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A Unified Theory for Physical Therapy and the Treatment of Pain

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  • Barrett, I think learning to play a musical instrument will do the same thing as learning to juggle. :lightbulb :thumbs_up
    Diane
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    "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

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    • For anyone who hasn’t noticed, I’ve had a bit of writer’s block recently. But, as usual, I can always count on Barrett’s writing to get me going again. I’ll reveal which essays in a bit (they’ll probably be obvious to anyone whose read them).

      I knew that I wanted to write about Kandel’s findings, but couldn’t figure out how to go on to what I wanted to say in this section. So, I’m going to abandon that line of thought for the moment. Maybe I’ll meander back to it later.

      Let’s think about typical testing in our evaluations. When we do a seemingly simple test, such as range of motion for example, what are we actually testing? The obvious answer is, of course, the movement of a joint through space. What does that movement depend upon? As we’ve discussed in the previous sections, our motions are non-consciously generated, and carried out dependent upon context. So, with a simple ROM test, we are actually testing the movement through space for a person in an environmental contest (ie. therapy clinic, standing in front of a therapist), overlaid with the explanatory context of the patient.

      An argument may be made that you are testing the various mechanical properties of the involved tissues. In terms of tissue stress theory, theoretically, we should be able to tell a lot about how a person tends to move, or even the trauma they have been through based on their tissue architecture. Our tissues adapt/remodel based upon the stresses that are imposed upon them. But, how can we test tissues in their relation to movement without testing motor control at the same time? Any motor control is going to be context dependent, and we’re back to the same problem. I can think of very few tests that in a conscious patient that would test pure tissue property.

      Provocative testing, you might say, is meant to tell us what movements are related to the person’s pain. I would agree. But they still are going to be context dependent, and the therapists presence is always going to affect that context. If we were holding ourselves in the clinic as accountable as we like to hold outcome studies accountable, we would be at very low validity for all of these tests.

      So what does this have to do with treatment? This is, after all, a thread about treatment, not evaluation.

      One method of testing, even within the therapeutic context, will give some insight into common threads between treatment techniques. The concept of the comparable sign (I think Maitland coined that term?). I’m not advocating for this as the testing method of choice, but instead am hoping to draw some information from its use.

      More in the next post. Please read Barrett’s essay The End of Evaluation, and the thread the Five Questions.
      Cory Blickenstaff, PT, OCS

      Pain Science and Sensibility Podcast
      Leaps and Bounds Blog
      My youtube channel

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      • The comparable sign is when a test movement, which causes pain, is able to be changed in a way that causes less pain.

        An example would be painful shoulder flexion, which is reduced when a posterior force is applied to the front of the shoulder. The mulligan technique is pretty much built on this principle.

        Remember the 3 ways that I envision of reducing the threat level from posts 48-51: non-threatening environment, novel stimulus, graded exposure.

        I want to think from the periphery how these might look and I'm going to start with the comparable sign to (hopefully) help.
        Cory Blickenstaff, PT, OCS

        Pain Science and Sensibility Podcast
        Leaps and Bounds Blog
        My youtube channel

        Comment


        • I like using the comparable sign as a way to think about why certain therapies are effective, because it gives an immediate feedback that there is less pain with the intervention just applied, and it remains within the same context as the testing. So, even though it falls into the same problem of overall validity, it does at least give a certain bit of validity for that person, within that context.

          To stay simple, I'm going to stick with Wall's descriptions of the sensory nerve fibers.
          A beta are sensitive to gentle pressure
          A delta are sensitive to heavy pressure and temperature
          C are sensitive to pressure, chemicals, and temperature

          Lucky for me (and anyone who reads it) the five questions thread discusses the origins of pain. So, I'll not repeat it here.

          From that discussion, 4 origins of pain were introduced:
          1) Mechanical deformation
          2) Chemical irritation
          3) Abnormal axonal impulse generation sites
          4) Central deaferentation

          Remember, if pain is the output, real or potential threat is the culprit. The above can be present in the absence of pain. One of my favorite quotes, which I have seen in both Lorimer Moseley's, and Nicholas Lucas' writing is "nociception is neither necessary nor sufficient to cause pain."

          We can look at the 4 origins as those which have the capacity to generate a threatening stimulation.

          Going back to one of the original generalities, successful treatments are those that reduce threat level, we can now attempt to apply this to the origins of pain.

          By definition, 1 and 2 would be the only ones that could be changed rapidly, and likely 2 (chemical irritation) only in the case of ischemia. From Barrett's The Origins of Pain essay:

          Mechanical deformation beyond any tissue’s tolerance-and this can vary from tissue to tissue and moment to moment-is certainly painful and that pain will rapidly change right along with the amount of deformation present. (I’m rather conveniently ignoring centrally mediated influences here) Thus the patient with this sort of problem will describe distinct alterations in their discomfort dependent upon position and use. In other words the origin of the problem becomes clear on history-it’s mechanical deformation. Similarly, if movement doesn’t alter the pain the origin is chemical irritation. It’s history then that reveals the origin of the problem. Simple as that.
          Thinking back to the comparable sign now, we can apply this thinking to state that the reduced pain is a result of reduction of threat by either a reduction in mechanical deformation, and/or a reduction in tissue ischemia, and/or placebo mechanism.

          How we doing so far? Comments please.
          Last edited by BB; 25-10-2006, 07:13 AM.
          Cory Blickenstaff, PT, OCS

          Pain Science and Sensibility Podcast
          Leaps and Bounds Blog
          My youtube channel

          Comment


          • Cory,

            Sounds fine to me.

            In:
            Remember, if pain is the output, real of potential threat is the input...
            ..did you mean to say reality?

            I suspect that reduced mechanical deformation, tissue ischaemia and placebo/nocebo response are all strongly correlated.

            Nari

            Comment


            • Nari,
              Oops. Real OR potential threat. I changed it in the post. Thanks.

              I suspect that reduced mechanical deformation, tissue ischaemia and placebo/nocebo response are all strongly correlated.
              I agree.:thumbs_up
              Cory Blickenstaff, PT, OCS

              Pain Science and Sensibility Podcast
              Leaps and Bounds Blog
              My youtube channel

              Comment


              • Ian sent me this book review just recently. It offers philosophical opposition to Damasio's stance. It seems that the process of unification might be harder to come by and the disunity extends further than simply PT.
                Last edited by Jon Newman; 25-10-2006, 01:05 PM.
                "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

                Comment


                • Cory,

                  Great stuff. Pointing out that threat alone is sufficient to elicit a painful response (along with a rise in sympathetic support, I presume) relates perfectly to the ways in which I see many therapists relate to patients. They ask, “What if they don’t like what I’m doing? What if they want something else?” They understand that their current methods make little or no sense and are well-aware of their ineffectiveness but are even more concerned about some future confrontation - so concerned in fact that any proposal to change in their approach is rejected immediately. I was recently told by the supervisor at a large hospital who had closed two outpatient clinics so that 16 of his staff could attend my workshop that by the end of the next day most weren’t using anything they’d learned. He said, “They have already explained it away.”

                  To me, this is the power of fear, especially of future difficulty.

                  Keith Olbermann’s recent “special commentary” was related to this as well. He pointed out that, “The dictionary definition of the word ‘terrorize' is simple and not open to misinterpretation: "To fill or overpower with terror; terrify; coerce by intimidation or fear." Note please that the words ‘violence' and ‘death' are missing from that definition. For the key to terrorism is not the act-but the fear of the act.”

                  These days many of us are surrounded by perceived threats from a number of angles. No wonder the rise in chronic pain.

                  Therapists can offer in return two things: education and movement. I contend that in order to do that well they have to first become consumers of those same things.

                  No small task.
                  Barrett L. Dorko

                  Comment


                  • From Garrison Keillor today:

                    "We are engaged in a struggle between freedom and the forces of terror, my little macacas, and mostly I side with freedom, such as the freedom to look at big shots and stick out your tongue and blow, but of course terror has its place too. The dude strolling down our street at night does not break into our house to see what's available because he is terrified that if he's nabbed, his girlfriend Janine will run off to Philly with her ex-boyfriend Eddie who's been hanging around. She's the best thing in Benny's life right now. So he walks on by and leaves our stereo be.

                    The terror of everlasting hellfire kept me away from dances until I was 12 years old and away from smoking cigarettes until I was 15. So that's good. Dancing was briefly thrilling, and then I caught sight of myself in a mirror and I haven't gone to a dance since. Fear of ridicule is powerful too."

                    This "not dancing" Keillor does is precisely the absence of full and free ideomotion that I have often contended contributes to chronic pain. In an earlier post on this thread Cory come up with the following and it's something I now show every class:

                    Options and Considerations for motion:

                    Avoid Pain

                    Resolve Pain

                    Don’t get laughed at

                    Clearly, Keillor has chosen the third when it comes to movement. Fortunately for him he's found other ways of personally and creatively expressing himself.
                    Barrett L. Dorko

                    Comment


                    • Jon,
                      Thanks for posting that book review. After reading it, I'm curious if the author actually read Damasio's book. He is clearly confusing Damasio's definitions of emotion and feeling, as demonstrated by his examples. So, if he did read it (and I'm sure he did) then his problems would be with those definitions, which are not addressed in the criticisms. Additionally, he faults Damasio for ripping off William James. Damasio repeatedly gives credit to James as originating ideas that he expands upon, and then goes on to describe where they differ.

                      The key to this review may come at the end, where the author has 2 books named. It is evident from the review that Damasio's views and findings are not in concert with the thoughts of this author... thoughts which are likely spelled out in his books. I am even more inclined than usual to be skeptical when a review is done by an author with something to lose.

                      I really like the quote from Nicholas Lucas' interview : “when a man who is honestly mistaken hears the truth, he either ceases to be mistaken or he ceases to be honest"

                      I could of course be wrong about his motives...
                      Last edited by BB; 26-10-2006, 02:30 PM.
                      Cory Blickenstaff, PT, OCS

                      Pain Science and Sensibility Podcast
                      Leaps and Bounds Blog
                      My youtube channel

                      Comment


                      • I was searching to see if Damasio had himself written any responce to the review posted by Jon. Haven't found one yet. I did come across the Second World Conference on the Future of Science where video files of some notable speakers can be found (including one from Damasio). All relevant to this discussion. Charge up the iPod Jon.

                        eric
                        Last edited by EricM; 26-10-2006, 06:29 AM.
                        Eric Matheson, PT

                        Comment


                        • I would like to discuss further the concept of mechanical deformation as an origin of pain.

                          The concepts of tissue stress are fairly well spelled out. PTs in general are pretty familiar with this stuff, so I won't spell it out here. One tissue, however that the appllication of tissue stress model is actually less commonly understood in the PT world, and that is of course neural tissue.

                          One neural tissue stress model that I want to emphasize is that of neurodynamic sequencing. Michael Shacklock has been able to show that the amount of strain on a portion of neural tissue is affected by the order in which the body parts adjacent to the nerve are moved. For example, in an ulnar nerve neurodynamic test, the most tension is placed on the neural tissue at the wrist, if the wrist is the first body part moved.

                          While Michael, Butler and others have made great strides in describing the mechanics and neurodynamics of the nervous system, their descriptions are limited to the large trunks. This gives a certain amount of predictability to movements and the nervous system. However, as the nervous system continues to branch as it approaches its terminal ends, it continues to gain in complexity. While there is no reason that I know of to doubt the consistency of the concept of neurodynamic sequencing throughout each level, this increasing complexity makes predictability much more difficult. Most have heard that saying that there is like a gazillion miles of nerve in the body. Well, most of those miles fall within this increasingly complex zone between the larger branches, and their terminus.

                          Barrett actually asked Michael Shacklock about this in the live chat.

                          For mechanical deformation to communicate with the brain in a way to cause an output, like pain, it must signal an impulse through the nervous system. It must cause nociception. I'm going to sound like a broken record, but I think it's important to keep this clear. Nociception must be considered threatening for it to cause an output of pain. Nociception does happen without causing pain. Many believe that movement patterns are the cause of nociception. Others believe that nociception is the cause of altered movement patterns.

                          I believe that a case could be made for both depending on the situation. There is no doubt, however, pain causes peripheral sensitization (an increase in sensitivity, or lowering of firing threshold) through changes in the nerves such as changes in density of mechanoreceptors, and descending excitation, that, through the concepts of neurodynamic sequencing, would change the ways in which we move. Put simply, peripheral sensitivity will make the neural tissue be more easily stimulated and thus more easily painful.

                          Here it is very important to make an observation. Peripheral sensitivity from descending excitation occurs when pain is present. Therefore, we must be careful to know that there is a difference between movement patterns that are tagged to pain output, and their often identical looking, non-painful counterparts.

                          For this reason, we cannot assume that a movement pattern is reponsible for, or even associated with, a persons pain even if it is consistent with increased tissue stress. However, since movement patterns can indeed result from a pain output, through the effects of neurodynamic sequencing on a nerve that is peripherally sensitized, changing movement patterns could be an intervention that would decrease mechanical deformation.

                          Comments?
                          Last edited by BB; 26-10-2006, 02:26 PM.
                          Cory Blickenstaff, PT, OCS

                          Pain Science and Sensibility Podcast
                          Leaps and Bounds Blog
                          My youtube channel

                          Comment


                          • Cory,

                            I think that this issue of specificity in testing and movement toward recovery is the great shadow of the neurobiologic revolution. In fact, David Butler seemed to address it specifically in the What is a neurodynamic test? thread recently featured on his site. Nothing was resolved there, as far as I could see.

                            I’m always asked about “compensatory” patterns of use that many therapists are convinced “cause” the problems they see in their patients. Long ago I saw this as a great black hole of rationalization that simply delayed treatment, justified treatments that didn’t work especially well and perpetuated mesodermal fantasies of function/dysfunction. Other than that it’s really quite useful.

                            When we begin to understand and use two things: evolutionary reasoning and ideomotion, then we’ll begin to make some progress toward resolving the abnormal neurodynamic rampant in our clinics.

                            I think. I’m almost sure.
                            Barrett L. Dorko

                            Comment


                            • Hi Eric,

                              I think the opposition comes down to philosophical issues (not necessarily scientific ones)--specifically the issue of representationalism.
                              Attached Files
                              "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

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                              • Cory I've been considering your comments regarding nociception, I can't disagree. A few years ago there were a couple of excellent discussions on noi concerning nociception that might come in handy. here and here.

                                eric
                                Eric Matheson, PT

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