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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 30, 2006 6:19:00 AM
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Sebastian Asselbergs
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Doug - yes it does. Sometimes views polarize and make us go over the top sometimes. Me included. It comes from getting trained in a system that commonly used terms like "it's gotta hurt to get better" and "We have to break down those adhesions" and "Don't focus on the patient's pain - focus on the function" etc etc. Obviously, when I evolved a bit, I tend to become sensitive to certain words.
I'll learn....
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Mundi vult decipi
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Re: Painless physical therapy vs. pain during treatment - August 30, 2006 6:57:00 AM
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dfjpt
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Doug, [QUOTE]I'm a little baffled by the response my post has received[/QUOTE]In your post dated August 29, 2006 04:37 PM you attacked or at least sounded like you were attacking Nari, which is what prompted me to become involved. You accused her of insulting your intelligence, in case you don't remember... I was moved to reply because of that. I'm done now.
Fondly,
Diane
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Re: Painless physical therapy vs. pain during treatment - August 30, 2006 8:13:00 AM
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Bournephysio
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Diane, My response was probably a little strong.
What Nari's argument boils down to is that I don't understand current pain science. I would have no problem with the statement if she backed it up. In this thread she has made the comment twice and has refused to back it up. If she was correct she should easily be able to point out my mistake and provide a reference. She has done neither. I can't think of a venue where this would be an acceptable argument but it is particulary poor on an internet forum.
Doug
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Re: Painless physical therapy vs. pain during treatment - August 30, 2006 11:12:00 AM
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nari
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Doug
Your response does not concern me one bit, and I have not had opportunity to reply to your post where you invited me to point out discrepancies or whatever with back up.
Since then, others have provided relevant information; so I will say that your knowledge of pain science is not in question, but my point is the application of that knowledge to clinical presentations. As Bas has stated, we do become polarised, and he gave some good examples of memes that we all have grown up with over the years.
If I have offended you, that is not intended, and I regret that. However, to me the 'why' of how exercise A works or exercise B or Z is the crucial thing; not the 'how'.Some of us come in from a different perspective which is towards managing pain, and not function. Sarah has implied this in her posts, as others have. Every patient is different; it may mean that their presenting conditions are similar, but how and why they respond in a certain way to our interventions makes for more precise outcomes. Each person responds to pain differently, so giving them method A because of presenting dysfunction will addresses the ROM or dysfunction and may not address pain effectively.
Anyway, no hard feelings. We are treating from different perspectives; the outcomes may be quite similar but each of us uses what makes sense and has support from established literature.
I am also lousy at arguing endlessly when clinical perspectives are different; I get bored.
Hope this resolves any issues you may still have.
Nari
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Re: Painless physical therapy vs. pain during treatment - September 1, 2006 3:14:00 AM
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Randy Dixon
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I think Doug's argument is pretty sound and hasn't been refuted. It seems the arguments are running parallel rather than counter to each other.
My simple interpretation of Doug's post is this: If I break my arm, snap it in two, I'm going to feel pain. This is entirely due to the nervous system. The fact that nociception isn't sufficient to cause pain or any of the other points brought don't matter, what does matter is that my arm is broken. Sometimes pain IS just a sign or symptom and not the problem.
I don't think I'd be worried about my arm because of an ignorance of neurobiology.
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Re: Painless physical therapy vs. pain during treatment - September 1, 2006 3:54:00 AM
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Jon Newman
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Hi Randy,
I think you are wrong when you state pain is "just" a sign or symptom and not the problem. If so then we would simply cast, sling or repair the arm and that would be that--problem fixed. Next.
No one here has ever suggested that musculoskeletal pathology doesn't exist or that pain doesn't coexist with it. Nor has anyone suggested that we should ignore the musculoskeletal system. On my reading it was an argument about explanation and levels of analysis.
In the Sept./Oct. edition of the The Skeptical Inquirer, Massimo Pigliucci's regular column (Thinking about science) is titled One More Take on Reductionism vs. Holism
From the article (italics mine)
[QUOTE]Reductionism begins with the (unwarranted) assumption that it is always possible to reduce complex systems to the properties of simple parts; at the opposite end, holism begins with the (equally unwarranted) assumption that the world is inherently complex and does not admit of reductionist explanations. Mechanism is a happier middle ground, where the scientist (and the philosopher) negotiate the proper level(s) of analysis, depending on what nature actually tells us.[/QUOTE]and
[QUOTE]Mechanism, in Brandon's conception, is the philosophical position that, both methodologically and ontologically, there are in fact several levels of analysis and complexity in the world and that scientists should not begin by assuming how many levels there are and where they can be found. Rather, science can in part be construed as an attempt to reach a "reflective equilibrium" between its methodology/ontology and the way the world actually is.[/QUOTE]Doug seems to be arguing for a reflective equilibrium. It is my opinion that Nari, et. al. are not ignoring the mesoderm but rather that those aspects are already a fundamental part of our educational background. Fundamentalists aside, I think most are seeking this equilibrium also. It's just that PT seems to be in a far from reflective equilibrium state and it takes a few strong attractors to create some change. I, for one, am happy for their contributions.
_____________________________
[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 - September 1, 2006 5:20:00 AM
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srcase
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Randy,
I agree with you that the arguments seem to parallel one another later in the thread. Taken out of context, my statement
[QUOTE] but I'd bet my money that the "irritable tissue" is the nervous system anyday, versus the ligament, capsule, muscle, joint, or fascia [/QUOTE]was not implying that we should ignore the musculoskeletal system. It was merely a tongue-in-cheek remark meant to illustrate that we shouldn't treat just the joints, muscles, etc. and ignore the nervous system. Which is in agreement with Doug's point that the two systems are interelated and you can't separate one from the other....aka a complex system.
If you read previous posts, the original patient case was one in which the patient had no pain in the clinic. I was the one that suggested treating the mechanical interface (muscles). By making my statement (above), I was merely arguing the case that we shouldn't be so concerned with finding the how and what (stenosis, derangement, entrapement, etc), as with the why?? That is the distinction between what I see as the reductionists vs. the holists.
By arguing that "x" technique produces this outcome in this type of patient, we are stating that we are more concerned with how and what (McKenzie, CPR's), but the question "why" remains unanswered. It's as if the ends justify the means. This is not a bad thing, and is a good step toward understanding a complex system, but it has it's limitations. On the other hand, the opposite would be arguing the why (neurophysiology, pain science) at the expense of the how, which I don't think the other group has done. Diane and others have made the why and the how very clear in their posts.
So, hopefully we can learn from each other to integrate the two ways of thinking and reach, as Jon so eloquently states: a reflective equilibrium.
Sarah
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Re: Painless physical therapy vs. pain during treatment - September 1, 2006 7:14:00 AM
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dfjpt
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I like what Michael Shermer said about science in an article posted at edge.org:
[QUOTE]Science is a verb, not a noun.[/QUOTE]If PT is going to gain credence in science, it will have to stop seeing/teaching/treating mesoderm in cognitive isolation.
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Re: Painless physical therapy vs. pain during treatment - September 1, 2006 7:29:00 AM
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Jon Newman
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Good point Diane. We could say the same thing about "physical therapy".
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Re: Painless physical therapy vs. pain during treatment - September 1, 2006 11:20:00 AM
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dfjpt
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And we could say the same thing about the nervous system. That it's a verb, not a noun that is. Which makes it more clear that it is a system that is interacted with rather than done unto.
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Re: Painless physical therapy vs. pain during treatment - September 3, 2006 1:18:00 AM
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Randy Dixon
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Jon,
I agree with the articles you posted. I understand the desire to balance what some percieve as one extreme position by presenting the opposite extreme. I believe, as you pointed out, the best course lies somewhere in the middle, which is what I believe Doug was saying as well.
I disagree that pain can't be just a sign or symptom, in the case of the broken arm, if we could remove all the pain originating from the break in the arm, this would have done nothing to insure that the arm would heal properly. On the other hand, if we insure that the bones are set, that no further tissue damage is being done and that it is immobilized and protected, then the pain takes care of itself.
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Re: Painless physical therapy vs. pain during treatment - September 3, 2006 3:19:00 AM
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Jon Newman
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[QUOTE]On the other hand, if we insure that the bones are set, that no further tissue damage is being done and that it is immobilized and protected, then the pain takes care of itself.[/QUOTE]I agree that ideally this happens Randy. However, pain can also disappear long before a bone is sufficiently healed. Although sometimes the pain sticks around for much after it has healed. The former puts the patient at risk for further injury and the later for deterioration of the person. Tissue damage and pain are simply not of the same logical kind although it is common for them to appear in tandem.
I think most posting in this thread would agree that pain, especially when persistent, no longer is serving as a useful indicator of whether someone is doing something that is corrective in nature. We need other markers for that.
_____________________________
[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 - September 3, 2006 1:57:00 PM
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ginger
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This thread has been a great read this morning, lots to think about. In my offerings about method over the past year or so , I've made regular mention of Continuous mobs and its best effects , particularly where musculoskeletal pain is being treated as a presumed/proven referred event from spinal joints/structures. Weighing in with CM as my preferred method to deal with these problems ,causing pain during the process of restoring normal pain free movements to facet joints is a fearture of this process. It is a usefull guide to the effetcs of mobs. Not much pain is needed . pain is felt as an equal and important corrolory to resistance ( to passive mobs). Pain reduces as resistance reduces as movements improve as hypertonic muscles relax as the protective event is turned off. Without the valuable sensation of pain I find myself attempting movements that are not capable of altering the string of neuromuscular events attendant to a hypomobile facet joint. In the working out of the ideal passive movements that produce the ideal reductions in tone etc, I have come to regard pain as a necessary feature ( of treatment) that very few patients consider to be difficult to bear. Indeed many will say that the effects of mobs , including the pain/discomfort that goes with it , is satisfying. Particularly when rapid improvements are noted, which is most of the time.
The most fascinating aspect though it seems for most patients, who had been previously treated for various musculoskeletal problems by attention by others to the site of the pain, is the rapid amelioration of the pain/dysfunction , as it becomes clear to have been a referred problem (so called tendinosis is just one).
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The Grand Pediculator
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Re: Painless physical therapy vs. pain during treatment - September 3, 2006 2:30:00 PM
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dfjpt
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Ginger:
[QUOTE]I've come to regard pain as a very useful feature in the sortings out of and the treatment of , in particular , musculoskeletal problems. In the throws of doing my work , there certainly are variances noted in the way pain is dealt with by people.
The following are some of the main types I've categorised according to the vocalisations immediate to the pain experience.
Operatic. a loud hoooooowwww that cascades over and over , somewhat like the diva made famous while singing the "ring cycle". one can imagine a stout blonde maiden with plaits and a horned helmet .
Ethnic. a hurrrow sound similar to a japanese ninja just stuck with one of the samurai's swords.
alternate name for this type is Chinese.
Religious. utters blasphemous profanities , using the word God, or Jesus. usually preceeded with OOhhh, as in Ohhhh God!.
Toilet.Similar to religious , but delete God and insert the swear word ( use your own language or favourite here ) for faecal matter.
Sexual. a short expletive , almost barked out as if to emphasise the depth of the sufferers intention to shock him or herself "F..K".
Narrative. wants to tell you in graphic detail , when and where the pain is , sometimes extolling the insights that go with it. Even down to the last time this was felt and the circumstances of the painfull experience. Usually female over forty.
Indigeonous. a slow low deep rumbling throaty warble , not unlike a didgeridoo
Feline. meeeooooow!, only when provoked, settles into a more bovine sound if pain continues[/QUOTE]Some of us really are trying to get away from this image of PTs as pain causers/provokers. Could this be why Australia has such an epidemic of persistent pain that it has become a fountain of PT specialization in pain science trying to undo that which has been done unto its citizens by others in the same profession? Reap what you sow?
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Re: Painless physical therapy vs. pain during treatment - September 3, 2006 3:46:00 PM
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ginger
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From: Melbourne Victoria
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Yes Dianne , You may well have the moral high ground in the hill of discontent. My patients only care to have their problems solved. Should you be willing at some point to climb down I'd be only too happy to share usefull insights with you. Particularly in the light of what appears to be a method (CM )that is learnable , teachable , safe and immediately effective. I did my best with your offerings. At one point I asked you to describe your methods . All I got for my trouble was a plethora of wishy washy mumbo jumbo. I'll continue to state my case with as much clarity as I'm able . You are free to spend your time offering little but saying much.
_____________________________
Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Painless physical therapy vs. pain during treatment - September 3, 2006 5:02:00 PM
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dfjpt
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I know you've tried to enlighten me many times about where to push to clean up anything that presents, yet my "plethora" works ok without inflicting more pain on people.. so I guess I just don't get why you apparently do. Is it a price your patients must pay/you need to extract from them to have you "solve their problems"? Why can't they learn to solve their own (pain) problems?
As for describing my "plethora of wishywashy mumbojumbo", I guess you must like to write more than you care to read.. but if you ever want to know more about it, there are a lot of fairly concise descriptions posted at a site that I know you frequent. They're there for free to read if you want.
As for wanting me to take on any of your treatment ideas, no thanks, been there, done that, can't ever go back. The future of pain treatment won't be about hanging onto the spine for dear life as if it were a dock out into a scary ocean. Learn to swim sometime.
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Re: Painless physical therapy vs. pain during treatment - September 4, 2006 5:20:00 AM
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SJBird55
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Diane, you seem to have the attitude that pain is bad. Pain is neither good nor bad. Pain is just pain.
Ginger, both you and Diane have seemingly different approaches to your views on approaching the patients that you treat. Diane, I do tend to side somewhat with Ginger in [QUOTE]plethora of wishywashy mumbojumbo[/QUOTE]Ginger is more detailed and concise and concreate in his writings and descriptions, whereas you, and those that believe as you do, are definitely more vague, abstract and philosophical. I've come to believe that you are both very passionate in your belief system. What generates in my mind from both of you is why? Why can both approaches seem to work? Where are the commonalities? I think it would be interesting to be a fly on a wall in both of your clinics observing and contrasting/comparing.
The other thing that pops into my head is the plain and simple question of whether both of you are truly remembering your experiences/outcomes with patients accurately. Neither of you have statistics to provide on your claims of having results with patients. Ginger, I am excited that you are moving forward and will be looking at that aspect and I will be looking forward to what you learn. Diane, on the other hand, no one in your group finds value in taking the time to assess the results achieved with your type of approach. Talking about it, writing about it, going to workshops, having Nick write, spewing negative attitudes toward evidence based practitioners and posting mainly at 2 sites isn't going to change everyone. Going Cross Country isn't going to make large impacts either. Basically, the way to encourage change, especially with those therapists that are members of associations and are trying their best to be evidence based practitioners is to publish some actual data or a case study or something. I do believe that the manner in which you argue your stance does create a divide and isn't going to achieve much of anything except arguments and defensiveness.
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Re: Painless physical therapy vs. pain during treatment - September 4, 2006 6:34:00 AM
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dfjpt
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SJ, only those who bother to read anything are ever going to be able to understand the differences in the two approaches. (I seriously doubt that will be you, somehow..)
Furthermore, no one is ever likely to get the whole picture of itatrogenically perpetuated/augmented pain all into one picture. It's a broken mirror and the whole picture is a distorted mess. At least a start would be to recognize that pain exists, that it is unpredicatable, that what one does to someone's nervous system through efforts to push things around might have an effect.
When the effect is good, fine, it props up the claim the practitioner is making that their favorite mesodermal poke-a-thon is effective. When it doesn't the patient is a whiner, or crazy. So much for outcome studies. No one seems to count the failures, just the successes.
Katherine Harmon, a PT turned pain researcher at Dalhousie, says, "Whatever you do to patients, please do not turn them into chronic pain patients with provocative tests." I live my life by those words, and make my interventions accordingly. If someone doesn't improve at least I'll know it wasn't me who made their pain state worse. Without pain, it's amazing what people can go on to do with their bodies and their lives, even if they still have crappy "function" by obsessive biomechanical standards.
This whole profession has fixated on the wrong thing for wrong reasons. From Barrett's latest post..
[QUOTE]Again we return to this: Progression in the profession will not result from what we sell or how we package it. It will result from a fundamental change in the way therapists see their role in relation to painful human dysfunction. Given reliable information free of basic inaccuracies, what they see will lead to a certain bias that should be free of the effects of belief or faith or personal philosophy or emotional needs that have nothing to do with nature , which contains none of this.[/QUOTE]I completely agree with him on this point.
Fondly,
Diane.
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Re: Painless physical therapy vs. pain during treatment - September 4, 2006 7:32:00 AM
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proud
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dfjpt,
A "broken mess"you say? I figure the resaon for that is that is "too many cooks spoil the broth". What on earth is a patient with back pain supposed to believe nowadays?
We need to develop structure and recognized authority on the topic of conservative MSK management in order to dig patients out of the "mess" so many have put them in. Of course EBM is not perfect, but the alternative is resulting in a horrific epidemic of MSK issues.
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Re: Painless physical therapy vs. pain during treatment - September 4, 2006 7:45:00 AM
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dfjpt
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Proud, I fully sympathize with your sentiments, and wanting to stand up for a lucid understanding of back pain. Try understanding just plain "pain" first. It might help when it comes to fathoming pain felt in the back, but not necessarily of the spine, or not necessarily of anything in the back at all.
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