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RE: Mesoderm, ectoderm, etc

 
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RE: Mesoderm, ectoderm, etc - June 7, 2012 8:52:32 AM   
Tom Reeves DPT ATC

 

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quote:

Tom, you may think that "disadvantaged foot structure" is a causative factor in the deveopment of pain but that would be highly speculative and for the most part contrary to where pain sciences and clinical literature has us today


If i ever said causative I meant contributory factor. Read my post, I clearly state that there are many factors that influence why we hurt.

I have read Butler and Moseley.

Sometimes there are monsters.

(in reply to proud)
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RE: Mesoderm, ectoderm, etc - June 7, 2012 8:55:08 AM   
Tom Reeves DPT ATC

 

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quote:

ORIGINAL: proud

quote:

ORIGINAL: Tom Reeves DPT ATC

here's one
http://www.japmaonline.org/content/93/6/481.abstract

and another one

and another one

You make me tired proud. this search took me 2 minutes.


What is your point? I said I could find two for every one that you found. Do we want to do that here?

Not really, it would be a pissing match where you would not convince me I'm wrong and I wouldn't convince you that you were wrong.

I agree that there is a central component, I do not dismiss that. But, I do not think that it is the only, or necessarily best way to treat all of my patients. For some, yes, for others no.

(in reply to proud)
Post #: 102
RE: Mesoderm, ectoderm, etc - June 7, 2012 9:08:16 AM   
Sebastian Asselbergs

 

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Tom, sorry, but I will not agree to even "contributory".
That study does NOT show there is any contribution to the pain they have - even if the foot alignment was "corrected" and pain relief occurred, it still does not mean the alignement issue was a contributing factor. It may have simply been a defensive adaptation.
All that the study showed was that people with knee pain have such-and-such alignment (generally speaking) and people with ankle pain, so-and-so alignment.
We should stay away from getting too horny about correlations and pain. Pain is too complex - as you yourself have indicated.
I will always agree with you that pain is a complex experience with a ton of factors influencing it.

Yes, there are monsters. That's why we test for red flags. And listen carefully to the history. But they are far and few between.

(in reply to Tom Reeves DPT ATC)
Post #: 103
RE: Mesoderm, ectoderm, etc - June 7, 2012 10:55:19 AM   
Tom Reeves DPT ATC

 

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quote:

ORIGINAL: Sebastian Asselbergs

Tom, sorry, but I will not agree to even "contributory".
That study does NOT show there is any contribution to the pain they have - even if the foot alignment was "corrected" and pain relief occurred, it still does not mean the alignement issue was a contributing factor. It may have simply been a defensive adaptation.
All that the study showed was that people with knee pain have such-and-such alignment (generally speaking) and people with ankle pain, so-and-so alignment.
We should stay away from getting too horny about correlations and pain. Pain is too complex - as you yourself have indicated.
I will always agree with you that pain is a complex experience with a ton of factors influencing it.

Yes, there are monsters. That's why we test for red flags. And listen carefully to the history. But they are far and few between.


So the only things that can conceivably contribute to knee pain/nociception are direct trauma, chemical injury, or psychosis?

(in reply to Sebastian Asselbergs)
Post #: 104
RE: Mesoderm, ectoderm, etc - June 7, 2012 11:03:19 AM   
honker23

 

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Causation vs correlation can be a black hole at times.  What in medicine has a perfect cause and effect relationship?  We could argue Nothing!  The literature is looking for the highest correlation possible to help us guide our patients to resolution.  I would contend that if 100 pain free healthy pts wore an orthotic with 20 degrees of lateral posting for 2 weeks, they would develop ankle and knee pain.  If they wore it for 3 years would they adapt how they walk and run and possibly be able to walk pain free...sure, maybe.  I also contend that if we took the wedge out at 2 weeks and allowed them to walk in their normal shoe they would have resolution of their symptoms. 

Did the orthotic cause pain...no, the brain decided to output pain based on the input it received.  The brain felt that the post tib may become inflammed or rupture, syndesmosis may be injured, fib may break, patella may sublux if we continue to walk/run on an extremely everted foot, so it produces pain to alert us to this threat and possibly take the shoe off if we could, to avoid injury.  Did the wedge cause pain in this case or ever...no, but it is highly correlated in my opinion in this hypothetical situation.


(in reply to Sebastian Asselbergs)
Post #: 105
RE: Mesoderm, ectoderm, etc - June 7, 2012 11:12:29 AM   
rwillcott

 

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Tom,

How about this unfortuante runner with overpronation:

http://www.youtube.com/watch?v=EAW87NsiGuI

Haille Gebrselassie and millions of runners world wide overpronate. And most run injury free. Haille doesn't wear motion control shoes, stability shoes, or orthotics. He doesn't suffer from injuries and ailments as a result of his overpronation. His pronation actually protects him upon impact. In most cases, it is a sign of weakness and poor technique elsewhere in your running gait, NOT a disease to be treated.

(in reply to Tom Reeves DPT ATC)
Post #: 106
RE: Mesoderm, ectoderm, etc - June 7, 2012 1:35:49 PM   
Tom Reeves DPT ATC

 

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Proud already posted this and I commented on it. In the comments below the video it also references that he required achilles surgery recently.

Would you say that there are preferred methods of movement with anything? Are there some techniques that you might think may predispose a person for injury either macro or micro? If you think that there are, would you agree that perhaps 1000s of micro injuries can either: 1) cause adapation and make them stronger or better at managing the motion or 2) eventually the person cannot adapt adequately and they get what I would call an repetitive use injury? (I am not saying that only one can happen, I am saying that both happen and the ones that we see in our clinic are the ones fall in to category 2.

(in reply to rwillcott)
Post #: 107
RE: Mesoderm, ectoderm, etc - June 8, 2012 7:12:51 AM   
Sebastian Asselbergs

 

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quote:

So the only things that can conceivably contribute to knee pain/nociception are direct trauma, chemical injury, or psychosis?
\
First, again: pain/nociception?!? As if they are interchangeable?
Do not put words in my mouth: nociception, excessive tissue stress, non-physical aspects, etc etc. ALL can contribute to developing the pain experience. I have said that so often that I fail to see why you ask the above question. The study you posted did nothing to demonstrate that biomechanical findings were "effect/defense" or "contributory" - my comment was aimed at the study.

My argument is NOT whether nociception or biomechanics CAN contribute to pain development; my point is that we simply have no way to establish reliably whether nociception is the main driver or even involved in most of our patients.

Honker, interesting thought, but so what? I have been in the army and have had to use boots after having lived in soft footwear for 20 years - I had to carry 45 lbs of gear for many many miles at medium to fast pace - never having done more than play competitive non-contact sports and being 158 lbs 6 foot tall. Was there pain? Nope. Sore muscles? Yep - many. And there were a lot of us recruits - very few "painful conditions" other than a blister, sore muscles and bad tempers. Can we base any conclusions about correlation of biomechanics on my story?
NBo, not really. It is just a story of many guys in a certain context. That's all.

(in reply to Tom Reeves DPT ATC)
Post #: 108
RE: Mesoderm, ectoderm, etc - June 8, 2012 9:00:55 AM   
rwillcott

 

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Tom,

I think it's very difficult to determine what movements or techniques predispose someone for injury. Think of all the back pain patients we see that have no mechanism of injury. Also, think of a person with CP that hyperextends their affected knee and has excessive pronation and is pain free.

I would agree that there are some people that can adapt to repetitive motion and someone that cannot and have injury. However, I don't think we can state that it is simply a biomchanical fault that led to the injury. There is no reliable way to identify this. In addition, as Bas mentioned there is no way to determine reliably if nociception caused the pain. Remember, pain is an output from the brain.

(in reply to Sebastian Asselbergs)
Post #: 109
RE: Mesoderm, ectoderm, etc - June 8, 2012 10:44:44 AM   
Tom Reeves DPT ATC

 

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In my mind, biomechanics includes motor control.

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RE: Mesoderm, ectoderm, etc - June 8, 2012 11:38:01 AM   
honker23

 

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rwillcott-  Do I really need to post articles on the correlation between valgus collapse at the knee and ACL injuries, hip IR and Add with patellofemoral pain, DF and Eversion with sydesmosis injuries..........

http://somasimple.com/forums/showthread.php?t=13127
 
Thoughts on this article?

(in reply to Tom Reeves DPT ATC)
Post #: 111
RE: Mesoderm, ectoderm, etc - June 9, 2012 3:46:10 PM   
Chocco

 

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quote:

ORIGINAL: proud


I am assuming then you see the science of pain is more theory than say...weak Tra is a source of LBP?

I'm confused Chocco...what do you consider "solid principles" and what do you consider "theory".



Proud
Sorry I haven't replied sooner had a bit of a bad week

As for the above above it would depend on your definition of the science of pain. I would say that Fear avoidance behavior is a solid principle as I've seen plenty of research and personal experience to back it up. I think the meso/ecto talk that people use to try to explain it would be more theory.

I try to avoid sharing as much theory with a patient a I can. On the occasion that I do, i do my best let the patient know that we really don't know if that is whats going on so I don't bias them in the future when theories are found to be inaccurate.

My personal theory on injuries on injuries changes regularly and is based on research and personal experience. ( I am going to use the term physical to mean meso/peripheral/biomechanical etc and emotional to mean ecto/central/ etc. I understand that it isn't perfect terminology). Generally I think when an injury happens it is traumatic both physically and emotionally. Some injuries create more physical trauma, some more emotional. Some people have a more physical reaction and others more emotional. A person needs to address both the emotional and physical aspects of their injury. People that are more effective at dealing with emotional aspect of their injury are less likely to have chronic injuries conversely people that have difficulty dealing with emotional aspects of their injury tend to be more chronic. I think with chronic injuries it is important to address the peripheral and biomechanics as well as the emotional ( an advantage PTs have over Psychologists) even if it is just as a way to reassure the patient that they can perform a movement or task without without injury or symptoms. I don't completely rule out the fact that there can be underlying physical causes in chronic injuries although research suggests it's much less likely. I intentionally used the word injury above and not pain. I am Physical therapist not a pain therapist. I understand that pain is a big part of what we do but it's not the only part of an injury. PTs that focus solely on the pain risk enabling the patient's perseveration on that same pain. It is important to address other impairments (ex. joint mobility) and functions ( ex. ambulation) with or without the presence of pain. Again this is just theory. I understand and except that research and my experiences will change that is why I try to keep it general and why I don't share it with patients.

(in reply to proud)
Post #: 112
RE: Mesoderm, ectoderm, etc - June 9, 2012 11:27:56 PM   
rwillcott

 

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Chocco,

One error you're making is defining ectoderm as emotional. This is wrong. This implies that the Rx is directed at a person's behavior/emotions. Ectoderm is simply a way of identifying the nervous system as part of the pain experience. Therfore ectoderm involves a physical component such as peripheral nerves, ganglion, inter-neurons, laminae, spinal cord, brain stem, cortex etc. This is often not considered by manual therapists when perfroming manual therapy which historically only recognizes the joint, bone, muscle and fascia.

For example, when performing manual therapy to improve joint mobility you can't simply treat the joint. In order to do that you would have to remove all skin, fascia, fat, blood and peripheral nerves etc. Not tp mention the PERSON attached to the joint with past experiences, expectations, beliefs, emotions etc. Therefore if a patent has improved dorsiflexion following a talocrural manipulation you can't say it is because we effected th talus. We don't know exactly what mechanisms we effected. All we know is that dorsiflexion imporved. However, if you review pain science and neurophysiology there is evidence that we are causing a neurophysiological effect.

< Message edited by rwillcott -- June 9, 2012 11:33:06 PM >

(in reply to Chocco)
Post #: 113
RE: Mesoderm, ectoderm, etc - June 10, 2012 2:45:28 PM   
Chocco

 

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quote:

ORIGINAL: rwillcott

Chocco,

One error you're making is defining ectoderm as emotional. This is wrong. This implies that the Rx is directed at a person's behavior/emotions. Ectoderm is simply a way of identifying the nervous system as part of the pain experience. Therfore ectoderm involves a physical component such as peripheral nerves, ganglion, inter-neurons, laminae, spinal cord, brain stem, cortex etc. This is often not considered by manual therapists when perfroming manual therapy which historically only recognizes the joint, bone, muscle and fascia.

For example, when performing manual therapy to improve joint mobility you can't simply treat the joint. In order to do that you would have to remove all skin, fascia, fat, blood and peripheral nerves etc. Not tp mention the PERSON attached to the joint with past experiences, expectations, beliefs, emotions etc. Therefore if a patent has improved dorsiflexion following a talocrural manipulation you can't say it is because we effected th talus. We don't know exactly what mechanisms we effected. All we know is that dorsiflexion imporved. However, if you review pain science and neurophysiology there is evidence that we are causing a neurophysiological effect.


I don't disagree with you on this. I know physical and emotional aren't the best terminology . As far as meso and ecto I was just trying to fit them into those two categories and admit I shouldn't have done that. I really don't like classifying things as meso and ecto ( as I mentioned before). There are too many unknowns once we start heading down that road.

(in reply to rwillcott)
Post #: 114
RE: Mesoderm, ectoderm, etc - June 10, 2012 7:12:27 PM   
proud

 

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Chocco,

Well I find myself pretty tired at the moment (inlaws down for a visit, all kinds of family stuff going on). I will say this and let it marinade for a bit...then I promise I will be back to explain.

I found practically everything about your above two posts to be flat out missing things entirely.

(in reply to Chocco)
Post #: 115
RE: Mesoderm, ectoderm, etc - June 10, 2012 8:49:48 PM   
Chocco

 

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quote:

ORIGINAL: proud

Chocco,

Well I find myself pretty tired at the moment (inlaws down for a visit, all kinds of family stuff going on). I will say this and let it marinade for a bit...then I promise I will be back to explain.

I found practically everything about your above two posts to be flat out missing things entirely.


Proud
I am pretty open to criticism on my thinking. I am not naive enough to think I have it figured out.
I look forward to it.

(in reply to proud)
Post #: 116
RE: Mesoderm, ectoderm, etc - June 11, 2012 8:40:36 AM   
proud

 

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quote:

Proud
Sorry I haven't replied sooner had a bit of a bad week


I'll start by saying by bad I hope you mean "busy" and nothing tragic or anything.


quote:

As for the above above it would depend on your definition of the science of pain.


How about this: Pain: a neuroimmunological experience caused by a cortical decision to protect the body based upon multiple variables including but not limited to those which are related to biological, psychological and social threats.

quote:

 I think the meso/ecto talk that people use to try to explain it would be more theory.


This comment is flat out wrong. The above definition, IASP's definition, in fact any modern definition are way beyond theory at this point. MESO/ECTO may not be people's favorite but it's a quick manner in which to differentiate factors for which the Ortho manual gods of the PT world seem to flat out reject. The pain science is pretty well established....manual therapy and it's actual infuence on connective tissue...not so much.

quote:

I try to avoid sharing as much theory with a patient a I can.


Then this is not evidence based practice as far as I can tell. There exists a plethora of literature out there that demonstrates effective outcome simply by educating patients about how pain works. But I suppose the "educator" first has to know how pain works.

quote:

On the occasion that I do, i do my best let the patient know that we really don't know if that is whats going on so I don't bias them in the future when theories are found to be inaccurate.


Again, pain science and the mult-factorial influences upon it are no longer theoretical.

quote:

 Generally I think when an injury happens it is traumatic both physically and emotionally. Some injuries create more physical trauma, some more emotional. Some people have a more physical reaction and others more emotional. A person needs to address both the emotional and physical aspects of their injury. People that are more effective at dealing with emotional aspect of their injury are less likely to have chronic injuries conversely people that have difficulty dealing with emotional aspects of their injury tend to be more chronic.


This sounds like you are equating pain science with emotional? What do you think happens phyiologically when you do something simple like...oh...sprain your ankle? Do you think anything cortical happens?

quote:

 I am Physical therapist not a pain therapist.


This statement slayed me. Have a look at your schedule today (assuming you are in an orthopedic setting). How many of your patients have pain? Here is a quote for you:

"When the primary complaint is pain, the treatment of pain should be primary"

quote:

 I understand that pain is a big part of what we do but it's not the only part of an injury.


Not one person has stated otherwise.

quote:

 PTs that focus solely on the pain risk enabling the patient's perseveration on that same pain.


I know approximately ZERO PT's who focus soley on "the pain". I know many well educated PT's who place pain as primary, educate properly with the goal to get patients moving and functioning better. This may or may not involve some form of hands on approach.


quote:

 It is important to address other impairments (ex. joint mobility) and functions ( ex. ambulation) with or without the presence of pain.


This I think is backwards. Why would I address "joint mobility" without pain? Also....do you think you are effecting any change to connective tissue within session with "joint mobilization"? When you see a patients ROM improve markedly within session with any "joint mobilization" do you think you have affected mature connective tissue that rapidly...or is something else happening?


quote:

Again this is just theory. I understand and except that research and my experiences will change that is why I try to keep it general and why I don't share it with patients.


Then I would suggest NOW would be the time to change. Apparently what you think is theory...isn't. You should be sharing this with patients....now.

< Message edited by proud -- June 11, 2012 8:54:04 AM >

(in reply to Chocco)
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RE: Mesoderm, ectoderm, etc - June 12, 2012 7:15:12 AM   
Chocco

 

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Proud,

I agree with a lot of what you are saying. About 4 years ago I started changing the way I was thinking of the science of pain and I credit people posting on this website ( including yourself) in pointing in the right direction regarding research of the topic of pain. I have since tried to expose as many of my coworkers to the same ideas. I have reviewed multiple articles (during staff article reviews) including this one http://ptjournal.apta.org/content/91/5/700.full that later became inservice for our outpatient department.

My problem lies more with the use of ectoderm as terminology. I didn't want to get into a discussion about the specifics why, but if I must. I think using the term ectoderm implies that the nervous system functions ( including pain) are independent of the structures from the other germ layers and by using embryological terminology we are failing to recognize the integration of the body's systems.

I don't have time to finish all my thoughts on your post now but I will get back to after work.
here are a few articles I will reference

http://m.pnas.org/content/106/49/20900.full#sec-9
http://www.ncbi.nlm.nih.gov/m/pubmed/17351536/
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2650821/

(in reply to proud)
Post #: 118
RE: Mesoderm, ectoderm, etc - June 12, 2012 1:19:38 PM   
proud

 

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Thank for those Chocco,

Although from the Apkarian et al paper:

quote:

“[Chronic back pain] patients have back pain yet no conservative or surgical pain relieving measures directed at the back appear effective. They display a number of biomechanical abnormalities, however treatment directed at normalising lumbar biomechanics has little effect and there is no relationship between changes in outcome and changes in spinal mechanics. Finally, these patients demonstrate some psychological problems but psychologically based treatments offer only partial solution to the problem. A possible explanation for these findings is that they are epiphenomena, features that are incidental to a problem of neurological reorganisation and degeneration.” (Wand and O’Connell, 2007)


Does this not support what I have been saying here all along? The brain is the tissue at issue and not the otherway around.

Also from the paper:

quote:

The role of descending modulation on acute pain has been extensively studied and reviewed (Basbaum and Fields, 1984). Recent research indicates that descending anti-nociceptive pathways projecting from the periaqueductal gray (PAG) through multiple brainstem links is complemented by additional pathways that act in a pro-nociceptive fashion as well (Lima and Almeida, 2002). Moreover, there is now good evidence that this descending modulatory circuitry may be involved in more general tasks than just adjustments to pain and injury, such as micturition and sleep (Mason, 2005).


Right so even acute pain is going to involve descending modulation. We also know that manual therapy tends to light up the PAG. The question though is why does it do that? What I do know is that any modulation in pain via attempts to remodel connective tissue is pure tooth fairy science.

Also:

quote:

Although nociceptive-responsive neurons have been found in the dorsal column pathway, at least in monkeys and rodents (Al Chaer et al., 1997), their role in acute nociception has not been considered substantial, perhaps because dorsal column lesions in humans spare pain perception, instead disrupting only touch and proprioception (Aminoff, 1996).


Now that's interesting.

Anyway...this paper supports my stance of the relative position of orthopeadic manual therapy in the general pecking order of importance.

Thanks.

< Message edited by proud -- June 12, 2012 1:24:36 PM >

(in reply to Chocco)
Post #: 119
RE: Mesoderm, ectoderm, etc - June 12, 2012 9:43:36 PM   
Chocco

 

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Proud
Would my theory above be more acceptable to you If I replaced Physical with Peripheral and Emotional with Central as it is below?
quote:

ORIGINAL: Chocco

Generally I think when an injury happens it is traumatic both peripherally and centrally. Some injuries create more peripheral trauma, some more central. Some people have a more peripheral reaction and others more central. A person needs to address both the central and peripheral aspects of their injury. People that are more effective at dealing with central aspect of their injury are less likely to have chronic injuries conversely people that have difficulty dealing with central aspects of their injury tend to be more chronic. I think with chronic injuries it is important to address the peripheral and biomechanics as well as the central ( an advantage PTs have over Psychologists) even if it is just as a way to reassure the patient that they can perform a movement or task without without injury or symptoms. I don't completely rule out the fact that there can be underlying physical causes in chronic injuries although research suggests it's much less likely.


< Message edited by Chocco -- June 12, 2012 9:44:47 PM >

(in reply to Chocco)
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