Understanding Pain-Part 2

In my previous blog ‘Understanding Pain’, I briefly mentioned the connection between psychological stress and muscle tension.  I did not diverge down that path because the blog was focused on symptoms brought about by prolonged muscle tension. But a discussion of pain without looking at the psychological portion is hardly complete.

So let’s start with simple stress:  You hear a lion roar, and your brain reacts quickly.  Not your conscious mind but the limbic system.  This deeper part of the brain is where: short term memories are converted to long term(in the hippocampus), trauma is recorded for later recall(in the amygdala), the master control of your hormonal system resides(the hypothalamus and pituitary gland). Hormones are released to get the adrenal glands acting. Blood vessels constrict and decrease the blood supply to your skin and digestive tract to make it available to your muscles and brain. Blood pressure and heart rate go up and your immune system is suppressed. All energy goes toward surviving. If you sprain your ankle while fighting or running away, swelling won’t be noticed because healing tissue is not important now. If you survive, you can heal injuries and digest food later.  This system is built to run briefly and shut off.  When the danger is over, systems go back to normal.  But when chronic stress is involved, these reactions don’t return to normal.  Any or all of these systems can break down and send you to a specialist. Keep that blood pressure up and your cardiologist will see the damage done.  Limit the blood supply to the stomach and you won’t get the mucus coating that protects the stomach from the strong acid it must contain. So you see the gastroenterologist for ulcers. Don’t give the skin proper circulation and you are seeing the dermatologist.  Suppress the immune system, you get sick more. Then there are the muscle issues described before. 

These are the pitfalls of living with persistent stress, but the pain story runs deeper than that.  Just as a sound can initiate such a massive response, so can a smell or a memory.  Remember; past traumas have been recorded in the part of the limbic system called the amygdala. It is like the black box that records everything that happens on a plane flight. But in a human, emotional trauma and pain get recorded in that black box.  Have you ever wondered how an amputee can have phantom limb pain?  Pain can’t originate in a non-existent limb.  But it can in that black box we call the amygdala.  A signal starting there(for whatever reason) that reaches the outer surface of the brain where sensations such as itching or aching or sharp pain are mapped, will be felt just as if that signal had started in a limb.

No signals starting from below(in a limb for example) can be mapped as sensations without connecting with the limbic system along the way. But signals can start IN the limbic system without coming from below. So stress and previous physical and emotional trauma are always possible contributors to pain symptoms. A signal can start below but then get amplified or diminished in this deeper part of the brain as with a volume control on your stereo.  

For some pain sufferers, learning to recognize their feelings and memories that trigger symptoms is the major key to stopping their pain. Others, need physical treatment of guarding muscles and joints while also addressing the psychological stressors that add to the mix. In the first blog, I mentioned that resolving pain required addressing the source.  That means what starts below the limbic system(somatic and viscero-somatic) and what starts in and around the limbic system(psycho-somatic). 

The case against Evidence Based Practice

Over the last decade, the physical therapy profession has been consumed with evidence based practice. This is likely derived from an inferiority complex when comparing themselves to physicians and chiropractors. Those who determine the direction of physical therapy in the U.S. decided that better letters after a therapist’s name and a focus limited to what they felt had adequate research to ‘back it up’ would give them more legitimacy. That would make them more like doctors.

But there is a great difference between reading and digesting research with the intent to try incorporating it into a practice and throwing away useful tools because they haven’t been researched ad nauseum. The former is a logical approach to marry science and art. The latter is an arrogant and dismissive means to minimize the efficacy of the profession. A skillful and experienced therapist can use new research to prune from his repertoire those things that research indicates are marginal or feckless. Young therapists possess neither the palpatory skills nor the clinical judgement to do this. Schools now close their minds by telling them ‘this is the only way evaluate or treat this problem, and you don’t need to learn other approaches’. Feeding their egos and closing their minds greatly damages the profession.

But research is good, right? Research in the field of physical therapy(or chiropractic for that matter) is rife with flaws. For starters, it generally tries to study that which is subjective: pain. Researching back pain is quite different from researching something with more objective measures like a hormone or white blood cell count in the blood stream. Determining the group to study is a nightmare. Let’s say you want to study a treatment approach to low back pain. You could limit your study participants to only people who had a disc bulge or herniation confirmed by MRI with some frequency or chronic duration of pain episodes. But we already have research showing that a majority of people with that type of MRI result don’t have back pain. We also know that emotional states will increase back pain. Organs produce back pain. Sacroliliac dysfunction will relate to back pain. Various muscle produce back pain. If you can’t restrict your study to participants with the same cause of symptoms(disease or disorder) then what use is the study?

And where is the funding for this brave new world or research? Are pharmaceutical companies begging to get answers for what exercise or manual therapy can do? How about the NIH? Let’s face it, research in this field isn’t just hard to do. It’s not funded like the big boys either.

And last but certainly not least: What makes the evidence lovers think that condensing treatment down to one treatment approach is of use? A body is a complex system where symptoms can arise only after its ability to compensate for various problems is exhausted. I don’t look for one magic key to fit into one lock that will change the patient’s life. I use multiple approaches to identify and treat a host of different things to reach the goal. I might see a ‘back patient’ and move from the foot to the sacroiliac joint then focus on several muscles like a hip flexor(which attaches on the lumbar spine) and a leg or calf muscle. I might do all this and finish with fascial manipulation in that region or move up to treat the apposing rib cage and shoulder. I might also treat organ adhesion/scarring along with the function and drainage of the pelvic floor. Rarely ever would my treatment be limited to a regional approach like some one trick pony in a research article. Just how does someone study the efficacy of that approach?

And where has this new gold standard taken the profession of physical therapy in the U.S.? Down the road to reductionism. To a place where skilled older therapists who have been treating patients for multiple decades sit over lunch talking about how difficult they find it to hire a young therapist capable of learning. Words like ‘brainwashed’ and ‘arrogant’ generally pop up in such conversations as they lament where the profession is heading. Behold the new era where we try to wow patients with a degree and hubris instead of getting them better.

Managing patient expectations

The general population assumes that the location of the pain IS the location of the problem. But most manual therapists know that, often times, the painful region is not the site of dysfunction. The painful area is usually the area that could not adapt well to dysfunction elsewhere. It is the victim but not the criminal. When the patient paying for treatment comes into the clinic expecting treatment at an area that is not the cause of symptoms, the therapist must negotiate a solution. If not, the patient will be upset and lose faith in the therapist and this may even create a negative placebo effect. The therapist must still find and treat the actual problem, but he must do so strategically.

Solving this problem begins with taking a thorough history. As the patient describes symptoms, the therapist will ask: when they occur, are they related to any other activities, what lessens them, what treatments have worked or failed for these symptoms, what diagnostic testing was done, etc. The more questions that the therapist asks and the more he listens to what the patient has to say, the more the patient will come to trust that the therapist cares and truly knows how to do his job. The therapist should not interrupt the patient unless that patient continually wanders off the subject. But the therapist will direct the patient with open ended questions to find the important facts that the patient may not think are important.

Questions regarding what has worked and what has NOT worked in the past are one key to educating the patient during this process. For example: a patient complains of low back pain and lumbar muscular tightness that is worsened by walking but massage and joint manipulation treatments to the spine gave her only short term relief. The therapist knows that the lumbar spine and muscles could be involved but now knows that several treatments to the muscles and joints were not affective. He has not done his own assessment yet but he can gather more information and help to make the patient more receptive to his future treatment by what he says. He would like to know specifics about those treatments and those specifics will help him educate. Example: How many massages did you have? What areas did they treat? So they spent a lot of time working into the muscles but it did not change things? In this last question, the therapist is not only confirming what he has been told but he is also planting a seed of doubt in the patient’s mind. The patient might now consider that there is more to the problem then the lumbar muscles.The therapists will ask questions about the joint treatment. Example: Were joints adjusted above or below the problem?, Was the pelvis evaluated? The therapist knows that dysfunction at the pelvis can cause the same lumbar symptoms and are often worsened by walking. He wants the door open for evaluating and treating the area so he leaves those questions in the mind of the patient. It is wrong for the therapist to assume or say that he knows the problem before the physical evaluation but it is important to open the patient’s mind to the possibility that the real problem could have been missed in the past by looking in one region. If a treatment did seem to help but not resolve the problem, the therapist can help open the patient’s mind by saying: ‘it sounds like treating this area helped but there must be more to it. It sounds like several things are adding up to cause this problem’.

Even if the patient has not had failed treatment, there are still ways to help open the mind of the patient. If the patient has had any exposure to Traditional Chinese Medicine, they know that it is common to be treated with acupuncture far away from the area in question.  They have accepted that the mind and body are connected in very intricate ways but they likely still have a mental block that keeps them from seeing Physiotherapy, like TCM, should be performed to treat the body as a whole of interconnected parts…not just single part.

When the physical exam begins it is important to acknowledge where the symptoms are and touch that area. This lets the patient know that you are listening to her. Verbal confirmation helps build trust. Example: ‘yes this is tight, yes this is sensitive’. At this point, the therapist knows that he still needs to fully examine the patient but that the patient does not know what that is or why it is needed. The therapist must explain this briefly to keep the confidence that he has built. Example: ‘past treatment probably failed because no one found the biggest problem causing your symptoms, I would like to do a more extensive examination to find it’,or ‘it is very common for other parts of the body to be involved with these types of symptoms, I need to be thorough when examining you to find all of the problems’.

Even with the best communication skills, the patient may still be quite close minded. This can be frustrating for the therapist who knows human anatomy, kinesiology, neurology and various treatments and approaches that he has seen work. The patient might agree that the PT knows more about these things but still believe that he knows more about HIS symptoms and HIS body.  The therapist can use analogies that fit things that the patient already knows.  Here are just a few examples: 1. the business man: ‘if a business owner has 10 workers and 5 workers do any work, which will complain? Those who have to do twice as much work! Should the owner correct them or the 5 lazy workers? If all the workers do their own work, things will run smoothly and there won’t be complaining. The body is the same way. If we find the parts that aren’t working, then the overworked parts should stop complaining’ 2. the mother: ‘if you aren’t watching the 4 toddlers on the floor and one started screaming and crying do you wonder if another toddler caused the child to scream by hitting or taking a toy away? That is the way that I think when looking at the body. It is very common for one part of the body to feel pain because another part of the body caused the aggravation’. 3. the mechanic: ‘if the car battery dies and then you replace it but that battery dies too, do you think the problem may be somewhere else? The alternator must recharge the battery and if it doesn’t, the battery will die. The battery dying was a symptom of the problem but the alternator was the problem. The body is very similar.’

These types of analogies may bring out some of the pride that the patient has in their work which gives the therapist a chance to tie the picture together.  The business owner could say: I don’t let people like that work for me’. The PT can agree and say: ‘I wouldn’t either. And I don’t like seeing parts of the body that don’t do their jobs. I can’t fire them, but I can make them start doing their job.’  The mechanic might say: ‘it might not be the alternator but the wiring or both’. The PT can agree and say: ‘You know more about engines but I know about the human body and it is complex. I have a big list of things to look for when someone has your symptoms’. In both cases, the patient has told the therapist that he can problem solve and it opened the door for the therapist to explain that he thinks the same way but applies it to the human body.

In the end, the biggest thing to build patient confidence and lead that patient to return for another appointment is to improve symptoms. That opens the door for you to treat whatever problems you find. But building trust and changing the patient’s assumptions from the beginning of that first visit(and throughout each session) may determine success or failure.

Where have all the osteopaths gone?

These days in the U.S., people often don’t know what an osteopath is(or was). This is because they are rare indeed. Certainly many Doctors of Osteopathy(D.O.) come out of schools every year. Probably more than ever before, but are they osteopaths as we used to know of them?

Andrew Taylor Still, MD, DO was the first to be called an osteopath.  It is fair to say that he is the first true alternative medicine physician in the U.S. He was a surgeon who realized that there was more to how the body worked and how the body could be treated than was taught in medical schools back in the late 1800s. He thought the musculoskeletal system played a role in disease. He was a reformer. He had fought against slavery and then he would fight against a medical community that still used substances like arsenic, castor oil, whisky and opium as medications. He founded the first school of osteopathy in 1892 hoping for a day when physicians would still use surgery but would also utilize manipulation of the musculoskeletal system and would be more prudent with the use of drugs.  He started a revolution.  There had been forms of manual therapy long before Dr. Still.  Hippocrates wrote of joint manipulation techniques more than 2000 years prior. But it had long since been a tool of the ‘bone setter’.  It remained outside of medical consideration passed from father to son without formal education or study.  A.T. Still brought it into the hands of physicians, with an intimate understanding of anatomy, who were accustomed to the scientific method and analytical problem solving. With the advancements and mentoring provided by A.T. Still, osteopaths would follow such as: Chapman, Sutherland, Mitchell, Jones to name a few who would continue to add newer and better ways to treat disease and dysfunction.  Osteopathic manual therapy(OMT) flourished.

But this holistic revolution would take a strange turn. Over time, the system of payment in America would cause this more holistic approach to medicine to decline. Insurance companies rewarded physicians who saw more patients per hour. The age of big pharmaceuticals and paperwork had arrived.  With the growing demands of insurance filing and payment management, front office staffs soon outnumbered physicians in most medical practices.  In such a system, the days of the physician sitting and talking with a patient and assessing and treating with his hands in the office were numbered. Writing a prescription for medication and therapy and then moving to the next room to see another patient was the predictable outcome.  How else could a practice run when it needed to support a giant staff and also pay tens of thousands of dollars in malpractice insurance premiums annually?

Osteopathic physicians found that they could keep the doors of the business open and make far more money if they devoted more time to: delivering babies, doing surgeries, prescribing medicines etc. and they put much of osteopathy in the closet.  Indeed, most osteopaths in the U.S. could be characterized as ‘oreopaths’ because they are osteopaths on the outside but MDs on the inside.  And the nation’s colleges of osteopathy have moved with the times. Manual therapy and A.T. Still’s approach to looking at the body have been put on that shelf by the very institutions built to produce the D.O.

But while some of the gains made by osteopaths may have been lost, there were osteopathic physicians who did not want to see true OMT disappear.  Other manual therapists such as physical therapists and chiropractors wanted to fill that void and a handful of osteopaths felt an obligation to give what they could of OMT to the next generation.  Below are a few of those osteopathic physicians that deserve credit for decades of work passing this torch.

Loren Rex, D.O.

In 1976, the D.O. known by his friends and students as ‘Bear’ started educating licensed healthcare practicianers and did so for nearly 40 years.  While some sought to simplify and compartmentalize the osteopathic approach, Bear sought to preserve and pass along as eclectic and esoteric a body of knowledge as possible. He stayed true to the embryological approach that he had learned and taught it.

Ed Stiles, D.O., FAAO

Dr. Stiles formed a bridge from the glory days of osteopathy to the present.  The grandson of A.T. Still, George Laughlin D.O., mentored him and passed along a powerful but elegant form of treatment known as functional indirect technique. He also worked beside Fred Mitchell Sr. DO.(founder of muscle energy technique). He helped to found Pikesville College School of Osteopathic Medicine and has published research findings showing the benefits of OMT with various disease states.  He has taught OMT in seminars to physical therapists and physicians in the U.S. and Europe since 1970.

Philip E Greenman, D.O., FAAO

Dr. Greenman was a charter faculty member of the Michigan State University College of Osteopathic Medicine where he served as Professor and Associate Dean between 1972 and 2004. In that time, the late Dr. Greenman advanced research in the field and was instrumental in establishing manual medicine seminars that spread OMT not only to osteopathic physicians but also to allopathic physicians(M.D.s), physical therapists and dentists.

Understanding Pain

One general way to define Chronic pain is: pain that continues past 12 weeks, or beyond the time that it takes tissue to heal from an injury. It can be called ‘unresolved’ pain because the pain persists after the injury(if there was an injury) has healed. There are several reasons for this that are amenable to treatment.

  1. one or more factors are continuing to irritate the tissue.
  2. the nervous system has adapted in such a way that symptoms persist.

Your nervous system runs the show.  It basically provides the phone lines for messages coming in from nerve endings and messages going out to: 1. the muscles to make them contract to move your bones and change blood flow and 2. to organs such as your adrenal glands and stomach, heart, lungs etc.  The nervous system also contains the brain or your spinal cord segments that interpret the information being sent and forms a response to it which may or may not involve making your conscious mind aware of it.  They can both tell muscles to contract or hormones to be released.  In a reflex, such as when you place your finger on a hot stove, your body reacts(at the spinal cord segmental level-not the brain) and muscles contract to pull your hand away before it even registers in your brain that you have pain.

The nervous system also interprets the environment and creates the tension in the muscles as the situation requires.  You may have noticed that the tension of your muscles is quite different when you are relaxing at the beach versus when you are confronted with danger or stress.  In the latter case, your nervous system is sending more electrical impulses(higher frequency) to the muscles to cause them to tighten in readiness for fight or flight.  When stress or danger has passed, these muscle groups should come back to a more relaxed state.  But often following an injury, they do not.  They may remain stuck at the wrong level of tension as if you had set the thermostat in a house to 100 degrees.   Effective treatment of chronic pain is much like resetting thermostats throughout the body.

If the nervous system has adapted in a way that provokes symptoms, there are generally tight and tender muscles and restricted joint motion that will make this evident.  The muscle groups not only fail to function as a team (since some cannot relax and some are likely not coming on properly), but they will send messages in to the spinal cord saying that they are overworked and irritated.  We used to think that this created a self perpetuating cycle when the nervous system responded by telling the muscles to tighten more to deal with the irritation.  Research now tells us that components of the nervous system can actually physically change in response to repeated irritating signals.  Nerves become more reactive and dormant connections between nerves are awakened.  This makes the brain think that areas that are not injured or even touched are producing pain. This state can exist even when the injury is healed and there is no external stimulus causing those messages.  What’s more, the system that normally dampens pain messages as they ascend to the brain lets more messages through to reach the brain. Research also shows that by removing aggrevating factors such as myofascial trigger points and postural overloading of muscles, the system can start returning to normal.  It is important to remember that the nervous system is build to help us survive, not to help us feel great. While comfort is important to us, the nervous system is wired to protect us from the dangerous world around us and comfort doesn’t factor into it’s programming.

What can be done about chronic pain?

Find and remove the cause or symptoms don’t go away.  For example, a client complains of knee pain and an evaluation finds myofascial(connective tissue joining and incasing muscles and bones) restrictions in the thigh or lower leg and a restriction of motion at the ankle or foot joints.  Treatment would be to those areas….NOT the knee.  Treatment of painful shoulder motion would likely focus on things such as the rib cage, collar bone and reflexes rather than you exercising the rotator cuff muscles.

Re-educating (or rebooting) the patterns in the nervous system is always part of dealing with chronic or acute problems.  Osteopathic treatments developed over the last 120 years and, more recently, intramuscular manual therapy (the treatment of muscle trigger points with a needle but no medication) have proven to be tremendously powerful tools to treat chronic pain by way of the nervous system. There are also ways to trick the nervous system by using its own reflexes.  All of these techniques require identifying what patterns have arisen and dealing with them one by one in the proper order.  Treatments of medications or massage or adjustment that feel good initially, but do not last, didn’t reset that thermostat.

As the osteopathic community has taught for over 100 years, symptoms are generally found away from their root causes.  For example, if you have previously been to physical therapy for a “herniated” disc and someone used traction or encouraged you to perform exercises to alter/change that disc or if a physician injected the region with a steroid, then you experienced someone treating your “injury”.  But the best treatment might be to ribs that are not moving properly, other joints of the spine, fascial restrictions or troublesome muscles.  This is where many readers think, “but I saw the MRI and the disc IS the problem”.  So this is when I give them something to challenge their viewpoint: 40-42% of the population in the US is walking around pain free with one or more bulging and/or herniated lumbar discs.  So there is often more to the picture.

Lastly, if exercise is needed it should focus on proper patterns of muscle cooperation after improper patterns have been broken down or released.  Research now shows how pain limits muscles’ ability to strengthen.  Simply doing exercises is often a fruitless approach to pain.  If you don’t know what is wrong with the car, then you probably aren’t going to fix the problem by driving it faster.