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  • #16
    Isn't this the old mind-body separation belief?
    Break a leg: pain, trauma, loss of function. Peripheral problem, treat peripherally. Even if it is recognised that pain originates in the brain, the analgesics take care of that. Mobilise as per protocol, and exercise.
    Fairly straightfoward peripheral issue, unlike CRPS...
    Until Oliver Sacks woke up one morning, (A Leg to Stand On) lost all contact with his ex-broken leg and wrote about it.

    What do we do? I think we have been trying for some years to clarify the peripheral/central thingy in the clinical scene. It's only when outcomes are not what PTs expect that central issues are considered. And moreover, the answer is still 'psychosocial', although I wonder how this gets categorised...

    Warning: Anecdote...
    My daughter in another state recently attended a highly-regarded PT for ongoing cervical-shoulder-ribcage pain. It has been intermittent since 1993 when she crashed on rollerblades. She was told that the tissues haven't healed and need 'healing' by taping for support, and specific exercise. She may well get better, but the words 'sensitivity' and 'defence' will not enter the dialogue, I'm sure. (As to why I haven't 'treated' her - one doesn't educate members of one's family- it's doomed for cynicism).


    Nari
    Last edited by nari; 04-09-2008, 03:19 AM.

    Comment


    • #17
      I've started treating the few recent fractures I see as if the pain is of central origin. I the use light skin stretches for lymph drainage to calm the pain before I do anything else. Works like a charm so far. So much nicer for the patients than passive or active stretches of stiff joints. (It's so calming, I find myself nodding off at times.)
      Guess learning is a lifestyle, not a passtime.
      Those people who think they know everything are a great annoyance to those of us who do. ~ Isaac Asimov

      Comment


      • #18
        Ah. Thanks for that, Barrett.

        Funny that patients "get" this so much easier than many PTs. Lack of pre-drilled holes, filled with pre-chewed facts, I guess.

        Leading them away from too much deductive reasoning may require quite a feat: completely changing a focal point of their brain/mind attention. Present deductive thinking is SO mired in detail (details=knowledge in which PTs take great pride), and a simultaneous fear for complexity or chaos, that it is ripe for a magician to dazzle them.

        Re-setting the minds into a different mode of "looking, thinking, and seeing" will require a more profound (earthquake?) shake.

        When I talk to patients or insurance-agents about pain, I have to always begin with the basics. I suggest "pain is a personal neurological experience" that is seamlessly tied in with input from and output to the body. That it can vary form one day to the next, that stress can affect it enormously, that it can cause fear and fear can cause more pain behaviours which can cause more sensitivity to pain ..... Thankfully I have articles like Shacklock's to refer to.

        The hardest group to convince of the fuzzy neuromatrix approach to pain - any pain - acute or "chronic" - are my colleagues, who have a knee jerk reaction to pain. Still, in this day and age; "I treat dysfunction, NOT pain."
        These are the ones who will HAVE to have tests for the central and peripheral "components" - to unravel the little parts and assign values to each part. This type of thinking is how we were and are taught. Despite improvements - it still prevails.

        Ooops. A free association moment.
        We don't see things as they are, we see things as WE are - Anais Nin

        I suppose it's easier to believe something than it is to understand it.
        Cmdr. Chris Hadfield on rise of poor / pseudo science

        Pain is a conscious correlate of the implicit perception of threat to body tissue - Lorimer Moseley

        We don't need a body to feel a body. Ronald Melzack

        Comment


        • #19
          Do you think that central and peripheral are mistaken in that they are attempting to use a description of a place when a description of a viewpoint would be more useful? Wouldn't bottom up and top down be a better description as it described the place from which you are viewing? Some scenes you can see better from above and others from below, but the top and bottom exist in both situations.

          More on top down/bottom up processing.
          Cory Blickenstaff, PT, OCS

          Pain Science and Sensibility Podcast
          Leaps and Bounds Blog
          My youtube channel

          Comment


          • #20
            Bas, great post. Way to free associate.
            BB, great link to stroop test. Loved this bit:
            In fact this effect is so reliable that it has been used to catch spies. If a Russian agent is pretending to be American they can be tested to see if they exhibit the Stroop Effect for Russian words. If you cannot read a language, there will be no delay; if you can then you cannot avoid the delay.
            I think (regarding the peripheral/central issue) that it's important to remember that everything from dorsal horn in is central processing.
            Diane
            www.dermoneuromodulation.com
            SensibleSolutionsPhysiotherapy
            HumanAntiGravitySuit blog
            Neurotonics PT Teamblog
            Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
            Canadian Physiotherapy Association Pain Science Division Facebook page
            @PainPhysiosCan
            WCPT PhysiotherapyPainNetwork on Facebook
            @WCPTPTPN
            Neuroscience and Pain Science for Manual PTs Facebook page

            @dfjpt
            SomaSimple on Facebook
            @somasimple

            "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

            “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

            “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

            "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

            "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

            Comment


            • #21
              What percentage of the problem can we reliably consider the result of a central mechanism and what tells us that?--Barrett Dorko
              Barrett, your clarification

              Once I make it clear that the output of pain (the "problem") is the consequence of two mechanisms working in concert, most therapists will want tests that delineate one from the other. They will want some idea of how much each contributes so that they might devise a strategy to oppose it.--Barrett Dorko
              helped and reminded me of the following quote

              Whether a placebo-controlled trial can assess the contribution of various treatment components rests on the assumption that each treatment component has an additive effect. Only on this additive model can the observed effect be thought to be constructed from a series of components, each adding a discrete proportion of the observed efficacy. Treatment components may, however, have a more complex relationship. For instance, psychological and physical effects may interact with one another. An optimistic outlook may enhance the efficacy of a physical effect, and a physical effect may buoy a patient's optimism that a treatment is in fact working. This multiplicative relationship between treatment components would tend to undercut the ability of a trial to focus on particular components in isolation.
              From this paper
              "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

              Comment


              • #22
                Jon,

                Wonderful quote, and right on point here. Often I have to decide these days whether or not to bring a patient to the department or treat them in their room. In the late AM I find the environment among others (including staff) potentially threatening though it may happen that the possible encouragement from other patients will be lost if I don't bring them in. I also have to consider the day of the week and which staff may or may not be nearby.

                This is all part of the clinician's art, I think, and, like all art, its effect may be unknown to the one controlling its expression.

                I like Cory's "bottom up and top down" terminology and wonder if a therapist might craft a story to illustrate this complex relationship between mechanisms. As always, we need a story. Any ideas are appreciated.

                I was recently asked, "How do we know that neural tension exists and if it does when does it become clinically significant?" I could easily point to a couple of books but isn't there a study out there about the rapid and significant effects of tension and blood flow in the nerve? Something I can rattle off as if I always knew it?
                Barrett L. Dorko

                Comment


                • #23
                  Still, in this day and age; "I treat dysfunction, NOT pain."
                  Gosh, not only is this pervasive, but it's emphasized to the Nth degree. I think most manual texts I've got (biomechanical as they are) and many course descriptions ALWAYS give this statement in some form or another.

                  You mean, I'm supposed to help their pain issues, too??!! Ugh!
                  Nate Mosher, PT, DPT, SCS, CSCS
                  Board-Certified Clinical Specialist in Sports Physical Therapy

                  Comment


                  • #24
                    I could easily point to a couple of books but isn't there a study out there about the rapid and significant effects of tension and blood flow in the nerve? Something I can rattle off as if I always knew it?
                    I'm still looking for such a paper myself.
                    Maybe Shacklock's book will list one or several..
                    Meanwhile, I did a search for nervi nervorum lately, and found papers by Lundborg (from the 80's, not online) which look promising. I think his name cropped up quite a lot in both Shacklock and Butler's books.

                    One that I was able to get was Rat Peripheral Nerve Components Release Calcitonin Gene-related Peptide and Prostaglandin E2 in Reponse to Noxious Stimuli: Evidence that Nervi Nervorum are Nociceptors.
                    Not a very catchy title, I'm afraid..

                    Link.
                    Last edited by Diane; 05-09-2008, 05:12 PM.
                    Diane
                    www.dermoneuromodulation.com
                    SensibleSolutionsPhysiotherapy
                    HumanAntiGravitySuit blog
                    Neurotonics PT Teamblog
                    Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
                    Canadian Physiotherapy Association Pain Science Division Facebook page
                    @PainPhysiosCan
                    WCPT PhysiotherapyPainNetwork on Facebook
                    @WCPTPTPN
                    Neuroscience and Pain Science for Manual PTs Facebook page

                    @dfjpt
                    SomaSimple on Facebook
                    @somasimple

                    "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

                    “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

                    “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

                    "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

                    "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

                    Comment


                    • #25
                      Her is another by the same researcher, June 2008:
                      Sensory transduction in peripheral nerve axons elicits ectopic action potentials.
                      Link.
                      Diane
                      www.dermoneuromodulation.com
                      SensibleSolutionsPhysiotherapy
                      HumanAntiGravitySuit blog
                      Neurotonics PT Teamblog
                      Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
                      Canadian Physiotherapy Association Pain Science Division Facebook page
                      @PainPhysiosCan
                      WCPT PhysiotherapyPainNetwork on Facebook
                      @WCPTPTPN
                      Neuroscience and Pain Science for Manual PTs Facebook page

                      @dfjpt
                      SomaSimple on Facebook
                      @somasimple

                      "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

                      “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

                      “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

                      "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

                      "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

                      Comment


                      • #26
                        I could easily point to a couple of books but isn't there a study out there about the rapid and significant effects of tension and blood flow in the nerve? Something I can rattle off as if I always knew it?
                        Barrett,

                        Here's what you are looking for (and much more).
                        Attached Files
                        Luke Rickards
                        Osteopath

                        Comment


                        • #27
                          What percentage of the problem can we reliably consider the result of a central mechanism and what tells us that?
                          It was in the "Thoracic Manipulation" thread that I re-posted my comment from the EIM debate about cervical manipulation. That comment addresses Melzack's concept of the pain "neurosignature," which is the output from the pain neuromatrix. Whether the neurosignature is adaptive or mal-adaptive, I think is the relevant question, not how long the neurosignature has been churning out from the neuromatrix. For those of us who treat pain of any kind, temporal demarcations have proved essentially useless, and as Barrett aptly stated are "personally idiosyncratic."

                          I suggested making a determination of the level of central sensitization as a clue to the risk or presence of a mal-adaptive pain neurosignature. Luke then brought in the concept of "long-term potentiation", so I'll defer to his deeper knowledge of the literature on this as to which would be a more useful "marker" to predict risk or identify current presence of mal-adaptation to pain. I think trying to predict mal-adaptation from just a psychosocial perspective may, and based on my experience has, resulted in a lot of false negatives. There are lots of apparently "low-risk" patients who end up with persistent, mal-adaptive pain, nonetheless.

                          To answer the question that Barrett originally asked: I think that the percentage of contributions are so dynamic and there are such complex feedback loops from the stress-regulation component, that identifying a distinct proportion contribution of central mechanism influences on the pain neurosignature is a very tough target to hit, indeed.

                          Sorry about my late arrival to the conversation. I was feeling crappy.
                          John Ware, PT
                          Fellow of the American Academy of Orthopedic Manual Physical Therapists
                          "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
                          “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
                          be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

                          Comment


                          • #28
                            (Aha. This is the thread where Barrett asked for a paper.
                            Here's a link to Rempel's paper.)

                            About percentages, I'd guess... oh... I don't know... maybe 100%?

                            Nociception does not equal pain, I think that is clear by now. To many anyway. Although I could be wrongo on that...

                            Pain is a response by CNS to incoming (usually), not the actual incoming, furthermore it can be generated strictly from within the CNS sometimes...

                            Here is a link to CNS mechanisms of pain control.

                            Glad you're feeling better John.
                            Diane
                            www.dermoneuromodulation.com
                            SensibleSolutionsPhysiotherapy
                            HumanAntiGravitySuit blog
                            Neurotonics PT Teamblog
                            Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
                            Canadian Physiotherapy Association Pain Science Division Facebook page
                            @PainPhysiosCan
                            WCPT PhysiotherapyPainNetwork on Facebook
                            @WCPTPTPN
                            Neuroscience and Pain Science for Manual PTs Facebook page

                            @dfjpt
                            SomaSimple on Facebook
                            @somasimple

                            "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

                            “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

                            “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

                            "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

                            "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

                            Comment


                            • #29
                              I'm gaining a greater appreciation for history although there is so much new information that going backwards feels like I'm losing ground even if that's exactly what would help. For those with some interest, here is my first encounter with the Rempel reference.

                              The conversation took place seven years ago and is notable for the general tone of agreement amongst the posters.

                              Are we there yet? Are we there yet? Are we there yet?
                              "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

                              Comment


                              • #30
                                Jon, you are a funny man. You are also a man with a memory an elephant would envy.
                                Butler:
                                Most of us (me incl) were not given any neurobiology or related subjects during undergraduate training, just a hint of physiology. Maybe neurobiology wasn’t invented back then. Biological knowledge stopped once you had cut up the poor rat. Yet molecular biology/neurobiology/neurochemistry MUST become a foundation subject for manual therapy. This is critical – it drives creative clinical thinking and research and as so many professions have/will require knowledge from this area it can bring diverse ideas and professions together. This same issue has been pushed by the IASP. And the teachers have to get used to the new concept of a dynamic subject - unlike anatomy and biomechanics there are knowledge revolutions occurring almost daily in neurobiology.
                                Barrett mentions the word “interlocking” in relation to theories. Its important for research groups and professions as well. In physical medicine, “blobs” of research/concepts/ideas even professions, exist in a three dimensional void, awaiting linkage. Three examples – the epidemiological research, often driven by psychologists seems to go on a parallel pathway to the neurobiological research. For example, we know that fear of pain/reinjury is a predictor of outcome/chronicity, yet we also know the neurotransmitters, CNS areas involved and we know the potentially destructive nature of the stress chemicals. Research groups don’t seem to relate. Secondly there is a lack of “between level” understanding. For example, to my mind the two best pieces of writing on peripheral nerve pain are the chapter by Devor and Seltzer in the 1999 Textbook of Pain and a review article by Rempel et al in JBJS (81A, 1600). The authors don’t mention each other – one group is existing at molecular level and the other at tissue level. Other research/discipline blobs floating around which have just made contact include stress biology and pain science and the immune system with the nervous system.
                                Manual therapy floats around like an blob in the chaotic mess of physical medicine. Unjoined, unlinked, each idea, profession/research area “must endure the crucible of skepticism, experimentation and a host of competing theories (BD)”. There has never been a better time for a professional shift. How do we make it happen?
                                Yup, there it is.
                                And years later, manual therapy is still a "blob," floating around in the "chaotic mess of physical medicine."
                                Diane
                                www.dermoneuromodulation.com
                                SensibleSolutionsPhysiotherapy
                                HumanAntiGravitySuit blog
                                Neurotonics PT Teamblog
                                Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
                                Canadian Physiotherapy Association Pain Science Division Facebook page
                                @PainPhysiosCan
                                WCPT PhysiotherapyPainNetwork on Facebook
                                @WCPTPTPN
                                Neuroscience and Pain Science for Manual PTs Facebook page

                                @dfjpt
                                SomaSimple on Facebook
                                @somasimple

                                "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

                                “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

                                “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

                                "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

                                "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

                                Comment

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