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Thursday, December 22, 2011

Only 23 1/2 Hours Per Day

I came across this excellent video, made by Dr. Mike Evans, about exercises and disease.




This really is so easy. Humans are built to move. So the question is, "Can you limit your sitting and sleeping to just 23 1/2 hours per day?"

Just Move,

Tank

Lorimer Moseley - Why Things Hurt

     If you have followed this blog for any amount of time the name Lorimer Moseley is probably somewhat familiar. Lorimer is a clinical neuroscientist with a physical therapy background. Lorimer is currently working for the University of South Australia and you can follow his work on his website here. Lorimer, together with his team of researchers are seeking a better understanding of the interaction between the body, brain and mind in chronic and complex pain disorders.

     Recently Lorimer was selected to give a TEDx presentation about pain and it did not disappoint. To my knowledge, Lorimer is the first and only physical therapist to be selected to give a TED presentation, and I think he does an excellent job representing our field and educating the public how pain works.




Enjoy,

Tank

Saturday, September 24, 2011

Shattered Glass and Painful Illusions

     Thanks to an unfortunate yet interesting event today, I was reminded just how complex the brain’s regulation of pain can be. Distracted by the Georgia Bulldogs football game, I dropped a glass while taking it out of the cabinet. Before I had time to react, the glass shattered all over the counter and floor, making a mess you would think came from a glass three times its size. Being my stubborn self, I refused to put sandals on before cleaning the mess, despite pleas from my fiancĂ©e.

      Sure enough a minute later I stepped on a razor sharp piece of glass, or so I thought. I felt a sharp piercing sensation followed by immediate pain and a flexor withdraw because of a piece of glass under my left heel. As I frantically reached for my left foot to examine the damage I was immediately surprised and let out a laugh as I brushed a small crumb of food from my heel. All that pain sensation from something that any other time I would have hardly noticed.

     Despite the empty space now in the cabinet, this was a great reminder of just how well the nervous system can modulate pain. The brain is constantly on the lookout to maintain our survival and the sensation of pain is an extremely effective means to accomplish this (Melzack, 2001). Pain is the implicate perception that tissue is in danger (Moseley, 2007). Put more simply, pain is perceived threat. My glass shattering experience is a great example of this. As I was cleaning up the glass my brain was on high alert trying to save my feet from being damaged by a piece of glass. As soon as my brain received the slightest afferent signal from my heel, it immediately output a painful sensation. Even though this response was maybe a little over the top, it was exactly what my brain should have assumed given the potential threat of the situation. Our brains first priority is to keep us safe.


     However, I couldn’t help but remember a great two part blog post by David Butler, PT, PhD (Part 1, Part 2). As health care professionals we should take great care in how we educate our patients about why they are having a painful experience. We should try to assure patients that, while pain has many uses, it DOES NOT provide a measure of the state of the tissues (Moseley, 2007). In fact, believing that pain accurately reflects the state of the tissues has been shown to increase the perception of pain in subjects with persistent low back pain (Moseley et al 2004, Moseley, 2004). Additionally, neurophysiology education ALONE has been shown to significantly decrease pain ratings in subjects with persistent low back pain. (disclosure: while the results were statistically significant, they were not considered clinically significant) (Moseley et al, 2004)

     In conclusion, understanding pain and being able to provide effective pain education to patients should be considered a high priority clinical skill.

Just Move,

Tank


References:

1. Melzack R. Pain and the neuromatrix in the brain. J Dent Educ. 2001;65(12):1378-1382.
2. Moseley GL. A pain neuromatrix approach to patients with chronic pain. Man Ther. 2003;8(3):130-140.
3. Moseley GL. Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. Eur J Pain. 2004;8(1):39-45.
4. Moseley GL, Nicholas MK, Hodges PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clin J Pain. 2004;20(5):324-330.
5. Moseley GL. Reconceptualising Pain According to Modern Pain Science. Physical Therapy. 2007; 169-178

Friday, July 15, 2011

The Culture of Food

I came across this TED talk as I was putting together a presentation on childhood obesity.

All I can say is brilliant, simply brilliant.



Hope you enjoy and share this message.

I will have a series of posts related to childhood obesity to follow shortly.

JUST MOVE,

Tank

Tuesday, July 12, 2011

The Father of Modern Pain Science

Here is a short biography of Ronald Melzack and the journey that led him to the discovery of the gate control theory and eventually the Pain Neuromatrix.

Enjoy!

Thursday, June 30, 2011

The 10 Commandments of Pain




"We’ve learned more about the brain’s functioning in the past seven years than we had in the previous thousand. Because of this, there are now “knowledge gaps” between what we know and clinical practice.

A paradigm is a story that moves us forward in thinking. Paradigms occasionally clash, and when they do a winner emerges. The biomechanical and biopsychosocial paradigms clashed when it came to chronic disease, and the former lost. The “bio” in biopsychosocial is NOT biomedical – it’s he big picture.

The hunt for cause makes people worse.

Pain is a defender – NOT an offender. It is one of many defenders marshaled by the brain.
David Butler

This quote gives a little insight in to the confusion and clashing that is modern physical therapy practice. The 'knowledge gaps' between modern pain science and PT education seem to be growing instead of shrinking.

These 'knowledge gaps' are what allow gurus with nonsense theories to make millions with nothing more than charisma. (MFR)

Below is a three decades of research condensed into 10 simple ideas made relevant for physical therapists. This list was carefully consolidated and agreed upon by the moderators at somasimple.

I hope you find this helpful for advancing your evidenced based physical therapy practice.


Nothing Simple - Ten Steps to Understanding Manual and Movement Therapies for Pain


1. Pain is a category of complex experiences, not a single sensation produced by a single stimulus.

2. Nociception (warning signals from body tissues) is neither necessary nor sufficient to produce pain. In other words, pain can occur in the absence of tissue damage.

3. A pain experience may be induced or amplified by both actual and potential threats.

4. A pain experience may involve a composite of sensory, motor, autonomic, endocrine, immune, cognitive, affective and behavioural components. Context and meaning are paramount in determining the eventual output response.

5. The brain maps peripheral and central neural processing into each of these components at multiple levels. Therapeutic input at a single level may be sufficient to resolve a threat response.

6. Manual and movement therapies may affect peripheral and central neural processes at various stages:
- transduction of nociception at peripheral sensory receptors
- transmission of nociception in the peripheral nervous system
- transmission of nociception in the central nervous system
- processing and modulation in the brain

7. Therapies that are most likely to be successful are those that address unhelpful cognitions and fear concerning the meaning of pain, introduce movement in a non-threatening internal and external context, and/or convince the brain that the threat has been resolved.

8. The corrective physiological mechanisms responsible for resolution are inherent. A therapist need only provide an appropriate environment for their expression.

9. Tissue length, form or symmetry are poor predictors of pain. The forces applied during common manual treatments for pain generally lack the necessary magnitude and specificity to achieve enduring changes in tissue length, form or symmetry. Where such mechanical effects are possible, the clinical relevance to pain is yet to be established. The predominant effects of manual therapy may be more plausibly regarded as the result of reflexive neurophysiological responses.

10. Conditioning for the purposes of fitness and function or to promote general circulation or exercise-induced analgesia can be performed concurrently but points 6 and 9 above should remain salient.




Bibliography

Books:
Pain: The Science of Suffering - Patrick Wall
The Challenge of Pain - Patrick Wall, Ronald Melzack
Explain Pain - David Butler, Lorimer Moseley
The Sensitive Nervous System - David Butler
Phantoms in the Brain - V. S. Ramachandran
Topical Issues in Pain Vol's 1-5 - Louis Giffiord (ed)
The Feeling of What Happens - Antonio Damasio
Clinical Neurodynamics - Michael Shacklock
Eyal Lederman - The Science and Practice of Manual Therapy

Research articles:
Melzack R. Pain and the neuromatrix in the brain. J Dental Ed. 2001;65:1378-82.
Craig AD. Pain mechanisms: Labeled lines versus convergence in central processing. Ann Rev Neurosci. 2003;26:130.
Craig AD. How do you feel? Interoception: the sense of the physiological condition of the body. Nature Rev Neurosci. 2002;3:655-66.
Henderson LA, Gandevia SC, Macefield VG. Somatotopic organization of the processing of muscle and cutaneous pain in the left and right insula cortex: A single-trial fMRI study. Pain. 2007;128:20-30.
Olausson H, Lamarre Y, Backlund H, Morin C, Wallin BG, Starck G, Ekholm S, Strigo I, Worsley K, Vallbo AB, Bushnell MC. Unmyelinated tactile afferents signal touch and project to insular cortex. Nature Neurosci. 2002;5:900–904.
Moseley GL. A pain neuromatrix approach to patients with chronic pain. Manual Ther. 2003;8:130-40.
Moseley GL. Unravelling the barriers to reconceptualisation of the problem in chronic pain: The actual and perceived ability of patients and health professionals to understand the neurophysiology. J Pain. 2003;4:184-89.
Moseley GL, Arntz A. The context of a noxious stimulus affects the pain it evokes. Pain. 2007;133(1-3):64-71.
Moseley, GL, Nicholas, MK and Hodges, PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clin J Pain. 2004;20:324-30.
Crombez G, Vlaeyen JWS, Heuts PH et al. Pain-related fear is more disabling than pain itself. Evidence on the role of pain-related fear in chronic back pain disability. Pain. 1999;80:329-40.
Zusman M. Forebrain-mediated sensitization of central pain pathways: 'non-specific' pain and a new image for manual therapy. Manual Ther. 2002;7:80-88.
Dorko B. The analgesia of movement: Ideomotor activity and manual care. J Osteopathic Med. 2003;6:93-95.
Threlkeld AJ. The effects of manual therapy on connective tissue. Phys Ther. 1992;72:893-902.
Lederman E. The myth of core stability. Retrieved at: http://www.ppaonline.co.uk/

Friday, June 17, 2011

More Pain Science

Here is a great youtube video on some of the basic ideas of modern pain science. As PTs, many if not the majority of patients we will see have a primary complaint of pain. Understanding pain and how to explain pain to our patients is very valuable and often overlooked skill for PTs.

Here is the lecture by Allan Basbaum PhD, FRS



Some of the main take home points I took from the video:

No brain, no pain.

Pain threshold is actually very similar between all people. Where people differ is in their pain tolerance.

Pain depends on the psychological state of the subject when they are being stimulated.

The stimulus DOES NOT determine the amount of pain a person has, it is far more complex

Pain is higher when you attend to the pain. (distraction can effectively reduce pain)

Placebo can be very good. If you have a good placebo use it.

I hope you enjoy the lecture. More to come soon.

Tank