TENS => Hands-In or Hands-Out?

[emad]

Hi Bernard;

i have not used TENS before to treat pain :!: :idea:

cheers
emad

[Diane]

I have much to say about this (Bernard, have you been visiting other forums?) I'll try to boil it down. All of my argument is now based on Melzack's neuromatrix model: First, some definitions:

1. Neuromatrix: The anatomical substrate of the body, which exists as a
"large widespread network of neurons that consist of loops between thalamus and cortex as well as between the cortex and limbic system." The whole network's "spatial distribution and synaptic links are initially determined genetically and are later scultped by sensory inputs."

2. Neurosignature:
a)Characteristic pattern that develops from "repeated cyclical processing and synthesis of nerve impulses through the neuromatrix." ("The loops diverge to permit parallel processing in different components of the neuromatrix and converge repeatedly to permit interactions between the output products of processing.")
b) continuous outflow from the body-self neuromatrix projected to areas
in the brain -> the "sentient neural hub" - "in which the stream of nerve impulses (the neurosignature modulated by ongoing inputs"(!!!!!!)") is converted into a continually changing stream of awareness."

(...Pssst...THIS is the bit that we are trying to alter with our treatments! We are trying to affect the "sentient neural ring" by catching a ride on the "neurosignature" within the "neuromatrix" in a new little 'neuromodule' that we make with our sensory input. If we're effective we create a new 'subsignature' that will impress itself on the larger 'neurosignature'.)

He says that each brain has a characteristic pattern of firing called the neurosignature. any input from the body has to go through the neuromatrix and meet with the neurosignature.

Certain neuromodules within the neuromatrix are specialized to deal with major sensory events; he mentions three of these, injury, temperature change, and stimulation of erogenous tissue. I think there should be a fouth catagory there, hands-on treatment. It is a "major sensory event" that I'm sure the brain studies closely. Probably it could classify as a neuromodule, because it is a) sensory and b) major and c) an event, a 'special event' to deal with something scary, i.e. pain.

I'm SURE another nervous system is the only input complex enough to change this set-up. I'm certain no TENS unit no matter how sophisticated with randomly changing inputs will ever be able to convince a neuromatrix full of pain to change the way a pain of hands can.

But further to this, we have the hands-off practitioners who are very effecive like Nari. Well guess what? She is providing input too, a "Major Sensory Event" through her voice, her eye contact, her measured pauses, her containment of herself. She is making each patient's neuromatrix reach out to her, rather than her to it, and she is coaching them to change their own neuromatrices by their own means, giving them a chance to regain control.
Cheers,
Diane

[Diane]

The worm has turned it seems. Barrett himself (the Simon Cowell of PT forums) has blessed my post with his approval. I have provided a link to the long version.
http://www.rehabedge.com/forums/Forum15/HTML/000089.html
Cheers,
Diane

[BB]

Diane,
Thank you for your insight on this topic. You tied, what is for me, very complicated neurobiology type material, into an understandable and usable commentary. Learning is always exciting!

Cory

[rolf]

Hi Diane!
After reading"Change your Brain change your life" by Daniel G.Amen
i might agree with you Diane when you say "the body is merely an outgrowth of the brain."
Most people and therapist dont see how important thoughts are .
Bernard might not agree but every thought we have sends electrical signals throught our brain.Thoughts have actual physical properties.
As Amen conferm ,they are real!,and have significant influence on every cellin your body.When our mind is burdened with many negative thoughts,it affects your limbic system and causes deep limbic problems as
irritability,moodiness,depression etc.
Your body react to every pos. or neg. thought you have.
Happy thoughts make your brai release chemicals that is cooling the limbic system,sad thoughts increase deep limbic system(seen with SPECT)
The front half of the hypothalamus sends calmings signals to the body
through the parasympathic nervous system when we are thinking possitive thoughts,result,muscle relaxation,slower heart beat,our breath rate decrease etc."A negative thought is like pollution to yuor system."
where do TENS fit in here .It dosent .I have tried it and dont like it!
But others find it as agood helper in decreasing chronick pain!
RIN

[nari]

Diane, an excellent summary of the thoughts of two great scientists.

I think this is what the profession needs - to be able to 'do' something that others are not able to do in the health spectrum. So much of what we do can be done by a skilled nurse, for instance; we need a new drive to place us above the image of "manipulation. exercises and ultrasound'.
This is what David B was trying to say in 1991, but the new knowledge was not available then to verify his 'instinctive drive.'
Unfortunately, 13 years later, there has not been much progress in educating physios towards treating the brain effectively.

Cheers

Nari

[Diane]

Thanks Nari,
I think things have progressed some... there are seeds planted, and now there's the internet. It takes time for information to get out, to be repeated enough times in the right way for it to stick etc, but critical mass will come at some point and although it seems like too long a time between 91 and now, really it's not long considering how peripheral tissue based thinking has worked its way into institutional thinking for 300 years, as Melzack pointed out in that little article in that little book. (Actually, I see now why David put into Explain Pain that picture of Descartes being tipped off his pedestal!)

Don't worry, I think PT will always be there as a trusted morphable catchment for all things new, or old.. there have always been new minds dreaming up new effective ways to touch people or as in your case, not touch people.. now there's a science basis to justify our interactions, lengthy, intensive, intimate, caring, patient. We're building new neuromodules, and that's not fast work. The science basis will be against the 5/hour types of therapy, the 80/hour types of poppers, the machiners and the electrotherapists (sorry Bernard, yet I'm sure you want your context to evolve as fast as you do. Now there's a chance it can.) Hurray, science is on the side of slow and effective. Insurers won't be, but that's ok because they are a royal pain anyway... :?
Cheers,
Diane

[Diane]

Ah, my dear Bernard, but no one is leaving out the periphery, including Melzack. The whole thing seems very mandala-esque, kaleidoscopic even, a huge circle of function that is constantly shifting and changing, yet seems to make more sense if turned over so the system can be seen to work from top down rather than bottom up..

I remember a post by Joy Colangelo that described herd animal behavior. She said that a herd was a flat, shifting circular macroorganism of sorts, that individual animals always tried to go to the center of the herd, the fight of stressed or uneasy individuals for the center (more protected) area of the herd would displace outward, peripherally, the more relaxed, physiologically rested animals. She said this had all been worked out, this pattern of behavior of individuals in a herd.

As a visual pattern, I like that example a lot, and sort of see a firing pattern in it.. an analogy might be, peripheral impulses certainly going upward but they aren't the whole story, there is a movement from center outward too, of a more regulated, more coherent sort of nervous system firing pattern, calming down the whole. And the whole herd is like the whole neuromatrix.

By considering this thought: 'The body is just an extension of the brain with more "filler" between neurons'
...rather than the one we are used to; 'the brain is just an extension of the body where everything ends up'
...it makes more sense, at least to my mind..

That Candace Pert lecture suggests (to me anyway) that perhaps that receptor messaging system could be part of the "sentient neural hub" Melzack mentions.
Just some thoughts,
Diane

[nari]

Hi Bernard

Although I am not a hands-on person, there are selected patients where the only way 'in' to the matrix or whatever we are trying to 'reach' is through hands-on. This of course includes the periphery. Some patients are so stressed and self-centred and tearful I do not even try to 'talk' to them to any extent. I see the need to 'massage' the brain - the amygdala, SS1, AC, etc... and I am doing this. initially, with hands-on, Diane-esque, to reduce the nociception pouring into these people as they talk about their pain. But I strike a deal - I will 'do' what they are expecting (ie hands-on), but they must do what it expected of them.
I do make it clear while massaging the medium (Marshall McCluhan) that only they can make themselves better, and I will guide.

As with all things. win some, lose some...


Nari

[nari]

Hi Bernard

Are two approaches better than separate? I don't know, but suspect they are. We can look at them separately:

Hands-On:
A multitude of choices, from neural glides and tensioners to interferential/US/massage/traction/stretches of muscles and so on. Let's assume that a session of US, interferential and stretches after 2 sessions, gives relief for a day. The next session gives relief for a few days. Maybe three weeks later, there is a good outcome; the patient is discharged feeling better, and happy with physiotherapy.
Six months later (or earlier) they are back, with the same pain, maybe worse. They are quite happy for more of the same.

Hands-Off:
Education, demonstration of homework after assessment and a long absorption of patient's history . Aim is to put the onus onto the patient. If the patient does not like this, and keeps looking for passive answers, then some short relief hands-on is useful, to get the ball rolling.
In this way, patient becomes more receptive to education, because we are doing what is expected from us.

With either method, expectations from both parties should be clear.

A combination, then, is most likely to be more effective - a bit of give and take, a meeting of expectations.

I listened the other day to a very good talk from a physio about the latest protocols in orthopaedics (acute). The knowledge was there, rapport with doctors there; but what were ortho physios doing? Walking patients, giving them static quads, moving ankles, deep breathing, or whatever else the protocol stated for hips and knees and things....

For the life of me, I cannot understand why physios are needed to perform such activities. To me it is a tremendous waste of well paid, intelligent physios. When they could be out there, learning about the brain and all its relevance to orthopaedics and so on.

But I am biased :lol:

Nari

[nari]

Bernard -

I think we were both missing each other's point of view - never mind, perhaps it was me on my high horse again. ( ie being arrogant??)

I laughed for minutes with your phrase ..'kangaroo in the roof top' ; it is just so splendid !! We have kangaroos on the roads, on golf courses, and on beaches...I think the rooftop may be the next.

Can you explain what you mean by: low back and neck exs? I do not consider them 'hands-on'. Sorry, mon ami, but you have lost me!

Bon soir


Nari :(

[Diane]

Hi Nari,
"what were ortho physios doing? Walking patients, giving them static quads, moving ankles, deep breathing, or whatever else the protocol stated for hips and knees and things....

For the life of me, I cannot understand why physios are needed to perform such activities. To me it is a tremendous waste of well paid, intelligent physios. When they could be out there, learning about the brain and all its relevance to orthopaedics and so on. "

Nari, this made me think of all the countless hours I used to perform such tasks until I was too bored to continue, and my own neuromatrix forced me to move on.

Actually maybe it isn't such a waste of time or intelligence. By doing these tasks PTs are in contact with people, they are laying down enormous substrates of info about human subtleties inside their own neuromatrices. Why can they not do two things at the same time, learn about the brain, and do a routine-'appearing' sort of job until they choose to move on? Maybe there could be new and interesting layers to bring to those boring protocols...

Yes, there's the mindset that says, why should I learn all this stuff about the brain when my job is to walk people?

And my response would be, because. There's a brain in that person and in you. Learn what's making life tick. Maybe you'll want a different expression of PT one day. Get with the program. Don't let your education or current job expression interfere with your learning.

Actually, I bet any job in contact with people, even hairdresser or spa worker, can be done with a new level of understanding and intention when 'how the brain works' becomes a new cognitive neuromodule in the interaction. Ooh...I'd love to get a facial from someone who understood neuromodulation! (I've never had a facial, but I'd make an exception in that case.)
:),
Diane

[emad]

Hi diane ,bernard&nari:

i tried to catch the topic at its begining ,but you were writing too long replies/posts for me to read online ,
t check now the second page ,when iread i find the topic so interesting .

Diane :)

more than excellent reply ,you are fond o the brain (neuromatrix) :idea:
i will try as posiible read of the first page now .

cheers
emad

[emad]

Bernard:

good animation you have provided.

Nari ;

i agree with you both mands on &off are more effective .

Diane :

We are open minded ,looking forward ,trying ,modifying ,developing so we change our box contents .

cheers
emad

[nari]

Diane, what you say is quite true - both routine and new approaches can be achieved simultaneously, provided the need is recognised.
I think this is what Barrett is trying to say - that we need to move on when change is in the air and that change must be accepted as a very significant paradigm.

emad - yes, we need to change the box contents, and also look outside the box....



Nari

[bernard]

Hello Somasimplers,

Can you explain what you mean by: low back and neck exs? I do not consider them 'hands-on'.
Not hands-on? They have a hands-on component and a hands-off one (my view)?

I think that is exactly what Diane is saying about neuromodulation and neuromatrix. It is a perfect example of that way of Future.

[emad]

Nari;

Change is diferent from developing ,the last is better,yes ,you are right we have to slect from outside our box.

cheers
emad :)

[bernard]

Diane,

I love the theory of WALL and this one of Antonio DAMASIO that says brain needs body to achieve correctly the feeling process?

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14625365

Ann N Y Acad Sci. 2003 Oct;1001:253-61.
Feelings of emotion and the self.

Damasio A.

Department of Neurology, University of Iowa College of Medicine, Iowa City, Iowa 52242, USA. Antonio-damasio@uiowa.edu

The self is a critical component of consciousness. The neural correlates of self have proven elusive, but it is reasonable to suggest that, in its simplest form, the self process requires a composite representation of the ongoing state of the organism as reflected in subcortical and cortical somatic maps within the central nervous system. The basis for these maps is a wealth of signals originating in different sectors of the body-proper. Some of these signals portray the actual state of the body as modified by emotions in response to interactions with the environment; but other signals are the result of internal simulations controlled from other regions of the central nervous system.

PMID: 14625365 [PubMed - indexed for MEDLINE

[Diane]

Nick Matheson started a thread on another forum that is proving to be interesting (for me anyway) and that is related to the neuromatrix discussion.
http://www.rehabedge.com/forums/Forum15/HTML/000091.html

It is beginning to move into individual versus cultural expression via 'action neuromodules', and where do we fit as therapists. I'm not sure how to integrate this link into own own discussion here, but I'll present the link anyway. Perhaps in our own 'room' new and unique ideas will emerge.
Diane

[emad]

Yes ,Bernard;
you are right

But i see animals ,when they injured ,they have gone under protective reflex , avoiding pain leading to more tension and pain ,so in animals world there is no medicine ,research so ...on

they do not know how to deal with the prolem ,letting it with time every thing may be better.
cheers
emad

[flaviovitor]

Hi Diane, sorry for being too late in my question, but it was inevitable.

I agree with the Neuromatrix model of pain, of course! You neuronuts somasimplers had convinced me. There is no back to mechanics things!

But, a doubt, why mobs and manips provide such a fast response in pain relief? Could mobs neuromodulate so fast? And what about making new synapses in the brain, which could take hours or even days to be formed? Would the brain make new biochemicals?

In an old model for pain, for example, a stiff joint creating pain (in gate control theory of course, not the neuromatrix), it is easy to accept the rapidity on pain relief after an articular mobilisation. But, if we go to the Neuromatrix model, is there any possibility to exist this high speed in pain relief?

Just considering these facts and trying to grow up with you!



Flávio Vitor.

[bernard]

HI Flavio,
why mobs and manips provide such a fast response in pain relief?
Bacause they act directly on the firing component, the neuron and on CNS.

Could mobs neuromodulate so fast?
Yes. In few seconds.

And what about making new synapses in the brain, which could take hours or even days to be formed?
Thousands synapses are made, just in time, every second! ;) The simple fact to think or speak and move is a consequence of this moving assembly.

Would the brain make new biochemicals?
Neuron is able to create more than 20,000 different neurotransmitters. The proportion (quanta) released of each chemical is able to create a huge coding.

it is easy to accept the rapidity on pain relief after an articular mobilisation
Any mobilization move nerves. So, any mob is a neuromob!:shade:

[Diane]

Hi Flavio,
I am a simple person, so I like my life and my thinking to be simple..
I want to stay just at the skin; skin gets stimulated no matter how "deep" one thinks one is being with one's mobes etc.. we can't rule skin out, so why not start there? If skin receptors could be ruled out as having no effect whatsoever on the brain and on pain, only then I think could we legitimately adopt a biomechanical model of treatment of how joints might be affected, or of how stimulation of their movement might be of any relevance. (I'm SO not interested in orthopaedic things anymore..)

As it turns out, there are lots of skin mechanoreceptors that can do the trick. So why go any deeper? The ones I'm fond of just now are the slowadapting Type IIs, 19% of all skin receptors, respond to 200 picas, fire continuously with lateral stretch. Since most people have those intact, I'll stick with accessing/neuromodulating the brain through those.;):D (Why make life complicated and difficult when it can be made easier? Maybe I'm becoming French..:D) Really, the ease and rapidity with which pain can be reduced by stretching skin is likely a testament to how eager the brain is to not have to hear all its own noisy pain feedback.

If you google SA Type II a lot of stuff comes up. There are a few papers on skin proprioception at the knee and through the bottom of the foot being important for leg control.
Cheers,
Diane

[bernard]

Diane,

Could we say that SomaSimplers are minimalist in their intervention? :embarasse

[nari]

Flavio,

Think of this: stiffness does not always -->pain.
Pain does not always--> stiffness.
So mobilising a stiff joint and finding pain relief has to be neuromodulatory in effect.

I have been told I am a minimalist, but I take that as something of a compliment. It wasn't intended to be interpreted that way, however. Oh well..

However, I do think that if a patient walks into a physio's room and finds it full of gadgets and impressive machines, some of which go 'ping', it is a pretty powerful perception of a well-educated professional.


Nari

[bernard]

I have been told I am a minimalist, but I take that as something of a compliment.

I take it as a compliment too but it is rarely the case for the patient? :confused:
It seems however logical that the most effective "technique" is the one that uses the least means.
In this era of progress and technology, Medicine must employ external things or is regarded as son of the Past.:cry:

[Diane]

Bernard, I'm not a minimalist in most ways. I consider as many things as I can before I treat, listening closely to the story being brought my way by the patient, taking notes, asking questions. Winnowing out possibilities. I really do believe that one cannot rule out that which one has not considered.

But when I touch a body, I know I'm touching all that physiology and anatomy and brain receptivity, and that nothing I do can ever surmount it. Brute force, in other words, will only injure it. So I don't go there.

Working lightly/slowly can definitely influence it all, however. So I try to work in a way that will disarm the brain, let it know I am its ally. Because if I don't, it won't allow relaxation to happen. If relaxation can't happen, nothing will change. When relaxation happens, the brain has let down its defences, it changes the body automatically. Simple.

Diane

[bernard]

Diane,

My English needs a further development! :D

I was saying that it seems that I discarded all things that was useless, keeping only the essential ones. It is a minimalist way since I concentrated my action with my powerful hands and a better reflexion and thrown many techniques away...

A manual therapist is seen as obsolete or marginal in France. (But we know that it is just the contrary but patients aren't aware of that for now)

[Diane]

A manual therapist is seen as obsolete or marginal in France. (But we know that it is just the contrary but patients aren't aware of that for now) Bernard, I completely agree.
:shade:,
Diane

[bernard]

I was saying that it seems that I discarded all things that was useless

:mg: What a terrible phrase! Sorry Diane :o

[nari]

Bernard
Plenty of folk whose primary language is English write sentences such as you wrote!
Don't worry!! Your English skills have increased exponentially over the last couple of years!

Nari

[Diane]

:shade: Nari is right, no need to apologize.
Diane

[bernard]

I was kidding but I must install and learn the English lessons that I bought last year!:lightbulb

[flaviovitor]

Diane,

skin cannot be ruled out, but, is its approaching so effective in neuromodulating an articular pain? Which approach would be more efficient in neuromodulating such a pain: myofascial release techniques, skin therapy or articular mobilization (grades I to III). Why not go deeper, since mobs might be more efficient? Or, why not to sum up skin treatment with articular treament?
Any randomized controlled study?

Going far, what about the patient's satisfaction: articular mobs X myofascial release?


Flávio.


To be continued...

[flaviovitor]

An articulation is injured ® an inflammation arises ®brain reacts producing pain! ®Treatment? ®Approaching the injured area! OK?


But, at the moment of the injury, the articulation had ever been stiff. During repair, brain pays more attention at the stiffness, thus creating / painting a new image of it (the articulation). When repair stops, brain concludes that the stiffness, who before the injury was non-painful, now is so offensive. This process could relate to pain memory, cortex reorganization and even a new (sub) neurosignature.


So much so, after the first episode an acute low back pain, it is easier to get a new episode, even with the absence of inflammation.



These new LBP episodes are related to brain sensitization. Treating the stiffness, we are neuromodulating the brain (telling it with our hand-on treatment: now that the articulation can be moved properly Mr. Brain, release it! Cause the articulation to be pain free Mr. Brain!). Thus, by fixing the stiffness, it will be more difficult to the brain to consider such an articulation as a threat. Maybe, even hands-on treatment could re-map the brain, constructing a new sub-signature (Diane has said this before!) and convincing it that there is no mechanical thing happening in body tissues.

Considering all this, a question comes to my mind: if this is so, why not approach all the tissues, either the brain and body tissues with their mechanics? Could we be incomplete in treating only the brain or the body tissues?



Flávio.



PS: Bernard, what is wrong with my SOMASIMPLE text editor?

[Diane]

Considering all this, a question comes to my mind: if this is so, why not approach all the tissues, either the brain and body tissues with their mechanics? Could we be incomplete in treating only the brain or the body tissues? I think that's a good question. The body tissue I try to treat/affect most often is the neural tunnels, especially where they run quite superficially, around big joints and along long bones (e.g., medial tibia). No matter where you put your hands on neurologically intact skin, brain is reading you and being affected. No matter what body tissue you think you are targeting, all of them are going to feel you and respond somehow (hopefully in the way you want), because of the brain.
Diane

[bernard]

PS: Bernard, what is wrong with my SOMASIMPLE text editor?
I saw that you wanted some -> with your post but you changed the font type I suppose?

Flavio,
I found it! You used the symbol font but it is not yet enabled on the discussion board! (I will enable it).

[nari]

Going back to an earlier post where the word 'minimalist' was suggested - by Bernard I think- I thought I might elaborate on that further...

There are minimalists and reductionists; I have never been one to throw the book at a patient; try everything to begin with sort of philosophy. Ending up doing very little hands-on suggests dissatisfaction on the patient's part and might suggest to others that the PT simply isn't trying hard enough. I can undrestand that, easily. I have never obtained consistently excellent results from passive mobilisation of joints; when it worked it seemed to be a fluke. Sure, ROM would improve, but the patient didn't. However, education and suggestions always worked better, and improved function at the same time. I went through a period of thinking that slogging away at improving joint ROM seemed rather pointless most of the time; I got over that for a while, but never passively mobilised necks/backs with the aim of improving ROM.
I always considered functional changes were the aim.

One thing which swung me away from jumping up and down on necks was the fact that if the left shoulder was elevated during or after cervical rotation to the right, cervical ROM was vastly increased. To me, that has nothing to do with 'stiff facets or whatevers', this was neural stuff. Not only that, but after the procedure, the previously bunchy trapezius suddenly behaved itself better.
No myofascial procdures or trigger therapy or anything like that....;)

Which is why other PTs often think I am weird and not doing the profession any favours...but I don't mind. :)

I am also on Diane's side of the skin...it is extremely important stuff!!

Nari

[Diane]

I am also on Diane's side of the skin...it is extremely important stuff!!
..not to mention the fact that skin doesn't magically disappear just because you imagine it is facet you are trying to have some effect on. You have to go through skin no matter what you do to the body. Seems to me we do orthopaedic research backwards: we should start at the skin, rule out all the complex factors associated with IT, and whatever is left over will be effect on facet..
:),
Diane

[bernard]

Flavio,
Stiffness is rarely a local thing! It is often a brain response. Brain augments muscle tone and movement is thus made stiffer.

[flaviovitor]

Alphabetically, Bernard, Diane and Nari, once more, than you all!

From Nari: "Think of this: stiffness does not always -->pain. Pain does not always--> stiffness. So mobilising a stiff joint and finding pain relief has to be neuromodulatory in effect."

OK, 'neuromodulatory effect', as Diane also suggest! I am 'learning by heart' this fact!

Bernard, you THE hacker! You are better than Microsoft, IBM and Apple experts. thank you! i would not find out the problem with the fonts (letters).

No more queries for the time being. Just learning by heart and having a re-reading on EXPLAIN PAIN!


Flávio.

[bernard]

Flavio,

I'm only a old PC/Mac user. I started in 1982 with an Apple II, then a Mac, then another one, and a third one. But needed to cross the human line to the Pc machine because some professional softwares weren't available on Mac:sad:.

The symbol font is viewable on Netscape and IE but not on FireFox (for the moment). It is not a BB problem but a browser problem.:o

[flaviovitor]

Nari, Bernard and Diane,

thank you all. Invredible your clinical reasoning. It is just the way I like and was needing!

Thinking in neural stuffs (its function, mechanics, brain analysis of facts, neuromodulatory effects, suggestions, mirror neurons?, etc, etc, etc...), it's most up-to-date way to approaching patients needs.

Thank you for enabling me to going into this fantastic journey!



Flávio Vitor (a few more music to celebrate it Bernard? :teeth: ).