Deconstruction of a chiro pain article

[Diane]

Hi, I was wondering if anyone would like to join me in sorting out the good memes from the bad memes in this chiro article? I read it through once and spotted a few.. also, I came away with a sense that the human body is a big spine (the usual chiro impression that is left), with several mentions of laminae inside it, that this one does actually have a brain at the top, generating pain, and lots of "tissue" (mesoderm) outside and around it that can be generating "nocioception", but that still the only way to really conquer nocioception was to manipulate those spinal joints. Oh, and no skin anywhere on this human organism. Not even mentioned.
Comments? Anyone else spot anything else? The 15 page article is attached below.. I gave it a name of my own. The actual name is Spinal Pain Syndromes: Nocioceptive, Neuropathic and Psychologic Mechanisms. That's another, uhm.. issue I have, the term "psychologic mechanism".

[nari]

It's long and I haven't perused it well, but found these points:

- still talking about musculoskeletal pain and neuropathic pain, as though they were two completely distinct entities;
- the reference to "psychological pain"; definitely outdated in terminology.
- the spine is obviously crucial, and PTs are delegated to modalities and soft tissue work, generally speaking.
However, it is an old paper, and a heck of a lot more has been known since pre-millennium days. I guess we can excuse them for that.

I'll probably find more points to ponder when I reread it more leisurely.

Nari.

[Diane]

Hi Nari,
The paper was written in 1999, so it's not overly old. It was certainly written prior to SNS, but not before most of the info that Butler put into SNS.

-the spine is obviously crucial

Kind of like it is to Ginger..

I guess we would expect that from a paper submitted by Seaman, a chiro, to a journal called the Journal of Manipulative and Physiological Therapeutics (and did you check out the logo? Looks like a crucified angel). "Physiological Therapeutics" is what chiros call their version of PT (same initials) when they aren't busy calling it "physiotherapy" or "physical therapy." It's a journal that is built around application or applications of a set of human social grooming tricks, a journal for a certain clinical motor output that has been elevated to the staus of organized religion, which builds a case for it.

OK, enough preamble..

He starts off the article well enough by discussing the impact pain has on the world of humans, and before long he declaritively states,

The crisis is obvious. If we cannot determine the cause of the pain, it wil be impossible to provide a treatment program that has any chance of offering short- or long- term relief.

OK, agreed.. so when I read that I was eager to learn all about the nervous system from a chiro perspective and do a comparative analysis with how pain has been deconstructed in PT.

Then he quotes someone's 1986 comment, Vert Mooney, given in a "presidential address";

In the case of low-back disease

(What? Disease? Does he mean low back pain? ..Yes! He used the word disease!)

In the case of low back disease, although we are aware of it, the depth of our ignorance must be emphasized (...) We apparently could not find the source of pain.

The he says,

Using this as an example, we must ask where the pain comes from. Some say pain comes from the zygapophyseal joints, some from the muscles, others from the nerve root compression from the intervertebral foramen or disk, and finally, others from the disk itself. Ultimately, the theory that we should support one opinion over another is foolish. Each patient is different, and we need to do our best to determine the cause of pain for every patient.

My bold. There you go Barrett, there are multiple causes of pain and they are all equally valid, according to this guy. And note how the nervous system is not even mentioned yet.

My main point is, he's already got us thinking about all these tissues and how they are all causing pain differently in everyone and everone's different and the pain's coming from the spine, from somewhere in the spine, from some mesodermal thing in the spine.. He's leads the parade down a dark alley into a box canyon.

Many times throughout the article, I'm nodding and thinking, ..this is ok, this sounds right.., but then he'll completely default to chiro interpretation, usually using some quote from some other chiro at some other prestigious chiro event as back up to add weight to his interpretation, appealing to the religious module in the minds of chiro faithful. Looking through a chiro lens darkly. And of course, it all boils down to, you have to manipulate the spine or all this low-back disease will go on and on. And I'm still confused by his explanation of different sorts of pain.

The church of chiro has taken on pain. More to come, but I invite others to comment.

[Barrett Dorko]

Diane,

In my Forest Gumpy way I sat in a car with Vert Mooney for a few hours in '77. (I was driving speakers back and forth to a distant airport for a conference) Mooney, an orthopedist, at the time was injecting lumbar facet joints and claiming great success. I don't know what he's up to these days.

And you're right about looking for causes - it's a black hole.

[Diane]

OK, sounds like chiros love to hear tidbits from orthopedists then, same as ortho PTs are so hungry for attention from these types. You certainly are Forest Gump Barrett, augmented by your former chauffeur proclivities..

Nineteen eighty-six would have been just before a big pain deconstruction wave of info. Not that the orthopedists seem to have changed any of their tunes much as a result..

[Diane]

Next, our article writer goes on to discuss "The Nature of Pain." In his definition of pain he says "It should be emphasized that pain is always subjective" and backs that up with a 1991 quote from Wyke:

Contrary to longstanding traditional views, it is now clear that pain as a phenomenon of human experience is not a primary sensation in the sense that vision, hearing, smell, taste, touch, pressure, thermal sensitivity, and kinaesthesis are. On the contrary, it is an abnormal affective state, i.e. an emotional disturbance, that is called into being by the development of mechanical and/or chemical changes in the tissues of the body whoose nature and magnitude are such that they give rise to activity in afferent systems withion the neuroaxis that are normally quiescent.

He discusses categories of pain syndromes next:

Discussions about pain syndromes often can be confusing unless consistent terms are used. From a pathogenic perspective, pain can be induced through injury of either nonneural or neural tissues.

Really?!
He goes on:

Pain caused by neural tissue injury is referred to as neuropathic pain. Psychologic mechanisms can be involved in the p[romotion of pain. Bonica and Portenoy have indicated that pain syndromes are either nocioceptive, neuropathic, psychogenic/psychologic in nature, or a combination of the three.

He moves to defining nocioceptive pain. It's the most common type seen in clinical practice, he says. Then he gets into the inaccuracy of the term "pain receptor"... so far so good.. nocioceptors are found everywhere, long list of tissues .... even skin... that are found in the back. The rest of the body doesn't exist apparently. The physiology and the discussion of allodynia seems ok.. he talks for awhile about pathology, and that structural changes don't need to be coexistent with pathological changes.. touches on biochemistry, all of which is a leadin to where he really wants to go:

Seaman has suggested that the term "joint complex dysfunction" refers to the negative effects of immobilization, inflammation, and the aforementioned muscle imbalances.

Note: "joint complex dysfunction" is code for "subluxation" in chirospeak. The latter term has fallen away a bit after a lot of mysticism became too embedded within it.

It is time that medical and chiropractic doctors focus on pathophysiological changes involving nocioceptive processes as the cause of most spinal pain syndromes instead of the pathoanatomical changes involving neuropathic processes.

That is a reference to Waddell.

He goes on to discuss nocioceptive referred pain, that it is more likely to be seen than neuropathic pain from a nerve root, sclerotomal pain distribution. I'm still fuzzy on sclerotomal pain distributions. I first heard about them from a DO, but I wonder now if he was pulling from chiro lit. It's starting to sound to me as if chiros are the only ones who really care about sclerotomal pain patterns, because when I asked Butler about them, he'd never heard of them. So I'm guessing they are likely as chiropractically substantive as subluxation is, i.e., only chiropractors can find and treat them (by manipulation of course.)
More to come.

[Diane]

After a bit of a discussion of non-nocioceptive mechanoreceptive pain, which left me with question marks circling my head, because I thought nocioceptors included mechano reception (Moseley), our DC moves on to neuropathic pain: "allodynia to light stroking of the skin probably involve mechanostimulation and the subsequent activation of neciooceptive projection neurons as a result of dorsal horn reorganization in response to nerve injury, ie, neuropathic pain." He says that the neuropathic type sort is rare, but to avoid telling patients they have pinched nerves. He goes on to discuss central neuropathy, sympathetically maintained pain, psychologic pain, anxiety, depression, tension myositis/psychosomatic back pain, mentioning Sarno. He finishes with CBT. He says that CB therapists

use an integrated assessment method in the treatment of pain. For this reason, the CB approach was discussed in some detail. However, numerous methods for assessing pain are available to the clinician.

I suppose, like pressing on the spine to see if it hurts.

His concluding remarks are that it is "important for practitioners to be aware of treatments that can effectively reduce nocioceptive pain, including spinal adjusting/manipulation, muscle lengthening/stretching, triggerpoint therapy, rehabilitation exercises, electrical modalities, and a variety of nutritional factors." (News flash: Chiros actually consider PT one of the things they can bill for. No respect for boundaries whatsoever. Also, no need to question the underpinnings or inherent value or lack thereof of any of these.)
For the psychologic component,

All patients need to be encouraged and reassured, they need to become active participants in the treatment process

(which is sort of hard when the creme de la creme, the centerpiece of the chiro approach is to pop them)

which helps patients become more confident and less prone to anxiety and depression.

Then the best bit of all:

Doctors also should consider using health-oriented homework, such as inspirational and motivational books and tapes, which are psychologically uplifting.

(Argh! I'd be running the opposite direction in a hurry. )

[stregapez]

I'm enjoying the thread. I will probably have many questions later.

Yeah, that last bit would not appeal to me either, and i'm an American. It does seem many Americans want some cliched, pre-fab, book on a shelf (Christian, New Age, 8-step or whatever) idea of religion and "spirtuality," to be subtly mandated and inextricably woven into everything including health and wellness. What's odd and kind of scary to me is that the medical practitioners who lead with suggestions of those types are basically acting as if people never had a clear thought of their own about such things. And, of course, they therefore haven't already, nor can they, make such decisions on their own. I mentioned having an experience like that with a (new age) gyn nurse prac , who totally misdiagnosed me. Then I went to the head of the department, got no religion and a correct diagnosis, and a (physical) treatment that worked.

Sorry to go so off-topic. I'll get back to pain and tissue and spines eventually.

Dana

[stregapez]

Originally Posted by stregapez

8-step

Dana

lol, i meant 12-step

D

[nari]

Not very psychologically uplifting for us , meaning health care providers, to be told the bleedin' obvious...

A great deconstruction, Diane; their suggestions remind me of how pain clinics used to be run (and maybe some still exist) - music, tapes for relaxation education, positive thinking, etc etc plus drugs and daily dozen exercises.
Interesting that they mostly get their physiology right, but still focus on the "joint complex dysfunction". Surely they can't have it both ways....?


Nari

[Jon Newman]

Strepgapez,

We just thought you were referring to the accelerated rehab program.

Nari,

I was amazed, unfortunately more than once, when I spoke with people attending the APS meeting who seemed to have a deep understanding of pain and STILL thought people needed to go to PT to be essentially forced to stretch and strengthen. Perhaps you can imagine the look on my face. Et tu Brute?

[nari]

Yes, jon, I can see your face and perhaps it would also display a need to do a bit of wailing....

Nari

[Diane]

Interesting that they mostly get their physiology right, but still focus on the "joint complex dysfunction". Surely they can't have it both ways....?

I'm afraid they can have it anyway they want. It's all about justifying manipulation, so it doesn't matter if there's double vision. To sound impressive, sounding like you know a lot about something, is more important than really understanding it, or any ill effects your favorite trick might have on people who are on the edge of being turned into a persistant pain person.