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Old 11-08-2013, 10:03 PM   #1
murradou
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Default Pain questions

Hello everyone,

I figured there is no group of people better to ask this question to (just hope I picked the right forum). I'm just starting to get into understanding more about pain and educating my patients about it.

Here are my questions:

1) Night pain. Why does pain for some people get worse at night (absence of red flags of course)?? I've had a few patients who's pain and function have greatly improved, to only suffer more at night. I'm finding these occur more in shoulders and knees.

2) Why does Post assessment/post treatment flare ups have a delayed effect?. Typically I get a sense of people's irritability during assessment and I do my best to respect it. But I find most are more sore a few hours later or the next day, even if I don't do any overpressure or aggressive testing. With some people I just watch them move, test ROM, and they are fine in the clinic but flare up later.

Also, I never do any painful manual techniques. If it hurts, I modify or stop. I've had a few people who I've done some joint mobs, that don't hurt, and improve ROM. The patient informed me that a few hours after their pain increased.


I'd love to hear peoples thoughts on these pain experiences.

Thanks
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Old 11-08-2013, 10:34 PM   #2
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About sleep:
in knees and shoulders it may be as simple as the ongoing nociception without the therapeutic motion of living in the daytime. Combined with possible stressful positions (not terrible, just added stress), and the critter brain may be well ready to pull the bell.

The delayed effect? As the first paragraph, pure speculation, but there may be some motion that the patient has been avoiding partially or completely - the increased input of motion in increased end ranges may have triggered a post-motion tension - which then can lead to increased neural anoxia, etc etc.

All strict speculation.

When a patient asks me, I generally say: "I can not really tell you, cause we do not know exactly."
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Old 11-08-2013, 10:39 PM   #3
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Two things regarding night pain. First, just because you've ruled out red flags doesn't mean that the patient doesn't have an ongoing chemically/inflammatory origin of their pain. This tends to spike at night probably due to venous stasis w/ lack of movement. Secondly, lots of people get very distressed when they can't sleep and the distress can become a very potent input into the left side of the neuromatrix, and then we know what can happen from there. I've reassured patients that just because they wake up with some discomfort and they have to get up and move around or go sit in a chair, doesn't mean that their entire night's sleep is going to be a total wash out. I instruct them to use the opportunity to try some relaxation breathing or even listen to a body scan audio (which I give them in CD form or as an MP3 attachment).

Post-assessment flare ups are probably more often than not attributable to post hoc ergo propter hoc fallacious reasoning. The fact is that the clinical encounter has, to some extent, re-directed the patient's attention to their problem, and they may have an unreasonable expectation that after seeing a knowledgeable health care provider that they won't have anymore serious flare ups. When they do, then they blame it on the assessment plus their disappointed that their not magically all fixed. They may also be experiencing some cognitive dissonance if the therapist began to address some of their thought viruses. I "warn" my patients about this without making it sound like a warning, if that makes any sense.

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Old 11-08-2013, 11:00 PM   #4
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A lot of it might be a) lack of movement leads to slowed down alterations in neurodynamics (movement, mechanical stimulation) needed by the intraneural vascular array, and b) lack of other (waking) distractions makes the brain notice discomfort a lot more.
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Old 11-08-2013, 11:25 PM   #5
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Inevitable increased sympathetic activity as we sleep? Doesn't this reduce our adaptive potential? Isn't it useful to go to sleep "warmer," having done some of things suggested during treatment?

I make this argument anyway though I'm sketchy on the details.
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Old 12-08-2013, 12:12 AM   #6
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I'll go with the lack of movement and the critter brain that Diane mentions.

If a person goes to bed in order to try to sleep despite pain, that person may already have been sitting or lying beforehand with a degree of hypoxia in the NS. Analgesics may dull the pain for a few hours only.

Sleep studies (Michael Moseley's series)have also shown that one does not need 8 hours straight sleep - as long as the accumulated hours add up more or less to 8. This fact may help to reduce anxiety about about sleeping.

Just some thoughts.

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Old 12-08-2013, 03:57 AM   #7
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Quote:
Isn't it useful to go to sleep "warmer," having done some of things suggested during treatment?
This is the home program I give to patients with pain at night....

I like to have a patient lie down on a treatment table and ask them how their body feels and go through that process of feeling where the body is flush with the table. Where is the stiffness? Where does the body feel soft? I will move the body part to give feedback to the patient.

Then do some movement awareness exercises, diaphragmatic breathing, relaxation exercises and manual therapy then retest. Hopefully the patients notices a difference. In Barrett's 4 hour lecture on Simple Contact, he has a patient lie on his back and diagrammatically breathe. Then notice the difference with the legs crossed. Then notice the ease of breathing with the legs spread apart. Then Educate and work on ideomotion. Patients will tend to notice more relaxation afterwards.

when patients notice the change in flexibility, I like to explain possible reasons for this increased movement.

1. they are in a relaxed state. I will give patients the example of excessively tightening the wrist while flex/extending it. Then relaxing the wrist while flexing/extending. Most seem to get it that relaxation tends to promote more movement, rather than protective tightening. (from Peter O'Sullivan's youtube video)

2. Protective tightness from the nervous system is in the subconscious level. which may also be maintained at night.

3. chest breathing due to the cultural response of holding the abdominals is like moving the body in a tightened state which may put the rest of the body in that tightened state. They may be doing that all night.

4. Preventing our body to move in a way it wants to is also a cultural. - relating this to ideomotion

5. Diaphragmatic breathing and ideomotion is the only "exercise" they can do at night to help the body relax

5. Pain education in the best way I can to relate it to the patient's nervous system.
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Old 18-08-2013, 09:02 PM   #8
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Thanks for all the great responses. Looks like I will be doing lots of reading about ideomotion.
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Old 21-10-2014, 09:12 PM   #9
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Many thanks, will add it to my reading list and, no, not what i'd want for anyone but the human bodies ability to continue on is always astounding.

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Old 21-10-2014, 09:54 PM   #10
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Hello ali,
Would you please start a thread and introduce yourself in the welcome forum?
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Old 10-05-2017, 10:10 AM   #11
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Most of the peoples get very distressed when they can't sleep and makes unusual postures while sleeping which can also lead to the night pain.
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Old 11-05-2017, 01:22 AM   #12
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After due diligence to rule out bad things, consider this: At night, all of the things that distract one from thinking about their pain go away. So in bed, it's just the person, and their pain. Sleep occurs when the brain changes from the thinking mind to the imaging mind. When one is thinking about pain, sleep does not come, and only worry continues, which creates more thinking, which creates more worry, which creates more thinking, and so on through the night...... Believe it or not, trying to purposely use imagery will help to fall asleep faster. Picture a basic shape on a blank background. Or if you can picture something more elaborate, go for it. Like anything, this takes practice and many give up before they have practiced enough. Give it two weeks of nightly practice of visualizing before drawing any conclusions as to whether or not it works for you. If your patients think it does not work for them, they probably did not practice enough. The brain is trainable.
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Old 11-05-2017, 02:55 AM   #13
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Hormones can play a part - cortisol drops through the night before rising in sync with our wake cycle.

Pain can impact that cycle.

That cycle can impact pain.
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Old 16-06-2017, 04:21 AM   #14
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Adrenaline and cortisol levels are lowest at 3am. That's why depressives and asthmatics often wake with problems at this time.
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Old 16-06-2017, 12:48 PM   #15
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Symptoms aren't multifactorial then? I suppose the word "often" covers the fact that it might be.

Many things may "help" because the body is both self-healing (should time, position and metabolic economy take place) and self-corrective. That second one is something not known or considered by many.

Are you suggesting that therapists just "try" things or "blame" things? Might thoughtfulness play some role here?
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