Wednesday, January 30, 2008

SomaSimple Pain Consensus

Lately Luke Rickards DO, a moderator at SomaSimple, initiated this consensus. Several people contributed their thoughts and eventually agreed on the following, reproduced here in its entirety:
"Behind the scenes at SomaSimple the moderators study continuously, deal with the issues inherent to our task and decide together how we can advance our mission of sharing relevant and rational information about therapy theory and practice.

Recently Luke Rickards listed ten things he felt we now know about the nature of painful sensation. It has since been modified and referenced and you’ll see the document below. We have had an intricate and prolonged conversation about each point, and now invite your questions and commentary. The following list has been compiled in an effort to present you with succinct points derived from contemporary pain related research so that you may better understand the view points of the moderators and many of the regular posters at SomaSimple. The list is subject to change as our understanding improves.

As with all statements born of scientific reasoning these are provisional, but we feel at least a few will stand the test of time. For those interested in gaining a more detailed understanding of the generalized items on the list, we recommend reading the material referenced in the bibliography.


The Moderators"

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. Therapies that are most likely to be successful in treating non-pathological pain 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.

7. 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

8. The corrective physiological mechanisms responsible for resolution are inherent. In non-pathological pain states a therapist need only provide an appropriate environment for their expression.

9. There is little correlation between tissue length, form or symmetry and the prevalence of pain. Manually applied forces will almost never directly result in clinically relevant and lasting change in tissue length, form or symmetry. The effects of manual therapy are more plausibly regarded as the result of reflexive neurophysiological responses.

10. Neuromuscular reconditioning is best initiated after near or full resolution of the pain experience. Conditioning for the purpose of fitness and function or to prompt exercise-induced analgesia can be performed concurrently but threat and nocebo should be considered. Conditioning should be conducted in the knowledge that there is no substantial evidence that posture, muscular weakness or weight are risk factors for neuromusculoskeletal pain.


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:

1 comment:

Unknown said...

The Ten Steps are a wonderful summary of things that I have learned from your blog and the many resources you link to. I first found your blog when I was researching pain to better understand what I was going through with chronic arthritis of the knee, a failed arthroscopic surgery, and finally a total knee replacement. I am delighted that you and your colleagues are getting this news out! I am sorry to say that it does not seem to be well known in the medical community. I realized after the fact that a large stumbling block in my own recovery was when my surgeon counseled me prior to the replacement surgery. He meant well, and was striving for open and honest disclosure. What he said was "My one concern is that we will have trouble controlling your pain following the surgery". It was his concern. It was my obsession and greatest fear: severe, unrelenting physical pain. Now I see that my fearful state contributed greatly to my experience of pain. Opiates were increased to the point where my respiration was depressed and the nurses feared for my life (350 mg oxycodone per day). In hindsight, it all seems so absurd, but at the time it was a very serious matter. At my age (57) I have numerous acquaintances who are experiencing similar problems in dealing with pain. It is of the utmost importance that these 10Steps be made known to the entire medical community.