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  • #46
    I think it's important to be explicit whether someone is speaking about (detectable) pathology or not. See post #31 on this.
    "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

    Comment


    • #47
      Luke? What say you?

      I think the thread started because we were talking about pain relief, not causes.
      I stand behind everything I said in post 43.

      The class "fruit " contains apples, but apples are not everything that fruit is, or its digestion.

      The class "pain" contains peripheral drivers which might be temporarily mechanical, but peripheral drivers are not all there is to pain, nor changing them to its resolution.
      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
        Yes, that's true, but doesn't mean that peripheral drivers don't exist or we don't affect them with therapy or it isn't worthwhile to look for them and attempt to treat them.

        I think most cases of mechanical pain would qualify as "non-pathological", or any relevant pathology in terms of degenerative changes isn't likely relevant.
        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


        • #49
          Yes, that's true, but doesn't mean that peripheral drivers don't exist or we don't affect them with therapy or it isn't worthwhile to look for them and attempt to treat them.
          1. "doesn't mean that peripheral drivers don't exist"
          We "suppose" that they exist to give us something to focus on so we can interact with someone's nervous system. They are "constructs" be they impingements by joints on neural tunnels (see Rod's statement, "I believe the gapping has a very specific effect of relieving mechanical deformation") or be they neural stress on a nerve anywhere in the body, acting up because it started to send hypoxia signals upstairs, and the brain decided to create a pain output to get the attention of the conscious awareness module it also gave rise to, supports, and organizes, the way I posit. I think I already explained why I feel they are a necessary evil. I already explained why I think my construct is equivalent to anyone elses' construct. I already explained why I think they are probably all irrelevant in the greater scheme of things. I think Barrett has already destroyed all the ones he ever used, and works without them, purely kinesthetically and without reference to any"thing." I think Luke himself all the way along on our little adventure has demonstrated how easily they can be knocked over. I think it's time to admit that they are mostly convenient mirages, and that as such, they are useful for playing let's pretend in order to communicate but that they, like the tooth fairy, are not real, and like tooth fairy science, a lot of info can be derived from positing they exist, but their plausibility in the first place is probably more rather than less like "subluxations" are to chiros, and about as useful. And about as real.

          2. "or we don't affect them with therapy" We affect "something" with therapy - we affect the brain of the person we are treating, and it does its thing all the while, and its a great big chemistry set that tries to adapt to whatever is going on around it, to it, and within it. That I think we can safely say we "know" and we don't know anything else for sure.

          3. "or it isn't worthwhile to look for them and attempt to treat them." See number 1.
          Last edited by Diane; 17-07-2009, 05:29 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


          • #50
            Not that anybody asked my opinion, but I think Diane's point is being missed here, or dismissed too quickly at least.

            If we think in terms of necessary and sufficient: what is necessary for resolution of mechanical pain? Resolution of perception of threat is my entry. Is there anything else that is necessary? Can pain relief occur without it?

            I think if we can agree that this is necessary then we can discuss what brings this about. I've been thinking about this all day and I think that the most simple way of thinking about it would be top-down processing (which would include placebo, or we could even replace placebo response with "product of top-down processing, I think) or bottom up processing, which would include all of those entries consisting of a peripheral origin.

            Resolution of perception of threat can occur through any myriad of combinations of top down and bottom up processes, all being sufficient without any particular combo particularly being necessary.

            I think a compelling case could be made, if I understood Damasio's work accurately, that top-down processing is always involved in a perception initiated by or involving bottom up processing. But, top down also can occur in absense of bottom up contribution (the as-if body loop). This would make a case for the necessary outcome of resolution of threat necessarily having a top-down processing component that would be synonymous with what we are referring to here as a placebo response.

            In the nerve root example Rod gave below, do you think pain relief could have occurred without the central processing? Could it have occured without the peripheral input, concievably?
            Cory Blickenstaff, PT, OCS

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

            Comment


            • #51
              but doesn't mean that peripheral drivers don't exist or we don't affect them with therapy or it isn't worthwhile to look for them and attempt to treat them.
              I don't think so. Just because something is sufficient instead of necessary doesn't mean they don't have utility. Assuming that there is no risk that makes the potential benefit not worth it.
              Cory Blickenstaff, PT, OCS

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

              Comment


              • #52
                Small question from this Cory.
                ...what is necessary for resolution of mechanical pain? Resolution of perception of threat...
                Is asking, "what is necessary for resolution of the origin of mechanical pain," the same as asking "what is necessary for resolving pain of mechanical origin?"

                Trying to keep up here.
                Eric Matheson, PT

                Comment


                • #53
                  This is a great thread. Diane, it seems to me you are overstating your position a bit.

                  There is a significant stretch between these two positions [my own words]:
                  A: "The brain has a powerful influence on the pain experience, and much of the positive effect we see from treatment can be adequately explained by the placebo response."
                  B: "We can safely ignore everything else, such as peripheral mesodermal drivers of the pain, they are not relevant."

                  While "A" would have my wholehearted support, "B" would not. Or is my interpretation inaccurate?

                  Comment


                  • #54
                    B: "We can safely ignore everything else, such as peripheral mesodermal drivers of the pain, they are not relevant."
                    Butting in a bit: If we are talking about non-pathological pain, then I tend to agree with (B). There's a problem with the definition of non-pathological, but I assume it to mean no apparent reason for peripheral pain to occur.
                    That does not include nerve root compression, which is a pathology (?)and symptoms can be altered, in some cases, by 'mesodermal' intervention/s.

                    Nari

                    Comment


                    • #55
                      Jon is right, we do need to be explicit about what we are referring to. Just to be clear, I've been referring to placebo as positive responses resulting directly from the patient's interpretation of the meaning of a therapeutic encounter. This encompasses conditioning, positive expectation, social context and culture. Specific effects usually refer to therapeutic physiological mechanisms we hypothesize to be responsible for positive outcomes following specific elements of treatment application. Note that placebo responses may not encompass all non-specific effects. For example, positive responses following injection therapies for "MTPs" were thought to be due to the injected substance. It was later discovered that needle penetration (a non-specific and unavoidable by-product of delivering the actual treatment) was a stronger predictor of outcomes than whatever was injected. Enter dry needling of "MTPs", where needle penetration is considered responsible for the specific effects.

                      Luke? What say you?

                      I think the thread started because we were talking about pain relief, not causes.
                      I started this thread primarily to discuss how our interpretations of pain science influence the development of our treatment models and our clinical application of these. More specifically, if one's understanding indicates that elements of a model are completely irrelevant to outcomes, why include these in the model and base clinical applications on them? If our interpretation of the evidence is that the placebo response is the only relevant therapeutic mechanism following manual therapy, why not design treatment around that understanding instead of constructing highly complex manual therapy models involving specific handling for specific purposes? (It's worth pointing out that an implication within Barrett's post #27 touches on possible ethical considerations to different stances here. We might explore that in another thread.)

                      it is still going to be the brain having the final veto power, the final yea or nay say in whether or not it accepts the proffered "reduction in mechanical deformation." And its acceptance or rejection is still going to depend on a lot of other context, other variables. Right?
                      There is no doubt that the brain is the key player, however, I think we need to be careful about attributing this kind of exclusivity to it. While it is true that in some, usually exceptional, circumstances pain is experienced in the absence of peripheral input (or no pain is experienced in the presence of peripheral input), the transmission of nociception into the CNS is still a very common 'cause' of pain. The brain doesn't "reject" a reduction in mechanical nociceptive signaling in the presence of a local anesthetic, just as it has no power to generate a pain experience under the same influence. We could claim that the process of injection facilitates sufficient placebo analgesia to eliminate pain in such a case, but evidence from studies using double blinded, placebo-controlled analgesic blocks strongly suggests than local disruption of nociceptive transmission is a valid explanation for pain relief, even in common presentations of chronic pain (eg). Similarly, a complete quadriplegic doesn't experience mechanical pain below the level of injury. A person with congenital analgesia has a brain that has never produced a threat response because it has never received a nociceptive signal from the periphery. Hacking off someone's legs right in front of them, as threatening as this would be, would not be painful if you gave them an epidural first (I have even read that a sufficient period of anesthesia prior to amputation significantly reduces the incidence of phantom pain).

                      what is necessary for resolution of mechanical pain? Resolution of perception of threat is my entry. Is there anything else that is necessary? Can pain relief occur without it?
                      We might equally ask, can reduction or elimination of nociception itself be responsible for the resolution of a perception of threat. The above cases (and many others) would indicate, yes. So I agree with Jason: we cannot dismiss the peripheral components of the neuromatrix.

                      that like it or not, skin is being stretched and therefore the neural bits within it are too, and the brain is reading that first, before any "gapping" could have any specific effect.
                      True, but that does not rule out a relevant specific effect on mechanical deformation following such a movement? I'm still confused as to why you use specific positioning if you think it is unimportant.

                      you cannot rule out (nor can we really measure, except perhaps by real-time fMRI some day), interactor effect - and lean toward operator effect, i.e. specific effect specifically from joint gapping - unless you're working on an unconscious patient, without skin.
                      Diane, ruling out an "interactor effect" is not on the cards here. I thought we were trying to understand how our views on the features of that interaction affect what we do. In your post #49, you imply that all treatment constructs including your own are "equivalent", and even more, they are all "irrelevant". Yet this view does not seem to significantly inform your clinical approach. Why not? What makes DNM the most relevant "crutch of some sort" of all the irrelevant crutches out there? (I'm truly not intending to be confrontational here). I know DNM makes sense, but why is making sense important if we are actually discussing the tooth fairy?


                      John,
                      I'll get to your question later.

                      Ian,
                      Where are you?
                      Last edited by Luke Rickards; 17-07-2009, 12:18 PM.
                      Luke Rickards
                      Osteopath

                      Comment


                      • #56
                        Originally posted by BB View Post
                        I don't think so. Just because something is sufficient instead of necessary doesn't mean they don't have utility. Assuming that there is no risk that makes the potential benefit not worth it.
                        You lost me here.

                        I think there are far too many examples in support of the position that resolution of peripheral input is often sufficient (every placebo controlled trial on analgesic medication for example) to resolve the pain experience for peripheral input to be dismissed.

                        On the topic of "non-pathological pain" - I think this is a concept that needs some deconstruction. When I see a patient with low back pain who also has some degenerative changes in their spine and perhaps a HNP, I can't be sure whether that pathology is relevant to his complaint or not initially - there are ways to help determine this but we often proceed with therapy/treatment in the presence of some pathological condition that may or may not be relevant. Often we just don't know. I don't think actual clinical life can be neatly divided into "pathological pain" and "non-pathological pain".

                        I think anyone who dismisses the periphery completely and only attends to central mechanisms is missing out on a lot of useful therapy for many patients - and my current read of the literature suggests that such a rejection of attempts to examine or treat the periphery (as part of a larger approach that addresses other factors) appears to be speaking beyond the existing evidence.

                        Diane I'm reading here that you consider peripheral input to be irrelevant for treating mechanical pain conditions and that you consider constructs surrounding the evaluation and direct attempts to treat such things as "tooth fairy science" while positing that the treatment model of choice is one that relies on central mechanisms only - perhaps I'm just misunderstanding or mischaracterizing your position?
                        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


                        • #57
                          OK, working backwards...

                          Jason's last post:
                          Diane I'm reading here that you consider peripheral input to be irrelevant for treating mechanical pain conditions and that you consider constructs surrounding the evaluation and direct attempts to treat such things as "tooth fairy science" while positing that the treatment model of choice is one that relies on central mechanisms only - perhaps I'm just misunderstanding or mischaracterizing your position?
                          Yes, I think you are.. not intentionally probably. I think peoples' mesodermalitis might be flaring a little.

                          Let me state this for the record: Peripheral input is NOT irrelevant. Touch is important. The entire human troop in this culture not only does not move enough, but is also kinesthetically anorexic.

                          We are still (after lo all these many years and careful debate) arguing over CONSTRUCTS. It's ridiculous to do that, in my opinion, in this thread, at least. Which is to sort out if handling produces anything more than placebo response. (First, we tried to sort out what that was. Did it sort yet? Synopsis: Placebo response = favorable synaptic chemistry, elicited in the context of a therapeutic relationship. Placebo = pretending to have done so without actually making sure it's been done. How to tell the difference? Feel the patient, physically, to find out. All the way through the session.)


                          Here's how I see it:

                          1. We have a patient who is a chemistry set. Their chemistry set is is setting up a pain. For whatever reason. They seek help.

                          2. This can't be framed as simply as "Help me. I have a pain. Please hold my body part, into the representation of which my brain is sending the upregulated sensitization, which creates cord changes and peripheral sensitization as well." No. Next to nobody understands that language yet. It usually sounds more like, "Help me. There is something wrong with my back/neck/leg/arm/butt/knee. It hurts."

                          3. The illusion of "body" pain is confirmed and reinforced by conceptual illusion and perceptual fantasy of whatever mesodermalism your profession founded itself upon, whichever ones feed the profession and its members, and therefore reinforce the illusions back out to the public. This is the cultural spell we are all still under, to varying degrees.

                          4. Every time I had a patient (and I say "had" because I stopped working three weeks ago) I would take the time required to break the cultural spell, first. (I can guarantee you it took a lot less time to do this with patients than it does writing about it endlessly and perhaps fruitlessly on the internet.)
                          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


                          • #58
                            I think this whole thread should be etched in stone somewhere. No, wait, the Internet is our modern equivalent of that, isn’t it? Of course, if no one ever reads it, well, it’s kinda like the Dead Sea Scrolls.

                            When I say pathology I’m talking about something that requires healing or repair for complete resolution. Whether or not these pathological changes are relevant to the patient’s complaint of pain is something we can guess at after management that doesn’t address the repair or healing is begun. This leads to my saying, “Well, I can’t do anything about the x-ray changes but that doesn’t mean that movement can’t help make the nervous tissue in the region sufficiently healthy to lead to relief. In any case, if you don’t get better, I can always blame the x-ray (ha, ha).” Funny - very few patients see the humor in this. Maybe it’s my delivery.

                            The monolith of the brain’s effect on our sense of pain or threat is just that, a large and undeniable thing. In relation, our efforts may seem David-to-Goliath like but, like the story; it endures because there’s some truth to it. (I’m beginning to wonder about two biblical references in one post today)

                            Maybe the Russian hockey team in ’80 would be a better example.

                            I think you’re all right, and that Diane helps her patients because she knows so doggone much. Despite her misgivings about the significance of technique or intricate active and/or passive maneuvering (I certainly have my own), that knowledge is reflected in her presence and her touch. What happens (or not) varies depending upon the internal storms we often cannot sense within the sea of the patient and the water they are currently swimming in. As this becomes more detectable some of this will be sorted out.

                            This thread is a wonderful example of how hard we’re working to do that.
                            Barrett L. Dorko

                            Comment


                            • #59
                              I don't think actual clinical life can be neatly divided into "pathological pain" and "non-pathological pain".
                              True. Few in the broad clinical world would agree on what constitutes any "cause" for pain, let alone anything from top-down.
                              For the purposes of this thread, I assume we are talking about non-pathological pain, benign and without severe neurological signs?

                              Nari

                              Comment


                              • #60
                                What a great discussion!

                                Luke, you stated this:
                                There is no doubt that the brain is the key player, however, I think we need to be careful about attributing this kind of exclusivity to it. While it is true that in some, usually exceptional, circumstances pain is experienced in the absence of peripheral input (or no pain is experienced in the presence of peripheral input), the transmission of nociception into the CNS is still a very common 'cause' of pain.
                                I disagree somewhat. The brain is absolutely essential and central to pain. Peripheral input is of course present at all times, but it is the brain that interprets the input as a "threat" or as "negligible". It gives value to the input from the periphery. No matter HOW much nociception there is, it is ultimately the brain that "causes" the pain. After all the periphery as the patient perceives it, is entirely a virtual construct of the brain.
                                I think you agree with this, but it seemed in the above quote that you did not....

                                Interesting example of beginning the therapy at the brain:
                                The education (pain neurophysiology and neuromuscular defensive patterns) of a patient with persistent impingement syndrome and adaptive patterns was sufficient to modify the brain's output and normalize his condition.
                                He then started to do his own exercises to strengthen his shoulder, because now he was painfree.


                                Last: we need to replace "placebo" with a better terminology. Even "placebo-response" evokes too much of an image of a charlatan-effect. "Cerebral output modification" seems more appropriate.
                                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

                                Comment

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