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NEXT Workshop is on May 21 and 22, 2011 at Cebu, Philippines
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What's being said about Manual Medicine?

Sunday, November 30, 2008

Re chiropractic terminology and technique discrepancies

Posted by: "Noel A. Taylor" drnat@operamail.com   drnatus

Sat Nov 29, 2008 7:23 am (PST)

It seems that you're asking for thoughts and/or observations regarding the 
apparent contradictions on this page, so here are mine:

1) "Right rotation" references the spinous process, as evidenced by the 
details given for the positions of the transverse processes. This would be
the same as "body left."
2) "Posteriority" as it appears on this page is most likely a transcription 
error
 intended to read "anteriority. " (Is _that_ in your Encarta?) In the 
absence of dictionary definition, I think it's OK to rely upon conceptual 
terminology which is consistent between several schools -- National's "left 
posterior" being the same as Diversified' s "spinous right" and Gonstead's 
"PLI" (recognizing coupled motion).
3) "Lives" is most likely a typographical error, and was meant to be 
"lies." (It's all lies anyway.....GRIN) Otherwise, the instructions for 
inferiority seem straightforward enough.
4) It is quite possible for the patient to follow the given directions for 
the given rotational malposition by lying on his left pelvis and right 
shoulder. However, standing between the patient's legs in this position and 
delivering an anteriorward thrust upon the inferior transverse process would 
require the doctor to reach under the patient and deliver the "thrust" 
(pull) by contracting his triceps and rhomboids with his right arm in 
extreme external rotation. Has anyone ever seen DeJarnette do this? Gives 
a whole new meaning to the word "pretzel." I'll pass.
5) Replacing the first "posteriority" with "anteriority" renders the 
passage non-controversial. Both this action and changing the word "lives" 
to "lies" provides contextual consistency.

My 2 cents worth.....

--Noel

------------ --------- --------- ------

Sacro Occipital Technic Notes 1965 Page 56

Section Four……The Lumbar Spine

Rules to follow in adjusting the lumbar spine.

Lumbar five is in Right Rotation.

The right transverse process is anterior of normal.

In rotations, your contact is always over the posterior transverse process.

In rotation adjusting involving the lumbar vertebrae, the patient always
lies on the side of posteriority, and on the side of the active indicator in 
the cervical spine.

A right rotation of lumbar five gives a right transverse process indicator
at atlas.

Patient lies on his right side for the adjustment.

Your contact is over the left transverse process of lumbar five.

The Inferior Lumbar Vertebra

Fifth lumbar right inferior…right styloid process painful to palpation.

The patient lives on the non-painful styloid process side, which in this 
instance would be left.

In inferiorities of the lumbar spine, the patient lies on the high 
transverse side.

The low transverse process is your contact in making the adjustment.

In all lumbar five technic, your position is between the patient’s legs to 
stabilize his pelvis.

Once again, just so you won’t forget; Rotations…contact posteriortransverse 
process
…indictor cervical painful on side of rotation, which would be the 
anterior transverse process side.

Inferiorities… fifth lumbar involves styloid process as the indicator. 
Patient lies on high transverse process side with low transverse process 
side up and the styloid process indicator up.

(Note: “Posteriority” is not found in the Encarta Dictionary)

David Rozeboom, D.C, C.C., B.A.
Librarian
The Rose Ertler Memorial DeJarnette Library
Moderator
Sacro Occipital Technic Forum
8390 Delmar, Suite 1008
Saint Louis, Mo. USA, 63124

Join The Manual Medicine Group on December 14, 2008 for a Workshop on Visceral Manipulation and Its Somatic Dysfucntion Integration

an invitation to study Visceral Manipulation in the Philippines

symmetry and equilibrium in manual medicine

From: Benjamin Katz gmail.com>To: OsteopathyForAll@ yahoogroups. comSent: Saturday, 29 November, 2008 10:36:00 PMSubject: Re: Osteopathy For All Re: symmetry
Matt,
I think what I was trying to get at is that I feel it is the harmonious balance of the features that is attractive in a more symmetrical face and not symmetry per se. I would say the same of spinal curves, or of acid-base balance, or anything else. It's harmony that matters.
A harmonious system is always moving. It is in a dynamic state of balance. It never rests in the middle, but only passes through it briefly as it continually adjusts itself around this point of reference. Even our faces are always moving and often, the most beautiful and moving thing about someone's face is an idiosyncratic and asymmetrical facial expression. Take the Mona Lisa, for example.
So, symmetry and straightness are points of reference for adynamic equilibrium about which the human organism continually re-organizes itself through time. We can help our patients to reconnect with these inherent points of reference but if we impose them from outside, we risk adding unnecessary stress to their system, as we may compromise the adaptive compensations that are maintaining the system in a state of balance.
I would go so far as to suggest that the exercise programs you prescribe help your patients not because they develop new motor patterns but because in re-learning how to move, they are re-connecting with their internal points of reference. They re-discover their own sense of symmetry or balance or whatever we wish to call it and in so doing they find new and more economical adaptations and their movement can continually adjust itself around this improved sense of orientation.
Below is an abstract of an article that explores a mechanism for how this might work, from a Neuroscientific perspective. The essence of the idea is that touch healing therapies work (at least in part) by helping us to re-model our sensory maps. If anyone is interested, I could email or post the whole article.
I would be most intrigued to hear what you think of this as a possible explanation for our work.
Best wishes,
Ben
THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 13, Number 1, 2007, pp. 59–66
©Mary Ann Liebert, Inc.
DOI: 10.1089/acm. 2006.5245
Cortical Dynamics as a Therapeutic Mechanism for
Touch Healing
CATHERINE E. KERR, Ph.D.,1RACHEL H. WASSERMAN,1and CHRISTOPHER I. MOORE, Ph.D.2
ABSTRACT
Touch Healing (TH) therapies, defined here as treatments whose primary route of administration is tactile
contact and/or active guiding of somatic attention, are ubiquitous across cultures. Despite increasing integra-
tion of TH into mainstream medicine through therapies such as Reiki, Therapeutic Touch,™and somatically
focused meditation practices such as Mindfulness- Based Stress Reduction, relatively little is known about po-
tential underlying mechanisms. Here, we present a neuroscientific explanation for the prevalence and effec-
tiveness of TH therapies for relieving chronic pain. We begin with a cross-cultural review of several different
types of TH treatments and identify common characteristics, including: light tactile contact and/or a so-
matosensory attention directed toward the body, a behaviorally relevant context, a relaxed context and repeated
treatment sessions. These cardinal features are also key elements of established mechanisms of neural plastic-
ity in somatosensory cortical maps, suggesting that sensory reorganization is a mechanism for the healing ob-
served. Consideration of the potential health benefits of meditation practice specifically suggests that these prac-
tices provide training in the regulation of neural and perceptual dynamics that provide ongoing resistance to
the development of maladaptive somatic representations. This model provides several direct predictions for in-
vestigating ways that TH may induce cortical plasticity and dynamics in pain remediation.

Tuesday, November 25, 2008

what happens when you mix manual medicine and gastronomic cures?

Can you Imagine how good you'll feel when you can make immediate positive functional changes for your patients?
Once you get to that point and find the compulsion so overwhelming, you may want to sign up with us for another remarkable workshop on December 14 2008 at Pasig City? Yup, it'll be at our gastronomic home: AICA. Check out our friends at: http://aicaculinary.com/

Saturday, November 22, 2008

anatomic landmarks for lumbosacral palpation


manual medicine workshops

Hi! If it isn't clear yet, here's the deal:
It's up to you. 
Let us know what you want to learn.
Help us rank topics of interest so we know what to deliver soonest.
We're also considering accepting invites from a few schools to share what we have.
Ring us, drop us a line, send us a proposal.
This is about you, after all.

Visceral Manipulation Study Group and Workshops

Anyone else wanna learn visceral manipulation with us on December 14 2008?
Now's the time to sign up at 
assist@truecaremed.com

Or, please get in touch with Harold. His mobile number is at:
www.manualmed.bravehost.com

pending feedback, we might just make this a learning combo, with pain managment and / or sympathetic over-response ablation and / or RDT techniques.

You'll let us know, right?

Right now?

Thursday, November 20, 2008

join our study groups?

Towards A Synthesis of Manual Medicine Approaches
Spurring an Evolution in the Manual Therapy Field
The Manual Medicine Group
The RDT Study Group

Tuesday, November 11, 2008

best evidence re LBP management with manual; medicine

Segmental Spinal Mechanicss

a proposed order of examination for LS-innominate area examination

ASIS compression test

wanna learn more techniques?

Dear Colleagues,

As soon as you find yourselves even more interested in learning MM techniques with us, you may want to also start posting questions at our website.

Statins Reduce Heart Attack Risks

The cholesterol medication Crestor, manufactured by AstraZeneca, can reduce by about half the risk for heart attack, stroke and death among patients who do not have high cholesterol levels but tested positive for high levels of a protein linked with increased risk for heart attack, according to a study presented Sunday at the annual meeting of the American Heart Association in New Orleans and published online in the New England Journal of Medicine, the Wall Street Journal reports (Winslow, Wall Street Journal, 11/10).

For the study, called JUPITER, researchers led by Paul Ridker, director of the Center for Cardiovascular Disease in Women at Brigham and Women's Hospital, examined almost 18,000 patients worldwide. Participants included men ages 50 and older and women ages 60 and older who did not have histories of heart disease or high cholesterol levels. However, participants had high levels of C-reactive protein, which indicates inflammation in the body. Participants took either Crestor, part of a class of cholesterol medications called statins, or a placebo.

Researchers had planned to continue the study for five years but decided to end the study after two years because of the apparent benefits of Crestor cited by independent safety board that monitored the research (Belluck, New York Times, 11/10). According to the study, in comparison with participants who took a placebo, those who took Crestor were 54% less likely to have a heart attack, 48% less likely to have a stroke, 46% less likely to need angioplasty or bypass surgery, 44% less likely to experience any of those cardiovascular events and 20% less likely to die from any cause (Stein, Washington Post, 11/10).

Ridker is an inventor involved with patents related to CRP held by Brigham and Women's and has received grants and fees from AstraZeneca (Wall Street Journal, 11/10). Reaction
According to researchers, the results of the study could help explain the large number of heart attacks and strokes that occur in individual with normal cholesterol levels, as well as promote the use of tests for CRP levels. Elizabeth Nabel, director of the National Heart, Lung and Blood Institute at NIH, said medical groups likely will revise guidelines to recommend that physicians test patients for CRP levels and prescribe statins to those who have high levels (New York Times, 11/10).

Experts said that U.S. physicians might prescribe statins to as many as seven million more patients as a result of the study (Marchione, AP/Austin American-Statesman, 11/10). Treatment of patients with high CRP levels with Crestor or other statins could prevent as many as 50,000 heart attacks, strokes and deaths annually, experts said (Maugh, Los Angeles Times, 11/10). American College of Cardiology President Douglas Weaver, said, "This takes prevention to a whole new level," adding, "Yesterday, you would not have used a statin for patients whose cholesterol was normal. Today, you will" (Washington Post, 11/10).

However, some physicians questioned the need for treatment of all patients with no risk factors for heart attack other than high CRP levels, as few cases occur in such patients and the practice could cost as much as $9 billion annually. In an editorial that accompanied the study, Mark Hlatky, a Stanford University cardiologist, "Everybody likes the idea of prevention," adding, "We need to slow down and ask how many people are we going to be treating with drugs for the rest of their lives to prevent heart disease, versus a lot of other things we're not doing" to improve health (AP/Austin American-Statesman, 11/10).

Online The study is available online. An extract of the editorial also is available online.

CBS's "Evening News" on Monday reported on the study. The segment includes comments from Ridker, Nabel and a patient who takes a statin (LaPook, "Evening News," CBS, 11/10).

Online Washington Post reporter Rob Stein on Monday at 11 a.m. hosted an online discussion that focused on the study (Stein, Washington Post, 11/10).

Reprinted with kind permission from http://www.kaisernetwork.org. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at http://www.kaisernetwork.org/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation.

on the power of belief

Michael Neill (bestselling author & probably the world's foremost happy success coach) says that there are only two questions you really need to answer in terms of getting what you want:

  1. What do you want?
  2. What stops you?

While it really is as simple as that, there are a number of factors that can make it challenging to get "clean" answers to the "What do you want" question. Here are some of the "other factors" that I'm aware of:

  • Thinking it's not OK to want what we want
  • Thinking it's not possible to get what we want
  • The "I don't know what I want" story
  • Thinking we need to get what we want in order to be happy
  • Thinking something bad will happen if we get what we want
  • Thinking we'll become something bad if we get what we want
  • Thinking we don't deserve what we want
  • Thinking others won't approve if we get what we want

Here are some of my favourite questions for helping clarify what you really want:

  • What do you want?
  • How will you know you've got it?
  • What would you want if you didn't have to be unhappy about not getting it?
  • What would you want if you knew you couldn't fail?
  • What would you want if you knew it was OK to fail?
  • What would you want if you were guaranteed to get it?
  • What are you afraid would happen if you got what you want?
  • What are you afraid it would it mean about you if you got what you want?
  • How could you make sense of the idea that you're already getting exactly what you want, that what you're getting at the moment is actually what you want?
  • If there were a miracle tonight, & when you woke up tomorrow, everything was exactly as you want it to be, how would you know a miracle had occurred? What would you see, what would you hear, what would you feel, what would you believe, what would you experience that would let you know a miracle had taken place?

Once you get a really clear answer to the "What do you want?" questions, that's half the battle - when you allow yourself to want what you really want, you tap into a source of motivation & passion that will give you the energy you need to really take action & get what you want.

But there's a second part.

What stops you?

All too often (I'm talking about 90% of the time or more) the answer is "limiting beliefs".

  • Limiting beliefs about what's possible in this world
  • Limiting beliefs about what's possible for YOU
  • Limiting beliefs about what you're worth
  • Limiting beliefs about what you deserve
  • Limiting beliefs about what you're capable of

Of course, there are other factors - lack of money, lack of time, lack of skill. But the person who has control over their beliefs can exert a massive influence over all of these factors.

On the other hand, if you can't control your beliefs, then your beliefs are controlling you, the results you get & the quality of your experiences in life!

The person who CAN'T control their beliefs, on the other hand, is the victim of their programming... the set of unconscious beliefs & ideas about the world that they've been learning ever since the day they were born.

The Psychological Effect of our "laying of hands"

Martin,
I am going over this again because I think it it vitally important:
You say
"But would we still need the charade of doing something, in order to get the
psychological effect?"
Even if this was in jest (which it probably was) it must be clear that any form of deceit in the consultation with the patient is counter-productive. ....
You have to genuinely believe in what you are doing. Which is where our training and our science and our discipline are so important.
We have to hunt down self illusion and wooly thinking. We have to resist the the idea that rigor and training don't matter and 'so let's all get together and do healing work'.
There are many here on the forum whom embody these principles.. ..most recently Robert and David who may disagree at times but both clearly are on the same quest for truth and knowledge.
JJ


Brian -

That is a very interesting and relevant point. I always wonder how much my
patients improve because of what I do to them with my hands, and how much is
despite what I do but because i am doing it "nicely" - being reassuring,
attentive etc.

Maybe we should concentrate less on our techniques and more on being "nice".

But would we still need the charade of doing something, in order to get the
psychological effect?

Martin

--- In OsteopathyForAll@ yahoogroups. com, brian mckenna
wrote:
>
> i think it was in the book the biomechanics of LBP that they said
something like "when people consult you they are not saying they have back
pain, but that they have back pain and cannot cope any more"
> by helping them to cope through support in all its forms, manual as
well as psychosocial can we prevent them becoming chronic and or save the
NHS money by reducing care seeking behaviour?
>

------------ --------- --------- ------

"Find it, fix it, and leave it alone. But make sure you find it, make sure
you fix it, before you leave it alone!!" -Dr. Andrew Taylor Still

Placebo is Good!

Why we care to care for patients

In April, Kaptchuk et al [1] published a paper on the benefits of placebo effects for irritable bowel syndrome. Been friendly, listening to the patient, using empathy, using silence and communicating confidence and positive hope are beneficial. They have shown that 37% of patients improved after a placebo acupuncture intervention which included these previous components whereas they were only 20% with only the placebo acupuncture intervention and 3% of those on the waiting list.

This randomised clinical trial shows to what point the psychological components of care are important in improving results for functional disorders.

  1. Kaptchuk TJ, Kelley JM, Conboy LA, Davis RB, Kerr CE, Jacobson EE, Kirsch I, Schyner RN, Nam BH, Nguyen LT, Park M, Rivers AL, McManus C, Kokkotou E, Drossman DA, Goldman P, Lembo AJ. Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome. BMJ. 2008 Apr 3

Monday, November 10, 2008

it's not too late to join us

You'll join us this time on the 19 of November for our second part of the low back series, right?
Canatoy is at jhim_ptrp@yahoo.com
Manual Medicine is also on Facebook!
We are waiting for your questions at manualmed.bravehost.com

instrument-assisted connective tissue mobilization

I have discussed soft tissue lesions in this column for years, and have taken all types of courses on their evaluation and treatment. This education, and my own clinical practice, left no doubt in my mind that pressure/loading of soft tissue produces a healing effect.

What I didn't know until recently is that a relatively new treatment protocol, the Graston technique, would substantiate my experience.
Research literature has documented the effects of loading on soft tissue. We now know that we are affecting it on a cellular level from many aspects, one being the piezoelectric effect.1 Soft tissue loading causes fibroblastic proliferation that is responsible for the synthesis and maintenance of collagen, fibronectin, proteoglycans and other proteins of the connective tissue matrix. Additionally, we know there is a resorption of restrictive fibrotic tissue. Finally, there is the importance of creating a vascular disruption - necessary to initiate a new inflammatory cascade, and ultimately the remodeling stage of new collagen formation along the normal lines of stress.2-4 Tensile load is also proven to create an increase in proteoglycan synthesis and collagen synthesis in the extracellular matrix.5
However, to identify the source of soft tissue lesions, soft tissue loading must be based on accurate functional testing. Practitioners must have a method of palpating this abnormal tissue for diagnosis, and a technique for effective treatment.
Enter Graston and its stainless steel instruments. My experience with the technique during this past year-and-a-half has convinced me that our profession now has available a truly revolutionary advance in the diagnosis and treatment of soft tissue lesions.
I discussed my experiences with the instruments in a Dynamic Chiropractic article in September 2001.6 A few months before I wrote that article, the Graston staff had contacted me and sent a trained clinician to my office to demonstrate the unique effectiveness of the technique. Over the next two months, I used the instruments in my own practice and became convinced of their capacity to detect and treat soft tissue lesions. Now, after using the instruments over an extended period, my original impressions are magnified. (Currently, I instruct a 12-hour advanced course on the technique that details functional testing of soft tissue lesions and their treatment. Prior to the advanced seminar, clinicians are required to attend Module I, a 12-hour basic training lab course on the hand-holds, strokes and techniques needed to treat the various soft tissue sites of the body. This module includes indications and contraindications for use of the technique.)
My fascination with the instruments is that, although they do not reveal skin temperature, moisture and tissue layers as can the hands, they can significantly magnify what you can feel. The pads of the fingers cannot distinguish individual fibers and many hidden restrictions, but the stainless steel instruments can. It is not uncommon for me to locate with the instruments a deep fibrous restriction, bumpiness, gristle-like deposits or scar tissue that I could not have found with unaided manual palpation. The instruments leave no doubt in my mind, or that of the patient's, that a significant area needs treatment. On occasion, I may ask the patient's relative or friend who may accompany the patient to touch the instrument while I pass over the area, and even this person can "feel" the lesion by way of the vibratory sensation.
Not only do the instruments assist in identifying areas in need of treatment, which formerly were not apparent, but also in directing the clinician in the precise treatment. The instrument can be passed over the lesion in multiple directions, typically five or six, to find the usual two or three directions that create the abnormal barrier sensation. This reveals to the practitioner and the patient that if the lesion is treated in a particular direction, the treatment will be specific to provide rapid response and recovery. I have often suspected that the direct patient understanding, made possible by the instruments, helps the patient be more involved in the process and promotes more rapid recovery.
Areas of involvement proximal or distal to the lesion are essential, and must be treated. Manual palpation will not help locate many of these areas, necessitating the aid of the instruments. The technique also enhances manual treatment, which expands our effectiveness in many ways. Hamstring problems, for example, can be prevented by using the instruments passively over the hamstrings and related areas in "normal" athletes only to reveal potential minimal restrictions that may eventually result in a tear. Personally, a considerable benefit of the instruments is the reduction of wear and tear on my own hands and joints.
For years, I used a T-bar to reach difficult areas, but its effectiveness fades when compared to the six Graston instruments. Each is fashioned to conform to the anatomy of the body, and has either a single-or double-beveled edge, designed to treat specific tissue types in specific ways. The type of edge used depends on the location of the lesion, and the instrument/edge will vary depending if the lesion is in the belly, musculotendinous or insertion area of muscle/fascia, or if it is locally around a joint (maleollei, patella, greater tuberosity, etc).
This technique has permitted me to send orthopedists, internists and podiatrists reports on their patients when previous treatments have failed. These reports explain how I achieved positive results with the technique. Not only have doctor referrals increased as a result, but patient referrals have risen substantially.
References
Hammer W. Piezoelectricity, a healing property of soft tissue. Dynamic Chiropractic November 2002.
Frank CB, Hart DA. Cellular response to loading. In: Leadbetter WB, Buckwalter JA,Gordon SL, eds. Sports-Induced Inflammation: Clinical & Basic Science Concepts. Park Ridge, IL: American Academy of Orthopaedic Surgeons, 1990.
Davidson CJ, Ganion LR, Gehlsen GM, et al. Rat tendon morphologic and functional changes resulting from soft tissue mobilization. Med Sci Sports Exerc 1997;29(3):313-319.
Komuro I, Kathoh Y, Kaida T, et al. Mechanical loading stimulates cell hypertrophy and specific gene expression in cultured rat cardiac myocytes. J Biol Chem 1991;266:1268-1275.
Toyda T, et al. The effects of tensile load on the metabolism of cultured chondrocytes. Clin Orth & Rel Res 1999;359.
Hammer W. Graston technique: a necessary piece of the puzzle. Dynamic Chiropractic 2001;19(20).
Warren Hammer, MS, DC, DABCO Norwalk, Connecticut


softissu@optonline.net softissuoptonline.net

Thursday, November 6, 2008

Not everything is HVLA

HVLA techniques are not the Holy Grail they are often thought to be by novices and, sadly the frequent Joe Public. One tool does not fit all.

"My personal journey over the past 48 years, since I graduated from BCNO (now BCOM), has seen the proportion of soft tissue modality use, shift from around 50%, to around 90% of manual treatment applied.
This has not been an age related change but - I believe - one based on experience of perceived patient benefit.
Also, within that umbrella term 'soft tissue manipulation' , the methods used have moved increasingly from direct to indirect modalities."

Leon Chaitow ND DO
Honorary Fellow, University of Westminster,
Editor-in-Chief, Journal of Bodywork & Movement Therapies

Saturday, November 1, 2008

Chronic Pain Primer

Definition of Chronic Pain

CHRONIC PAIN (non-cancer pain) generally refers to intractable pain that exists for three or more months and does not resolve in response to treatment. There is some variation in terms of the required pain duration, in that some conditions may become chronic in as little as one month, while some pain specialists adhere to the six-month pain duration criteria employed in the past.

Chronic Pain VS "Psychogenic Pain"

Perhaps no other issue has done as much damage to individuals with chronic pain as this one. Many health care professionals fail to recognize the complexity of pain and believe that it can be dichotomized based on the presence or absence of physical findings, secondary gain, or prior emotional problems. As a result, countless individuals have been informed that "The pain is all in your head". And if these same individuals react with anger and hurt, we (health care staff) are ready to compound the problem by labeling the individual as hostile, demanding, or aggressive. 

In actuality, the correspondence between physical findings (e.g., MRI, CT, or X-ray results) and pain complaints is fairly low (generally, 40% to 60%). Individuals may have abnormal tests (e.g., MRI shows a "bulging disk" or a herniation) with no pain, or substantial pain with negative results. This is because chronic pain can develop in the absence of the gross skeletal changes we are able to detect with current technology. Muscle strain and inflammation are common causes of chronic pain, yet may be extremely difficult to detect. Other conditions may be due to systemic problems (e.g., HIV-related pain or sickle cell pain), trauma to nerves (e.g., post-thoracotomy pain), circulatory difficulties (e.g., diabetic neuropathy), CNS dysfunction (e.g., central pain syndromes), or many others. Yet, in each of these cases we may be unable to "see" the cause of the problem. Instead, we have to rely on the person’s report of their pain, coupled with behavioral observations and indirect medical data. This does not mean that the pain is psychogenic. Rather, it means that we are less able to detect or understand its cause. 

In actuality, healthy individuals feigning pain for secondary gain purposes are relatively rare. And in most cases, clear monetary motives will be evident. Additionally, the presence of secondary gain does not at all indicate that an individual’s pain is less "real". In this country most individuals with chronic pain receive at least some type of benefit (not necessarily monetary) for pain complaints. Therefore, exaggeration of pain or related problems is to be expected. Unfortunately, many less aware practitioners use the presence of secondary gain or pain amplification as an indication that the person’s pain is not "real".

Factors Influencing the Experience of Pain

Pain is a complex response by the organism to a number of factors. 

Physiological/Biological Factors

  • Site of injury or source of painful stimuli   
  • Intensity of stimulation/degree of tissue damage   
  • Type and density of receptors present   
  • Biologically-based individual differences in pain threshold and sensitivity   
  • Amount of competing sensory (large fiber) activity

Psychological Factors

  • Emotional status of the individual (in general, negative emotions increase pain; positive emotions reduce pain)   
  • Attentional effects   
  • Individual beliefs and expectations regarding the experience of pain (pain can be experienced with no noxious stimulation if it is expected)   
  • The individual's belief regarding their ability to establish control over the pain   
  • The individual's history of pain experiences and pain sensations (cultural and learning effects)   
  • General physical health of the person with pain

As pain duration increases, more of these factors begin to influence the experience of pain. Thus, successful chronic pain treatment often involves multiple specialties delivering a range of interventions for a variety of related problems.

Chronic Pain Assessment

The presence of chronic pain does not always mean that the individual with pain is in distress. Surprisingly, pain may be experienced, but may not be perceived as unpleasant. Therefore, when measuring chronic pain, one needs both quantitative, qualitative, and distress measures

Quantitative measures are used to judge the "amount" of pain. The best quantitative measure is a scaled self-report of pain. Many of these scales exist. They include verbal descriptive scales, nonverbal scales, scales for children, and number scales. The easiest and perhaps best-validated quantitative measure is the pain Visual Analog Scale (VAS), using either a 0-100 or 0-10 reference line. A typical 10-point VAS, and the version we use, follows:

NAME _____________________________________________

DATE _____________________________________________

TIME _____________________________________________

Place a vertical mark across the line at a point which shows what your

current pain level is. 

|----------------------------------------------------| 

NO PAIN UNBEARABLE

PAIN

The line length is 10 cm. Scoring the response simply involves measuring the distance between the "no pain" endpoint and the individual’s response, in centimeters (e.g., a score of 5.2).

Measures of tissue damage, autonomic levels, and reports of others have not been found to be very reliable or accurate quantitative measures. In fact, correlations between medical staff estimates of an individual’s pain level and the person’s own rating generally are quite low. Behavioral measures of pain (e.g., facial expressions, postural changes, etc.) are accurate but usually require much more time to score.

Qualitative measures are used to differentiate between possible etiologies. Suggestions for gathering some qualitative pain information follow:

  • Have the person describe the pain in their own terms. If they have difficulty, provide a verbal list of possible descriptors as examples (e.g., "Is the pain throbbing, aching, pulsating, cutting, burning, shooting, stabbing, pounding, or burning?").
  • Determine if it is constant or intermittent. If it is intermittent, ask how often it is present, and what, if anything, seems to trigger it.
  • Ask what makes the pain better, and what makes it worse.

Distress measures provide us with information as to how much the pain interferes with the person’s life. The more it interferes, the more unpleasant it is perceived. Distress measures include assessment of emotional distress, marital/family dysfunction due to pain, financial pressures due to pain, and a variety of other indicators.

In order to effectively diagnose and treat chronic pain we typically need to incorporate measures from all three of these pain domains (i.e., quantitative, qualitative, and distress) at a minimum. At present there are no universally accepted means of measuring these pain domains. 

Chronic Pain Syndromes

In deciding how to treat chronic pain, it is important to distinguish betweenCHRONIC PAIN and a CHRONIC PAIN SYNDROME. A chronic pain syndrome differs from chronic pain in that people with a chronic pain syndrome, over time, develop a number of related life problems beyond the sensation of pain itself. It is important to distinguish between the two because they respond to different types of treatment. 

Most individuals with chronic pain (estimates are about 75% nationally) do not develop the more complicated and distressful chronic pain syndrome. Although they may experience the pain for the remainder of their lives, little change in their daily regimen of activities, family relationships, work, or other life components occurs. Many of these individuals may never seek treatment for pain. Those that do often require less intensive, single-modality interventions. 

The 25% who do develop chronic pain syndromes tend to experience increasing physical, emotional, and social deterioration over time. They may abuse pain medications (usually narcotics and/or muscle relaxants), and typically require more intensive, multimodal treatment to stop the cycle of increasing dysfunction. Based on past VA experience, and the prevalence of other complex problems among individuals served by the VA, it is likely that the percentage of veterans with chronic pain who develop a chronic pain syndrome is higher than in the general population.

  Symptoms Of Chronic Pain Syndromes 

  • Reduced activity   
  • Impaired sleep   
  • Depression   
  • Suicidal ideation   
  • Social withdrawal   
  • Irritability   
  • Fatigue   
  • Memory and cognitive impairment   
  • Poor self-esteem   
  • Less interest in sex   
  • Relationship problems   
  • Pain behaviors   
  • Kinesiophobia, or the avoidance of certain movements or activities due to fear of reinjury or re-experiencing the pain.   
  • Helplessness   
  • Hopelessness   
  • Alcohol abuse   
  • Medication abuse   
  • Guilt   
  • Anxiety   
  • Misbehavior by children in the home   
  • Loss of employment

There are at present no empirical methods of determining whether or not a chronic pain syndrome is present. Distinctions between the two are based on clinical judgments. Generally, the more of the above symptoms the individual reports or the more severe the symptoms are, the more severe the chronic pain syndrome is. However, the above are symptoms of a chronic pain syndrome only when they are primarily or mostly due to the pain itself.  For example, individuals with a history of substance abuse or depression which preceded their chronic pain would not meet the requirement that their symptoms be primarily due to their pain. 

How Do Chronic Pain Syndromes Develop? 

As individuals try to cope with chronic pain, they adopt predictable patterns of behavior which appear to provide short-term relief. Unfortunately, the long-term effects of these patterns tends to be increased pain and more daily impairment. Typically this results from the chronic pain cycle:

pain > less activity > weaker muscles > more pain > less activity > weaker muscles

The deterioration is exacerbated by Kinesiophobia, or avoidance of certain movements or activities due to fear of reinjury or re-experiencing the pain. Kinesiophobia leads to more protective behaviors, or changes in posture, gait, or movement that reduce the pain for the short term. Unfortunately, over time they may lead to increased muscle weakness, reduced circulation, muscle spasms and inflammation, reduced flexibility, and, in some cases, muscle atrophy.

Models of Treatment

There are four primary models of chronic pain service delivery, which are based on the results of the International Association for the Study of Pain (IASP) Task Force on Guidelines for Desirable Characteristics for Pain Treatment Facilities. These models are represented both in the private sector and in the VA. 

Single service clinics or modality-oriented clinics are outpatient clinics that provide a specific type of treatment for pain but do not provide comprehensive assessment or management. Most often they are staffed by individuals from a single discipline with some expertise in a range of pain interventions falling within their areas of specialty training. Examples include a nerve block clinic, a transcutaneous nerve stimulation (TENS) clinic, or a biofeedback clinic. In general, these approaches are best suited for individuals with chronic pain, but without a chronic pain syndrome. The goal of treatment is pain reduction.

The next level of intervention occurs within a pain clinic. These outpatient clinics specifically focus on the diagnosis and management of individuals with chronic pain. They are staffed by individuals from one or more disciplines with specialized training in chronic pain. They may focus only on selected pain problems (e.g., a "headache clinic", or a "back pain clinic"), or on more general pain conditions. They may refer to outside consultants or staff for services not available within the clinic. They are most appropriate for individuals with more severe pain but without a chronic pain syndrome. However, those with mild chronic pain syndromes also may be appropriate. 

As we increase in treatment intensity and complexity, we next come to themultidisciplinary (or interdisciplinary) pain clinic This level of intervention includes a specific outpatient or inpatient program of treatment which typically includes at a minimum physical restoration, medical, educational, and psychological services delivered by an identifiable team of individuals from a range of disciplines with extensive training and experience in chronic pain interventions. These pain programs are most suited for those with mild to moderate chronic pain syndromes who require more global and intensive treatment of their pain and their related areas of dysfunction. Goals include improvement in pain, activity level, flexibility, strength, endurance, and psychosocial functioning.

The final type of treatment delivery is provided through a multidisciplinary (or interdisciplinary) pain center. The pain center is the largest and most complex type of pain treatment model, and typically is associated with a medical school or teaching hospital. Such centers offer treatment of both acute and chronic pain using a dedicated, interdisciplinary staff working in a team setting. Staff specialize in pain treatment. Unlike the multidisciplinary pain clinic, pain centers also must engage in active pain-related research and staff education. Pain centers are most appropriate for individuals with moderate to severe chronic pain syndromes, and for those with less severe pain syndromes but very complex and refractory pain problems. They also are most appropriate for individuals with chronic pain whose rehabilitation is complicated by concurrent medical or emotional problems that require closer monitoring and the immediate availability of emergent and supportive services. TheChronic Pain Rehabilitation Program at James A. Haley Veterans Hospital is the only program in the VA that currently meets the pain center criteria and is CARF-accredited (visit www.vachronicpain.org for more information).

Guidelines for pain treatment facilities are available from the Task Force on Guidelines for Desirable Characteristics for Pain Treatment Facilities of the IASP.

  Examples of Popular Pain Treatment Modalities

  • Pain medications (e.g., narcotic analgesics, NSAIDs, Tricyclic antidepressants, anticonvulsant medications, "muscle relaxants", etc.)   
  • Bed rest/braces for pain reduction   
  • Surgery   
  • Nerve blocks/steroid injections   
  • Trigger point injections   
  • Acupuncture   
  • Patient controlled analgesia pump   
  • Dorsal column stimulator implant   
  • Physical Therapy-passive modalities (e.g., ultrasound, infrared, massage)    
  • Electrical Stimulation Therapy   
  • Physical Therapy-active treatments (e.g., exercise, TENS, gait training)   
  • Manipulation   
  • Biofeedback   
  • Relaxation   
  • Group therapy   
  • Individual therapy   
  • Behavior therapy   
  • Cognitive-behavioral therapy   
  • Hypnosis   
  • Education   
  • Multidisciplinary pain management programs

Unfortunately, popularity of a treatment does not guarantee its effectiveness. It is up to the individual practitioners to determine whether a given treatment is potentially effective for the condition, and to ascertain if professional or state guidelines or standards of care governing the treatment of certain pain conditions exist. 

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