night pain

[mike]

Hi all!

I have just a question regarding some clinical reasoning regarding a pt.

30 years old man with LBP since almost a year. Working nights and while during this sits a lot in his car. He wakes up every night (to be precise, day since working night time) with LBP and the pain is described as having a tight belt in his lower back. After walking around a bit, basically moving his spine, the pain starts to diminished and he can go back to bed. This can take a while. During his wakening time his doing fine.

During standing exam I could find some slight lateral bending to the right in T/L junction, hypertonia and slight hypertrophy of T/L paravertebral muscles
Slumps didn’t show anything neither SLR. Hi can easily put his hands to the floor while bending forward from standing with straight knees (if this give any information!?)

I have done some soft tissue work on his lower back (skin stretching, deep tissue massage), mobilisations and teach him how to activate the deep abdominal muscles ( reciprocal inhibition of the lumbar muscles).
I also had him try to stay in a flexed position with his spine (static opener maybe?) while wakening up and feeling the pain.

What could be the pain mechanisms here? Do you have any tip on how my clinical reasoning should be about this patient?

Thanks in advance
Mike

[Diane]

Mike, is the anterior thigh crease tender anywhere? So many long cutaneous nerves that course down diagonally from T12 down have exit points through the superficial tissues along the inguinal ligaments. I would check to see if there were any tender points/entrapments along there. If he sits a lot, I bet there are. If there are, I'd tackle them. Once they are gone, the "back" can operate with less internal motor struggle. My favorite position for mopping those up: supine, legs over bolster, a finger to locate tender point, other hand to stretch thigh skin distal (just an inch or two away, very light stretch, no pressure, go slow and stop when the tender point a) stops feeling tender or b) until it palpates as homogenous with the surrounds or c) both.)

ITBs might need a bit of wringing out also. The posterior knee might be gnarley. Those are areas to look at if you are doing hands-on.. sounds like your guy would benefit most from a lot more moving and a lot less sitting.

[nari]

Mike,

My take on this is his sedentary night-lifestyle. So when he goes horizontal,in the day to sleep the brain objects to all this lack of movement, and it often seems to object loudest when horizontal for a length of time.

Chronic pain is centrally regulated, so directly treating the body bits usually doesn't help, much. What will help is movement, during the night. Doesn't matter much what he does in the way of movement. TA activation might help if he actively practises it; but it won't necessarily solve the problem.

Does he have to remain seated in the car for long periods? What does he do?
Can he avoid sitting as much as possible?
What do you think static flexion will 'open'?

More later

Nari

[Walt Fritz]

Mike,
The techique for stretching the skin, as Diane described above,may help in more ways that she described. In chronic sitters, the hip flexors often shorten over time and, given their origin and insertion, will either pull upward on the femur or, more commonly, pull forward and down on the lumbar spine. The area that you described as tender, and Diane also described as having neurological involvement, also is the area where the hip flexor (iliopsoas) crosses the pelvis. So, stretching or releasing these tissues can have great value, though you may find that you get deeper than just the skin. Let me know if you want more info.

Walt

[nari]

Diane and Walt

Fair enough that this guy has shortened structures due to sitting.
His adaptive potential is low, for sure.
How do you explain the 'day' pain when he is not sitting?
What do you recommend that he do to overcome the problem on a long term basis?
Do you see your methods resolving the issue long term?

Nari

[Diane]

:). Although it's nice to recall and register in your own mind the anatomical structures that lie within, there is no real need to go "below" the skin, technically. The brain will know what to do. Just invite it to respond by giving it some sensory input. The structures aren't so much shortened probably as they are unused to eccentrically lengthening. I'd lay odds that any "structural" shortening is strictly at the level of skin/neural tunnel.

Nari, motion is definitely lotion. I think I already said that in my first post.

[Jon Newman]

Mike,

I'm confused about this fellow's pain complaints. You mention his night pain is extinguished with a change in position. Does he have day time pain? What are the circumstances of the pain? At night, does he find he wakes up in the same position all the time or does it vary? 30 is quite young but does he have any co-morbidities? Is he a smoker? What brought on his pain a year ago? What has he been trying to do for it since then? Some questions to start with.

[nari]

jon

If you reverse this fellow's times: day = night for him, and vice versa, then his 'night pain' is his 'day pain'...Mike, I am interpreting your post correctly?
That's how I read it and it seems to make sense that way.

Nari

[Jon Newman]

Good point Nari. I should have said, pain while trying to sleep versus otherwise. I'm left unsure of his pain complaints during waking hours.

[mike]

Hi!
Thank you for your reply!
This fellow is working at night and sleeps during the day, so Nari you got it right:) . He is working as a security officer and in doing that he has to drive a lot. During the night when he is working he feels no pain.( and this is where I would like some pain mechanisms to be explained. If he is sitting so to a great extent why doesn’t he feel pain while doing that if the problem is lack of motion?)
So I go with Nari: “How do you explain the 'day' pain when he is not sitting?”

Jon,
I asked him about the position when he wakes up but he was not sure. He said that he’s moving a lot while asleep. The pain just came “creeping” from out of nowhere. No smoker. He’s been to a doctor who said that his hamstrings probably are to short , I’m not that convinced they are as he had no problem putting his hands on the floor.

Hi Diane,
Which nerves are you referring to? Just so I can se the connection to the lumbar area where he is felling the pain. When having the legs over a bolster is that to produce some flexion of the hip, slack the area treated in a sort of way?

Nari,
“What do you think static flexion will 'open'?”
Good question, I was thinking of some kind of flushing method, that the problem is that he’s sleeping in a, for him, “closed position” and flexion would open up his spine to get blood, nerves, whatever to “breath” better.

Walt,
I’m would be glad to receive info about your treatment suggestions. I have been reading the discussions regarding the MFR post and I have been thinking about what a treatment session with MFR would look like? So, how would you treat the psoas tissue?

Mike

[nari]

Hi Mike

If he is confined to his car most of the night, then flexion becomes an accustomed position, and positioning away from that can be a problem. That's one hypothesis; but I guess as a security officer, he would occasionally get out, walk around, check things, and so on, therefore there is movement.

I wonder if encouraging a flexion movement/position as you stated would reinforce the brain's perception that flexion's OK, and trying to lie in bed out of flexion (unless in foetal position) would crank up the pain. Particularly in supine...
People confined in wheelchairs are in flexion, unless perfectly positioned,and some get back pain and others don't. The issues are more related to movement than anything else. CPs for instance are in almost constant movement, and the brain is probably happier with that.

What happens if you test spinal extension? Does he ever lie prone in bed?
I am not an avid Mckenzie fan, but sometimes it deals well with adaptive shortening, and he can try this, both at work and at home.

Nari

[Diane]

Mike,
Which nerves are you referring to? Just so I can se the connection to the lumbar area where he is felling the pain. When having the legs over a bolster is that to produce some flexion of the hip, slack the area treated in a sort of way? I'm talking about the superficial cutaneous branches (anterior and lateral) of the ventral branches of the regular nerve roots. Netter has some nice pictures of these in cross-section. In the thoracics they travel along the ribs. Where there are no ribs, they course downward and forward and around the bottom of the trunk between the muscle wall layers. Where they surface they immediately branch into anterior and posterior branches to innervate their various respective receptive fields/dermatomes. But where they exit and branch AP, they can get hung up. The principle of a nerve entrapment anywhere (or even the perception by the brain that there might be one) being able to refer pain anywhere along its length/into any branch applies..

The ones that negotiate the inguinal area/surface in the groin are, from lateral to medial, T12 lateral just back of the ASIS, iliohypogastric and ilioinguinal from L1, lateral cutaneous of the thigh (L2-3), sometimes (10% of people) an accessory obturator nerve (L3-4) anterior to the obturator nerve, superior to the superior pubic ramus near the femoral vein.

Hope that helps..

[Jon Newman]

Mike, it sounds like lost sleep to pain is this fellow's main complaint. That is, he is not otherwise bothered by pain. Is that right?

I realize this is not night pain but bear with me. Everyone's radar will start bleeping when they hear night pain. I wonder if night pain isn't really pain while sleeping, which typically happens at night but clearly not always. That said, here's an abstract (Bernard, feel free to edit this to make it look nicer. I've yet to figure out how to post the colorful abstract you post).

Spine. (javascript:AL_get(this, 'jour', 'Spine.');) 2005 Sep 1;30(17):1985-8. Related Articles, (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Display&dopt=pubmed_pubmed&from_uid=16135990) Links (javascript:PopUpMenu2_Set(Menu16135990);) http://www.ncbi.nlm.nih.gov/entrez/query/egifs/http:--www.lwwonline.com-pt-pt-core-template-journal-lwwgateway-images-pmlogo.gif (http://www.ncbi.nlm.nih.gov/entrez/utils/lofref.fcgi?PrId=3159&uid=16135990&db=pubmed&url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0362-2436&volume=30&issue=17&spage=1985)
The symptom of night pain in a back pain triage clinic.

Harding IJ (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Harding+IJ%22%5BAuthor%5D), Davies E (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Davies+E%22%5BAuthor%5D), Buchanan E (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Buchanan+E%22%5BAuthor%5D), Fairbank JT (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Fairbank+JT%22%5BAuthor%5D).

Nuffield Orthopaedic Centre, Oxford, United Kingdom. ianharding@doctors.net.uk

STUDY DESIGN: Prospective longitudinal study of patients attending a back pain triage clinic with night pain. OBJECTIVE: To assess the importance of the symptom of night pain in patients attending a back pain triage clinic. SUMMARY OF BACKGROUND DATA: The 1994 US Agency for Health Care Policy and Research guidelines suggest nighttime pain should be used as a "red flag." Night pain is known to occur in many conditions, and although common in patients with known serious pathology, the prevalence of night pain in a back pain triage clinic is not known. METHODS: A total of 482 consecutive patients attending a back pain triage clinic were assessed, including history of frequency and duration of night pain. Clinical examination was performed, and demographic data obtained. Magnetic resonance imaging was performed if indicated according to local guidelines. Oswestry, visual analog scales (for pain), and hospital anxiety depression scale, patient-based outcome scores were obtained. RESULTS: There were 213 patients who had night pain, with 90 having pain every night. No serious pathology was identified. Patients with night pain had 4.95 hours continuous sleep (range 2-7) and were woken 2.5 times/night (range 0-6). Patients with pain every night had higher Oswestry, visual analog scale, and hospital anxiety depression scale scores than those who did not. CONCLUSIONS: Although it is a significant and disruptive symptom for patients, these results challenge the specificity of the presence of night pain per se as a useful diagnostic indicator for serious spinal pathology in a back pain triage clinic.

PMID: 16135990 [PubMed - in process]

[nari]

Glad you posted that one, jon. Puts into perspective the fact that night pain MAY mean 'red flag' but is quite common amongst patients whose pain does not worry them during waking hours but find it extremely disrupting during sleeping time. I have met quite a lot of people whose symptoms are primarily at night. Never have worked out why, but would be good to know...

Nari

[Walt Fritz]

Nari:
How do you explain the 'day' pain when he is not sitting?

Mike:
I’m would be glad to receive info about your treatment suggestions. I have been reading the discussions regarding the MFR post and I have been thinking about what a treatment session with MFR would look like? So, how would you treat the psoas tissue?

Just a question, does he sleep on his back/stomach a lot, or curled on his side? Questions I often ask are; pain while, for example, washing dishes/brushing teeth, or standing still for a while. Shortening of the psoas (we are narrow focusing a bit here for the sake of discussion, it is often the entire anterior myofascial complex of the lumbar spine, rather than just the psoas) will cause the lumbar spine to increase its lordosis, with a secondary protective response from the posterior lumbar muscles ("back spasm"). Tightness and shortening of the psoas and related myofascial complex can cause a wide variety of local and more distant pain and other forms of dysfunction. Of note, the psoas actually has muscular slips at the proximal end that, in addition to attaching to the spine itself, some differentiate to attach right into the disc. An often overlooked cause of disc problems. But, as John says, "Find the pain, look elsewhere for the cause". Disc issues on one side of the body often are due to excessive myofascial restriction on the opposite side.

Treatment? Eval first, check the pelvic tilt: In side view, measure angle of ASIS and PSIS. The norm for males is 5-10 degrees (10-15 degrees for females) of anterior tilt. If more, a problem. Suspect shortening of the psoas, quads (attachment on ASIS, if tight, will pull the pelvis forward), and a fixation of the thoracolumbar fascia in the rear in a compensatory action. Check hip flexor tightness via Thomas test, quad tightness in prone knee flexion.

Treating the psoas: In MFR training John teaches a wide variety of methods, but lets stick to Diane's suggestion about stretching the skin. Alter the hand position slightly from her description to place one flat hand on the lower pelvis, over the belly of the psoas (just out from the umbilicus), fingers pointing up toward the head. The other hand crosses over the first (click on this link to see what I mean. In the photo, John is obviously treating the back, but the hands are arranged the same way for this release)

http://www.myofascialrelease.com//seminars/sem_mfr1.asp?wss=F45EDDB724934E52BD1F11267F00DD8E

The second hand is placed low on the pelvis, covering the route of the psoas as it crosses over the ilia and inserts into the proximal femur. As Diane stated, slowly and gently separate your hands until a very mild resistance is felt and hold that barrier. After 90-120 seconds, you may feel some warmth or movement. Without increasing your pressure, follow the release as the hands open up a bit. the hands may move in a direction somewhat different from the original, but be patient, stay with it. each fascial restriction takes the 90-120 seconds to release, so the longer you stay, the more you will get done. While beyond the scope of explanation in this forum, a lumbosacral decompression, in supine or prone would also be indicated. Using the skin as a handle allows you to access deeper layers. as you speard your hands apart, the first barrier you feel will obviously be the tightest, which may be quite deeper than the skin. it takes a while to get the feel, so be paient with yourself. You will be able to release the trapped nerves that Diane reffered to as well as deeper musculature, fascia, scar tissue, etc.

Hope this helps, let me know if you'd like more info.

Walt

[nari]

Walt

If this fellow spends a lot of time sitting, how do you explain that he would have an increased lordosis? Without seeing him?

Nari

[Walt Fritz]

Nari,
Good question, of course I couldn't definitively answer without seeing him, but if one spends a lot of time in sitting, especially with the pelvis in a position of tension in the psoas, etc, (common in our culture, leaning forward at the computer, sitting while under stress) will, over time, cause the hip flexors to become tight/shorten. Once the person stands, or lies flat, with the distal end of the hip flexor forced to it's limit, the flexibility of the lumbar spine will cause it to draw downward toward the insertion of the psoas (increasing the lordosis)

Walt

[Synergy]

So what do we know here: 30 y/o, sitting the majority of the time during work, has negative slump test, negative SLR, thoracolumbar hypertonus, no pain with forward bending and apparent full ROM with that manuever, and initial attempts to sleep are painful until after walking around for a bit and can then go to bed.

More questions: (1) What about other movements in standing, i.e. extension, sidebending each way, rotation...what effect do these have on his pain? (2) How does his gait appear, i.e., does he walk somewhat flexed at his hips/knees? (potentially suggesting neural tension). (3) How's the length of his quads, better yet, have you tried placing him prone to see if passive hip extension with a flexed knee creates femoral nerve tension?

These are just a few questions, but I'm curious nonetheless. I agree with Nari and Diane in regards to his static position and its role in neural tension. Not much of a red flag if he can find a position during sleep that relieves his pain.

Nari,

Isn't it plausible if this gentleman sits the majority of the day that his iliopsoas will be tight, potentially increasing his lordotic curve? The spasms in his t/l spine are compensatory and are most likely neurophysiologically 'turned off' because of the 'abuse' of sitting too long. Obviously without seeing this patient it's difficult to be completely sure, but these are just a few of my thoughts. :)

[nari]

Hi Chris

Yes, it is plausible that a tight psoas could cause Lx lordosis; but I don't think that has a lot to do with Mike's patient, somehow. The occurence of the pain is quite specific - as far as I know, from Mike's text - ie, when he lies down for a period of time to sleep.
Lordosis or not, this is a chronic pain pattern, almost certainly an abnormal neurodynamic (but that is a guess from Mike's information.)

I think I will wait until Mike gets back to us to answer the plague of ???:)

Nari

[mike]

Hi all,
I’m seeing this pt on Thursday so I will get back to you with more info then.

More info/answers
Flexion, extension and lateral flexion in standing did not evoke any pain.
Nari,
If I got it right I think he said he’s falling asleep in supine and then sleeps to the sides. We also tried extension in prone (ala mc kenzie) with same result, no pain. I gave him the “cat/camel” exercise to “floss” the lumbars. But I think that he’s not going to do it as often as he should. We will find out on Thursday.

Diane :thumbs_up
Thank you, I will have a look in Netter.

Jon,
I’m also glad you posted this abstract. This was very useful information. My first response regarding night pain has always been “red flags”.

Walt,
Thank you for your time explaining how to treat with MFR. When studying in Prauge for Prof. Karel Lewit he showed us this technique. He describes it in his book Manipulative Therapy in Rehabilitaion of the Locomotor System Third Edition (page 204). Lewit learned it from Ward. Is Ward someone who is familiar to you?

Chris,
I didn’t study his gate neither did I try femoral nerve tension test. I will take that with me to the next session.
“Not much of a red flag if he can find a position during sleep that relieves his pain.” This is interesting because he can’t find a position to release the pain. He says that he has to walk around doing some stretches and then after some time the pain diminish and he can go back to bed. So we don’t know for sure if the pain can be controlled by movement or if it just is time that eases the pain.

This is some kind of chronic pain pattern but still, why is it that we can not provoke the pain during exam (by different positions/movements) and during sleep there is some kind of position/movement/lack of movement that is producing pain.

Can someone in a simple but informative way explain the pain pattern?:D :angel:

Mike

[Jon Newman]

Hi Mike,

I also started a thread titled "pain at night" because I thought it deserved its own subject and didn't want to detract from your case.

[Synergy]

Chris,
I didn’t study his gate neither did I try femoral nerve tension test. I will take that with me to the next session.
“Not much of a red flag if he can find a position during sleep that relieves his pain.” This is interesting because he can’t find a position to release the pain. He says that he has to walk around doing some stretches and then after some time the pain diminish and he can go back to bed. So we don’t know for sure if the pain can be controlled by movement or if it just is time that eases the pain.

This is some kind of chronic pain pattern but still, why is it that we can not provoke the pain during exam (by different positions/movements) and during sleep there is some kind of position/movement/lack of movement that is producing pain.

Can someone in a simple but informative way explain the pain pattern?:D :angel:

Mike

Mike,

Your patient may have pain when attempting to sleep, but you said he gets up, moves around a little bit, and then can go back to bed with minimal to no discomfort...right? This is why I said “Not much of a red flag if he can find a position during sleep that relieves his pain". Is this confusing or am I not making my point correctly? The point is, he evenutally finds relief enough to go back to bed and rest undisturbed...correct?

The factor that seems more 'red flag' to me is the inability to reproduce his pain via positional change or other assessment procedures. Here's a link to an article recently published in Spine that may be of some help to you. You may want to pay particular attention to 'Figure 2'.

[mike]

Hi,
I met the patient with night pain, the security officer, the other day and he stated that he has done some improvement since we first met. I forgot to mention that he also sometimes while waking up from sleep also had some kind of cramp in his abdomen, probably some muscle spasm. He hadn’t felt any of this during this last week. He also reported that when he woke up with the now somewhat slighter pain he could relax better with help from the deep abdominal muscle exercise.

Throughout this session I did the femoral nerve tension test=nothing! Did slumps again, but this time with more pressure since this man is very flexible mabye even hypermobile he then reported some slight stretch (mabye some pain) in the lower lumbar. I looked for tenderness in the inguinal area, as Diane suggested, and found that he was more tender on the left side and treated that area with skin stretch. He was also more tender on the left paraspinal muscles in the T/L junction which I also treated with skin stretch/MFR, the “hand position” that Walt recommended.
I then put some tape, cross taping, in his lower back with the reasoning proprioceptive information and some slight feedback to avoid to much slumping posture while sitting in his car. Since he stops ones in a while stepping out of his car, I suggested that he do some extension exercise of the low back (ala mckenzie) to get some motion in this area.
It’s going to be interesting to se if this soft tissue treatment will improve his condition further.
He will come back for visit nr 4 next week.

For those of you who work in a private setting, how many sessions would you treat this kind of patient before you would think that maybe your type of treatment doesn’t work?
It shouldn’t be any different than working in a non private setting, but the fee is lower in a non private setting over here and therefore it is easier for them to reserve more sessions.

This question reflects the problem I have being a contractor in the health business and maybe it should be in another thread…just something that comes to my mind every now and then::confused:

Just to see if I got it right regarding the skin stretch in the inguinal area.

• Do I treat the superficial cutaneous branches of the femoral nerve, nervi nervorum?

• And by that alter the “internal motor struggle” in the dermatom of the femoral nerve L2?

• If the L2 dermatom is effected shouldn’t he feel pain in the entire dermatom i.e. also in the upper part of the anterior leg?

All the best,
Mike

[Diane]

Mike,
Sounds like you got the idea.

Just to see if I got it right regarding the skin stretch in the inguinal area.

• Do I treat the superficial cutaneous branches of the femoral nerve, nervi nervorum? I doubt you can actually "treat" nervi nervorum, but it's good to have them in mind as you treat.. the nerves I mentioned are not off the femoral nerve as such, they are from higher up on the nerve roots.

• And by that alter the “internal motor struggle” in the dermatom of the femoral nerve L2? I think lots of things happen at lots of levels when skin is stretched. I think the brain will alter its own "internal motor struggle" to do with that body area that is acting out the conflicting messages.

• If the L2 dermatom is effected shouldn’t he feel pain in the entire dermatom i.e. also in the upper part of the anterior leg? Not necessarily... some branches can be unaffected, some branches can be affectd but not cranky, some branches can be cranky but not giving overt problems.. it's hard to predict the nervous system and what it will do, how it will signal distress, how that distress will show up.

About numbers of treatments, once you've been on the right patch of skin and affected it the right way, and the brain has had its chance to "fix" things to a new and better resolution, the "problem" resolves.. the brain (I think) has had a chance to solve its own internal conflicts and therefore its outputs won't be in conflict. I see people 3-6 times usually. Lots of people just once, lots for more often than 3-6.. depends on tha patient and how easily they can process information, new info, coming to them through their senses, through their kinesthesis. They have to sift through and make sense, and they of course need to do awareness homework and some b-mod. If the nervous system itself is unpredictable, the actual individuals are even moreso.

[nari]

Mike, sounds like he's getting better; though with three different methods going, hard to say which, if not all, helped the most. Keep going this way, and let us know how he fares. The cramps are suggestive of L2 involvement,as is the groin tenderness. But, as Diane says, the CNS is unpredictable.

Nari

[mike]

Thursday again, and the 4th session with the night pain patient.
I’m now very used to that particular smile most of the patients get when I ask them::o
- How you tried your exercise. So this man is quite ordinary regarding exercise policy, i.e.haven’t done it much.

Hi still have problems with his back during bed time. Today he reported, that Wednesday had not been so good. He woke up with pain/cramp in his left scapula region. I examined his left shoulder region (rhomboids and middle trapezius area, no pain) but the upper trapz where very tender to palpation. Hi still had that tender area in the inguinal region so I treated that with some skin stretch and then concentrated on his upper trapz.
I tried different positions and at the same time stretch the skin over the area but didn’t succeed to get the upper trapz to relax. I wonder what is going in his “sensitive nervous system”. I used the following method:
Prone with his left arm in adduction, flexion (to but the tender muscle in a more relaxed position) I then had one hand on his occipute and one hand just inferior of the spine of scapulae and separated my hands to develop skin stretch. I held on for 2-3 minutes and thought that this approach would be very relaxing, but when palpating after the muscle was still very tender.
Sometimes while at work he has to wear a special security vest that's pretty heavy and that of course adds extra tension to the system.

Regarding his lower back I still go for the reasoning that he has to pay for the motion he doesn’t get/do during the wakening hours. I told him to do the cat/camel exercise and to relax his psoas before going to sleep (he was heading to bed right after the treatment) and then observe if it will change anything.

We will se what will happen next week. Since his LBP problem has been for almost a year maybe you can’t mop the problem away in 3-4 visits, but some patients had pain for so much longer, and it would be nice just to show his body that this condition could be reversible at least for a night or two.

Mike

[nari]

Mike

The thing about a sensitive CNS is that pain appears at seemingly random places, sometimes from week to week. It's not random, but just seems that way. Have you explained that he is not falling apart and determined if he has any great concerns over this pain experience? Education and assurances do a lot to reduce perceived threats.
Red flags are highly unlikely...the pain is not constant, and varies with position.
Like most patients, he is not compliant with exercise. Compliance with exercise is not always associated with improvement, either!

It would be interesting to see what effect Simple Contact has on his pain. However, that is not very easy to demonstrate via words only, on this forum.
The only other thing I can suggest (without seeing the fellow in the flesh) is vertical taping, somewhere along the paravertebrals. Diane has done much more of this than I have, but when some tape was stuck vertically from about L4 to T12 (doesn't matter much), I have had good results, though am not sure about long term results.

Nari

[mike]

Nari,
Do you put the tape in any direction i.e draging the skin a little bit superior or inferior? And can you use ordinary sporttape that is not elastic?
About the sensitive CNS. I would like to know more about why pain pop around like that. You say it's not by random. Is there something about it in butlers book? Do you know?
:teeth: Mike

[Barrett Dorko]

Nari,

I hate to be picky and I know you know this already, but wondering what affect Simple Contact has on any pain implies that Simple Contact is something that it isn't. I approach people manually or verbally when I suspect they have an abnormal neurodydamic with one thing in mind-the amplification and presistent expression of ideomotion. It is this motion of course that relieves the pain-not the Simple Contact, which is, essentially, nothing.

Like I said elsewhere on this forum I sit and I read and I think and I write and I practice. Anyone can take this concept of Simple Contact wherever they like and I wouldn't feel it because it isn't something I own or can sell or give away. The movement I depend upon for pain relief belongs to the patient and no one can buy that either. It's either expressed and understod or it isn't.

I guess this is what I teach. Sometimes I wonder why they'd pay me to do so small a thing. It seems to me that all you have to do is read about it.

[nari]

Barrett

You're right...I was misleading Mike in terminology. Thanks for pointing that out. I did know it, but didn't express it well.

Mike
Forget about your fancy taping 'rules'...just some strips, maybe 5-7 inches long, probably best to be elastic, but doesn't matter. Don't pull the skin, just lay it onto the skin; in normal comfortable standing, perhaps. Not sure about that, but it probably shouldn't go slack and sloppy when supine, so standing may be best. Just make sure he is not allergic to tape/band aids ets, of course.
Michael Shacklock's book Clinical Neurodynamics and David Butler's Sensitive nervous System are excellent starting points. You could probably pick one up on Amazon (?) as they are expensive. Also read up on Ramachandran's work; and there has been heaps posted on SomaSimple by various posters, particularly Diane and Barrett.


Nari

[Diane]

Mike, I'm a little bit pickier about direction of the taping, after doing lots of experimenting on my own skin and after taping lots of patients, this way and that way, and asking them which way feels best. Tape as Nari suggests, that is to say not pulling it tight, just laying it on the skin. If you use stretchy tape, it's ok to stretch it just a little but leave lots of play in it so that the skin can stretch with the tape during movement.

About taping the back, I've found the following method works well. Right on the spinous processes, tape from top caudally. Paravertebrally, tape from bottom up. Ask the patient to do the movement that is uncomfortable, to see if it feels painfree with the tape on. You might waste some tape til you get it right, so don't be too cheap, and remember that human anatomy is variable, including skin ligaments probably. Keep trying until you get a definite yes from the patient, as in "yes, I can do that movement and it doesn't hurt, and I feel strong there again."