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Re: Painless physical therapy vs. pain during treatment
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 3:15:00 PM
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Bournephysio
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From: Calgary
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Nari, please state with specificity where anything that I have written is inconsistent with current pain science. Maybe I’m missing something. If you can clearly state where I am wrong and reference it, I will concede the point.
Sebastian, I was going to go through your post point by point but we are not far off on most of them so I’m not sure you quite get my point. Going through point by point would distract from my most important point so I’ll just quote one:
“"While it is possible that direct nervous irritation without the involvement of other tissues is possible, I don’t think we commonly see it in the clinic."
Maybe not.”
This is the most important point. Your theoretical framework is extremely important to how you interpret the literature, how you make predictions, what literature you search out.
Hypothesis one: Most chronic pain is caused by irritated nerves and an absence of involvement other structures.
Predictions:
Effective treatments will target the nervous system
Support: This is very well supported in the literature.
Treatments that target other tissue will be ineffective
Support: Joint replacements are HUGE hole in this theory amongst others. Eccentric exercises “may” also be unsupported by this framework.
Sought our research:
Likely to concentrate on pain physiology which of course is good. Likely to be unfamiliar with the huge body of knowledge on the biology, biomechanics and mechanobiology of other tissues much of which could readily explain sensitization of the nervous system. Unlikely to be familiar with genetic research showing that defects in structural genes (Coll2) and metabolic genes (MMP’s) are large risk factors for diseases such as OA.
Hypothesis two: Most chronic pain occurs in the presence of some form of tissue damage.
Predictions:
Effective treatments could target anywhere from effected tissue to brain
Support: This is completely consistent with the literature.
Sought our research:
Just about anything.
Doug
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 3:18:00 PM
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nari
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Proud,
Go for it. You have nothing to lose and the patients have everything to gain. It's all fascinating stuff, without the imaginative hype of those who promote techniques based on figurative and dodgy science; as with many alternative practitioners within and outside of physiotherapy.
Nari
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 3:36:00 PM
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Jon Newman
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Hi Doug,
I don't see arthritis as being a HUGE whole at all. OA is a well defined, detectable pathology occurring in tissue unable to repair itself by its genetic nature. The body was not evolved to expect knee replacements and thus the pain is likely defensive and serves to protect the person. Meanwhile they are made to go through a wait and see, synvisc, PT and alternative treatment regime before someone agrees to perform a TKA. Also, the pain relieved by a simple TKA tends to behave quite predictably unlike many forms of chronic pain seen in the clinic. And if I'm not mistaken, the reason knee replacements don't hurt (meaning ideally and in the long run) is because the irritated neural tissue, along with the cartilage has been removed. The fact that this works is actually quite surprising as the "remove the nerves" strategy doesn't typically work all that well.
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 3:38:00 PM
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Bournephysio
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Jon: I believe that most nociception that we see in the clinic is a combination of mechanical and chemical but in the presence of some form of tissue damage. The biology/chemistry of tissues is very very complex. The number of possible chemicals that can lead to nociceptive signals is gargantuan (Gargantuan. You know I've always liked that word gargantuan, and I so rarely have an opportunity to use it in a sentence :) Examples: Chemokines, Cytokines, NO, O2, Neurotransmitters such as substance P. There are many causes for these chemicals to be released including mechanical loading.
I don’t think that it is fully appreciated that “healed” tissue does not equal “pre-injured” tissue.
I agree that PTs often have an obsession with ligaments, capsules etc but as inert structures not biologically active tissues. This does not justify an obsession with the nervous system to the exclusion of others. A balance needs to be maintained between anatomy and physiology. Currently the most effective treatments appear to be neuromodulatory in nature at least short term. That does not mean we should be blinded to other possible treatment mechanisms. Maybe the effect of eccentric exercises is not neurally mediated?
Doug
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 3:44:00 PM
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Jon Newman
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The relief of pain is neurally mediated. The effect of eccentric loading itself may exert its influence elsewhere. I think flipping some genes on or off is being looked at seriously.
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[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 3:48:00 PM
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jboypt
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Contractile dysfunction-dysfunction of the contractile unit. Passive movements will not elicit pain. Resisted movements will reproduce pain usually noted by a painful arc. For more information and treatment see The Human Extremeties Mechanical Diagnosis & Therapy (Robin McKenzie and Stephen May) for more info.
I attended the McKenzie Conference of the Americas earlier this month in Montreal, Canada. Dr. Karim Khan presented his research titled TENDONOSIS, NOT TENDONITIS-THE CLINICAL IMPLICATIONS. I only report this because his work has been mentioned in this thread. During his presentation he reported that he believes his reasearch is the model that represents a contractile dysfunction in the clinic. This is important because it is scientfic evidence for McKenzie's assertion/belief/definition of a contractile dysfunction. The main points of Dr. Khan's presentation regarding tendons previously referred to as tendonitis:
1. No inflammatory cells present
2. Disorganized collagen
3. Abnormal blood vessels & nerves (in the tendon)
4. Abnormal increase of GAG's and PG's
5. Abnormal extracellular matrix
He reports the process whereby a tendon remodels is termed mechanical transduction. This guy is very physio friendly and understands the need for scientific models to support clinical findings.
Newman-Check out the above book for suspended healing definition
John
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 3:58:00 PM
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proud
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Nari,
I have read Butler's work and feel I have a pretty good grasp. However, I can acknowledge when others seem to have a deeper understanding( including almost all posts here... despite the different viewpoints).
In your opinion, is Butlers work enough or do you recommend a particular text?
Thanks.
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 4:03:00 PM
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rwillcott
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From: Canada
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Curwin and Stanish have performed some excellent research in this area of eccentrics. They state that there will be pain present.
Rob
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 4:06:00 PM
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Bournephysio
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Jon, I have to be very careful with definitions. I meant it may not be neuromodulated within the nervous system but may be removal of the nociceptive input. The flipping of genes on or off is the mechanobiology that I am talking about. Part of my research is studying the effect of loading on gene expression in cartilage. I can detect coll2 and aggrecan mRNA in individual chondrocytes.
OA has many similarities with chronic pain. Pain is not directly related to pathology. Disability is much more related to psychological factors than pathological. I just saw a presentation in Munich where performance on a six minute walk test is determined mostly buy how far the patient thinks they can walk than any pathological factors. I concede that OA may not be the perfect example but I think that the main difference between it and other forms of chronic pain is that we can recognize the pathology to a certain extent.
Doug
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 4:33:00 PM
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Jon Newman
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Hi Doug,
Check out section V in the "Pain is not quale" link. I can't help but wonder if it doesn't describe what you're talking about in your last post as well as what we're talking about in general in this discussion.
PS. Those looking for books might be interested in [URL=http://www.clas.ufl.edu/users/maydede/pain/Frontmatter_PainMIT.htm]PAIN: New Essays on Its Nature and the Methodology of Its Study[/URL] where I found the essay.
[URL=http://selfpace.uconn.edu/paper/ClarkAusPainQual.html]Pain is not quale[/URL]
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 4:40:00 PM
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nari
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Rob
Have you read Butler's Sensitive Nervous System or his MOTNS (revised original text)? Because this is a fast growing field, the original Butler text (around 1990) is now outdated.
Michael Shacklock's Clinical Neurodynamics is a recent text and goes into the levels of sensitivity which should be respected when doing anything to a body or body bits.
These guys from Down Under are leading the field in teaching clinical neurophysiology; but there is a lot being researched in the deep model - ie the nuts and bolts of neurons, glia, nociception, mirror neurons, pathways. Ramachandran's books are good for the deep model, which needs to be considered when dealing with pain.
Have a google with V S Ramachandran.
Nari
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 5:26:00 PM
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Jon Newman
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Some more thoughts on this:
[QUOTE]I meant it may not be neuromodulated within the nervous system but may be removal of the nociceptive input.[/QUOTE]It may be. A reasonable question is whether it did so through a decrease in the mechanical deformation of the nerves or through a decrease in some chemical of intermittent frequency and concentration. Or it could be a decrease in ion receptors available to sense nociception. Or it could be neuromodulated within the nervous system, perhaps anatomically, as in a degeneration of c-fiber sprouting, or electrically as in descending inhibition or alternative routing of action potentials. Or of course, more than one of the above. Speculation is the stuff of discussion boards and I fully enjoy it. I especially like it when the speculations start to jive with what researchers later demonstrate. It almost makes it seem like we're not so off kilter.
_____________________________
[URL=http://www.sonymusic.com/clips/selection/30/064887/064887_03_03_30.wav]Evidence[/URL]
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 6:13:00 PM
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dosrinc
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Man, how did I miss all of this? Where have I been? Good thing we closed the practice tomorrow for what is now no more than a bad thunderstorm ( I cant believe I just had to type that), now I can catch up on what looks like a very interesting thread.
Rick
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 9:53:00 PM
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avalon
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[QUOTE]Maybe the effect of eccentric exercises is not neurally mediated?
[/QUOTE]Doug, I know the serious you carry in your study but such a sentence is against your evidence. You say that it is painful and pain is neurally mediated, isn't it?
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Re: Painless physical therapy vs. pain during treatment - August 29, 2006 10:37:00 PM
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avalon
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Here is the point of view of a great physiotherapist =>
http://www.algoless.com/pdf/meme.pdf
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Re: Painless physical therapy vs. pain during treatment - August 30, 2006 1:34:00 AM
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Sebastian Asselbergs
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Doug and others, I really appreciate your time spent here.
I just want to single out an issue from Doug's post:
"Likely to concentrate on pain physiology which of course is good. Likely to be unfamiliar with the huge body of knowledge on the biology, biomechanics and mechanobiology of other tissues much of which could readily explain sensitization of the nervous system. Unlikely to be familiar with genetic research showing that defects in structural genes (Coll2) and metabolic genes (MMP’s) are large risk factors for diseases such as OA."
Now, consider the assumption "unlikely to be familiar" is wrong. Then think about HOW the tissue biology, biomechanics and mechanobiology are targeted in treatment. Any rehab/intervention/treatment of those issues, requires interaction with the nervous sytem. It IS the everpresent system.
Any exercise requires neural input and output and processing, any hands-on technique (ANY) (and it's positive effects) is by nature an interaction between the therapist's nervous system and the patient's, and any education or even modalities requires the patient's neural system to be involved.
Advertisement follows:
Positive effects of rehab are "brought to you by your nervous system".
"Pain is brought to by your nervous system".
"motion is brought to you by your nervous system"
"Relief is brought to you by your nervous system".
"Restoration is brought to you - mainly- by your nervous sytem"
I just want to finish by saying that I have been studying (in spurts) more neuroanatomy, biology, physiology, psychology, exercise, biomechanics, manipulation, to cognitive neurosciences- YOU NAME it, and have found that my main focus in rehab is engaging the patient's nervous system. Since that makes the most sense and has the best patient outcomes for me.
Thanks.
_____________________________
Mundi vult decipi
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Re: Painless physical therapy vs. pain during treatment - August 30, 2006 4:57:00 AM
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dfjpt
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Sebastian, I was going to go there too. :)
My point was going to be, Doug, as soon as you lay your hand on someone's spine or scapula or knee or anything mesodermal, there is that layer of ectoderm, of sensing nervous system in between. There is no escape from it. It will read your contact long before you can make up any story, plausible or not, about your intentions toward the mesodermal structure you are trying to get through to.
BTW, Henry's link is a hilarious spin on the "I have a Dream" speech by MLK written by Nick Matheson in Nova Scotia, and is germane to this topic.
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Re: Painless physical therapy vs. pain during treatment - August 30, 2006 5:42:00 AM
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Shill
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Eric mentioned
[QUOTE] I hope that you are not suggesting that anyone is guessing about how to treat their patients. Doesn't seem like those therapists hang out here. Some of you are much better read than others, but none of us has all of the answers. And, if everyone fits neatly into diganostic categories, PT for you must be pretty mundane and I would guess then that you have stopped learning from your patients? [/QUOTE]I would reply that first, I am not suggesting anything. One must be careful to avoid reading into a written statement where tone of voice can not be interpreted. I am saying that if one ends up with nothing after an evaluation, then there can only be guesses. Most patients can be categorized by symptom behavior, and rather than that being mundane, I call it structured. I have said it may times, and will say it again, while the individual with the dysfunction, diagnosis, condition, (whatever we want to call it) may be different from the last patient, there are more similarities to said dysfunction than differences. The similarities are in symptom behavior and characteristics, evaluation findings, both subjective and objective. The main differences only lie in the patient's interpretation of the problem, and its affectations on the daily routine. We treat the interpretation through education, and the functional problems through activity modification and perhaps some bodymechanics training as needed to irritate things as little as possible while still getting things done.
Sarah asked
[QUOTE]Are you saying that you are absolutely sure what the cause of a patient's problem is from day 1? I always thought PT was about making an assessment based on subjective and objective findings, then developing a working hypothesis about the treatment effects and prognosis, testing that hypothesis, then based on the results, either continue to treat or change to a new hypothesis. Isn't that the scientific method?? [/QUOTE]I would reply to this with a "NO" for the first question. Some studies show that when attempting to accurately diagnose the tissue of origin (at least for LBP), even the experts are incorrect about 80% of the time. I am not above the research, and hence the "NO". However, what I am saying is that my evaluation gives me direction based on findings, as you so eloquently stated right after your first question. My point in the post is no findings, no direction.
Sarah also noted
[QUOTE] What I do know is that the human body is a complex system and no two individuals are the same. [/QUOTE]For this, see the comment for Eric. If we submit to the fact that everyone is so different that we must treat each person differently, we go down the path of having 400 "accepted" but not necessarily "effective" ways to treat the same problem, which lacks the structure needed to ever gain the credibility that our field seems to seek by a number of other means.
And finally, Sarah added
[QUOTE]I'm happy for you that most of your patients fit into neat boxes....mine don't. ... but I'd bet my money that the "irritable tissue" is the nervous system anyday, versus the ligament, capsule, muscle, joint, or fascia
[/QUOTE]My reply here is thank you for being happy for me. You are obviously a very nice person who cares greatly for people and patients. However, I will still take the bet. Sometimes its nerve, sometimes it isnt. One is not supposed to shoot the messenger. Isnt the nerve that messenger?
_____________________________
Steve Hill PT
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Re: Painless physical therapy vs. pain during treatment - August 30, 2006 5:45:00 AM
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Bournephysio
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Sebastian, yes my comment was a little over the top but you have to admit that attitude is seen here.
Diane and the rest of Sebastian's post, I don't see how anything that I have said contradicts your points.
Just because our treatments main effect is through the nervous system does not mean that the originating pathology/problem is in the nervous system.
Even though all our treatments have to stimulate the nervous system does not mean that their main effect is through the nervous system. The evidence suggest that they do but that does not have to be the case.
Very precise thinking of the mechanisms is important. For example: exercise A may be beneficial because in neuromodulates the pain through a serotonergic pathway or exercise A may improve motor control which decreases stresses in the tissues and thus decreases nociceptive activity. Of course other mechanisms are possible. This is just an example. Both effects are due to the nervous system but are different. If the first is correct then exercise A is likely a good treatment for the problem. if the second is correct then maybe exercise A can be used to prevent the condition in question.
I'm a little baffled by the response my post has received. The last two posts suggest that it has been misunderstood. I hope this clarifies a bit.
Doug
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Re: Painless physical therapy vs. pain during treatment - August 30, 2006 5:47:00 AM
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Bournephysio
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Avalon, the statement was clarified previously.
By last two posts I meant Diane's and Sebastian's
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