Doctor of Chiropractic Question

Off Topic
41

I agree with you on two parts of that:

  1. I agree that centralization isn’t the ‘end-all, be-all’ of pain but rather one of two parts (the other being peripheral factors)

  2. that somasimple can be close-minded. I don’t really spend much time there, I prefer bodyinmind and just saw that article linked there.

However, I disagree with you that Butler promotes centralization and the neuromatrix as the only thing to consider when it comes to pain. In fact in the book I mentioned he dedicates a chapter to peripheral factors and plenty of space discussing how to differentiate types of pain that are predominately one or the other. I think he provides a voice of reason between the two camps and especially between clinicians and researchers; if someone completely throws out all their standard techniques in the name of centralization then I believe they have made a misinterpretation of the material.

With that said, you can’t ignore all the studies demonstrating that looking at soft tissue is not a reliable way to determine injury even remotely, and the tons of ‘muscle balance’ and other treatments being no more effective than any other type of treatment (extensive # of studies reviewed on bodyinmind covering this).

I don’t have an article on the topic, but I remember reading that Ramachandran (or an interpretation of Ramachandran’s work) had offered one explanation for this as guarding:

An injury occurs (let’s say a sprained ankle) and plastic changes immediately happen in the brain. The changes wire the actual thought of moving (premotor activity) to pain. The evolutionary beneficial reason for this would be that if your brain allowed your body to try to move your injured ankle, then the pain signals had to fire and that signal had to come all the way back up to you brain, you would keep moving your injured joint around and it would never heal (or at least heal a lot slower). The actual evidence of this is the there is a large amount of activation in the premotor and motor cortices when someone is experiencing pain.

The idea then is that if, due to guarding, you do not move your ankle for extended periods of time (or at least not in the way you used to), the space on the motor cortex dedicated to controlling ankle movement will begin to atrophy. The brain matter itself won’t deteriorate, but neighboring body areas which experience more stimulation will start to invade and normally neat boundaries will blur. This has been demonstrated numerous times that this occurs, most dramatically in amputees but even more simple experiments like sewing fingers together in monkeys, etc.

For those that are not familiar, amputees frequently experience pain post-amputation in their non-existant limb. Brain scans show that when this pain occurs, the typical motor and sensory maps in the brain have become distorted (due to the complete lack of feedback from all the receptors that are now gone from the amputated limb). Through an optical illusion, Ramachandran (and others since him) have had a lot of success treating this type of pain. The interesting thing is that when these people’s pain improved, the motor and sensory brain areas normalize.

Centralization of pain can occur once the brain map changes in an otherwise healthy individual. The evolutionary advantage of this would be that if the brain does not feel comfortable with a joint (i.e. an injury or simply poor control over the joint due to poorly defined motor areas) it can cause pain there to prevent joint movement. Being able to adapt quickly, compensate, and use other joints in light of this is definitely a plus.

That is just one possible explanation, but one that makes a lot of sense.

42

So I Haven’t read the book nor even considered the subject much. This is me trying to understand, not necessarily negate what you’re saying.

How would one palpate a nerve? From a quick search, it looks to start at cutaneous nerves and then move on, but How would this happen among even slightly overweight people?

And couldn’t manual therapies (SMT, Soft tissue, activation etc) be enough to cause propreoception to the joint or area in general to create a change in the tissue and CNS?

The idea seems interesting and Ill have to try to find the book and our school’s library. If you could shed some light on my questions I’d appreciate it. Always eager to learn!

43

So I Haven’t read the book nor even considered the subject much. This is me trying to understand, not necessarily negate what you’re saying.

How would one palpate a nerve? From a quick search, it looks to start at cutaneous nerves and then move on, but How would this happen among even slightly overweight people?

And couldn’t manual therapies (SMT, Soft tissue, activation etc) be enough to cause propreoception to the joint or area in general to create a change in the tissue and CNS?

The idea seems interesting and Ill have to try to find the book and our school’s library. If you could shed some light on my questions I’d appreciate it. Always eager to learn!

44

By the way, I didn’t mean to derail your thread, but you asked about the future of chiro so I figured it was something you would be interested in. If you want to be relevant professionally, these are some things you should be aware of. As far as your questions go…

You can palpate many nerves directly, whereas some have to be done indirectly. You palpate them just like you would anything else - you just need to know where to look. Ex: You can easily feel the tibial nerve by sitting down with your leg straight out (hip flexed knee extended) and feeling for a thick cord-like structure. Nerves are quite hard, harder than really any other soft tissue, so they are not too hard to find. Naturally, pressing on them does feel a little weird, which makes them easy to palpate on yourself.

I wouldn’t run out and start palpating nerves though; the palpating of nerves is just a small piece of the book (and the puzzle). The book I recommended itself is about evidenced-based reasoning in the treatment of pain, palpating nerves and what not is just a small portion.

The content of this book and the blog linked is at the proverbial bleeding edge. Think of it like Supertraining except instead of just an encyclopedia of studies it actually links everything up to provide best practices across all manual therapies… and then at the end introduces new techniques for good measure. It takes forever for this sort of thing to find its way into school curriculum (which is very unfortunate). By default, practically whatever you are taught in school (regardless of field of study) you are practically always behind.

As far as your question goes about using manual techniques to change the CNS… from a physiological perspective, sometimes, but usually not. For example, stimulated to a much greater degree by self-created movement, not passive movement. Plastic changes are like learning in a way.

Think about it this way… imagine you are teaching a kid how to swing a baseball bat. You might guide him through the motion a few times, but eventually he will need to swing the bat himself a few (or many) times before he will get the hang of it. If you guided him through the motion every day but never let him swing, he would never learn and would get very little benefit (change) out of the deal.

Manual techniques creating significant, long-lasting changes in the CNS is akin to thinking that simply by showing someone how to perform something, they will learn without any practice. It is very hard to do something to someone and have them actually learn from the experience. Plasticity is dependent upon It attention, and it’s hard to pay attention to much of anything unless you are doing it yourself. The brain learns through exploration. Note that since pain is the one stimulus that commands a lot of attention, so adaptations are rapid when exposed to it.

Now, this is not to say that manual techniques are worthless. If someone is having elbow pain, a little soft-tissue work and corrective exercise can work wonders. Perhaps a small local nerve is trapped and creating undue tension and releasing it will fix the problem. Both of the situations are very realistic. However, if they have been having elbow pain off and on for most of their adult life and they finally came to see you because they were tired of it, all the (insert therapy here) is probably not going to do much.

The greater picture here is that pain in and of itself is ultimately a central (CNS) modulated process. We experience pain in our brains, not in our tissue. A simple example of this is that children who are born with a congenital condition resulting in a missing limb can still develop phantom pain despite no actual trauma.

Essentially, pain is processed and occurs in the brain rather than at the injury site. This may seem like semantics but it is much more than that. Any time you experience pain, the pain signals are sent to the brain are then re-created in the brain. Based on any number of factors pain signals can be amplified, quieted, or simply created within the brain.

Take away point: If you want to be part of the future of pain treatment for the head and spine (areas very susceptible to chronic pain), you will need to start digging in to the rapidly increasing literature on the neurology of pain.

I would be happy to answer any other questions you have but for now I will be logging for the night!

45

It is something I’ll definitly look into. Thanks for the information.

46

Challer1, is there any recommend reading list that you could provide or PM for further education on this subject? It would be much appreciated.

47

sure, PM sent

48

Thanks

49

If nerve manipulation how he affects centralization or peripheal causes?

What other ways would you treat centralization?

50

Nerve manipulation is just a small piece, another tool to use. It is recommended for peripheral issues. Centralization is not an all-encompassing piece, it is basically the other “half” that is what has made current pain treatment techniques so ineffective.

An example would be if someone had a local nerve misfiring due to pressure, nerve flossing might alleviate that. The local nerve was misfiring and misrepresenting the information to the brain. Perhaps if this had been going on for years, some centralization may have occurred and more work would need to be done.

Centralized pain is being treated in a variety of ways and people are coming up with fascinating stuff to say the least. Butler and Moseley’s outfit (NOIGroup) for example has built their own system for those with chronic hand and foot pain.

I am not sure who originally discovered this but it turns out many people with long term hand or foot pain get a distorted sense of perception.

To them, their painful hand appears larger when they look at it. Even more mysteriously when presented with a picture of a hand or foot in different positions and then asked to identify whether it is left or right, they are unable to do so. A normal person would have no problem doing this.

In this situation, they have developed flash cards which have right and left hands and ask the people to identify them. They also have a computer program which does a similar drills. They have found that in an impressive number of cases, once a person begins to excel at the task, their hands (or feet) once again appear to be normal size and their pain goes away or is at least significantly reduced.

The original method of treating pain was mirror box therapy (lots of stuff in google) which worked well for amputees and is certainly used in a lot of settings, but it is only convenient for limb pain due to the nature of the task.

Z-Health (there are a few tnation articles on zhealth) is based off this system as well. I have used this personally and have had a lot of success with it.

Several studies now have shown great results with just imagery techniques - that is having the person lie down in a comfortable position and imagining themselves perform normally painful movements. This thought process can cause strong stimulation in the motor cortices and teaches the person to experience those movement patterns in the brain without the associated pain.

51

BBB, Do you adjust or are you able to adjust (use SMT) in the UK? Feel free to pleade the fifth? Do you UKers know what that means? Haha

53

That’s pretty awesome. I wasn’t sure how it worked over there. Here you have to be licensed and it within your scope. In some states PT aren’t able to use SMT so I didn’t know if you not finishing clinic was keeping you from being able to adjust.

54

[quote]challer1 wrote:
I agree with you on two parts of that:

  1. I agree that centralization isn’t the ‘end-all, be-all’ of pain but rather one of two parts (the other being peripheral factors)

  2. that somasimple can be close-minded. I don’t really spend much time there, I prefer bodyinmind and just saw that article linked there.

However, I disagree with you that Butler promotes centralization and the neuromatrix as the only thing to consider when it comes to pain. In fact in the book I mentioned he dedicates a chapter to peripheral factors and plenty of space discussing how to differentiate types of pain that are predominately one or the other. I think he provides a voice of reason between the two camps and especially between clinicians and researchers; if someone completely throws out all their standard techniques in the name of centralization then I believe they have made a misinterpretation of the material.

With that said, you can’t ignore all the studies demonstrating that looking at soft tissue is not a reliable way to determine injury even remotely, and the tons of ‘muscle balance’ and other treatments being no more effective than any other type of treatment (extensive # of studies reviewed on bodyinmind covering this).

I don’t have an article on the topic, but I remember reading that Ramachandran (or an interpretation of Ramachandran’s work) had offered one explanation for this as guarding:

An injury occurs (let’s say a sprained ankle) and plastic changes immediately happen in the brain. The changes wire the actual thought of moving (premotor activity) to pain. The evolutionary beneficial reason for this would be that if your brain allowed your body to try to move your injured ankle, then the pain signals had to fire and that signal had to come all the way back up to you brain, you would keep moving your injured joint around and it would never heal (or at least heal a lot slower). The actual evidence of this is the there is a large amount of activation in the premotor and motor cortices when someone is experiencing pain.

The idea then is that if, due to guarding, you do not move your ankle for extended periods of time (or at least not in the way you used to), the space on the motor cortex dedicated to controlling ankle movement will begin to atrophy. The brain matter itself won’t deteriorate, but neighboring body areas which experience more stimulation will start to invade and normally neat boundaries will blur. This has been demonstrated numerous times that this occurs, most dramatically in amputees but even more simple experiments like sewing fingers together in monkeys, etc.

For those that are not familiar, amputees frequently experience pain post-amputation in their non-existant limb. Brain scans show that when this pain occurs, the typical motor and sensory maps in the brain have become distorted (due to the complete lack of feedback from all the receptors that are now gone from the amputated limb). Through an optical illusion, Ramachandran (and others since him) have had a lot of success treating this type of pain. The interesting thing is that when these people’s pain improved, the motor and sensory brain areas normalize.

Centralization of pain can occur once the brain map changes in an otherwise healthy individual. The evolutionary advantage of this would be that if the brain does not feel comfortable with a joint (i.e. an injury or simply poor control over the joint due to poorly defined motor areas) it can cause pain there to prevent joint movement. Being able to adapt quickly, compensate, and use other joints in light of this is definitely a plus.

That is just one possible explanation, but one that makes a lot of sense. [/quote]

Sorry if it seemed as if I was saying Butler focuses on centralization, I meant a lot of practitioners point to Butler as one of their big sources, and the reason why centralization is the be all end all, (ex some of those on somasimple). I haven’t read the book in its entirety, but I realize Butler discusses those peripheral factors, and I agree, he does well in bridging the gaps between the two camps, sorry if there was some confusion there.

In regards to determining the site of soft tissue injury, you and I both know that many studies do not asking the correct questions. At best any study that examines interexaminer reliability is only testing the reliability between those two examiners, you can’t truly extrapolate that out through every practitioner regardless of skill set and say something like “palpation is unreliable” I think you’ll agree that palpation is a highly refined skill, and the more you palpate the better you get at differentiating muscle junctions, nerves, veins, focal adhesions, etc. However, something like palpation is only one piece to the puzzle, so you need to see how the patient moves and compensates (again a highly refined skill) and look at a variety of data points to isolate the top dysfunctions and how they might be affecting the pain perception.

I agree that our bodies are going to spare more vital structures (nerves) at peril to other soft tissue, so by that respect pain can be a liar. In compensation I always give my patients the student analogy (You have 2 kids working on a project, one is slacking off, the other is working hard, which one will complain?) The key lies in finding out why that other kid isn’t doing work and fixing that dysfunction.

Thanks for a little more explanation of the reason this compensation would be important, my biggest question I guess lies in why would we not revert to the most mechanically advantageous activation pattern after that dysfunction is removed?

Some of my thought process is this: Our bodies are task and economy oriented, so we’re going to fire the muscles that are at the best mechanical advantage to complete a task, but if by firing those muscles we would put another structure at risk of damage, we will compensate around it to accomplish the task without putting undue load on the irritated structure
ie. decreased glute activation that is found in patients with disc irritation due to the compressive load on the discs that is caused by glute contraction. This decrease activation pattern (and subsequent increased activation in less mechanically advantageous synergists like hip ERs, hamstring) would then spare that increase in compressive load, thereby sparing the disc. Let me know if this appears to make sense or if I’m coming at you from Mars… I am very far from knowing everything and appreciate the info and feedback, it’s not common to find someone who is actually interested in intellectual discourse when it comes to these sort of things, so I appreciate it.

I’m still delving into this myself, and I know that acute pain processing and chronic pain processing are different in the cortex, the change in activation you mentioned, is that in chronics or acute?

55

Yes, I agree that studies on the efficacy of treatment are inherently flawed simply because they basically assume that all practitioners have the same skill, which is of course a fallacy.

With that said, there are a lot of well-done studies (on palpation for example, see this recent review Personal Loan for Small Business | Body In Mind ) and you can’t simply write those off.

I would say this is because the overwhelming directive of the brain is survival. Efficiency and task are just a piece of that. First and foremost the brain needs to feel safe. Also, the brain is plastic and it needs repetition to change; the body is certainly capable of being very efficient but it is still a slave to the brain. Post-injury if good motor control to a joint was never restored, then the motor patterns controlling that joint will be poor, and the brain will not find those easy to use.

Think of the way many elderly walk. It is anything but efficient, even if they are not in pain. Think about the weekend marathon runner who is much younger. Watching them slog it out around the neighborhood can be painful to watch. They certainly are not being efficient, it is just how that is comfortable for them to move.

I think moving in the most mechanically advantageous activation pattern is a a characteristic of high-end athletes, not the average person.

I think that this certainly can be restored, but in this case it would take work beyond anything you can do with your hands.

I am not sure what you are referring to with the change in activation - could you clarify?

56

[quote]challer1 wrote:
Yes, I agree that studies on the efficacy of treatment are inherently flawed simply because they basically assume that all practitioners have the same skill, which is of course a fallacy.

With that said, there are a lot of well-done studies (on palpation for example, see this recent review Personal Loan for Small Business | Body In Mind ) and you can’t simply write those off.

I would say this is because the overwhelming directive of the brain is survival. Efficiency and task are just a piece of that. First and foremost the brain needs to feel safe. Also, the brain is plastic and it needs repetition to change; the body is certainly capable of being very efficient but it is still a slave to the brain. Post-injury if good motor control to a joint was never restored, then the motor patterns controlling that joint will be poor, and the brain will not find those easy to use.

Think of the way many elderly walk. It is anything but efficient, even if they are not in pain. Think about the weekend marathon runner who is much younger. Watching them slog it out around the neighborhood can be painful to watch. They certainly are not being efficient, it is just how that is comfortable for them to move.

I think moving in the most mechanically advantageous activation pattern is a a characteristic of high-end athletes, not the average person.

I think that this certainly can be restored, but in this case it would take work beyond anything you can do with your hands.

I am not sure what you are referring to with the change in activation - could you clarify?[/quote]

I’ll take a look at those studies, don’t have time to at the current moment…

Good point on survival being the main directive, and efficiency and task only being portions.

It’s interesting you mention the elderly patient, or the inefficient marathoner. How do you know those aren’t the most efficient patterns of locomotion due to their peripheral dysfunctions? I would say that by-in-large decreased efficiency in locomotion in an elderly patient would be due to some type of peripheral dysfunction (arthritis, adhesion, etc) than simply a motor program issue. (I dunno, maybe we’re just saying the same thing in different ways)

I’m with you somewhat on the point of mechanically advantageous activation pattern being more of a characteristic of high end athletes. I think the difference between maximal efficiencies is definately more motor control like you said. But I’m talking about taking a high end athlete/patient or client from 90% efficient to 95% efficient. The vast majority of the population is going to be thrilled with being even 75% efficient, and it seems to me that one could get to that level with saving sensory-motor training for after peripheral dysfunction is reduced. Sorry for the completely arbitrary numbers, I hope they serve to illustrate what I’m trying to say.

Maybe it’s just my corner of the world, but there are many PTs, and personal trainers who want to jump immediately to sensory motor training, even before their patient/client has restored quality motion in the area, and I just think that is a HUGE oversight.

You said this:
The actual evidence of this is the there is a large amount of activation in the premotor and motor cortices when someone is experiencing pain

I was wondering if that change in activation you are mentioning is in the premotor and motor cortices when someone is in chronic pain or acute pain. I remember learning that pain processing changes when someone begins to move from the acute to the chronic pain phase, but couldn’t recall what areas shifted when. I probably should just go dust off the Neuro books…

57

[quote]bushidobadboy wrote:

[quote]mch60360 wrote:
BBB, Do you adjust or are you able to adjust (use SMT) in the UK? Feel free to pleade the fifth? Do you UKers know what that means? Haha[/quote]

Well yeah, of course. How else would a chiro work without adjustment? Sure, some of them pussy out and stick to mobilisations and/or massage, but 90% of the work of the regular chiro is adjustment.

The irony in my own situation is that I am fully insured (up to $15,000,000) to do everything a chiropractor can (plus some other stuff they are not), yet my insurance costs almost a 1/3 of what they have to pay as a ‘chiropractor’ through the govenment authorised scheme.

Even the private insurance company I use charge double what they charge me, just for the title of chiro, because there is greater percieved risk.

Makes me LOL.

BBB[/quote]

You must send out holiday noop baskets to the insurance agents…

:slight_smile:

58

Just read the abstract…wow, pretty interesting, gonna have to pay attention for follow ups to that. Really hammers home the point that pain on palpation is just one data point, and that many more findings need to be taken under consideration to reach a reliable diagnosis.

Don’t take it to mean that I don’t think the mind has incredible power over our perception and response to treatment, because it absolutely does, I just think the diagnostic capabilities we have at our disposal are incredibly lacking when it comes to musculoskeletal dysfunction when it is below the threshold of “pathology”.

60

[quote]
It’s interesting you mention the elderly patient, or the inefficient marathoner. How do you know those aren’t the most efficient patterns of locomotion due to their peripheral dysfunctions? I would say that by-in-large decreased efficiency in locomotion in an elderly patient would be due to some type of peripheral dysfunction (arthritis, adhesion, etc) than simply a motor program issue. (I dunno, maybe we’re just saying the same thing in different ways)[/quote]

Nothing is all or none, you will have to do your own evaluation and come to your own conclusions, but at the end of the day you can’t discount that nearly everyone has peripheral abnormalities whether it be DDD, discs, ulnar nerve damage, partially torn rotator cuff, arthritis, etc despite not having any pain or dysfunction.

The appeal of neuro approach is it answers the question of what separates the people who have no pain despite peripheral abnormalities from those that have pain and dysfunction. Nearly everyone has peripheral abnormalities.

[quote]
You said this:
The actual evidence of this is the there is a large amount of activation in the premotor and motor cortices when someone is experiencing pain

I was wondering if that change in activation you are mentioning is in the premotor and motor cortices when someone is in chronic pain or acute pain. I remember learning that pain processing changes when someone begins to move from the acute to the chronic pain phase, but couldn’t recall what areas shifted when. I probably should just go dust off the Neuro books…[/quote]

Even when subjected to acute pain (shock, heat, etc) motor areas in the brain are heavily activated (along with other brain areas).

@BBB - In the study they performed local nerve blocks to isolate the z joint that was actually sending off pain signals, and this was noted. At a later date they then went back and pressed on each z joint to see if the person could identify which nerve was the “correct” area of injury.