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  • CT Is less always more??

    I'm still juggling a couple of concepts. Descending Modulation and Descending noxious inhibitory control (DNIC), particularly within the context of providing manual therapy.

    Moseley said:
    In conclusion, I have one beef and one take-home message: My beef is that I reckon DINC was called DINC by people who thought if it modulates pain it must be by modulating nociception. I would predict if the main mechanism was at the dorsal horn, or even the thalamus, it would not have its greatest effect when the second stimulus is on the opposite foot and it would not be so easily modulated by cognitive factors. Happy to be debated on this point of course.* My take-home message is that if you have a sore finger, it would seem more sensible to stand on your toe than bite your lip.
    http://bodyinmind.org/descending-inh...xious-control/
    I said:
    So the question becomes, do we rule out the use of these (heavy/aggressive) interventions on an 'operator' assumption that the intervention is damaging to nerve (or other) tissue nociceptive? Or do we trust our clients nervous system's ability to 'handle' the intervention let us know what it needs(interactor model?), and use these interventions for clients who find them beneficial?
    http://www.somasimple.com/forums/sho...6&postcount=13
    Why not let our clients tell us what they think they need as far as treatment goes?

    Barrett said:
    When we decide that a patient's verbiage means something or that it will result in something we are asking for trouble.http://www.somasimple.com/forums/sho...74&postcount=7
    Can you expand on this Barrett? Are you saying that the non-conscious mind knows better than the conscious mind? If a minimal approach is always used we assume that such an approach is always sufficient. If not, the assumption is that it's limited benefits outweigh the risks of a more aggressive approach. The risk, in this context, is gains in efficiency of the nociceptive system, and an assumed increased risk for future pain problems. Moseley seems to be saying that DNIC is not really related to nociception. So perhaps the risk of up regulating the nociceptive system should not be a concern?

    My question is, who are we to judge if an intervention causes nociception? And how can we assign value to any nociception we judge to be present in an intervention? It has been said here often that assigning value to nociception can't be done. So how do we know? How can we know if decreases in pain result from descending modulation or DNIC? I admit there are extreme examples where nociception is obvious (bike tube wrap thread). I also acknowledge that a minimal approach probably ensures there is no nociception caused by the intervention, and therefore any pain reduction is not DNIC.

    But is the minimal approach always sufficient? Do some clients need more? Are some patients missing out? Is less always more?

  • #2
    To throw out a DNM example: One of the costal nerve techniques even mentions that pain could be elicited via the pressure to the area and that it is ok.

    If nociception is not measurable or relevant to therapy, then are we saying that we just don't want to create pain through our techniques?

    I have found using a gentle grip, pinch and lift of tissue/skin to elicit some remarkable ideomotion and reduction of objective and subjective pain. Similarly, I have used deep pressure up to the point of causing no pain but quite deep to also elicit similar DNM/SC results.

    I would love to hear some thoughts.

    Nathan

    Comment


    • #3
      Pain - its presence or absence is not a characteristic of correction. Sometimes, and unpredictably so, correction might occur in sensitized tissue that sends a threatening message the brain might decide to deal with in a painful manner.

      It won't last.
      Barrett L. Dorko

      Comment


      • #4
        During ideomotion, there may be pain experienced which was absent in that particular area previously or in the original area. It can be ignored.

        I think, from various readings about pain, that the nonconscious brain does know better than its conscious counterpart when it comes to pain resolution. After all, it is the boss of us all.

        Nari

        Comment


        • #5
          If the nonconscios brain knows better, than Why does chronic pain persists?

          Comment


          • #6
            If the nonconscios brain knows better, than Why does chronic pain persists?
            That first part is a bit of any oxymoron. The issue is that the primate brain is a kluge of primitive and modern parts thrown together in a "stew" of processes that at any given point in time may be at odds or in sync with each other.

            What arrives in consciousness I think is context dependent. If you're being chased by a bear, you'd better hope that your primitive brain parts win out. In a chess tournament, you want those higher brain areas dominating what arrives in consciousness.

            For the patient with persistent pain, a consummatory act of movement is what is required for resolution. I understand that this is instinctual, so there must be errors in the patient's understanding and values that repress this innate drive.
            John Ware, PT
            Fellow of the American Academy of Orthopedic Manual Physical Therapists
            "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
            “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
            be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

            Comment


            • #7
              I don't think anyone really knows why some folk develop persistent pain and others don't, given a similar environment and circumstances.

              In the same vein, it seems simpler sometimes to talk about nonconscious vs conscious so that anyone lurking for the first time isn't lost in unfamiliar wording (which can be learned later anyway).

              Nari

              Comment


              • #8
                Oh, Patrick, this is so perfect!

                I couldn't remember what was the term I'd heard over the weekend, DNIC, but I'm sure that is it. And if I understand correctly, it is part of the question that is on my mind a lot: why do my clients want me to hurt them? Why does it sometimes feel good to create a sensation that, under less controlled and less voluntary circumstances, would be called "pain." Why is it the my clients often say, "It hurts so good"?

                Is this always a bad thing?

                I want to make sure I'm understanding the terminology correctly, because you know I'm a massage therapist and we are not schooled in this terminology.

                "Descending noxious inhibitory control" = more or less describing alleviating pain by creating pain, yes? For instance, pushing on irritated tissue, like many of us massage therapists do? "Deep tissue work"? "Trigger point work"? Etc.?

                I have wrestled with this for years. My Russian massage teacher told me in 1994 about the CNS being in control and that we should not create pain, that creating pain created a stress response and that creating pain would lead to more pain. What she said in those respects is in complete agreement with the ideas usually expressed here.

                And . . . I continued to use "aggressive" treatments. Why? Partly because my clients wanted it. Now, as a massage therapist, my situation is different from that of the PTs, and I'm often in the uneasy situation of feeling like I have to accommodate my clients' preferences. This is another thing my teacher would chastise me for. "You're the therapist. Your clients should not be telling you what to do." But she came from a system where the MTs worked in hospitals and clinics, they were a lot like physios but focused on massage, were educated at a university level and respected as health care professionals, and their patients (not clients) assumed they knew what they were doing and did not tell them what to do. It's different here and I've got one foot in being a health care provider and one foot in being a service provider, though I try to put more weight on the former than the latter.

                But back to why do I continue sometimes to do more "aggressive" work, though less aggressively than in the past? (I rarely make my clients sore any more, so that's an improvement, and step by step, am finding gentler approaches.) Well, it often has seemed to work and, frankly, it can feel very good and very effective. Why? Are we masochistic by nature? What is it that we crave?

                I wonder if the craving is not so much for pain but intensity. There is a kind of relaxation that occurs when we are overwhelmed by strong stimulus and then "give up" in the face of it, that an intense external experience can trigger a response to let go. I'm not sure that's always a bad thing, though I see at least one significant limit to it. (Another being that yes, I'm convinced that creating pain is not good for the nervous system and conditions more pain.) If the experience has to be intense then it often has to come from the outside & then we are dependent on someone/something external to provide it. If, on the other hand, we are able to learn a relaxation response from very gentle input, I think there is more of a possibility that we can later recreate that experience for ourselves from the inside. I don't know. This is on my mind a lot. Thanks for asking the question, Patrick.

                Comment


                • #9
                  John said:
                  For the patient with persistent pain, a consummatory act of movement is what is required for resolution. I understand that this is instinctual, so there must be errors in the patient's understanding and values that repress this innate drive.
                  Thanks John,
                  What is going on with the client who responds well to deep massage or heavy treatment? There are enough of these people around to create a demand for an entire industry. So they are not just outliers? Is it true correction or DNIC?

                  I have this nagging thought that a minimal approach is sufficient for persistent pain problems, where clients tend not to tolerate 'more than minimal' approaches. But for other clients, with seemingly more robust (i cant think of the right word here) nervous systems, a minimal approach may not always be sufficient for correction. Correction may arise from more aggressive treatment, and may not actually be DNIC.

                  Am I talking nonsense?

                  Comment


                  • #10
                    The only place I have ever found it useful (in the long run, based on my own interoceptive appreciation of having it done to me, and on outcomes reported by patients) to activate a bit of nociceptive input is in the skin along the spine, and along the sternum. Back ends and front ends of ribs, but not on skin over the ribs, rather the exit points of a) the dorsal cutaneous nerves, and b) the exit points of the anterior cutaneous nerves, found between rib attachments.
                    So...why?
                    Because (IMO), these trunk nerves' cutaneous fields are huge, with very low resolution. The mechanism proposed for DNIC is all about the brain inhibiting the field, all but for the center point of it, which it amplifies. I think it helps the brain sharpen its sensory focal length, in other words, makes the sensory input less fuzzy for awhile.
                    And it certainly does not require heavy pressure. Mostly it just requires being on the right levels front and back for a little while. (This is where having obtained a white belt long ago in ortho-ey anatomy comes in handy once in awhile.)
                    The technique itself derived originally from some silly chiro operator model dreamed up long ago with some g-awful completely implausible proposed mechanism about controlling blood flow to organs or something. It feels good, makes the rib cage feel incredibly mobile and expansive and openable. I doubt that it would be as effective if repeated. I think the novelty is key.
                    So, anyway, I like that one.
                    I would not condone any DNIC anywhere else on a person's body. Why? Because I don't think it's worth the powder to shoot a rat, anywhere else on a person's body.
                    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


                    • #11
                      Thanks Diane,
                      I certainly don't have any sadistic desires to cause pain- just thought I'd clarify that. And I don't want to have pain reduction from DNIC, I want my clients to have true pain resolution. I'm still unclear on how we can know whether true correction or DNIC has occurred. It seems that there is an assumption that DNIC has occurred as soon as treatment reaches beyond the depth of the skin into joints and muscles. I'm not convinced that DNIC is necessarily part of the picture.

                      Alice said:
                      There is a kind of relaxation that occurs when we are overwhelmed by strong stimulus and then "give up" in the face of it, that an intense external experience can trigger a response to let go.
                      Is this DNIC? I don't know... But my guess is no. I doubt it would be effective for highly sensitized persistent pain clients but with the right explanation, I think this approach can still be considered interactor rather than operator. I even think that there is some benefit to temporarily giving away the locus of control during treatment, as long as the therapist is sure to treat it with respect and is sure to give it back, and maintains a long term view toward self management.

                      Diane said:
                      I would not condone any DNIC anywhere else on a person's body
                      How do you know when DNIC has occurred (vs true correction)?

                      Cheers,

                      Pat
                      Last edited by PatrickL; 12-05-2012, 07:21 AM. Reason: Amendment

                      Comment


                      • #12
                        How do you know when DNIC has occurred (vs true correction)?
                        Pat, I don't quite know what you mean by "true correction".. complete longterm resolution?


                        Anyway, I don't know that you can "know" (if you've had some effect), other than by testing the resolution of the cutaneous receptive fields, with maybe one of those dolorimeters.
                        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


                        • #13
                          Yikes! If we can't know then what the heck are we all talking about here?

                          This reminds me of a conversation that was like a machete to my heart a number of years ago, one that to this day that still creates major cognitive dissonance for me; it was with Miguel Ruiz, author of the four agreements. Miguel happens to have been a neurosurgeon before giving it all up to teach what some of you might know about today. Anyway he said to me about my work as a manual therapist, "you know, there's nothing you can do, right"?

                          I have battled with those words everyday since.
                          Last edited by zendogg; 12-05-2012, 08:26 AM.

                          Comment


                          • #14
                            Originally posted by zendogg View Post
                            Yikes! If we can't know then what the heck are we all talking about here?

                            This reminds me of a conversation that was like a machete to my heart a number of years ago, one that to this day that still creates major cognitive dissonance for me; it was with Miguel Ruiz, author of the four agreements. Miguel happens to have been a neurosurgeon before giving it all up to teach what some of you might know about today. Anyway he said to me about my work as a manual therapist, "you know, there's nothing you can do, right"?

                            I have battled with those words everyday since.
                            Pretty much.
                            (Another manual therapist wakes up, learns he is a dead man. :angel
                            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


                            • #15
                              Diane said:
                              Pat, I don't quite know what you mean by "true correction".. complete longterm resolution
                              I guess i mean any pain resolution other than DNIC. Remember at the course last week you were talking about finding a way for the client to experience the "Joie". I assume that any pain resolution that arises from "joie" is not DNIC.

                              A minimal approach to manual therapy ensures as much as possible that reductions in pain are not DNIC. But what i think i see is that other deeper/heavier methods seem to be able to elicit "joie" with subsequent reductions in pain. If the client's brain decides that it likes the intervention, or that it likes "letting go / giving in" to the intervention, I don't think that DNIC is part of the picture.

                              I don't think this means that deeper/heavier interventions should always be used. It makes sense to me to use a minimal approach, to apply as little force as necessary. I am curious though as to whether some clients might need more than a minimal approach to provide the 'critter brain' with novel and safe input that is meaningful enough to bring about a reduction in pain.

                              Cheers,

                              Pat

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