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  • #46
    Thanks Diane,

    I found this comment from you to be very useful too.

    It (the nervous system) finds most things that fall under the heading "treatment" threatening. It wants the world to know that none of that stuff is REALLY necessary. It wants the world to know that simple human primate social grooming will do. But that, alas, human primate social grooming without use of a good construct doesn't get any treatment interaction very far, because that human bit, prefrontal cortex etc, must be fed by a good story, so that the primate bits, hindbrain etc., can get the physically-provided, non-sexualized, primate social grooming they are starved for, i.e., kinesthetic brain food, in sufficient and necessary amounts to assist them to change. Also, alas, that human primate social grooming without first being lubricated by a good construct/"story" doesn't make it very far out into the world either, in written form.
    Given what follows here, do you think I've interpreted you comment correctly?
    The message I get is that we don't need fancy, specific manual therapy interventions. They feed the therapists ego more than anything else. Manual therapy serves no other purpose other than helping the non-conscious hindbrain sort out its top-down management of incoming info. So in theory, any physical contact should do (assuming it is non-threatening). But in order for this to occur, the conscious mind needs to be fed a good story. For you, you use DNM because it is a better story than those offered by the rest of the therapy community.

    Comment


    • #47
      At least to my own brain, it is.
      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


      • #48
        Come to think of it, one of the main reasons I became disappointed in the U of Alberta pain management course, and dropped out last June, was because although a variety of "pain theories" by various leading pain researchers was presented, none of them was the neuromatrix model. In other words, all of them had nociception as a foundation for pain. Only the neuromatrix model does not. But it was not presented. It was deliberately ignored. I found that deeply upsetting.

        There was no acknowledgement of how revolutionary it is, or how important its implications for those among us who do not use drugs or surgery or mesodermalist (bottom-up) concepts to treat patients.

        I tried to discuss this (among other things) with the instructor, but got nowhere, decided there was nothing new to learn there after all, felt I was gradually being herded into a biomedical corner and a traditional role for PT, that of handmaiden to the physician, and left the program. Even though the emphasis was interdisciplinary, there was clearly going to be no change in the mindset, so it would have been playing "let's pretend we're all equal on the same page" - it seemed to me there was going to be nothing really cutting edge about the program, so, wanting to save whatever might be left of (whatever size) mental hard drive I owned, decided to pursue independent, 'university of life' studies instead.

        Our profession will go nowhere if it stays in the same old rut regarding pain science that it's been in all along. It has to recognize the potential to move over into a different... for lack of a better word, pain paradigm - the one that is, from a nervous system POV, "top-down", or at the very least, multiply processing. The members in it will stay asleep, will continue to vegetate in the mesodermalist coma we were put into in school, dealing with the same contradictions and headbangers and impasses we have had to deal with throughout the Cartesian dichotomy era of the last 400 years, but shouldn't have to anymore.

        "Rene Descartes was very very smart, but as it turned out, he was wrong." - Lorimer Moseley.
        Last edited by Diane; 28-03-2012, 11:40 AM.
        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


        • #49
          I thought I would attach a handout I use with patients sometimes as an adjunct to pain/injury education I give patients, it may be helpful to others and seems to fit into this thread.
          Attached Files
          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


          • #50
            Sorry if I am a little out of synch with the rest of this thread. I don't get to come to this site that often, so I often do hit and run posts and then am not around to reply to questions or comments. I thin this appears rude and I don't mean to be. So I'm going to reply to the comments made about my earlier posts, even though it might mean going backwards.

            Steve-What got switched off in the cognitive science view for the lady in the armbar? I would say the "cognitive" part. Pride, expectations, adrenaline, all play their part in people making bad decisions. I'm sure she felt it, she just decided that other things were more important.

            Bas-Yes, I understand and stated that Pain is in the Brain, my point was that a whole lot more is going on than just what is happenig in the brain.

            Kory-I understand your point. I mostly agree with it, we like to be able to point at something we can see and say "there is the problem" while it may or may not have any real significance. This is especially true with regards to pain. It has been stated here, ad nauseum, that pain does not equate to harm, but this works both ways. Thing can be harmful without causing pain. I understand the difficulty in trying to assign specific causes to complex systems, and humans are certainly complex systems. Chaos theory, Heisenberg and others can explain this better than I can, but this doesn't mean that we can't make intelligent informed decisions, guesses, at what is harmful and helpful, and this is true in regards to biomechanics, movement, and physics as they relate to the human body.

            The example you gave is that speeding doesn't mean you will crash and not speeding doesn't mean you won't. That is true, that doesn't mean that we shouldn't advise people against speeding, that we shouldn't check our tires and alignment, make sure the brakes are working or taking other measures. A person may not be in pain, but if they are functioning near the limits of their adaptive potential,they are closer to being injured, probably closer to being in pain. We can identify and change some of those factors, raise their functional limits and/or lower the level they have to work at. We can do this using both ectodermal and mesodermal methods. Allowing free expression of movement and increasing strength and endurance for example, they both have their place.

            I am not sure if some people here place no value in the latter, or they are simply focused on pain and the order of importance of these different factors.

            Comment


            • #51
              I wouldn't disagree with any of that, Randy.
              On the preventing injury thing....look herehttps://m.facebook.com/?refsrc=http%...ser=1299482045
              (not sure if the link will work)


              [From my iPhone, please excuse typing]
              Jason Silvernail DPT, DSc, FAAOMPT
              Board-Certified in Orthopedic Physical Therapy
              Fellowship-Trained in Orthopedic Manual Therapy

              Certified Strength and Conditioning Specialist


              The views expressed in this entry are those of the author alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

              Comment


              • #52
                Eric said:
                Nociception is part and parsel of human physiology just as are their body parts therefore it is always clinically relevant. Is there any clinical way of determining its role greater than other part of an individuals physiology, no prob not. It is one of the many inputs onto our CNS that informs of its interoceptive status of our being.
                Yes I agree,

                Luke said:
                A true positive with complete pain relief from a double-blind, placebo controlled diagnostic block tells us a lot about the relevance of local nociceptive afferents to a regional pain experience.
                Luke,
                To my thinking the fact that it is possible to shut down pain entirely via regional anaesthetic block, does not allow me to assign a greater value to the contribution of nociception to a total pain output in any given client. It only tells me that it is possible for nociception to be the dominant contributor to the pain output. But i dont think i can ever know if it is a dominant factor in a real patient. You said:
                I think a large proportion of my patients present with clinically relevant nociception
                This sounds like you're having a guess at breaking down the total pain output in terms of relative input of nociception vs other factors. If this is what you are doing, how do you estimate the relative inputs of each?

                Comment


                • #53
                  Patrick,
                  It only tells me that it is possible for nociception to be the dominant contributor to the pain output.
                  Yes. Exactly the point.

                  This sounds like you're having a guess at breaking down the total pain output in terms of relative input of nociception vs other factors.
                  Yes, I do think that a diagnosis, or at least a differential diagnosis, is an important responsibility before providing treatment.

                  However, like Barrett, I find the most reasonable approach for pain complaints is an essential diagnosis based on the origins of pain (see post 2). If a patient presents complaining of a pinching pain when they approach full Cx rot in one direction I think it is more than a guess to conclude that there is a relative difference in physiological mechanisms when compared with a central pain issue like 'fibromyalgia'.

                  Although on our part it's probably a manual therapist-centric conclusion, I agree that for many patients "touch is important. It helps the brain sort out its top-down management". But if you accept that a warm, supportive afferent input effects central pain processes then you have to acknowledge the obverse: a barrage of noxious afferent input effects central pain processes. You can't have it both ways.

                  Sure, address top-down central management. But if it's relevant, why not also consider bottom-up processes? Warm and supportive touch when the "critter brain that is freaked out" by mechanical deformation of a tissue beyond its tolerance might certainly lead to comfort, but so can an instinctive corrective movement (or even a lucky passive one) that resolves the mechanical deformation and the resulting nociceptive barrage.
                  Last edited by Luke Rickards; 29-03-2012, 12:54 PM.
                  Luke Rickards
                  Osteopath

                  Comment


                  • #54
                    I'm with Luke here. The history is crucial to making an educated estimation (not an exact determination) of the origin of pain via mechanism, and I would say the vast majority of my patients have nociception as the main driver if their pain experience.


                    [From my iPhone, please excuse typing]
                    Jason Silvernail DPT, DSc, FAAOMPT
                    Board-Certified in Orthopedic Physical Therapy
                    Fellowship-Trained in Orthopedic Manual Therapy

                    Certified Strength and Conditioning Specialist


                    The views expressed in this entry are those of the author alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

                    Comment


                    • #55
                      Kory,

                      I really like your education Pain vs Injury document. Is it all right if I use it as well....keeping your name on it as author of course.

                      Evan

                      Comment


                      • #56
                        Originally posted by eburkedpt View Post
                        Kory,

                        I really like your education Pain vs Injury document. Is it all right if I use it as well....keeping your name on it as author of course.

                        Evan
                        Thanks Evan. Yes, please feel free to use.
                        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


                        • #57
                          Originally posted by Randy Dixon View Post
                          Kory-I understand your point. I mostly agree with it, we like to be able to point at something we can see and say "there is the problem" while it may or may not have any real significance. This is especially true with regards to pain. It has been stated here, ad nauseum, that pain does not equate to harm, but this works both ways. Thing can be harmful without causing pain. I understand the difficulty in trying to assign specific causes to complex systems, and humans are certainly complex systems. Chaos theory, Heisenberg and others can explain this better than I can, but this doesn't mean that we can't make intelligent informed decisions, guesses, at what is harmful and helpful, and this is true in regards to biomechanics, movement, and physics as they relate to the human body.
                          Yes, I agree we can make intelligent informed decisions, SWAGs if you will (Scientific Wild Ass Guess). But I think we need to be remember they are just that. Often we here for example: "If we improve your posture so it is not forward bent your acromion won't impinge the humerus on elevation of the shoulder to get over your shoulder pain." I agree some shoulder exercises and thoracic mobility will often times help these individuals. I still would probably do some of the same things as I did previously when I gave a patient this explanation. And many times they would get better, but when I think back, I don't think their posture ever really changed much.

                          Originally posted by Randy Dixon View Post
                          The example you gave is that speeding doesn't mean you will crash and not speeding doesn't mean you won't. That is true, that doesn't mean that we shouldn't advise people against speeding, that we shouldn't check our tires and alignment, make sure the brakes are working or taking other measures. A person may not be in pain, but if they are functioning near the limits of their adaptive potential,they are closer to being injured, probably closer to being in pain. We can identify and change some of those factors, raise their functional limits and/or lower the level they have to work at. We can do this using both ectodermal and mesodermal methods. Allowing free expression of movement and increasing strength and endurance for example, they both have their place.

                          I am not sure if some people here place no value in the latter, or they are simply focused on pain and the order of importance of these different factors.
                          Could you give an example of why you don't think some people place no value in the latter? I think I give it value, but just as much as I once did, and I see what potential value it has with a different understanding from before.

                          When you are saying they are functioning near the limits of their adaptive potential, can you give an example? If a person's max lifting ability is 80# and I have them lift 75# boxes all day, I would agree they are at greater risk for injury then the person that can lift 200#. Because they don't have "enough" thoracic extension or they pronate 2 degrees more then normal, then I don't think I agree they are at greater risk.
                          Last edited by zimney3pt; 29-03-2012, 08:03 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


                          • #58
                            SWAGs are like stones tossed into a pool. I will toss one in from my side, the orthopod, from theirs, the GP from theirs, the masseur from theirs and so on. Each one often using different, profession specific, language and all stirring up the waters just a little bit more. The first one makes a nice pattern of concentric ripples, the second interfers a little and again and again and at some point chaos. It is harder to stand on the edge and choose to not throw the stone in. Even when you are feeling confident you have it right - because of the risk of having it wrong. Patients with multiple conflicting diagnoses are hard work. The iatrogenics of language.
                            I think it stems from naming confering assumed understanding and helping the patient to buy in to your solution. I can name it - I can fix it.
                            Vague and right every time, does no harm - thats my two cents!
                            Kind thoughts,
                            Steve
                            Peering over the shoulders of giants.

                            Know pain. Know gain.

                            Comment


                            • #59
                              Steve great metaphor. It has been termed a cauldron before when we think about what we toss into a patient's neuromatrix.

                              We think our SWAG was a simple stone and we think, what's the harm, it is only this.

                              Only if only we could see that all the stones has created this.
                              Last edited by zimney3pt; 29-03-2012, 07:17 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


                              • #60
                                Thanks Luke,
                                Please bear with me... I'm not trying to be argumentative. Just looking for better understanding.

                                Luke said:
                                If a patient presents complaining of a pinching pain when they approach full Cx rot in one direction I think it is more than a guess to conclude that there is a relative difference in physiological mechanisms when compared with a central pain issue like 'fibromyalgia'.
                                Jason said:
                                When a patient with radiating arm pain comes in and I get them supine and manually glide their neck so as to open the foraminal opening on that side and the patient reports instant change for the better, are you saying that is due only to a central effect such as placebo? If that were true, wouldn't it not matter if I did the opposite and "closed down" that side? I've seen people throught my 11 year career (as of this writing) respond in just such an immediate and positive way in many situations. I grant its possible that it's always expectancy, but the model we're working with doesn't seem to point that direction.
                                http://www.somasimple.com/forums/sho...8&postcount=39

                                Both these examples, I would argue are still guesses if you strictly adhere to the neuromatrix model. If it is 'more than a guess' as you suggest, it implies that you 'know' what is the driver of a client's pain. My confusion is this... the reasoning you and Jason present in the examples above make sense clinically in terms of cause and effect. And i dont hide from the fact that i use this reasoning everyday. But is this not the same as Cartesian thinking? Isnt this the type of thinking you are trying to change? What is the point in having a model like the neuromatrix if we simply project our own (granted informed) opinions onto it? If as a model, the neuromatrix accommodates both your bottom up reasoning as described above, and also strictly top-down reasoning, does it mean the model itself is faulty? Or if not faulty, does it make it unusable? i.e by explaining everything it explains nothing.

                                This brings me back to my original comment at the start of this thread:
                                the mesoderm's contribution to the output of pain is irrelevant, accept for those circumstances when it is relevant
                                Perhaps i should have said "As Therapists adhering to the neuromatrix model we argue that the mesoderm's contribution to the output of pain is indeterminate, accept for those circumstances when we think it is"

                                Comment

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