CT The Chestnut Challenge!

[byronselorme]

I would like to lay down a Chestnut Challenge for all the members on SomaSimple.
I will not deny the limitations of this challenge. But some of the rules I hope will allow freedom to hone in on your Theory Of Everything.

Why Chestnut Challenge? Because I like the fact that a chestnut looks like a miniature brain (I know the walnut usually gets this title but I still prefer the chestnut). The idea of the challenge being to get to your core understanding and specific Theory Of Everything as only you can best encapsulate it "in a nutshell".

Anyone who is a member of SS can write here but I hope you will respect the idea of this Thread.

Here are the rules:
1) 400 words max. Brevity is the hardest part I know, but maybe this constraint will force you to a new level of elucidation.
2) 1 entry on this thread per member. Unlimited edits of that entry.
3) If your edit is because you have a new understanding that contradicts an old one, separate and move the old idea to the bottom of your post and [date it], make a (*) where the modified entry is entered so that others can see your evolution (this is not necessary for grammar or wording clean up).
4) No links, quotes, or outside references. Original thoughts in your own words only.
5) No rebuttals, attacks, or defenses of any other entries. Save it for other threads.
6) No rants about any other system or belief. This is your 2 paragraphs of what you believe is most important about the/your ideas expressed here.

Here is what I plan to use this thread for:
This page will be used as a link in other places that I post/write but it will always be a link so that if your understanding/concept evolves, it will be the most recent version that others see. I would like to expose more people to SS via this challenge.

If you think that any of these points above need revisions or outright changes, post to the discussion thread here so that we can keep on point with each of the posts in this one.

I hope that many of you accept this challenge. I am currently working on my own entry but have to admit it is a tough one.

Try to answer this question "What people need to know that I have learned about pain and therapy is...."

That’s 400 words up to here.
_______________________________________________________________
Jon Newman started a discussion thread here for questions [added July 18, 2011]
"Leave old idea intact but put the strikethrough over it" [removed July 30, 2011]

[Bas Asselbergs]

I'll keep it brief.

"What people need to know that I have learned about pain and therapy is...." the concept of the neuromatrix, the importance and role of skin in manual therapy and the nature and importance of corrective movement.

Addition:
I have learned that everything in a human life can be of influence in the development of pain, and that as a therapist I may affect many of those aspects.
I have learned from much greater minds than mine, that through my most plausible explanation of the general neurophysiology and pain neurophysiology, I can affect the patient’s experience directly.
My hands and the CNS behind them have learned that less is more as far as contact with the patient is concerned.
My ego has learned it needs to take a backseat to the patient’s experience and solutions.

The last decade has seen the erosion of my “total open-mindedness” that allowed even the most esoteric of fanciful explanations and theories equal time as those most plausible and consistent with laws of nature. Occam’s razor has become my favourite tool. My mind remains just slightly ajar.

[Diane]

A whiplash “injury” in 1990 afforded me a direct opportunity to learn from a personal “pain” experience. A ten-minute skin-deep, slow, careful manual treatment by another therapist obliterated it forever a few days later. In 1994 I opened a practice and for years successfully treated pain in other people using that same method. Later I learned that skin and brain both came from the same ectoderm layer of embryo, but still didn’t know much about the neural structures that connected the two together, also from ectoderm.

In 1998 I attended a neurodynamics class by Butler; all the pieces fell into place, made sense: I found out where my “pain” had arisen (neuromatrix model), and why it had felt as though it was in my neck (somatosensory cortices). I learned that nerves were the first tissue to respond to injury by setting up a malfunction that often results in “pain” output. I already knew they contained nervi nervorum and what sort of manual contact could alleviate it (skin and positioning). Butler’s information made me think about superficial neurodynamics.

In 2007 I had a chance to dissect skin; I saw with my own eyes small cutaneous rami that branched at intervals from the lateral cutaneous nerve of the forearm, travelled an inch or so obliquely to the surface to invest the underside of skin. Then, I pondered the bends and twists of occipital cutaneous nerves and at last understood how one can end up with such vicious neck pain (movement guarding) and tenderness (secondary hyperalgesia) following a car crash, and why mine had gone away completely with a single treatment (novel kinesthetic and sensory input) which had felt enormously reassuring and restorative (‘human primate social grooming’).

This led to DermoNeuroModulation. DNM weaves what is known about pain and what is ethical to do to patients, with a method. From an operator standpoint, it works effectively for most uncomplicated pain experienced as a result of injury, anywhere in the somatic output system; it often works even for those with longstanding pain complicated by yellow flags; it can help separate out red flags, conditions which may give rise to pain for which DNM won’t work at all. From an interactor standpoint, it helps build trust and communication all the way along; the patient can practice sensory awareness and internal locus of control by guiding the therapist’s physical contact.

[tonyf315]

Pain is an output from the brain based on perceived threat that can be from many sources (including treating practitioners-don't be one of them! Do no nocicepting!) How a therapist is with their patient matters as much as what is done with/to them. The specifics of a technique aren't what's important as much as how the nervous system of the person receiving that touch interprets that technique. Sometimes no touch is the right touch. We can't stretch fascia or isolate specific joints for mobilization (or un-knot stuck sarcomeres?) but we can provide or facilitate sensory input and motion that improve circulation and therefore health of tissues especially nerves; we can also teach the brain with words and touch, that it's ok to move and new options for doing so that make that brain feel less threatened.

The skin is the brain exposed and is our most potent "handle" to get our hands on to impart these changes, and is accessible on all of our patients without having to worry about what ideal length of time to do a technique or direction to push or referred patterns, or vascular catastrophes or if the person is too overweight or immobile to feel landmarks or get positioned in a certain ideal way. Words can be a nocebo ( a new word that I first learned here) as much as the wrong kind of touch. Strengthening for pain might work but not for the reasons we used to think; think now of that perception of increased support reducing a brain's perception of threat. There are no magic bullets and beware of gurus, multi-level certifications and brand-named techniques. Keep reading and learning.

[zimney3pt]

Pain and Therapy are infinitely more complex then I ever knew, Explain Pain and Painful Yarns (thanks Butler, Moseley) taught me more than PT school and any other Con Ed course ever did about pain and how to treat it not manage it (also thanks to Neuroscience advancements). Pain once seen as an input (Descartes) is known to be an output of the brain (Neuromatrix Model) – thank you Melzack! It is an amazing fractal of cognitive, sensory and affective connections of the brain that is intertwined with both nature and nurture influences. Anything the brain concludes is actually or potentially threatening damage to the “self” the brain has the potential to produce pain.

Spending a majority of my PT career looking for “things/nouns” that I believed could be “operated” on (muscles, joints, fascia, etc) to help treat the causes of pain – biomedical model. I slowly had come to understand and continually learn (SomaSimple, cognitive dissonance and critical thinking are the drivers behind this) the nervous system was the primary system and began a journey to understand and accept uncertainty with “interacting” with it – biopsychosocial model. It is a journey with no end (continue to ask and seek to understand the WHY?). My patients and students I teach deserve my diligence to continue to advance my understanding of pain and therapy. This is what evidence based practice should be about – Learning and using the best science based evidence, to help evolve my clinical expertise and experiences all while taking the patient's situation into account.

Therapy I once provided was directed toward mobilizing joints and fascia, exercises to increase strength to correct postural/”core” or movement faults and modalities to reduce pain and increase function. I have to come to understand the things that I believed worked (I believed so because patient’s “got better” and it was what I was taught) often times were due too pure chance at best or because of principles I did not understand. Now I think more on the lines of methods that fit into these principles: education, eliciting ideomotor expression and interoceptive awareness of novel movements (patient inside-out neuromodulation); placebo (patient expectations); and neurodynamic mobility, dermoneuromodulation (skin and HPSG) and purposeful movements with graded exposure (outside-in neuromodulation). As I do therapy with these in mind at the forefront of all of it is “do no harm”, be optimistic and laugh a little because zebras don’t get ulcers.

[joebrence9]

What people need to know that I have learned about pain (and therapy) is that…
Pain is simply an output from the brain due to an actual or perceived tissue threat. It is dependent on a neural interpretation. It’s a descending output. It always involves the brain.

The brain is the most complex organ in the human body. “It” is self-aware. “It” knows what it is and knows what “it” does. The human brain has not only figured out how to study what it “does” but also how to quantify the results of “its” studies, and how to interpret the results.


The brain has also found ways to trick or mislead other brains. Individuals have come up with unproven theories on the origin of pain, within their brain, and have derived ways of teaching others to believe in these theories. So the brain can actually trick other brains into believing false-truths. The brain can be manipulated.


Pain can be manipulated through many techniques which alter expectations, perceptions, and emotions. This is why placebo and nocebo are sometimes effective. Just expecting a positive result, can cause a positive result. This is often forgotten.

Therapists and others who treat pain often ignore the brain. By understanding the complexity of the brains involvement in pain, I feel like I am nearing truth as a therapist.

[nari]

Right from the start of a professional life decades ago, I felt something was missing. I didn't know what was missing, but I was concerned about those patients who improved in a vague sort of way but when I saw them again (and again) they had not improved significantly, only temporarily.

My interest from the start lay with those with some kind of issue with the brain, acquired or genetic. As I never exercised and disliked sport, I found it difficult to dole out modalities and then give an exercise program. As the profession advanced, things got better but there were still those patients who did not stay better. Maybe it was a detectable lack of enthusiasm on my part and hence a lousy placebo response.

In early 1990 I listened to David Butler from Australia give a full day's workshop. Most of my colleagues were not interested and felt most of their valued methods were being demobilised in their minds. I thought: this makes SO much sense. Then along came Moseley, and others who were looking into the brain's worldview for some answers. Yay!

In early 2000 Somasimple began its cyber life with four of us, all still there today. Then Barrett joined and we progressed (slowly) from there on. With the concept of instinctive movement and consequent correction, things really became exciting. Those patients who didn't improve much were now on the way to optimum resolution of pain, stiffness and 'weakness'.

What I can say to anyone out there who has the job of restoring function and improving mobility in a patient with pain, think about the brain first; think about how it governs every aspect of our lives, including pain, first and foremost. Then think about skin, the conduit to the brain. Think less about that pesky LBP, sore neck or weak VMO and look at the origin of the problems, not where the symptoms SEEM to originate.

The cosy aspect of trying to assimilate all this "brain" knowledge is that it is neuroscience-based, cannot do harm and is increasingly supported by research.

Nari

[caro]

It could be said that pain is one of the many kinds of music produced by a human nervous system and that in the world of manual therapy, the people who can help alleviate pain are musicians. It could be said that there are two kinds of musicians : those who can improvise and well... those who can't. The symphony, for example, is full of the latter : fine, accomplished players who can't produce a note to save their life, if they don't have their transcriptions guiding them. And there is nothing wrong with that, classical music is beautiful. But I think if you want to help people in pain, you have to learn how to play Jazz.

Understanding the Neuromatrix can turn any manual therapist\ classical, sight reading musician, into an improvisational Jazz genius. It will help that musician\therapist understand which notes need to be played and which notes need to remain tacet, when it's time to blow and when it's time to go to Coda.

It will make them understand that it matters not a whit what instrument they are playing or if they are a sideman or the leader of the band.

And that all they need to make it work is to listen. Very, very carefully.

[Joy H]

"What people need to know that I have learned about pain and therapy is...."

The brain and the nervous system are *always* involved. Muscles don't contract without neural involvement. Postures don't get held. Pain doesn't get perceived. Reduced movement doesn't cause concern. My job is to work out what configuration of brain, nervous system and body are likely to be involved, explain this sensibly and then be a catalyst that helps create an environment in which the brain/ nervous system can calm down.

I've learnt that a huge proportion of my job can be done just by talking and educating. I've learnt that the rest of it is about being as non-threatening to the patient's nervous system as possible. I've learnt that a change the patient makes in their day-to-day life that stops them irritating their nervous system so frequently has many, many times the therapeutic benefit of anything I will do in clinic (bar a decent explanation of pain).

I've learnt that I'm never going to stop learning about pain and how it gets created - and I'm pleased about that. I've learnt that none of this makes it easy for me to slot in with my colleagues, but that there is a wonderful place on the internet (thanks, SS!) where I feel at home and challenged all at once.

[ginger]

My own real journey towards the clinical practices I now employ, began when I took a job as a sole physio in an isolated islander community in the Torres Straight of far north Queensland, in my second year after graduation, 1987. I had been taught a raft of local and spinal treatments that I quickly became frustrated with. For the most part , these methods didn't work.
One patient, the bishop's wife, had a painful shoulder that I had been ultrasounding, stretching and worrying over for weeks with only minimal effect. Till the day I treated her neck, using the Maitland mobilising method I had been taught, and presto, her shoulder improved dramatically. This seminal moment, led me on my real journey.

Over the years I found that the more I mobilised spinal joints, the better the results. Progressively I abandoned the localised MSK treatments that didn't work to concentrate on the spine. I found that a wide range of MSK problems , that I had been taught were of either mysterious origin or disease states, responded well to spinal treatment.
My approach, originally pure Maitland, evolved over time , gradually losing elements of little value and concentrating on that which induced the strongest changes. This method is now sufficiently different to warrant a name for itself, thanks to posters here on SS and on RE it is now known as Continuous Mobilisation (CM).
I have sought to explain CM related treatment effects as best I can , drawing on neuroscience and my own observations ,by writing a theoretical model that seeks to explain the effects of CM and of spinal movements generally.
The essence of which is that the spine, along with other major systems and organs , has a threat response. The nature of this response is to limit spinal movement, the effect of which is ultimately, pain, altered sensations and altered patterns of recruitment of spinal and other muscle. It is by restoring normal non threat states of movement to the spine, that many pain and dysfunction issues can be resolved, whch had been caused by interference to nerve function at the spine.
Progressive acceptance of and use of this notion of spinal protective behaviour and it's effects, are noted in the literature generally since first posting these ideas in 2005.
I acknowledge the contributions to my thinking by the scientific community gathered here, which has , by small increments, lead me to believe there is value in sharing, in mentoring and in staying in touch with the science of pain.

[Jon Newman]

What people need to know that I have learned about pain and therapy is....

I’ve learned that pain is both a sensory and emotional experience which is usually described as tissue damage even when there isn’t any. Also, the experience is unpleasant for the experiencer. What I think is important to note is that

1. Pain is the subjective experience and necessarily occurs as a process in the brain and
2. To produce an experience of pain the brain typically uses pathways that involve motivated behavior under all but very unusual circumstances. It is debatable whether those unusual circumstances can be defined as pain (e.g. the experience of a lobotomized patient to noxious stimuli.)

I’ve learned that hyperalgesia--having a pain experience in response to an increasing range of stimuli, including nondamaging stimuli--is the name of the chief complaint of most patients in the clinic.

I’ve learned that pain is to be distinguished from nociception (the neural process of transducing and transmitting noxious stimuli) while simultaneously acknowledging that nociceptive pain is more prevalent than neuropathic pain in the general population (my conjecture).

I’ve learned that there is no “pain center” in the brain. Rather there is a widespread network of cells whose specific pattern of firing creates the experience of pain and this network and pattern is dynamic, or at least potentially so.

I’ve learned that any therapy can be conceptualized as mechanical, chemical or thermal stimuli which affects the pattern of activation of the brain. These stimuli could be taken up a level of analysis and be classified as being in the biological, psychological, social/cultural domains and a particular stimulus may accurately be classified in any or all the domains.

I’ve learned that the context of the stimuli and patient expectations can interact in unpredictable ways but there seems to be a general principle that creating contexts that are congruent with patient goals (i.e. not threatening) are helpful, if not critical, for the patient to reach resolution. Learning what the patient considers threatening (goal thwarting) and effectively avoiding that environment are important aspects of therapy.

I’ve learned that patients can’t act on their therapist’s desires. They can only act on their own desires but this can include their desire to please their therapistsomeone else [or other interests of the self (such as it is).]

I’ve learned that unhelpful cognitions (i.e. beliefs) can slow, if not defeat, the resolution of pain.

I’ve learned that it is okay for PTs to address cognitions related to patient treatment goals.

Do I have any unhelpful cognitions? I’m open to criticism/revision.

[byronselorme]

I spent 14 years in public school and hated most of the later years. 5 years of that in High School, well I got it done at least. 4 years in College studying Mechanical Engineering, mostly bored but enjoying the changing lifestyle and getting it finished. I thought education was a torture. I guess I forgot that I hated education so I became enamoured with personal and emotional development leading to some extra-curricular University courses in psychology, which I loved.

Unfortunately, through this entire path, there was no education in how to think critically. 18 years of education and I was still taken by any idea that “felt” good and gave me the “warm and fuzzies”. No wonder I found Yoga so exciting.

Enter a Car accident at the end of 2001 and, of course, with positivism and Yoga I was going to heal myself in no time. Not a complete fool, when this initially happened I visited...ahem….my own MD, 4 PT’s, 2 Osteopaths, 2 RMT’s, 1 Chiropractor, 1 bored Kinesiologist, 2 Acupuncturists, 2 Psychologists, 2 Physiatrists, 1 Podiatrist, 3 Designated Assessment Centers, 4 Lawyers, 5 MRI’s, 2 EMG’s, 3 XRAY’s, 3 Ultrasounds, Several Yoga Therapists, a genuine Indian Bonesetter (in India no less), repeated Kiss records, and finally a Neurologist. Not once did anyone explain pain to me.

Sick of the repeated trial and disillusionment I decided to school myself in critical thinking. I bought books, subscribed to newsletters, and visited Blogs that specialized in debunking. I learned as much as I could (and still counting). I started to seriously debunk the claims in my own Yoga profession which led to some startling and disheartening discoveries. Strength and flexibility doesn’t help with pain????

Somehow my old interests in psychology still led me forward on a parallel track to all of this studying. The developments in neuroscience and enthralling neuroplasticity captivated me. I remember reading in a GNC store in 1999 “The brain does grow new neurons in later life!” I didn’t realize how big a shift was occurring.

I ended up at a website that connected everything I was studying, struggling with and completely committed to. I discovered what pain was and what true scientific debate coupled with myriad curiousities could lead to and it wasn’t agreement. It was refreshing and never-ending learning. It was patient / client centered, brain, consciousness and non-consciousness based. It was just SomaSimple.

[gollygosh]

I graduated in 1982 at which time part of standard operating procedure was to stretch patients with limited range until faces were quite literally red. Incomprehensibly, some of those patients achieved their range, strength, and function goals.

Whether it was the message of my Alma Mater, or the message I chose to hear, I had the impression that as long as I provided for the safety of my patient, I was free to try many interventions in pursuit of the patient's goals. With that permission to be creative, I tried several courses which while totally missing the science behind what they were doing, invited me to be less and less physically aggressive. In addition a Trager class I took, introduced me to the idea that we were working with the brain. I am married to black belt in karate, and together we took a couple of T'ai Qi classes, which further softened my approach to patients emphasizing not only gentler touch, but more exploratory, and less right movements. This approach led me away from the protocol driven patient diagnoses, and more and more into the realm of the pain patients who nobody knew what to do with. I remember in one billing discussion, one of co-workers told me that I should probably use the neuro muscular re-ed charge most of the time.

At that point I took the Simple Contact class, and loved it. I began integrated the information, and the pursuit of self correction in a more deliberate fashion. Because I am an "e-phobe" it took me way too long to soma simple, and I continued to bungle around following my intuition.

In November I overcame my e-phobia enough to accept the invitation Barrett Dorko extends to all his students, and joined Soma Simple. At that point I learned that while intuition is great, it is no substitute for knowledge. I realized that I have a lot of learning to do. Pain is an output from the brain. That sentence turns most of what we are taught to "do" to our patients upside down. It challenges every intervention to be an appeal to the brain through every portal available. The brain, and the nervous system are more intricate than could have been imagined, and therefore hold many opportunities for the resolution.

[Jason Silvernail]

What people need to know that I have learned about pain and therapy is....
…that understanding the physiology and psychology of pain should completely change everything about the way you approach clinical life and should immediately cause you to reject most of what passes for treatment in medicine and therapy.

The most powerful parts of this idea is understanding what we now know about the origins of pain (we put them into four origins here) and understanding that psychosocial aspects play a part in the experience. This knowledge helps you realize you must find a sensible way to address mechanical pain from "issues in the tissues" and find a way to relate to people and translate the available evidence into a treatment philosophy.

Issues in the tissues we can address are mechanical in nature, so that means movement. Manual therapy (passive movement), active and ideomotor movement are sources of this. Not ultrasound, lasers, rubbing something with a steel bar or plastic wedge, poking it with a needle, injecting it with something, or cutting it out. Mechanical pain needs movement – full stop. Throw the other crap away - and there's a lot of crap. A detailed and skilled exam can help you find the most relevant places to treat with targeted passive movement and motor control/neuroscience knowledge helps you conduct sensible active movement. This helps you focus on things that really make sense and helps put more control in your patient’s hands. It also helps you decide which therapeutic approaches make sense to pursue when you are considering advanced training – which I think makes a huge difference in your ability to address these peripheral problems.

Psychosocial and cognitive approaches don't require that you become a clinical psychologist but that you have a broad concept of the influence of those factors and that you account for them in your encounters with your patients. Know the literature and be able to give management advice based on evidence. When people come to see you they want a plan. Have a plan that is defensible and that works toward their goals. Address concerns, fear avoidance, other stress, and unhelpful beliefs with compassion, understanding, empathy, and informed knowledge.

Understanding why people hurt is part of our professional responsibility and should change most everything we do on a daily basis away from traditional methods and towards methods defensible with modern science.

[Karen L]

What people need to know that I have learned about pain and therapy is....

The neurophysiology and neurobiology of pain needs to be taught as a core competency in all medical and allied care disciplines from the very beginning. It is virtually impossible to end up with odd notions of muscle imbalance and postural dysfunction as a cause of disease when you have an firm understanding of neuroscience as it pertains to pain.

I have learned regardless of raspberries from conflicted interests, the Neuromatrix Theory of Pain by Ronald Melzack is still the best explanation of pain currently available. It is still critically examined in publications and modifications are happening as new discoveries about mind and consciousness are made. Lorimer Moseley has done an incredible job of making the neuromatrix diagram into a learning, teaching and treatment tool I would be lost without.

I have learned the basic resolution to pain of mechanical origin is not to ignore the prodrome and move. The brain will move us to protect its nervous tissue. It is a great system that we over-ride and ignore at our peril.

The knowledge I have acquired about pain is my greatest ally when I meet a person with pain. The more complex presentations of pain are interesting and challenging for me on many levels. However I try to not lose sight of the fact that there is a person on the other end of the semantics. A person who needs understanding and real care.

The thing about pain I look forward most to learning is; what is the precise mechanism for the perception in the brain of pain. Then many of the arguments creating chasms will fall to the side.

If I could be anything else tomorrow morning at 8:00am. I would be a researcher in Ellen A Lumkin's lab or the new guy on my radar Gary R Lewen. PubMed search them. They are among the top skin researchers in the world. If they wouldn't have me they I'd beg Lorimer Moseley if I could clean windows at his house.

One final comment, The hands can see pain better than the eyes, the can hands hear pain when language fails, the hands may move tissue but the brain moves pain.

Karen Lines RMT