Thursday, August 14, 2014

My take on the role of manual therapy in the treatment of pain

1. Manual therapy is not a "thing" - it's an intrinsic behaviour evolved from social grooming in vertebrates and conceptualized by human primates, taught from the time humans could talk, bottom-up/operator style.

2. Manual therapy should be about pain and pain relief.

3. Pain, and relief of pain, is strictly a top-down phenomenon. It occurs only in ectodermal derivatives, specifically the brain. Nerves and spinal cord are antecedent, and very important physiologically, to a emergent pain production.

4. Manual therapy models must adapt, teach about pain, teach top-down, not just bottom-up, and interactively, not only operatively.

5. The senses are the only way into any patient's brain. Talking/education are paramount; furthermore, touching is allowed us; skin receptors have the fastest highway into the brain (DCML), and to its output mechanisms, by any manual therapist, so these should be in sharp focus.

6. People who get stuck in a bottom-up mindset because they ponder far too hard about what deep receptors are where, how to affect them, are going to lose sight of the whole point of touching somebody on their skin, i.e., stress and pain relief.

7. Nociception is mostly irrelevant to the brain and is handled immediately, effectively, automatically, by the internal regulation system, without ever becoming or having to become pain.

8. If anything out in the periphery needs moved, by a manual therapist, it's nerves themselves: neural anatomy is unique, crossing many tissue boundaries, and the connection to accompanying vascular supply is vulnerable to mechanical deformation (e.g., simple inactivity, habitual resting positions, or repetitive strain); enough signalling from these, over a long enough period, will challenge spinal cord cell interaction/immune cell physiology enough to change it, which can give rise to an actual pain situation.

9. Worrying or perseverating about anything else, i.e., receptors that may lie in deep tissue other than nerve tissue, or arguing to include them/it in a treatment or in an explanatory model of manual therapy, is a massive waste of time, and would serve to keep the profession mired in mesodermal mutterings, whereby we see misled therapists misleading ever more therapists into the fogbound foreseeable future.

From this thread at SomaSimple:


Jacob Hinga said...

Hello Diane, I've recently been researching trigger points, and myofascial release and after getting excited about the idea I did what most scientific minds should do - questioned it. So I browsed the internet looking for criticisms towards the idea and ran across your blog. I like some of the ideas you have presented and can certainly see a few flaws with the idea of myofascial release.

I have a question about your idea that it's all CNS related and a top-down approach. If you say it's not muscle what exactly is tense and then after treatment becomes relaxed? Some structure in the cutis/subcutis region? Muscle? Something else? Obviouosly we feel something release it's tension even if we can't determine what IT is. If myofascial advocates believe it's muscle being released which relieves nerve irritability, then do you say that it releaves nerve irrititability that allows the brain to send a message to the muscle to relax? Or do you take a stance that you don't know what exactly is going on too, you just know the theory of myofascial release has flaws?

thanks and hoping to hear from your response

-from an interested kinesiology undergrad.

Diane Jacobs said...

Hi Jacob, I'd say the tension is behaviour, motor output. I'd say the only entity capable of "releasing" it is the brain attached to the tension. Not the practitioner.
The practitioner provides a therapeutic context, and some novel stimuli. The patient's brain takes care of everything else.

Jacob Hinga said...

In the book by Travell and Simons they propose one possible explanation of muscle contraction is due to damaged sarcoplasmic reticulum which would release all it's calcium into the mucle causing a contraction until either availbable ATP disapears or the calcium is able to dissolve out of the area.

In this case there is no longer communication between CNS and muscle, and yet the muscle is still able to contract on it's own through the spillage of calcium. Their idea then relates to a localized region of ischemia and mast cells and platelets releasing histamine and seratonin which sensitize the neurons in the region which can cause pain. Wouldn't theurapeutic techniques both potentially "flush" out the local area of ischemia restoring blood flow which fixes your idea of the problem (CNS getting a blockage of blood supply and irritability of the nerve) and potentially relieving the site of calcium and or restoring proper balance so the neuron can "shut off" the muscle.

I would like to mention that even Travell and Simons which get scoffed at even realized the limitations of their model and virtually say Trigger points (or muscle points) are only one point of the larger sore point picture.

"when one injects a TP, the needle frequently encounters a region of muscle in resistant like hard rubber, suggesting strongly contracted muscle fibers, organized exudate, or fibrosis. At other times the needle encounters a firm encapsulated structure on the order of 1 or 2 mm in diameter. It feels like a well organized connective tissue. The nature of this structure remains to be demonstrated histologically in conjunction with TP's."

-directly from travell and simons.
it seems they agree with your sentiment that it's not always muscle and the actual structures could be a variety of things.

I think most likely there are parts that are muscle caused, due to the muscle malfunctioning creating a problem with the CNS, and there are other times where the CNS possible causes the issue itself. Also there are probably a variety of other sources for similar symptoms.

Sorry for the long posts and I appreciate your comments I have one last question.

Isn't it possible to "break up" scar tissue. Either through repeated ROM exercises or massage and other tool techniques, softening up the collagen and other connective tissue that has been hardening? Wouldn't that also be independent of CNS?

Diane Jacobs said...

I suspect all improvements in sore spots and/or in discrete localized areas of abnormal physiology that are palpable, are due to the nervous system sorting out itself and inhibiting itself properly again by adapting to a novel input of some kind.

I really do NOT think it's necessary to turn people into pin cushions to do this. Nor do I think palpable sore spots are in muscle.

They must be in the skin organ, or else they would not be "sensitive" to palpation. There has to be an *extero*ceptively sensitive, hyperalgesic neuron involved, or a sore spot wouldn't palpate as sore. (Last I checked there were no exteroceptive neurons in muscle.)

I would recommend not wrapping all hypotheses to do with pain around concepts of muscle. Try wrapping them around the nervous system itself.

Jacob Hinga said...

Why couldn't muscle be pulling on skin which in turns senses this and creates a "sore" feeling?

Diane Jacobs said...

Good point. And what would make muscle pull on skin (or perhaps, on nerves that surface up to skin.. )?

Why might they do that?

Jacob Hinga said...

Well through the theory of fascia- through the fascia aha.

Also if you tear a hamstring and can feel the pain in moving it, why couldn't you feel the pain of a trigger point getting pressed on?

Diane Jacobs said...

Are you feeling the hamstring? Or are you feeling nociception? Or are you feeling a sudden change of mechanical deformation of some affected portion of the 72 kilometers of nerves that populate our physicality?

Yes, one can feel sore spots, if pressed on by someone... Why do people who press them seem to think these are located in muscle?