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PPP Management How to help PPP patients.

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Old 22-02-2012, 01:09 AM   #1
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Default Belief in different kinds of pain?

I had a conversation not long ago with a PT and the topic turned to pain.
She is my daughter's good friend who runs a solo practice in a busy suburb.
When the mention of pain arose, I took the opportunity to talk to her about recent pain science, Moseley et al. She mentioned Butler and did use neurodynamics, but 'they are only really helpful for very acute pain'.

Her conclusion was that in her practice, 'there are so many different types of pain: acute, chronic, psychosomatic and pathological....it's quite difficult to sort out which is which....'

At which point I changed the topic.

Is this belief in different sorts of pain experience common? If so, then no wonder so many therapists stick to treating mesodermal structures.

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Old 22-02-2012, 01:27 AM   #2
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They think one day each "kind" of "pain" they imagine exists will be linked to a specific kind of tissue they already know exists. More bottom-up fallacy regarding pain.
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Old 22-02-2012, 01:47 AM   #3
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Oh yea, therapists belive in "types" of pain.

They have NO clue.
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Old 22-02-2012, 05:20 AM   #4
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Should have asked her if she had different kinds of hunger or thirst?

Does she think acute hunger is different from chronic hunger or psychosomatic hunger?

I would have probably changed the topic as well.
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Old 22-02-2012, 07:00 AM   #5
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I changed topic because my daughter would have upbraided me somewhat about the conversation, and it pays to lie low with close relatives. It might have been interesting to see what she thought about hunger and thirst, but I suspect she woud have thought I was decidedly odd and possibly New Age...

It was a surprise to me that for her, pain had been labelled into quite separate categories, depending on history. I hadn't thought of mesoderm-oriented physios in that way before. Duh...

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Old 22-02-2012, 10:05 AM   #6
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Default Yes!

Yes we do believe in different types of pain. That is what we learn. Bottom up for acute; inflammatory cascade, wind up progressing to central sensitisation at the cord leading to re-organising of brain and disturbance of mind and the correlated change in social functions. Psychosomatic - deriving from pyschological issues projecting into the body. It might stem from the McGill - different words describe different types of pain.
That makes kind of sense within the framework that come from. Outside to in. And the paradigm shift towards an inside to out view is really quite tricky.
We are a knowledge based profession with some essential manual craft skills but the knowledge base is what secures us and succours us. To dismantle the foundation of a structure and rebuild it on the fly is really unstable. It is sapping - in the ancient meaning of the word.
I have an old theoretical basis I do not trust. Tricky because this fits with the cultural memes of my peers and my patients so resistance to change surrounds me. I am holding the threads of a new understanding that explains everything a lot better and arises from evidence but I have yet to weave a cohering fabric. I do not yet know it well enough to use it reliably with the people for whom I have a duty of care. I do not yet know it well enough to challenge the honestly held misconceptions of my peers. So my work today will be schizoid.
This is not new to you - it is to me. The process has been observed by you many times over the last seven years. You have seen it work and not work. You mentor in your own idiosyncratic styles. May I recommend compassion as a stance to take as a default approach. Notice your exasperation and impatience and be mindful. The fact this site is here, with the resources it possesses and the ability to log on, start a thread, ask a question and be guided is the only thing that is going to help shift paradigms. It might break into the mainstream one day - it should. But in the present it will be here for Nari's daughter's friend when the dissonances within the current construct create enough force that they to seek a different way.
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Old 22-02-2012, 11:24 AM   #7
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I gave a Thank You to ste5e because he raises a very important point.

There is a sort of quiet desperation on SS at times. SS wants it's ideas to be accepted, but often shows little patience in getting those ideas across to new comers.

Teaching of any sort is a process, it has to start from the beginning, and when new students come in, they have to be taught from the beginning, no matter how boring, frustrating that may be.

Even then it takes some time for an individual to replace one paradigm with another.

Yes, SS is frustrated, I understand this well from having the same issues with my own profession.

Still not everyone comes here to argue, some really are looking to learn.

One case that i found particularly distressing was here http://www.somasimple.com/forums/showthread.php?t=12467

Glenn Pendlay, a highly respected world class coach showed up with a very open mind (a characteristic shared by most great coaches) and was treated with riddles and Zen koans.

Here's a man a week away from taking a stable of athletes to Olympic tryouts. Yes this is a big deal, and extremely stressful, yet he's spending time on this forum, and saying hey, i'm an open book here, tell me something.

I really love the information i find here, but i study Advaita Vedanta, i love a Zen koan, I don't care that that method is one that takes many years to bear fruit. I don't mind being made to look like foolish. I imagine in part because this isn't my main profession, but an important aspect of it. I'm not expecting anyone here to give me the time of day.

Is it appropriate for everyone always though, or just a mark of frustration?

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Old 22-02-2012, 11:50 AM   #8
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We are all on a journey, all at different parts and on different paths. I look back my knowledge and what I did with patients a few years ago in horror. And the deeper the journey gets the more complex it gets. The latest reading I have been doing has been more neuro immune and how all the systems speak to each other….. so much easier to manip T4.

However the more complex the knowledge gets the more simple my treatment gets...... I wonder what I'll be doing in 5 years????

But to be on a journey you need to begin. Nari, maybe your daughter’s friend will someday soon. Or maybe that drive is not there, we are all wonderfully different
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Old 22-02-2012, 12:08 PM   #9
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I too read that thread with unease.

http://www.somasimple.com/forums/showthread.php?t=12467

Something in the tone towards someone who has not posted before.

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Old 22-02-2012, 12:26 PM   #10
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Being a great coach and understanding the neuroscience of pain are two different things.

I'm no coach.

I think this man can take it, and that's a compliment I would also think he understands.
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Old 22-02-2012, 12:39 PM   #11
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Of course they are different things we all know that. That's why he's here, not playing the expert, and as far as i can tell being very straightforward.

Sure he can take it, but WHY should he be expected to?

Isn't that the equivalent of his elbow treatment? Make him mentally wince enough and he'll come around? Even then, come around to what? From his perspective? Was there anything there that was actually useful?
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Old 22-02-2012, 12:54 PM   #12
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WHY should he be expected to?
Because he's not a hot house flower.

Aren't those in his care waiting? What about them?

Shouldn't those he depends upon to know about injury, healing and pain know this? Do you imagine they do? Has he complained that he has not been treated with respect? Personally, I don't bother with those I DON'T respect. I'm taking time with him, as are many of us. I suspect he appreciates it.
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Old 22-02-2012, 04:26 PM   #13
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I guess I'm not done responding to the question.

NO ONE here has been called any names or referred to as stupid. NO ONE'S integrity or motivation has been called into question.

What we've done is ask questions in order to assess levels of knowledge, experience and current level of expertise. We have asked that statements be defended.

It's called "a discussion on a scientific level" and it's what we have done here for years. I assume Glen understands that and wouldn't dream of taking offense.

As Achenbach says, "In science, if you don't work hard enough to prove yourself wrong your friends will gleefully take up the slack."

The operative word there is friends.
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Old 22-02-2012, 05:01 PM   #14
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This conversation seems to come up on a regular basis.

In communication it is the responsibility of the person presenting to ensure that the message their audience is receiving is the same as the one the presenter intended.

I understand the idea that "you are safe but your ideas are not" and i think it's a good one. However the common perception of new people on this site (and those who have been around for a while) is not in line with that statement as evidenced by this threads theme reoccurring as well as the fact that when soma is mentioned elsewhere it is usually followed with a disclaimer something like "great information if you can get past the atmosphere"

If these are both true then has there been a failure in communication? And if so what can be done to change this?

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Old 22-02-2012, 05:31 PM   #15
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The way we communicate here doesn't need changing.

If those treating others began accepting the responsibility for learning that their patient's need, well, that would be nice.
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Old 22-02-2012, 07:45 PM   #16
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Quote:
Originally Posted by Barrett Dorko View Post
Because he's not a hot house flower.

Aren't those in his care waiting? What about them?

Shouldn't those he depends upon to know about injury, healing and pain know this? Do you imagine they do? Has he complained that he has not been treated with respect? Personally, I don't bother with those I DON'T respect. I'm taking time with him, as are many of us. I suspect he appreciates it.
Yes that's all true, and perhaps a poor argument on my side.

I suppose the biggest difficulty i was having in that particular thread is the questions weren't helping but confusing and in some cases they even seemed to be irrelevant when they could have been used to draw him in, make the SS message become something that he could want to discover more about.

You said it yourself, he's not a scientist. You're right he wasn't being offended or called names, but i don't think he was being compelled to listen or offered anything of help either.

Knowing that you are particularly frustrated with the lack of visibility of the SS message, i guess this looked to me like a wasted opportunity. Maybe i'm wrong. The guys he was referring to that he 'trusts' are mega meso but also have a wide audience. Starret has a very popular blog mobility wod.

Anyway, i'm not trying to stir anything, just have a discussion.

Thankfully that thread has also taken a turn for the better but will Glenn want to come back and see the latest comments?
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Old 22-02-2012, 07:56 PM   #17
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I appreciate that updating concepts of pain can be destabilising for many, as they come to realise the errors of their past work with patients.
I look back on the work I did with pts in the 90s and feel guilty in hindsight that it was not the appropriate way to go. But the new knowledge and understanding wasn't there. We did what seemed appropriate at the time, because we didn't know any better. There weren't the forums such as SS to nut it out.

Now the new understanding is well founded (ie, the sun does not revolve around the earth) there is little excuse to continue working as if it did.

However, a radical change in the approach to resolve patients' pain issues may seem insurmountable to many who are faced with such dissonance rolling around in their brains. But it can be achieved in time, with some hard slog on their part. The first step is to consider those patients whom we didn't help in the past, such as the persisting pain patients, and why didn't the old thinking work??

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Old 22-02-2012, 07:58 PM   #18
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Nari,

I have never heard of PTs trying to subdivide pain like your daughter's friend had done. However, I have heard PT's state that applying pain education and neurodynamics is reserved for more chronic patients. I beleive it is based on the idea that when acute treating the mesoderm will solve the problem. If this fails then throw the Butler 'stuff' at them and hope that works. They should read Dianne's thread regarding the importance of discussing pain day one regardless of stage of injury.
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Old 22-02-2012, 08:01 PM   #19
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As I think about this furrther I do recall a PT state that if it is a 'burning' pain then it must be a nerve therefore apply neurodynamic techniques. However, if not then use joint mobilizations since the pain is more than likely articular. We certainly have an uphill battle!
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Old 22-02-2012, 08:03 PM   #20
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Quote:
the questions weren't helping but confusing and in some cases they even seemed to be irrelevant
Being confused usually means you don't know enough. If this concerns a subject of great relevance to your job you should simply seek to learn more - not just cover your ears. I doubt this man even considered such a thing.

The questions weren't irrelevant.

A couple of months ago I was explaining something to a PTA when I saw she was just looking out the window. She hasn't spoken to me since and I watch her mistreat patients every day. I find her willful ignorance disgusting,and being "nicer" or more patient with such a thing hasn't gotten our profession anywhere.
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Old 22-02-2012, 08:09 PM   #21
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There are all sorts of "mesodermal pain" beliefs out there, and people willing to take bullets to save them!
Bone pain. Muscle pain. Trigger points in muscle. Ligament pain. Tendon pain.

I don't object quite so much to "area" pain - pain felt as though it is coming from an area - shoulder pain, hip pain, knee pain, back pain, toothache, headache, etc. To me this is more like waving vaguely at a map of the planet and saying, Antarctica is near the south pole.

What I can't stand anymore are all the erroneous and misleading attempts to conflate "pain" (which is never ever peripheral, ever! It's in the brain 100% of the time!) with nociception, then further conflating nociception as being specifically from .... different flavours of mesoderm, of all things.
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Old 22-02-2012, 08:34 PM   #22
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What gets me is "referred pain" - if it's extending down the limb, it's a facet joint or a prolapsed disc or degenerating arthritis...in the absence of severe neurological deficit, this is all sheer speculation or imagination.

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Old 22-02-2012, 09:05 PM   #23
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This is something I find I address with some regularity and I'm starting to think that maybe I'm the only one who views SomaSimple this way, but here it goes (again) anyway. SomaSimple is a discussion board with many diverse views being expressed. There is no "SS message" nor does SomaSimple have an idea it wants to have accepted. SS can't get frustrated.

Individuals here have their own ideas, individuals bring the ideas of others here, individuals may get frustrated, individuals here criticize or praise each others comments, etc.

Some new members like things right off the bat. Some new members hate participating here. The latter can be due to having had their ideas (or ideas of others) criticized, not experiencing the type of discourse they were excepting, etc.

I don't think there is a SomaSimple mission statement, practice guidelines, continuing education courses, etc.

One last thought is that communication abilities of individuals will change over time. This includes both the listening and the narrating ends. Regardless, SomaSimple itself can't have a communication style or ability.

That's how I view SomaSimple anyway and I'm glad it exists. It's a rarity in the PT world to have an ad-free environment in which to discuss PT relevant matters.

Regarding the original post, "Pain" has one definition per the IASP. There are further sub-classifications that tend to include some sort of mechanism or physiological process (e.g. neuropathic pain, nociceptive pain, etc.) but pain is pain.
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Old 22-02-2012, 09:13 PM   #24
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Nice Jon.
I can speak to the "unwelcoming" aspect of communicating with some regulars here (on other forums and message boards) - I felt deeply insulted, taken to task, felt harshly treated.
Then I started to read and see what the actual - the actual! - messages were pointing out. They had nothing to do with me. They had to do with what I understood as proper and reasonable approaches and methods.

I would not have moved from "belief" PT to science-based PT without those hard and valuable lessons. They forced me to try and find solid support for MY opinions, and when that was found wanting.....

Here I am, still not a clone of Barrett, Diane, Jon, Jason et al - but likely one of the ones who can be crusty and direct.
It has been said before: this is no tea party. If it had been, I may not have made it this far....
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Old 22-02-2012, 10:09 PM   #25
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Is part of the communication issue that all of us are still learning how to communicate on a digital platform where we cannot read the body language that, in person, may belie the perceived harshness of the tone.

I struggle with this and look for ways to improve my communication skills within this medium yet I recognise that it will crude at best as compared to those who follow or that this format will be superseded as bandwidth, technology and cost alter the digital world.

regards

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Old 23-02-2012, 12:38 AM   #26
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I am a newcomer to this site and at times tentative to post since I don't feel that my knowledge and experience is at the level of some on this site. However, I have learned to get over this fear since the potential to learn outweighs this fear. I feel fortunate to have found a site that offers so much valable information. My hope is that as I continue to post and absorb the information on this site I will gain a more accurate perspective of pain and injury.
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Old 23-02-2012, 01:06 AM   #27
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keep posting, you will, and you know more than you think you do.

regrds

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Old 23-02-2012, 01:11 AM   #28
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Quote:
Originally Posted by advantage1 View Post
Nari,

I have never heard of PTs trying to subdivide pain like your daughter's friend had done. However, I have heard PT's state that applying pain education and neurodynamics is reserved for more chronic patients. I beleive it is based on the idea that when acute treating the mesoderm will solve the problem. If this fails then throw the Butler 'stuff' at them and hope that works. They should read Dianne's thread regarding the importance of discussing pain day one regardless of stage of injury.

Which of Dianne's threads are you referring to here? Do you have a link?

Thanks,
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Old 23-02-2012, 01:30 AM   #29
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Few people have made more boneheaded statements than me on internet forums. Although even more of my statements have been totally misperceived. For instance on that interminable trigger point thread at another blog, I was accused of making a "racial slur" for pointing out that a non-native English speaker might not be familiar with a totally non-racial, idiomatic phrase that I thought was appropriate at the time.

My post was swiftly censored. But then, sometime later in the same thread another poster accused a well-respected clinical researcher of essentially colluding with the editorial board of a journal to get his study published. That's right, he was accused of the worst kind of academic misconduct based entirely on circumstantial evidence for which he had some years previously provided a clear and rational explanation. Yet, that "prejudicial" accusation remains un-edited over at that site.

Jon's absolutely right that you will not find more varied views than what you find here at SomaSimple. You also won't find a more judicious and thoughtful group of regular members and moderators in the manual/physical therapy blogosphere, if I do say so myself.
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Old 23-02-2012, 02:34 AM   #30
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Cole,

Speaking for myself alone (and never SS) I seek out places where I will get called to task. I am sick to death of being validated and wrong at the same time. I think several different views came out with Glen. He is a big man and can take it. That is the psychological challenge of it I guess. If someone will only pick out the couple of statements that upset them and then leave the sandbox without coming back...well I guess they weren't really interested in finding the truth.

He also posted a video of a technique for getting rid of pain that he had only known of for 4 days. That sets a red flag off for me.

Perhaps we all want things to get along and everyone to like everyone but I know I still have the ability to learn from people I don't like and vice versa.

Who knows, maybe the discussion has sparked Glen's interest. People are much more complicated and durable then we realize. They don't need kid gloves. The self esteem movement failed miserably.
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Old 23-02-2012, 02:41 AM   #31
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Quote:
Originally Posted by pohlm297 View Post
Which of Dianne's threads are you referring to here? Do you have a link?

Thanks,
Erik

Not sure which one as there have been many, but here is the latest one: New treatment encounter
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Old 23-02-2012, 03:15 AM   #32
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Quote:
Which of Dianne's threads are you referring to here? Do you have a link?
Erik and Dianne,

Yes it is the thread with the link to 'New Treatment Encounter 1-5'
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