A Unified Theory for Physical Therapy and the Treatment of Pain

[BB]

Thanks for the links Diane.

Now let's get to the fun stuff. The purpose of my starting this thread was to spell out a theory of what common threads lie behind successful physical therapy treatments, whatever the method. So far we have really only discussed neuroscience in general. Now it is time to put this background to use.

We have so far discussed how things from what I'm calling an inside-out approach. That will continue in this section as well. I'll try to make some points from the perspectives discussed above already.

After treatment is considered from this perspective, I am going to move on and attempt to describe from 2 other perpectives, that of explanatory mechanisms and placebo, as well as an outside-in approach. All go hand in hand and the story won't be complete until we are all the way through, but waiting till then to start drawing some conclusions would not be ideal based on the amount of information.

Therefore, lets talk a bit about what successful treatments have in common from an inside-out approach....

[BB]

Remember above when we talked about how we can only sense those events to which we can make an appropriate motor response?

From Patrick Wall's Pain: The Science of Suffering p. 150:

What are appopraite motor responses to the arrival of injury signals? They attempt: first, to remove the stimulus; second, to adopt a posture to limit further injury and optimize recovery; and third, to seek safety, relief, and cure.

So, with pain 3 types of motor plans are made, 1) remove the stimulus 2) protective posturing 3) seek safety, relief, cure.

We also talked about how pain is a need state. In order for pain to be extinguished the mind must be satisfied that the motor plans have been fulfilled.

again on p. 150

If the sequence is frustrated at any stage, the sensation and posture remain.

and:

we need to reexamine whether pain signals the presence of a stimulus or whether it signals the stage reached in a sequence of possible actions.

In the most general terms, those treatments which satisfy the needed action sequence will be successful.

[BB]

The next logical question is, "What happens when the sequence is frustrated before being completed?"

Answer: persistent pain.

This is where all that talk of the different types of self are going to come into play. Let's imagine that the action needed for relief is to stick out the belly as far as possible, for the rest of the week. As soon as a person does this it stimulates the change in core self. This action and is then compared against the autobiographical self, which in western society is going to contribute past memory which says sticking out your belly looks funny, people might laugh, they definately won't think you are beautiful. The result is that the person makes the decision (consciously or non-consciously) to inhibit this action and continue to walk around with their belly sucked in tight.

The action sequence is interupted and the pain continues.

Now this person is going to have pain with movement. The hippocampus (the association maker) is going to associate any movement made in the sympathetic state (that which is correlated with pain), that is similar to the original offending and therefore threatening movement, with other implicit memories that have been associated with the history of this pain (applying the autobiographical self based on experience). This tells the processing centers of the brain that this movement is a threat and pain remains necessary. Since the hippocampus is constantly making new associations, the things associated with this threat continue to grow and the result is more and more movements hurt. The pain spreads.

Looking back again, we discussed how Damasio stated that "When variations that trespass into a dangerous range are about to occur, they can be averted by some preemptive action." A person in persistent pain will learn quickly avoidance by a pre-emptive action. Splinting for example. We will talk more about this in the outside-in discussion, but mechanical input from the periphery (nociception) can be averted by protective splinting. The hippocampus continues to make its associations and build on the autobiographical self, which now has memory of splinting. Since the pain persists, the splinting avoidance behaviour continues and quickly becomes compulsive. By compulsive, I mean that it becomes well enough engrained that consciousness no longer attends to it. It becomes a background action. Of the possible actions that are presented to the organism the dominant compulsive action has been chosen so many times in the past that it becomes the only option considered non-consciously.

I think we can even make a generality from this description. I believe that there are treatments that actually foster compulsive avoidance of painful movements. I feel that they often do not actually bring about resolution but simply avoidance of pain, and therefore can also foster fear of movement, at their worst. If resolution of pain does occur, the threat associations with certain movements remain and are likely to be easily re-provoked.

I'm curious on thoughts about this before I move on.

[nari]

Cory,

This is all great stuff; but for me it needs time to extrapolate the thoughts to real life clinical situations.
Two things have grabbed my attention, amongst many:
Wall states:

If the sequence is frustrated at any stage, the sensation and posture remains

.

and

We need to re-examine whether pain signals the presence of a stimulus or whether it signals the stage reached in a sequence of possible actions.

I like the second possibility in the second quote.
I keep thinking of regimes like those of Maitland and McKenzie, where good results happen to begin with but tend not to persist into full resolution. In other words, some systems settle down well, and others do not; and it is these latter folk who may be in the category of "frustration".
These frustrated systems are the ones I see at present with every patient. In simplest terms, we should attend to the need states more, recognising them for what they are. I don't think it matters what models or methods we use, we can use them better than we do.
This is the great advantage of ideomotion - we stay out of the risk of messing up the sequences.
With traditional physiotherapy, I am extremely cynical of most of its long term effectiveness; so I have to think a lot more about a unified theory....

Nari

[Barrett Dorko]

Cory,

I think Nari's on the right track and this is what I try to teach.

The "splinting" you speak of might very well be the beginning of resolution. After a brief period of time I think that we can assume it is. If at that point we misinterpret it as the protective response then care designed to help will have the opposite effect. Simply put, the isometric activity we can easily palpate is a defense and not a defect. Using evolutionary or ultimate reasoning the former should be allowed to complete its action and the latter should be ablated if possible. In this case the isometric is encouraged to become an isotonic and corrective, pain-relieving movement will emerge - theoretically. If this is not allowed for whatever reason the sequence is frustrated and Wall becomes amazingly prophetic.

See Asking Why - Evolutionary Reasoning and Manual Care for more on this.

In effect Wall says, "Food is to hunger what movement is to pain." Of course, not just any food would be ideal, and not just any movement would be either.

[BB]

I am glad I requested comments. Very helpful.

Barrett,
Your post makes it clear that I need to separate protective avoidance as I described it, with persistant defense, as you did.

In my description I had in mind an active inhibition, an order protect from the the autobiographical self. For example, someone who has pain with dorsiflexion when they step, and therefore "splints" in plantarflexion. Avoidance of a painful movement.

The "splinting" you speak of might very well be the beginning of resolution.

By this, I think you are referring to the second step of "appropriate action" of which Wall speaks: "Adopt a posture to limit further injury and optimize recovery."

Thinking in terms of neural sensitivity (which we will discuss at length in the outside-in discussion), it would make sense that such a posturing would be accomplished through an isometric contraction of the muscle surrounding the nerve that has become sensitive, thereby reducing it's mechanical stimulation of stretch and pressure mediated receptors locally. So, in these terms the posturing is absolutely a part of the resolution process.

Simply put, the isometric activity we can easily palpate is a defense and not a defect.

To everybody reading: please read Barrett's link below.

I don't believe the isometric defense would still be considered compulsive itself (that is the term in the manner used by Moshe Feldenkrais, by the way), but would contribute to all movements in a way that would make them compulsive, as I described above.

And Nari,
A thought I had on a clinical correlation to my previous post would be splints or braces applied to those in pain in the absence of an orthopaedic pathology. For example, wrist splints for wrist pain, slings for shoulder pain, etc.

[BB]

Continueing.....

Nari,
McKensie's system takes controlled avoidance to a whole other level. It does promote movement, but also systematically describes those motions that are to be avoided like the plague. Avoidance on a whole other level. I believe that his system does advocate eventually re-introducing previously painful movements, however.

Here is an interesting discussion about McKensie and avoidance that includes responses from the McKensie institute.

[Gil Haight]

Cory,
Interesting thread. I think we must see Wall's sequence as being bidirectional. A fear of slipping back into withdrawal can reasonably perpetuate a protective stance. Furthermore the PT community is actually quite good at helping individuals from withdrawal to protection. Unfortunately, we are quite poor at facilitating the next sequence. This is probably due to the fact that as we proceed through the sequence, the process becomes increasingly idividualized. In other words choreography is germane early on as the patterns are likely more steorotypical. Gil

[BB]

Gil,
Please post more often!

I think we must see Wall's sequence as being bidirectional. A fear of slipping back into withdrawal can reasonably perpetuate a protective stance.

A great way of looking at it. I think what I was trying to say fits in with fear of slipping back into withdrawal. Defensive posturing in the context of avoiding pain.

Context is very important here. I'll present it more fully in the explanatory style/placebo discussion, but it is worth bringing up here. This quote is also from Gil in the "Brain in conflict" thread.

The number ( as in too many) of options is not the problem. How and upon what basis we choose is however a different story.

The core self provides the autobiographical self with many potential action options, all of which are somatically marked (see somatic marker hypotheses above). This is then mapped against the autobiographical self. The autobiographical self is very context driven, as seen in the discussion of the hippocampus. The option chosen will depend upon the context through which the autobiographical self filters and upon the somatic marker most successful in that context in previous experience.

A choice made in the context of "avoid pain" will be different from one made in the context of "resolve pain" and will be different from one made in the context of "don't get laughed at."

From this we can add to the previous generality:

Those treatments which satisfy the needed action sequence in the context of resolving pain will be successful.

[BB]

The last addition to the general statement needs some defining. What is "the context of resolving pain?"

I want to bring back the quote from Damasio in post 21:

The dispositional arrangement ensures that the environmental variations do not cause a correspondingly large and excessive variation of activity within. When variations that trespass into a dangerous range are about to occur, they can be averted by some preemptive action; and when dangerous variations have already occurred, they can still be corrected by some appropriate action.

Pain would be the result of a variation that trespasses into a dangerous range. A threat. The context of resolving pain is the context for acting to correct a threatening variation by some appropriate action, according to the above statement. This is consistent with what Wall has said with the three stages of resolving pain.

[BB]

Now we need to determine what would be a dangerous variation.

Martin Seligman is a psychologist and author of the book Learned Optimism. In Ledoux's book The Emotional Brain the following is described on page 236:

He (Seligman) argued that perhaps we are prepared by evolution to learn about certain thigs more easily than othes, and that these biologically drived instances of learning are especially potent and long lasting.

Several studies have been performed on preparedness theory which have in fact shown that bodily fear responses are stronger to certain biologically plausable stimuli, however it has also been shown that learning is particularly important in this process.

p. 237

It has long been thought that monkeys have an inherited fear of snakes, so that the first time a monkey saw a snake it would act afraid and protect iteslf. However, Mineka showed that laboratory-reared monkeys are in fact not afraid on the first exposure to a snake. If the young monkey is shown the snake when separated from its mother, it doesn't act afraid. It appears that the infant learns to be afraid of the snakes by seeing its mother acting afraid. The young monkeys did not learn about nonfrightening things in this way, suggesting that there is something special about biologically relevant stimuli that makes them susceptible to rapid and potent observational learning.

biologically relevant stimuli are related to survival.

This applies directly to the uses of the self. The autobiographical self is then able to build upon experience to form associations that will act as reminders of dangerous situations.

From p. 239

during a traumatic learning situation, conscious memories are laid down by a system involving the hippocampus and related cortical areas, and uncounscious memories established by fear conditionaing mechanisms operating through an amygdala-based system. These two systems operate in parallel and store different kinds of informatinon relevant to the experience. And when stimuli that were present during the inital trauma are later encountered, each system can potentially retrieve its memories. In the case of the amygdala system, retrieval results in expression of bodily responses that prepare for danger, and in the case of the hippocampal system, conscious remembrances occur.

This is a lot of quotes to make the point that a dangerous variation is going to be determined by
1) Threat related to evolutionary survival needs
2) Learned responses to those threats
3) Other factors associated with those threatening situations

[BB]

When our patients come to us in pain with movement, they display the findings just described.
A threat to survival: real or potential tissue damage
Learned responses to that threat: pain behaviour
Associations made with that threat: experiences in the past which have caused continued or increased pain, or that they thought would cause continued or increased pain.

This last one is big. People who have been abused are going to be more threatened by touch. People who have been hurt in physical therapy are going to be threatened by physical therapists and any associations that were made to that physical therapy experience. Movements that have been causing pain are going to be a threat. Etc.


Those interventions which allow a movement to be perfomed in a non-threatening context will be successful.

[nari]

This one:

Those interventions which allow a movement to be performed in a non-threatening context will be successful

is right up with my priorities.

Working in a pain clinic brings to attention the nociceptive nature of many patients' past experiences with a PT, and really drives this unhappy situation home. When it is clear a patient is anxious with me and trying madly not to show it, I often say: I'm not going to do anything at present - no hands-on - what sort of PT have you had in the past.?...
It usually pours out: how painful and scary going to a PT is....

I think that is a major problem with our profession but I also think we all know it is.

Nari

[EricM]

The scientific community must be paying attention to your thread Cory. I found this abstract today. Does unconventional medicine work through conventional modes of action?

eric

[Gil Haight]

I am really excited about how we are continuing to develop our concept of appropriate movement. We have at length, over many months promoted and supported the notion that appropriate movement is best identified somatically. Cory’s, posts and proposed model continue to support that notion, but also introduce a new fly in the ointment. What happens when the biologically appropriate response does not feel appropriate? Surely this would have a negative influence on the process. This is a real tough situation that I see regularly. What do we do?
Gil