Forum Moderators' Current Consensus on Pain

[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!

[HeadStrongPT]

Question

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.

[HeadStrongPT]

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.

[HeadStrongPT]

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.