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? 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 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.
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