SomaSimple Discussion Lists  

Go Back   SomaSimple Discussion Lists > Physiotherapy / Physical Therapy / Manual Therapy / Bodywork > Barrett's Forums
Albums Quiz PubMed Gray's Anatomy Tags Online Journals Statistics

Notices

Barrett's Forums This discussion is devoted to the latest advances in neuroscience and the clinical phenomena it explains.

Reply
 
Thread Tools Display Modes
Old 17-05-2006, 04:41 AM   #1
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 65
Posts: 23,531
Default Five Questions

"I thought, the way you solve a problem in biology is you solve its simplest representation."

Eric Kandel

My workshop ends with a lecture on “The Vitals of Pain.” This is the name I gave to five aspects of the patient’s presentation that I feel are essential to know and understand in order to proceed with evaluation and care. All of these are spoken of in one way or another throughout the day but I don’t have them listed specifically. Instead, I’d like to begin a thread that examines each of the five as well as my “End of Evaluation” concept.

To me, this view of evaluation and consequent care is the most important thing about my workshop but I’m not convinced many of my students see this. Perhaps this thread will help.

Let’s begin with the heretical notion that we should begin to spend less time and effort evaluating our patients. I know we’ve been pushed to consider, investigate and test for more as our knowledge of the body has grown, but for reasons Buchanan makes clear in “Ubiquity – The Science of History,” careful consideration of a multitude of factors in any complex system does us no good when we are attempting to understand and control it. This is especially true when it is in a critical state. See The End of Evaluation? for a detailed explanation of this reasoning.

The Kandel quote above says it all, and he won a Nobel Prize with this sort of minimalist approach. Not that I’ve any aspirations. But I ask just five questions of every patient to begin with and I thought it might be useful to present them here, one at a time. This should generate enough discussion to clarify these issues; maybe even change the nature of the questions themselves.

First Question: What is the origin of the pain?


How would you determine that?
__________________
Barrett L. Dorko
Barrett Dorko is offline   Reply With Quote
Old 17-05-2006, 02:58 PM   #2
Luke Rickards
Null-A
 
Luke Rickards's Avatar
 
Join Date: Oct 2004
Location: Adelaide
Age: 42
Posts: 2,540
Default

There are only 4 origins, so that narrows it down a bit.

1. Mechanical deformation - most common. Pain that changes with position or use.
2. Chemical irritation - common, may occur concurrently with pain of mechanical origin. Pain is generally constant in nature, may be associated with local heat and/or swelling, often worse at night.
3. Abnormal axonal impulse generation / Ectopic discharge - often occurs after peripheral nerve injury. Hyperalgesia along nerve trunk and/or cutuneuos distribution. Often varied or odd descriptors of pain sensation and altered stimulus/response relationship.
4. Central deafferentation - rare.
Luke Rickards is offline   Reply With Quote
Old 17-05-2006, 04:11 PM   #3
Diane
Human Primate Social Groomer and Neuroelastician
 
Diane's Avatar
 
Join Date: Mar 2004
Location: Weyburn Sask.
Posts: 25,392
Default

We could start with just one origin- the nervous system.

The way I understand it is, it hurts because it isn't getting enough oxygen. It's a system that comprises only 3% of the body mass but uses 20% of the oxygen taken in.

AIGS as physiologic change to increase the effectiveness of the warning system, occur whether the pain is benign, i.e. strictly mechanical/nocioceptive, or pathologic/neuropathic, i.e.:
1. referred to sensate portions from non-sensate portions (e.g., in viscera) which are undergoing mechanical irritations from pathology, such as tumor compression;
2. the nerve axons are infected e.g. herpes
3. the nerve axons are being killed off e.g. diabetes
4. of central origin e.g. deafferentation.

The pathologic manifestations can be ruled out/referred on through history-taking, because "pathologic" pain of any category behaves differently than "benign" pain (single category). AIGS can be confusing, can make the nocioceptive and neuropathic categories seem to overlap a bit. But they will clean up within 3 days of effective motion (motion is lotion) if they are part of the mechanical pain scenario. People can have pathologic and benign pain at the same time. What we can offer patients will clear up only the benign type; although the pathologic sorts of pain may be ameliorated by more motion/better oxygenation, the conditions giving rise to them will not.

This concurrent NOI thread might as well be brought here.
__________________
Diane
www.dermoneuromodulation.com
SensibleSolutionsPhysiotherapy
HumanAntiGravitySuit blog
Neurotonics PT Teamblog
Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
Canadian Physiotherapy Association Pain Science Division Facebook page
@PainPhysiosCan
WCPT PhysiotherapyPainNetwork on Facebook
@WCPTPTPN
Neuroscience and Pain Science for Manual PTs Facebook page

@dfjpt
SomaSimple on Facebook
@somasimple

"Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

“Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

"In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

"Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

Last edited by Diane; 17-05-2006 at 06:47 PM.
Diane is offline   Reply With Quote
Old 17-05-2006, 04:14 PM   #4
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 65
Posts: 23,531
Default

Luke,

Thanks for this. I begin my courses by identifying the first two and then introduce the third during a brief examination of Ramachandran's writing, principally his opinion of Patrick Wall on page 18 of A Brief Tour of Human Consciousness.

The third origin (AIGs) you've identified intrigues me and may one day enter into my thinking, but at the moment I remain unconvinced that these are distinct from a combination of chemical and mechanical irritation as it is eventually manifest in the nervous tissue itself. My understanding is that such things occur in the presence of persistant chemical and/or mechanical abnormalities and are perpetuated by an absence of their reversal.

As I recall, the primary problem ends up being a nerve with too many ion channels, many adrenosensitive, and that these will only diminish with a concurrent reduction in the circumstances of their growth - again, chemical and/or mechanical origin. Naturally occuring processes remodel the nerve toward normalcy within a few days, I think.

Are these AIGs what many therapists mistake for "trigger points," ostensibly in the contractile element? Can manual care for such things be justified, or is a movement therapy that reduces the mechanical deformation in the nerve a more reasonable and defendable option?

I stopped looking for or at these things many years ago though I know the search for them remains a staple of care in many clinics. Of course, that's no recommendation in my opinion.

In short, if I were to somehow discover such a spot I'd figure that this was just a local manifestation of the first two origins you mention and I'd move on, not assuming I'd discovered anything special or anything that would alter my care.

I'd love to see other opinions on this "fourth origin."

Diane,

I don't disagree with what you've said but I think you're confusing origin with source. It's important that we sort this out at this point in the thread. When I talk about origin I'm referring to a circumstance, not a place.
__________________
Barrett L. Dorko

Last edited by Barrett Dorko; 17-05-2006 at 04:18 PM.
Barrett Dorko is offline   Reply With Quote
Old 17-05-2006, 04:38 PM   #5
Luke Rickards
Null-A
 
Luke Rickards's Avatar
 
Join Date: Oct 2004
Location: Adelaide
Age: 42
Posts: 2,540
Default

Barrett,

As I understand it, the difference between the first two and the third is that mechanical deformation and chemical irritation involve transduction. Abnormal axonal impulses do not begin as stimulii transduced at a receptor site. They occur spontaneously within the axon its self. Thus the mechanism is quite different; conduction occurs in the abscence of transduction.
Luke Rickards is offline   Reply With Quote
Old 17-05-2006, 04:49 PM   #6
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 65
Posts: 23,531
Default

Luke,

I'm learning a great deal here. The trick now is to convince others that I've known this for a long time.

So, when the origins (chemical and/or mechanical) occur in the axon itself we have a special case that differs from transduction via other tissues. I can appreciate that this deep model is special in a certain way, but does it alter the presentation of pain or our approach to care?

How is this fourth origin discovered?
__________________
Barrett L. Dorko
Barrett Dorko is offline   Reply With Quote
Old 17-05-2006, 05:06 PM   #7
Luke Rickards
Null-A
 
Luke Rickards's Avatar
 
Join Date: Oct 2004
Location: Adelaide
Age: 42
Posts: 2,540
Default

Barrett,

Don't get too excited. I was writing from memory of lectures at uni and I've just had a quick look at The Sensitive NS and can't find this. Butler describes the expression of ion channels in bare axolema or on the cell body, which would produce transduction, but also talks about spontaneous discharge. I'm starting to question my understanding now. Anyone? (I'll email Nic.)

I'll have to look up my notes on central deafferentation.

Luke

Last edited by Luke Rickards; 17-05-2006 at 05:08 PM.
Luke Rickards is offline   Reply With Quote
Old 17-05-2006, 05:46 PM   #8
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 65
Posts: 23,531
Default

No rush Luke.

Once we get this origin issue settled and determine the simplest way to figure it out I'll go on to the second question in the "vitals of pain."
__________________
Barrett L. Dorko
Barrett Dorko is offline   Reply With Quote
Old 17-05-2006, 05:50 PM   #9
stregapez
Senior Member
 
Join Date: Apr 2006
Posts: 115
Default

I'm going to take a (perhaps naive) stab at this.

So, if I am asking myself, "what is the origin of this pain?" that a specific individual has, in the sense of circumstance, might I not ask, among other things, depending on what i might already know and/or have been told:

1)What does the pain feel like?
2) Is it constant or have you noticed that certain activities or inactivities aggravate it it?
3) When did you first begin to experience this ?
4) Were you engaging in any particular activity when you first noticed this, and/or had you been using your body differently than usual for a period of time before you noticed it
5) Have you been experiencing unusual emotional/mental stress lately, or have you for a prolonged period of time?
6) Do you generaly feel pretty happy with your life?
7) Have you had any other unusual symptoms?
8) Do you sleep ok?, is your diet decent?, do you drink excessively? , smoke excessively etc, etc, etc?

Thanks for the topic Barrett, just tell me if i am off topic I might have to run for a few hours (not sure yet) but will look at this later tonight if so

Dana

Last edited by stregapez; 17-05-2006 at 06:09 PM.
stregapez is offline   Reply With Quote
Old 17-05-2006, 05:59 PM   #10
Luke Rickards
Null-A
 
Luke Rickards's Avatar
 
Join Date: Oct 2004
Location: Adelaide
Age: 42
Posts: 2,540
Default

I've emailed Nic. In the meantime, I found this - "The mechanisms of neuropathic pain include totally or partially deafferented dorsal horn cells which become disinhibited and hyperexcitable, producing an increased spontaneous firing rate"

Luke
Luke Rickards is offline   Reply With Quote
Old 17-05-2006, 06:07 PM   #11
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 65
Posts: 23,531
Default

Dana,

With the possible exception of #2 these questions provide answers that don't tell us much about how we should proceed with care. Some invite the patient to share information I feel confuses the issue of origin or aren't relevant to my practice.

Maybe it's just me, but asking anyone about their level of happiness is something I never, never do. I'm terrified that they might tell me.

Luke,

This is one deep model of central pain, right?
__________________
Barrett L. Dorko
Barrett Dorko is offline   Reply With Quote
Old 17-05-2006, 06:44 PM   #12
Diane
Human Primate Social Groomer and Neuroelastician
 
Diane's Avatar
 
Join Date: Mar 2004
Location: Weyburn Sask.
Posts: 25,392
Default

Quote:
I think you're confusing origin with source
OK...
Concurrent NOI thread.
Forever muddled,
__________________
Diane
www.dermoneuromodulation.com
SensibleSolutionsPhysiotherapy
HumanAntiGravitySuit blog
Neurotonics PT Teamblog
Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
Canadian Physiotherapy Association Pain Science Division Facebook page
@PainPhysiosCan
WCPT PhysiotherapyPainNetwork on Facebook
@WCPTPTPN
Neuroscience and Pain Science for Manual PTs Facebook page

@dfjpt
SomaSimple on Facebook
@somasimple

"Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

“Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

"In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

"Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

Last edited by Diane; 17-05-2006 at 06:48 PM.
Diane is offline   Reply With Quote
Old 17-05-2006, 07:14 PM   #13
christophb
Null-A
 
christophb's Avatar
 
Join Date: Oct 2004
Location: Seattle, WA
Age: 43
Posts: 715
Default

Question regarding # 4 for my own clarity/confusion


Are you referring to central sensitization as a change in the sensitivity of the dorsal horn to peripheral input, or some brain changes/top down regulation problems? Would homoncular problems be central (I'm thinking of phantom limb stuff and CRPS)?

Chris
christophb is offline   Reply With Quote
Old 17-05-2006, 09:29 PM   #14
stregapez
Senior Member
 
Join Date: Apr 2006
Posts: 115
Default

Barrett,

I need to read the End of Evaluation essay.

As for the emotional state and life-style/habbit related questions, the reason I'd inquire would be that pain (and tension) often have a psychogenic/psycho-social component, and sometimes a lifestyle component (drinking etc)

I personally believe it sometimes does very much, and sometimes not much at all. I may not be able to affect that much directly, but when it seems to be a possibility, i think it's sometimes helpful to help bring it to the attention of the client/patient, and /or to reassure them that such things are within "normal" experience, and they can get help for them from friends, family, mental health professionals or elsewhere, and also help themselves just by being more aware of them. Same with the lifestyle questions and bringing them into the attention (drinking heavily, smoking, etc can affect pain).

I admit I find myself in a bit of "counseling" role at times with clients, mostly in that I listen (do not diagnose nor usually give firm opinions) Usually that happens because they start talking about such things. At first it bothered me, and now it usually doesn't at all. I wouldn't usually out of the blue ask "are you happy with your life?," nor when i first met them. My friends and clients tend to overlap some too. I haven't had any problems with "duel roles" though, that i'm aware of, amazingly.

In your essay "The Pallbearer, " about treating the man who had back pain which surfaced after carrying the heavy coffin, you seemed to indicate there was an emotional component (that he may have been blaming himself a little for his injury in unhelpful way, and you joked with him to get him to ralax about it, and said you could then feel the heavines easing from his body) if I read that correctly. So ~ if i'm reading that right, there's an example of where you might be addressing someone's state of mind as well as body.

Hope that wasn't to long. I don't mind of noone wants to dwell on this too much, since it's one of the very few things i already do understand a bit

Dana
stregapez is offline   Reply With Quote
Old 17-05-2006, 09:36 PM   #15
stregapez
Senior Member
 
Join Date: Apr 2006
Posts: 115
Default

Diane (or anyone) what is AIGS ?

Diane I love the artwork (the last one too) !

Dana
stregapez is offline   Reply With Quote
Old 17-05-2006, 10:23 PM   #16
Diane
Human Primate Social Groomer and Neuroelastician
 
Diane's Avatar
 
Join Date: Mar 2004
Location: Weyburn Sask.
Posts: 25,392
Default

AIGS: Abnormal Impulse Generating Sites, ectopic firing sites. I think there is still confusion at our interpretive level about how they form or why, but they indicate that a nerve is in trouble and is firing wildly, and they are part of a "sensitization" sequence of events, where nocioception is turned up, spontaneous firing occurs, and pain is more readily felt. If you google AIGS with google scholar, you'll get a bunch of studies that talk about them.

(Found the artwork with the google image tool. )
__________________
Diane
www.dermoneuromodulation.com
SensibleSolutionsPhysiotherapy
HumanAntiGravitySuit blog
Neurotonics PT Teamblog
Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
Canadian Physiotherapy Association Pain Science Division Facebook page
@PainPhysiosCan
WCPT PhysiotherapyPainNetwork on Facebook
@WCPTPTPN
Neuroscience and Pain Science for Manual PTs Facebook page

@dfjpt
SomaSimple on Facebook
@somasimple

"Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

“Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

"In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

"Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire
Diane is offline   Reply With Quote
Old 17-05-2006, 11:05 PM   #17
nari
NeuroNut Evangelist
 
nari's Avatar
 
Join Date: Mar 2004
Location: ACT Aust
Posts: 9,438
Default

From David's notes:

AIGS or ectopia

Quote:
Pain and other symptoms from peripheral nerves must come from a change in sensitivity, number or organisation of receptors in the axolemma, or it can arise from innervated connective tissue of nerve. Concepte of ectopia fit neatly with the neurodynamic concepts.
The neural pathway is designed for conduction only - generation of impulses occurs probably at the ends, or at the DRG. When sprouting occurs, or the myelin is damaged in some way, AIGS occur. When they do, the DRG becomes extremely anxious...

Interestingly, the maximal firing can take up to 21 days to occur, but it is also possible for nerve injury to be symptomless for up to 14 days. Steroids can repair the damage; also remodelling (spontaneous) which occurs every 1-2 days.

I presume that 'injury' may include mechanical deformation...

So once we have identified an abnormal neurodynamic and proceded with whatever treatment is chosen, is our aim to calm down the DRG? By enhancing remodelling and/or decreasing ischaemic states? One would hope so.

Nari

Last edited by nari; 17-05-2006 at 11:13 PM.
nari is offline   Reply With Quote
Old 17-05-2006, 11:26 PM   #18
Jon Newman
Enjoy a moment of whimsy
 
Jon Newman's Avatar
 
Join Date: Dec 2005
Posts: 9,015
Default

Quote:
First Question: What is the origin of the pain?

How would you determine that?
I suppose I would determine that by whether the person is able to alter their pain with movement or positioning. If not, manual therapy is unlikely to be of much benefit.
Jon Newman is offline   Reply With Quote
Old 17-05-2006, 11:27 PM   #19
Diane
Human Primate Social Groomer and Neuroelastician
 
Diane's Avatar
 
Join Date: Mar 2004
Location: Weyburn Sask.
Posts: 25,392
Default

Quote:
I presume that 'injury' may include mechanical deformation...
I think so too. The system is alerted to any decrease in oxygen levels by the chemoreceptors, part of the nervi nervorum/nocioception sensor array right on the nerves themselves, the sensory nervous system of the nerves. The DRGs get interested.. The nerve starts to "hurt..", sets up the AIGS. It isn't necessarily damaged yet (pain is just neurogenic not neuropathic), and the AIGS can be reversed with increased circulatory flow, which will;
a) bring the preferred levels of oxygenation to the nerve, so the chemoreceptors go quiet, and;
b) wash out all the neural metabolites.

It's probably not 100% precisely accurate, but to patients I say that the AIGS on a nerve are like diaper rash on a baby; it needs fed, and cleaned, and changed, and that increased circulation/more motion(lotion) will do it all, will help provide the necessary factors to quiet down the system/help it dismantle the AIGS/heal the rash within a few days.
__________________
Diane
www.dermoneuromodulation.com
SensibleSolutionsPhysiotherapy
HumanAntiGravitySuit blog
Neurotonics PT Teamblog
Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
Canadian Physiotherapy Association Pain Science Division Facebook page
@PainPhysiosCan
WCPT PhysiotherapyPainNetwork on Facebook
@WCPTPTPN
Neuroscience and Pain Science for Manual PTs Facebook page

@dfjpt
SomaSimple on Facebook
@somasimple

"Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

“Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

"In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

"Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire
Diane is offline   Reply With Quote
Old 18-05-2006, 12:21 AM   #20
nari
NeuroNut Evangelist
 
nari's Avatar
 
Join Date: Mar 2004
Location: ACT Aust
Posts: 9,438
Default

I think that is an important distinction; ie pain as a result of an AIGS developing is not necessarily neuropathic - but neurogenic.

jon

If ALL movement/positioning increases pain and nothing reduces it - does that imply manual therapy is not useful, or is it just the alteration of the pain experience that indicates MT would help?
I'm thinking of the persistent pain people who have 24/7 pain and, fear avoidance aside, nothing improves the pain? Just curious.

Nari
nari is offline   Reply With Quote
Old 18-05-2006, 12:50 AM   #21
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 65
Posts: 23,531
Default

Nari,

Alteration, not elimination.

Jon's post fits accurately and simply into this discussion, I think.

Last time I talked to David Butler in person I told him that, to me, AIGs were represented by neural membranes that were more like lace and less like canvas. He didn't like this but didn't tell me why. Of course, I couldn't get him to listen to anything about ideomotion either. Guess he was too busy.

This first question has generated plenty of discussion and has almost been answered - to my satisfaction anyway.

The second question soon.
__________________
Barrett L. Dorko
Barrett Dorko is offline   Reply With Quote
Old 18-05-2006, 01:17 AM   #22
nari
NeuroNut Evangelist
 
nari's Avatar
 
Join Date: Mar 2004
Location: ACT Aust
Posts: 9,438
Default

Barrett

I didn't suggest or imply elimination but I think I have answered my own question anyway.
nari is offline   Reply With Quote
Old 18-05-2006, 01:41 AM   #23
Luke Rickards
Null-A
 
Luke Rickards's Avatar
 
Join Date: Oct 2004
Location: Adelaide
Age: 42
Posts: 2,540
Default

Barrett,

The answer from Nic is, 'Yes, spontaneous discharge does occur in the absence of transduction. This may happen both within the DRG and the nerve axon.

Luke
Luke Rickards is offline   Reply With Quote
Old 18-05-2006, 02:13 AM   #24
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 65
Posts: 23,531
Default

So, four origins can be defended. The last two are probably the most difficult to alter rapidly with therapy though it's concievable that a carefully concieved program might succeed eventually.

The origin most likely to respond to the corrective movement Simple Contact reveals is mechanical deformation, of course (not that the others cannot be concurrent), so it's the one I want to know is present. A single question will reveal this.
__________________
Barrett L. Dorko
Barrett Dorko is offline   Reply With Quote
Old 18-05-2006, 03:42 AM   #25
Luke Rickards
Null-A
 
Luke Rickards's Avatar
 
Join Date: Oct 2004
Location: Adelaide
Age: 42
Posts: 2,540
Default

Chris,

Central deafferentation pain refers to pain related to central nervous system damage from stroke (often post-thalamic) or spinal cord injury. It is different to central sensitisation in that pain may be genearted in the absence of any peripheral input.

Luke
Luke Rickards is offline   Reply With Quote
Old 18-05-2006, 05:45 AM   #26
stregapez
Senior Member
 
Join Date: Apr 2006
Posts: 115
Default

Nari (or whomever) what is DRG?

Dana
stregapez is offline   Reply With Quote
Old 18-05-2006, 05:47 AM   #27
Luke Rickards
Null-A
 
Luke Rickards's Avatar
 
Join Date: Oct 2004
Location: Adelaide
Age: 42
Posts: 2,540
Default

DRG- dorsal root ganglion
Luke Rickards is offline   Reply With Quote
Old 18-05-2006, 12:53 PM   #28
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 65
Posts: 23,531
Default

I think it's time for the second question: Are there any disease processes or pathological problems that are relevant to and might be responsible for your pain?

Obviously, this is no small issue. As I say to my classes, "I'm a PT and my ability to diagnose is severely limited. I depend upon my referral souces to answer this question and make no apologies for this limitation on my part."

Thoughts?
__________________
Barrett L. Dorko
Barrett Dorko is offline   Reply With Quote
Old 19-05-2006, 12:37 AM   #29
Crazy Pole
Senior Member
 
Crazy Pole's Avatar
 
Join Date: Feb 2006
Location: Wisconsin Rapids, WI
Age: 37
Posts: 131
Default

Barrett,

I'm not sure, but I think what you are getting at is the relative uselessness/meaninglessness of PT diagnoses. The more I practice and learn, the more I would agree; if that is in fact your point.

You may also be hinting at the idea of "if nothing is wrong (in terms of true pathology), then do nothing". Simple as it sounds, I like it and have been trying to integrate it into my practice. Strangely, I find it quite satisfying to have a patient recover while I do essentially nothing.

Maybe I am way off on my assessment, but I'm trying to think like I think you would think. Someone let me know if I'm getting warm.

Wes
Crazy Pole is offline   Reply With Quote
Old 19-05-2006, 02:31 AM   #30
Jon Newman
Enjoy a moment of whimsy
 
Jon Newman's Avatar
 
Join Date: Dec 2005
Posts: 9,015
Default

I have to admit that I rather enjoy having the process of labeling a disease and pathology done by someone intensively trained to do that. I think I could recognize if such a thing exists but I am not particularly interested in labeling it. Unless something requires careful restriction of movement, a special pill or surgery, most of those labels are not going to be particularly helpful in guiding what I do next. I suppose that last point is a bit redundant as I think Wes already addressed it.
Jon Newman is offline   Reply With Quote
Old 19-05-2006, 03:08 AM   #31
nari
NeuroNut Evangelist
 
nari's Avatar
 
Join Date: Mar 2004
Location: ACT Aust
Posts: 9,438
Default

Barrett's question #2 is addressed to the patient, by the PT; which I thought rather odd at first, as patients sometimes know of their pathology (eg scleroderma) and often they don't. But their narrative and the concepts therein can be very helpful.

If I get a reply such as 'arthritis', 'slipped disc', 'torn RC', 'osteophytes', etc, then the labeling by the doctor needs some deconstruction, by the PT. The cause remains somewhat irrelevant and may be wrong or inaccurate, but that does not mean we then apply another label, whatever that may be. We might describe to the patient the process by which we will proceed with Rx; and leave it at that.

In this country we are used to making our own diagnoses, and have done that to some degree for decades. Ours may not be any more accurate than the doctors', however.

I am somewhat stuck with this question, so will leave further comments for a later date.

Nari
nari is offline   Reply With Quote
Old 19-05-2006, 03:25 AM   #32
EricM
Null-A
 
Join Date: Mar 2005
Location: Nanaimo, BC
Age: 43
Posts: 1,809
Default

I assume that at least a part of the answer to question #2 lies in the length of time that has elapsed since any actual tissue injury. If there had once been an injury, detectable by the cardinal signs of inflammation, and sufficient time has passed to allow for tissue healing, then no significant pathology would be present.
This is what you mean right Barrett?

Additional disease process could include something like cancer, or any of the odd problems diagnosed on House. (which has been good this season, in my opinion).

eric
EricM is offline   Reply With Quote
Old 19-05-2006, 04:47 AM   #33
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 65
Posts: 23,531
Default

I like what Eric has said here, and it's certainly something I consider when listening to the answer to question #2.

The following is a compilation of posts by Sean Collins, a PT who moderates the “Medical Complexity” forum on Rehab Edge. Early in its formation he questioned the appropriateness of questions posed by an osteopath who now co-hosts the forum. I thought his concerns were quite legitimate and have highlighted a few lines I liked. I was never convinced that his questions were answered.


"I always respond as in a direct access scenario, but direct access does not mean examination or treatment that may be outside the scope of practice. Given the scenario provided I think this child needs a medical examination first, so I would refer them either to the ER or to a MD. Just because you accept walk in appointments does not mean you should automatically jump to examine each and every person that walks in the door.

Also - this is my response based on "direct access" without the ability to order a radiograph.

when did direct access mean diagnosis of pathology as opposed to direct access post diagnosis for diagnosis of impairment, functional limitation and/or disability? Am I missing something?

…perhaps the diagnosis does not require an xray to diagnose - however - are PT's really supposed to be making such differential diagnoses without medical supervision - even with direct access?

If I am correct - should the new thought processes (this is what Dr. Wagner suggests the quizzes regarding diagnosis are about) be geared toward scope of practice of the physical therapist as opposed to physicians? Do such cases and examples for PT's confuse the scope of practice issue, and make it more difficult for therapists to contribute to an understanding of what direct access, autonomy, PT diagnose are within the scope of PT practice?

I agree that it is within our scope of practice to examine and evaluate to convey our impression if we have to refer. And that it is important to know when to treat and when to refer - this is the entire point of the direct access movement. I also agree that it is not our role to send all cases to the ER - but in cases you are unsure of based on the history, and can possibly be dangerous to perform examinations on until certain (worst case scenario) diagnoses are ruled out should be sent to the ER for medical evaluation."

Me again. When it comes to "PT diagnosis" my main feeling remains an uneasy confusion.

More on this soon.
__________________
Barrett L. Dorko
Barrett Dorko is offline   Reply With Quote
Old 19-05-2006, 05:29 AM   #34
nari
NeuroNut Evangelist
 
nari's Avatar
 
Join Date: Mar 2004
Location: ACT Aust
Posts: 9,438
Default

The apparent issues surrounding direct access are difficult to comprehend.

It doesn't mean there is a need for PTs to order XRs, it doesn't mean referral-only PTs become pseudodoctors if they gain direct access.
It does mean we should be able to interpret XRs with knowledge and consider what we find as part of a Rx plan - or not.
It does mean we use our knowledge to know what is beyond our ability to intervene safely and ethically.

The incidences of sending a patient off to ER are few. They happen, but anyone with an understanding of physiology and red flags would prefer to err on the side of caution and risk a possibly unnecessary referral to ER or the GP, faced with a possibly undiagnosed ominous sign.

How do Canadians feel on this issue?

Nari
nari is offline   Reply With Quote
Old 19-05-2006, 05:39 AM   #35
Diane
Human Primate Social Groomer and Neuroelastician
 
Diane's Avatar
 
Join Date: Mar 2004
Location: Weyburn Sask.
Posts: 25,392
Default

I've sent a handful of people off to see the doctor since I've been direct access.
The most dramatic was a pregnant woman with leg pain. When I looked at her legs, one was swollen and the other was not. Uh-oh. I laid her down and phoned her doctor right away, who called back immediately and said, "Put her in a cab to VGH and tell her I'll meet her there in Emerge." Yup, she had a huge clot. She lived to thank me a few years later. The other stuff has been skin cancer mostly. One guy who seemed like his low back pain was more visceral in nature than somatic.. I was thinking prostate.
Most of the people who come in to see me have already gone and been checked out medically.

On one occasion prior to direct access I sent a woman whose heel pain wasn't resolving, and who had a rash across her nose, back to her doctor to ask him to check her out for lupus. Darned if I wasn't right about that.

On the other side of the coin are people who've been scared by their PTs jumping to conclusions that a knee pain and a bit of a loose drawer sign automatically indicates a torn cruciate, etc., who have sent them in to get CT scanned/MRI'd, whatever.

I feel that PTs should be taught to make good assessments/PT diagnoses and refer if necessary, rather than have to wait on the other end of the pipe for referrals; I think overall it would bring costs down. It's expensive for people with benign pain (which most pain is) to have to pay for or have a system pay for medical workup then be referred to PT. A PT diagnosis will always be about pain<->function, not defined pathology.
__________________
Diane
www.dermoneuromodulation.com
SensibleSolutionsPhysiotherapy
HumanAntiGravitySuit blog
Neurotonics PT Teamblog
Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
Canadian Physiotherapy Association Pain Science Division Facebook page
@PainPhysiosCan
WCPT PhysiotherapyPainNetwork on Facebook
@WCPTPTPN
Neuroscience and Pain Science for Manual PTs Facebook page

@dfjpt
SomaSimple on Facebook
@somasimple

"Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

“Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

"In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

"Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

Last edited by Diane; 19-05-2006 at 03:35 PM.
Diane is offline   Reply With Quote
Old 19-05-2006, 06:14 AM   #36
nari
NeuroNut Evangelist
 
nari's Avatar
 
Join Date: Mar 2004
Location: ACT Aust
Posts: 9,438
Default

Another aspect of the problem of PTs dependent on referrals is that they could miss out on those patients who may need us more than the sore finger/sprained something/weak quads referrals; we miss those who go to the doctor with back pain, are given drugs, told to rest up and see a PT if it isn't better in two weeks.

It is expensive for many to fork out money to see a doctor only to be told to go to physio; assuming there has not been direct trauma which needs investigation.

A patient can have unexpected indications of a serious nature at any time; even if seen by a doctor in the recent past. An elderly woman, in the outpatients' dept of the hospital, came for "physio" to her left arm, which had been annoying her off and on for a few weeks. She had headache, stiff neck, and a sleep deficit. What raised my suspicions at once was the complaint of a 'sore throat' - which she described as 'sort of deep' pain. Off to ER - where she was treated for unstable angina. Now she may have had some degree of physio-treatable arm pain; but that was irrelevant.

All PTs should be in the position of recognising red flags, access or not.

Nari
nari is offline   Reply With Quote
Old 19-05-2006, 02:21 PM   #37
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 65
Posts: 23,531
Default

I've given this issue a great deal of thought and today I feel it comes down to this: The "hole" in therapy through which many patients fall is created and maintained by the therapy community's lack of knowledge and understanding of the very basics of neuroscience as it is related to painful problems. I see this hole growing larger as the neuroscience advances while the work/interest in learning it decreases. It is extremely common for physical therapists directing that portion of the rehabilitation in a specialty pain clinic to be completely unaware of Wall, Ramachandran, Butler, Gifford, Breig and others as well as being distinctly oblivious to any information available on the Internet. I am not exaggerating and I am in a unique position to know this, getting around as I do.

I will always wonder why a profession so poorly prepared to understand, much less treat, painful problems such as an abnormal neurodynamic -and most would agree these are an enormous percentage of our patients - would want to add even more responsibility to their job.
__________________
Barrett L. Dorko
Barrett Dorko is offline   Reply With Quote
Old 19-05-2006, 07:58 PM   #38
Jon Newman
Enjoy a moment of whimsy
 
Jon Newman's Avatar
 
Join Date: Dec 2005
Posts: 9,015
Default

Hi Barrett,

I remember that thread at RE and if I'm not mistaken I had PM'd Sean about it.

I'd like to track back to the second of five questions

Quote:
Are there any disease processes or pathological problems that are relevant to and might be responsible for your pain?
When I ask this question the patient typically cites something. This leads to the usual confusion of biomedical diagonsis being equivalent to pain. Pain is the same kind as tendonitis, it the same kind as a degenerated disk. I think it is what is called a category mistake.

I'll add that I think it is a mistake to become more and more skilled at learning about the alternate category (biomedical diagnosis) when there is already a profession devoted to do that. This seems to tie in with what Eric has commented on as well as your previous comments regarding PT's niche is 'for when things go wrong'.

Last edited by Jon Newman; 19-05-2006 at 10:03 PM.
Jon Newman is offline   Reply With Quote
Old 20-05-2006, 12:12 AM   #39
nari
NeuroNut Evangelist
 
nari's Avatar
 
Join Date: Mar 2004
Location: ACT Aust
Posts: 9,438
Default

Barrett

Call it traditional thinking - it is much easier to follow what a charismatic teacher enthusiastically tells them to do and has a million RCTs and other studies to back it up. Takes effort out of the consolidation process in PTs' brains. The other side of the story could be that they simply do not have the confidence (or courage) to question the contents of a course that is basically about home ground; even if the outcomes are inconsistently positive.
Those who do question the premises behind numerous popular techniques are seen as renegades or outsiders.

I don't agree that diagnosis should be left entirely to the medicos and radiologists; but I come from an environment where diagnoses are usually questioned and altered, sometimes, by PTs - it's just part of our physio world. Of course I am referring to the simple stuff, the causes for aches and pains in joints, and so on. It's part of the learning process....

jon,

Does knowing that a "torn rotator cuff muscle" exists alter the way you would treat it? Especially when it responds well to methods that have nothing to do with "strengthening" ? Just curious.

Nari
nari is offline   Reply With Quote
Old 20-05-2006, 12:48 AM   #40
Jon Newman
Enjoy a moment of whimsy
 
Jon Newman's Avatar
 
Join Date: Dec 2005
Posts: 9,015
Default

Hi Nari,

I think that's a reasonable question. I assume that the person before me is there primarily because they have pain that is likely coupled with one sort of limitation or another. History and a general observation of movement would likely reveal whether tissues need to be protected. Perhaps history alone would reveal that. I don't think it would alter MY care although strengthening and stretching connective tissue is not my primary approach when someone comes to me in pain. I imagine that if these were my primary strategic approaches, such knowledge would alter my care. Maybe that's the obsession with the (in honor of Diane) mesodermal diagnosis.
Jon Newman is offline   Reply With Quote
Old 20-05-2006, 01:27 AM   #41
nari
NeuroNut Evangelist
 
nari's Avatar
 
Join Date: Mar 2004
Location: ACT Aust
Posts: 9,438
Default

That is worth a thread on its own...the validity of mesodermal diagnoses which seem to lead so many PTs astray, including many of those who attend Barrett's classes and find a lack of mesodermal thought.....

Nari
nari is offline   Reply With Quote
Old 20-05-2006, 03:37 PM   #42
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 65
Posts: 23,531
Default

Wonderful discussion.

Jon,

Your link regarding category mistakes is especially relevant. As some of you know, I'm currently in Las Vegas where my family has gathered to greet my son Alex. He's home from Iraq for two weeks and his stories of searching the road for explosives designed to deceive him fit here perfectly. He says, "When you travel the same road every day you just know when something has changed." Isn't examination of the human body similar in many ways?

I'l be writing more about this.

I think much of this issue revolves around discovering and defending an accurate and relevant essential diagnosis. This doesn't require great leaps in knowledge toward medical school minutia. I think it's wise to leave that to the physician, whether or not he or she does it well.

The third question:: What is your autonomic state and how is that related to your breathing pattern?

Thoughts?
__________________
Barrett L. Dorko
Barrett Dorko is offline   Reply With Quote
Old 20-05-2006, 07:48 PM   #43
EricM
Null-A
 
Join Date: Mar 2005
Location: Nanaimo, BC
Age: 43
Posts: 1,809
Default

I observe breathing patterns looking at apical vs diaphragmatic excursion and rate. I ask about the presence of cold hands or feet. However, recently at least for me, the clinical answers to this question have been split roughly 50/50 in similar chronically painful states. This makes me think either I may be missing something in my assessment, or that autonomic imbalance may only be relevant to the patient in question. What I might interpret as 'normal' may be abnormal to the patient and thus still have a significant influence on the pain state.

Eric
EricM is offline   Reply With Quote
Old 20-05-2006, 11:32 PM   #44
nari
NeuroNut Evangelist
 
nari's Avatar
 
Join Date: Mar 2004
Location: ACT Aust
Posts: 9,438
Default

I think that many patients consider cold hands and feet 'normal' because they have always had cold extremities. However, in someone who feels quite 'normal' ambient temperature in the extremities, an increased sensation of warmth after contact is informative.
Long before learning SC, I noticed that patients in an altered ANS state had high RRs, often around 25-30, and apical. After some diaphragmatic practising, they reported feeling calmer and their RR decreased; sometimes the pain decreased, and other times, not. They usually put it down to relaxing.
Then I worked out that they needed to practise deeper breathing while moving around; this worked sometimes; and if they practised during neurodynamic movements, they noticed the pain less, which I put down to distraction.
Several patients found a significant difference between breath-holding and breathing during neurodynamic movement. Some found it much better to hold their breath (on a neutral chest expansion, not on inhalation) during the movement. I personally find the same thing - but I know I am the only person to think this fact.

Eric, I agree that sometimes the autonomic state may only be relevant only to the patient in question. I have seen some dire chronic pain people who are quite warm despite their 24/7 pain state. Not sure about this.

Nari
nari is offline   Reply With Quote
Old 21-05-2006, 03:52 PM   #45
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 65
Posts: 23,531
Default

Nari,

I would say that my experience of this has been remarkably similar to yours.

Hidden within each of the "five vitals of pain" that lead to the questions is something most evaluative schemes do not have: opportunities to teach and learn along with an obvious relevance. Because of this, a great deal of care is provided during evaluation. This certainly shortens the time necessary to treat people. It'll probably cost the therapist money as well. Too bad.

Cooling in relation to those physiologic and behavioral processes that accompany sympathetic increase is the "physiologic signature" of the abnormal dynamic. I know that there are patients who aren't cold and should be but typically they're good diaphragmatic breathers for some reason, most commonly chior or yoga. In any case, this third question gives me the opportunity show them how these things relate to their discomfort and thus draw them further toward a realization that much of their pain is a consequence of their behavior - behavior they can control.

Abnormally warm people are also out there. Most of the time they have mid-thoracic issues and, I presume, are dysautonomic. I've seen this improve dramatically coutless times. I have no way of proving that of course, so I make no claims.
__________________
Barrett L. Dorko
Barrett Dorko is offline   Reply With Quote
Old 21-05-2006, 04:51 PM   #46
Diane
Human Primate Social Groomer and Neuroelastician
 
Diane's Avatar
 
Join Date: Mar 2004
Location: Weyburn Sask.
Posts: 25,392
Default

Lately I treated a woman who is one of the warm ones. She even said, "My feet get so hot that they burn.. I strap ice packs to them so I can go to sleep." She certainly had lots going on between the blades...

The autonomic system has always flummoxed me. I've never understood it well enough to be able to convince myself I can predict what it can/will do, or that anyone else who sounds like they have it down pat, really does. And I've never believed that popping backs somehow enhances or normalizes its function.

I've just acquired another Burnstock book, called Comparative Physiology and Evolution of the ANS.. Haven't started it yet.. if I can make head or tail of it, I'll let you know. All I know right now is that in lots of different species including our own, autonomics make skin change color and hair lift up. Also that skin has ten times the amount of blood flow it needs for its own maintenance, so it can be a metabolic heat radiator/entropy radiator. Meanwhile, for pain, I think it's safe to say that producing any kind of change in autonomics into the opposite direction of wherever they seems stuck, is beneficial. Maybe the rule could be, if it's cold make it warm, if its hot, make it cool.

The other big clue I got was finding out not that long ago that autonomics do the opposite thing in the skin than they do in muscle. I'm still composting that. It's so big that it's taking quite awhile.. it makes sense that the blood shunting mechanism would be different for mesoderm than for ectoderm and endoderm, thinking embryologically. It makes me more convinced than ever that skin is the key to the mansion, not only for pain diminishment but also for autonomics.. just trying to work out why and how.
__________________
Diane
www.dermoneuromodulation.com
SensibleSolutionsPhysiotherapy
HumanAntiGravitySuit blog
Neurotonics PT Teamblog
Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
Canadian Physiotherapy Association Pain Science Division Facebook page
@PainPhysiosCan
WCPT PhysiotherapyPainNetwork on Facebook
@WCPTPTPN
Neuroscience and Pain Science for Manual PTs Facebook page

@dfjpt
SomaSimple on Facebook
@somasimple

"Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

“Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

"In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

"Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

Last edited by Diane; 22-05-2006 at 01:02 AM.
Diane is offline   Reply With Quote
Old 21-05-2006, 05:48 PM   #47
Jon Newman
Enjoy a moment of whimsy
 
Jon Newman's Avatar
 
Join Date: Dec 2005
Posts: 9,015
Default

Hi Diane,

You may be interested in the following. This is a side bar and if anyone wants to discuss it further maybe a new thread can be started. The current one has a good flow right now but I do think this is pertinent to the discussion.

One of the poster presentations at the APS conference was titled Skin potential as a measurable correlate of moderate to severe chronic pain--a case report and was authored by Donald D'Angelo.

Quote:
Introduction

There exists a perceived need for an objective measure of pain and pain relief. There is a device used in veterinary medicine to perform bilateral measurements of the electric charge of the skin, skin potential (SP). SP can be used to detect distinctive asymmetries caused by the autonomic nervous system as it responds to moderate to severe persistent pain. SP can accurately reflect changes in the ANS. The goal of this study was to determine if this device might reliably assess pain in humans.
While the methods and results are certainly important, I will simply summarize as this is 'only' a case study. The measuring device is trademarked as PainTrace manufactured by Biographs LLC, Bayville, NY. Here's a quick summary of what they are measuring:
Quote:
If both palms produce equal voltage, the linear trace will be a flat, horizontal line down the center of the graph paper. We take this line as the X axis of our graph, with the arrow of time to the right. This functions as a neutral baseline with a value of zero. When the right palm is producing higher SP than the left, the linear trace will be above the neutral baseline on the graph. When the right palm is producing lower SP than the left, the linear trace will occur below the neutral baseline.
The picture they show is simply a nickel sized electrode placed in the palm of each hand with the leads running to a chart recorder.

Quote:
The asymmetrical SP can be accounted for by the ANS innervation of the skin. It has been found in numerous mammalian species that an autonomic response is demonstrated with persistent pain. At the onset of acute pain, the ANS raises sympathetic tone and accordingly blood pressure and heart rate, which have been shown to normalize with respect to time. The activation of baroreceptors by elevated BP, triggers an increase in vagal tone in an attempt to restore homeostasis. This increase in vagal tone has been demonstrated to provide an opioid-mediated partial anti-nocicipetion in both animal and human models. The primary pathway for this effect is mediated via the right cardiac vagal trunk. In addition to the heart, the vagus affects other physiologic changes including a lowering of SP. Thus, during moderate to severe chronic pain, skin on the right side has a lower SP than on the contralateral side, while mild pain fails to trigger the baroreceptors and therefore does not produce changes in SP. After pain relief, vagal tone moves back towards normal, with a coincident fall in SP on the right side.
This D'Angelo fellow by the way is an MD working for New York Harbor VA medical center in the dept. of anesthesiology.

Quote:
Summary: In all five sessions for this individual, SP was lower on the right side during moderate to severe chronic pain (VAS 4-10). After pain relief, SP on the right rose. Distinguishing between painful and pain-free states in this patients was as simple as seeing whether the trace was above or below the neutral baseline.
It will be interesting to follow whether this technology, if validated, comes into play in future pain studies.
Jon Newman is offline   Reply With Quote
Old 21-05-2006, 06:08 PM   #48
Diane
Human Primate Social Groomer and Neuroelastician
 
Diane's Avatar
 
Join Date: Mar 2004
Location: Weyburn Sask.
Posts: 25,392
Default

Thanks Jon.
Quote:
At the onset of acute pain, the ANS raises sympathetic tone and accordingly blood pressure and heart rate, which have been shown to normalize with respect to time. The activation of baroreceptors by elevated BP, triggers an increase in vagal tone in an attempt to restore homeostasis. This increase in vagal tone has been demonstrated to provide an opioid-mediated partial anti-nocicipetion in both animal and human models. The primary pathway for this effect is mediated via the right cardiac vagal trunk. In addition to the heart, the vagus affects other physiologic changes including a lowering of SP. Thus, during moderate to severe chronic pain, skin on the right side has a lower SP than on the contralateral side, while mild pain fails to trigger the baroreceptors and therefore does not produce changes in SP. After pain relief, vagal tone moves back towards normal, with a coincident fall in SP on the right side.
It still doesn't make sense yet. In other words, I still can't quite "see" it yet. I see a vague random rise and fall, sort of like the sea heaving around but I can't make out what is calming it down and what is making it rise. My confusion is directly proportional to the lack of focal length/ability to see a big(ger)/ the big(gest) picture, and was based originally on a category mistake named "peripheral/central" instead of "ectodermal/mesodermal/endodermal".

Other thoughts/beliefs I've held about the ANS that need closer looking/ deconstruction:
1. parasympathetic good for pain, sympathetic bad for pain
2. touching improves parasympathetic function
3. exercise increases sympathetic function
4. autonomics are essential for breathing, digestion, heart function
5. that there must be consistency somewhere in it that I'm missing (maybe there isn't any consistency or fixedness or predictability, maybe there is only perpetual dialectic)

Definitely, let's start a new thread. (I started one awhile ago.. can't find it just now.. I posted a picture of an interneuron. The thread died and got lost. I'll repost the picture.)
__________________
Diane
www.dermoneuromodulation.com
SensibleSolutionsPhysiotherapy
HumanAntiGravitySuit blog
Neurotonics PT Teamblog
Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
Canadian Physiotherapy Association Pain Science Division Facebook page
@PainPhysiosCan
WCPT PhysiotherapyPainNetwork on Facebook
@WCPTPTPN
Neuroscience and Pain Science for Manual PTs Facebook page

@dfjpt
SomaSimple on Facebook
@somasimple

"Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

“Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

"In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

"Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

Last edited by Diane; 21-05-2006 at 07:44 PM.
Diane is offline   Reply With Quote
Old 22-05-2006, 12:36 AM   #49
Barrett Dorko
Writer and Clinician
 
Barrett Dorko's Avatar
 
Join Date: Nov 2005
Location: Cuyahoga Falls, Ohio
Age: 65
Posts: 23,531
Default

A new thread about the autonomic state in pain and during correction sounds good. To me, it's the least well understood portion of the "five vitals" equation. Jon's attendance to that conference is really paying off for all of us here.

Time for the fourth question : Which ways do you want to move and how does that make you feel?

I always ask my classes at this point - How do I ask this question?

Any takers?
__________________
Barrett L. Dorko
Barrett Dorko is offline   Reply With Quote
Old 22-05-2006, 12:58 AM   #50
Diane
Human Primate Social Groomer and Neuroelastician
 
Diane's Avatar
 
Join Date: Mar 2004
Location: Weyburn Sask.
Posts: 25,392
Default

Quote:
How do I ask this question?
Manually.
__________________
Diane
www.dermoneuromodulation.com
SensibleSolutionsPhysiotherapy
HumanAntiGravitySuit blog
Neurotonics PT Teamblog
Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
Canadian Physiotherapy Association Pain Science Division Facebook page
@PainPhysiosCan
WCPT PhysiotherapyPainNetwork on Facebook
@WCPTPTPN
Neuroscience and Pain Science for Manual PTs Facebook page

@dfjpt
SomaSimple on Facebook
@somasimple

"Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

“Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

“If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

"In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

"Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire
Diane is offline   Reply With Quote
Reply

Bookmarks

Thread Tools
Display Modes

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is On
HTML code is Off

Forum Jump

Similar Threads
Thread Thread Starter Forum Replies Last Post
Questions to Michael Barrett Dorko CHOICES: Perspectives on the Future of PT 29 18-08-2006 12:17 AM


All times are GMT +2. The time now is 10:50 AM.


Powered by vBulletin® Version 3.8.11
Copyright ©2000 - 2017, vBulletin Solutions Inc.
SomaSimple 2004 - 2017