Don't poke

[Barrett Dorko]

I’m concerned that I’ve bypassed simplification and gone all the way to simplistic with these posts, but with Diane’s help that’s always correctable.

I was at Ohio State while Woody Hayes was there and I once had a personal encounter with him (another story). He loved to expound on subjects way past what most felt was required. Among the faculty there was a joke: Don’t ask Woody what time it is unless you want to know how a watch is made.

C-mechanoreceptors in the dermis are nociceptors and they respond to steady indentation (poking).

Having said that, I’ll make this short.

It doesn’t make sense to stimulate a nociceptor when handling someone in a fashion meant to be therapeutic.

Among several unacceptable excuses for doing this are:

1) I’m breaking up adhesions

2) This really works

3) They taught me this in school

4) Patients tell me “it hurts good”

[Diane]

Originally Posted by Barrett Dorko

It doesn’t make sense to stimulate a nociceptor when handling someone in a fashion meant to be therapeutic.

Among several unacceptable excuses for doing this are:

1) I’m breaking up adhesions

2) This really works

3) They taught me this in school

4) Patients tell me “it hurts good”

I've been saying this all my life. Even before I knew about nociceptors (i.e. "how a watch is made.." ). Once a person learns about them, why would anyone for any reason want to stimulate them? Even by mistake?

[Barrett Dorko]

Whew!

Diane, I'm glad to see that you agree with "going simply" here. It seems Woody was always teaching something, whether he meant to or not.

Where does this popular and painful technique come from? Who's promoting it? Why does it endure in the face of evidence to the contrary? Why do some patients seek it?

To me, the answers lie deeply embedded in cultural myth and expectation.

[Diane]

Mesodermalism.

[tonyf315]

I’m concerned that I’ve bypassed simplification and gone all the way to simplistic with these posts, but with Diane’s help that’s always correctable.

Barrett,

this gives me a bit of a brainstorm for you RE: structuring your course for that "difficult audience"...I might ramble a bit getting this out so hope you'll bear with me and hope it might have potential.

I personally kind of like these very simple little nuggets. I'm someone that (out of laziness primarily!) will bounce between wanting to dive in and really know and just want to know enough to get by. I suspect there are others out there, as well as others that want no more than the "just enough to get by part"

So RE: your course. This might also serve as a bit of a gimmic too. How about starting out with a list of these simple nuggets. Bottom line points right from the get-go. Basic "level 1" understanding. take nothing else home but these mechanical ideas, and at least you will go back to work and hurt your patients less.

Then, after the brief intro of each of these points, proceed with a medium detailed ("level 2) elaboration of each one. Probably very similar to what you already do? And at the end of each lecture, give the invite to examine a related thread here (assuming there probably is one) "for further information" ("Level 3")

I don't know if that is any help especially since I haven't seen your course in action yet but just something that popped into my head reading this. Which I like BTW...I'm a recovering "poker".

I've been saying this all my life. Even before I knew about nociceptors (i.e. "how a watch is made.." ). Once a person learns about them, why would anyone for any reason want to stimulate them? Even by mistake?

I wish I still had the course materials I could show you Diane, but in the early 90s I went to a series (upper and lower body) put on by some Japanese therapists teaching to do that ON PURPOSE. Their claim was that Trigger Points (what they called "muscle hardenings") were the result of a healing process that got "stuck" and that painful stimulation activated polymodal receptors that would recreate an acute inflammatory response basically (in modern day terms) rebooting the healing process. It involved long (90 minute), full body treatments with "deep friction". bruises were common. They made it all seem very scientific.

Fortunately I myself couldn't physically keep up with doing such a method long enough to hurt many people.

And Barrett, you'll love this: know where I was first introduced to this? School.

[Bas Asselbergs]

To me, the answers lie deeply embedded in cultural myth and expectation.

I agree completely.

Barrett, I like to comment on calling this simplistic:
it is like calling E = mc2 simplistic because of its brevity.

Yes, the conclusion/tenet/paradigm may be simplistic in appearance, but it is based on a long and complex process of examination and study - and firmly based on scientific plausibility!

I will never call that post simplistic. I call it short.
And I really, really like it.

[Diane]

Here is something about the watch, how it's made, why we shouldn't poke.

[Jason Silvernail]

Love this.
If mechanical pain is about movement, why would poking people help?

[Sheffphysio]

i've been to training days, where we learnt about all different strengths of poke..... or grades as we like to call them to make us sound professional.

I wish i had read this post first, I would have asked,

"So, whats the difference between a grade 2 poke and a grade 3 minus poke?"

[Bas Asselbergs]

"A bit more nociceptive."
Would have been accurate, but you'd never hear that.....

[Jon Newman]

Originally Posted by Barrett Dorko

Where does this popular and painful technique come from? Who's promoting it? Why does it endure in the face of evidence to the contrary? Why do some patients seek it?

To me, the answers lie deeply embedded in cultural myth and expectation.

You can poke people on facebook too, so one way or another, poking is here to stay. I thought the explanation of poking on facebook comes pretty close to what happens in the clinic.

Many Facebook users use this feature to attract attention

People interpret the poke in many different ways, and we encourage you to come up with your own meanings."

People often reciprocate pokes back and forth until one side gives up, an event known as a "Poke War"

I see the "poke war" as the PT giving up after the patient doesn't get any better in any enduring way, perhaps secondary to facilitating central sensitization, or the patient giving up or feeling better.

[tonyf315]

Cool post, Jon!

[Ryan Appell]

Originally Posted by Barrett Dorko

To me, the answers lie deeply embedded in cultural myth and expectation.

No pain, no gain.

This, for me, is the most difficult mental hurdle and expectation for me to change in patients, even with all the education on pain.

[zimney3pt]

No pain, no gain.

That's where we need to change the culture to a more accurate explanation "know pain, know gain". Yes, Ryan I would agree it is very difficult hurdle for some.

[raisonbrann]

ok if all poking is bad, then then how do things like Nimmo's Receptor Tonus Technique, also known as N.M.T., work?

I guess you would also say there is nothing to reflexology and shiatsu? what is the redeeming value of these approaches, someone at sometime found them valuable enough to develop them, do they have any knowledge from which we can learn?

It sounds to me like your firmly in the fascial mobilization school of thought. would you agree?

all you guys have had way more training then me, I'm just a interested citizen, so please correct me, janet travel, david simons, raymond nimmo, were heading down the wrong path?

[Sheffphysio]

Originally Posted by raisonbrann

It sounds to me like your firmly in the fascial mobilization school of thought. would you agree?

all you guys have had way more training then me, I'm just a interested citizen, so please correct me, janet travel, david simons, raymond nimmo, were heading down the wrong path?

No, certainly not fascial mobilization.

And just because people head down the wrong path doesn't mean what they have done is not useful and enable further understanding and development of new models.

[Diane]

They might overlap with perceived improvement (by the patient) enough of the time to convince their purveyors they are worth teaching/propagating, or prospective koolaid drinkers - oops, I mean, manual therapy students, that they are worth spending time/$ on.

It relates back to placebo. It's easy enough to fool a person that something (anything) has helped them (placebo effect). It's not as easy to actually persuade the nervous system itself (with all its evolutionarily acquired, more ancient threat-detecting, life-preserving bits) to change itself (placebo response).

You can't get anywhere in terms of eliciting placebo response, a genuine improvement, in perceived pain and observable function, by adding nociception. IMHO.

[Diane]

"It hurts more if you believe someone is doing it to you on purpose."

[caro]

I think this blog entry by Cory Blickenstaff ties in nicely.

http://blog.forwardmotionpt.com/2011_05_01_archive.html

[Frédéric]

At the risk of being chastized

Patients tell me “it hurts good

I don't entirely agree with this one. When I do something to a pt that soothes strongly their main pain complaint but it gives them some form of discomfort/pain that isn't part of their initial complaint, if I can't achieve the same instant gratification painlessly I find acceptable, to give them this trade off provided they like the sensation. Often they will feel the caracteristics of correction at the same time or at least some of them. Their breathing will change, they will sometime exclame a pleasurefull moan and ask that I go on with what I am doing or even that I do it longer.

[Barrett Dorko]

I can't disagree with all of that Frederic, and I've always said that if pain increases simultaneously with the characteristics of correction it should be ignored. It's presence or absence is, in effect, unimportant as a subjective response, and, in my experience, does not produce the withdrawal seen otherwise.

Perhaps this is the key; withdrawal's presence or absence.

I was talking about the therapist who says this all day long and feels that it's necessary and implies improvement.

[allenbr4]

Originally Posted by Diane

It relates back to placebo. It's easy enough to fool a person that something (anything) has helped them (placebo effect). It's not as easy to actually persuade the nervous system itself (with all its evolutionarily acquired, more ancient threat-detecting, life-preserving bits) to change itself (placebo response).

Diane,

How would you describe the difference between a patient who experiences elimination of neck pain after a painful "deep-tissue" massage and one that had the same improvement after DNM or ideomotion?

I'm really trying to understand how the nervous system would vary in 2 people that feel better.

Thanks a lot!

[Diane]

I guess I don't even understand the question. How does the movement differ before and after, and what are the two patients' different biopsychosocial factors prior. I guess I'd need to know more. It (the question) doesn't make much sense at all to me, otherwise.

[zimney3pt]

Brian, my understanding (and Diane can clarify my mistakes when she reads your question), is that deep tissue massage can elicit potentially a placebo or nocebo response; whereas, DNM can elicit potentially a placebo response only.

Placebo effect is basically a psychosocial context effect, these data indicate that different social stimuli, such as words and rituals of the therapeutic act, may change the chemistry and circuitry of the patient’s brain...Benedetti (2011)

While placebo effect and placebo response are terms usually used interchangeable. But I differentiate (which may be incorrect) the placebo effect is what we input into the system through context, stimuli, rituals, therapeutic act; where as, placebo response is what the patient's brain does with the input. But placebo "affect" is something different see here.

When you elicit placebo the nervous system can pick one of three things to decide (neuromatrix) about the input (good, bad, nothing). With "poking" you get a chance for any of the three. With "no poking" you eliminate the risk for nocebo (bad) and left with nothing or good. I like those odds better.

[allenbr4]

Diane,

I think you were implying that a patient might feel better after, for instance, deep-tissue massage, primarily due to beliefs (no pain, no gain) and placebo effect. But that it'd be more difficult to truly create a positive placebo response.

I guess I'm trying to understand the difference there. If a patient feels better due to the placebo effect, isn't that a placebo response by the nervous system?

I don't think we'd argue that a massage therapist might help patients to feel better AND have an increased ROM, decreased neural tension, etc., following a treatment, but rather some would argue that the painful treatment wasn't necessary and their reasoning for the improvement was flawed.

Other than that patient having a flawed perception of what caused the improvement, how does a patient with all of those improvements after massage differ from one who improved after a milder, non-nociceptive treatment?

[smikolic]

I've always said that if pain increases simultaneously with the characteristics of correction it should be ignored. It's presence or absence is, in effect, unimportant as a subjective response, and, in my experience, does not produce the withdrawal seen otherwise.

Perhaps this is the key; withdrawal's presence or absence.

I like that addition...sensation is not the same (or as important??) as response to sensation....I'm struggling explaining this aspect to the students in a very clear way, but this might help a lot......

[Barrett Dorko]

...how does a patient with all of those improvements after massage differ from one who improved after a milder, non-nociceptive treatment?

Was the massage client educated rationally (the truth according to modern neuroscience, not mesodermal dogma)?

Was the movement induced corrective in nature and how could the practitioner tell?

Is the patient now able to reproduce the relieving effect with further movement?

[nari]

What about the surprise response with DNM that one would not get with mesodermal massage which is expected by the patient?

Nari

[Barrett Dorko]

Nari,

Good point. It is certainly surprising. The word we've used many times before is novel.

This implies that the brain gains interest, begins to change and doesn't activate the movement of withdrawal (Wall's first of the three instinctive movements in response to "a painful signal."

I want to also say that the "hurts good" response I get from patients is in reference to their movement - not my pressure.

[gilbert]

And what about all the patients who come back with their painful problem made worse by the deep tissue massage? Seriously I wish many, many more people would follow this simple "don't poke" rule.

[nari]

I recall a number of patients who reported that after a long session with a MT they felt much better but to me they said the pain is still there. They intended to keep on with MT and looked at me to fix up the pain. Uh-oh...

Nari

[Barrett Dorko]

gilbert,

That's called "a healing crisis" and it means they need more treatment and lessons in truly lett...sorry, I couldn't keep a straight face.

[proud]

When you elicit placebo the nervous system can pick one of three things to decide (neuromatrix) about the input (good, bad, nothing). With "poking" you get a chance for any of the three. With "no poking" you eliminate the risk for nocebo (bad) and left with nothing or good. I like those odds better.

True, the risk of nocebo is eliminated and that should clear things up.

Now I may be chastized for saying this but my experience has been that the more woo woo I threw at people (rotated innonimates, scar tissue etc), the better the results.

Without the woo woo, I find I have been less likely to elicit anything from patients( I said less likley Ginger because I know you are reading).

I just don't think being deceptive (or ignorant) is ever a good idea just to get a patient better. But I must admit....it's a constant struggle to muzzle myself knowing that if I could just convince someone that I just unstuck some fascia...they'd likley improve

I think being deceptive (or ignorant) is essentially a house of cards...destined for failure long term. I'd say the developed world's track record when it comes to painful condtions has demonstrated this to be true....

[Jon Newman]

If capital P Pain is "An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." and

note: Accordingly, pain is that experience we associate with actual or potential tissue damage. It is unquestionably a sensation in a part or parts of the body, but it is also always unpleasant and therefore also an emotional experience. Experiences which resemble pain but are not unpleasant, e.g., pricking, should not be called pain. Unpleasant abnormal experiences (dysesthesias) may also be pain but are not necessarily so because, subjectively, they may not have the usual sensory qualities of pain.--IASP

then if someone does not have an unpleasant emotional experience and/or doesn't experience (or describe) actual or potential tissue damage, it seems that it isn't really Pain they're experiencing. Perhaps they're just experiencing hurt or pressure or "good pain", but not Pain.

But still, chances are good that nociceptors are being stimulated if peripheral sensitization is present or the nociceptive neurons are normally sensitive (whatever that means) but near a firing threshold amount of deformation.

Perhaps it's more realistic to try to avoid creating a Pain experience versus trying to avoid nociception. I want to emphasize that I'm not advocating that one tries to evoke nociception. Just that if you have to, try to keep it from becoming a Painful experience.

[Alice Sanvito]

This thread addresses things that have been on my mind a lot.

I freely confess to having been a massage terrorist. My Russian massage teacher began to lure me away from that for the very reasons you all outline. Pain creates a stress response. What she said about the CNS is so consistent with what I am hearing from you all now and again makes so much sense.

So why is it that, when a muscle aches, we intuitively want to press on it? And the pressure, while making it ache more, feels good and often relieves the ache. It is not only because people have been brainwashed that they seek this out. I discovered this on myself quite young and many people do. I'm not yet convinced that this is always a bad thing. If it is feeling good to the client, then their interpretation of the experience is that it is not pain. And many do experience relief afterward.

I still do NMT (we don't "poke," Barrett, we compress. Mean people poke. ) but I do it much less aggressively than in the past. I have to work at educating my clients that one cannot force the body, one can only coax it. I do not seem to be very successful at convincing them of this.

I had a very sad (to me) situation not long ago of a young woman who came in. She has seen a lot of doctors in the last 3 years, is one of those people who hurts all over yet cannot get a diagnosis. It began with a tailbone injury and a year later her whole body hurt. I don't know if "central sensitization" is an agreed upon diagnosis/concept yet or not, but if it is, I would suspect that she is a prime candidate. (I also wonder, in cases like hers, whether the fact that about 1/2 of her body is covered with tattoos would contribute in any way? That's a lot of time spent poking the body with needles.) Anyway, she's been getting deep tissue massage for an hour once a week for the last year. I asked, "Did it help?" "Sometimes, a little." I pointed out that it didn't seem to be improving her condition, asked if she was willing to try something different. Spent quite a bit of time explaining to her talking about the CNS. Had just gotten a copy of Explain Pain, which I showed her and spoke to her about. She said she was willing to try.

So, I did a very gentle soothing 1/2 hr. treatment on her that we use for fibromyalgia patients. She got up, said it was very pleasant, said she felt very relaxed, which she said is a foreign experience to her. Also said, "But I still hurt." I let her know that her condition has existed for three years and probably isn't going to go away in an hour. She booked a second appointment and I haven't seen her since. Now, there could be all sorts of reasons for that but I can't help but think that she really wanted me to hurt her and I'm just not going to do that. And I'm someone who does do deep tissue and NMT, but not painful massage, just firm, and in her case it seemed like a very wrong thing to do.

So, I'm glad to see this discussed. The questions in my mind are: 1) why is it that it does feel good when an ache is compressed and if we experience that as feeling good, then does that mean it is not a painful experience and I don't have to feel guilty about doing that sometimes? 2) How do I go about learning other ways of relieving pain that are kinder to the CNS and effective? 3) Why do some people want us to hurt them? Are they masochistic? Are some manual therapists engaging in a sadomasochistic relationship with their clients/patients? 4) How can I be more effective in communicating to my clients? I would buy ten copies of Explain Pain and make my clients buy it, but at $74 a copy, I doubt most of them will go for it.

[Bas Asselbergs]

1) why is it that it does feel good when an ache is compressed and if we experience that as feeling good, then does that mean it is not a painful experience and I don't have to feel guilty about doing that sometimes?

I do not equate an ache with "pain" per se.

2) How do I go about learning other ways of relieving pain that are kinder to the CNS and effective?

Maybe it really starts with the deeper understanding that is ISN'T you relieving the pain - you are facilitation the recipient nervous system to do that itself.

3) Why do some people want us to hurt them? Are they masochistic? Are some manual therapists engaging in a sadomasochistic relationship with their clients/patients?

There IS a big role of expectations in this. When one is taught from an early age that "it has to hurt to heal or feel better" or "it's gotta hurt to work", it WILL create that expectation and those who provide exactly that will be successful (for a bit)

4) How can I be more effective in communicating to my clients?

Practice. But also use some of the blog suggestions out there. http://healthskills.wordpress.com from Bronnie, saveyourself.ca from Paul, http://bodyinmind.org/ from Lorimer.

[allenbr4]

Originally Posted by proud

Now I may be chastized for saying this but my experience has been that the more woo woo I threw at people (rotated innonimates, scar tissue etc), the better the results.

Patients like to be told what is wrong with them and what you are going to fix, especially when it fits with their beliefs ("Something MUST be out of place").

Like many of you, I struggle with this a bit. The other chiro in our office is of an extremely biomechanical (mesodermalist) mind-state. I think many patients are more satisfied with his explanation than me talking about a cranky or irritated...(insert nerve here).

He puts off much more of an appearance of knowing what your biomechanical fault is, when I have a much more vague description of why this happened to the patient. He's more likely to say that pain is due to the rotated pelvis, whereas I'm more likely to say the pelvis is rotated due to the pain.

[byronselorme]

This is a side track but I wonder if there is a link.

Listening to Sapolsky talk about the anomaly of tickling and how inorder for us to feel tickled there needs to be an element of surprise.

Diane may have the link to this, but there was an experiment that Sapolsky referenced that used a machine to help the person tickle themselves. It was a contraption that held a feather or something over their opposite palm. They pushed a lever and the feather would move across the palm. If the feather movement followed the lever push by a delay (I think of 500ms or more) the experience was a tickle. If the feather moved in a direction that was 90° or more from the direction the lever was pushed a tickle was experienced.

It was only when the movement violated expectations enough. SO where I am going with this is would there be a difference between poking yourself and being poked by another.

Do the C-mechanoreceptors responds the same no matter who pushes. Does expectation link in to this here as well?

[Barrett Dorko]

Context means everything.

When the guy who just hit a walk-off home run gets pounded it doesn't hurt - as long as it's a congratulatory gesture by his teammates.

[byronselorme]

I absolutely get the context part.

So is it possible to Poke yourself, or press on a painful area, to invoke the same response that would happen if someone were to perform ART on you? Or is this impossible unless a similar tickle machine were created?

[Jon Newman]

Hi Byron,

Here is the research that I believe you're citing as it pertains self-produced and externally produced stimuli.

[caro]

How's this for the ultimate ''Poke''.

http://www.youtube.com/watch?v=I75OA...0CF37F8FAC0009

[nari]

Are tattoos a good example of the ultimate poke??

Nari

[byronselorme]

Boy Caro,

I couldn't help but feel sick watching that video. It seems so violent to me. Kind of like watching a live fish get gutted.

[byronselorme]

Originally Posted by Jon Newman

Hi Byron,

Here is the research that I believe you're citing as it pertains self-produced and externally produced stimuli.

That's the one Jon, you're like a Jon-linkipedia amazing

[smikolic]

I think it is an example of a poke and context, Nari.

I actually put a slide of someone who's face was literally covered in peircings, and she (I think) was smiling (I asked about how miserable she must be with all that pain...).....and then I put up a bunch of pictures of people with extensive bodywork as well....to illucidate the importance of context and pain (got a lot of people gasping - some even covered their mouths in shock!).

I have several peircings of my own and a tatoo as well.....and they hurt, but were not threatening. In fact, I got one of my piercings at particularily emotionally painful point of my life....helped make the pain real somehow.....so I could "deal with it" perhaps...who knows. Haven't really examined that connection before...

Anyway, it's really about threat and threat response to me, I think. Pain can be non-threatening, and adaptive, but can't be therapeutic....too risky, as far as I understand it.....why even go there as a therapist....we should know better.