Sunday, May 03, 2009

Still waiting

Still nothing. Still no offers on my condo..

I'm still in the transition zone therefore, feeling a bit bored, a bit restless. I decided to go where I had never gone before and put a few ideas out onto a taxonomy thread at IASP.

In a recent conversation about possibly renaming the syndrome currently known as fibromyalgia, a poster (MD) wrote:

">"Whatever we call tenderness in 11 of 18 spots with associated cognitive dysfunction is bound to be confusing unless there is an examination based on an agreed methodology (which currently doesn't exist) to identify specific muscles (40 % of tender points are thought to be TrPs in some studies and treatable with injections) that are the source of some or all of the patient's pain in distinction to CNS dysregulation."

I replied:

"Here is a thought (harboured for a long time) about the tenderness detection method used to arrive at a diagnosis of fibromyalgia: Please bear with me while I explain:

With all due respect, it seems to me, that unless the clinicians who originated this way of determining 'muscle' tenderness first physically removed the skin and its attached subcutis, then tested for tenderness, then placed the skin back on again, the idea that they actually found tender points in 'muscles' might be (dare I say) erroneous.

Cutis/subcutis is very thick, in case anyone doesn't remember. It contains a great deal of physiological tubing (nerves and vasculature and smooth muscle), sensitive structure and function, most or all of which is regulated by the sympathetic NS and efferent function of sensory nerves. Skin is closely read by the brain, and by the S1 sensory cortex, in full awareness by the non-anesthetized, non-hypnotized patients being tested for point tenderness.

I would like to propose, therefore, that tenderness in skin itself and its attached layers will always be a confounding variable to finding and being able to assert that point tenderness is from something wrong in muscle tissue. I'd say chances are rather high that some structure located within cutis/subcutis itself is what feels "tender" - a cutaneous nerve perhaps.

I'm speculating - however, I think my speculation is likely more accurate than the supposition that somehow one can locate tender points in muscles, by:
1. conceptually subtracting skin as though it did not exist, or was not sensitive, or didn't count;
2. forgetting that cutis/subcutis can be a good inch thick and is full of sensory neural structure, or that palpable hardness can't develop and then disappear within C/subC itself;
3. forgetting that a dense tough layer of fascia (hard to palpate through) surrounds and contains and separates 'muscles' from one another;
4. assuming the patient's brain/nervous system (already stressed and producing pain output) wouldn't read skin input first and regard exteroceptive pressure as something it needed to defend its organism from by making the patient flinch;

... all of which I think should be factored in long before the clinician/examiner assumes he or she has found a TrP in somatic 'muscle' tissue.

I respectfully submit that one should not rule out anything one has not already considered.

Diane Jacobs PT"

Maybe I am getting a bit ornery these days, or as a result of aging, or as I prefer to think about it, ripening while still on the vine, but I'm not going to sit back and stay quiet anymore about anything, anywhere.

As talk-show host Ellen is fond of saying, "ANY-way..."

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