??? A good pain

[PatrickL]

Diane Said:

I think it would be wise to realize that at joints, way more is going on anatomically than simply "tendons" : think about what else has to make a living in there. Nerves (which go all the way to hands and feet) have to slide through narrow tunnels that undergo large ranges of motion squeezed against bulbous ends of long bones. Likewise, vascular structures supplying distal parts of limbs have to slide past the same anatomical obstacles. All of these other, highly physiologically sensitive, physical "noodles" (some of which are hollow and others of which are not) come equipped with large (probably larg-ER) numbers of "danger sensors" (nociceptors) due to the precarious circumstances where soft tissue is decreased, hard tissue is increased, large movement is present.
Don't you think this default physical set-up might imply that the brain would be awfully interested in something threatening its organism at large joints, quite apart from any concern about tendons, or mere proprioceptive feedback therefrom?
I suppose if you think that hurting somebody to get them better is a good idea, wrapping tubes around joints is a pretty logical place to start. Like hitting a sore thumb with a hammer, it ought to feel better when you stop.
After I learned that the nociceptive system is a good learner and will gain efficiency over time, through long term potentiation, and that eventually (like in old age) it won't take much to set it off, I decided that counterirritative techniques were likely one of the worst things a human primate social groomer could do to someone.
Yeah, they might work in the short term, sort of like a chocolate bar fills you up, but it doesn't last long and leaves a system primed the wrong way.
Can you tell I think this is not a great idea?

http://www.somasimple.com/forums/sho...9&postcount=25

this is from the tendinitis voodoo thread where the guys wraps his arm in a bike tube to relieve lateral forearm pain.

Im curious if the criticism directed at this intervention applies to other commonly used tools in the clinic such as foam rollers on ITBs and tennis balls squashed into piriformis muscles. Im assuming it does, especially if the input itself is painful.

What about though, the client who describes "good pain". This is something I hear a lot. Until finding this site, I was not bothered if a client said "it hurts, but its a good pain... it feels like i need it". I was in fact encouraged by it. Now im not so sure.

Is "good pain" the same as the bike tube forearm wrap? I would guess no, because the wrap increased pain, and relief was only gained from it removal, while "Good pain", as described by a client, occurs during treatment e.g. deep massage. What is going on here at a neural level? Is it essentially the same as the bike tube wrap, but at a sub-painful pressure? if the pressure applied (by foam roller, tennis ball, elbow) is not perceived as "bad" pain by the client, can it be of therapeutic benefit?

Just to be clear, Im not referring to the client who wants to endure pain because he/she thinks it will provide future benefit e.g. the guys who rolls out his itb on the foam roller while wincing in pain but rather, the guy who loves to roll out because it feels like good pain.

Cheers,

Pat

[Diane]

Peoples' brains are wired up in funny ways sometimes. There are communities for that, called SM communities. The people who populate these communities are wired up a bit different, I think. A lot of them have chronic pain, even. Like cutters, they need to "externalize" "pain", by overwhelming it with fresh nociception. I suppose a change is as good as a rest, but I doubt it lasts for long, and I doubt it helps long term. Even mixing up nociception with sexual pleasure (which is what they cultivate, promote, perpetuate) isn't going to change the fact they are (frequently) people who have chronic pain, some of it from medical conditions, some from necessary medicalization of conditions, or that they aren't going to get rid of pain that way. How do I know? From treating people from that community, who when it comes right down to it, don't really like being in pain any more than anyone else does - they have adapted to it by joining a community that laughs at pain. Maybe the way people laughed at death 500 years ago, made art out of death images. It was a way to deal with it in an ongoing manner.

[Randy Dixon]

You really think that only masochism can explain this? You don't think that even when we move instinctually that sometimes resolution requires us to move through pain?

If that is your belief, I don't believe you are correct. When tissues are oxygen deprived, there is often some degree of pain involved when they get oxygen, when healing takes place there is often pain involved when movement occurs, this isn't masochistic, it isn't something to be avoided, it is something that should be encouraged.

[Barrett Dorko]

Coming out of a hammerlock after a prolonged period is often briefly painful. I presume that this is because of the movement of sensitized nervous tissue, even if it is in the right direction. All four of correction's characteristics will typically be present during the painful movement.

I can't sort out what "good" means to each individual. It depends on their worldview.

[ian s]

Randy,

I am with you on this . Very common age related pain syndromes require a certain amount of fortitude to 'go through'. Degnerative tendonopathies which unfortunately I have a great deal of experience of don't get better with many or any of the things we can offer (or medicine for that matter).
I have learnt that moving and edging into pain and passing through it works.
Deep 'tissue' massage similarly can be really beneficial on many levels especially when pain is met and accepted . I presume this is some deep brain DNIS activity . I have always responded well to this form of modualtation and I don't go to shady clubs or where funny clothes to receive it!

[garydiny]

I have trouble with this concept when a patient reports it "hurts but feels good".

A similar thing that I bring up is if I sit a certain way with my leg crossed...ankle crossed at the knee...my foot will eventually "fall asleep". nerve compression, decreased blood flow, etc. It does not produce pain until after I move out of the position, then to me the pain comes as it is returning back to "normal". The return of blood flow, I get tingling and sensations that are very unpleasant, ie painful, but it is the path to a better place.
My daughter experiences this if I carry her on my shoulders for a few minutes. I will ask her if her legs hurt and she will say no, but when I get her down, then she will experience pain in her legs and in her words her legs are "crinkly" (her word for tingly I think).

NOt sure what others make of it, or how others view it. In the clinic, I give the patient the ability to pursue it as they see the need to as long as the are monitoring the change in symptoms/pain and not pursuing the hurt during the intervention itself.

Gary

[Barrett Dorko]

I think it's also important to remember that patients assign value to all perceptions, and that they do this uniquely and individually and variably from moment to moment.

When we decide that a patient's verbiage means something or that it will result in something we are asking for trouble.

Of course, doing what we do for a living is itself asking for trouble.

[Diane]

Originally Posted by Randy Dixon

You really think that only masochism can explain this? You don't think that even when we move instinctually that sometimes resolution requires us to move through pain?

If that is your belief, I don't believe you are correct. When tissues are oxygen deprived, there is often some degree of pain involved when they get oxygen, when healing takes place there is often pain involved when movement occurs, this isn't masochistic, it isn't something to be avoided, it is something that should be encouraged.

Perhaps there is a continuum. One of those tall hat/bell curves.
I had that in mind when I wrote late last night but I see I didn't include it specifically.

[zimney3pt]

This is a dangerous slippery slope - good pain/bad pain. Since pain and injury are not the same. Increase or decrease in pain does not mean increase or decrease in injury. So for me I think, "How dangerous is this or is it sore but safe?" and also ask the patient "How dangerous do you think this is and is it safe?"

[Diane]

I give you comment 1 in this link, Unveiling opioid receptors, as there may be a clue found here (not in perception of "pain" as good or bad, but in the ability of the system itself to take care of nociceptive input), by Laura Bohn at the Scripps Research Institute:

From Pleasure to Pain
"What will the new crystal structures mean to therapeutic development?

"The μ- and κ-opioid receptors could be considered the yin and yang of opioid receptors as their endogenous ligands transmit seemingly opposing physiological responses. Whereas agonists to the μ-opioid receptor (MOR) are renowned as potent analgesics (think morphine), activation of the κ-opioid receptor (KOR) by its endogenous agonist, dynorphin, can mediate painful responses. Furthermore, while MOR activation promotes euphoria, KOR activation leads to dysphoria. Perhaps, physiologically, these two receptors act in concert to maintain balance.

"The current high-resolution crystal structures of these receptors may provide insight into how agonists bind and, therefore, could direct the design of new ligands. This will be immediately important for the development of ligands that are selective for one receptor over the other. In addition to providing insights for selective agonist design, the crystal structures may also open new avenues into fine-tuning therapeutics for improved efficacy. This may be inspired by the emerging realization that the chemical structure of the ligand can induce the activation of distinct signaling cascades downstream of the receptor. It is believed that the binding of the ligand will impart a change in the conformation of the receptor structure that will impart differential affinity for, or exposure to, downstream signaling messengers (such as G proteins or arrestins).

"For example, there is significant evidence to suggest that an agonist that promotes G protein coupling rather than inducing arrestin interactions with the MOR may produce significant analgesia with limited development of constipation or respiratory suppression (Raehal et al., 2011). With researchers actively probing the biology for physiologically significant signaling downstream of μ- and κ-opioid receptors, opportunities begin to become apparent for generating ligands that will not simply bind to, but communicate direction to, receptor signaling by affecting the structure. The major advance of these reports is that we now have these structures in hand. Further, the authors have demonstrated, particularly for the KOR, that the ligands bind in distinct manners. The fun begins when we start to determine how the biology correlates with the docking—especially when the biology can be correlated with particular signaling pathways that are invoked by the ligand binding."

Reference:
Raehal KM, Schmid CL, Groer CE, Bohn LM. (2011) Functional selectivity at the μ-opioid receptor: Implications for understanding opiate analgesia and tolerance. Pharmacol. Rev.63(4):1001-19. Epub 2011 Aug 26.

[MaxG]

Originally Posted by Diane

Peoples' brains are wired up in funny ways sometimes. There are communities for that, called SM communities. The people who populate these communities are wired up a bit different, I think. A lot of them have chronic pain, even. Like cutters, they need to "externalize" "pain", by overwhelming it with fresh nociception. I suppose a change is as good as a rest, but I doubt it lasts for long, and I doubt it helps long term. Even mixing up nociception with sexual pleasure (which is what they cultivate, promote, perpetuate) isn't going to change the fact they are (frequently) people who have chronic pain, some of it from medical conditions, some from necessary medicalization of conditions, or that they aren't going to get rid of pain that way. How do I know? From treating people from that community, who when it comes right down to it, don't really like being in pain any more than anyone else does - they have adapted to it by joining a community that laughs at pain. Maybe the way people laughed at death 500 years ago, made art out of death images. It was a way to deal with it in an ongoing manner.

I would imagine wether a person with masochistic tendencies enjoys a painfull sensation or perceives it as uncomfortable depends wholly on the context the sensation is occuring in.
Is it related to sensations triggering pleasure/sexual maps in the brain?
Is it a safe environment for the person? Is the pain inflicted by someone he/she trusts?
Is the outcome fo the injury on every day life uncertain?
Is the pain infliction still controllable or does the origin lie outside of the person's control?

I don't think there is one type of "pain" that is felt each and every time.

[Diane]

I agree.

[PatrickL]

MaxG said:

I would imagine wether a person with masochistic tendencies enjoys a painfull sensation or perceives it as uncomfortable depends wholly on the context the sensation is occuring in.
Is it related to sensations triggering pleasure/sexual maps in the brain?
Is it a safe environment for the person? Is the pain inflicted by someone he/she trusts?
Is the outcome fo the injury on every day life uncertain?
Is the pain infliction still controllable or does the origin lie outside of the person's control?

I don't think there is one type of "pain" that is felt each and every time.

i also agree with these statements. but they miss the point i'm driving at... which is my fault, because I didn't get to it in my first post.

I'm interested in the criticism directed at the intervention, and other (not so extreme examples) like it e.g. foam roller, tennis ball, deep massage.The following statements were made in the tendinits voodoo thread in response to the bike tube elbow wrap video.
Diane said:

I suppose if you think that hurting somebody to get them better is a good idea, wrapping tubes around joints is a pretty logical place to start.

CDano said:

Lifters tend be very enamored with all things foam rolling and this seems to go right along with that mentality.

docjohn said:

if one must "roll out" first in order to exercise then it seems a new program may be in order...and maybe some recovery time as well.

Byronselorme said:

If oxygen and glucose are the important things for nervous tissue, this seems to be the antithesis of that.

What if the client claimed that the intervention didn't hurt, but actually felt good? It's probably unlikely in the elbow wrap example... but what about a foam roller into an ITB, or deep massage?
Barrett said:

I can't sort out what "good" means to each individual. It depends on their worldview.

Within this context, I dont see that we have to sort it out. Can we not simply ask them if the intervention feels good or not. e.g. "does this pressure feel good?"

So the question becomes, do we rule out the use of these interventions on an 'operator' assumption that the intervention is damaging to nerve (or other) tissue? Or do we trust our clients nervous system's ability to 'handle' the intervention (interactor model?), and use these interventions for clients who find them beneficial?

[Diane]

Originally Posted by PatrickL

..the question becomes, do we rule out the use of these interventions on an 'operator' assumption that the intervention is damaging to nerve (or other) tissue? Or do we trust our clients nervous system's ability to 'handle' the intervention (interactor model?), and use these interventions for clients who find them beneficial?

I like how you think Patrick.

I'd say the latter, not the former.
Although, as one half of a treatment dyad, I reserve the right to not do treatment I don't like doing or that takes too much physical toll. So if I wasn't a good fit for the patient I'd say so to them.

[Greg Lehman]

Hi Patrick,

Thanks for starting this discussion.

I wrote blog post on ITB foam rolling here (http://thebodymechanic.ca/2012/03/17...-is-not-tight/) and it is getting a lot of attention (i.e. interesting comments) thanks to Jeff Cubos.

The interesting part is the comments where you can get some insight into what some patients think and certainly what therapists think. What is interesting is that most people who defend its use for pain defend it with a mechanism that tends to lead to a neurocentric focus. There are some adhesion aficionados but there arguments don't discuss pain. Most seem to think that tension/trigger points are beat to submission with a roller via neural mechanism. Its very interesting.

On as side note, I have a question related to something Diane wrote. Diane (or as I like to call her Deanna, just kidding, you know what I'm talking about) in your quote you concluded that the painful treatment will help in the short term but not in the long term.

Why is this? Why would there be a short term gain that lasts a few days or even weeks (which people report but may not be what Diane meant). What is the mechanism?

Thanks bunches,

Greg

[Diane]

Originally Posted by glehman

On as side note, I have a question related to something Diane wrote. Diane (or as I like to call her Deanna, just kidding, you know what I'm talking about) in your quote you concluded that the painful treatment will help in the short term but not in the long term.

Why is this? Why would there be a short term gain that lasts a few days or even weeks (which people report but may not be what Diane meant). What is the mechanism?

Thanks bunches,

Greg

Could you provide a link to the post where I said that?
That would be helpful, to put an answer into context.

[Randy Dixon]

I'm pretty sure that the reference is this:
I suppose if you think that hurting somebody to get them better is a good idea, wrapping tubes around joints is a pretty logical place to start. Like hitting a sore thumb with a hammer, it ought to feel better when you stop.
After I learned that the nociceptive system is a good learner and will gain efficiency over time, through long term potentiation, and that eventually (like in old age) it won't take much to set it off, I decided that counterirritative techniques were likely one of the worst things a human primate social groomer could do to someone.
Yeah, they might work in the short term, sort of like a chocolate bar fills you up, but it doesn't last long and leaves a system primed the wrong way.
Can you tell I think this is not a great idea?-Diane

[Diane]

If that's the right quote (thanks Randy), then the mechanism would be longterm potentiation at the level of second-order, afferent neurons, and at the first and second synapses on each end of them.

[MaxG]

"Overcoming" a pain sensation can be a very empowering feeling, a catharsis so to speak.
Enabling people to experience this catharsis in a environment that gives them a safety (a certainty that the person leading them to this catharsis, the therapist, knows the boundaries to actual injury) can be a very strong modulator of brain activity, most certainly of parts of the pain neuromatrix.
A strong brain modulator, so to speak.

This all, of course, is my own ill-informed oppinion; how I understand the dramatic, sometimes immediate, effects of such interventions.

[PatrickL]

...the nociceptive system is a good learner and will gain efficiency over time, through long term potentiation, and that eventually (like in old age) it won't take much to set it off

Thanks Diane,
For clarity, changes at second order neurons and their synapses can result in the absence of a pain experience? The only requirement is a regular barrage of nociception? e.g. Using elbow wrap regularly over a weightlifting career, or rolling out ITB on a weekly basis for years and years. If the client doesn't experience pain from the nociception, will the nociceptive system still gain efficiency through long term potentiation?

[Diane]

Originally Posted by PatrickL

Thanks Diane,
For clarity, changes at second order neurons and their synapses can result in the absence of a pain experience?

Yes. If the frontal lobes decide they don't want the pain, and can deal with/set aside as meaningless, all the emotional content unleashed by pain, they can gang up on the critter brain, and change the picture. (I managed to do that with my "frozen shoulder" pain. Yeah, N=1, I know..). But that is top-down descending modulation. Just so we're clear. And very very primed, so that the input is as minimal as necessary. (Of course, in a highly sensitized nociception system, "minimal" is so sufficient that anything more would be overkill.)

The only requirement is a regular barrage of nociception? e.g. Using elbow wrap regularly over a weightlifting career, or rolling out ITB on a weekly basis for years and years.

You shouldn't have to do any of that regularly. The brain adapts, and such interventions (include manual therapy in that!) will lose their novelty. I.e., don't abuse the critter brain. Teach the human one how to get along with it.

If the client doesn't experience pain from the nociception, will the nociceptive system still gain efficiency through long term potentiation?

I think it's set up to do exactly that. But at the same time, humans are incredibly adaptive. I've noticed that old people (80's, 90's) with longterm pain, psychosocialize it by just talking about it as if it's completely normal, in sentences directly adjacent to how many carrots they plan to peel for supper or a remark about so-and-so down the street's pretty garden. I think in the old days this was called "bearing up."
We're all going to end up with bodily entropy. I'm not sure if I'll be glad to have a human component to my brain at the endofitall, or sorry to have one... But I'm going to use the heck out of it to try to remain comfortable when the day comes, if I have to be conscious of my physicality at that time..
(No indications of any of this happening anytime soon. )