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  • #16
    Good points Stve.

    I was mulling this over:
    Patrick, when a patient can SEE the swelling in the foot/knee/hand or the discoloration, when there is inflammation and heat, when there is joint noise, or a brace, stitches etc etc, there are clear perceptions in the brain that "something" is going on and thus - barring any higher priorities - the brain's continued attention to the perceived threat.

    This alone makes it harder - not impossible - for the system to reduce the threat perception and response (pain).
    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

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    • #17
      Patrick I like you comments I think they are cutting to the heart of the matter. This is how I like to think of it. The perception of pain is not dependent on nociception but changes in levels of nociception can influence the perception of pain.

      1) Nociception is always present even in non-pathological states.

      2) The CNS responds to changes in nociception information nonconsciously. That shift you did in your chair just now while reading this was due in part to nociception.

      3) The changes higher level centers respond to is due to changes in baseline levels at lower nonconscious centers. Sufficient nociception above the levels higher centers are accustom to given the context can drastically alter pain perceptions.

      4) Moods, emotions and higher center states can increase/decrease the awareness and susceptibility of higher centers generating a pain perception (i.e. descending control) based on a stable flow of nociceptive information from below.

      5) Even in states where tissues are damaged, inflamed, it is always possible (in most nervous systems) to achieve some level of descending control through contextual modulation and movement.

      I for one try not separate useful and un-useful pain states. The utility of the information lies in the persons ability to be informed by such information and make appropriate decisions and actions. Which is the heart of the issue why patients are there to see us. We are there to guide them through acute trauma or a persistent pain state and help them make sense of their reorganizing bodies and minds so they can get back to tackling the bigger things in life their minds love to do.

      Eric
      Last edited by Milehigh; 26-03-2012, 04:04 PM.
      --------------------------------------------------------------
      Body is imbued with mind, and mind is embodied.

      Comment


      • #18
        Agreed Eric, when I use the idea of purposeful and purposeless pain it is a simplification to aid the patient to alter their perception of threat. And all simplifications are risky.

        I noticed this today through lunchtime reading of Deric Bownd's Mindblog. The concept is the neural democracy model and kind of explains some of this paradox.
        http://edge.org/response-detail/2943...ul-explanation
        As ever the idea mine that is The Edge question of the Year comes up with more nuggets of Wow!
        So that makes my a lobbyist? Uh! I must go and wash....
        Kind thoughts
        Steve
        Peering over the shoulders of giants.

        Know pain. Know gain.

        Comment


        • #19
          Typically our brains interpretation of threat is pretty accurate and consistent with tissue damage/inflammation in the acute stage. Usually in a properly functioning nervous system, the threat level decreases as tissue healing occurs. BUT.....our healthcare systems, patient fears, beliefs, expectations, can mess up this process and upregulate our threat level, and our pain diverges from a relationship with tissues.

          In a simplified broad sense, the more chronic the pain is the less correlation it has with the tissues. This is just my opinion and there are many examples to contradict this, but it's how I simplify it for my patients.

          Comment


          • #20
            Originally posted by Josh View Post
            Typically our brains interpretation of threat is pretty accurate and consistent with tissue damage/inflammation in the acute stage.
            I don't necessarily agree with this statement. I think this largely depends on our priori of previous experiences with pain and their contexts. There are cases on both ends of the spectrum where initially can be well controlled and totally out of control regardless of the tissue damage. Some great examples are listed above. Clinically I have found very few (if any) special tests or diagnostic work-up that can determine the extent of tissue damage. The closest would be the far from perfect knee ligamentous testing.
            --------------------------------------------------------------
            Body is imbued with mind, and mind is embodied.

            Comment


            • #21
              Nice discussion of the entire topic in this new interview with David Butler.
              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


              • #22
                Originally posted by Milehigh View Post
                Patrick I like you comments I think they are cutting to the heart of the matter. This is how I like to think of it. The perception of pain is not dependent on nociception but changes in levels of nociception can influence the perception of pain.
                Eric
                Thanks Eric,
                I think your comment clarified the way I've been defining sufficiency. I was stuck thinking that if nociception is not sufficient to produce pain, it's influence could theoretically be reasoned away. But when I look at it as you've stated it

                "changes in levels of nociception can influence the perception of pain"
                I see that nociception on it's own is not sufficient to produce pain, but it still has an influence, and the influence may be more or less significant depending on how the CNS processes it amongst all the other contributing factors.

                I still think though, that implicit in comments that point to difficulties in achieving a reduction in pain for scenarios in which there is healing or repair is a notion that there exists some degree of linearity between nociception and pain. Eg.

                Luke said
                "I think a large proportion of my patients present with clinically relevant nociception"
                Barrett said:
                "In my experience, knee pain often contains a good deal of mesodermal irritation and problems that require healing or repair, thus ideomotion is unlikely to help as much as it might elsewhere."
                I don't believe that Luke or Barrett were implying that nociception causes pain, but when I get up in front of my colleagues in a few weeks to attempt to swing their thinking away from mesodermal practices, I can see some of them throwing these types of arguments at me. So I guess I'm playing devils advocate a bit here.

                Comment


                • #23
                  Ok I would love to chime in here because Patrick is asking questions that are right up my alley. I hope that I am aligned with the thread.

                  So supposing I roll my ankle off a rock during a hike (which I definitely have done). In the first moment I remember feeling not much pain but a hell of a lot o surprise. Then seconds after I felt the pain happen. Odd that if tissue was torn it should take a moment of "realization" that I just mashed my ankle to bring pain to conscious realization.

                  Point: what within the nervous system decides to create swelling? Is this a placebo illusion too? Obviously when that oh so familiar streak of black and blue happens along the lateral ankle it is clear that tissue has been torn. I find it very difficult to articulate the thoughts that my awareness sees but my learned knowledge can only compartmentalize. BUT, why should pain and swelling be differentiated outputs? Why should a multitude of processes be separated from the experience/perception of pain when it seems like a continuous whole, meaning... limping, fearful thought processes about the ankle AND uneven ground, basketball of an ankle...
                  I am struggling to get these questions out in a way that makes sense on a holistic way because so much is included in each question.

                  Let me put it this way:

                  Massive ankle sprain...black and blue, serious swelling. For whatever reason IT HURTS!!! (top down or bottom up)

                  DNM is not going to fix damage to the tissue.
                  ART is not going to fix the damage and if employed here may really piss off the patient.
                  Mental games are not going to fix the fact that I HAVE TO limp or I am going to make it very challenging to heal TISSUE DAMAGE which is directly linked to my brain's decision to make walking a sucky event.

                  I understand war might make the damage to my ankle a secondary situation and make survival a first priority thereby making pain output unnecessary at the time. But, for most normally wired humans we are going to FEEL IT SOON.

                  I have to get these thoughts out of my system..soooo

                  WHere does posture and high heels come into play? If posture is irrelevant to pain, why don't we suggest high heels to ankle sprain victims?
                  What effect can increasing bloodflow to an injured area have? (i think most deep tissue at best just adds blood and oxygen to an area). I am trying to understand why deep tissue therapies area often discounted on SS.
                  How does graded movement exposure to a massively damaged ankle actually help heal an ankle? In reality, I think damage is damage period. It will never be the same EVER AGAIN! Then WHy should our movement ever be the same as prior to injury and why should our therapy be designed to that end?

                  Lastly (for now) What is the mission statement of SomaSimple? It is so easy for me read the posts here and think that my many tools are for nothing as they are designed to effect the mesoderm, allegedly.
                  Can anyone help me to connect these dots within my questions to see what I think Patrick is getting at and what I see so many debates wandering on about here?

                  I don't think I am a dead man yet but wandering in a purgatory waiting for someone to truly and finally raze my mezzo, or put 2 and 2 together. either way I am ready to go.

                  Comment


                  • #24
                    Hi Nathan,
                    Originally posted by zendogg View Post
                    Point: what within the nervous system decides to create swelling? Is this a placebo illusion too? Obviously when that oh so familiar streak of black and blue happens along the lateral ankle it is clear that tissue has been torn.
                    Um... capillaries are torn, and leak blood out into skin, which one can see. Bruising doesn't automatically mean that "tissue" has been torn, if by "tissue" you mean, something structural.

                    why should pain and swelling be differentiated outputs? Why should a multitude of processes be separated from the experience/perception of pain when it seems like a continuous whole, meaning... limping, fearful thought processes about the ankle AND uneven ground, basketball of an ankle...
                    On the contrary, the illusion of perception, and of conception, is that they all get conflated into each other.


                    Massive ankle sprain...black and blue, serious swelling. For whatever reason IT HURTS!!! (top down or bottom up)
                    Yes, it usually does. But remember the caveat - whatever the brain decides to output depends entirely on context.

                    DNM is not going to fix damage to the tissue.
                    Of course not. But who said that tissue was really damaged?
                    Swelling is an output of the nervous system (and nervous system includes more than only brain, lest we forget). Brain can trump nervous system however. Yes, it can. It can inhibit visceral afferents which have told the vessels in the area to dilate, a pretty automatic response to nerves being jerked around, not just tissue being jerked around. Interoception and autonomic outflow can be conditioned, then de-conditioned, then re-conditioned, by operant conditioning, or non-conscious "learning".

                    ART is not going to fix the damage and if employed here may really piss off the patient.
                    Mental games are not going to fix the fact that I HAVE TO limp or I am going to make it very challenging to heal TISSUE DAMAGE which is directly linked to my brain's decision to make walking a sucky event.
                    But oddly, if you just slap kinesiotape over stuff, the limp can disappear entirely. If the "tissue" were "damaged", how would something as stretchy as kinesiotape be able to help the pain and limp?

                    Lastly (for now) What is the mission statement of SomaSimple?
                    It's whatever it is. There isn't a "mission statement", SomaSimple is a place to talk. Whatever Bernard had in mind when he developed it. It's a safe place to deconstruct nonsense.

                    It is so easy for me read the posts here and think that my many tools are for nothing as they are designed to effect the mesoderm, allegedly.
                    You got it.

                    Can anyone help me to connect these dots within my questions to see what I think Patrick is getting at and what I see so many debates wandering on about here?

                    I don't think I am a dead man yet but wandering in a purgatory waiting for someone to truly and finally raze my mezzo, or put 2 and 2 together. either way I am ready to go.
                    It's good to see people thinking hard. :angel::thumbs_up
                    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
                      Quote:
                      Massive ankle sprain...black and blue, serious swelling. For whatever reason IT HURTS!!! (top down or bottom up)
                      Yes, it usually does. But remember the caveat - whatever the brain decides to output depends entirely on context.
                      If I hear you correctly, I am assuming only vascular damage has occurred, no? You do not think that it is possible that I just ripped the talofibular ligaments? Would this not destabilize the functional unit enough to necessitate a limp if for nothing else than to give the system time enough to decide what recruitment patterns it finds safest and effective for locomotion?

                      Also, context for most of my clients does not involve serious adrenaline inducing fear. They have just rolled their ankle and on top of everything else they are stressed about, now they can't walk.

                      Quote:
                      ART is not going to fix the damage and if employed here may really piss off the patient.
                      Mental games are not going to fix the fact that I HAVE TO limp or I am going to make it very challenging to heal TISSUE DAMAGE which is directly linked to my brain's decision to make walking a sucky event.
                      But oddly, if you just slap kinesiotape over stuff, the limp can disappear entirely. If the "tissue" were "damaged", how would something as stretchy as kinesiotape be able to help the pain and limp?
                      When? 1 day after the sprain? 6 months after the sprain? I understand each time frame to have its relative effect on the brain's perception of the situation.

                      The question which I still have not seen answered directly is about tissue damage.
                      !) has an ankle sprain torn a muscle, tendon, ligament? I guess no one has ever decidedly imaged a before and after? I say that because no one seems to tackle by way of a direct answer that bleeding is occurring, therefore something got broken.
                      2) IF IF IF Tissue has been damaged (=muscle, tendon, ligament or even nerve) then what place does physical therapy serve?
                      3) I totally get that if A) the body has miraculously resolved the damage that it should be able to return to all functionality, but, B) if a pain groove has been worn into the nervous system a skillful intervention that reduces that groove is warranted. How much should be dealing with the honest to goodness tissue damage and how much should be dedicated to avoidance issue? (I know these can't be answered directly in terms of an A-Z protocol but I am hoping that someone sees the underlying question of tissue damage vs. threat avoidance strategies). And C) I would love somebody to comment on trying to restore function to a system that has modified itself to be able to deal with an unreconcilable situation such as a severed ligament as it pertains to locomotion. wouldn't it be best to add "strength" to this most unusual asymmetrical choice the body has made to cope with missing ligaments and therefore muscular leverage?
                      Last edited by zendogg; 27-03-2012, 10:04 AM.

                      Comment


                      • #26
                        PS
                        Diane,
                        I realize now that I have made a functional mental error with respect to how and why I am phrasing my questions as they are.
                        I have been presuming that you are here to defend DNM as the answer to the pain equation. I see that is a very separate topic that needs direct questioning for each situation proposed. My fault on that one.
                        Opposite side of the coin is that I am trying to figure out what techniques that I have paid big bucks for over the years are actually going to help in the clinic beyond being placeboic or perhaps, at best, instagatory of blood flow. AY caramba.

                        Thing is, my schedule is fairly full. The wretched part is I don't have the explanation for why if you get my meaning. What the hell did I just do to that guy who's hip had been killing him for 6 months (first session success- the worst session of all for the ego) and now can walk pain free?

                        Thank you all again for learning a new way of presenting what you have already groked many times before.
                        Last edited by zendogg; 27-03-2012, 09:56 AM.

                        Comment


                        • #27
                          I am trying to figure out what techniques that I have paid big bucks for over the years are actually going to help in the clinic
                          zendog,

                          I think you'll find that it is the explanations you've paid for rather than the techniques that are more or less helpful in your clinical life.
                          Luke Rickards
                          Osteopath

                          Comment


                          • #28
                            My answers for what its worth....(which might not be very much)

                            The question which I still have not seen answered directly is about tissue damage.
                            !) has an ankle sprain torn a muscle, tendon, ligament?
                            some have i'm sure

                            2) IF IF IF Tissue has been damaged (=muscle, tendon, ligament or even nerve) then what place does physical therapy serve?
                            guide, educator, graded exposure and stressing tissues in appropriate way to get best healing.

                            3) I totally get that if A) the body has miraculously resolved the damage that it should be able to return to all functionality, but, B) if a pain groove has been worn into the nervous system a skillful intervention that reduces that groove is warranted. How much should be dealing with the honest to goodness tissue damage and how much should be dedicated to avoidance issue? (I know these can't be answered directly in terms of an A-Z protocol but I am hoping that someone sees the underlying question of tissue damage vs. threat avoidance strategies). And C) I would love somebody to comment on trying to restore function to a system that has modified itself to be able to deal with an unreconcilable situation such as a severed ligament as it pertains to locomotion. wouldn't it be best to add "strength" to this most unusual asymmetrical choice the body has made to cope with missing ligaments and therefore muscular leverage?
                            B) who knows, everyone is different, bit of both I expect.

                            C) Getting issues healthy is a good thing I'm sure, why not.
                            Last edited by Sheffphysio; 27-03-2012, 11:00 AM.
                            Dave

                            Comment


                            • #29
                              I think what is being discussed is one of the things that many people find confusing about the whole pain dynamic and the way it is viewed here on this site. Yes, pain is a subjective thing that is the brains response to perceived threat which doesn't have to be a real threat, this is often the focus for many people on this site, yet there are also real threats and Physical Therapy and other healthcare providers also have to deal with these real threats, pathologies and injuries that require more than just trying to reduce the perceived threat.

                              I look at it this way. If I place someone in an arm bar, blocking their elbow and hyperextending it, it is true that the pain they are experiencing is purely subjective, their brain can either perceive a threat and create pain from this nociceptive input or it can ignore the threat, not perceive a threat and not create pain. From the pain perspective often presented here, what I do to that arm as the person cranking on it doesn't matter, all that matters is how the other persons brain perceives it. However, having been on the other end of an arm bar, I can attest that it really does matter what that other person does to the arm. This is the interaction between real threat and perceived threat.

                              This interaction also occurs in the clinical setting and the question becomes, can we identify and do something about the real threat. That seems to be where the differences of opinion lie. Some people feel that nothing can be done, that the body is too complex to understand the real source of the threat or that healing can't be helped by anything we do, others think that we can actually identify the source and help the healing process. This becomes particularly problematic when we are talking about things less obvious. "Real Threats" are a problem beyond the pain that may result from them, we all agree on this I think, but is a biomechanical fault a "real threat", can it even be considered a fault? My feeling is that oftentimes the answer is yes, just like the case of my armbar example we can sometimes identify problems that are creating nociception, which may or may not be causing pain, and that we can correct. That isn't the prevailing opinion here though.

                              Comment


                              • #30
                                Zenndog,
                                What we learn at college is the confidence, the chutzpah and pizazz! To take charge, calm, advise, direct and set free. Check Benedetti on the Doctor/Patient interaction.

                                I am not a techy bloke. I can get in a right state trying to get through some Windows self-diagnostic and be stuck tring to reconfigure a broadband router. I call up the tech guy or gal they take remote control, ask a few questions, the mouse pointer moves and drop downs happen and a few subroutines are run and hey presto I am reconfigured!

                                You have learned your competancies - it is just dressed up in the meso language that your patients will mostly ubderstand/expect. See behind the curtain how the magician of the brain really does its tricks!

                                Personally I see that the ligamentously ruined ankle should proprioceptively and nociceptively inform the brain of danger and the brain output is pain and the behavioural response is to limp. How active is ligamentous integrity in normal walking? Surely the first line of control is muscular. So it is feasible that the top down is just taking precautions - muscular control is working so lets walk carefully because we don't want to risk an inversion incident just now.

                                My question is what thread should I read to get caught up with the top down regulation of swelling because my head is still in the torn cell walls spill out prostaglandins and triggers the cascade which feels very local, tissue and meso. Guide me....
                                Kind thoughts,
                                Steve
                                Peering over the shoulders of giants.

                                Know pain. Know gain.

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