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  • Matthew Rupiper, PT
    replied
    Originally posted by Michael Ray View Post
    Stuntdill

    Matthew - being more human is spot on. Often I'm struck at the oddity how we must strive to be more human, given how many label this skillset as "soft" or a given...turns out it takes effort and practice. Regarding suffering, I appreciate your accounts of clinical practice and I too have often thought about what leads to human suffering. I imagine the societal/cultural influences you bring up are a bit daunting to most as this inherently implies there are factors either mostly/completely out of our control (I'll save us from the free will discussion) or are a massive undertaking to change - which inherently leads to burnout when faced with millimeters of change vs the expected feet or feeling as the effort doesn't match progress. The other aspect of this discussion that is tough for me is the observer labeling the person as suffering or not suffering. I tend to accept someone is suffering by what they are telling me (similar to pain) rather than decide for them if they are or are not suffering. I don't believe that is what you are saying here just more pointing this out. However, these discussions do occur within our society, specifically referencing disability cases as an example.[/FONT]
    Hi Michael

    ...being my devil's advocate here...which I do frequently...

    I say being more human, but to be honest, what does that even mean? What does being "patient-centered" mean? I've worked with clinician's I'd considered bleeding hearts and others that come across as heartless. Both do well with at least half their patients. Is it being a chameleon? Praying with one, hugging another, rubbing the hand of the next? Telling the next to suck it the hell up and walk it off? Does it really matter when talking about relevant long term outcomes? I don't know. I'd put a small wager on it improving patient satisfaction, business and performance appraisals. That may lead some to suggest it does improve outcomes because it's "maximizing the placebo effect." (something I detest...)

    As for the sociocultural factors:
    Whether right or wrong, I tell students the outcome and prognosis were likely determined before we meet the patient. For some it's refreshing and others its come off as nihilistic.

    As for suffering;
    You're correct, I do not try to define who is and is not suffering. The individuals I referenced told me in one way or the other they were suffering. I can still see one of them from a decade ago. Elderly woman with advanced RA. A back surgeon performed an L5-S1 fusion. Like many she came away with more pain and disability. I did my best to advocate for activity and function, after learning any discussion or hinting at BSP information was ice skating uphill She did not care to hear any of it. Even when she did make an effort to listen, her ability to actively listen more than 3 minutes was clouded by the agony she was in. She told me straight to my face: "If I have to choose between improving my walking and strength or taking pain medication and sitting in a chair taking pain meds, I choose the chair. I don't care about my walking, endurance or strength. I just want to escape the pain." I still think back, knowing what I know now, and admit, I'd likely get the same result today as I did back then.
    Last edited by Matthew Rupiper, PT; 05-30-2020, 02:03 PM. Reason: because

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  • Stuntdill
    replied
    Originally posted by Michael Ray View Post
    Stuntdill

    Phantom Limb Symptoms - Yeah – so this is an interesting line of inquiry that has some benefit by asking a particular set of questions that lead us down a particular path (biology) and will likely lead to us learning more and more about the spectrum of function to dysfunction of the human body but won’t entirely explain the human experience. This is the reason we see championing of frameworks expanding beyond biomedicine, one in particular we talk about at Barbell Medicine is BioPsychoSocial that was ushered into healthcare by George Engel in the 1970s. However, there are other frameworks for examining our experiences, one being expanding our lens with philosophy (like phenomenology) to further understand the lived experience. Ideally, we will see inter-disciplinary work and the falling away of dichotomizing (mind vs body) or trichotomizing (bio vs psycho vs soc) in future research.

    EBP and Language: Yes, Michael Amato and I did a podcast on this topic that she should check out. https://www.listennotes.com/podcasts...h-GQPYe2uL4wE/
    Ultimately this comes down to talking to people (Jim, Sally, Charlie, etc) rather than a low back, shoulder, etc. This is much more of a holistic approach to helping humans.

    Diagnosis - This is very dependent on the human and the context of the situation – which is why it’s difficult to give generalizable outlines on discussions. In regards to the shoulder, I may say broad “labels” such as activity related shoulder pain rather than subacromial impingement syndrome. This shift in language can have profound impact on the individual in the short and long term. I'd recommend reading up on the articles we've released while also listening to our podcasts on these topics. Much of this will come down to reading on the topics and then through practice applying them.

    I also agree with what Matthew Rupiper, PT said above, that a clinical instructor and getting some reps under her belt will help A LOT with integrating this information into clinical practice.

    Matthew - being more human is spot on. Often I'm struck at the oddity how we must strive to be more human, given how many label this skillset as "soft" or a given...turns out it takes effort and practice. Regarding suffering, I appreciate your accounts of clinical practice and I too have often thought about what leads to human suffering. I imagine the societal/cultural influences you bring up are a bit daunting to most as this inherently implies there are factors either mostly/completely out of our control (I'll save us from the free will discussion) or are a massive undertaking to change - which inherently leads to burnout when faced with millimeters of change vs the expected feet or feeling as the effort doesn't match progress. The other aspect of this discussion that is tough for me is the observer labeling the person as suffering or not suffering. I tend to accept someone is suffering by what they are telling me (similar to pain) rather than decide for them if they are or are not suffering. I don't believe that is what you are saying here just more pointing this out. However, these discussions do occur within our society, specifically referencing disability cases as an example.

    Awesome, I'll take a listen as well and send her all this.
    Thanks so much

    Leave a comment:


  • Michael Ray
    replied
    Stuntdill

    Phantom Limb Symptoms - Yeah – so this is an interesting line of inquiry that has some benefit by asking a particular set of questions that lead us down a particular path (biology) and will likely lead to us learning more and more about the spectrum of function to dysfunction of the human body but won’t entirely explain the human experience. This is the reason we see championing of frameworks expanding beyond biomedicine, one in particular we talk about at Barbell Medicine is BioPsychoSocial that was ushered into healthcare by George Engel in the 1970s. However, there are other frameworks for examining our experiences, one being expanding our lens with philosophy (like phenomenology) to further understand the lived experience. Ideally, we will see inter-disciplinary work and the falling away of dichotomizing (mind vs body) or trichotomizing (bio vs psycho vs soc) in future research.

    EBP and Language: Yes, Michael Amato and I did a podcast on this topic that she should check out. https://www.listennotes.com/podcasts...h-GQPYe2uL4wE/
    Ultimately this comes down to talking to people (Jim, Sally, Charlie, etc) rather than a low back, shoulder, etc. This is much more of a holistic approach to helping humans.

    Diagnosis - This is very dependent on the human and the context of the situation – which is why it’s difficult to give generalizable outlines on discussions. In regards to the shoulder, I may say broad “labels” such as activity related shoulder pain rather than subacromial impingement syndrome. This shift in language can have profound impact on the individual in the short and long term. I'd recommend reading up on the articles we've released while also listening to our podcasts on these topics. Much of this will come down to reading on the topics and then through practice applying them.

    I also agree with what Matthew Rupiper, PT said above, that a clinical instructor and getting some reps under her belt will help A LOT with integrating this information into clinical practice.

    Matthew - being more human is spot on. Often I'm struck at the oddity how we must strive to be more human, given how many label this skillset as "soft" or a given...turns out it takes effort and practice. Regarding suffering, I appreciate your accounts of clinical practice and I too have often thought about what leads to human suffering. I imagine the societal/cultural influences you bring up are a bit daunting to most as this inherently implies there are factors either mostly/completely out of our control (I'll save us from the free will discussion) or are a massive undertaking to change - which inherently leads to burnout when faced with millimeters of change vs the expected feet or feeling as the effort doesn't match progress. The other aspect of this discussion that is tough for me is the observer labeling the person as suffering or not suffering. I tend to accept someone is suffering by what they are telling me (similar to pain) rather than decide for them if they are or are not suffering. I don't believe that is what you are saying here just more pointing this out. However, these discussions do occur within our society, specifically referencing disability cases as an example.


    Last edited by Michael Ray; 05-27-2020, 01:32 AM.

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  • Stuntdill
    replied
    That point about suffering is significant.
    Resonates with me as well since I do have chronic back pain and once I was definitely suffering compared to now where it sucks once in awhile and sucks more once in awhile. Other than that my life's pretty great and when I am more stressed I do feel more pain. So addressing all factors and not just the pain experience is important for sure.
    I'm going to relay these messages to her because I think the Santa one especially she will appreciate since she loves being herself and creative with problem solving.

    Thanks both of you!

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  • Matthew Rupiper, PT
    replied
    Stunt,

    Your GF is experiencing what many DPT's experience after reading, learning and memorizing from a firehose of information that is a DPT curriculum. If the student explores outside fhe curriculum in search of conflicting information it becomes more challenging. Add to that; if the student is lucky enough to have a clinical instructor familiar with the material you and Michael are discussing.....as I've seen with all my students....you'll get a confusion, frustration, overwhelmed "you mean there is not Santa Claus and why did I pay so much for this education?" type of response. But soon after you'll see the "oh thank god there's no Santa....I can start to be myself" student experience. It's enjoyable to watch. They move from robot thinker to human interactor. She'll need a clinical instructor that has been down the rabbit hole you're discussing here for that to occur.

    I first read about John Quintner in the comments section at BodyinMind. It was the original website of Lorimer Mosely and Neil O'Connell (Researcher and Member of Cochrane Reviews). Since then it's been shut down. I thought I had a grasp of the subject matter that is "pain"...then I started reading Quintner's stuff. I then had to read it again....and again...and again. I continued seeing him poke holes in anything NOI related, BIM related or anything BPS related.

    It pulled me into many a rabbit hole, few I found relevant to me as a full time practicing clinician. It did help me think more and put me BACK at the bottom of the Dunning-Kruger curve. In the end I circle back to the comments and questions you ask.

    "we are faced with helping the individual with their pain related suffering and this relationship is variable between pain and suffering from human to human. We are tasked with identifying why the person is suffering due to pain which typically includes loss of sense of self which is related to activities they'd like to engage with in their environment."

    My first question: is the person suffering? Pain is going to occur, like hunger and thirst. But not everyone that has pain, like hunger or thirst, is suffering or starving.
    My first clinical position was in an affluent, high socioeconomic setting. I saw many people with the same "diagnosis" as every other clinic in the world. The difference was I only saw 2-3 people who were, what I'd call, "suffering." The rest had everything in life going for them. They got better and in many cases were satisfied with my "expertise." My second position brought me to an underserved, low socioeconomic setting. I jokingly called it the "exclusion criteria." Same diagnosis, but real human suffering. At the surface, it was "knee pain." But it was easy to see by digging deeper, it was poverty, unemployment, domestic violence, illness/disease, drugs, etc. My "success" levels plummeted, but luckily for me, I was armed with knowledge from people like Quintner et al, so I didn't take it personally. I strove to be more human with people, be less robotic and really connect. From an outcomes perspective I may have been a "poor" clinician. From a personal and professional perspective I was much better for it.
    Last edited by Matthew Rupiper, PT; 05-22-2020, 10:45 AM.

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  • Stuntdill
    replied
    Michael Ray The human body is so interesting,

    the one article said "Phantom pain probably results from peripheral or spinal cord mechanisms, or both, rather than from more rostra1 mechanisms." Do we know more about this nowadays? Would that mean it isnt "in the brain" but nerve receptors are anastamosing (idk the word for nerves) from the arm to upper arm, to spine, and the upper arm or spine nerves send a signal to the brain and its received as the end of the arm thats no longer there?
    Or are there certain elements of the brain that light up in fMRIs or something showing whats going on with phantom limbs?

    "we are faced with helping the individual with their pain related suffering and this relationship is variable between pain and suffering from human to human. We are tasked with identifying why the person is suffering due to pain which typically includes loss of sense of self which is related to activities they'd like to engage with in their environment."

    One thing I know she's struggled with is that they teach her so much about evidence based practice and biopsychosocial model and movement patterns, anatomy, etc, but don't seem to go over how to actually help a patient. They'll just say "language is important, dont do this, dont do this, dont do this" but never say "do this/try this" Would you have any general advice or tips on what helps you most properly assess a clients needs or how to progress?

    From what I've seen Dr, Baraki say, assess goals, expectations, educate. But, people want answers (diagnoses) how do you deal with that if you cant confidently give one? (e.g shoulder pain)
    Could be anything causing the shoulder pain, management strategies likely will be the same, but what language helps them not need an answer to "whats wrong with my shouldeR?"

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  • Michael Ray
    replied
    Stuntdill - yes, I believe you are on the right path here. I would only add that suffering at the individual level related to a pain experience can vary greatly from individual to individual. Meaning, an event one human may view as pain related suffering, another may view as pleasureful (example being BDSM community). Two reports of note here are Henry Beecher, an Anesthesiologist involved in World War 2, published this paper - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1803463/
    The article discusses the variability in pain expression from soldiers presenting with trauma from the battlefield, some even reporting no symptoms nor wanting medication (not suffering from shock of trauma).

    A second paper is by Carlen et al where 73 male Israeli solders with injuries necessitating limb amputation from the Yom Kippur War (1973). https://n.neurology.org/content/28/3/211
    When assessing for phantom limb pain, the authors reported some participants reported “frank pain or unpleasant sensations” in their phantom limb. In total, 33% of participants had no pain and 67% had phantom limb pains immediately post-amputation or the weeks following. Wall (cited above), a co-author on the Carlen et al article, later released an article on the variable relationship between injury (tissue damage). In this article he discusses the Israeli soldiers' experience, “As part of an ongoing study of Israeli soldiers who had suffered traumatic amputations during the Yore Kippur war, we asked about their initial reactions. Confirming Beecher, the majority spoke of their initial injury as painless and used neutral terms such as bang, thump, blow etc. to describe their first feeling and often volunteered their surprise that it did not hurt. On enquiry about the actual circumstance, some told of being in the same type of desperate situation as at Anzio but some injuries were caused by accidents, sometimes of their own making. Far from relief and euphoria, some spoke in their pain free state of feeling guilt at letting down their comrades, annoyance at allowing the injury to occur and misery about the future consequences.” (Wall 1979)

    I bring all of this up to say, often in the clinical setting like the one your girlfriend will be involved with as a DPT - we are faced with helping the individual with their pain related suffering and this relationship is variable between pain and suffering from human to human. We are tasked with identifying why the person is suffering due to pain which typically includes loss of sense of self which is related to activities they'd like to engage with in their environment. However, one unfortunate consequence of being in clinical practice and often what is indoctrinated in school is searching for problems to explain pain within the physical body (supposed abnormalities) without adequately teaching how one can actually label something a problem necessitating an intervention or not (which is where scientific evidence becomes handy, especially as it relates to efficacious interventions), or how investigative findings fit into the context of the individual's case and how much do they matter. I realize this may have been more in-depth of a response than expected but this entire discussion on pain and pain-related suffering is...nuanced.
    Last edited by Michael Ray; 05-21-2020, 01:55 PM.

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  • Stuntdill
    replied
    I appreciate such a long thought out reply tremendously.
    A lot of this is above my head but I think I'm grasping some of it
    Just to clarify
    It seems as though the way gate control theory was hypothesized could be one aspect of pain, however it isn't a complete concept but led to further understandings or models of the pain experience
    And also, utilizing these theories is only helpful if it further aids in reducing people's suffering

    Is this correct?

    Thanks again


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  • Michael Ray
    replied
    Thanks Stuntdill for providing context to the discussion.

    So the short answer to your question - no, pain gating isn't something I give much credence to our discussion. The term has morphed over the years to phrases such as DNIC (Diffuse noxious inhibitory control) - which I also don't tend to speak to with patients or teach. We know pain may improve for many reasons (natural history, regression to the mean, expectations, conditioning - to name a few). Often when I hear pain gating or DNIC - I'm waiting for the inefficacious intervention (read as silly bs) to be peddled so my skepticism spikes fairly high.

    There have been many proposed theories over the years about pain. There were 4 primary pain theories that emerged in the 1800s and 1900s, the ones which stand out:
    1. Specificity Theory (1895)
    2. Intensity Theory (1874)
    3. Pattern Theory (1929)
    4. Gate Control Theory (1965)
    You can read more about these HERE.

    A major premise for the Gate Control Theory (GCT) by Melzack and Wall -

    “The central tenet of the GCT was that the transmission of nerve impulses from afferent fibers to spinal cord transmission (T) cells were modulated by a spinal gating mechanism operating through the substantia gelatinosa.”

    However, later GCT was built onto creating the neuromatrix of pain. According to Melzack regarding GCT's greatest contribution to our understanding of the human pain experience:

    "I believe it was the emphasis on CNS mechanisms. Never again, after 1965, could anyone try to explain pain exclusively in terms of peripheral factors.

    The theory forced the medical and biological sciences to accept the brain as an active system that filters, selects and modulates inputs. The dorsal horns, too, were not merely passive transmission stations but sites at which dynamic activities - inhibition, excitation and modulation - occurred.

    This then was the revolution: we highlighted the central nervous system as an essential component in pain processes.” See
    Melzack 1999

    The nueromatrix idea expanded on GCT with these 4 conclusions:
    1. Brain processes can be activated and modulated by inputs from the body and can act in the absence of any inputs (e.g., phantom limb pain)
    2. Origins of patterns underlying our experience can be found in the neural networks of the brain: stimuli may trigger the patterns but do not produce them.
    3. Body as unity and identified as “self” - distinct from other people and environment.
      Body as “self” is produced by central neural processes and cannot derive from the peripheral nervous system or spinal cord.
    4. The underlying brain processes creating self are “built-in” by genetic specification BUT can be modified by experience.

    Sullivan (linked above) proposed the BioPsychoMotor model of pain. Lorimer Moseley is likely one of the more well known for being considered the individual who took Engel's BioPsychoSocial Model and adapted to the human pain experience. However, much of this has become hinged heavily to a neurocentric (brain and nervous system) cornerstone to why someone experiences pain (output of the brain). I do not agree with this premise and tend to lean more towards pain as an emergent phenomenon where we clinicians try and examine known variables that we may influence (one of which sometimes is biology/physiology) and others are related to behaviors such as responses to the experience of pain or modifiable factors such as sleep, physical activity, and stress coping. I don't have a model to label this approach but I think Stilwell and Hartman are leading us in a good direction for understanding pain by layering in philosophy and cognitive sciences with a 5E enactive approach.

    Are these testable ideas, from one perspective yes we may create inquiries through these models of pain and as such the information we garner builds upon the evidence we have about pain (pain theories). On the other hand, we must stop and reflect on our premise about the human experience pain and our purpose for inquiry - if it is to solve pain then I'm afraid we are doomed to fail but if it is for addressing human suffering related to pain, then perhaps we can learn some information through the scientific method as researchers and clinicians to help individuals with their pain experience and coping. These are tricky waters to navigate that I certainly don't postulate to have the answer to but try to critically think through as many others do as well.
    Last edited by Michael Ray; 05-20-2020, 05:16 PM.

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  • Stuntdill
    replied
    Originally posted by Michael Ray View Post

    Good question. Just so we are on the same page, can you define "pain gate theory" for me? Out of curiosity, what source did you read regarding this topic?
    My girlfriend is studying to be a DPT and she mentioned it
    I send her a lot of yours and Derek's blogs and comments sometimes and she always enjoys it
    ​​​​​​She learns the biopsychosocial model of pain in school and evidence based practice and what not. Seems she will be one of the good ones.!
    I'm not sure resources she's read on it I just did some googling myself and listened to her explanation.
    From my (brief) understanding certain pain stimuli reach different neuronal connections or gates that they have to cross to reach your brain and be felt.
    Whereas touch or mechanoceptors or any non painful stimulus neurons can override/shut these gates so the pain experience isn't felt.

    It made sense to me because of things i could easily be misunderstanding

    as humans we naturally grab on to things we've hurt like ow my arm. Grabs arm

    Also, since I have chronic back pain not much other pain bothers me ("high pain tolerance") and apparently (correct me if I'm wrong) it's difficult to feel multiple pain experiences at once which I think they got the idea like pinch yourself and it'll stop hurting


    So I was wondering if this theory is a normal scientific theory I. E proven or theoretical
    And if so, do you believe in it at all?
    The practical value I'd see it having is why massage and what not would transienyly help pain

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  • Michael Ray
    replied
    Originally posted by Stuntdill View Post
    Is the pain gate theory utilized in your practice?
    Perhaps initially some touch/ manual therapy to reduce someones pain to get them open to certain movement so they can get more self-efficacy later,
    or is it not something proven, worth considering

    I don't know much about it but came across it and it was interesting. Made me think is that why we naturally rub our arm or something if we hurt it

    Interested in your thoughts if you have any

    Thanks
    Good question. Just so we are on the same page, can you define "pain gate theory" for me? Out of curiosity, what source did you read regarding this topic?

    Leave a comment:


  • Stuntdill
    started a topic Pain Gate Theory

    Pain Gate Theory

    Is the pain gate theory utilized in your practice?
    Perhaps initially some touch/ manual therapy to reduce someones pain to get them open to certain movement so they can get more self-efficacy later,
    or is it not something proven, worth considering

    I don't know much about it but came across it and it was interesting. Made me think is that why we naturally rub our arm or something if we hurt it

    Interested in your thoughts if you have any

    Thanks
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