Premise

[Keith]

The premise list above essentially outlines a specific scenario of nociception following ischemia and its resolution via movement. Nothing controversial there. I wonder if others see this as too simple though. Does something need to be said about central modulatory processes here? What effect might the "context that promotes ideomotion" and narrative interpretation have beyond the mechanical effects of ideomotor movement?

This is where I stand.

I am still trying to formulate (concisely) an explanation that addresses how Simple Contact alters a 'painful' neurotag rather than placing an emphasis on ischemia and neural tension (not that I deny its plausibility).

I think what makes more sense to me is an explanation of how different areas of the brain are utilized in improvisational movement in comparison to more goal-oriented actitivities than more 'typical' movement therapies (i.e. conventional exercise, yoga, pilates), that ideomotion provides the individual with greater degrees of freedom of movement, the benefit of the integration of deep-breathing and enhanced interoception. Non-specific effects are also (obviously) at work as well.

When I see videos of the influence on chronic pain with TMS focused at the motor cortex and I consider how the motor cortex is fundamentally activated (or so I suspect) differently with ideomotion and I think of the plasticity of the system...well...I don't have it put together yet, but these are some of the thoughts that bounce around in my mind.

Anybody else out there thinking along the same lines?

Respectfully,
Keith

[Barrett Dorko]

SF says:

Agree on that, but we can't ignore the fact, that when I cut my finger, there will be tissue damage and there will be pain.... Never saw anyone tear his/her ankle ligaments with a smile on their face during a football match.....

Did you actually write this or was your keyboard highjacked?

Bas pointed out this massive error and you've ignored it. I can't find the word "absolutely" anywhere in Bas' post.

[HeadStrongPT]

Mr. Finger, let me suggest hanging out a while and reading some of the sticky threads before testing the water with both feet. It sounds like you are a curious person, but there may be a few gaps in your knowledge that can be easily addressed with a bit of time and reading.

You are welcome to continue down the path you're on here but it might be a more productive use of your (and our) time to take it slow.

[Bas Asselbergs]

Agree on that, but we can't ignore the fact, that when I cut my finger, there will be tissue damage and there will be pain.... Never saw anyone tear his/her ankle ligaments with a smile on their face during a football match.....

What Barrett said.

[Patrick Septon]

Originally Posted by Luke Rickards
The premise list above essentially outlines a specific scenario of nociception following ischemia and its resolution via movement. Nothing controversial there. I wonder if others see this as too simple though. Does something need to be said about central modulatory processes here? What effect might the "context that promotes ideomotion" and narrative interpretation have beyond the mechanical effects of ideomotor movement?

I'm thinking along a similar line to Keith. There's no denying the non-specific effects of the context typically created around Simple Contact; and no denying that those non-specific effects may very well account for the majority of the treatment effect. As far as a central process that may be occurring...

With patients to whom I've already thoroughly explained the central nature of pain, and that the brain (or nervous system, or "pain system") is in control of everything, sometimes I say something to the effect of: "Your brain has a built-in mechanism for resolving a painful problem like this. At this stage, the brain needs to run a few test programs. Explore the space, test the waters (of movement). Allowing this movement to be fully expressed - allowing the brain to run it's own diagnostic programs to completion - will help the system more easily move towards the next stage (resolution)."

At least a few patients seem to have bought into this. Any thoughts?

Could corrective movement be (among other things) the brain's way of re-establishing the fine detail of its somatosensory maps? Exploring range of motion and assessing what exactly the limitations are through experience? Is the brain able to more easily resolve a painful problem once it has established this foundation?

[Luke Rickards]

Anybody else out there thinking along the same lines?

Me.

Taking myself through the exercise, the simplest it gets is:

1. Local changes resulting in reduction of nociception to below tolerance
2. Central somatotopic modulation following novel interoceptive input
3. A context and narrative interpretation that reduces the perceived threat value

Regarding method, though I am a fan of Simple Contact in my practice I have to admit that there are many ways one might proceed and still achieve those outcomes - passive and active, rational and irrational.

As Jason so eloquently presents in Crossing the Chasm, there's some value in many of the commonly used methods of treatment, especially those for which we do have good clinical evidence, but the explanatory framework is critical.

[John W]

Am absolutely aware of disc hernia's in people who aren't in pain, tendinopathies in people that are not in pain etc etc etc list is endless... Never stated that tissue damage is absolutely necessary to be in pain...

Sausage,
You seem to be identifying examples of "false positive" findings on imaging, which is a separate and distinct point from the one Bas was making about the contextual relationship between the pain experience and acute trauma. Think about soldiers on the battlefield who continue to fight despite having grave wounds.

So Bas was making the point that nociception is not sufficient for pain, while you are focussed on a different aspect of the argument, which is that tissue damage findings on imaging or exam frequently doesn't correlate with pain.

[PatrickL]

Here's my thoughts about the sufficiency of nociception for pain. This is from a post over at linkedin

i actually think nociception can be sufficient for a pain experience. i think that neural circuitry exists in newborns. my little baby, at 4 weeks old had immunization injections and an obvious painful reaction for a bout 5-10sec. at 4weeks i imagine there isn't much in terms of a complex cognitive/emotional appraisal of this nociceptive event. i think that we start off life with a salience detection signaling system that, by virtue of the saliency of the input, is sufficient to generate an unpleasant emotional or sensory experience (pain).

I think this system is rapidly modified by life experiences, and the development of the prefrontal cortex and emotional regions and memory regions of the brain. As soon as meaning begins to be attached to a potential or actual nociceptive event, or as soon as meaning begins to attached to a painful experience, the relationship between nociception and pain loses any constancy it might have initially had. It is true that a delta fibres project to the somatosensory cortex, true?

So i guess the big question is, if it does exist initially, does a patient retain some remnant of this basic linear nociception = pain circuitry beyond infancy? does this explain why it will probably hurt 99/100 people if you hit them in the shins with a bat? or is it the relatively stable contextual assessment across 100 people that accounts for the painful experience in 99/100 people?

i think it is possible for nociception to be sufficient for a pain experience but i don't think i can make a claim that it is ever the primary variable for a patient, by the time i get to see him/her, meaning has been applied to the initial event, and meaning has been attached to subsequent experiences, c fibres have gotten involved, glial cells activated, dorsal horn joins the party etc etc.

It complex. there's no getting around it. For the typical patient that presents to me in the outpatient ortho setting, I stop well short of claiming that nociception is the cause, especially the ongoing cause of the presenting complaint. Causation is out the window.

This doesn't mean I cant make a guess at a likely source of nociception that might have initially contributed to the threat processing that led to the initial onset of pain i.e. if history is medial knee pain following valgus force to knee, i'll guess that nociception from a torn MCL probably contributed to the threat processing that resulted in the initial pain.

It DOES mean though that I CAN'T guess at the extent to which that initial source of nociception is still contributing to the current threat processing responsible for the current state of symptoms, especially if the healing timeline for any injured tissues has passed.

There's just no way to make a reasonable guess. the salience detection network might be ringing alarm bells and driving a persistent pain state because (to list just two alternatives):

- of persistent afferent flow from nociceptors. but that continuous afferent flow might be from a super sensitized dorsal horn, and the actual flow from tissues to dorsal horn could be normal.

- of persistent afferent flow from non noxious chemo/mechanoreceptors that cognitive and affective have labelled as threatening, and there's actually no contributory nociception activity at all

[zendogg]

I know I am fishing for certainty but with what you said Patrick, and with the comments I made in Eric's "what I've learned from my failures" thread regarding the shoulder pain that did not resolve with my efforts, what can be said when we've told someone about all the ectodermal reasoning, how pain cannot be pinned down to tissue, and then they go have surgery/cortisone/whatever AT THE SITE OF PAIN and the pain goes away? (Run-on sentence, I know)

[Diane]

That has happened to me more than once.
You accept the situation and you move on.
It's never about any ultimate truth, only the proximal truth - of the patient.
That is what we all have to recognize, accept, move on from, but not pander to, not allow to drive our own thought process.

[zendogg]

I understand your point Diane. In terms of a premise, the correlation of spot specific intervention and clear, distinct positive change, I can see how at least surgical or injection therapy could lay claim to validity.
While we cannot know for certain what is the impetus for pain output I think speak of target tissue being a potential contributor should definitely be discussed with the patient so that an informed plan can be agreed upon.

[Diane]

I understand your point Diane. In terms of a premise, the correlation of spot specific intervention and clear, distinct positive change, I can see how at least surgical or injection therapy could lay claim to validity.
While we cannot know for certain what is the impetus for pain output I think speak of target tissue being a potential contributor should definitely be discussed with the patient so that an informed plan can be agreed upon.

In so far as it constantly bothers/mechanically deforms a nearby nerve. Yeah, that is always a possibility that co-exists right alongside the possibility that it won't, or that it could stop.

[Barrett Dorko]

Of course that happens. Not always. Sometimes. It's been explained many, many times.

Non-invasive care and education should precede it, don't you think?

Care to take a stab at the surgeon's premise?

Anyone?

[zendogg]

Of course that happens. Not always. Sometimes. It's been explained many, many times.

Non-invasive care and education should precede it, don't you think?

Care to take a stab at the surgeon's premise?

Anyone?

Non-invasive care and education are gonna cost you. Will it work? Don't know. Medical intervention will cost you. Will it work? Don't know.
As someone who deeply respects people's money, time and sanity this is a difficult reality.

Surgeon's premise would be that THE TISSUE is and always has been the problem. You may get some relief for some length of time with manual therapy and movement but, give it a month, year or decade and that tear is gonna need repair.

[John W]

You may get some relief for some length of time with manual therapy and movement but, give it a month, year or decade and that tear is gonna need repair.

This is a demonstrably false premise.

They don't care.