Forum Moderators' Current Consensus on Pain

[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.

[HeadStrongPT]

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?

[HeadStrongPT]

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...

[Jon Newman]

Having a lack of evidence suggesting a relationship doesn't necessarily lend support for a specific alternative.

This is quite true but there is actually evidence that such relationships have a low correlation.

My second convern 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".

That's ok. I'd rather leave room for reasonable uncertainty. Pick at the edges, it's what improves our understanding.

However from a strictly logical standpoint, shouldn't each statement stand on it's own merit without depending upon the others?

This list is likely to change. We tried to make stand alone points. I guess what I was trying to say is that both points speak to tissue architecture at some level. It doesn't immediately make sense to me to accept one and reject the other.

[HeadStrongPT]

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

Yes. This is where I agree with the rule that states there isn't a direct connection, but there must be some connection. Also I did as requested and started another thread on the topic.

[HeadStrongPT]

This is quite true but there is actually evidence that such relationships have a low correlation.

Fair enough...I need to do my homework before I have any room to argue this point.

That's ok. I'd rather leave room for reasonable uncertainty. Pick at the edges, it's what improves our understanding.

Agreed. I was just hoping you'd have all the answers laid out in front of me. It would have saved me a lot of time!

This list is likely to change. We tried to make stand alone points. I guess what I was trying to say is that both points speak to tissue architecture at some level. It doesn't immediately make sense to me to accept one and reject the other.

I understand. I've been trying to look at things from a more logical perspective lately (not that I was completely illogical before). I know that for an argument to make sense, each link in the chain must work. I may have taken it a bridge too far.

[Barrett Dorko]

Dear Yul,

I really appreciate your work here and look forward to being able to answer questions about AC with more than "It seems that this condition is unique in the body, and, as far as I know, mobilizing the involved structures in order to create more range, enhance recovery and reduce pain isn't a good idea."

Maybe this new thread will improve that answer.

[HeadStrongPT]

Dear Yul,

I really appreciate your work here and look forward to being able to answer questions about AC with more than "It seems that this condition is unique in the body, and, as far as I know, mobilizing the involved structures in order to create more range, enhance recovery and reduce pain isn't a good idea."

Maybe this new thread will improve that answer.

Thanks...Yul was the man.

[Luke Rickards]

Hi Roderick,

Jason has given us a very good background to these issues here. It's well worth checking out. Also, now you have ten posts you should be able to access our Sounds of Silence forum, where you'll find the Red File. There are dozens of papers that provoke a re-examination of the dominant thinking behind common approaches to manual therapy diagnosis and treatment. The list is not exhaustive, but its growing.

I want to address your questions more specifically but it's late now, so I'll leave it till tomorrow. In the meantime, there's something I really like from Max Zusman's 2002 paper that pointed to the direction that recent understanding seems to be moving us.

The evidence will then be interpreted to create a new image for manual therapy (MT), namely that of informed ‘desensitizer’ of this system. The process of physical and psychological desensitization is proposed to involve a combination of mechanical stimulation (movement-based therapy), accurate information [see Moseley for more on this], reassurance and instruction. It is anticipated that this evidence-based image of MT would be readily recognizable and acceptable to all of the major ‘stakeholders’.

[Luke Rickards]

Roderick,

I understand from another discussion that you feel your input into this thread was essentially ignored by everyone, except Jon. Please know that this isn't the case. Jon's response here involved behind the scenes input from the other moderators. Further, I was under the (mistaken) impression that your response in the post following this indicated a general concordance with the concerns raised.

Nevertheless, as I stated before, these are not rules, and are thus subject to change in light of all reasonable input. After further discussion, No. 9 has now been modified.

[HeadStrongPT]

I appreciate the modifications Luke and regret if my comments in the other discussion came off sounding like sour grapes. Initially Jon was the only one who acknowledged the modification to #9. I appreciate the willingness to embrace alternate ideas.

My comment on the rehab edge discussion stemmed from the notion that none of us has all the answers and shouldn't act as authorities on specific topics. As I'm sure we can all agree, there are no authorities in science. We are all here to learn, exchange information, and not belittle each other in the face of disagreement. Backhanded comments such as "mesodermalist" and "neuroreflexologist" (my phrase) only serve to polarize the discussion. I think we can all learn a great deal from each other and look forward to the continued interaction.

[bernard]

I think we can all learn a great deal from each other and look forward to the continued interaction.

Most of us, here, are initially ortho grounded but evolved to give more importance to the neural component.
There is actually no good reason to make an inverse shift, again.

[Frédéric]

About # 9

How are we to explain how gymnasts (an exemple) became so flexible (both muscular-ligament-and other connective tissu) ?

I would assume a high volume of streching is involved and repetitive extreme postures maybe.

Now, since painfree (understand : with usual forces below microtraumatic changes in the tissu) manual therapie (including streching) can't induce lasting changes in tissu lenght, I would assume that the streches those gymnasts are doing are very painfull to produce sufficient forces for permanent tissu deformation.

Unless those persons were already very flexible to begin with.

I am just thinking outloud here because I can't help but thinking that tissu lenght is modifiable without extreme forces provided enought time/freqency for the specific strain applied to the tissu.

I might agree though that typical manual therapy might not provide that amount of time/frequency in straining the tissues.

An example : strech an elastic with your fingers for 3 minutes twice a week : chances are it won't change in lenght

Now, strech it less put for 2 weeks without stopping, I would assume (I did not try) that there would be permanent changes in that case.

That exemple could also apply to mecanical rubber belts in a car that could need so re-tightening after many miles of strains that are not strong enought to damage the rubber.

So maybe it is more a duration/frequency of the applied forces in manual therapy that are insufficent rather than the amount of force.

This is not based on a physic book, but I now that the creep theory relates to that to some extent.

Anyone has any thoughts on that ?
Is my logic wrong ?

Frédéric