Adrienne and my cranky leg

I think I lucked out at Sherwood Physiotherapy... a few weeks ago someone dropped by and left off a resumé. Once in awhile people leave resumés, usually for a reception job, but this one was from a PT. I checked it over and liked what I saw. New grad but a mature thirty-two years of age, already through one career as a professional dancer, experience with sports injuries, has already done a research project.

It seemed curious that she would pick my practice to apply to, so I gave her a call to find out more. We decided to meet so I could show her the clinic, then go for coffee. Turns out she wanted to work from my space in order to be convenient for all the dancers that live in the 'hood, where yoga and dance studios are everywhere. She had done her homework, had moved into the neighbourhood three weeks earlier, and decided to aim for employment at my place, which is the only PT clinic for blocks and blocks.

To call it a "clinic" is a bit presumptuous of me... It's more like a room in a nice office suite. A non-PT practitioner also has a practice in that suite, who I get along with quite well. Our practices have no overlap, other than we share the cost of a receptionist. My practice is one-on-one, carefully teasing the pain out of people while accompanying them for one or a few sessions.

It was dreadfully slow in Feb, so there was nothing for her to pick up, but this week is going better. She will take over my normal Wednesday off. See patients. Help pay some of the overhead.

We have been busy getting some promo material together, chatting about pain, treatment... I loaned her some books, the treatment manual I developed. Today she tried out some manual therapy on me.

Well, all I've got to say is the woman has hands on her that are like butter. My cranky right leg (which has been cranky for over 50 years) very much liked what she did to it. It's still working with what she was able to get it to let go of. It feels like it has little happy faces mixed with 7-up bubbles running through its vessels instead of blood. Walking home it felt like it was looser, stronger, longer and didn't get as tired as the left leg did, so I know my S1 cortex must have neuroplasticized a fair bit.

My cranky leg/ankle foot stems from a sprain at age 5. Age 5. I vaguely remember that it hurt for what felt like months. It was never handled, never cared for, never treated.

Lucky for me, I have the right mix of receptors or something, because it never gave rise to CRPS or fibromyalgia or anything. Most of the time it hasn't "hurt", exactly. It just felt shrunken and tight, like the antigravity suit was a bit too tight in the leg zone. No amount of yoga ever helped. Nothing I learned to do (to or with it, on my own) in over 50 years, almost 40 of which was spent being a PT, helped. OMPT certainly didn't help - in fact it made it hurt a lot for awhile. I saw a massage therapist who helped the pain, but my sense of it feeling "wrong" remained. I figured out a lot of my imaginative tape techniques by using my own leg to practice on.

This is all a big lead up to what happened today. I had let Adrienne watch me treat a few people, with their permission of course.. so today she wanted to practice a tarsal tunnel treatment, and knee treatment. Long story short, the work she did felt remarkable, and still does; all the Barrett Dorko characteristics of correction (fondly referred to as C's of C) - warmth, softening, effortless(!) movement (quite a bit of that - twitching, pulsing etc.), surprise (I've not had those sorts of results from other practitioners who've worked on me) - developed during the session. It was like my leg had been waiting for this for a very long time and was more than ready to have its nerves treated instead of its bones and muscles and joints.

So, I'm sold on Adrienne. So's my leg. Here's a little write-up about her that I attached to my website. I feel really good about the prospect, when the time comes, of leaving my practice, and all the people who've come to it for 15 years, in her very, very good hands.

More on Lorimer Moseley, and mirror therapy

I stumbled upon a blog called Psychology of Pain (in which I found a link to humanantigravitysuit, about which I'm pleased), authored by Gary Rollman, Professor of Psychology at UWO in London Ontario.

In it I found a post, The Mirror Cure for Phantom Pain, which is linked to an article by Lorimer Moseley, PT and currently pain researcher at Oxford.

The article by Moseley, also called The Mirror Cure for Phantom Pain, has just been published in SciAm.

Excerpt:

"To consider how mirror movements might reduce pain, it might be helpful to first consider what pain is. I argue that pain emerges from the brain in accordance with the brain's unconscious perception of danger to the body part in question. Sensory input of danger (called nociception) is important, but not sufficient (nor necessary actually), for pain. Perhaps mirror movements simply convince the brain that all is exactly as it should be, which removes the brain's need to evoke pain. Alternatively, perhaps mirror therapy is a great distracter: distraction remains our most effective analgesic. Such explanations are very reasonable, but not particularly exciting.

Here is a more exciting theory, one the authors' introduction suggests they had in mind. It is based on the idea that phantom limb pain results from an internal conflict in the brain. Although sensory feedback, from the nerves that used to supply the missing limb, tells the brain that the limb is still present, visual feedback tells the brain it is not. According to that theory, seeing the phantom would remove the conflict and attempting to move the phantom (i.e. the other two conditions) might exacerbate it (although removing visual feedback didn't help, which doesn't fit neatly into the theory). That anaesthetizing the stump can eliminate phantom limb pain seems consistent with this theory. Perhaps anaesthetizing the stump brings sensory feedback into line with visual feedback, whereas mirror movements bring visual feedback into line with sensory feedback."

He goes on to discuss implicit versus explicit movement, citing one study showing no difference, and another that does.


References, additional reading:

1. The Neurotopian: Mirror Box Therapy

2. The Neurotopian: Pain for Dummies

3. Neurotonics: blogpost search for Virtual Body

4. List of publications by Lorimer Moseley (up to 2005)

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.

Signed,

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.

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/

Neil Pearson's Pain Webcasts

On October 15th, CPPSG (Canadian Physiotherapy Pain Sciences Group) co-chair Neil Pearson did a free three-hour presentation on pain to a group of about 60 women who had gathered to listen. About half of the audience was there to participate in a study that Neil is conducting, to determine the effects of education alone on persistent pain.

He has agreed to allow me to post links to the entire talk, in three sections.

This information is freely available here to anyone who would like to learn more about pain, whether it is pain they have, pain they are treating in patients, or pain in a family member/friend.

I've also put these links in the menu to the right.

Neil Pearson's Webcast Part 1 (45 minutes)

Neil Pearson's Webcast Part 2 (42 minutes)

Neil Pearson's Webcast Part 3 (60 minutes)

It is a really good series. Educate yourself - it's the best way to grow hope.