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Old 05-05-2012, 12:17 AM   #1
Randy Dixon
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Default A whack a mole issue

You hit it and hit it but it keeps popping back up. Here it is again.

I think it is important for those of us who are talking about pain to use the same terminology, both here on SS and when talking to others outside of SS. The reasons for this I think are obvious. I don't know if there is an accepted authority used as the standard on this site so I am going to use the one from the International Association for the Study of Pain (IASP).




I have either discussed or been asked about some of the following:

Allodynia*
Pain due to a stimulus that does not normally provoke pain.

Analgesia
Absence of pain in response to stimulation which would normally be painful.

Hyperalgesia*
Increased pain from a stimulus that normally provokes pain.

Hypoalgesia
Diminished pain in response to a normally painful stimulus.


and the big one:

Nociceptive pain*
Pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors.

Notice that Nociceptive Pain is not defined as:
Delusional belief of those who are either ignorant of, or have a poor understanding of, pain science.

You will notice that these terms are defined by their comparison to a "normal" pain response. Which is an expected pain response consistent with the nociceptive input. I believe that this is also the way most practitioners define it in practice as well. If a person presents with a complaint of knee pain, there is no assumption that it is the result of an abnormal neurodynamic, a physical examination looking for tissue damage or threat is first done. It is only when this damage is not present or that the pain is not consistent with expectations given the tissue damage is an abnormal neurodynamic expected. In short, we can say that consistency with these terms means that:

With a NORMAL neurodynamic there is a positive and somewhat predictable correlation between nociception and pain.

It is the absence of this correlation that defines an ABNORMAL neurodynamic.

Barrett has already answered that his understanding is not the same as IASP's stated understanding of pain, at least as I presented it. What do other people think?
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Old 05-05-2012, 12:43 AM   #2
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Quote:
somewhat predictable correlation between nociception and pain
There perhaps lies the nub of the question Randy, I don't think we can predict it and the correlation can be all over the place alters with time and is a dynamic relationship in nature.

regards

ANdy
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Old 05-05-2012, 04:11 AM   #3
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Then what is "normal"?
and if there is no normal, how can there be an "abnormal"?
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Old 05-05-2012, 04:21 AM   #4
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Nociception is normal. Pain isn't, always..
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Old 05-05-2012, 04:24 AM   #5
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Quote:
Originally Posted by Diane View Post
Nociception is normal. Pain isn't, always..
I'm going to let you have 3 or 4 more beers and then we can continue this in French.
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Old 05-05-2012, 04:40 AM   #6
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Something just for you, Randy the Dixon. "Yes, pain really is all in your head."
It's a news story out of NZ making the rounds on Fbook. It features pictures of none other than D. Butler, and Ramachandran, and discusses phantom limb pain, mirror therapy.

Nociception is not mentioned. Not even once. Sorry Randy.
It's kind of irrelevant to pain, and is losing ground by the day.
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Old 05-05-2012, 05:18 AM   #7
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From the article:
"which recognises that some types of chronic pain are caused not by tissue damage but by changes in the wiring of the brain."

"A decade and a half of brain imaging has found that although tissue damage is very important in determining pain, it is not the only ingredient. "

It mentions nociception when it talks about tissue damage. No one has denied that there are cases of abnormal dynamics, such as the case in the article you referenced. This does nothing to contradict my statement that with a NORMAL neurodynamic there is a positive and somewhat predictable correlation between nociception and pain. It is the lack of this correlation that defines an ABNORMAL neurodynamic.

There is absolutely nothing new in that article, please see my note about what "Nociceptive Pain" is not defined as by the IASP.
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Old 05-05-2012, 06:00 AM   #8
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Hi Randy,
Quote:
This does nothing to contradict my statement that with a NORMAL neurodynamic there is a positive and somewhat predictable correlation between nociception and pain. It is the lack of this correlation that defines an ABNORMAL neurodynamic
I've been thinking about your statement in reverse. I have a client at the moment, 3/52 post slap repair with hardly any pain, way less than what I would describe as normal for this stage of her rehab. Is this an abnormal neurodynamic in reverse? I don't see that it is. I think she is normal in that regard. So what i conclude here is that she has a normal neurodynamic, with lots of nociception but not much pain. This to me, points to a lack of correlation between nociception and pain in the absence of an abnormal neurodynamic.

Thoughts?
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Old 05-05-2012, 06:27 AM   #9
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So, is this more a question of threshold? is this a person who never hurts, or is it only this particular post-op pain that seems less than normal?


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Old 05-05-2012, 07:31 AM   #10
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Quote:
Originally Posted by Randy Dixon View Post

and the big one:

Nociceptive pain*
Pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors.
But
Quote:
Originally Posted by IASP
Nociceptor*
A high-threshold sensory receptor of the peripheral somatosensory nervous system that is capable of transducing and encoding noxious stimuli.
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Old 05-05-2012, 07:42 AM   #11
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Quote:
Originally Posted by Randy Dixon View Post
This does nothing to contradict my statement that with a NORMAL neurodynamic there is a positive and somewhat predictable correlation between nociception and pain.
Huuu, NO!
There is a missing component in the equation: BRAIN.
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Old 05-05-2012, 12:15 PM   #12
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Are you taking this as a given or do you have some specific piece of evidence for this,

Quote:
positive and somewhat predictable correlation between nociception and pain
I don't think we actually have that, it is an assumption, there is I think rather more complexity than that statement suggests.

Quote:
It's kind of irrelevant to pain,
I think that might be a bit strong Diane?


regards

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Old 05-05-2012, 12:26 PM   #13
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Quote:
Originally Posted by amacs View Post
I think that might be a bit strong Diane?


regards

ANdy
Not if pain if defined as a brain output, not an input, ANdy. See picture I just made.
If descending modulation is of the right kind, pain perception won't result, and the two circles will not be overlapped.
Attached Images
File Type: png Screen shot 2012-05-05 at 6.25.19 AM.png (24.3 KB, 20 views)
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Old 05-05-2012, 12:49 PM   #14
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II understand with where you are coming from but I am not sure if you are downplaying the left side of the matrix a bit too much. Given in your diagram if nociception was irrelevant there should be no overlap?

regards

ANdy

p.s. what on earth time do you get up in the mornings? if your 7 hrs behind me?
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Old 05-05-2012, 12:58 PM   #15
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Quote:
Originally Posted by amacs View Post
p.s. what on earth time do you get up in the mornings? if your 7 hrs behind me?
And she is prepping to start a course in 2 hours...and she is adjusting to a time change as well after a flight yesterday too. I have wondered the same thing.

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Old 05-05-2012, 01:25 PM   #16
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Middle-age-fu kicks in at some point and one finds oneself making the 6 hours of sleep one may get if one is lucky, more efficient.

The point I was trying to make is, the brain does whatever it can to keep the two circles apart. Completely.

Nociception is there.. it just isn't very important. To the person. Usually. Just as baroception, chemoception, thermoception, mechanoception, proprioception, and all the other -ceptions provided by visceral afferent sensory neurons (aka, interoception) are not important to the person in the organism (although the brainstem finds all this stuff interesting, uses it to regulate its organism, somewhere well below dim human conscious awareness).

If you have a heart attack you may suddenly become aware of the dysregulation of your own brain's sudden inability to dampen perception of mechoreception/baroreception in the heart, perhaps. Chemoreceptors, always informing the brainstem of oxygen mix, may start to go a bit sideways and breathing will change, and the person will feel suffocated.
If the brain starts to not be able (maybe because of stressors) to dampen/deal with in an ordinary manner, nociceptive input, same difference. It's a perturbation by the brain, in its ordinary function, sufficient to create a perception of "pain", by the person in the organism. I define "Person"as a module of brain function possessing the ability to pay attention to something, and/or have its attention captured by something (inside or outside) that represents a novel situation to which must be assigned a valence and/or salience value.
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Old 05-05-2012, 01:40 PM   #17
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I see the unintended size of the overlap as unconsciously representative of the mental encroachment of an upcoming day of teaching imposing itself upon everything else you do - but maybe that's just me. Been there.

I always say, "The brain decides that there is some danger and it says, 'I'm going to make you hurt until you do something about it.'"

Also, the brain might be wrong.
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Old 05-05-2012, 04:49 PM   #18
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Quote:
I always say, "The brain decides that there some danger and it says, 'I'm going to make you hurt until you do something about it.'"
I agree but I am not sure we can say nociception is irrelevant.

That,

"nociception is neither necessary nor sufficient for the output of pain"

does not lead us to a place of saying nociception has no role to play in pain. At present I would not read the neuromatrix as telling us that either.

I do agree completely we struggle to have any idea what it is telling us and that in and of itself it tells us little as to why the brain chooses to output pain. I am not sure if we are discussing two temporally different perspectices in that I am thinking acute episode rather than chronic (all caveats considered).


regards

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Old 06-05-2012, 09:54 AM   #19
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Quote:
Originally Posted by PatrickL View Post
Hi Randy,

I've been thinking about your statement in reverse. I have a client at the moment, 3/52 post slap repair with hardly any pain, way less than what I would describe as normal for this stage of her rehab. Is this an abnormal neurodynamic in reverse? I don't see that it is. I think she is normal in that regard. So what i conclude here is that she has a normal neurodynamic, with lots of nociception but not much pain. This to me, points to a lack of correlation between nociception and pain in the absence of an abnormal neurodynamic.

Thoughts?
My thoughts. If there is less pain than normal, then it is abnormal, and a sign of an abnormal neurodynamic. This does not always lead to something bad for the patient. Why do you describe something as normal and then say it is not normal?

Alternatively you could just be misjudging what is normal. How does what you describe not coincide with the definition of "hypoalgesia" in the IASP terminology I discussed?
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Old 06-05-2012, 10:04 AM   #20
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Huuu, NO!
There is a missing component in the equation: BRAIN.
No Bernard,

It is NOT missing. It is part of the neurodynamic. It too has normal and abnormal responses to nociceptive input.

If there is no normal pain response, then how do you know when you see an abnormal one? You can't really define normal as that which is not abnormal, without knowing already what is normal.

This is the problem with the focus here on abnormal neurodynamics. I understand the focus, because they are the cases most amenable to the type of treatment provided here, but the majority of pain occurs in the context of normal neurodynamics. This is why the understanding here regarding pain is different than that in organizations like the IASP, because the IASP deals with both normal and abnormal neurodynamics. Moseley, Shacklock, Ramachandran and other researchers that are so popular here also deal almost exclusively in the field of abnormal neurodynamics. There is nothing wrong with this focus, but there is something wrong when this focus distorts understanding, which is what is happening here.
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Old 06-05-2012, 10:08 AM   #21
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Are you taking this as a given or do you have some specific piece of evidence for this,

Quote:
positive and somewhat predictable correlation between nociception and pain-Randy
I don't think we actually have that, it is an assumption, there is I think rather more complexity than that statement suggests.

Pain is more complex than nociception but the statement above doesn't need to be. The definitions of IASP as well as other explanations and discussions of pain refer to "normal". You can neither recognize nor define "normal" without this correlation. You can't define or recognize "abnormal" without "normal".

Quote:
It's kind of irrelevant to pain,-Diane
I think that might be a bit strong Diane?

It is more than a "bit strong", it is contradicted in the very article she referenced.


regards

ANdy

Sorry for the formatting. I couldn't figure out how to quote a quote.
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Old 06-05-2012, 10:17 AM   #22
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Originally Posted by Diane View Post
Not if pain if defined as a brain output, not an input, ANdy. See picture I just made.
If descending modulation is of the right kind, pain perception won't result, and the two circles will not be overlapped.
Diane,

Once again, hopefully but not likely for the last time, we all understand that pain can occur with no nociception and no pain can occur with nociception. That is not being disputed. When this occurs though it is a sign of an abnormal neurodynamic.
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Old 06-05-2012, 10:22 AM   #23
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Quote:
Originally Posted by amacs View Post
I agree but I am not sure we can say nociception is irrelevant.

That,

"nociception is neither necessary nor sufficient for the output of pain"

does not lead us to a place of saying nociception has no role to play in pain. At present I would not read the neuromatrix as telling us that either.

I do agree completely we struggle to have any idea what it is telling us and that in and of itself it tells us little as to why the brain chooses to output pain. I am not sure if we are discussing two temporally different perspectices in that I am thinking acute episode rather than chronic (all caveats considered).


regards

ANdy
What I am arguing is it is not the difference between acute and chronic, but normal and abnormal neurodynamics. Nociception not being necessary... is true both in chronic and acute cases, but not in both normal and abnormal responses to pain.
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Old 06-05-2012, 01:05 PM   #24
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Randy,

I believe I am not reading this the way that you intend it to be read, and think that it may just be my difficulties here...

When I have a papercut that hurts like a SOB, but has (quite obviously) less tissue damage than when I lacerate my finger when peeling veggies and I bleed all over the place while NEVER experiening pain...is this the result of an abnormal neurodynamic?

Just having a hard time following your logic at the moment.

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Old 06-05-2012, 01:14 PM   #25
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Logic?
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Old 06-05-2012, 01:48 PM   #26
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Rational discussion flowchart.

Excerpt:
"Can you envision anything that will change your mind about this topic?"
No ->This is not a discussion - I will not talk to you about this topic.
Yes:
"If one of your arguments is shown to be faulty will you stop using that argument (with everyone)?"
No -> This is not a discussion - I will not talk to you about this topic.
Yes:
"Are you prepared to abide by basic principles of reason in discussing this topic?"
Examples:
  • The position that is more reasonable and has more supporting evidence should be accepted as true.
  • The person asserting a position bears the onus of demonstrating its truth.
No -> This is not a discussion - I will not talk to you about this topic.
Yes:
(List of rules)
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Old 06-05-2012, 01:54 PM   #27
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My thoughts. If there is less pain than normal, then it is abnormal, and a sign of an abnormal neurodynamic.
This seems to exclude the psycho-social aspect of the neuromatrix, no?

I am thinking of soldiers in battle who do not experience the levels of pain on the battlefield that you may expect in more "traditional" environments.

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Old 06-05-2012, 03:20 PM   #28
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majority of pain occurs in the context of normal neurodynamics.
I would expect no pain with a normal neurodynamic.

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If there is less pain than normal, then it is abnormal, and a sign of an abnormal neurodynamic.
What is normal? If a professional golfer and a sedentary person have the same injury to their finger with the same tissue damage the pain response more than likely will be different.
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Old 06-05-2012, 04:01 PM   #29
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The word "abnormal" confuses things here until you define it as "Inefficient and inadequate mobility in the nervous system."

Now, I came up with that definition myself because I couldn't find one otherwise, but it does beg the question: What is efficient and adequate?

I think this depends upon how the nervous system is challenged and within what context.

Eventually, the word unless plays a role here.

I can't sit in a kyak comfortably unless I'm using it to save someone else's life. That being the case, I wouldn't notice the lack of neural mobility at that time but maybe later - maybe not.

We're dealing with humans here, not a car short on oil.

In short, "abnormal" isn't an indication that something is normal and therefore needs to be identified. Words like inadequate and inefficient play a role here and in humans they are often changed.
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Old 06-05-2012, 08:46 PM   #30
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Randy sounds like he's equating persistent pain with the abnormal neurodynamic. This is a categorical error in logic.

If one can site a single incidence or example of an abnormal neurodynamic where no persistent pain exists, then Randy's argument falls apart. I can site many (I think this is what Bernard was getting at, and it's times like this when I really wish I could read French.)

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I understand the focus, because they are the cases most amenable to the type of treatment provided here, but the majority of pain occurs in the context of normal neurodynamics.
Actually, this is the only "type" of pain that needs treating (at least from someone trained and licensed to provide health care as a professional service) at all.

And now we're back to my original problem with the term "nociceptive pain" because it seems to stem from a need by biomedically-inclined professionals to label everything as a "disease", so they can place it in their little medical kits along with their fancy coding systems and provide expensive- and often unnecessary- interventions for said "disease".

Then, we end up with what is often referred to here as a harmful meme, which pervades and pollutes the culture resulting in more of the problem that it was originally intended to help.

Thus, we end up at our current unsavory destination, which was paved ever so meticulously by brick after brick, slab after slab of good intentions.
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Old 06-05-2012, 09:15 PM   #31
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positive and somewhat predictable correlation between nociception and pain

I think you have to evidence this Randy, you cannot make this kind of assertion which is central to your argument and leave it without a foundation.

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Old 07-05-2012, 12:41 AM   #32
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This seems to exclude the psycho-social aspect of the neuromatrix, no?

I am thinking of soldiers in battle who do not experience the levels of pain on the battlefield that you may expect in more "traditional" environments.

Respectfully,
Keith
Do you think that troops in the midst of battle are experiencing normal neurodynamics?
If you have a patient come in, let's say with Patrick's example of a SLAP lesion or surgery to repair it. Do you consider, like Patrick did, that this may be contributing to pain, or do you just ignore the fact that there is tissue damage? If there is no correlation between tissue damage and pain with a normal neurodynamic then why would you even consider the tissue damage. You should just ignore it. I suspect you don't. I suspect you think differently about a patient with a recent SLAP lesion repair complaining about pain in their shoulder and one with no discernible or known tissue damage or pathology complaining of the same pain.

Why? Because you know there is a correlation between pain and nociception with a normal neurodynamic. There has been a logical fallacy presented on this site that because pain can occur without nociception and nociception can occur without pain that the two don't have any correlation. This is a type of "false dichotomy" or black-white reasoning that argues that because something isn't ALWAYS true, it is NEVER true.
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Old 07-05-2012, 12:44 AM   #33
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I think it's an improvement over the assumption that because it is occasionally coincidentally present, it must always be the case.
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Old 07-05-2012, 12:46 AM   #34
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What is normal? If a professional golfer and a sedentary person have the same injury to their finger with the same tissue damage the pain response more than likely will be different.'

Yes, whenever we deal with something subjective, whether pain, emotion, or most human experience, assigning an objective value to it is difficult. This is a problem in application though, not understanding.

Why do you think the IASP uses the term "normal" though? Do you think they have an incomplete understanding of pain and don't realize that it is a subjective experience? No, it is because it is the best, though imperfect, descriptor available.
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Old 07-05-2012, 12:47 AM   #35
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Because you know there is a correlation between pain and nociception with a normal neurodynamic
Hi Randy

I see your frustration coming through but again I ask if it is so clear,

what is the correlation?

if you cannot actually give it what are you basing your treatment on?

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you think they have an incomplete understanding of pain
I wouldn't think that at this juncture that anyone is claiming they have a complete understanding of pain - the field is still very much ion its early stages, bit of a red herring this really?

ANdy
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Old 07-05-2012, 12:54 AM   #36
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[QUOTE=John W;130000]Randy sounds like he's equating persistent pain with the abnormal neurodynamic. This is a categorical error in logic.

If one can site a single incidence or example of an abnormal neurodynamic where no persistent pain exists, then Randy's argument falls apart. I can site many (I think this is what Bernard was getting at, and it's times like this when I really wish I could read French.)



No, I'm not equating persistent pain with the abnormal neurodynamic. I've already stated that an abnormal neurodynamic can occur acutely or chronically. There are many examples of people not feeling pain when they are expected to, are you arguing this is normal? Isn't this "Analgesia"?
Analgesia
Absence of pain in response to stimulation which would normally be painful.

This is from the IASP, not me. Why should I, or anyone else, reject the IASP's definition and understanding in favor of your own?
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Old 07-05-2012, 01:01 AM   #37
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Actually, this is the only "type" of pain that needs treating (at least from someone trained and licensed to provide health care as a professional service) at all.-John W.

I think there may be some reasonable disagreement here, but let's accept that.-Randy

And now we're back to my original problem with the term "nociceptive pain" because it seems to stem from a need by biomedically-inclined professionals to label everything as a "disease", so they can place it in their little medical kits along with their fancy coding systems and provide expensive- and often unnecessary- interventions for said "disease". -John W.

The term is from the IASP, you aren't making an argument here, only making an assumption of bad faith on their part. -Randy

Then, we end up with what is often referred to here as a harmful meme, which pervades and pollutes the culture resulting in more of the problem that it was originally intended to help.

Thus, we end up at our current unsavory destination, which was paved ever so meticulously by brick after brick, slab after slab of good intentions.[/QUOTE] John W.

I think this is the problem, you are trying to combat one false meme, that nociception and pain are equivalent, with another false meme. that there is no correlation between nociception and pain, ever. I believe that with an abnormal neurodynamic, there is little, or maybe even no, correlation, and since this is the only type of patient you deal with or can help then it is understandable that is what you focus on, but this is not helpful or accurate with regards to the understanding of pain that is not caused by an abnormal neurodynamic.

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Old 07-05-2012, 01:04 AM   #38
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I think you have to evidence this Randy, you cannot make this kind of assertion which is central to your argument and leave it without a foundation.

regards

ANdy
What evidence do you want Andy?

My argument is a matter of logical deduction. If you think the IASP is wrong in both its understanding and its definitions make your case for why your understanding and definitions are superior.
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Old 07-05-2012, 01:09 AM   #39
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Originally Posted by Diane View Post
I think it's an improvement over the assumption that because it is occasionally coincidentally present, it must always be the case.
Diane,

I'm not sure exactly what this was in reference to but I think you are saying that tissue damage and/or nociception is only occasionally present in pain, and then it is merely coincidental? Is this correct?

I think it is more than coincidence and more than occasional, but I will agree with you that in the case of an abnormal neurodynamic tissue damage/nociception can be coincidental or absent.

I don't think this justifies the opposite meme, or the use of a false dichotomy.
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Old 07-05-2012, 02:24 AM   #40
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Pain and tissue damage are from different planets.
And so is the reportage by nociception, and pain, therefore.
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Old 07-05-2012, 02:59 AM   #41
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The term is from the IASP, you aren't making an argument here, only making an assumption of bad faith on their part.
Untrue. I suspect the IASP, as I mentioned in the other thread on this, arrives at its definitions by means of a committee, which, like any committee, is susceptible to pressure from a variety of stakeholders. In this case, the biomedical professionals not only have a large stake in the pain treatment industry, but their biomedical model continues to dominate the provision of all of health care in modern societies. It's the dominant paradigm and as such occupies a uniquely lofty status that the IASP must acknowledge if it is to be taken seriously as an organization providing education to medical professionals, a large portion of which are medical doctors.

To make the leap that I am "making an assumption of bad faith" by IASP is disingenuous and suggests that you don't just disagree with my position, but you are hostile to it.

I'd ask that you think twice before you continue to display such hostility towards others' positions, but you've been on such a run these past weeks that I don't think it would matter. So I won't.
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Old 07-05-2012, 03:32 AM   #42
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Hi Randy,
Quote:
If you think the IASP is wrong in both its understanding and its definitions make your case for why your understanding and definitions are superior.
Quote:
Allodynia*
Pain due to a stimulus that does not normally provoke pain.

Analgesia
Absence of pain in response to stimulation which would normally be painful.

Hyperalgesia*
Increased pain from a stimulus that normally provokes pain.

Hypoalgesia
Diminished pain in response to a normally painful stimulus.

Nociceptive pain*
Pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors.
i think these definitions are subject to the problem of defining normality with regards to the relationships between sensory/discriminative inputs and pain.
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Old 07-05-2012, 04:57 AM   #43
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Untrue. I suspect the IASP, as I mentioned in the other thread on this, arrives at its definitions by means of a committee, which, like any committee, is susceptible to pressure from a variety of stakeholders. In this case, the biomedical professionals not only have a large stake in the pain treatment industry, but their biomedical model continues to dominate the provision of all of health care in modern societies. It's the dominant paradigm and as such occupies a uniquely lofty status that the IASP must acknowledge if it is to be taken seriously as an organization providing education to medical professionals, a large portion of which are medical doctors.

To make the leap that I am "making an assumption of bad faith" by IASP is disingenuous and suggests that you don't just disagree with my position, but you are hostile to it.

I'd ask that you think twice before you continue to display such hostility towards others' positions, but you've been on such a run these past weeks that I don't think it would matter. So I won't.
John,
Your clarification is still not an argument about why you think the IASP is wrong, you are still merely assuming that the IASP is wrong without stating anything other than you think they are acting according to ulterior motives.

There is nothing hostile in that comment. Should I add a smiley face?

I have asked you to provide me with a another source for these definitions that is more widely accepted or more authoritative. I have looked at other sources such as the American Pain Society, The American Academy of Pain Medicine, The American Pain Foundation and a few others. They either use IASP as a reference or they use very similar definitions. This is from the APF, which I just grabbed as the first thing that popped up:

"Complex regional pain syndrome (CRPS) is a chronic pain disorder. CRPS usually begins after trauma such as an injury to the tissue, bone or nerves of your limb (arm or leg). Although the symptoms vary greatly from one person to the next, there is one symptom that all people with CRPS have. Everyone has pain that feels much worse than you would expect for the injury and that continues long after the injury should have healed."

I will point out the last sentence says "pain that feels much worse than you would expect", which is congruent with my statement that there is a correlation, an expectation of a certain degree, between tissue damage/nociception and pain. It is incongruent with the idea that there is no expected correlation between the two.

Why are they wrong and you right?
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Old 07-05-2012, 05:11 AM   #44
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i think these definitions are subject to the problem of defining normality with regards to the relationships between sensory/discriminative inputs and pain. -Patrick

Of course they are. Pain is a subjective experience, we can't objectively share that experience with others. This communication problem doesn't change the way things actually work.

Have you ever used a pin prick test on somebody, or at least have you heard of it being done? It is quite common and its validity is well established so hopefully it is something that we won't have to argue over just to accept. A pin prick test is nothing more than pricking someone with a pin and observing their reaction. In other words, you apply a mild noxious stimulus (nociception) and expect a mild pain response.

If there is no pain response, is this normal? If there is an extreme pain response, is this normal? If there is no correlation between nociception then they are all normal, even a pain felt in the foot or the eye when the finger is pricked would be considered normal. In fact, in the case of an abnormal dynamic any of those things might actually happen, but that would be a sign of an abnormal neurodynamic, not what is normal or expected.

Can I, or anybody, make a clear definition of what a "normal pain response" is to a pin prick? No. but that doesn't mean that there is not a normal pain response or that we can usually predict and recognize it.
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Old 07-05-2012, 05:21 AM   #45
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I made no such inference of an "ulterior motive". That's your cynical interpretation of my position.

My position is that the IASP is, like many of us, making difficult choices about very complex, moving targets to advance its mission.

Your assessment of my position is narrow and inaccurate, and it is framed in a sensationalized way that puts me in an adversarial posture against IASP.
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Old 07-05-2012, 05:21 AM   #46
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I'd ask that you think twice before you continue to display such hostility towards others' positions, but you've been on such a run these past weeks that I don't think it would matter. So I won't.-John W.

Why would you suggest that I not display such hostility towards others positions? I don't think I have displayed any hostility, but if I have, isn't that what we are supposed to do? Isn't that what I was told when I said people were being rude, that you weren't attacking them but their positions?

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Old 07-05-2012, 05:53 AM   #47
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Can I, or anybody, make a clear definition of what a "normal pain response" is to a pin prick? No. but that doesn't mean that there is not a normal pain response or that we can usually predict and recognize it.
I don't understand what you have said here- sorry. If we can't define a normal pain output, how can we predict or recognize it?
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Old 07-05-2012, 06:24 AM   #48
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Do you think that troops in the midst of battle are experiencing normal neurodynamics?
Certainly not...but Shacklock states that an abnormal neurodynamic can be symptomatic, asymptomatic, relevant or irrelevant. And the neuromatrix model takes into account a lot more than nocioceptive input. Most would argue that the neurodynamic doesn't change in the hospital after battle as much as the psycho-social variables "computed" within the neuromatrix...but again, no one really knows. We only know that any of it may be important.

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If you have a patient come in, let's say with Patrick's example of a SLAP lesion or surgery to repair it. Do you consider, like Patrick did, that this may be contributing to pain, or do you just ignore the fact that there is tissue damage?
I understand that the patient (in this example) has mechanical deformation of tissue coupled with an inflammatory response (both nocioception) that is processed by the brain in an unpredictable manner based on that patient's expectations, personal history, biases (etc).

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If there is no correlation between tissue damage and pain with a normal neurodynamic then why would you even consider the tissue damage.
I do not think that I make patient's tissues heal faster, do you?

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You should just ignore it. I suspect you don't. I suspect you think differently about a patient with a recent SLAP lesion repair complaining about pain in their shoulder and one with no discernible or known tissue damage or pathology complaining of the same pain.
I rarely see SLAP repairs, so feel more comfortable talking TKRs compared to (for instance) "OA pain". Both patients receive education to reduce fear avoidance/catastrophic fears, gentle mobilizations, movement therapy...I emphasize thermal agents post op (CP for 20-30 mins every hour).

I cannot help their TKR heal faster, nor have I read that I can alter the cytokines likely responsible for nocioception in the "OA knee" with my hands or exercise...I understand that I am limited in this regard.

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Why? Because you know there is a correlation between pain and nociception with a normal neurodynamic.
I am still confused as to how you are measuring nocioception and how you account for the potential classification of an irrelevant or asymptomatic abnormal neurodynamic.

And NO I do not KNOW that there is a correlation. I do not argue that there isn't a potential relationship, but I am uncertain how I assess nocioception or how I treat it directly and measure the effect of my treatment without taking into account all the other variables that impact an individual's pain experience.

I have a subluxing ulnar nerve bilaterally...which always made for fun parlor tricks in PT school but really hinders my ability to maintain a buff physique (although Diane could attest to the fact that my buttocks are sublime ). If I go out and throw a football around for 30 minutes in my backyard, I may or may not develop pain in my throwing elbow...sometimes it hurts, sometimes not. I will always have a positive ULTT finding...ALWAYS. So what? Are you arguing that the environment that I am in, how much fun I am having, how well I am performing and/or the weather play no role in whether I have a painful experience or not? It seems apparent to me that if I am throwing a ball around (approximately) the same number of times across the same yard with the same abnormal neurodynamic and the same noodle-arms as always, but the result is consistently variable...well, I attribute those bad days to more than just nocioception alone.

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There has been a logical fallacy presented on this site that because pain can occur without nociception and nociception can occur without pain that the two don't have any correlation. This is a type of "false dichotomy" or black-white reasoning that argues that because something isn't ALWAYS true, it is NEVER true.
I am sorry, it is late, and do not have time to go back through the thread at the moment (been typing longer than anticipated already)...but...has anyone said that an individual never experiences pain from nocioceptive input or have they said that the degree of pain that a patient experiences (directly as a result of nocioceptive input) cannot necessarily be measured/accounted for by any tools presently available to us?

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Old 07-05-2012, 12:08 PM   #49
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First,

thank you Keith for your post, I think it may help clear up some of the misunderstanding that seems to be occurring.

Randy,

the quote below makes it clear that the relationship between nociception and pain is less than clear.


Quote:
RECONCEPTUALISING PAIN ACCORDING TO MODERN PAIN SCIENCE

G. LORIMER MOSELEY

Physical Therapy Reviews 2007; 12: 169–178



... [t]wo findings consistently emerged from those studies. First, the injury, or noxious stimulation, initiates the change in behaviour. Second, neither pain behaviour nor nociceptor activity hold an isomorphic relationship with the state of the tissues. By clearly demonstrating these things, those studies provided the first experimental evidence that pain does not provide a measure of the state of the tissues.

One limitation of animal experiments is that they do not tell us about pain. Human experiments, however, can. Although it is difficult to justify injuring
human volunteers, it is possible to deliver non-harmful noxious stimuli, for example brief thermal, electrical or mechanical stimuli (see Handwerker and
Kobal5 for a review of various methods of experimentally inducing pain). By recording activity in nociceptors while simultaneously recording subjects’ pain ratings, experimenters have been able to evaluate the relationship between the state of the tissues (in the absence of tissue damage), activity in nociceptors, and pain6

Human pain experiments corroborated both findings from the animal data. Specifically, noxious stimulation is necessary for nociceptor activity, which
usually reflects the intensity of the stimulus, and nociceptor activation does not provide an accurate measure of the state of the tissues.6

The human experiments went further because they showed that the relationship between pain ratings and nociceptors activation is variable. In fact, some authors have proposed that the notion of nociceptors is misleading
because small diameter fibres (Aδ and C fibres) respond to very small (non-harmful) changes in the internal state of the body.7

That said, some small diameter fibres are not responsive to small changes
(so-called high-threshold neurons) and this sub-class of small diameter fibres may reflect what we call nociceptors. Regardless, it is clear that experimental studies do not show an isomorphic relationship between pain and nociceptor activity, nor between pain and the state of the tissues. Rather, they show a variable relationship that is modulated by many factors.
For my "money" this means that nociception may have a role but it is unclear what, Diane believes its role is irrelevant, I don't go that far. Keith, I think, makes a more pragmatic suggestion in that what does it change in terms of what we do which may actually bring us back to Diane's assertion that it is irrelevant at least therapeutically after all we cannot really accelerate healing. I do wonder if we can affect cytokine responses via some of the neuro-immune responses but my understanding of this is at this time rudimentary.

To whit that leaves the state of play as one where the relationship between nociception and pain is murky, is not a uniform linear relationship, they are not synonymous, that pain can exist in the absence of nociception and the longer pain persists the less nociception has to do with it (which comes back to my earlier point about chronology which was directed toward Diane's argument not at yours).

regards

ANdy
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Old 07-05-2012, 12:53 PM   #50
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Quote:
It too has normal and abnormal responses to nociceptive input.
Randy, you also asked "What is normal?" I think that goes to the core of the issue.
We will NOT be able to establish: a) whether there IS nociception, b) whether there are normal or abnormal responses to nociception (in the clinic), and c) whether anything we do is really addressing that nociception.

There are too many variables on the left side of the matrix to assign roles to the individual factors.
In fact, they become irrelevant as individual inputs.

As long as we keep trying to assign values of importance or normalcy, we are not giving due to the chaotic nature of the pain experience.

For what it's worth, I think the IASP is weak on its definition, exactly for the above reasons.
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