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Old 07-09-2010, 11:59 PM   #1
Barrett Dorko
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Default An ugly hole

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Although we have been conditioned by personal experience and a long tradition in science to equate pain with injury (or objects that cause injury), they are not actually equatable.
David Biro

This is perhaps the hardest thing I have to teach. I can also quote Wall on the matter as well but it doesn’t make much difference. There have been many therapists look at me when I make this point, and I can tell what they’re thinking; “Oh really Barrett? How about I punch you in the nose, break your face and see whether or not you hurt?”

No, I don’t have to read their mind. The ideomotion is easily seen, especially the clenched fists.

When we take away the injury meme we expose the enormous hole in therapy.

It’s ugly.
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Old 08-09-2010, 12:21 AM   #2
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Barrett,

I have often used the example of pinching one's arm, or having one's arm get pinched.

It certainly will cause an experience of pain, yet no tissue damage is evident. Patients seem to get this nearly 100%. They realize that if whatever stopped pinching their arm, the pain would be resolved.

Pain did not mean something was damaged, but something was in a state of need for a different action/lack of action.

Maybe you could ask the participants in the class to pinch their neighbor, or them selves to "prove" the point.

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Old 08-09-2010, 12:27 AM   #3
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I've used this example, and others.

The problem is not the therapist's inability to understand, but their ability to change, admit they've been wrong their entire career and do what is necessary to know more.

They don't call me Barrett the Great Destroyer for nothing.

Well, okay, they don't actually call me that, but I'd like to hear one day.
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Old 26-10-2010, 03:40 PM   #4
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I'm just reading Biro now. On page 61 he states (bold mine):

Quote:
...Wittgenstein assures us that we can communicate what we hold to be most private, but to do so we must rely on the public sharable aspects of those experiences.
I think another name for "public sharable aspects" would be "culture". There are numerous cultural stories that people can subscribe to even if they all share a similar narrative.

I think losing a well rehearsed story and having to learn (and teach to patients) a new one at least takes time for the therapists that are willing. It's probably too much for some.

I think the idea ties in nicely with an excellent question Frederic asked in the Ask Dr. Bialosky a Question thread.


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Originally Posted by Frédéric View Post
Should'nt we try to find better/new ways to achieve these, and superior, neurophysiological effects instead of constantly revisiting the same ones, actually invented along the lines of a biomechanical paradigm?

Q5 : Do you think, these mechanically oriented treatments maintain their popularity because they fit nicely in the patients and therapists' default belief system?
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Old 26-10-2010, 05:26 PM   #5
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The problem IMHO is our continual need to justify our treatments. It is interesting that we choose to justify (to show to be just or right), the only way to justify something is right is for it to be right 100% of the time. Unless we get every patient to complete resolution of their symptoms 100% of the time, we can not "justify" our treatment. We have to accept we do not have the right to "justify" things because we are not infallible. This is one of humankinds biggest faults.

With changing behavior I think it sometimes is important to begin where other people are. Noiception (tissue injury/danger signals) is a variable in the pain equation, and can be a powerful one, but it is not the only variable. We have to appreciate the complexity of the nervous system and the pain equation. No complex equation can be solved with knowing one variable. I do not know anyone using algebra skills that can solve for P (pain) in the eqation P = I + T + N + S + B + E + M, if we only know the values for T (tissue) and I (injury). Especially since the brain can change any of the addition signs to subtraction, multiplication or division at any given time. Also some of the list of other variables is always changing. Wouldn't it be nice to try to learn about a few of the other variables a little? Don't your patients come to you for wisdom to help with solving their problem? How can we help out to the maximum with limited wisdom?

We have appreciate and except we can not justify any treatment, but we can do better.
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Old 26-10-2010, 09:34 PM   #6
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Barrett,

You are right, once the ideas that there is an injury to the tissue or a maintained pathology in the tissus are out, the traditionnal mindset of most PT is left with a hole with a whole lot of cognitive/psychological issues that come with it. Ones that one will often protectively try to avoid. After all, the whole profession is resting on these pilars of sand. He who wants to willingly confront this is aware that agitated waters lay ahead.

Most have always based their whole clinical reasonning, pt's explainations, treatment justifications and so on, on this very premise.

Gary,

About the pinched elbow analogy :

It fits provided the pain is secondary to a mechanical deformation that can be alleviated.
Many chronic pain conditions are sustained without such mechanical influence, such that in the pinched arm analogy, the arm would remain painful even a long time after the pinching has stopped.
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Old 26-10-2010, 09:52 PM   #7
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Kory,

I really like your post, and, accurate or not, I'm going to call it The algebraic analogy of Zimney.

Sounds exotic.
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Old 26-10-2010, 10:15 PM   #8
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Thanks Barrett, interesting you would choose exotic as your description of this. From Dictionary.com
Quote:
ex·ot·ic

–adjective 1. of foreign origin or character; not native; introduced from abroad, but not fully naturalized or acclimatized.
2. strikingly unusual or strange in effect or appearance.
3. of a uniquely new or experimental nature.

This is what I felt like (as I would assume most did) as a traditional mesodermal therapist when I openned myself up to additional wisdom of the ectoderm and what the brain and nervous system have to do with all of this in regards to pain.

(I left off definition #4 out on purpose, you can look it up for a good laugh, though it might somehow tie into skin....lol)
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Old 26-10-2010, 10:24 PM   #9
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True for me too - the "foreign" part, I mean.

Anyway, Zimney sounds like a foreign country or, at least, a region of one.

It's non-Euclidean, non-linear math by the way, which fits perfectly.
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Old 26-10-2010, 11:10 PM   #10
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Kory,

I really lke your algebraic analogy too.
Written out in full, it may help others in their pain/injury/pathology dilemmas.

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Old 26-10-2010, 11:30 PM   #11
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Kory, I love this equation you posted.

Quote:
With changing behavior I think it sometimes is important to begin where other people are. Noiception (tissue injury/danger signals) is a variable in the pain equation, and can be a powerful one, but it is not the only variable. We have to appreciate the complexity of the nervous system and the pain equation. No complex equation can be solved with knowing one variable. I do not know anyone using algebra skills that can solve for P (pain) in the eqation P = I + T + N + S + B + E + M, if we only know the values for T (tissue) and I (injury). Especially since the brain can change any of the addition signs to subtraction, multiplication or division at any given time. Also some of the list of other variables is always changing. Wouldn't it be nice to try to learn about a few of the other variables a little? Don't your patients come to you for wisdom to help with solving their problem? How can we help out to the maximum with limited wisdom?

Can you fill in what each letter you are referencing. I have my thoughts, but want your thoughts. I would also like to use this in my presentation I am giving on Thursday 10-28-10.
P= pain
I= injury
T=tissue
S
B
E
M

I concur with Barrett in its title.
Quote:
I'm going to call it The algebraic analogy of Zimney
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Old 26-10-2010, 11:55 PM   #12
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If E = education, it maybe should be 2E
Education x educator= 2E

(haven't done any algebra in a long time. Is 2E the right way to describe a multiplied factor?)
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Old 27-10-2010, 03:17 AM   #13
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Quote:
Originally Posted by Diane View Post
If E = education, it maybe should be 2E
Education x educator= 2E

(haven't done any algebra in a long time. Is 2E the right way to describe a multiplied factor?)
Education and educator wuold have to be 2 different variables (because they're not equal) such as Etion and Etor and their product would be EtionEtor. But 2E works for me and you've clearly got the right idea.
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Old 27-10-2010, 03:32 AM   #14
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As soon as Kory develops the model I intend to make a slide out of it.

I'm sure he's working on it feverishly.
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Old 27-10-2010, 06:13 AM   #15
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I'm glad it has been received well. Wish I could say I knew all the variables in the equation, it would make working with patients a little easier.

When I quickly was putting them down my thoughts were S = spinal cord, B = brain, E = emotions, M = motivation, I know I left out many others. I do like the 2E.

That is the interesting thing about it, is it probably fits into Chaos Theory (if I could really grasp what that is all about). It is non-linear as you stated Barrett.
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Old 27-10-2010, 06:29 AM   #16
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I thought M = meaning. Oh well.
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Old 27-10-2010, 07:48 AM   #17
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M for meaning or motivation seems fine either way.

I was also thinking C = context.

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Old 27-10-2010, 11:50 AM   #18
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We should also include "A" for attractiveness.

What I'm talking about here is the effect of the patient's appearance and manner on the credulity of of the therapist. Where I work the word is "cute." So, in that setting it should be "C." If the patient is "cute" enough all manner of complaint will be believed. Otherwise, they're just considered cranky old losers ("L").

Yea, I know.
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Old 27-10-2010, 11:53 AM   #19
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Quote:
Originally Posted by Diane View Post
If E = education, it maybe should be 2E
Education x educator= 2E

(haven't done any algebra in a long time. Is 2E the right way to describe a multiplied factor?)
Since it is not algebra but Human Nature you may have something different.
I'm not sure you can multiply talents but surely you could add them, thus ;

Education + Educator > 2E if the process is achieved in a good way
or Education + Educator < 2E if the process fails at any stage (may result a 0 or -1...)
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Old 27-10-2010, 12:52 PM   #20
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I like it Korey!
I know there are all kinds of cool algebraic symbols and have forgotten them, so I must resort to simplicity.
How about:

P= I + Ex + Pn + Sc + B + Em + M + En - in which any variable can be omitted and still add up to P

I= injury
Ex= expectations
Pn=peripheral nerve
Sc=spinal cord
B=brain
Em=emotion
M=meaning/motivation
En=environment

However - I think I am taking this too far - these modifications may be affecting its elegance......Oh well. Back to simplicity.
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Old 27-10-2010, 12:59 PM   #21
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I think that "D" for "deformation" should be in there. I doubt that elegance or simplicity will be easily seen in Kory's algebraic analogy, but in our understanding of what a therapist can do to reduce the value of "P" both of these may emerge.

They will be seen in the manner we adopt and the things we actually do to the patient's body.
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Old 27-10-2010, 01:06 PM   #22
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Of course you are correct Barrett - "D" must be there.
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Old 27-10-2010, 02:31 PM   #23
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I = Insult. Mechanical deformation or chemical irritation or both. No need for D. The patients perception and past experiences B effects I. Mossley has several examples in his book where the I was dramatic yet the B kept the pain down. K I S S works best. I do like your equation variables Bas.
just my 2 cents
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Old 27-10-2010, 03:19 PM   #24
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I also like this very much! I like the + symbol, and don't think that is going too far, Bas.

Barrett the Great Destroyer is in no way an "L"....
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Old 27-10-2010, 03:46 PM   #25
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Quote:
If the patient is "cute" enough all manner of complaint will be believed. Otherwise, they're just considered cranky old losers ("L").
Oh man, this is so timely. I'm taking a gerontology course right now and we recently had to write up a case study of an elderly patient, post it online and discuss it. One of the PTs in the class posted a case study of a "depressed" and "rude" old woman who incessantly complained about her pain. In an academic case study paper he actually used the term "Queen of pain tolerance", and he wasn't being complimentary, trust me.

As I have found myself doing more and more lately, I'm defending patients who have been mis-treated by the current medical disaster for the treatment of pain problems, and written off as grumpy, depressed, cognitively and emotionally "challenged" and so on.

My final response to his entry was "There are so many 'Eleanors' (his patient's pseudonym) out there, and it's tragic."

To date, silence. It's as if I were speaking from deep underground within a hermetically-sealed... well, you know.

Here's an excerpt from the paper:
Quote:
Social History: ...Her health history was significant for orthopedic issues, however was quite extensive. She had both knees and both hips replaced, had 4 surgeries on her lumbar spine including 3 levels that are fused, suffered from restless leg syndrome, and was diagnosed with fibromyalgia. She also had Gastro esophageal reflux disease (GERD) due to long term medication doses.

Current Health Status: The patient currently lives in a nursing home where she is in the independent living section. She has a one room apartment with her own bathroom and small refrigerator. She has recently been diagnosed with a low level dementia. She is able to continue to live in her current situation if her symptoms do not progress per input from her daughter. She is also being treated for depression and Eleanor’s daughter noted that they have been receiving complaints about her mother being rude to other residents. These 2 diagnoses were not revealed by the patient either because of pride or confusion. She spent a majority of her time complaining about her orthopedic issues particularly her low back pain. She expressed frustration that the Doctors are not doing anything about her back pain, and claims that they (her doctors) do not know what they are doing. They have injected her spine 2-3 times over the past year or two, and she takes OxyContin regularly. She is on Amitriptyline for her depression, Nexium for GERD, Atenolol for high blood pressure, Diltiazem for angina, and Neurontin for “nerve pain” due to her lumbar history and restless leg syndrome. She is also being treated for skin cancer through her Dermatologist and is having simple laser procedures to remove and/or biopsy suspicious lesions. She currently ambulates with a straight cane or rolling walker depending on the distance. She no longer drives, and is dependent on family for special errands or groceries needed. Eleanor is oriented to person, place, and time; however she spends portions of our interview going off on tangents not related to my questions that appear consistent with a defense mechanism or memory loss and low levels of dementia. She is independent with dressing and bathing. She participates occasionally in social activities within the nursing home such as church, crafts, and special hymn sings, however sits alone from the interactions I noted. She reports not participating in the exercises classes or utilizing a physical therapist that comes into the home. She spoke a lot about her family in the area and her children and grandchildren. She was quick to point out those who had not been to see her recently, and the idea that “they must be too busy for me”. When asked about friendships at the nursing home she states that she does not have close interaction with anybody, and was quick to change the subject.
Pain isolates and it robs. Why don't therapists understand this?
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Old 27-10-2010, 04:03 PM   #26
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In light of John's post, maybe there should be an "L" added to Kory's equation, where L=Lack of understanding by caregivers, or perhaps that factor could be expressed as "-C" or "-U".


E could also stand for Environment.
How about adding an "S" for Stress?
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Old 27-10-2010, 04:09 PM   #27
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Bravo John,
I know I read a paper about Chronic Pain and early Dementia, but cant locate it now. The more therapists understand that THEY are to be THERE for the PATIENT and not the other way around our frightening version of the elephant graveyards will become more humane.
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Old 27-10-2010, 04:13 PM   #28
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John and Diane, how about an "N" for nocebo to cover that type of non-care giving?
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Old 27-10-2010, 04:31 PM   #29
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Originally Posted by Bas Asselbergs View Post
John and Diane, how about an "N" for nocebo to cover that type of non-care giving?

Yup, N would cover all that stuff.
There could be an appendix, perhaps, with all the things N could ostensibly cover, but they wouldn't all have to be in the equation itself.
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Old 27-10-2010, 04:38 PM   #30
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Bas and Diane,

Whatever designation its given in the equation-"N" for nocebo, "L" for lack of understanding, etc.- I think it needs to be a multiplicative or even exponential factor because it really, really screws people up.

Just adding it in doesn't seem to do it justice.
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Old 27-10-2010, 04:53 PM   #31
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My final response to his entry was "There are so many 'Eleanors' (his patient's pseudonym) out there, and it's tragic."

To date, silence. It's as if I were speaking from deep underground within a hermetically-sealed... well, you know.
One can only hope that after reading your paper they were over taken with shame for their faults in not fully understanding the biology of pain. Where is the empathy...use your mirror neurons people it is a fourth of your brain.

When you read her story and all she is going through you can biologize everything from the depression, GERD, dementia, vocabular changes, etc. because of the sympathetic changes with long standing persistent pain. Sorry just needed to vent.

I'm better now, back to the equation. I guess all these variables go back to the Pain Neuromatrix of Melzack, just in a different visual analogy.
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Old 27-10-2010, 05:03 PM   #32
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How about this?

Sn

Where S=screwedup and n=exponentially noceboic
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Old 27-10-2010, 05:34 PM   #33
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Quote:
When you read her story and all she is going through you can biologize everything from the depression, GERD, dementia, vocabular changes, etc. because of the sympathetic changes with long standing persistent pain.
Yeah, the real tragic things about Eleanor's predicament is that it is a) avoidable and b) largely created by people who think or pretend to care about/for her.

Diane,
If "nocebo" were a rational number that could be assigned a value as an exponent, I'd give it a "3"- that is, whatever value of all the other factors/addends cubed for each dimension of the neuromatrix (the "N" could also stand for "Neuromatrix").
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Old 27-10-2010, 05:48 PM   #34
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Don't forget the fourth dimension, time. I'd give it "4" as a value.
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Old 27-10-2010, 06:00 PM   #35
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Kory said this

Quote:
I guess all these variables go back to the Pain Neuromatrix of Melzack, just in a different visual analogy
Thus:

Pain = Ce (Expect + Mo + Exper) * Sd (D + Pn + I + T + SpS) * Ma (HPA + NaS + S + Im + Eo + L)

Ce is cognitive-evaluative
Exptectations
Mood
Experience
Sd is Snesory-discriminative
Deformities
Peripheral nerve
Injury
Tissue
Special Senses (visual, hearing, vestibular, smell)
Ma is Motivational- affective
HPA is hypothalmic-pituitary-adrenal
NaS isNoradrenalin-Sympathetic
Stress
Immune
Endogenious Opiods
Limbic


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Old 27-10-2010, 06:42 PM   #36
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I wonder since when get into the circle of the Body-Self Neuromatrix that we might need to look at pi (since it is an irrational number and a mathematical constant) it might fit in with the equation.

Quote:
Informally, this means that an irrational number cannot be represented as a simple fraction.
A mathematical constant is a special number, usually a real number, that arises naturally in mathematics. Unlike physical constants, mathematical constants are defined independently of physical measurement. (from Wikipedia)
Pain is not simple, it is special, and real and it arises naturally and has to be defined independently of physical (tissue and injury) measurements.
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Old 27-10-2010, 08:03 PM   #37
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Default suffering and treating people

John-Eric Cassells book may help some of your colleagues ?
http://www.amazon.com/Nature-Sufferi.../dp/019508912X
This was the first book I had to read for my post grad course and it reaffirmed my belief that humane care first and foremost is the goal of medicine .
Unfortunately, as you describe people become objects and a list of problems. What really influenced me was Havi Carel's philosophical account of health within illness http://www.acumenpublishing.co.uk/di...%29&m=16&dc=18
Health within illness is I believe a practical way of interacting therapeutically with people especially in the case history you gave... Understanding the biology of pain is a really good starting point but really your case may point towards the widespread adoption of impersonal care plans dished out by automatons ....
David Biro has an interesting pdf on his site discussing the language of pain (from a Times-UK article) which is well worth a read ......
Probably not relevant to this initial post but you might be interested in the reviews above John.

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Old 27-10-2010, 08:04 PM   #38
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Surely, Collecting Butterflies fits in here.
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Old 27-10-2010, 08:29 PM   #39
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Quote:
John-Eric Cassells book may help some of your colleagues ?
If only they read...

Thanks, Ian.
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Old 27-10-2010, 09:52 PM   #40
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Very mathematically interesting thread!

If we want to make an equation where Pain is the result of a complex algebric equation of different variables, I think it is worth noting that the variables in the formula could also be explained themselves by a complex formula that comprises some or most of the variables in the Pain equation.

Thus, a more complete picture of the pain experience would be a multiple equations with many unknown variables.

Ex :

A(Pain) = B+C+D
B = C/2*E
C = F-3D
D = 2B - C


This could acount for the fact that what is a causal factor can then become a consequence and the opposite. Which helps to picture the circular relation between all the many variables influencing the pain experience.
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Old 28-10-2010, 02:07 AM   #41
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Quote:
Originally Posted by garydiny View Post
Kory said this



Thus:

Pain = Ce (Expect + Mo + Exper) * Sd (D + Pn + I + T + SpS) * Ma (HPA + NaS + S + Im + Eo + L)

Ce is cognitive-evaluative
Exptectations
Mood
Experience
Sd is Snesory-discriminative
Deformities
Peripheral nerve
Injury
Tissue
Special Senses (visual, hearing, vestibular, smell)
Ma is Motivational- affective
HPA is hypothalmic-pituitary-adrenal
NaS isNoradrenalin-Sympathetic
Stress
Immune
Endogenious Opiods
Limbic


Gary
Gary are those expressions of functions? If pain is an output, perhaps expressing it as a function is most appropriate but that would move us out of algebra and into calculus.
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Old 28-10-2010, 02:21 AM   #42
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Kory's calculus.
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