Zac Cupples Therapy Notes from EXPLAIN PAIN

Another enjoyable set of posts from Zac Cupples blog.  Really enjoying reading his entire blog, and thought I would post the material he has written about EXPLAIN PAIN, the well-known pain education book written by David Butler and Lorimer Moseley.  His summaries really help to reinforce the central points in the book.
Again, if you haven't read EXPLAIN PAIN, the notes are not a substitute, but these notes are definitely worth a read nonetheless.  Thanks Zac!

http://zaccupples.com/category/therapy-notes-explain-pain/

(Succinct & Excellent) Chapter Summaries - Sensitive Nervous System - David Butler

Universally accepted as a tremendous resource for modern neurobiology, pain science, and the biopsychosocial approach for nervous system and pain management, David Butler's "The Sensitive Nervous System" is essential reading.

Zac Cupples, a PT from Illinois, USA, has written some very excellent chapter summaries.  This link will get you to them.

http://www.somasimple.com/forums/showpost.php?p=154187&postcount=2

or can access his site directly:
http://zaccupples.com/

These are no substitute for reading the book, but once you have, these are excellent overviews and encapsulate the essential points in the book very well.  Great stuff!

Meditation and Pain

Another great post from Todd Hargrove at Better Movement. All about the role of meditation and mindfulness in training the ability to optimally filter sensory information.

http://www.bettermovement.org/2013/meditation-and-pain/

"Meditation seems like powerful medicine indeed, perhaps second only to general exercise in its health benefits. I find it fascinating that this all purpose mental muscle can be developed by something as simple as focusing attention on bodily sensations."

The Beautiful Brain - At the Juncture of Art and Neuroscience

Just found this one.  Very interesting and enjoyable to look through.

http://thebeautifulbrain.com/

The Beautiful Brain explores the latest findings from the ever-growing field of neuroscience through monthly long-form essays, reviews, galleries, short-form blog posts and more, with particular attention to the dialogue between the arts and sciences. The site illuminates new questions about creativity, the mind of the artist, and the mind of the observer that modern neuroscience is helping us to answer, or at least to provide part of an answer. Instances where art seeks to answer questions of a traditionally scientific nature are also of great interest, and for that reason you will hear from artists as well as scientists on The Beautiful Brain.

A classic drawing of a neuron by Santiago Ramón y Cajal:

Ten Steps to Understanding Manual and Movement Therapies for Pain

The moderators at SomaSimple (www.somasimple.com), have compiled a list of points related to manual and movement therapies for pain.  They have successfully presented succinct points derived from contemporary pain research, and have also included a reference list for those interested in gaining a more detailed understanding of the items on the list.  Super well done.

Here's the original link too:

http://www.somasimple.com/forums/showthread.php?t=4944

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
The Science and Practice of Manual Therapy - Eyal Lederman

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/
Lederman E. The fall of the postural–structural–biomechanical model in manual and physical therapies: Exemplified by lower back pain (2010)

Integrating knowledge and improving clinical reasoning

This is an older, but still very relevant, posting about how to best integrate new knowledge within the broad field of manual therapy. With so many diverse streams of information, and instructors sometimes teaching with extreme bias to their techniques, how do we best integrate and synthesize this information?

http://download.journals.elsevierhealth.com/pdfs/journals/1356-689X/PIIS1356689X99901959.pdf

A few quotes...

"participants need to maintain their vigilance, and critically evaluate and question the material presented"...

"should demand evidence of speakers and objectively examine their arguments in the light of current scientific understanding, whilst keeping an open mind to new ideas, even if they seem to contradict previously accepted notions."

"the successful management of many clinical problems requires well-developed clinical reasoning, often drawing on a number of manual therapy approaches."

Early NOIJAM Blog post: Straining Scientist - Clinician Relationships

For those of you that already subscribe to the Neuro Orthopedic Institute (NOI) Group newsletter, you will have already been informed in the last few days about their new blog: NOIJAM (www.noijam.com).  It sounds as though David Butler is taking the lead on this blog and facilitating good discussion through it.  Very exciting!  Make sure to bookmark this one.

In their words:
"This blog is for clinicians in the world of science.
NOI jam is about:
• providing an open liberal discussion forum led by experienced clinicians, focusing on the treatment of ongoing pain states via nervous system changing therapies based on movement and education
• facilitating findings from science into clinical decision making,
• enhancing links between clinicians and researcher,
• bringing researchable ideas from the clinic to the fore."

The posting on Feb 1st titled "Straining Scientist - Clinician Relationships" (http://noijam.com/2013/02/01/straining-scientist-clinician-relationships/) has been particularly interesting so far.  David Butler has lead off with some things that scientists should be looking for from their relationships with clinicians, and some of the responses so far have pitched the ball right back at clinicians and the level of evidence-based scrutiny we require when treating patients.  Very great points and excellent food for thought as we continue to become better clinicians and researchers.

Contextually, at GF Strong we really are fortunate to have relatively easy access to researchers.  We have ample opportunities to create momentum towards having our research questions explored, and to get involved with research that is already underway in areas of our interest.  

Additionally, there is currently hot debate on the value of core activities like stretching to improve range of motion or reduce contracture.  Clinicians are attempting to decipher a Cochrane review with generally limited experience in doing so. Clearly, as our profession moves forward, clinicians are going to have to become adept at understanding research, sifting through research recommendations, and integrating them into our clinical decision making.  

Every clinician is capable of single subject research design, and I can't help but think that this might be part of the middle ground.  The practice of developing ideas about what we expect from our treatments, collecting key information about them, and presenting it, is part of the work of being a clinician.  Anyone have any ideas about how to be more organized about it?  How to find the time? Perhaps a separate posting about it (single subject research design) in the near future is warranted.

Deconstructing/debunking the idea of "trigger points" & myofascial pain

Wow. I hadn't read this posting in a while, but it is essential reading for anyone who attempts to assess and treat/influence pain states that are felt in different areas of our & our patients bodies. A better understanding of the biology of why certain places in our body hurt when they are pressed on is essential to the effective treatment of these pains. Great posting Diane Jacobs!

An exerpt:

"no tissue other than neural tissue (i.e., neurons, direct ectodermal derivatives) can directly signal the brain (also direct ectodermal derivative) to provoke it into mounting a pain output/perception for our conscious awareness to,.. um, be aware of, consider. In other words, quite apart from the "trigger point" issue, is there really any such thing as "myofascial pain"? I would argue that no, there isn't. Only neural tissue can send sensory-discriminative information to the brain, and only the brain can mount that sort of cognitive-evaluative-motivational-affective-sensory-discriminative display known as "pain". Other kinds of tissue in the body are usually innocent victims, not guilty culprits."

Here's the posting link:

http://humanantigravitysuit.blogspot.ca/2011/07/why-i-dont-buy-idea-that-trigger-points.html

Remember to read the links from within this article.  Also great learning/reading.

Upcoming Webinar "Chronic Pain: Is it all in the Brain?"

The Canadian Institute for the Relief of Pain and Disability (CIRPD) is presenting a series of Webinars over the next 3 months.
On April 16, 2013, 1:00pm PST there will be a webinar entitled "Chronic Pain: Is it all in the Brain?" led by Dr. Fernando Cervero

Overview:
What changes happen to the brain when a person transitions from acute to chronic pain? Dr. Cervero will discuss these changes and help us understand that effective therapies must deal with both the cause of the pain and the change in pain perception that happens too.

Dr. Fernando Cervero will join us to explain these changes in pain perception and identify the brain mechanisms that cause them.

This webinar will help you:
To understand that the transition from acute to chronic pain involves the generation of increased excitability of the brain centres involved in pain perception.
To identify which brain mechanisms generate pain hypersensitivity and how these mechanisms cause chronic pain.
To understand how effective therapies for chronic pain must deal not only with the causes of pain (injury, inflammation etc) but also with the enhanced sensitivity of the brain to pain perception.

To register, see this link.

http://www.cirpd.org/GetInvolved/Webinars/Pages/ChronicPainIsitAllintheBrain.aspx

Sounds like a good one.  Will probably try to gather a group of people together at GF Strong to view it together.

Botox and the Brain

No big surprise, but interesting to read this research, from Neuroscience Research Australia (NeuRA)
http://neura.edu.au/news-events/news/don-t-let-botox-go-your-head-or-should-we

Botox reduces spasticity locally, at the site of injection, but also altered brain activity in the cortex – the brain region responsible for movement, memory, learning and thinking.

Read the full posting, and also the abstract from the Muscle and Nerve journal.