Five Questions

[Barrett Dorko]

"I thought, the way you solve a problem in biology is you solve its simplest representation."

Eric Kandel

My workshop ends with a lecture on “The Vitals of Pain.” This is the name I gave to five aspects of the patient’s presentation that I feel are essential to know and understand in order to proceed with evaluation and care. All of these are spoken of in one way or another throughout the day but I don’t have them listed specifically. Instead, I’d like to begin a thread that examines each of the five as well as my “End of Evaluation” concept.

To me, this view of evaluation and consequent care is the most important thing about my workshop but I’m not convinced many of my students see this. Perhaps this thread will help.

Let’s begin with the heretical notion that we should begin to spend less time and effort evaluating our patients. I know we’ve been pushed to consider, investigate and test for more as our knowledge of the body has grown, but for reasons Buchanan makes clear in “Ubiquity – The Science of History,” careful consideration of a multitude of factors in any complex system does us no good when we are attempting to understand and control it. This is especially true when it is in a critical state. See The End of Evaluation? (http://www.barrettdorko.com/articles/end_of_evaluation.htm) for a detailed explanation of this reasoning.

The Kandel quote above says it all, and he won a Nobel Prize with this sort of minimalist approach. Not that I’ve any aspirations. But I ask just five questions of every patient to begin with and I thought it might be useful to present them here, one at a time. This should generate enough discussion to clarify these issues; maybe even change the nature of the questions themselves.

First Question: What is the origin of the pain?


How would you determine that?

[Luke Rickards]

There are only 4 origins, so that narrows it down a bit.

1. Mechanical deformation - most common. Pain that changes with position or use.
2. Chemical irritation - common, may occur concurrently with pain of mechanical origin. Pain is generally constant in nature, may be associated with local heat and/or swelling, often worse at night.
3. Abnormal axonal impulse generation / Ectopic discharge - often occurs after peripheral nerve injury. Hyperalgesia along nerve trunk and/or cutuneuos distribution. Often varied or odd descriptors of pain sensation and altered stimulus/response relationship.
4. Central deafferentation - rare.

[Diane]

We could start with just one origin- the nervous system.

The way I understand it is, it hurts because it isn't getting enough oxygen. It's a system that comprises only 3% of the body mass but uses 20% of the oxygen taken in.

AIGS as physiologic change to increase the effectiveness of the warning system, occur whether the pain is benign, i.e. strictly mechanical/nocioceptive, or pathologic/neuropathic, i.e.:
1. referred to sensate portions from non-sensate portions (e.g., in viscera) which are undergoing mechanical irritations from pathology, such as tumor compression;
2. the nerve axons are infected e.g. herpes
3. the nerve axons are being killed off e.g. diabetes
4. of central origin e.g. deafferentation.

The pathologic manifestations can be ruled out/referred on through history-taking, because "pathologic" pain of any category behaves differently than "benign" pain (single category). AIGS can be confusing, can make the nocioceptive and neuropathic categories seem to overlap a bit. But they will clean up within 3 days of effective motion (motion is lotion) if they are part of the mechanical pain scenario. People can have pathologic and benign pain at the same time. What we can offer patients will clear up only the benign type; although the pathologic sorts of pain may be ameliorated by more motion/better oxygenation, the conditions giving rise to them will not.

This concurrent NOI thread (http://www.noigroup.com/cgi-bin/ubbcgi/ultimatebb.cgi?ubb=get_topic;f=5;t=000580) might as well be brought here.

[Barrett Dorko]

Luke,

Thanks for this. I begin my courses by identifying the first two and then introduce the third during a brief examination of Ramachandran's writing, principally his opinion of Patrick Wall on page 18 of A Brief Tour of Human Consciousness.

The third origin (AIGs) you've identified intrigues me and may one day enter into my thinking, but at the moment I remain unconvinced that these are distinct from a combination of chemical and mechanical irritation as it is eventually manifest in the nervous tissue itself. My understanding is that such things occur in the presence of persistant chemical and/or mechanical abnormalities and are perpetuated by an absence of their reversal.

As I recall, the primary problem ends up being a nerve with too many ion channels, many adrenosensitive, and that these will only diminish with a concurrent reduction in the circumstances of their growth - again, chemical and/or mechanical origin. Naturally occuring processes remodel the nerve toward normalcy within a few days, I think.

Are these AIGs what many therapists mistake for "trigger points," ostensibly in the contractile element? Can manual care for such things be justified, or is a movement therapy that reduces the mechanical deformation in the nerve a more reasonable and defendable option?

I stopped looking for or at these things many years ago though I know the search for them remains a staple of care in many clinics. Of course, that's no recommendation in my opinion.

In short, if I were to somehow discover such a spot I'd figure that this was just a local manifestation of the first two origins you mention and I'd move on, not assuming I'd discovered anything special or anything that would alter my care.

I'd love to see other opinions on this "fourth origin."

Diane,

I don't disagree with what you've said but I think you're confusing origin with source. It's important that we sort this out at this point in the thread. When I talk about origin I'm referring to a circumstance, not a place.

[Luke Rickards]

Barrett,

As I understand it, the difference between the first two and the third is that mechanical deformation and chemical irritation involve transduction. Abnormal axonal impulses do not begin as stimulii transduced at a receptor site. They occur spontaneously within the axon its self. Thus the mechanism is quite different; conduction occurs in the abscence of transduction.

[Barrett Dorko]

Luke,

I'm learning a great deal here. The trick now is to convince others that I've known this for a long time.

So, when the origins (chemical and/or mechanical) occur in the axon itself we have a special case that differs from transduction via other tissues. I can appreciate that this deep model is special in a certain way, but does it alter the presentation of pain or our approach to care?

How is this fourth origin discovered?

[Luke Rickards]

Barrett,

Don't get too excited. I was writing from memory of lectures at uni and I've just had a quick look at The Sensitive NS and can't find this. Butler describes the expression of ion channels in bare axolema or on the cell body, which would produce transduction, but also talks about spontaneous discharge. I'm starting to question my understanding now. Anyone? (I'll email Nic.)

I'll have to look up my notes on central deafferentation.

Luke

[Barrett Dorko]

No rush Luke.

Once we get this origin issue settled and determine the simplest way to figure it out I'll go on to the second question in the "vitals of pain."

[stregapez]

I'm going to take a (perhaps naive) stab at this.

So, if I am asking myself, "what is the origin of this pain?" that a specific individual has, in the sense of circumstance, might I not ask, among other things, depending on what i might already know and/or have been told:

1)What does the pain feel like?
2) Is it constant or have you noticed that certain activities or inactivities aggravate it it?
3) When did you first begin to experience this ?
4) Were you engaging in any particular activity when you first noticed this, and/or had you been using your body differently than usual for a period of time before you noticed it
5) Have you been experiencing unusual emotional/mental stress lately, or have you for a prolonged period of time?
6) Do you generaly feel pretty happy with your life?
7) Have you had any other unusual symptoms?
8) Do you sleep ok?, is your diet decent?, do you drink excessively? , smoke excessively etc, etc, etc?

Thanks for the topic Barrett, just tell me if i am off topic ;) I might have to run for a few hours (not sure yet) but will look at this later tonight if so

Dana

[Luke Rickards]

I've emailed Nic. In the meantime, I found this - "The mechanisms of neuropathic pain include totally or partially deafferented dorsal horn cells which become disinhibited and hyperexcitable, producing an increased spontaneous firing rate"

Luke

[Barrett Dorko]

Dana,

With the possible exception of #2 these questions provide answers that don't tell us much about how we should proceed with care. Some invite the patient to share information I feel confuses the issue of origin or aren't relevant to my practice.

Maybe it's just me, but asking anyone about their level of happiness is something I never, never do. I'm terrified that they might tell me.

Luke,

This is one deep model of central pain, right?

[Diane]

I think you're confusing origin with source
OK...
Concurrent NOI thread (http://www.noigroup.com/cgi-bin/ubbcgi/ultimatebb.cgi?ubb=get_topic;f=5;t=000580).
Forever muddled,

[christophb]

Question regarding # 4 for my own clarity/confusion ;)


Are you referring to central sensitization as a change in the sensitivity of the dorsal horn to peripheral input, or some brain changes/top down regulation problems? Would homoncular problems be central (I'm thinking of phantom limb stuff and CRPS)?

Chris

[stregapez]

Barrett,

I need to read the End of Evaluation essay.

As for the emotional state and life-style/habbit related questions, the reason I'd inquire would be that pain (and tension) often have a psychogenic/psycho-social component, and sometimes a lifestyle component (drinking etc)

I personally believe it sometimes does very much, and sometimes not much at all. I may not be able to affect that much directly, but when it seems to be a possibility, i think it's sometimes helpful to help bring it to the attention of the client/patient, and /or to reassure them that such things are within "normal" experience, and they can get help for them from friends, family, mental health professionals or elsewhere, and also help themselves just by being more aware of them. Same with the lifestyle questions and bringing them into the attention (drinking heavily, smoking, etc can affect pain).

I admit I find myself in a bit of "counseling" role at times with clients, mostly in that I listen (do not diagnose nor usually give firm opinions) Usually that happens because they start talking about such things. At first it bothered me, and now it usually doesn't at all. I wouldn't usually out of the blue ask "are you happy with your life?," nor when i first met them. My friends and clients tend to overlap some too. I haven't had any problems with "duel roles" though, that i'm aware of, amazingly.

In your essay "The Pallbearer, " about treating the man who had back pain which surfaced after carrying the heavy coffin, you seemed to indicate there was an emotional component (that he may have been blaming himself a little for his injury in unhelpful way, and you joked with him to get him to ralax about it, and said you could then feel the heavines easing from his body) if I read that correctly. So ~ if i'm reading that right, there's an example of where you might be addressing someone's state of mind as well as body.

Hope that wasn't to long. I don't mind of noone wants to dwell on this too much, since it's one of the very few things i already do understand a bit :)

Dana

[stregapez]

Diane (or anyone) what is AIGS ?

Diane I love the artwork (the last one too) !

Dana

[Diane]

AIGS: Abnormal Impulse Generating Sites, ectopic firing sites. I think there is still confusion at our interpretive level about how they form or why, but they indicate that a nerve is in trouble and is firing wildly, and they are part of a "sensitization" sequence of events, where nocioception is turned up, spontaneous firing occurs, and pain is more readily felt. If you google AIGS with google scholar, you'll get a bunch of studies that talk about them.

(Found the artwork with the google image tool. :))

[nari]

From David's notes:

AIGS or ectopia

Pain and other symptoms from peripheral nerves must come from a change in sensitivity, number or organisation of receptors in the axolemma, or it can arise from innervated connective tissue of nerve. Concepte of ectopia fit neatly with the neurodynamic concepts.

The neural pathway is designed for conduction only - generation of impulses occurs probably at the ends, or at the DRG. When sprouting occurs, or the myelin is damaged in some way, AIGS occur. When they do, the DRG becomes extremely anxious...;)

Interestingly, the maximal firing can take up to 21 days to occur, but it is also possible for nerve injury to be symptomless for up to 14 days. Steroids can repair the damage; also remodelling (spontaneous) which occurs every 1-2 days.

I presume that 'injury' may include mechanical deformation...

So once we have identified an abnormal neurodynamic and proceded with whatever treatment is chosen, is our aim to calm down the DRG? By enhancing remodelling and/or decreasing ischaemic states? One would hope so.

Nari

[Jon Newman]

First Question: What is the origin of the pain?

How would you determine that?

I suppose I would determine that by whether the person is able to alter their pain with movement or positioning. If not, manual therapy is unlikely to be of much benefit.

[Diane]

I presume that 'injury' may include mechanical deformation...
I think so too. The system is alerted to any decrease in oxygen levels by the chemoreceptors, part of the nervi nervorum/nocioception sensor array right on the nerves themselves, the sensory nervous system of the nerves. The DRGs get interested.. The nerve starts to "hurt..", sets up the AIGS. It isn't necessarily damaged yet (pain is just neurogenic not neuropathic), and the AIGS can be reversed with increased circulatory flow, which will;
a) bring the preferred levels of oxygenation to the nerve, so the chemoreceptors go quiet, and;
b) wash out all the neural metabolites.

It's probably not 100% precisely accurate, but to patients I say that the AIGS on a nerve are like diaper rash on a baby; it needs fed, and cleaned, and changed, and that increased circulation/more motion(lotion) will do it all, will help provide the necessary factors to quiet down the system/help it dismantle the AIGS/heal the rash within a few days.

[nari]

I think that is an important distinction; ie pain as a result of an AIGS developing is not necessarily neuropathic - but neurogenic.

jon

If ALL movement/positioning increases pain and nothing reduces it - does that imply manual therapy is not useful, or is it just the alteration of the pain experience that indicates MT would help?
I'm thinking of the persistent pain people who have 24/7 pain and, fear avoidance aside, nothing improves the pain? Just curious.

Nari

[Barrett Dorko]

Nari,

Alteration, not elimination.

Jon's post fits accurately and simply into this discussion, I think.

Last time I talked to David Butler in person I told him that, to me, AIGs were represented by neural membranes that were more like lace and less like canvas. He didn't like this but didn't tell me why. Of course, I couldn't get him to listen to anything about ideomotion either. Guess he was too busy.

This first question has generated plenty of discussion and has almost been answered - to my satisfaction anyway.

The second question soon.

[nari]

Barrett

I didn't suggest or imply elimination but I think I have answered my own question anyway.

[Luke Rickards]

Barrett,

The answer from Nic is, 'Yes, spontaneous discharge does occur in the absence of transduction. This may happen both within the DRG and the nerve axon.

Luke

[Barrett Dorko]

So, four origins can be defended. The last two are probably the most difficult to alter rapidly with therapy though it's concievable that a carefully concieved program might succeed eventually.

The origin most likely to respond to the corrective movement Simple Contact reveals is mechanical deformation, of course (not that the others cannot be concurrent), so it's the one I want to know is present. A single question will reveal this.

[Luke Rickards]

Chris,

Central deafferentation pain refers to pain related to central nervous system damage from stroke (often post-thalamic) or spinal cord injury. It is different to central sensitisation in that pain may be genearted in the absence of any peripheral input.

Luke

[stregapez]

Nari (or whomever) what is DRG?

Dana

[Luke Rickards]

DRG- dorsal root ganglion

[Barrett Dorko]

I think it's time for the second question: Are there any disease processes or pathological problems that are relevant to and might be responsible for your pain?

Obviously, this is no small issue. As I say to my classes, "I'm a PT and my ability to diagnose is severely limited. I depend upon my referral souces to answer this question and make no apologies for this limitation on my part."

Thoughts?

[Crazy Pole]

Barrett,

I'm not sure, but I think what you are getting at is the relative uselessness/meaninglessness of PT diagnoses. The more I practice and learn, the more I would agree; if that is in fact your point.

You may also be hinting at the idea of "if nothing is wrong (in terms of true pathology), then do nothing". Simple as it sounds, I like it and have been trying to integrate it into my practice. Strangely, I find it quite satisfying to have a patient recover while I do essentially nothing.

Maybe I am way off on my assessment, but I'm trying to think like I think you would think. Someone let me know if I'm getting warm.

Wes

[Jon Newman]

I have to admit that I rather enjoy having the process of labeling a disease and pathology done by someone intensively trained to do that. I think I could recognize if such a thing exists but I am not particularly interested in labeling it. Unless something requires careful restriction of movement, a special pill or surgery, most of those labels are not going to be particularly helpful in guiding what I do next. I suppose that last point is a bit redundant as I think Wes already addressed it.

[nari]

Barrett's question #2 is addressed to the patient, by the PT; which I thought rather odd at first, as patients sometimes know of their pathology (eg scleroderma) and often they don't. But their narrative and the concepts therein can be very helpful.

If I get a reply such as 'arthritis', 'slipped disc', 'torn RC', 'osteophytes', etc, then the labeling by the doctor needs some deconstruction, by the PT. The cause remains somewhat irrelevant and may be wrong or inaccurate, but that does not mean we then apply another label, whatever that may be. We might describe to the patient the process by which we will proceed with Rx; and leave it at that.

In this country we are used to making our own diagnoses, and have done that to some degree for decades. Ours may not be any more accurate than the doctors', however.

I am somewhat stuck with this question, so will leave further comments for a later date.

Nari

[EricM]

I assume that at least a part of the answer to question #2 lies in the length of time that has elapsed since any actual tissue injury. If there had once been an injury, detectable by the cardinal signs of inflammation, and sufficient time has passed to allow for tissue healing, then no significant pathology would be present.
This is what you mean right Barrett?

Additional disease process could include something like cancer, or any of the odd problems diagnosed on House. (which has been good this season, in my opinion).

eric

[Barrett Dorko]

I like what Eric has said here, and it's certainly something I consider when listening to the answer to question #2.

The following is a compilation of posts by Sean Collins, a PT who moderates the “Medical Complexity” forum on Rehab Edge. Early in its formation he questioned the appropriateness of questions posed by an osteopath who now co-hosts the forum. I thought his concerns were quite legitimate and have highlighted a few lines I liked. I was never convinced that his questions were answered.


"I always respond as in a direct access scenario, but direct access does not mean examination or treatment that may be outside the scope of practice. Given the scenario provided I think this child needs a medical examination first, so I would refer them either to the ER or to a MD. Just because you accept walk in appointments does not mean you should automatically jump to examine each and every person that walks in the door.

Also - this is my response based on "direct access" without the ability to order a radiograph.

when did direct access mean diagnosis of pathology as opposed to direct access post diagnosis for diagnosis of impairment, functional limitation and/or disability? Am I missing something?

…perhaps the diagnosis does not require an xray to diagnose - however - are PT's really supposed to be making such differential diagnoses without medical supervision - even with direct access?

If I am correct - should the new thought processes (this is what Dr. Wagner suggests the quizzes regarding diagnosis are about) be geared toward scope of practice of the physical therapist as opposed to physicians? Do such cases and examples for PT's confuse the scope of practice issue, and make it more difficult for therapists to contribute to an understanding of what direct access, autonomy, PT diagnose are within the scope of PT practice?

I agree that it is within our scope of practice to examine and evaluate to convey our impression if we have to refer. And that it is important to know when to treat and when to refer - this is the entire point of the direct access movement. I also agree that it is not our role to send all cases to the ER - but in cases you are unsure of based on the history, and can possibly be dangerous to perform examinations on until certain (worst case scenario) diagnoses are ruled out should be sent to the ER for medical evaluation."

Me again. When it comes to "PT diagnosis" my main feeling remains an uneasy confusion.

More on this soon.

[nari]

The apparent issues surrounding direct access are difficult to comprehend.

It doesn't mean there is a need for PTs to order XRs, it doesn't mean referral-only PTs become pseudodoctors if they gain direct access.
It does mean we should be able to interpret XRs with knowledge and consider what we find as part of a Rx plan - or not.
It does mean we use our knowledge to know what is beyond our ability to intervene safely and ethically.

The incidences of sending a patient off to ER are few. They happen, but anyone with an understanding of physiology and red flags would prefer to err on the side of caution and risk a possibly unnecessary referral to ER or the GP, faced with a possibly undiagnosed ominous sign.

How do Canadians feel on this issue?

Nari

[Diane]

I've sent a handful of people off to see the doctor since I've been direct access.
The most dramatic was a pregnant woman with leg pain. When I looked at her legs, one was swollen and the other was not. Uh-oh. I laid her down and phoned her doctor right away, who called back immediately and said, "Put her in a cab to VGH and tell her I'll meet her there in Emerge." Yup, she had a huge clot. She lived to thank me a few years later. The other stuff has been skin cancer mostly. One guy who seemed like his low back pain was more visceral in nature than somatic.. I was thinking prostate.
Most of the people who come in to see me have already gone and been checked out medically.

On one occasion prior to direct access I sent a woman whose heel pain wasn't resolving, and who had a rash across her nose, back to her doctor to ask him to check her out for lupus. Darned if I wasn't right about that.

On the other side of the coin are people who've been scared by their PTs jumping to conclusions that a knee pain and a bit of a loose drawer sign automatically indicates a torn cruciate, etc., who have sent them in to get CT scanned/MRI'd, whatever.

I feel that PTs should be taught to make good assessments/PT diagnoses and refer if necessary, rather than have to wait on the other end of the pipe for referrals; I think overall it would bring costs down. It's expensive for people with benign pain (which most pain is) to have to pay for or have a system pay for medical workup then be referred to PT. A PT diagnosis will always be about pain<->function, not defined pathology.

[nari]

Another aspect of the problem of PTs dependent on referrals is that they could miss out on those patients who may need us more than the sore finger/sprained something/weak quads referrals; we miss those who go to the doctor with back pain, are given drugs, told to rest up and see a PT if it isn't better in two weeks.

It is expensive for many to fork out money to see a doctor only to be told to go to physio; assuming there has not been direct trauma which needs investigation.

A patient can have unexpected indications of a serious nature at any time; even if seen by a doctor in the recent past. An elderly woman, in the outpatients' dept of the hospital, came for "physio" to her left arm, which had been annoying her off and on for a few weeks. She had headache, stiff neck, and a sleep deficit. What raised my suspicions at once was the complaint of a 'sore throat' - which she described as 'sort of deep' pain. Off to ER - where she was treated for unstable angina. Now she may have had some degree of physio-treatable arm pain; but that was irrelevant.

All PTs should be in the position of recognising red flags, access or not.

Nari

[Barrett Dorko]

I've given this issue a great deal of thought and today I feel it comes down to this: The "hole" in therapy through which many patients fall is created and maintained by the therapy community's lack of knowledge and understanding of the very basics of neuroscience as it is related to painful problems. I see this hole growing larger as the neuroscience advances while the work/interest in learning it decreases. It is extremely common for physical therapists directing that portion of the rehabilitation in a specialty pain clinic to be completely unaware of Wall, Ramachandran, Butler, Gifford, Breig and others as well as being distinctly oblivious to any information available on the Internet. I am not exaggerating and I am in a unique position to know this, getting around as I do.

I will always wonder why a profession so poorly prepared to understand, much less treat, painful problems such as an abnormal neurodynamic -and most would agree these are an enormous percentage of our patients - would want to add even more responsibility to their job.

[Jon Newman]

Hi Barrett,

I remember that thread at RE and if I'm not mistaken I had PM'd Sean about it.

I'd like to track back to the second of five questions

Are there any disease processes or pathological problems that are relevant to and might be responsible for your pain?

When I ask this question the patient typically cites something. This leads to the usual confusion of biomedical diagonsis being equivalent to pain. Pain is the same kind as tendonitis, it the same kind as a degenerated disk. I think it is what is called a category mistake (http://www.butterfliesandwheels.com/badmovesprint.php?num=63).

I'll add that I think it is a mistake to become more and more skilled at learning about the alternate category (biomedical diagnosis) when there is already a profession devoted to do that. This seems to tie in with what Eric has commented on as well as your previous comments regarding PT's niche is 'for when things go wrong'.

[nari]

Barrett

Call it traditional thinking - it is much easier to follow what a charismatic teacher enthusiastically tells them to do and has a million RCTs and other studies to back it up. Takes effort out of the consolidation process in PTs' brains. The other side of the story could be that they simply do not have the confidence (or courage) to question the contents of a course that is basically about home ground; even if the outcomes are inconsistently positive.
Those who do question the premises behind numerous popular techniques are seen as renegades or outsiders.

I don't agree that diagnosis should be left entirely to the medicos and radiologists; but I come from an environment where diagnoses are usually questioned and altered, sometimes, by PTs - it's just part of our physio world. Of course I am referring to the simple stuff, the causes for aches and pains in joints, and so on. It's part of the learning process....

jon,

Does knowing that a "torn rotator cuff muscle" exists alter the way you would treat it? Especially when it responds well to methods that have nothing to do with "strengthening" ? Just curious.

Nari

[Jon Newman]

Hi Nari,

I think that's a reasonable question. I assume that the person before me is there primarily because they have pain that is likely coupled with one sort of limitation or another. History and a general observation of movement would likely reveal whether tissues need to be protected. Perhaps history alone would reveal that. I don't think it would alter MY care although strengthening and stretching connective tissue is not my primary approach when someone comes to me in pain. I imagine that if these were my primary strategic approaches, such knowledge would alter my care. Maybe that's the obsession with the (in honor of Diane) mesodermal diagnosis.

[nari]

That is worth a thread on its own...the validity of mesodermal diagnoses which seem to lead so many PTs astray, including many of those who attend Barrett's classes and find a lack of mesodermal thought.....

Nari

[Barrett Dorko]

Wonderful discussion.

Jon,

Your link regarding category mistakes is especially relevant. As some of you know, I'm currently in Las Vegas where my family has gathered to greet my son Alex. He's home from Iraq for two weeks and his stories of searching the road for explosives designed to deceive him fit here perfectly. He says, "When you travel the same road every day you just know when something has changed." Isn't examination of the human body similar in many ways?

I'l be writing more about this.

I think much of this issue revolves around discovering and defending an accurate and relevant essential diagnosis (http://www.barrettdorko.com/articles/incant.htm). This doesn't require great leaps in knowledge toward medical school minutia. I think it's wise to leave that to the physician, whether or not he or she does it well.

The third question:: What is your autonomic state and how is that related to your breathing pattern?

Thoughts?

[EricM]

I observe breathing patterns looking at apical vs diaphragmatic excursion and rate. I ask about the presence of cold hands or feet. However, recently at least for me, the clinical answers to this question have been split roughly 50/50 in similar chronically painful states. This makes me think either I may be missing something in my assessment, or that autonomic imbalance may only be relevant to the patient in question. What I might interpret as 'normal' may be abnormal to the patient and thus still have a significant influence on the pain state.

Eric

[nari]

I think that many patients consider cold hands and feet 'normal' because they have always had cold extremities. However, in someone who feels quite 'normal' ambient temperature in the extremities, an increased sensation of warmth after contact is informative.
Long before learning SC, I noticed that patients in an altered ANS state had high RRs, often around 25-30, and apical. After some diaphragmatic practising, they reported feeling calmer and their RR decreased; sometimes the pain decreased, and other times, not. They usually put it down to relaxing.
Then I worked out that they needed to practise deeper breathing while moving around; this worked sometimes; and if they practised during neurodynamic movements, they noticed the pain less, which I put down to distraction.
Several patients found a significant difference between breath-holding and breathing during neurodynamic movement. Some found it much better to hold their breath (on a neutral chest expansion, not on inhalation) during the movement. I personally find the same thing - but I know I am the only person to think this fact.

Eric, I agree that sometimes the autonomic state may only be relevant only to the patient in question. I have seen some dire chronic pain people who are quite warm despite their 24/7 pain state. Not sure about this.

Nari

[Barrett Dorko]

Nari,

I would say that my experience of this has been remarkably similar to yours.

Hidden within each of the "five vitals of pain" that lead to the questions is something most evaluative schemes do not have: opportunities to teach and learn along with an obvious relevance. Because of this, a great deal of care is provided during evaluation. This certainly shortens the time necessary to treat people. It'll probably cost the therapist money as well. Too bad.

Cooling in relation to those physiologic and behavioral processes that accompany sympathetic increase is the "physiologic signature" of the abnormal dynamic. I know that there are patients who aren't cold and should be but typically they're good diaphragmatic breathers for some reason, most commonly chior or yoga. In any case, this third question gives me the opportunity show them how these things relate to their discomfort and thus draw them further toward a realization that much of their pain is a consequence of their behavior - behavior they can control.

Abnormally warm people are also out there. Most of the time they have mid-thoracic issues and, I presume, are dysautonomic. I've seen this improve dramatically coutless times. I have no way of proving that of course, so I make no claims.

[Diane]

Lately I treated a woman who is one of the warm ones. She even said, "My feet get so hot that they burn.. I strap ice packs to them so I can go to sleep." She certainly had lots going on between the blades...

The autonomic system has always flummoxed me. I've never understood it well enough to be able to convince myself I can predict what it can/will do, or that anyone else who sounds like they have it down pat, really does. And I've never believed that popping backs somehow enhances or normalizes its function.

I've just acquired another Burnstock book, called Comparative Physiology and Evolution of the ANS.. Haven't started it yet.. if I can make head or tail of it, I'll let you know. All I know right now is that in lots of different species including our own, autonomics make skin change color and hair lift up. Also that skin has ten times the amount of blood flow it needs for its own maintenance, so it can be a metabolic heat radiator/entropy radiator. Meanwhile, for pain, I think it's safe to say that producing any kind of change in autonomics into the opposite direction of wherever they seems stuck, is beneficial. Maybe the rule could be, if it's cold make it warm, if its hot, make it cool.

The other big clue I got was finding out not that long ago that autonomics do the opposite thing in the skin than they do in muscle. I'm still composting that. It's so big that it's taking quite awhile.. it makes sense that the blood shunting mechanism would be different for mesoderm than for ectoderm and endoderm, thinking embryologically. It makes me more convinced than ever that skin is the key to the mansion, not only for pain diminishment but also for autonomics.. just trying to work out why and how.

[Jon Newman]

Hi Diane,

You may be interested in the following. This is a side bar and if anyone wants to discuss it further maybe a new thread can be started. The current one has a good flow right now but I do think this is pertinent to the discussion.

One of the poster presentations at the APS conference was titled Skin potential as a measurable correlate of moderate to severe chronic pain--a case report and was authored by Donald D'Angelo.

Introduction

There exists a perceived need for an objective measure of pain and pain relief. There is a device used in veterinary medicine to perform bilateral measurements of the electric charge of the skin, skin potential (SP). SP can be used to detect distinctive asymmetries caused by the autonomic nervous system as it responds to moderate to severe persistent pain. SP can accurately reflect changes in the ANS. The goal of this study was to determine if this device might reliably assess pain in humans.

While the methods and results are certainly important, I will simply summarize as this is 'only' a case study. The measuring device is trademarked as PainTrace manufactured by Biographs LLC, Bayville, NY. Here's a quick summary of what they are measuring: If both palms produce equal voltage, the linear trace will be a flat, horizontal line down the center of the graph paper. We take this line as the X axis of our graph, with the arrow of time to the right. This functions as a neutral baseline with a value of zero. When the right palm is producing higher SP than the left, the linear trace will be above the neutral baseline on the graph. When the right palm is producing lower SP than the left, the linear trace will occur below the neutral baseline.

The picture they show is simply a nickel sized electrode placed in the palm of each hand with the leads running to a chart recorder.

The asymmetrical SP can be accounted for by the ANS innervation of the skin. It has been found in numerous mammalian species that an autonomic response is demonstrated with persistent pain. At the onset of acute pain, the ANS raises sympathetic tone and accordingly blood pressure and heart rate, which have been shown to normalize with respect to time. The activation of baroreceptors by elevated BP, triggers an increase in vagal tone in an attempt to restore homeostasis. This increase in vagal tone has been demonstrated to provide an opioid-mediated partial anti-nocicipetion in both animal and human models. The primary pathway for this effect is mediated via the right cardiac vagal trunk. In addition to the heart, the vagus affects other physiologic changes including a lowering of SP. Thus, during moderate to severe chronic pain, skin on the right side has a lower SP than on the contralateral side, while mild pain fails to trigger the baroreceptors and therefore does not produce changes in SP. After pain relief, vagal tone moves back towards normal, with a coincident fall in SP on the right side.

This D'Angelo fellow by the way is an MD working for New York Harbor VA medical center in the dept. of anesthesiology.

Summary: In all five sessions for this individual, SP was lower on the right side during moderate to severe chronic pain (VAS 4-10). After pain relief, SP on the right rose. Distinguishing between painful and pain-free states in this patients was as simple as seeing whether the trace was above or below the neutral baseline.

It will be interesting to follow whether this technology, if validated, comes into play in future pain studies.

[Diane]

Thanks Jon. At the onset of acute pain, the ANS raises sympathetic tone and accordingly blood pressure and heart rate, which have been shown to normalize with respect to time. The activation of baroreceptors by elevated BP, triggers an increase in vagal tone in an attempt to restore homeostasis. This increase in vagal tone has been demonstrated to provide an opioid-mediated partial anti-nocicipetion in both animal and human models. The primary pathway for this effect is mediated via the right cardiac vagal trunk. In addition to the heart, the vagus affects other physiologic changes including a lowering of SP. Thus, during moderate to severe chronic pain, skin on the right side has a lower SP than on the contralateral side, while mild pain fails to trigger the baroreceptors and therefore does not produce changes in SP. After pain relief, vagal tone moves back towards normal, with a coincident fall in SP on the right side. It still doesn't make sense yet. In other words, I still can't quite "see" it yet. I see a vague random rise and fall, sort of like the sea heaving around but I can't make out what is calming it down and what is making it rise. My confusion is directly proportional to the lack of focal length/ability to see a big(ger)/ the big(gest) picture, and was based originally on a category mistake named "peripheral/central" instead of "ectodermal/mesodermal/endodermal".

Other thoughts/beliefs I've held about the ANS that need closer looking/ deconstruction:
1. parasympathetic good for pain, sympathetic bad for pain
2. touching improves parasympathetic function
3. exercise increases sympathetic function
4. autonomics are essential for breathing, digestion, heart function
5. that there must be consistency somewhere in it that I'm missing (maybe there isn't any consistency or fixedness or predictability, maybe there is only perpetual dialectic)

Definitely, let's start a new thread. (I started one awhile ago.. can't find it just now.. I posted a picture of an interneuron. The thread died and got lost. I'll repost the picture.)

[Barrett Dorko]

A new thread about the autonomic state in pain and during correction sounds good. To me, it's the least well understood portion of the "five vitals" equation. Jon's attendance to that conference is really paying off for all of us here.

Time for the fourth question : Which ways do you want to move and how does that make you feel?

I always ask my classes at this point - How do I ask this question?

Any takers?

[Diane]

How do I ask this question? Manually.

[Barrett Dorko]

Diane,

You're right, of course. And the only way I know how to do this and acquire the information I want is to employ Simple Contact or your mild and intricate skin stretching stuff. You really do need to come up with a name for that.

If a student doesn't answer as you do but rather says, "Ask them which movement they would prefer to do in order to relieve their pain" I know I haven't gotten several key points about abnormal dynamics, ideomotion and autonomic change across - all of which they should know by now.

What answers am I looking for? Here's a hint (http://www.barrettdorko.com/articles/characte.htm)

[Diane]

the only way I know how to do this and acquire the information I want is to employ Simple Contact or your mild and intricate skin stretching stuff. You really do need to come up with a name for that. I called it sensory motor neuromodulation. I guess it could be manual neuromodulation. It's still too long. Lateral skin stretch is accurate but has no cache. Ruffini ruffling? If you have any suggestions I'd be glad to entertain them.

That's a very broad hint.

[Barrett Dorko]

While the rest of the world thinks about what to call Diane's method let's wrap up this hread with the fifth question: Where do your legs rest when you lie supine?

Take a look at post #7 of this thread (http://www.somasimple.com/forums/showthread.php?t=1835) for a clue.

[Diane]

Skinipulation. Skinotherapy. Skinovation.

Where do your legs rest when you lie supine?
I know your system says, if they lie there like Barbie legs in internal rotation they are working too hard. As legs develop embryologically and post birth they spiral in and drag their nerves along, into a loose inward spiral. In supine ordinary gravity should suffice to pull the feet/legs into outward rotation. If this does not happen the nervous system is protecting itself from hypoxia, usually obturator or saphenous nerve, above in the inguinal ligament, or even deeper within the pelvis.

Of course, if the nervous system is protecting itself from hypoxia of something shallower, i.e., the lateral cutaneous nerves of the trunk, and/or superior cluneal nerves as they flow over the lateral side of pelvis to the greater trochanter, one might see outward rotation of the legs that is protective rather than normal.

The best way I know to find out is to pick up the heels slightly/slowly, pull the skin over them in a caudal direction, and see if the skin "slides down" both legs evenly. There should be a perceptual fantasy of both legs actually elongating. A leg that doesn't feel like it lengthens will have a PNS that is hung up somewhere, often behind the knee but not always. While the feet are suspended, one can test the hip system for internal and external rotation, which should offer no resistance whatever.

My point is that a leg that looks like it might be in "normal" external rotation, may not be.. it may offer quite firm resistance to being turned inward. In that case, the more superficial PNS along the outside or back of the leg/body likely needs help.

[Barrett Dorko]

Diane,

Skindippity Just a thought.

I think our handling and interpretation diverge at this juncture. That's okay because I think we're both largely correct and can defend how we approach this posture therapeutically as well as our interpretation of it. Everybody else, of course, is essentially thoughtless and wrong. At least, that's my message to the classes.

After I see what people choose to do, I work to see what they can and cannot do, and then investigate what they want to do, all the while making sure they notice how this all relates to their symptoms and their breathing and the characteristics of correction.

This final question naturally leads me to review what they've learned so far and quite commonly allows me to begin adding some Feldenkrais movement therapy to their home program.

In supine lying I can show them what I eventually want from this position, how to acquire it spontaneously and how to maintain it. A little enforced internal rotation and adduction of the hip(s) brings the connections within the nervous system quite dramatically to their attention. It's a great position to work and teach from.

[Barrett Dorko]

Diane,

Skineration?

Okay, I got nothin'

I think this thread has run its course and I'm very pleased with the results. I thought I might clarify several important issues regarding my evaluative scheme and that has certainly happened. The branching thread regarding autonomic states in pain should be required reading for every therapist. I think it brings to light Butler's statement, "We aren't treating anatomy, we're treating physiology." Upon this we agree.

I can send my classes here after I do the "End of Evaluation" bit with complete confidence. Of course, as one Shakespearian character says famously to another in one of his plays, and I'm paraphrasing here, "Anyone can call up ghosts and apparitions from other worlds - the real issue is, Will they come?"

[Diane]

I agree. Maybe we should sticky this thread.

All I really know about autonomics is, when they aren't good, and when pain is a feature, some part of the nervous system somewhere likely can't breathe, and one must try to coax the system in a better direction.

Thanks for helping try to think of a name for skin work.. as you can see, it's not easy.

I thought of a name, based on the fact that skin is the brain's interface with the physical world around it. Are you ready? Interfacial Ectodermotherapy. What? Too cumbersome?

How about "Interfacial Release"? Just kidding.

[Jason Silvernail]

This thread is required reading for the student I am working with now. Perhaps she'll post if she feels up to it.

This thread symbolizes why I come here, we are discussing important things that I don't see anyone anywhere else talking about. I learned a lot.

Thanks everyone as always for the ongoing education.

J

[nari]

Jason

Your input is also much appreciated.

Nari

[stregapez]

Diane,

I kind of like Ruffini Ruffling. Skindippity is cute too (though possibly a little too cute) :)

Dana

[Diane]

Jason, ditto what Nari said. Your comments/thoughts are always welcome.
Dana, I'm leaning more toward Interfacial Ectodermotherapy.
Here is a link to the spin-off Autonomics thread (http://www.somasimple.com/forums/showthread.php?t=2426).

[nari]

Diane,

Are you serious? :) It might scare the horses...on the other hand, I haven't thought of a zippy name either.

Nari

[Barrett Dorko]

Thought I'd post briefly and bring this thread back to the top of the list for my classes this week.

The new thread regarding autonomic confusion (if it's fair to call it that) has already reduced the amount of time I need to spend explaining what's going on there. I still have a sense that I can state with confidence that warming accompanies correction and that this can be reasonably explained as a consequence of both normalization of the neurodynamic (most likely a reduction in tension) and a shift toward parasympathetic support.

Is there anything in that new thread that would specifically refute that? I'm trying hard not to characterize speculation as fact.

[Diane]

Is there anything in that new thread that would specifically refute that? Not especially, not yet, other than certain sorts of pain syndromes feel burning and have to keep a cold wet towel against skin. When was the last time we had that sort of pain patient visit us? Well, ok, there was the woman lately who told me she had to strap ice packs on her feet to go to sleep. But it does seem to be more common the other way round.

The autonomics thread is far from over. I've lots more to bring from the Grieve article and I was planning to bring what I could find in Butler there too. Unless someone else wants to beat me to the finish line and get Butler's content going... :)

[Luke Rickards]

warming accompanies correction and that this can be reasonably explained as a consequence of both normalization of the neurodynamic (most likely a reduction in tension) I just thought of that photo of Yves in Nanaimo retesting the ULLT after SC. This would actually make an interesting study.

Diane, I've got a patient at the moment who has to wear wet shoes to work!

Luke

[Diane]

OK. So the too hot thing happens too. Sample of two. There you go Barrett.

Somebody is going to have to do some counting some day, and determine the likely proportions of the too-colds versus the too-hots, in persistent pain states. Or maybe they are persistently cold in some areas of the body and too persistently hot in others.
Like everything else seen in outpatient practice these are people who function regardless, usually... blend in with the rest.. it would be nice to know more. Menopausal dysregulation would need to be ruled out somehow because of how confounding a factor it is.

[Luke Rickards]

Menopausal dysregulation would need to be ruled outIn my patient's case, that was quite easy. The beard was a dead give away:teeth:

[Diane]

The beard was a dead give away :teeth:
Well... all I can say to that is, it isn't always... :teeth:

[Luke Rickards]

You're hilarious:teeth: :teeth:

[Diane]

So are you Luke, so are you.
I think a deeper point that can be drawn from this banter is the fact that nothing in the nervous system, or at least the autonomic part of it, can ever be concusively one thing or another, same as with beards. Even if it is one way rather than the other, 99 times out of a hundred.
Maybe we should adjust the statement or category within the "characteristics of correction" or WESS, known as "warming", to something slightly more accommodating, such as "temperature change." That would change the acronym to TESS... temperature change, softening, surprise, effortlessness. (What do you think Barrett? Too radical?)

[Barrett Dorko]

Today I'd say that temperature change covers it about 90% of the time, toward warmth 80% (they don't always "feel" cold to begin with), toward cooling 5% of the time. This is my distinct impression and though I'm well aware of the problems of empiricism I have combined this with a plausible deep model, I think.

See "No Deep Model" on my site for more on this.

Thank you for your help. I will tell my class today that the finest minds in Canada and Australia are working on this for them today. I'm sure they'll be very impressed.

[Jon Newman]

I have something that I'd like to clarify for my own understanding.

It is my understanding that most of the thermoreceptors of the body are located in the dermis. Thus whatever warmth there is to experience originates here. Heat can only be conveyed through convection, conduction and radiation. I think radiation is an unlikely source for this warmth (the type being discussed here) which leaves conduction and convection. Hopefully we can straighten out some of my ignorance here. When we feel warmth due to changes in prevailing flow of blood (from core to periphery) I'm thinking this is due to conduction rather than convection but I am actually unsure. That is, the process that "heat" gets to a thermoreceptor from the blood is through conduction. Please correct me if I'm wrong about this.

Regardless, a shift of blood from core to periphery is normally associated with the parasympathetic nervous system and so it would make sense that a sensation of warmth in the absence of hot lamps or other forms of heat generation are likely due to this shift in blood flow and hence a sign of the parasympathetic activity occurring within.

[Diane]

That is, the process that "heat" gets to a thermoreceptor from the blood is through conduction. I wonder. I think the thermoreceptors are "stimulated".. conduction not convection is more likely in a system that is not liquid. Well, mostly non-liquid. Well, mostly liquid but the liquid is all compartmentalized so it might as well be non-liquid.

Regardless, a shift of blood from core to periphery is normally associated with the parasympathetic nervous system and so it would make sense that a sensation of warmth in the absence of hot lamps or other forms of heat generation are likely due to this shift in blood flow and hence a sign of the parasympathetic activity occurring within.
I don't know about that anymore. The story I now accept as useful, and congruent with evolution, is that the sympathetics, not the parasympathetics, open blood flow to the "periphery" (i.e., limbs as opposed to gut) to assist escape or combat with a predator. But they simultaneously drain skin, i.e., make it less vulnerable to bleeding out/minimizing blood loss, if there is going to be a conflict with a predator that involves ripping and tearing of skin. To me, now, it makes more sense to move away from lumping skin in with "periphery", and treat it separately. One could say, I think, categorically AND accurately for the most part, that sympathetics shunt blood away from endoderm AND ectoderm (including prefrontal cortex and other CNS used for thinking), and increase it to mesoderm. Our HPA axis is very busy but the rest goes on standby, which means we don't think straight and have to rely almost entirely on the non-conscious to rescue us.

The parasympathetics, on the other hand, assist metabolism. That is to say, they minimize blood flow from periphery and maximize it to core/gut to aid digestion, and to the skin to enhance thermoregulation. Parasympathetics turn down/decrease blood flow to mesoderm, and increase it to endoderm and ectoderm.

I don't know for sure what this might have to do with pain or no pain, but I'm thinking on it. Certainly, in a crisis (when the smpathetics take over, and blood is shunted to mesoderm, away from ectoderm, and the brain goes into survival mode due to a sudden, more immediate threat level to its existence, pain is forgotten about for a time.

I think the pattern of blood flow based on embryologic layer of origin is fairly workable. Makes more sense to me anyway, for now. Today. I think as an explanation it's more consistent with SC as well. What do you think Barrett? Luke?

[Jon Newman]

Hi Diane,

Your thoughts on ecto versus meso in terms of shift patterns relays a better conceptualization than "core to periphery" does. If it's accurate, that will help quite a bit.

The convection/conduction issue can likely be resolved with a better appreciation of the anatomic relation of blood and thermoreceptors (as well as what is found between the two). I suppose it is possible that both types of energy transfer could occur.

Please help squash some of my ignorance.

[Diane]

a better appreciation of the anatomic relation of blood and thermoreceptors I think at the finest level of microanatomy it would be awfully hard to tell the two apart anymore. Maybe only a cell membrane would separate them, same as between any other two cells.

[Jon Newman]

Hi Diane,

If that is the case then I'll stick with conduction as the most likely method of heat transfer.

Thanks for your help.

[stregapez]

(What do you think Barrett? Too radical?)

You're not on the orthopedic massage yahoo group, are you, Diane?

I am, and last night somene posted a neurology/brain related question about a client with limited movement in an arm . The topic made me think of this message board, and I suggested people on the yahoo group might want to check out Somasimple. I identified you folks as a very bright group of PTs with "somewhat radical" ideas (i did put radical in quotes)

Probably just synchronicity

Dana (becoming left-handed with the mouse)

[Diane]

You're not on the orthopedic massage yahoo group, are you, Diane? Nope. Not me.

[Diane]

I thought of a name:

Integumentals

What do people think?

[EricM]

How about...

Stratum Corneum Tactile Suasian Practitioner. Too wordy?

eric

[Diane]

How about...

Stratum Corneum Tactile Suasian Practitioner. Too wordy?

eric no.. it's .. interesting... "Stratum Corneum" sounds Latin, firm, and mesoderm-esque, while Tactile Suasion sounds soft and bendy like water.

But what do you think of "Integumentals", as a one-word name? The advantage is, I don't think anyone has ever used it before, so it isn't asssociated with any nonsense, at least not yet and not if I have anything to do with its useage.

[Luke Rickards]

Jon,

I think that we should consider warming in the same way we consider pain, ie What are its origins? It is clear that a generalised warming following correction is different in nature to the burning feeling some patients describe.

The origins of warmth would be -
1. thermoreception (most common)
2. chemical irritation (eg acid on skin)
3. secondary hyperthermia (CRSP/perihperal nerve damage)
4. central mechanisms (if they can create pain then I am sure heat as well)

Of course, processing is important as well (see attachment)

Luke

[EricM]

We have all seen how some people prefer heat to ice or vice versa to soothe their pains. Excluding the counterirritant effects, could a simple preference like this be any indication of what change needs to occur in the tissues?

eric

[Jon Newman]

How can you not love this site?

Luke, great summary.

[Diane]

Taking a page from Barrett's book, I think we need to distinguish between the "cause" of warming versus the "source" of warming.
In other words, warming comes from inside or outside. If it comes from inside it's from metabolism; the autonomic (effector) nervous system's job is to expel it through skin, through circulation through skin. (Cause?)

If it comes from the outside, it's the sensory (thermoreceptor/afferent) nervous system's job to bring the news in so the CNS can gauge the threat level. Too much, the thermoregulation gets thrown off track/overwhelmed. Too little warmth/too much cold, it will have to stoke up the inner furnace a bit. (Source?)

Of course, I'm still quite mixed up about which goes with what.
And blisters can come up on skin from a hypnotized subject who thinks they've been burned.

[nari]

...not only hypnotised people, but those who have had the "stick pointed at them". They can die within 30 hours from system shutdown, which is far too rapid for anyone to say that they starved or dehydrated to death.
Central mechanisms and beliefs are very powerful.

Nari

[Luke Rickards]

If it comes from inside it's from metabolism

Diane,

I think there is a difference between heat (an energy) and warmth/burning (a perception).

Luke

[Diane]

I think there is a difference between heat (an energy) and warmth/burning (a perception). Yes I agree.. I thought I covered that. No?

Anyone else here ever eaten jalpeno peppers? There is something that will link the taste receptors and the sympathetics and heat output mechanisms..

[Luke Rickards]

I should have included this part.
In other words, warming comes from inside or outside

The way I see it, heat comes from the inside or outside. Warming always comes from the inside.

Though I know we are concerned with both.

Luke

[Barrett Dorko]

Diane,

I've heard it said that the ingestion of spicy food is more popular in southern climates (that's northern for the Aussies here) because they make you sweat and thus lead to a general cooling of the body. This would explain the blandness of the food in Minnesota, the northern US state that I've spent this week in.

I can't help but wonder if there's some sort of correlation between the food and the climate and the consequent general behavior of the people in the culture. I read a book titled "Scandinavian Humor and Other Myths" years ago and can't help but remember it as half of my funniest lines fall completely flat here where so many Norwegians and Swedes and others settled a long time ago.

The therapists here are stoic as is to be expected, but the incidence of chronic discomfort among them seems no less (about 50%). They just don't say much, express much nonverbally or make any real effort to connect in ways I am used to. (not everybody) Not that I personally do much of this stuff myself. Maybe I should move here. Maybe my hard-earned parasympathetic dominance leads me toward the same sort of comfort with quietude. Maybe imposed quiet upon a system raging sympathetically is especially painful.

In other words, don't eat jalapenos in Duluth - you might explode.

[Jon Newman]

A joke I'm particularly fond of can be tailored to fit appropriately here.

"How do you tell an extrovert Minnesotan ?"
"When conversing with you, he's actually looking at your feet instead of his own !"

[nari]

What happened to Minnesoteans? Maybe the climate...

It is true that the hotter the climate, the more popular is the ingestion of heat. Mexico is an example, South East Asia and India even more so. My mother-in-law, who lived in Central Queensland (read: hot) made a fierce drink consisting of cloves, chilli and water. The Poms like a hot curry.

In Australia, lots of people drink hot tea when the temperature climbs over 101 degrees F; which it does almost everywhere. The sympathetic response seems to be quite enjoyable, regardless of the level of humidity. Someone told me that the 'built-up heat needs to be let out'...interesting thought.

As for humour, we are all different from country to country. I cannot understand many 'funny' USA films, and I believe, perhaps wrongly, they cannot as a whole, understand Aussie humour. But others are similar - we ran an advertisement to attract overseas folk, ending in a phrase which is normal speech for us..and Canada, the UK and the USA became quite upset.
I won't at this point relate the phrase - Bernard might censure me...;)

Nari

[Barrett Dorko]

I had a student in Minneapolis today really struggling with the postural issue. She was evidently unhappy with my lack of respect for the deeply imbedded ideas about erectness that drive so much of the traditional thinking, which I can understand, but beyond that, spoke about the effect of one foot forward in standing. Apparantly this is suppose to help something but I never did figure out just what or what actual literature would support this.

The fifth question regarding hip position while supine can be asked to some extent while the patient is standing and I find this change often quite dramatic, relevant and easily defended in all of the neurodynamic literature but this is precisely where the conflict with this student began. When I questioned her knowledge of the subject she admitted she knew the names of the people who have investigated the neural tissues but hadn't read their work. She said, "I have two kids," which I guess explains that, but I didn't push her on the subject further.

In any case, I'm hoping she enters the conversation here as she indicated she would, perhaps even inviting one of her teachers, Robert Hruska, (I may have his first name wrong) from whom she learned about the importance of posture as she attended one of his Postural Restoration courses. I'd invite him myself but my attempts to engage him in a dialogue about these issues in the past have been ignored. Perhaps they just got lost in the mail.

Luke,

She wanted your name because she had an interest in your research project. I told her you'd be glad to share anything you could about this.

[Barrett Dorko]

Obsessed as I am with theory and practice and, well, science, I found the web site for the Postural Restoration Institute (http://www.posturalrestoration.com/about/faculty.html) and the correct name of its main guy, Ron Hruska.

Now that we have it, those viewing this thread can easily contact them about the issues of posture and clinical practice that occupy so much of our time. Perhaps after reading the "science" portion of the web site some questions regarding what is proposed and concluded there might pop into your head. Boy, I know I sure have some! (ha,ha)

It would probably be best if I didn't make this request for more information myself. I seem to have become some sort of "participant repellent," for lack of a better term. I contend it has something to do with my hair.

So, anybody interested in inviting Mr. Hruska over here?

[nari]

It might be interesting to invite Ron Hruska over.

It could help in the translation of the science section.
It didn't make much sense to me. Notwithstanding my disinterest in muscles.

Nari

[Randy Dixon]

A bit of a strange coincidence. I have this half-thought out idea that has been in my mind for a couple of days and I had intended on posting it here, then I read this thread and thought I would present it here.

I was running the other day, went down some wooden stairs and they broke on me. My leg slammed into the lower step, scraping it up and making me curse like a schoolgirl, have you heard these shoolgirls nowadays? Anyway, I continued running home and over the next few days I stayed on it and kept up my running. It ached slightly and the scrape hurt, but I basically ignored it. Then my foot swelled up like I had elephantitis with dark blothces. I didn't like that. I went to the doctor, he probed around my lower leg where I had hit, it ached but didn't hurt but you could feel a small step off in my tibia. It was broken. He then touched my ankle where it was swollen and that hurt, a lot. He was sure that I had hurt my ankle, I insisted my ankle was fine.

The object of this story is not to convince you that I am an idiot, but the fact that the "deep" hurt of the broken bone didn't bother me much but the "surface" hurt from the swelling really hurt. A similar thing happened when I had a AC separation, it didn't hurt much it just felt wrong, I would say it just proves that I'm a fine example of macho indifference to pain but it was taped up and when they ripped the tape off I practically cried. I don't think everyone responds the same way, I believe some are relatively indifferent to "surface" pain but sensitive to deeper pains. Another observation, which I believe is related, is the depth some people like to be massaged, some are very sensitive, some want it "deep". My wife prefers me to place all my weight on an elbow and dig it into her traps, she seems unable to relax them by herself.

I was wondering if others had any thoughts or observations about this. I was considering the possible psychological and physiological reasons this may be when I read Dianes post about ANS influences being different according the depth of the tissue and a little lightbulb went off.

I did warn you it was only half thought out, didn't I.

[Randy Dixon]

I also read something about eating Jalapenos to induce sweating/warming and subsequent cooling. There are some rather interesting properties of capsaicin in treating pain. I wonder if that has anything to do with their popularity in hot climates.

[nari]

Apparently an old European remedy I heard from a German patient is to make a chilli paste and rub it onto the painful area,with vigor. She actually did this to her foot (which had an acutely painful plantar fascia) because it wasn't getting better with my treatment. She was painfree for three days.
Another one is the bee sting cure for low back pain.

Maybe there is more going on with counter-irritation than we think.

Nari

[Barrett Dorko]

Randy,

You've made a distinction between "deep" and "superficial" pain that, I guess, has something to do with the placement of the anatomy involved. Since the location of the part from which the painful signal rises has nothing to do with the severity of the pain experienced I really think you're on the wrong track and cannot therefore conclude anything about why you felt what you felt.

Go back to the origins of pain, think about the amount of mechanical deformation and/or chemical irritation possibly present in each of your painful experiences and I think it will all start making sense to you.

Your wife's problem relaxing probably isn't going to change as long as she continues to follow Iam's, uh, thinking and method. There are other ways to interpret it though. See Asking Why (http://www.barrettdorko.com/articles/asking_why.htm) on my site.

[stregapez]

I was running the other day, went down some wooden stairs and they broke on me. My leg slammed into the lower step, scraping it up and making me curse like a schoolgirl, have you heard these shoolgirls nowadays? Anyway, I continued running home and over the next few days I stayed on it and kept up my running. It ached slightly and the scrape hurt, but I basically ignored it. Then my foot swelled up like I had elephantitis with dark blothces.

This isn't exactly on the topic of pain, or Barrett's original theme, but fits in indirectly with the spicy foods theme, sort of ~

Don't run on a newly hurt leg! l'm not absolutely positive how scientific this is, other then my standard RICE training, but it works for me.

From '97-'99 I lived in southern Mexico , San Cristobal de las Casas in the mountains of Chiapas, where it was always cool at least by 5PM , and cold in Nov-Jan, but where we nevertheless could not eat anything without chillis or salsa, including peanuts and mangos.

While there I somehow sprained my ankle twice (both times because I was sitting, or squatting in an odd position and it went numb and then I tried to stand on it) It was pretty boring after a while hanging out in my tiny one-room dwelling, plus I had to at least go out for food (like chillis), since I lived with a crazy macho Mexican man who didn't know how to shop. We had to climb up and down a monumental set of stairs up a huge hill, at the top of which you could see the whole city. There was a little church at the top; we lived half way up. So, anyway, I didn't stop walking on my ankle either time, and both times it took months to heal. Ankle was fine for years after that. Until about 3 months ago when I was sitting in some bizarre position at the computer, ironically writing about my Mexican ex (which I hadn't done in years; no i don't think there was a connecton; interesting coincidence though) I jumped up and started to sprint to the bathroom on my numb leg, twisted my ankle severely, and thought OMG I'm going to be crippled for months again. This time I stayed off it as completey as possible for two days, iced it several times a day, did not start the cross-trainer at the gym again 'til it no longer hurt, and in less than a week it was healed.

Of course a break is going to take a bit longer to heal.

If anyone wants to see some Chiapas photos they are here

http://pg.photos.yahoo.com/ph/spiralpetals/my_photos

Here in Richmond, Va, USA the weather often changes dramatically from day to day (with the possible exception of dead of winter and dead of summer, which are not all that reliable either). I wonder what this says about our temperments. Are we thus more adaptable or just crazier?

Drinking hot beverages in hot weather tends to make me feel horrid, unless i'm in the ac, but i know other richmonders who like to drink hot things in hot weather (though they seem to be in a minority)

Dana

[Diane]

Randy's story makes experiential sense to me, and concept validity too..
First, the experiential part; once upon a time, I was jumping down over bleachers, my foot slipped into inversion and I felt a pop inside my shoe. It sort of hurt but not much, and the threat value seemed awfully low by contrast to the excitement of the party I planned on getting myself invited to (this was first year uni and I was all of 18 years old). I went to the party and even danced sockfoot. It was only when I tried to get my shoe back on and couldn't because of swelling that had built up in the meantime, did I think something might be actually wrong. I had to walk home in the snow in only a sock on that foot. Next day I hobbled to ER (it was a lot more painful by then) and it was a broken head of the fifth on xray.

Concept part; I think the takeaway point here is that mesoderm doesn't hurt. The sorts of physiological processes that occur in the surrounding nocioceptors as healing begins, do, and a lot (chemoreceptors). The brain does not want us to use the broken bone. (Duh.) The swelling etc. that builds adds a load of compression that hurts too (mechanoreceptors). The stoked "fire" in the zone, increased metabolism, cellular construction and deconstruction, add heat to the tissue, inflammation, and thermoreceptors become engaged too. These are all narrow diameter wide dynamic range polymodal receptors that act as nocioceptors when overstimulated/stimulated too many times too close together. (I think I got that right..) It's how the nervous system organizes affairs, keeps space optimized, by having a single kind of receptor that can convey all sorts of info when the "need" arises.

And I think it's true that skin (ectoderm) hurts way more than mesoderm. It makes sense that the outer wrapping of the body would have the fullest sensor array evolution could poossibly come up with, as it is our organismic intersection with the environment, both the outer and the inner environment. Was that your point Randy?

Lovely pictures Dana.

[Diane]

Here is something juicy, sent by Ian, on treatment of pain by capsaicin found in peppers, research being done on it, the link to temperature and to skin: Interview about article (http://www.in-cites.com/papers/MichaelCaterina.html).
Apparently nocioceptors can be killed. Yikes.
The capsaicin receptor: a heat-activated ion channel in the pain pathway” (Caterina M.J., et al., Nature 389[6653]: 816-24, 23 October 1997) ... ranks among the 10 most-cited papers in the field of Neuroscience & Behavior over the past decade, with 1,330 citations to date. Dr. Caterina’s record in this field includes 13 papers cited a total of 2,930 times to date. Dr. Caterina is an Associate Professor in the Department of Biological Chemistry at Johns Hopkins University School of Medicine. He also holds a secondary appointment in the Department of Neuroscience.
Excerpt:
About 60 years ago, it was recognized that capsaicin had specific effects on certain nerves in our skin. This work was mostly done in Hungary. The Hungarian culture values paprika and other spicy foods quite a bit, and so it was sort of the birthplace of capsaicin research. Some instrumental work came out in the ‘50s and ‘60s, when Hungarian scientists showed that you could not only cause pain with capsaicin but could also desensitize pain-sensing neurons with chronic administration of capsaicin. It was recognized that the way this was working was that capsaicin was actually killing off the nerves in the rats that are responsible for initiating pain sensation. If it was administered to newborn rats, it could actually kill off a subpopulation of nerves that innervate the skin and allow the rats to sense pain. So the nerves that mediate non-painful touch remain perfectly intact, but the nerves that mediate pain sensation are gone for life. If you administer capsaicin to the adult rat, the nerve endings die back temporarily but they eventually grow back. This is one of the reasons why people who eat a lot of capsaicin-rich food become resistant to capsaicin after a while. Their nerve endings are actually desensitized.

So tell us about what you discovered and what you reported in the 1997 Nature paper.

The fundamental discovery was the identification of a protein that is expressed in a sub-population of nerves; that is, an ion channel protein that can be activated by capsaicin. That was one part of it. Another big part was that we showed that this protein is restricted to just the nerves involved in pain sensation. The real kicker was that this same protein could also be activated in the absence of capsaicin simply by increasing temperature into the painfully hot range. So it’s temperatures above about 42 degrees Celsius, roughly 108 degrees Fahrenheit, that will activate it, and that is the temperature where we start to feel pain on our skin.

How did you come to realize that it would also be activated by temperature?

What we reasoned was that no one had ever identified capsaicin inside the body, so it seemed unlikely that nature had put this channel in our pain-sensing neurons just so we could enjoy eating spicy foods. It seemed more likely that capsaicin, when it was causing pain, was essentially doubling for something that would normally provoke a sensation of pain. So what we did was screen through a number of stimuli we knew were capable of causing pain and also stimuli that had already been shown to activate sensory neurons when removed from the animal, and looked at in a dish. A year earlier, two different groups had shown that if you take the sensory nerves that normally innervate a rat’s skin and put them in a dish and record from them electrically, you could activate a sub-population of those nerves by increasing temperature. So our group did the same thing with this molecule we had recently isolated. We were able to express it in a cell line that normally didn’t make it. And not only did these cells become sensitive to capsaicin, but they became sensitive to heat.

[stregapez]

About the mesoderm hurting/not hurting thing, I don't know if I am unusual or not, but the first time I sprained the ankle (tore a ligament i think, getting up from a park bench with a numb foot i'd been sitting on, and twisting it) the pain was very bad. In fact, I became very dizzy and nauseous and had to lie on the ground for a few minutes. Second time I don't remember one way or the other. Last time I had pain immediately too. I suppose the initial pain from the last time could have been from my cortex remembering i was supposed to feel pain, but not sure about that with the first time, which was my first ever ankle sprain (i think) I also had a pedestrian/auto accident in Mexico. I basically ran into a speeding car, on foot, or it ran into me, not sure which, and the car mirror sliced open a tendon on my right hand at the lower thumb joint I remember, again, being very dizzy and nauseous and nearly passing out (that Mexican dude in the pictures had to carry me across the highway) But I'm not sure I actually had too much pain at any point with that. I do remember the bandage ended up binding me so much that hurt and i had to go back and get that redone, after which it stopped hurting. The student doctor in San Cris did a decent job of stitching my tendon, by the way.
(right hand has "taken a beating" though it never gave my problems 'til post "old age" and weight-lifting)

About a year ago I burned myself badly on the arm, and it barely hurt at all...wierd? The corn I sometimes get on the bottom of my big two however, is sometimes very painful. I had the impression last year it caused mesoderm problems in the ball of my foot, because as soon as the corn was gone the other foot pain went away. That happen to anyone else?

Dana

[stregapez]

If you twist your foot enough to tear a ligament or tendon isn't it likely you are directly straining and tearing at nerves too? Wouldn't that maybe tend to hurt immediately?

Dana

[Barrett Dorko]

Recounting events that may or may not have hurt despite the severity of the tissue damage subsequently discovered simply reminds us that, as Patrick Wall says, "...tissue damage and pain are not so intimately linked that the two can be considered equivalent. We must therefore be very cautious and use one set of words for a stimulus event and another set for a perceived sensory event."



Can we say that sensory disturbances to the mesoderm are far less likely to hurt than those to the ectoderm? If we can back this up it's a powerful statement not only about what we look for but why we treat as we do.

Diane,

I know there's a thread specifically about how these two layers separate and into what. Can we link it here?

[Diane]

Here is the interactive site Bernard found that shows embryo formation (http://www.med.unc.edu/embryo_images/unit-welcome/welcome_htms/contents.htm). The very first section is about cell layers/differentiation (http://www.med.unc.edu/embryo_images/unit-bdyfm/bdyfm_htms/bdyfmtoc.htm).

Here is a link to the formation of mesenchyme thread (http://www.somasimple.com/forums/showthread.php?t=2066), in the folder "In the Beginning" in the forum, Best Evidences. (I don't think it is visible except to members.)

(I think that is the one you mean, Barrett.. if not let me know and I will put on the scuba gear and dive again for a different thread.)

Happy to oblige. I love embryology. It is definitely good evidence for why we do what we do, why we have a better chance of being interactive with another person's nervous system through handling skin rather than trying to dive through it into some mesodermal target, impossible to do anyway without the skin's knowing all about it.

[stregapez]

Can we say that sensory disturbances to the mesoderm are far less likely to hurt than those to the ectoderm? If we can back this up it's a powerful statement not only about what we look for but why we treat as we do.


With all due respect, but I can't. It's not my experience, nor what I find around me with other people for the most part. I just had a conversation with my son's dad, who's a nurse about this. He also has had very instant painful ankle sprains (I had to check with him for fear i was losing my mind and memory) Just watch some TV sports (I hate them personally but it's a good example) When people get injured on the football/socker field you often see them doubling over in excruciating pain quite instantly (because they injured an aspect of the "mesoderm") I don't see how I can ignore that there are plenty of sensory nerve ending in bones, tendons, muscles, ligaments, joint capsules as well as skin and fascia...

It doesn't have to be one or the other, like a religion or something, does it?

The honest truth is "the mesoderm doesn't feel pain and/or isn't important" is about as true to me as "memory is stored in fascia" (ok, only about 75% as bad)

Dana , disagreeing with everyone equally (it's lonely here)

[Diane]

Dana, check out in an anatomy book (in the nerve section) the tight neural tunnels directly behind/in front of the ankles, wrapping around the heel, into all sides of the feet. Then defend the idea that it is the mesoderm that hurts when you "sprain" an ankle.

It makes sense that mesodermal structures (in general, ok? as a rule) don't hurt as much as skin. It gives the critter (human or non) who has fallen over a cliff and broken a bone or ripped a tendon or whatever, a chance to escape and find a place to hole up away from predators before the pain really hits, to sleep and heal.

It's nothing to do with religion, it's what makes sense.

[nari]

Dana

Injuring a ligament or joint without a direct trauma to the skin doesn't necessarily hurt much; it depends on the nature of the injury. I was surprised that a ruptured ligament in the distal end of a finger produced a great deal of swelling and colourful bruising, but it didn't hurt; it was simply uncomfortable for a day or so. A cat scratch, even if shallow, can be quite painful, and so can a tiny cut from a knife. Think of that feeling one gets when we slice a bit of ectoderm with the edge of a sheet of paper - a quite instantaneously perceived sensory event.

It gets confusing when it comes to therapy, because there is nothing we do that does not involve skin contact. It might help to recall that the brain has no receptors for noxious stimuli - the surgeons can fiddle happily with the exposed brain and it is painless. (For them and the patient!)

Nari

[stregapez]

Are you talking about cutaneous nerves, specifically?

Unfortunately I don't have a decent anatomy book with that detail, and can't find that online offhand.

I know there are at least some deep nerves in the area too.

If you can convince me I will believe and even prophesize, even if it isn't a religion (forgive me it's late here) but I'm not yet convinced.

I can't believe I spelled soccer wrong , though that's sort of appropriate i guess.

Dana

[Diane]

I don't see how I can ignore that there are plenty of sensory nerve ending in bones, tendons, muscles, ligaments, joint capsules as well as skin and fascia Yes there are. But most of them just get to the cord and are handled there. The ones that get signals all the way to the cortex, rapidly, are the large myelinated ones from skin.

The thin unmyelinated/myelinated ones that are all through all types of tissues report all the time, and yes, if the structure gets broken/torn, pain will occur, but secondary to the inflammatory process set up to stop movement and heal the area, not so much from the actual initial primary tissue rippage, especially if skin is still intact.

I don't know what else to say, except, get reading.

[stregapez]

Nari,

We cross posted. While it's possible you're right, I was just talking (to my son's dad) about ruptures versus tears and we agreed tears are more likely to hurt lots than ruptures.... but maybe what I assumed or doctors told me were torn ligaments or tendons were actually curtaneous nerve trauma? I am not yet convinced of that but will consider the possbility. I did hear quite a loud pop last time.

Dana

[stregapez]

I don't know what else to say, except, get reading.

Ok, will do.

We cross-posted too.

Dana

[stregapez]

ps ~ I do much appreciate the dialogue/explanation.

D

[Luke Rickards]

Interesting thought. While I don't know whether stimulation to the ectoderm is associated with higher intensity pain perceptions, it is obvious that it is at least more sensitive.

I have put a lot of acupuncture needles into a lot of people over the years and it doesn't take long befor you realise that the most important thing about technique is to get through the skin quickly. Do this badly enough times and you lose the patient. Once you pass this you can twist and twirl and scrape away in tendon, muscle, ligament and peritoneum as much as you like and the patient usually feels very little, or at least the sensation is not distressing. But God help you if you accidently touch a peripheral nerve.

Luke

[nari]

Same with a cannula - smoothly and rapidly; those who go slowly so as not to hurt, hurt the most.

Dana,
I have heard that as well.
Rather like sprains, which tend to hurt more than fractures. I have no idea why but I'm sure the others all have answers.

Nari

[Diane]

Think of the skin as a two way street.
It is sensitive to what comes at the body from the outside, anything that would pierce through its integrity; needles, paper cuts etc. .. teeth, claws..
Why wouldn't the same nerves in the skin be equally sensitive to deformation from underneath? Especially in places where the skin is more tightly adjacent to boney joints? (Is it just me who thinks this way?)
I learned this in PT school at age 18.. with pressure sores. It's not so much the friction on the bedclothes that breaks skin down, it's the pressure of the bone out, out against skin from the inside that breaks it down by pinching it and depriving it of blood flow.
Since then, I've been interested in skin, what can I say? Without it we're goners.

In the case of sudden jolts to it from inside, forces hard enough to break a bone or actually rip some bit of mesoderm off some other bit of mesoderm, the skin may well get yanked too, depending on a multitude of factors and vectors and directions and variables... it is attached on its underside to the superficial fascial covering by little multidirectional moorings, many of which convey small diameter nerve/vessel. If one of those gets overstretched or ripped, don't you think there's going to be some pain involved, or bleeding/bruising of skin associated? It won't be so much from the mesoderm, but from these skin ligaments being ripped that one will "feel" immediate pain, if one feels immediate pain at all... otherwise, one will hear something or feel a dull "something" that's uncomfortable, and the brain will make you limp because of course, it will "know" even if your conscious (sensory cortex) awareness does not/has felt no sharp pain, and will act to protect the part, and of course later when healing has begun you will really feel that due to secondary sensitization.

Anyway, that's my story and I'm sticking to it..:)

[Barrett Dorko]

Consider the pain of a severe sunburn. Worse than a broken leg in most instances.

Dana, Nobody here is asking you to believe anything. In my opinion, clinical science should avoid belief as much as possible. Many of my students ask me if I don't believe in this or that and my answer - that when it comes to my clinical practice I don't think I believe anything, but rather that I understand things - is often unpopular.

[nari]

Dana

When you look at a diagram of the body in an anatomy book, look at the basic body, before it gets broken down into muscle and fascia and bones. Bare torso. Think about the cutaneous nerves that look like a tidy but complex spider's web in parallel and in series. Zillions of them.

Now think of that as the direct line to the brain; a super-efficient radar that is the forefront in the duty to protect the blob at the end of the brain (the body). Like the cat's whiskers - cut them off and the cat really can't function too well, and would fall off fences, etc.

The stimulus of a sudden impact on the skin, like running into a heavy object or skidding suddenly to a crashing stop as in baseball or football, sends off alarms++ that something is threatening the integrity of the organism/blob.

The fact that something is broken or torn underneath takes a while to set in.
Sometimes it takes days, if the organism has to run to a safe place or try to escape if it can't run....hence ongoing pain sometimes does not show up for up to 72 hours. (David Butler)

So when you massage someone, you are "talking" on a direct line to his/her brain. Pretty awesome when you think of it...

Nari

[stregapez]

Diane, I need to read the article on skin ligaments.

Barrett, I was partly being silly/joking there. As for the serious element I think it's party just semantics ~ What i meant is that if I somehow am presented with enough information that is believable to me my understanding may change.

How something should be "rated" in believability often is a big question for me too. There is sometimes the problem that information from seemingly "reputable" sources (eg Pubmed articles) contradicts, or maybe something Patrick Wall says will contradict with what some other pain scientist says (not sure about that yet), and i'm not a scientist so....How do I even know that when Wall, for example, states something , and cites *one* study (which he often seems to do) to back it up (one I don't have at my fingertips either) that I should even believe him (partly just an example, since i started to read on of his book)? Maybe these particular things we are discussing here re pain and skin vs mesoderm are more "cut and dried" then my limited knowledge would provide me (quite possible considering lack of training) but from what I gather so far it's not totally "cut and dried"

Dana

[stregapez]

Yes there are. But most of them just get to the cord and are handled there. The ones that get signals all the way to the cortex, rapidly, are the large myelinated ones from skin.

The thin unmyelinated/myelinated ones that are all through all types of tissues report all the time, and yes, if the structure gets broken/torn, pain will occur, but secondary to the inflammatory process set up to stop movement and heal the area, not so much from the actual initial primary tissue rippage, especially if skin is still intact.

I don't know what else to say, except, get reading.

Hi again Diane,

Where can I find something "believable" that tells me that? So far as I can see by skimming and reading a little, that specific info is not in either of the Wall books (which arrived here yesterday from amazon.com)
nor in my physiology book.

Btw, when you say large myelinated ones are you talking about A-beta or A-delta?

When I think of what might produce that immediate, sickening ankle-twist pain I tend to think perisoteum (ok, i will consider skin ligaments too!) Periosteum has the highest innervation os mesodermal tissue doesn' it? What kind of fibers innervate it? By the way, in all honestly I don't know if I get that in "a fraction of a second" or a second and 1/2, but less than 15 seconds for sure, i think .

(Luke did you mean to say peritoneum or periosteum?, by the way)

Thanks for your patience.

Off topic (sort of) ~ How much education in the nervous system and pain does the average PT student get in PT School? ~ I'm partly just curious, partly wondering how comparatively tedious i may or may not be to have a discourse with :)

Dana

[Barrett Dorko]

The word in science is "provisional," as in "all knowledge is provisional," meaning that virtually nothing is known completely and this is why theory and experimentation are always ongoing.

When I speak to my classes about Wall's work I begin by quoting Ramachandran's opinion of what Wall says. This highly regarded neurologist (to say the least) makes it clear that it doesn't matter what Wall says - we have to accept it as reasonable and verified with good evidence.

For some reason, many therapists think that everyone's opinion is of equal weight. This is not the kind of mistake a scientist would make.

[Diane]

when you say large myelinated ones are you talking about A-beta or A-delta? A-deltas are thin but myelinated. There is a thread here (on the marvelous nerve or fabulous skin or something like that, down the board a ways.) The info is here somewhere, is what I'm saying. Keep looking, you're getting warm.:)

[nari]

Dana

Modern PT schools in Australia, anyway, cover a great deal of neurophysiology. What they are still failing to do, but have improved out of sight over the last 10 years, is to link this knowledge with what the patient presents with. There is still mechanical thinking if a patient comes in with a sore knee or neck. As Diane says, it is the wrong end of the telescope.
Wall would not be pleased.

Most of us here have slowly increased their understanding of physiology through courses, reading and forums like this one.

Nari

[Luke Rickards]

Oops. Periostium.

[stregapez]

:)

Hmn, that is interesting that you can make needle contact with periosteum without too much discomfort, though wondering if it's the same if a ligament or tendon was pulled away abruptly from.

Dana

[Baecker]

hi, something interesting supporting the skin versus muscle pains.

3rd degree burns

Third-degree burns are typically considered those that involve the destruction of the entire thickness of the skin, penetrating the epidermis and dermis as well as the structures located within these layers, including the blood vessels, hair follicles, sweat glands, and sebaceous glands. Since pain receptors are also destroyed by third-degree burns, this type of injury is often initially less painful than a first- or second-degree burn, and may simply seem numb to the burn victim. If pain is experienced by the patient, it is generally due to nearby areas that may have only received second-degree burns. The appearance of third-degree burns is usually leathery, but the color may vary from white or tan to brown, black, or red.

Burns are classified by depth of skin damage and by percentage of skin damaged. First-degree burns injure only the epidermis (top layer), with redness, pain, and minimal edema. In a second-degree burn, damage extends into the dermis (inner layer), with redness and blisters. Third-degree burns destroy the entire thickness of the skin. There is no pain, because the skin's pain receptors are destroyed.

after more searching on the internet i found something interesting as well. i thought i might share this with you cause i found it pretty amazing.

"As for those who reject Our Signs, We will roast them in a Fire. Every time their skins are burned off, We will replace them with new skins so that they can taste the punishment. Allah is Almighty, All-Wise." (Quran 4:56)

[Randy Dixon]

And I think it's true that skin (ectoderm) hurts way more than mesoderm. It makes sense that the outer wrapping of the body would have the fullest sensor array evolution could poossibly come up with, as it is our organismic intersection with the environment, both the outer and the inner environment. Was that your point Randy?-Diane

That was pretty much my point Diane, and it got fleshed out more in this thread. The reason I brought it up on this thread specifically though was because you had brought up the different responses of the nervous system, especially the ANS, to different tissues. So I thought

A) Does the ANS then react differently to injury to the different tissues? Does injury to the skin have the same effect as injury to the muscles or bones?

B) Can we find out anything useful from different relative sensitivities of the ecotdermic/mesodermic layers. Sort of how Galvanic Skin Response might possibly be used as an indicator of the ANS state or to measure a pain state.

[Diane]

Those are juicy questions!
Here is my little stab at answering them; some is a hunch, the rest is reasoning..
A) Does the ANS then react differently to injury to the different tissues? No. (Hunch)
Does injury to the skin have the same effect as injury to the muscles or bones? I guess it depends on what you mean by "effect." Injury to skin lights up the cortex a lot more, and conscious awareness more, because that's where the brain keeps its storehouse of "maps" to do with the body.. its "virtual bodies." Injury to mesoderm eventually hurts, and hurts a lot, because of secondary sensitization (I think I'm using that term correctly) of the sensory nerves by all the juice that gets poured out and leaked out onto them thanks to the inflammatory soup. The brain gets notified after the fact, by this sensitization, and limits movement because of it, not because of the "injury".. well, ok, a broken leg might be a bit more limiting right from the get-go.. but the brain will try to keep the body going if it can, anyway it can, at least for a while, to get out of danger. (Evolutionary reasoning.)
B) Can we find out anything useful from different relative sensitivities of the ecotdermic/mesodermic layers. Sort of how Galvanic Skin Response might possibly be used as an indicator of the ANS state or to measure a pain state. I think you answered your own question, no? The skin responds/reacts to/reflects the inner environment to both the brain and to the outer environment, like a two way window. It responds, reacts to, reflects the outer environment also, by sensation, moving toward or away. It is the periscope of the submarine brain, and it's all around it, on all sides. It is an active communicator too.

[BB]

I knew this would happen! I'd have to spend full nights trying to catch up on all these great discussions (tomorrow's read will be the autonomic thread). Don't feel sorry for me. I'm behind becuase the beaches of Hawaii aren't conducive to computers.

Regarding question number 5:

Why always the hips? Is the autonomic state always reflected in the hips regardless of the area of origin of pain?

Is the reason that this an easy place to observe the tell tale markings of ANS adaptation?

In the posts that immediately followed question #5:
Diane,
Your post regarding this seems to spead to specific lower extremity abnormal neurodynamics whereas...
Barrett,
Yours seems to allude to a more general application.

Another great discussion.
Cory

[nari]

Cory

I think there are different means to the same end; viz, focus on an abnormal neurodynamic.

Nari

[Barrett Dorko]

Cory,

The hip position while supine is useful for a number of reasons:

1) The angulation and relation of the feet, one from the other, accurately depicts what the patient chooses when they first lie down. This is easily seen by everybody and the therapist has an opportunity at that moment to talk about this choice and its consequences both in terms of pain and breathing pattern.

2) Gentle passive movement from here reveals further wha