Forum Moderators' Current Consensus on Pain

[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]

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.

[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.

[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]

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...

[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?

[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.

[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.

[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]

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.

[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.

[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.

[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.

[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...

[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?