Very exciting times!

    [Reply]

  9. Dr Mick Thacker says:

    Hi Abby and John and others observing – someone asked me in person today what i meant in my brief comment so I will elaborate – We are all used to seeing neurons drawn schematically and synapses depicted as triangles and circles with little attention focused on axons and dendrites and not how they connect or get there in the first place. Simply put, one end of a so called peripheral neuron is in dorsal horn i.e the spinal cord i.e. in the CNS – so how can it really be a peripheral neuron?
    One end of the majority of dorsal horn neurons is in the brain i.e. they are not just a disconnected circle in the dorsal horn! I know people will say that it depends on where the cell body is (where the cell’s nucleus resides) and I can accept that up to a point but newer information from neuroscience suggests that protein synthesis can occur at sites other than the cell body e.g. at the synaptic terminals at either end of the typical neuron and that this may alter both their structure and function and that of the neurons and glia with which they synapse. We are perhaps beginning to make the trip up the afferent neuron and beyond that Pat Wall advocated over 20 years ago. These are indeed exciting times John, there is an increased appreciation of studying pain from systems and mechanism based perspectives, which should include philosophical constructs and reasoning together with cutting edge neuroscience. I believe that the current strategies employed in the understanding of consciousness may offer a template for an improved approach to the understanding of pain. Here we can philosophise further and ask whether these topics are in fact one and the same ?

    [Reply]

  10. Michael Ward says:

    I think that these are major steps – the difference between the CNS and the PNS is the width of a synapse – so what is the real basis for separating the 2. For a Kuhnian paradigm shift, we need to be external to it dont we? Such a step might include a de-emphasis on nerves.

    [Reply]

    John Quintner Reply:

    Michael, I think we are in a paradigm shift whenever the opinion leaders are convinced that the current paradigm no longer provides answers to the questions being asked and a better one is on offer. The scientific community then chooses whether to continue to work in the old paradigm or to adopt the new one.

    The peripheral/central divide of the nervous system has been useful but we need to remember that it was imposed upon the living organism by observers and that this divide was always going to be an artificial one.

    [Reply]

    Anonymous Reply:

    Thanks John and Mick,
    A major concern I have from reading comments elsewhere on this site and other sites is the fascination with the intricacies of the CNS and the expanding circuitry detail as if this more detailed circuitry fundamentally alters the approach to pain. We are so proud of smartness in deducing function from fMRI or whatever tool we use, yet only interpret the data (naturally enough, I suppose) within the current paradigm. While this knowledge has explained aspects of the pain experience better to a point, the intricacies seem to reinforce a compartmentalization of the nervous system (dualism in a different cloak) – firstly CNS vs PNS: an anatomical not a functional division; acute Vs chronic: an arbitrary clinical division; an over focus on the pure pain processing rather than the whole individual and all of this before we even get to the biochemical / “immunological” us, the basis of our squishy existence. So while there is much (neuro)science which points to a need for changing our thinking, there are many who can remain happily ensconced in the primacy of the neural pathway and pain loci. The only difference between this and 30 years ago is in the number of loci and number of connections. I think that it will take more than the proverbial 100th monkey for fundamental change to occur – or maybe I am just negative tonight :) John I would like to chase down your 2011 paper.

    Cheers
    KSMT

    [Reply]

    John Quintner Reply:

    I agree that we need to be very careful not to fall into the trap of endorsing neurocentric explanations for pain.

    Michael Ward Reply:

    Dear All, my apologies for not putting my name to the anomynous response – a late night oversight.

  11. Hello Abby – great post and discussions. I have a question about people with burns that I wonder if you could answer. Us PTs work on people after skin grafts, often pushing on them like mad to help recover movement of limbs and body. The treatment might last 45-60 minutes, leaving the patient exhausted from dealing with the pain of being stretched so hard. Yet, they do not typically have significant pain flare-ups after the treatment. Shouldn’t we expect that the damage to the ‘peripheral’ nociceptive neurons would have created shifts in the neurophysiology of these neurons similar to those science shows in other peripheral neuropathies? i.e., prolonged stimulation of people with sensitization typically creates a flare-up, yet not flare-up after treatment here, so does this mean there is no sensitization? How can that be? Maybe there is a difference between chemically mediated neuronal damage vs thermal (and the subsequent mechanical forces on the neurons related to scar tissues). It could be that central processes are different in people with burns, and this alters the peripheral neuron physiology. I must be missing some key knowledge to explain why there does not seem to be significant peripheral or central sensitization in people with burns. I have heard an argument that the nerves are dead, but that would mean that the pain reported during stretching is produced without nociceptive input (possible). Besides this I have not found an answer, and wonder if this situation is an indication that peripheral neurons can be damaged (a lot)without becoming sensitized. I may have been asking the wrong people to date.
    As a leap from this line of questioning, if there are central processes that somehow over-ride or shift the peripheral sensitization in people with burns, this would be provide some explanation for the findings that GMI (a primarily central treatment process, or at least one that starts without much direct input to the peripheral neurons – yup I know that is dualistic, and that one cannot be changed without the other changing) can create lasting changes in people with CRPS – in which the strong evidence for changes in the peripheral neurons leads some scientists to only expect treatment success from intervening to restore the peripheral neurons’ genetic and physiological activity towards ‘normal’.
    Thanks for considering this
    neil

    [Reply]

  12. Hi Neil,

    Thank you for highlighting some key issues in your post.

    In fact I think that the ‘leap’ you mention between questioning is hopefully not too much of a leap. There seems to be a disconnect between regeneration of neuroanatomy following burns and sensory function. The reduction in sensory function seems not to be accounted for in the comparatively small reduction in innervation in some cases. This could point to the fact that regenerated neurons do not possess the appropriate function in association with a systemic response to burns- altered perhaps by a change in molecular cues and a possible disrupted topographic representation after injury (partly as you say due to altered neurophysiology). I think that research into understanding some of your questions is following this tact, particularly relating to systemic changes that result in changes in the functionality of the nervous system as a whole in response to burns, not just isolating the periphery. Could this explain in part, the pain response, or lack there of, following stretching?
    In this sense the overlap into the use of GMI would make sense, despite it’s somewhat neurocentric roots, promoting functional regeneration following burns, from a whole body perspective.
    I would be really interested to know if you have used GMI with burns patients and the sorts of responses you get.
    Many thanks,
    Abby

    [Reply]

  13. Hi Abby,

    I am wondering if you have come across anything for Virtiligo…the white patches that appear on the skin due to pigmentation issues.

    Thank you.

    [Reply]

  14. Anonymous says:

    Where is the skin represented in the brain?

    [Reply]

    Abby Reply:

    Hi there,

    We have motor and sensory representations within our brains, known as homunculi. The sensory homunculus is made up of information from the skin (eg touch) and is found in the primary somatosensory cortex, part of the parietal lobe of the brain.
    Kind regards,
    Abby

    [Reply]

  15. I think it is in the Pineal Gland.

    [Reply]

  16. Alex Chisholm says:

    Hi Abby,
    I have used GMI with one severe, severe burn, and it worked amazingly. It worked so well, she begged to keep the mirror in the hospital room. Within one treatment she had increased ROM. I was very surprised by how well it worked. (I was lucky her other hand was unburned to be able to do it.) I have found some burn patients can get increased pain after stretching, and I have been treating burns on and off for 25 years.

    [Reply]

    Abby Reply:

    Hi Alex,

    Thank you for your comments, it is great to hear that what is being discussed here makes sense in the clinic too. It is really interesting to get a grasp of the different areas GMI can be useful.
    Thanks again for your posts,
    Abby

    [Reply]

  17. Stuart Miller says:

    Hi Abby,
    Sorry for my ignorance but I have a comment and a question. In terms of the periphery and central responses to inflammation, I think that there is a significant difference. Having treated lots of burns in my career and also seen lots of patients with MS and other patients with ‘centrally mediated/driven inflammatory responses via autoimmune issues’ I think there is a significant difference between macrophage response and microglial response to a ‘disturbance’ in the system – ? evolution in isolation (with blood/brain barrier); there also seems to be a significant difference in oligodendrocytes and Schwann cell responses to neural insult (add in other components of the ‘other brain’ as you wish for analogies comparing peripheral/central systems). I think it is far more complex than just looking at nerves (no reductionist viewpoints please). I definitely have trouble with the details but an integrated organic view of body, brain and environment is needed. The question I have with some of the burns I treated that did end up with chronic pain (one in particular with complex fractures as well as severe friction burns from rope/horse accident) was that the unresolved joint restrictions seemed to be the issue in terms of returning to meaningful function and possibly contributed to the facilitatory input from the CNS (possibly in terms of somatosensory reorganization but possibly something else) and not the superficial – deep thickness restriction in tissue length. I’m still trying to understand the complexity so I apologize for my limited perspective. Question is – in terms of awareness of new body image/ peripersonal space and whether it is ‘accepted’ or not by the person – does this influence the response ? Stu

    [Reply]

  18. stuart miller says:

    Hi,
    I had really appreciated the dialogue. I was just doing another course with Judy Colditz, an amazing occupational therapist who teaches the anatomy of the hand and upper extremity and who has also developed an excellent framework for restoring ‘normal’ movement patterns in the hand even in the chronic stages. Brilliant speaker (and well worth listening to). In terms of concepts of active redirection of movement via constraint or casting motion to mobilize stiffness (CMMS) I see an approach that may have helped with some of the really resistant movement patterns that developed with a few of the burn patients I treated 10 – 15 years ago. I have only started to really get my head around some of her approaches in the last 5 – 10 years and yesterday helped solidify some of the thoughts. She does not believe that aggression in restoring movement is indicated (nor does Paul Brand who treated a lot of patients with club feet via slow casting methods). She also believes that it takes time to reintegrate normal movement patterns due to cortical reorganization (and other factors). When it comes to patients with fear of movement (with significant acute or chronic pain) the belief structures of the people working with the patient are critically important (in my opinion). There are no absolutes (in my opinion) and I look forward to discussion about integrated movement patterns and belief structures with chronic pain in burn patients. I have really appreciated the blogs about fear and treatment paradigms. Thanks for listening. Stu

    [Reply]

  19. stuart miller says:

    Fiona, Abby, and others;
    I have not seen a lot of the burns with significant TBSA (Alex, I appreciated your insight). When I did see some of these patients, I had not usually followed them until an outpatient setting. Peripherally, scars initally responded to the stresses that were applied to them and the concept of compression was key in terms of managing scarring (hypertrophic or otherwise). How this could be altered in terms of ‘improving’ sensory input at critical junctures for somatosensory reorganization would be fascinating and I would welcome insight. Sorry, at times my paradigm hasn’t fully shifted and I haven’t seen a lot of burns in the last 5 years. I haven’t read Fiona’s or Abby’s work but am very interested. In terms of management of edema, whether it was a product of tissue trauma or of neurogenic inflammation (in which if it persists, there may be more CNS involvement in its persistence or maintenance, yes ?), the role of the lymphatics seemed important in terms of management ( recognizing that even thoughts can be inflammatory). For chronic stiffness, there are now improved techniques for restoring some patterns of movement and I would be very interested in the role of GMI through the continuum. I didn’t identify patients with CRPS with hand burns (reasons – my ignorance ?; are there a lot of cases with hand burns ?). My point is, acute management seemed critical for end results with more peripheral burns especially with hands. With bigger TBSA burns, I don’t know if Fiona, Abby or others can comment on the ‘body matrix’ or ‘peripersonal space’, in relation to chronic and/or complex pain (with or without larger TBSA burns) and their research (or others). I would love to hear other perspectives so that I could provide a more helpful approach to the patients I treat on a daily basis. I loved reading and hearing Patrick Wall’s and Dr. Paul Brand’s perspectives on the importance of translation of research to the clinical setting and appreciate all the insight I have received from Body in Mind. Thanks.

    [Reply]

  20. alex chisholm says:

    Hi,
    I have just read a fascinating article which reminded me of your post. It is by Tanya Fischer, showing reduced thermal pain thresholds in regions OUTSIDE of the healed thermal burn, including CONTRALATERAL limbs. The authors postulate this may be due to systemic or central mechanisms which may contribute to pain after burn injury. The article is titled”Extraterritorial temperature pain threshold abnormalities in subjects with healed thermal injury.”

    Thank you for all your comments. It is a great way for me to learn.

    [Reply]

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