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  • #31
    Kory,

    I'm glad you mentioned culture. Does Turkheimer discuss the effects of the beliefs of those not in poverty. Maybe a negative space, the absence if you will, of the need for acceptance of the other. I realize this is on the cause of things side but just wondering if it is addressed.

    Gil

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    • #32
      Gil, great question. My answer is I don't know.

      All I can share about Turkheimer at this point is what I copied in post #2 from the book. I have never been introduced or read any of his work before. I would like to explore him further because the comparison of poverty and pain seem to be very similar. I think there is almost some "universal laws" when dealing with an emergent system (I realize that is a very bold statement with no significant research that I am aware of at this time to back it up. I am purely basing it on two emergent systems, poverty and nervous system/pain, and seeing very striking similarities in how to interact with them create a more positive outcome. Yet one would normally not equate anything that pain and poverty should be similar in other then they are emergent systems.)
      Kory Zimney, PT, DPT

      http://koryzimney.blogspot.com

      "Study principles not methods, a mind that can grasp principles will create its own methods." - Gill

      "All truths are easy to understand once they are discovered; the point is to discover them." - Galileo Galilei

      Comment


      • #33
        Kory,
        There are universal laws (tenets) of evolution which is of course is emergent. Ken Wilber identified 20 tenets in Sex, Ecology and spirituality. Great stuff.
        Gil

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        • #34
          Thanks for everyone's input, that's what makes this an "emergent" process in of itself.

          Here's what I have so far trying to sum things up to this point before moving onto the next section from book - "Gloomy Prospect". (It may be a few days before continuing as I'm off to CSM tomorrow.)

          An emergent nervous system has the capacity to produce an output of pain.

          Pain thus will have properties of the tenets of emergent systems.

          Tenets of an emergent system:
          1) They are nonlinear in nature. Even if some of the constituent parts in isolation are linear, once they are put into the emergent system they fall under the property of that emergent system and will become nonlinear.
          2) No single constituent part can be responsible for the emergent system. The sum of the parts is always less then the product of the whole emergent system.
          Last edited by zimney3pt; 07-02-2012, 09:02 PM.
          Kory Zimney, PT, DPT

          http://koryzimney.blogspot.com

          "Study principles not methods, a mind that can grasp principles will create its own methods." - Gill

          "All truths are easy to understand once they are discovered; the point is to discover them." - Galileo Galilei

          Comment


          • #35
            So that is a nonlinear system working in a nonlinear culture, and people think they can predict with any sort of certainty what the outcome will be?
            Hmmm not sure if predictability is really the issue, in the end highly complex non-linear systems can be modelled relatively simply the classic example being pendular systems. I would be concerned that we might lose sight of where we are going if we start to look at predictability. After all we can in broad terms predict the weather another non-linear system with reasonable accuracy (at least in the short term) but it does not help us one whit in intervening in any meaningful way to control it. Chaotic systems are non-linear highly complex but remain deterministic – and in being so deterministic tempt us humans in to assuming we can predict them and in being able to predict them control them yet we fail to identify that they arise because of a huge complexity of underlying phenomena and it is the interaction of those phenomena that produce the outcome not the presence of the phenomena alone (trigger points spring to mind).

            This quote here from Higgins 2002 discussing non-linearity and complex systems in health may be of help,

            In contrast, a complex nonlinear system has been defined as "a system or whole
            consisting of an extremely large and variable number of component parts, where the individual components display marked variability over time, and are characterized by a high degree of connectivity or interdependence between variables" [8]. Rather thanexhibiting random behavior, most complex nonlinear systems will tend towards and manifest certain states more often, called
            "attractors." This leads to "Emergence,"which describes the order that arises from what on initial inspection appears to be disorder, firther, such emergence can arise from local and simple rules within the system [6].

            The difficult thing about emergence is that it is very hard in emergent systems to find the “root cause” of any problem. The positive side is that if you have negative cascades producing bad outcomes, it is also possible to have positive cascades producing good ones. Once you have a positive set of cultural cues, you can get a happy avalanche as productive influences feed on and reinforce one another

            Interesting to see how Damasio here resorts to what I think may amount to a shotgun approach. If you can change enough of the variable associated in a positive manner you can achieve a positive outcome. I am uncertain whether you can do this a easily or readily as that suggests. I wonder whether we do understand the nature of non-linear systems well enough to have any idea quite where to intervene even if we take a mutli-modal approach in an effort to create a “cascade” but it does perhaps provide an answer of a kind (maybe).

            I think there is almost some "universal laws" when dealing with an emergent system (I realize that is a very bold statement with no significant research that I am aware of at this time to back it up. I am purely basing it on two emergent systems, poverty and nervous system/pain, and seeing very striking similarities in how to interact with them create a more positive outcome. Yet one would normally not equate anything that pain and poverty should be similar in other then they are emergent systems.)


            I think there are universal laws or at least properties of such systems that can be identified such as periodicity, randomness etc and often there are stable states around which the system will oscillate for prolonged periods of time. Sometimes these can give an illusion of a stable linear condition, I think, which is one of the things I think we can forget as clinicians particularly if we indulge in a more mechanistic view that ignores or does not account for the body as a summation of many, many systems that goes through successive iterations and periodicities. I think actually Lederman speaks to this when he produced his recent(ish) paper that insisted we take a more systems/process orientated approach. I suspect he is nibbling at this carrot as well. I also think that Joel Bialosky is wrestling with this although the descriptive language of both is very different. As we have note dbefore language can effect our conception of what we are talking about and if this conversation did no more than give us a richer descriptive language that works with ambiguity and nuance I think we will be a step closer to being able to describe what we are really doing

            I like your current summary and think it is a good step in taking us forward, this is a poorly understood area and I know of very few physio who even consider this kind of material. Of those I know that do 95% are here.

            regards
            ANdy
            "Here is Edward Bear coming downstairs now, bump, bump, bump, on the back of his head behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there is another way, if only he could stop bumping for a moment and think of it." A.A. Milne

            Comment


            • #36
              Thanks Andy, these additions are very helpful. I'll need to read and re-read a few times to let them sink in and then let them percolate.

              You are right I don't want to get side tracked with the predictability as that is not the major discussion within this, but it is the wanting control that is more of an issue. And control will never be found in constituent parts as so many treatments tend to attempt (trigger points exactly come to my mind as well).
              Kory Zimney, PT, DPT

              http://koryzimney.blogspot.com

              "Study principles not methods, a mind that can grasp principles will create its own methods." - Gill

              "All truths are easy to understand once they are discovered; the point is to discover them." - Galileo Galilei

              Comment


              • #37
                I like your current summary and think it is a good step in taking us forward, this is a poorly understood area and I know of very few physio who even consider this kind of material. Of those I know that do 95% are here.
                realised I better clarify this, - it is a poorly understood area in healthcare and as best I can tell invisible in physiotherapy. Other areas such as physics and motor control have highly developed conceptions/understanding.

                ANdy
                "Here is Edward Bear coming downstairs now, bump, bump, bump, on the back of his head behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there is another way, if only he could stop bumping for a moment and think of it." A.A. Milne

                Comment


                • #38
                  Well, I have had a little vacation from this thread while off at CSM, but I don't want to let it die just yet. So lets continue on with breaking down some of the text from the book a little further.

                  For scientist this circumstance leads to what Turkheimer calls the “Gloomy Prospect.” There is no way to pin down and clarify causes of human behavior or trace the sources of this or that behavior. It is possible to show how emergent conditions, like poverty or single parenthood, can roughly affect big groups. It is of course possible to show correlations between one thing and another, and those correlations are valuable. But, it is hard or impossible to show how A causes B. Causation is obscured in the darkness of the Gloomy Prospect.
                  Can you say confirmation bias? This is Causes Confusion spelled out perfectly. It also points to why we need to get comfortable with some ambiguity with treating painful problems. Causation from constituent parts (trigger points, posture, stabilization, mobility, muscle balance, etc) is obscured in the darkness of the Gloomy Prospect. It also rings back to Norman Doidge's chapter on persistent pain - the Dark Side of Neuroplasticity.

                  An emergent nervous system (Body-Self Neuromatrix) has the capacity to produce an output of an emergent condition called pain. Factors from the constituent parts (cognitive, sensory, affective) of the Body-Self can contribute to this emergent condition.

                  That emergent condition (Pain) will have properties of the tenets of emergent systems.

                  Tenets of an emergent system:
                  1) They are nonlinear in nature. Even if some of the constituent parts in isolation are linear, once they are put into the emergent system they fall under the property of that emergent system and will become nonlinear.
                  2) No single constituent part can be responsible for the emergent system. The sum of the parts is always less then the product of the whole emergent system.

                  3) It is possible to show how emergent conditions can roughly affect large groups through correlations and those correlations have some limited value. But it is impossible to show how constituent part causes the emergent condition in any given individual, causation is obscured in the darkness of the Gloomy Prospect.
                  Kory Zimney, PT, DPT

                  http://koryzimney.blogspot.com

                  "Study principles not methods, a mind that can grasp principles will create its own methods." - Gill

                  "All truths are easy to understand once they are discovered; the point is to discover them." - Galileo Galilei

                  Comment


                  • #39
                    Well lets move on with statements from the book and get into the good stuff in regards to culture. I sort of jumped over it before and said I would get back to it, so here I am.

                    Fixate on whole cultures, not specific pieces of poverty. No specific intervention is going to turn around the life of a child or an adult in any consistent way. But if you can surround a person with a new culture, a different web of relationships, then they will absorb new habits of thought and behavior in ways you will never be able to measure or understand. And if you do surround that person with a new, enriching culture, then you had better keep surrounding them with it because if they slip back into a different culture, then most of the gains will fade away.
                    When dealing with emergent systems and the conditions that arise one needs to look at the whole culture and not specific pieces (constituent parts).

                    First I want to try and define culture, so I will keep it simple as that is what a simple therapist from Iowa normally does.

                    From Wikipedia - "Culture":
                    Culture (Latin: cultura, lit. "cultivation")[1] is a term that has many different inter-related meanings. However, the word "culture" is most commonly used in three basic senses:
                    • Excellence of taste in the fine arts and humanities, also known as high culture
                    • An integrated pattern of human knowledge, belief, and behavior that depends upon the capacity for symbolic thought and social learning
                    • The set of shared attitudes, values, goals, and practices that characterizes an institution, organization, or group

                    I don't think the first basic sense has much relevance to pain, but the second two very much so. This is where pain neuroscience education (Explain Pain) has to be involved in order to have any hope to assist in treating persistent pain problems over any long term basis. Unless we change the culture of a patients knowledge, beliefs and behavior about their understanding of persistent pain being a nervous system issue and not a tissue issue, I think we will be forever be treating the constituent parts and never get to the fundamental problem. When our treatment interventions are directed at specific tissues I think it will be very difficult for a patient to change to culture thinking of nervous system emergent system over constituent parts linear causation thinking. This creates a very dangerous road to travel during the treatment process if one chooses to treat constituent parts.

                    I understand treating the constituent parts can lead to many short term gains of function and pain. They can potentially reduce nociception. But, is our body not primarily a self healing and self correcting organism? Fall down skin your knee, wait a few weeks and viola it heals/corrects itself. Don't basically all tissues given adequate time and blood supply go through a healing process automatically baring significant pathology? I can potentially create a better environment for that healing: get improved blood flow to the area with movement, adequate stress to the tissues with graded exposure to help with proliferation and remodeling phases, limit risk for infection, etc. But it still heals itself on it's own whether I do anything or not. If you sprain your ankle it heals itself whether you take some NSAIDs or not. The NSAIDs may take away some nociceptive chemical input to reduce some suffering, but it does not change the healing. I also get that too much inflammation is not good for healing, but where is the demarcation line drawn of too much or too little, from normal to abnormal? Where is the demarcation line with TrPs, with posture, with muscle imbalances?

                    Again if we are treating constituent parts and not the culture how many patients show up a year or two latter for the same or possibly similar thing? Ever seen the carpel tunnel patient that also was a lateral epicondylitis patient maybe a shoulder impingement or cervical pain as well, or maybe first was on the right and know on the left? Dry needle the area, shoot it full of some cortisone, release some fascia, improve some muscle imbalances and we can see some short term gains but how often do they show up in year again maybe not at your clinic but somewhere else. Are we kidding ourselves when we treat these patients thinking we are getting them better? If we were getting them better, why is the persistent pain population currently around 116 million people according to the latest IOM report on Relieving Pain in America?

                    Is it hard to change culture, absolutely. No one ever said treating this patient population was easy. But I don't see any other way to make any lasting changes unless we can change the culture and that can only be done with knowledge of pain neuroscience.

                    The other portion of the culture is increased self-efficacy. A patient has to see that they are in control of the situation through movement and exercise to treat these conditions. Once they have absorbed these habits it is critical to keep them surrounded in a culture that supports this new culture or they will slip back and the gains fade away. Don't let them get confused because of an MRI report, or the latest fad on how to treat pain with this technique or pill or exercise device their social network has to support this new cultural thinking. This will be very difficult to do in our current social environment that is mostly biomedical in nature always searching for causes in constituent parts. We can not put a changed person back into the same culture and expect that change to be sustained, we have to change the environment as well.
                    Kory Zimney, PT, DPT

                    http://koryzimney.blogspot.com

                    "Study principles not methods, a mind that can grasp principles will create its own methods." - Gill

                    "All truths are easy to understand once they are discovered; the point is to discover them." - Galileo Galilei

                    Comment


                    • #40
                      Wonderful post Cory.

                      Watch a little daytime TV and you'll get a sense of what our culture has become, what it admires and what sort of arena we work within. Often, it has no relation to our personal take on reality but that's where we work, that's what we have to deal with and and that's what we must seek to understand rather than judge.

                      You're right, it's not easy.
                      Barrett L. Dorko

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                      • #41
                        Where Medicine Went Wrong: Rediscovering the Path to Complexity (Studies of Nonlinear Phenomena in Life Science) Bruce West

                        Where Medicine Went Wrong explores how the idea of an average value has been misapplied to medical phenomena, distorted understanding and lead to flawed medical decisions. Through new insights into the science of complexity, traditional physiology is replaced with fractal physiology, in which variability is more indicative of health than is an average. The capricious nature of physiological systems is made conceptually manageable by smoothing over fluctuations and thinking in terms of averages. But these variations in such aspects as heart rate, breathing and walking are much more susceptible to the early influence of disease than are averages. It may be useful to quote from the late Stephen Jay Gould's book Full House on the errant nature of averages: “… our culture encodes a strong bias either to neglect or ignore variation. We tend to focus instead on measures of central tendency, and as a result we make some terrible mistakes, often with considerable practical import.” Dr West has quantified this observation and make it useful for the diagnosis of disease

                        Sounds interesting and pertinent to this discussion. I would expect that it could be applied to pain as easy as any other system/disease process, unfortunately it is expensive but if you can dig it out of your library -


                        regards

                        ANdy
                        "Here is Edward Bear coming downstairs now, bump, bump, bump, on the back of his head behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there is another way, if only he could stop bumping for a moment and think of it." A.A. Milne

                        Comment


                        • #42
                          Andy thanks for posting this. (Karen any way of getting this one, you seem to have a way to find some of these:angel

                          I agree 100% this has a significant amount to do with pain.

                          An example I think of is with blood pressure.

                          We have studied blood pressure as it is a valuable measurement. We have a reliable and valid testing method with it. We know with in ranges what is normal, hypotensive, borderline hypertensive, hypertensive needing treatment, and more emergent hypertensive condition. These ranges vary based on age, sex, whether you are pregnant or not. But even with all this knowledge we know any one measurement of blood pressure is worthless. We have to take it multiple times over various times to see what type of problem it might be and if it may need treatment.

                          Compare to our measurement of posture, muscle imbalances, stability, trigger points and others. How great is the reliability and validity of these tests? Do we have strict ranges of measurements that define various levels and those that need immediate treatment and those that should be just watched over time? Do we know if these ranges change based on age, sex, race or other variables? Do we just measure once or do we use multiple readings over several occasions to see if just some anomaly or truly a condition worth treating?

                          They obviously don't match up very well at all compared to treating and understanding ones blood pressure. Yet we even treat these conditions almost more aggressively then we do blood pressure. If someone's blood pressure is creeping up we have them do some simple lifestyle changes with diet and add some basic exercise. With posture, muscle imbalances, stability, trigger points we immediately go into hard core treatment in attempt to alleviate them instantly as if they are life threatening.

                          It seems as if these have been overly medicalized and a true sign where medicine went wrong.
                          Kory Zimney, PT, DPT

                          http://koryzimney.blogspot.com

                          "Study principles not methods, a mind that can grasp principles will create its own methods." - Gill

                          "All truths are easy to understand once they are discovered; the point is to discover them." - Galileo Galilei

                          Comment


                          • #43
                            Kory, this is an excellent example. I can hear the PTs that base their treatments on trigger points and muscle imbalances now "I don't care what the evidence says, I can feel the trigger point being released!"
                            Rob Willcott Physiotherapist

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                            • #44
                              advantage1,

                              For that therapist that feels that "trigger point being released" have them read this the cognitive dissonance will be fun to watch and see them fight it. They will still most likely hold on to their beliefs, but it will be fun to see them struggle with it for awhile trying to hold on to their reality that was never really there in the first place.

                              As they step into the bright light of what science reveals to us, they will squint as you pull them out of the dark and struggle with the major shift and most likely run back into the darkness where they feel comfortable. But that struggle is fun to watch, if only they could stay in the light long enough to let their eyes adjust and die like many here have.
                              Kory Zimney, PT, DPT

                              http://koryzimney.blogspot.com

                              "Study principles not methods, a mind that can grasp principles will create its own methods." - Gill

                              "All truths are easy to understand once they are discovered; the point is to discover them." - Galileo Galilei

                              Comment


                              • #45
                                Kory the prologue of West's book alone is worth a read


                                regards

                                ANdy
                                "Here is Edward Bear coming downstairs now, bump, bump, bump, on the back of his head behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there is another way, if only he could stop bumping for a moment and think of it." A.A. Milne

                                Comment

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