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PPP Management How to help PPP patients.

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Old 19-09-2004, 12:22 AM   #1
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Default negative emotion= chronic pain=muscular imbalance/

Hi all!
Have you red "Change your brain change your life,by Daniel G Amen"
on side 52 he write"Increased activity on the right side of the deep limbic system is often assosiated with sadness,,emotional withdrawel,anxiety and repressed negative emotions,.....right side is more an internal problem."these emotions are often seen by chronic pain patients.
What do i find in my clinical examination ,testing CPP,right handed.
Decreased strenght in thir left body side ,and increased muscular tension!
I have written about this alot of time earlier but NO ONE seems to be interested in this clinical finding.I have asked you if you can do an isometic muscular test on the two body parts and compare the two sidese,,but no one seems to be ineterested ,i just wondwer why?
when i find this in my first examination i now that negative emotions(pain in it self is a negative emotion)might be a considerable factor this pain experience.The brain in it self are,when we are out of controll,emotionally,in my poiny of view, able to by efferent impulses create pain in all parts of the body.
What is your opinion?
:wink: :wink: :wink:
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Old 20-09-2004, 01:32 PM   #2
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Rin, are you also saying that you can identify right brain characteristics better by an assessment of muscle strength on both sides and then perhaps noting other (R) hemisphere features?

Given that fact - does an imbalance between the two sides change how we treat?

When you treat, do you aim to balance the two sides?
How do you do this?

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Old 20-09-2004, 07:22 PM   #3
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Hi!
Bernard:I might be slow but what do you mean by:Sometimes I encounter left weak side in right sided patients and some patients are in pain but strong and left sided. How are you able to find a difference in these cases?"

Nari:Iam just telling you nothing else than , that increased emotional stress ,which someone ,not me ,neuroscientists,consider to be a dominant right brain side experience is possible to detect in the left body side.

I do not focus on emotions/pain education,CBT,when the patient have no difference in strenght, in the two bodyparts.I then focus on physical limits.(but most of my chronic pain patients have diffrences -mostly women)

When pain decreases you wills see that the imbalance
is dissapearing?

This imbalance is a normal respons to daily stress.When you loose controll in one way or another,espesially on the personal level,(depression,anxiety,anger,fear,chronic pain=negative thinking)
this imbalance will be easily detected if you do the sidedifference test!
To many of us are to afraid to ask patients about their feelings, emotions.in their jobb,family etc etc.We are still living in the belive that body and brain are separated.(i do think you are one of the exceptions)
Start to do this test and give me some repons ,you might be suprised!
RIN :wink: :wink: :wink:
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Old 21-09-2004, 12:32 AM   #4
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Hi !
I mailed Daniel Amen about my side difference theory and he replied."Your hypotheses makes sense as the right brain is the more anxious negative side of the brain."
RIN :wink: :wink: :wink:
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Old 21-09-2004, 01:19 AM   #5
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The right brain certainly contains the anxiety triggers, and this has been shown in tests that place specific demands on either the right or left hemisphere.
Our innate calmness is definitely left-brained...but where does all this leave us??? Re treatment? Rin, I'm still not sure where you are heading...




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Old 21-09-2004, 07:54 AM   #6
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Hello mes amis,

Quote:
Bernard:I might be slow but what do you mean by:Sometimes I encounter left weak side in right sided patients and some patients are in pain but strong and left sided. How are you able to find a difference in these cases?"
1/ A right-handed patient is by nature more powerfull on right side than left one.

2/ Some patients (a left-handed) are strong on left but have chronic pain.

3/ I'm right handed and weak on left side and in pain (rarely). I fit the theory. But my right side was ever stronger. More, my right hand is weaker than the left one.

The problem for me is that to find a difference in the two sides, we must have an known anterior state? or suppose that the two sides were equal prior the painful conditions?
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Old 21-09-2004, 08:22 AM   #7
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RIN,

You may be onto something, but so far I haven't been looking for strength differences between sides because I don't really have a good clinical reason to do so, other than to identify muscle weakness in a myotome or muscle group. I have seen people with chronic pain and fairly global right sided weakness.

Have you considered the effect of your own testing on the results you get? Do you test people before you interview them, or after? Manual muscle testing is fraught with difficulties, so even if I did find a side difference I wouldn't know what to do with that information. Have you consdiered doing a formal research study to convince us once and for all? With independent blinded assessors, or even better, a machine that can grade strength? Can left-sided muscle weakness be recreated experimentally if you place people under stress?
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Old 21-09-2004, 01:58 PM   #8
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RIN, I found that one???

Are functional motor and sensory symptoms really more frequent on the left? A systematic review.

Stone J, Sharpe M, Carson A, Lewis SC, Thomas B, Goldbeck R, Warlow CP.

Department of Clinical Neurosciences, University of Edinburgh, Western General Hospital, Crewe Road, UK. jstone@skull.dcn.ed.ac.uk

OBJECTIVES: To test the hypothesis that unilateral motor and sensory symptoms unexplained by identifiable disease are more common on the left side of the body than the right. METHODS: Systematic review of the literature published since 1965. RESULTS: 121 eligible studies, involving 1139 patients, were analysed. The pooled proportion of functional left sided weakness and sensory symptoms in adults was 58% (95% confidence interval (CI) 55 to 61%). A much higher proportion of left sided symptoms (66%, 95% CI 61 to 71%) was found in studies where laterality featured in the title of the paper. However, when laterality was not mentioned in the title, no significant difference between left and right was observed (53% on the left, 95% CI 48 to 57%). This difference could not be explained on the basis of sex differences between the groups or the date of the study. Functional or "psychogenic" movement disorder was right sided in 68% (95% CI 61 to 75%). Handedness did not influence symptom lateralisation. CONCLUSIONS: The findings of this systematic review question whether functional weakness and sensory symptoms do in fact occur more commonly on the left side of the body. A type of outcome variable reporting bias in combination with non-blinding of investigators may be responsible for this long held but erroneous belief.

Publication Types:
Review
Review, Academic

PMID: 12397155 [PubMed - indexed for MEDLINE]
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Old 21-09-2004, 04:01 PM   #9
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Wow..
Quote:
when laterality was not mentioned in the title, no significant difference between left and right was observed (53% on the left, 95% CI 48 to 57%).
To me this suggests that our belief system is stronger than our motor cortex. If we believe in "laterality of symptoms" we will be more inclined as a researcher to find such a thing, and mention it in a title. If we don't believe in it, we won't find it and it won't be in the title of our article. Laterality of symptoms/strength is not something I've ever been interested in developing theories about or trying to find connections between, and I feel like now I know why.

Then there is the whole question of how subjective muscle testing is in the first place.. pitting one's own motor cortex against another's. Easy to prime one's own motor cortex with one's own belief system, absolutely unintentionally.

Quote:
CONCLUSIONS: The findings of this systematic review question whether functional weakness and sensory symptoms do in fact occur more commonly on the left side of the body. A type of outcome variable reporting bias in combination with non-blinding of investigators may be responsible for this long held but erroneous belief.
Sorry RIN, I agree with the article, and can't buy your theory until a machine is invented that can measure laterality of strength better than any therapist's pair of hands, and is exempt from having a cortex from which it must work.
,
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Old 21-09-2004, 08:27 PM   #10
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Hi all !
Thanks for your interest!
Pablo:I have had colleges to do the same test without telling the about sidedifferences and they have found the same difference.
I test them after i interview them, and then before and after any treatment session(more or less)
The left side difference tells me that emotions ,negative thinking in one way or another is a big part of the "problem."Hveing chronick pain in it self is" a personal treath"
Ill give you an example on the use of looking for side differences.
My father in law have just had an op. on his right shoulder.and his in constant pain which increases when he uses his arm in one way or another.But passivly,when i support his arm, he is able to relax almost 100% and the pain dissapears when i lead him through different passiv motions.To make a long story short ,his supraspinatus seems to be the problem.
Similar op. as my father inlaw have done,is quite commen and i have treated some during the years.The difference with my father in law and all the others are a lack of lateralisation .He hasent any sidedifference!?
Why?
His personality,is the reason.His a caaaaalm personality."We fix it tomorrow,dont worry be happy,he sees the opertunities not the limits etc etc.
In this case study i now that i do not have to focus on the persons cognition.This is more or less "aplain" physical problem.But i seldom see this cind of cases,most of them are lateralizated.
"Can left-sided muscle weakness be recreated experimentally if you place people under stress?"
Before i started work to day i asked a student working in our office to lie down.He told me that he wasent in any cind of pain before i tested him.
There was no sidedifference.then i asked him to think of an episode in his life which made a great inpact on him emotionaly(neg,thinking)
Retset gave redused strenght on the left side!!!!

Bernard:2/ Some patients (a left-handed) are strong on left but have chronic pain. Most of my few lefthanded are tested pos. on their right side,but i haven had that many to be as sure that iam on righthanded .
3.Thanks for fitting my theory, i fit my own theoy,we all do when we are out of controll emotionally,if you like it or not.You might have some active triggerpoints in the extensors?,they might reduse your strenght!???

Diane:It took a long time to belive in the body -mind connection for some and others still dont belive in it.I now my theory is alittle bit contoversial but to say that you dont belive in it before any maschine is invented that can measure laterality of strenght better than any therapists pair of hands is quite interesting.
Dont you belive in your hands when you do you examination or your treatment?
To all of you!
Next time when you are in pain emotional triggered(stress) tell your fried ,husband etc to do the tests.Let it be aperson who havent heard about the theory!Please give me some repons!
GooD Luck!
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Old 22-09-2004, 02:05 AM   #11
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RIN,

The answer to your question is no, I don't believe in what my hands are telling me when I measure muscle strength because as Diane and I have pointed out, there are many ways that these findings can be influenced by bias, either conscious or not. The human side of measurement, with all it's fallacies, has to be accounted for.

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Old 22-09-2004, 02:47 AM   #12
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Hi RIN,
Quote:
Dont you belive in your hands when you do you examination or your treatment?
Interesting question.

The short answer is "no."

The long answer is, depends on what I'm using them for. I don't trust them for muscle testing, never have. Too easy to overpower someone with mechanical advantage, and expectation. I don't trust them to really know what angle I'm holding someone's limb with my eyes closed. I don't trust them with knowing how much movement I feel under my hands with my eyes closed.

I do trust them for one thing, and that is to sense relative motion under them, of skin over other subcutaneous layers. When I feel for that however, I'm "feeling", not "testing." In my opinion there is a big difference. With "feeling" there is much less expectation on my part, and much more acceptance of whatever is there, than there is with "testing"..
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Old 22-09-2004, 03:37 AM   #13
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Rin, I do not believe in my hands when I do an examination or treatment.

I have no way of knowing the level of pressure or sensitivity; I am sure it varies sccording to mood, wellness, etc. Too many variables.
Therefore with the patient variables in tissue and end feel, and mine, I cannot draw definite conclusions one way or the other, just an estimation.


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Old 22-09-2004, 09:35 AM   #14
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Rin,

My actual thoughts are;

1/ is there a brain lateralization? yes
2/ is thre a brain lateralization with pain processes? possible
3/ Can we observe it? I don't know!

The third response is annoying, I know, but as subjective observers, we say actually that we induce a placebo effect within the patient so it will be very hard to stay objective observers?

BTW, some of you, said;
Quote:
I do not believe in my hands when I do an examination or treatment.
Does that means that, prior to the examination, you know that the findings are just for fun or a ritual manner to show our power? :mrgreen:
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Old 22-09-2004, 11:07 AM   #15
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Bernard

No, I do not think it is a show of power or that we do it for some reason so we can gain dubious figures (how can one really measure ER of the shoulder??) or spurious results. I think we do the best we can with what we have, and if what we have is inaccurate or unreliable, then we ride with that; there is strong evidence of strong interelability in some aspects of manual therapy.
I think quite a lot of manual therapy is placebo (or nocebo), and we can't measure that, but in the end, when a patient's function increases or their pain diminishes or both - it still does not mean that I did some highly diagnostic interpretation and got it right, but the patient improved, and in the terms of dollars spent, that is what counts.

It is only us who are concerned about how much of a role we have in a patient's improvement, and that is important, certainly, but I still do not think I can trust my hands to produce the results that I hope for in the outcome.
But I do not let the patients know that!!!


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Old 22-09-2004, 01:06 PM   #16
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Quote:
Originally Posted by Nari
I think quite a lot of manual therapy is placebo
So it's another way to say it but it's still remain the same?

Patients' expectation about the movements we do, the questions we ask and the treatments we propose will dramatically change the results.

It works because he believe that he will work!

They are just sand in our hands,
Their will creates mountains or plains.
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Old 22-09-2004, 02:35 PM   #17
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What you say is true, Bernard (I was going to write that in French, but too lazy to find my French grammar).
Another factor which influences how we interpret our findings (visual or tactile) is how we are actually feeling at the time. Diane will agree with me on this: if we are not in a motivated, alert state of interest, we won't find half the stuff we might otherwise; and feel more like telling the poor patient to go away....
We are directly affected by placebo and nocebo when we treat. Those factors are a measure of a sort of our professionalism.


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Old 22-09-2004, 02:43 PM   #18
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Nari,

I agree. But are we able to say to the patient; Not today, I'm not in condition?

Have you ever tried this?
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Old 22-09-2004, 03:58 PM   #19
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Good morning,
Bernard wrote,
Quote:
So it's another way to say it but it's still remain the same?

Patients' expectation about the movements we do, the questions we ask and the treatments we propose will dramatically change the results.

It works because he believe that he will work!

They are just sand in our hands,
Their will creates mountains or plains.
Bernard, I get the feeling that you think that Nari doesn't think or I don't think or Pablo doesn't think that hands-on is effective therapy to do, or that we don't know what we are doing with our hands when we treat people, based on the fact that we disagree with a TESTING process, and the clinical reasoning underlying it, supported by the article you kindly provided the abstract for.

Muscle testing and palpating for bumps/treating them are two quite separate things in my mind.

I have no doubt that Rin gets great and respectable results, for the reasons you have stated, even though I don't agree with his theory about weaksidedness having anything to do with anything; and I'm not willing to try it to find out, just to please Rin, because then my anterior cingulate would be on its toes looking for disproof. But I wouldn't be able to disprove his theory, because I wouldn't know if it was my own subjectivity interfering with the process, or if it truly isn't a true theory.

And that is pretty much the situation with PT isn't it? We have to fly blind, proceed with radar most of the time. Once in awhile a crack appears in the clouds with some (good) research. Not that I've seen down through enough cracks in the clouds to really know good from bad or how flat the ground is, but I've learned to sense mountains and fly around them. To me, the neuromatrix theory is such a cloud dispeller that when I incorporate it in my thinking, I think I can see forever.
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Old 22-09-2004, 04:09 PM   #20
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Quote:
Originally Posted by Diane
Bernard, I get the feeling that you think that Nari doesn't think or I don't think or Pablo doesn't think that hands-on is effective therapy to do
I was not my intent! I agree with all, of course but I wanted some explanations to comfirm my thoughts.

I'm still believing in what I'm doing. 8)
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Old 22-09-2004, 08:31 PM   #21
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Hi all!
Diane:"Muscle testing and palpating for bumps/treating them are two quite separate things in my mind."
What i do when i "test" the strenght i feel the decreased strenght!
When you palpate bumps you feel the bumps.If our profession is trying to go a little bit futher i think we have to be a little bit openminded.
and "
"I'm not willing to try it to find out, just to please Rin, because then my anterior cingulate would be on its toes looking for disproof. But I wouldn't be able to disprove his theory, because I wouldn't know if it was my own subjectivity interfering with the process, or if it truly isn't a true theory."

Manual therapy and physiotherapy are based on theories.How are you able to belive and use these theoris(if you do so)in your clinical practise if you dont belive my theory.Whats the difference between Butlers peripher nerve glide tests and mine?In these tests we are trying to deside if the nerve moves normaly by moving the arm,shoulder etc.

If this had been basic test in physiotherapy would you then have ignored it?
when we have patients with neurological problems,dont you ever test their strengh in any way?

Diane ,im not trying to get you,but just curious in how you are reasoning!
:wink: :wink:
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Old 22-09-2004, 11:46 PM   #22
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Rolf, I have, you have, we all have the right to construct our own theories to navigate about in our work lives. I will adopt or construct the theories I like, and you have the one you like. I can't put it any plainer than that, so let's leave it at that.
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Old 22-09-2004, 11:56 PM   #23
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Hi Diane!

I do agree ,got a little carried away!
Sleep well!
RIN :wink: :wink: :wink:
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Old 23-09-2004, 05:32 AM   #24
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No worries Rolf.
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Old 23-09-2004, 06:23 AM   #25
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Bernard

In answer to your question a few posts back - I do tell the patients I know very well if I am having a cranky sort of day; and they enjoy it.
It humanises us.

Haven't you come across a person or two who displays continuously a happy, smiling, courteous, chatty manner? No matter what??

It's enough to make one depressed.


Nari

PS: Bernard, one can believe that one is doing a good job -and that is fine. I am very glad you feel that way confidently enough to post it!
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Old 23-09-2004, 08:13 AM   #26
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Quote:
Originally Posted by Nari
Haven't you come across a person or two who displays continuously a happy, smiling, courteous, chatty manner? No matter what??
2 time in 25 years, it made me a lot of happiness (and was a bit jealous, too)

Quote:
Originally Posted by Nari
In answer to your question a few posts back - I do tell the patients I know very well if I am having a cranky sort of day; and they enjoy it.
It humanises us.
Yes, and sometimes they try to care the practitioner! :wink:
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Old 27-09-2004, 07:59 AM   #27
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Hi found that one?

Neurology. 1997 Aug;49(2):487-91. Related Articles, Links

Lateralized effects of self-induced sadness and happiness on corticospinal excitability.

Tormos JM, Canete C, Tarazona F, Catala MD, Pascual-Leone Pascual A, Pascual-Leone A.

Departamento de Fisiologia, Universidad de Valencia, Spain.

We studied the changes in excitability of the corticospinal projection evoked by self-induced sad and happy thoughts. Corticospinal excitability was probed using focal, single-pulse transcranial magnetic stimulation (TMS) applied to the optimal scalp position for evoking motor potentials in the contralateral first dorsal interosseus muscle. Fourteen right-handed subjects were studied while counting mentally, thinking sad thoughts, or thinking happy thoughts. In each of these three conditions TMS was applied in each subject randomly, 20 times to the right and 20 times to the left hemisphere. Sad thoughts resulted in a significant facilitation of the motor potentials evoked by left-hemispheric stimulation, while happy thoughts facilitated motor potentials evoked by right-hemispheric TMS, but decreased the amplitude of those evoked by left-hemispheric TMS. In two subjects an additional experiment using H-reflex measurements suggests that these changes are caused by changes in cortical rather than spinal excitability. These results further illustrate the lateralized control of mood in normal volunteers.

Publication Types:
Clinical Trial
Randomized Controlled Trial

PMID: 9270582 [PubMed - indexed for MEDLINE]
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We are to admit no more causes of natural things than such as are both true and sufficient to explain their appearances. I NEWTON

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