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  • Baecker
    replied
    I think it was taken from the D.O.'s Mitchell used to say: Pain is a Liar....

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  • Bas Asselbergs
    replied
    As Barrett and Diane stated, it is a very stubborn meme, that likely persists because it rang juicily "right" for the insurance companies, for the mechanically oriented PTs (and there were lots), and for the PTs who just did (and DO) not know what to do with the idea/concept of pain.

    Especially when a clear tissue related pathological link was absent.

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  • Barrett Dorko
    replied
    Marci,

    Perhaps the question should be: What is a relevant dysfunction and how did you determine that it was present?

    Early in my career I was armed primarily with notions about function and pain that proved untrue. Among other things (stiff spinal joints could be reliably assessed and blamed for painful movement, for instance), I had made A Big Mistake (as explained in the link) and didn't initially know where to turn to correct that. Breig's work righted me initially and then a plethora of others chimed in.

    I am treating dysfunction, just not the stuff I thought I once was.

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  • Diane
    replied
    Usually pain is the dysfunction.
    The Paris Proclamation was a mesodermal meme.

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  • Mary C
    replied
    If we use Moseley's approach, are we not treating dysfunction?

    When we use Diane's approach, are we not treating dysfunction?

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  • Barrett Dorko
    replied
    Nate,

    Paris began to articulate his "treat the dysfunction, not the pain" meme while I was working for him in Atlanta in 1976. What we had at the time was a perfect storm of ignorance, intimidation and charisma. Our colleagues never objected that I can recall and Ola Grimsby, whom I was teaching with at the time, went right along. So did I.

    I recall thinking years later while in my own tiny practice that this attitude would be really hard to maintain if one were faced personally with patients every day. That's where I ended up but, to my knowledge, Paris and Grimsby did not. My patients made it clear that it wasn't enough, and I listened to them.

    These days I speak to therapists working in virtually identical situations across town from each other. One will claim that pain is a major problem in their patients and the other that it is minor. A little careful questioning always reveals the same thing - the latter practitioner just doesn't ask about it.

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  • NateM
    replied
    Why do you suppose we're taught: "don't chase pain, treat dysfunction"?

    I've heard that at more than one course, the rationale for which seems to go something along these lines: if you "treat" pain, you'll just keep chasing it and never "solve" the problem.

    Why would this be so?

    I would guess that if polled, the majority of patients would agree that they would rather have their pain diminished/resovled more so that have me "fix" a dysfunction that I "found."

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  • Barrett Dorko
    replied
    I appreciate all the thoughtful contributions to this thread and hope to make it a regular reference for others hoping to understand more about the patient in front of them. In fact, I think it emphasizes how much more important understanding is than skill. Perhaps not knowing how these two mechanisms exist and interact is common but it may easily lead to haphazard care.

    Aside from the moving target this edge between peripheral and central gives us, the absence of a linear relationship between the size, intensity, severity or drama of the peripheral mechanism and the intensity of the brain's output of pain is something that needs further illumination and discussion. In my experience, therapists have great difficulty believing that could be true.

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  • Nick
    replied
    The Stories We Tell Ourselves

    Last month's Skeptic magazine had a review called A Mind of Its Own: How Your Brain Distorts and Decieves called The Matrix of the Brain.

    The reviewer states: "Although we like to think of ourselves as rational beings, our brains covertly strive to create for us a view of the world that and of ourselves that is self-serving but not necessarily consistent with reality. Beliefs and opinions are formed quickly and become part of how we define ourselves, so the brain selectively perceives and recalls evidence that supports cherished beliefs while disregarding or forgetting evidence that contradicts our beliefs." The author, Cordelia Fine, calls this "motivated skepticism."

    The reviewer continues: : It would seem that going through life deluded by our own brains would not be a good thing, but that is not necessarily the case. Some people have markedly more balanced self perceptions than normal people - they know clearly what their limitations are and how little control they actually have over their lives." ...

    "Life is pleasant inside the virtual reality of our minds. So what if we think we are more intelligent or virtuous than others and believe we are more in control than we really are? Such minor self-deceptions are, for the most part, harmless, and they may help us get through the day. But we are not necessarily prisoners of our minds. When the deceptions become harmful to ourselves and others, there is a way out. Science gives us a way to unplug ourselves from the Matrix of out brains."

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  • Jon Newman
    replied
    You are also a man with a memory an elephant would envy.
    Thanks Diane. It's search function enhanced to be sure. I remembered reading the article, not Rempel or the title of the article per se.

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  • Diane
    replied
    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."

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  • Jon Newman
    replied
    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?

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  • Diane
    replied
    (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.

    Leave a comment:


  • John W
    replied
    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.:sad:

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  • Luke Rickards
    replied
    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

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