Ref Forum Moderators' Current Consensus on Pain

[Diane]

Behind the scenes at SomaSimple the moderators study continuously, deal with the issues inherent to our task and decide together how we can advance our mission of sharing relevant and rational information about therapy theory and practice.

Recently Luke Rickards listed ten things he felt we now know about the nature of painful sensation. It has since been modified and referenced and you’ll see the document below. We have had an intricate and prolonged conversation about each point, and now invite your questions and commentary. The following list has been compiled in an effort to present you with succinct points derived from contemporary pain related research so that you may better understand the view points of the moderators and many of the regular posters at SomaSimple. The list is subject to change as our understanding improves.

As with all statements born of scientific reasoning these are provisional, but we feel at least a few will stand the test of time. For those interested in gaining a more detailed understanding of the generalized items on the list, we recommend reading the material referenced in the bibliography.

Signed,

The Moderators



Nothing Simple - Ten Steps to Understanding Manual and Movement Therapies for Pain


1. Pain is a category of complex experiences, not a single sensation produced by a single stimulus.

2. Nociception (warning signals from body tissues) is neither necessary nor sufficient to produce pain. In other words, pain can occur in the absence of tissue damage.

3. A pain experience may be induced or amplified by both actual and potential threats.

4. A pain experience may involve a composite of sensory, motor, autonomic, endocrine, immune, cognitive, affective and behavioural components. Context and meaning are paramount in determining the eventual output response.

5. The brain maps peripheral and central neural processing into each of these components at multiple levels. Therapeutic input at a single level may be sufficient to resolve a threat response.

6. Manual and movement therapies may affect peripheral and central neural processes at various stages:
- transduction of nociception at peripheral sensory receptors
- transmission of nociception in the peripheral nervous system
- transmission of nociception in the central nervous system
- processing and modulation in the brain

7. Therapies that are most likely to be successful are those that address unhelpful cognitions and fear concerning the meaning of pain, introduce movement in a non-threatening internal and external context, and/or convince the brain that the threat has been resolved.

8. The corrective physiological mechanisms responsible for resolution are inherent. A therapist need only provide an appropriate environment for their expression.

9. Tissue length, form or symmetry are poor predictors of pain. The forces applied during common manual treatments for pain generally lack the necessary magnitude and specificity to achieve enduring changes in tissue length, form or symmetry. Where such mechanical effects are possible, the clinical relevance to pain is yet to be established. The predominant effects of manual therapy may be more plausibly regarded as the result of reflexive neurophysiological responses.

10. Conditioning for the purposes of fitness and function or to promote general circulation or exercise-induced analgesia can be performed concurrently but points 6 and 9 above should remain salient.




Bibliography

Books:
Pain: The Science of Suffering - Patrick Wall
The Challenge of Pain - Patrick Wall, Ronald Melzack
Explain Pain - David Butler, Lorimer Moseley
The Sensitive Nervous System - David Butler
Phantoms in the Brain - V. S. Ramachandran
Topical Issues in Pain Vol's 1-5 - Louis Giffiord (ed)
The Feeling of What Happens - Antonio Damasio
Clinical Neurodynamics - Michael Shacklock
The Science and Practice of Manual Therapy - Eyal Lederman

Research articles:
Melzack R. Pain and the neuromatrix in the brain. J Dental Ed. 2001;65:1378-82.
Craig AD. Pain mechanisms: Labeled lines versus convergence in central processing. Ann Rev Neurosci. 2003;26:130.
Craig AD. How do you feel? Interoception: the sense of the physiological condition of the body. Nature Rev Neurosci. 2002;3:655-66.
Henderson LA, Gandevia SC, Macefield VG. Somatotopic organization of the processing of muscle and cutaneous pain in the left and right insula cortex: A single-trial fMRI study. Pain. 2007;128:20-30.
Olausson H, Lamarre Y, Backlund H, Morin C, Wallin BG, Starck G, Ekholm S, Strigo I, Worsley K, Vallbo AB, Bushnell MC. Unmyelinated tactile afferents signal touch and project to insular cortex. Nature Neurosci. 2002;5:900–904.
Moseley GL. A pain neuromatrix approach to patients with chronic pain. Manual Ther. 2003;8:130-40.
Moseley GL. Unravelling the barriers to reconceptualisation of the problem in chronic pain: The actual and perceived ability of patients and health professionals to understand the neurophysiology. J Pain. 2003;4:184-89.
Moseley GL, Arntz A. The context of a noxious stimulus affects the pain it evokes. Pain. 2007;133(1-3):64-71.
Moseley, GL, Nicholas, MK and Hodges, PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clin J Pain. 2004;20:324-30.
Crombez G, Vlaeyen JWS, Heuts PH et al. Pain-related fear is more disabling than pain itself. Evidence on the role of pain-related fear in chronic back pain disability. Pain. 1999;80:329-40.
Zusman M. Forebrain-mediated sensitization of central pain pathways: 'non-specific' pain and a new image for manual therapy. Manual Ther. 2002;7:80-88.
Dorko B. The analgesia of movement: Ideomotor activity and manual care. J Osteopathic Med. 2003;6:93-95.
Threlkeld AJ. The effects of manual therapy on connective tissue. Phys Ther. 1992;72:893-902.
Lederman E. The myth of core stability. Retrieved at: http://www.ppaonline.co.uk/
Lederman E. The fall of the postural–structural–biomechanical model in manual and physical therapies: Exemplified by lower back pain (2010)

[dswayze]

I have a question:

10. Neuromuscular reconditioning is best initiated after near or full resolution of the pain experience. Conditioning for the purpose of fitness and function or to prompt exercise-induced analgesia can be performed concurrently but threat and nocebo should be considered. Conditioning should be conducted in the knowledge that there is no substantial evidence that posture, muscular weakness or weight are risk factors for neuromusculoskeletal pain.

Even though you don't have "evidence" that posture, motor inhibition and weight (lifestyle factors?) is it not logical and apparent that inefficient posture, muscular inihibitions and poor physical fitness (weight) can lead to movement dyskinesias and mechanical irritation of soft (neuromuscular) and osseous (joint) pain syndromes?

I dunno. This image comes to mind:

http://images.acclaimimages.com/_gal...14-4924_SM.jpg

I think you're looking a little too closely at this one and should invoke a little Occams Razor on this one.

[Luke Rickards]

Hi there,

If we are going purely by logic, I'm interested in how would you account for all the overweight, kyphotic, deconditioned etc people out there that don't have pain?

[dswayze]

Originally Posted by Luke Rickards

Hi there,

If we are going purely by logic, I'm interested in how would you account for all the overweight, kyphotic, deconditioned etc people out there that don't have pain?

Because you aren't asking the right clinical question.

Are we talking about clinical pain only? What about subclinical populations? What about people who are not in "pain" but are in "discomfort"? I bet I could go and palpate people who aren't in "pain" and find "painful" areas of their NMS system. See?

Even a better question still, is why wait until "pain" arises when you can prevent, correct and maintain better function?

[Barrett Dorko]

Is "clinical pain" a term you just invented?

[Diane]

I see a lot of people in pain. In fact, that's the main reason people come in. Most of them are thin and fit with abs all toned. Can you s'plain me that?

[Luke Rickards]

I bet I could go and palpate people who aren't in "pain" and find "painful" areas of their NMS system. See?

No, I don't.
The clinical relevance of your findings may be zero. I think it would be unethical to tell an asymptomatic person that they need treatment because of a slightly tender palpated area of unknown current or future relevance. How about you?

why wait until "pain" arises when you can prevent, correct and maintain better dysfunction

This is purely hypothetical. Let's take the big one, LBP, as an example. There is no evidence that manual therapy (including SMT), postural advice or support, or movement education can prevent LBP. There is only limited evidence that exercise can prevent LBP, and the effect size is not strong.

[Diane]

Hi there. Just popping in to let everyone know that the Pain Consensus Feedback Thread has been merged into this one.

[Luke Rickards]

I can't work out how you can

prevent, correct and maintain better dysfunction

Are you sure this is logical?

[Kim LeMoon]

Originally Posted by dswayze

Even a better question still, is why wait until "pain" arises when you can prevent, correct and maintain better dysfunction (dyskinesis)?

This has got to be the funniest parapraxis I've ever heard in the context of therapy. Still giggling over here.

[toddhargrove]

Thanks for putting this together, its useful. I wonder if new readers of soma would benefit from getting directed to this type of thread for orientation on some of the fundamental concepts that have passed "peer review."

[Kim LeMoon]

I've already sent an email containing the above 10 steps (along with the link to this thread) to my chronic pelvic pain client. I offered to explain each step in detail, telling her that I agree with this statement 100%. I bolded the last line for her: "there is no substantial evidence that posture, muscular weakness or weight are risk factors for neuromusculoskeletal pain." I've been telling her this for so long, in so many ways. Maybe she'll believe it now.

Kudos to the moderators for this seminal work. I'm making it into a framable document to hang in my office. There is a big empty wall where trigger point charts used to be.

Edit: on making the document, I changed the first line slightly.

1. Pain is the sum of complex experiences, not a single sensation produced by a single stimulus.

[Diane]

There is a big empty wall where trigger point charts used to be.

[Jon Newman]

Hi Todd,

Thanks for putting this together, its useful. I wonder if new readers of soma would benefit from getting directed to this type of thread for orientation on some of the fundamental concepts that have passed "peer review."

You're very welcome.

There is a copy of it in the "Information for our guests" forum that is a read only copy.

Feel free to chime in on any of the 10 points. This is a modifiable document. I expect that a particularly compelling argument with evidence will be needed to change it but it will change.

[Kim LeMoon]

Originally Posted by Diane

9. Force is not necessary to produce a therapeutic change. Manually applied forces will almost never result in clinically relevant and lasting change in tissue length, form or symmetry.

1st sentence, I'm in agreement with. But can we look at the second sentence a little closer? Taken as it is written, this would imply that even gentle forces, such as those employed in DNM, will almost never result in lasting change. Also, I'm also curious about how some extreme forces used in manual therapies might actually cause tissue damage, subsequent to which, in the repair process, a lasting change might occur.

[dswayze]

Originally Posted by Barrett Dorko

Is "clinical pain" a term you just invented?

Clinically relevant.

[Diane]

Kim,

Taken as it is written, this would imply that even gentle forces, such as those employed in DNM, will almost never result in lasting change.

In DNM there is no attempt to change tissue in any way, period. A lateral stretch is applied to skin, not to try to affect tissue in any way, but rather to stimulate lateral stretch mechanoreceptors (eg. Ruffinis), and help the nervous system do something with the info (as per Gandevia) to down regulate its own pain production. The other thing with DNM is a (temporary) lengthening force (very small) applied to oblique skin ligaments and their neural contents, in order to induce vascular change within the container - less through force, more by introducing tissue differential, which can be very small and still be effective.

So, stretch skin, feed nerves (stimulate them to feed themselves), let go of skin. Skin goes back to its normal length. Softening of body bits below happens reflexively.

[EricM]

Diane and Kim,
I understand Kim's issue with the statement. Might it read better written as;

Force is not necessary to produce a therapeutic change. Manually applied forces will almost never directly result in clinically relevant and lasting change in tissue length, form or symmetry.

[Kim LeMoon]

Oh yes, Diane, I know that. I'm not arguing that force is necessary, but the language is a little vague. Maybe 'pain-inducing forces' would clarify. Also, in no way am I advocating such therapies, just trying to anticipate some criticisms and looking for precise language to say exactly what the mods meant by this one.

[Diane]

Looks good to me Eric.
(This is the process. Looks like we're still editing... )

[Kim LeMoon]

Originally Posted by Diane

Looks good to me Eric.
(This is the process. Looks like we're still editing... )

That looks good to me as well. Thanks Eric.

[Luke Rickards]

"directly" is locked in.

[Kim LeMoon]

Back on topic, I'd like to discuss #7, in particular the two middle items that deal with transmission. I get it now, but it took a couple of reads. The first few times, I thought you were alluding to therapies that have a greater potential to transmit nociceptive signals like Rolfing or Pilates.

7. Manual and movement therapies may affect peripheral and central neural processes at various stages:
- transduction of nociception at peripheral sensory receptors
- transmission of nociception in the peripheral nervous system
- transmission of nociception in the central nervous system
- processing and modulation in the brain

[Kim LeMoon]

Hey mods,

I see that the conversation about ART was moved to a more appropriate thread, but along with it went Luke's post about changing #9 to include the word 'directly'. Could you move that back here?

[bernard]

It is now the #22

[Luke Rickards]

Kim,

Manual therapies that might have an direct effect on peripheral transmission would include neurodynamic treatments. This sort of approach is useful when the origin of neural firing is in the axon itself, for example, in the case AIGS or peripheral nerve compression.

[Kim LeMoon]

Luke,

The 'affect' part is what I'm stuck on. It doesn't indicate whether the therapy improves the condition or has potential to exacerbate it. Could go either way. Maybe a clarifier, such as 'beneficially affect' would work??

I know I'm being picky, but if I didn't understand this point right away, others might not either.

[Luke Rickards]

It doesn't indicate whether the therapy improves the condition or has potential to exacerbate it.

Manual handling and movement therapies can certainly do both. Obviously, the former is desired.

[Barrett Dorko]

Interesting.

My son, the Army Captain, says the "surge" has been "effective," at which point his wife wants to smack him in the head. Fending off the blows, Alex goes on to say, "How are you going to put two brigades into a single city and not have an effect? I didn't say it was a good effect."

At this point we have to somehow consider what we mean by "good" or "positive." For me, a reduction in pain takes a back seat to an appropriate alteration in autonomic support. It's been my experience that pain relief follows that, and perhaps not immediately by any means. As Jason says, "We have to water the grass when it has turned brown and should not expect it to grow green right away." Or words to that effect.

Of course, first we have to find the lawn.

[Luke Rickards]

Barrett,

This is a good point, and, I think, also ties in with your frequently made argument that correction is not necessarily painless. Butler wrote the same thing in recent review.

[nari]

To my simple mind, #7 points out that the effect of manual and movement therapies can be positive or negative in nature. Or maybe neutral, according to many anecdotal reports from patients.

#8 then follows on, saying the only positively effective affect (sic) lies with inherent corrective movements. Reading #7 within the context of what follows to me makes sense.

I don't think that it needs to be spelt out that these corrective movements are not necessarily painfree.

Nari

[Luke Rickards]

I don't think that it needs to be spelt out that these corrective movements are not necessarily painfree.

And not just movements. Inflammation is both corrective and painful.

[nari]

True. In a similar but not a painful way, so is a fever.

Nari

[Luke Rickards]

After much discussion, #9 has been now been updated.

[Luke Rickards]

The title has also been updated.

[bernard]

Here is the wiki version of the thread.
http://www.somasimple.com/forums/showthread.php?t=4979

[Kim LeMoon]

#9 Revision looks great!!! I like the change in title as well.

Kudos to the mods!

[TexasOrtho]

9. There is little correlation between tissue length, form or symmetry and the prevalence of pain. Manually applied forces will almost never directly result in clinically relevant and lasting change in tissue length, form or symmetry. The effects of manual therapy are more plausibly regarded as the result of reflexive neurophysiological responses.


I've got a lot of deconstructing here to do regarding these steps. I think you all have done some great work here to be sure but want to get some clarifications. I wonder if someone could clarify the term "little correlation". This would seem to imply there is some correlation but not much. Would someone mind providing a few examples of when there might be more and/or less of a correlation between pain and tissue, length, form or symmetry?

I have a similar question for the following statement. I do agree in principle with this statement. I think periarticular tissue is extremely difficult to influence under manual therapy and believe there must be some alternative explanation for the clinical changes we see. However, could someone identify the specific rational for saying it is "more plausibly" one mechanism vs the other more conventional mechanisms?

I will certainly be spending time investigating the references following the ten steps. It should be very interesting reading. However, if someone want's to provide a Cliff's notes response here I would really like to hear your insights. Thanks!

[Diane]

I wonder if someone could clarify the term "little correlation". This would seem to imply there is some correlation but not much. Would someone mind providing a few examples of when there might be more and/or less of a correlation between pain and tissue, length, form or symmetry?

I think I can provide an example - if you were to be hit by a truck, chances are high that the external forces involved would leave you with pain correlated (at least a little) with changes in tissue length, form and symmetry.
The point being that it takes a lot to distort connective tissue/mesoderm, and next to no manual force at all to distort/excite/elicit behavior from the nervous system.

[TexasOrtho]

Originally Posted by Diane

I think I can provide an example - if you were to be hit by a truck, chances are high that the manual forces involved would leave you with pain correlated (at least a little) with changes in tissue length, form and symmetry.

Cute Diane. In all seriousness however, can you provide some relevant clinical examples? The phrase "relatively little" leaves the statement open for interpretation. I want to clarify what circumstances exist when tissue length would or would not correlate with pain.

For example in the case of adhesive capsulitis, pain and loss of motion exist to varying degrees throughout the course of the pathology. There must be some connection between tissue architecture and pain. How could statement #9 reconcile these relationships?

[Diane]

Rod, I was busy editing my post as you were quoting me. Obviously a truck can't apply "manual" force as it has no "hands"... my bad - it's a conflation my mind tends to make between orthopaedic therapy on the one hand and being hit by trucks on the other, I suppose. Anyway, sorry. I think your question will best be answered by some other member who actually does ortho type manual therapy, or who has left it behind...

[Luke Rickards]

Roderick,

I'm currently writing more in response to your first questions. In the meantime, re: adhesive capsulitis, it is interesting that you bring this up because AC was mentioned by Jon when we were discussing the content of this point, which led to wording that made room for some exceptions (I think manipulation under anesthesia was one of the points- not that PTs engage in such a treatment).

Please correct me if I'm wrong, but AC is a primary inflammatory condition, in which the inflammatory processes might suggest the primary origin of pain is chemical, leading to primary and secondary algesias. Capsular and tendonous thickening may be seen in many situations, post-trauma for example, which are not necessarily associated with pain. In my experience, during the thawing stage of AC, when the chemical influence has resolved, pain is not a primary concern, even though the tissues changes are still present.

[Jon Newman]

Hi Rod,

I think #9 came about due to a lack of evidence suggesting otherwise. If you have some compelling counter evidence then this is the place to present it.

This statement seems to be at the heart of your concern.

There must be some connection between tissue architecture and pain.--Rod

It occurs to me that if people can accept statements 1 and 2, then 9 should not be so controversial.

Given the option of betting on someone's pain state, I'd rather have an fMRI of their brain than an MRI of their shoulder. Not that I'd win the bet but I think my odds would be better. To take that idea a step further, consider giving a radiologist an fMRI of a brain suggesting someone is in pain and a series of pictures of various mesodermal parts (backs, necks, shoulders, knees, etc). I wonder if a radiologist could predict the location(s) of pain.

[Jon Newman]

Going yet another step with my thought experiment, I'd bet someone DOES have pain given only mesodermal scans suggesting tissue abnormality but I wouldn't have a very high confidence.

[TexasOrtho]

Originally Posted by Luke Rickards

Roderick,

I'm currently writing more in response to your first questions. In the meantime, re: adhesive capsulitis, it is interesting that you bring this up because AC was mentioned by Jon when we were discussing the content of this point, which led to wording that made room for some exceptions (I think manipulation under anesthesia was one of the points- not that PTs engage in such a treatment).

Please correct me if I'm wrong, but AC is a primary inflammatory condition, in which the inflammatory processes might suggest the primary origin of pain is chemical, leading to primary and secondary algesias. Capsular and tendonous thickening may be seen in many situations, post-trauma for example, which are not necessarily associated with pain. In my experience, during the thawing stage of AC, when the chemical influence has resolved, pain is not a primary concern, even though the tissues changes are still present.

Luke. Thanks for the response. Various authors have studied the histology of AC at the various stages and found it not to be a primary inflammatory condition. Rather, the researchers have found a significant amount of fibroblastic hyperplasia of capsular and periarticular structures (notably the coracohumeral lig.). Some have even discovered myofibroblasts within the anterior capsule.

In the case of AC, I sincerely believe there is an autoimmune / autonomic component that either precedes or is concurrent with the pathology. This would explain the strong connection with diabetics and, to a lesser degree, hyperthyroidism. I feel this is a case where there must be a strong connection between the pain and neurophysiology. Even more compelling is that the patients pain in AC often precedes any complaint of stiffness.

However, it is hard for me to largely disassociate the relationship between soft tissue architecture and pain in this case. I can certainly be convinced of an alternative view as my current paradigm hasn't completely unlocked the mystery. I appreciate helping me sort this out.

[Barrett Dorko]

I’m impressed with Jon’s “challenge,” in effect, for the radiologist and feel it explains why we must at times equivocate when it comes to predicting when something and/or someone is going to hurt. There are too many unseen and unseeable factors present (or not) to be as specific as we'd like. In short, this isn’t math.

I’m reminded of the Suppose This Were True thread. I think Rod’s question is answered there, sort of.

[TexasOrtho]

Originally Posted by Jon Newman

Hi Rod,

I think #9 came about due to a lack of evidence suggesting otherwise. If you have some compelling counter evidence then this is the place to present it.

This statement seems to be at the heart of your concern.

I think I can generally accept the first sentence in #9. My primary concerns are twofold. Firstly, having a lack of evidence suggesting a relationship doesn't necessarily lend support for a specific alternative. Although it seems like you do have quite a bit of peer-reviewed support, I just need to sit and wrap my brain around it. NB: I'm from Texas -give it time.

My second concern was in identifying the exceptions to the rule. When we say things like "almost never" and "relatively little", it does leave room for nerds like me to come in and look for boundaries of "almost" and "relatively".

It occurs to me that if people can accept statements 1 and 2, then 9 should not be so controversial.

I understand what you are saying, and again find myself generally agreeing. However from a strictly logical standpoint, shouldn't each statement stand on it's own merit without depending upon the others? Otherwise it would seem a rewording or restructuring of the steps would be in order.

Given the option of betting on someone's pain state, I'd rather have an fMRI of their brain than an MRI of their shoulder. Not that I'd win the bet but I think my odds would be better. To take that idea a step further, consider giving a radiologist an fMRI of a brain suggesting someone is in pain and a series of pictures of various mesodermal parts (backs, necks, shoulders, knees, etc). I wonder if a radiologist could predict the location(s) of pain.

I think if the radiologist were blinded, I'd certainly take you up on this bet. I don't find myself jumping up and down on these rules as they make a whole lot of sense. Thanks very much for your replies.

[Diane]

it is hard for me to largely disassociate the relationship between soft tissue architecture and pain in this case.

I propose a new thread be started to address anterior shoulder/capsule problems and pain, and how to deconstruct all of it. Do you want to do that Rod? The general discussion forum would be the place, if you want to do that. Maybe you could outline the general problem you have, as you see it just now.

[Luke Rickards]

Well, it's great to be brought up to date. So, if AC is autoimmune and autonomic, would you say that the mechanisms leading to nociception are mechanical, or still chemical? Can the hyperplastic changes in the tissue alone account for relevant stimulation of local mechano-nociceptors, even at rest.

Even more compelling is that the patients pain in AC often precedes any complaint of stiffness.

Wouldn't this lead somewhat to the conclusion that pain is not primarily related to the tissue changes?

[TexasOrtho]

Originally Posted by Diane

I propose a new thread be started to address anterior shoulder/capsule problems and pain, and how to deconstruct all of it. Do you want to do that Rod? The general discussion forum would be the place, if you want to do that. Maybe you could outline the general problem you have, as you see it just now.

Sounds good Diane. So let it be written...