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Is Pain Really A Math Equation?

January 29, 2019/in Article, Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain/by Valerie Bobb

In the January 2019, Pain Journal published an article comparing pain to the Bayes rule in math.

PAIN Symptom Perception, placebo effects, and the Bayesian brain. It suggests the brain can follow a theory of probability in math known as the Bayes rule. In statistics/math, the rule looks at the likelihood of a given hypothesis. It takes into account prior evidence, current evidence, likelihood probability of other related hypotheses and makes a prediction. The brain generates a top-down, out of our awareness, neurally encoded hypothesis about the state of us and the world. So cool!

This top-down hypothesis is met by its bottom-up sensory input. Any mismatch between the two results in a “coding error” or “prediction error” and the brain revises it’s hypotheses and prediction rules for next time. These hypotheses include those built in from evolution and the person’s personal experiences. Throughout our lifespan, they are constantly changing and updating to help predict the next set up sensory inputs. The implication of this theory is that we perceive not how the world actually is, but the brain’s best guess of it. This definitely makes sense when we think about visual perception.

In the case of chronic pain, the brain puts a high emphasis on the hypotheses generated by the brain and less precision on the sensory experience. Slight and otherwise harmless stimulus (or bottom-up experiences) cause the brain to misinterpret these as contributing to the pain and continue to modify the hypothesis to include these. Individuals without chronic pain would tend to ignore these inputs as “noise.” Conditions such as anxiety, threat, and catastrophizing have a tendency to worsen symptoms by maintaining vigilance to these predictor hypotheses.

So how does the Placebo Effect fit into this theory? The Bayesian perspective states relief of symptoms is not necessarily due to restoring bodily function but more about the lack of interference from the bottom into the hypotheses. As sensory input diminishes the hypothesis again changes. This change, however, seems to be slower if the patient does not have external cues that the change is happening. It’s almost like the brain ignores the improvement as “noise” unless there are other cues to say it’s time to revise the hypothesis. This may be why avoiding nociceptive language AND encouraging our patients that they are RESILIENT and CAN DO their important activities is so important. Your body is getting better so go ahead and revise your hypothesis! This may also be why the placebo effect works. Experiments where the patient was given analgesics in a manner that did not let them know the medications were supposed to help reported significantly less pain relief than those who were told what they were receiving.

I don’t think the article was saying anything we haven’t already approached with pain science. However, I appreciate this statistical analysis way of looking at it. Maybe it’s because I live in Seattle and there are tons of tech-driven people here, but I feel like I have one more analogy to help my patients. AND I don’t actually have to calculate any statistics!

What a Pain in the Groin!

January 21, 2019/in Article, Massage, Massage Clinic, Massage Therapist, Massage Therapy, Sport Massage, Therapeutic Exercise/by Valerie Bobb

I watch a lot of hockey….like A LOT of hockey. It seems like every offseason there are at least a handful of players having surgery for femoral acetabular impingement (FAI), “hernia” repairs and/or abdominal “tears.”

Whenever there is a huge increase in certain procedures, I’m always a little suspect whether it’s just the latest trendy thing to be done or truly necessary. In June of 2018, the Journal of Orthopedic Sports Physical Therapy even dedicated their whole issue to FAI occurrence and treatment.

It was an interesting issue that didn’t just address FAI, but a large number of complex groin pain. I realized much is the same as it was 20 years ago, but the understanding of the concurrent injury has improved.

What’s In A Name?

Complex and difficult to treat groin pain has gone by a lot of names over the years. Gilmore’s Groin, Sports Hernia, Core Muscle Injury, Athletic Pubalgia. All these different terms complicate literature searches and lead to poorly defined anatomy definitions.

It is now agreed upon to leave the term “hernia” behind because the injury usually involves the various structures that compromise the pubic and abdominal aponeurosis, but rarely a deficiency of the posterior wall.

The literature also doesn’t agree whether surgical intervention or conservative treatment is best. These patients may seek you out for pain management or while waiting for a diagnosis.

Who’s At Risk?

Males are at higher risk than females due to the narrow pubic arch angle. As well as athletes that involve high frequency of deceleration and acceleration particularly with cutting/pivoting such as ice hockey, soccer, rugby, and our military personnel.

71% can relate the pain to a reproducible, specific activity that usually involves hyperextension of the trunk and hip hyperabduction. And there is a high incident with a co-existing FAI. Athletes with limited ROM due to FAI will rely more on trunk extension and the pivot point of the pubic symphysis perhaps making them more at risk to develop tears of the aponeurosis. Repetitive pelvic motion against a fixed extremity with decreased range due to CAM or Pincer lesions may result in rectus abdominus sheath and oblique muscle fiber injuries (Strosberg et al 2016). Studies have shown if the athlete has their abdominal/groin tear repaired, but not FAI, only 25% return to sport.

However, if both are repaired 89% return to sport (Larson et al 2014).

What Do I Need To Look For?

We are not going to diagnosis an athlete with FAI or athletic pubalgia.

But what if our athlete comes to us with groin pain and we aren’t sure if it’s something muscular to treat?

What makes this diagnosis difficult is there is no great test or exam that is specific for these injuries. And studies have shown that there are potentially 17 different structure that can be involved! Common Hallmark Signs include:

Deep going or lower abdominal pain
Pain exacerbated by very specific sports activity that is relieved by rest
Palpable tenderness over a conjoined tendon or rectus abdominus insertion near pubic tubercle
Pain with resisted abdominal curl up
Pain with resisted hip abduction at 0, 45 and 90 degrees of hip flexion

And of course, if your patient isn’t responding to treatment, it’s always time to investigate further.

To Treat Or Not To Treat?

Most guidelines agree to always treat conservatively.

However, only 27% of athletes return long term to sport with conservative treatment.

Also, the length of a conservative treatment trial is somewhat controversial and inconsistent. Nature of injury, level of performance of the athlete and length of time before return to pre-injury play all need to be considered when deciding how long to have a trial of conservative treatment.

I think back to my college athletic training days and I realize there were quite a few “sports hernia” surgeries being done. So maybe this isn’t a new trend after all! However, it’s always good to remind myself of signs and symptoms and anatomy so we all make sure we are treating our patients effectively. It will, of course, be crucial for you to do your own assessment and use your critical thinking on how to progress with treatment, along with how to manage it as a conservative treatment as recommended. But at least after this hockey season is done, I’ll have my own answers as to how necessary the treatments on my favourtie players are.

References:

Cohen B, Kleinhenz D, Schiller J, Tabaddor R. Understanding Athletic Pubalgia: A Review. Rhode Island Medical Journal (2013)[serial online]. October 4, 2016;99(10):31-35.

Copperthite K. Athletic Pubalgia, Part 1: Anatomy and Diagnosis. Athletic Therapy Today[serial online]. September 2010;15(5):4-

Harris-Hayes M, Steger-May K, van Dillen LR, Schootman M, Salsich GB, Czuppon S, Clohisy JC, Commean PK, Hillen TJ, Sahrmann SA, Mueller MJ. Reduced Hip Adduction Is Associated With Improved Function After Movement-Pattern Training in Young People With Chronic Hip Joint Pain. J Orthop Sports Phys Ther. 2018 Apr;48(4):316-324. doi: 10.2519/jospt.2018.7810. Epub 2018 Mar 16.

Heerey J, Risberg MA, Magnus J, Moksnes H, Ødegaard T, Crossley K, Kemp JL. Impairment-Based Rehabilitation Following Hip Arthroscopy: Postoperative Protocol for the HIP ARThroscopy International Randomized Controlled Trial. J Orthop Sports Phys Ther. 2018 Apr;48(4):336-342. doi:10.2519/jospt.2018.8002.

Hopkins J, Brown W, Lee C. Sports Hernia: Definition, Evaluation, and Treatment. JBJS Reviews[serial online]. September 2017;5(9):e6

Larson CM. Sports Hernia/Athletic Pubalgia: Evaluation and Management. Sports Health. 2014;6(2):139-144. doi: 10.1177/1941738114523557

Munegato D, Bigoni M, Gridavilla G, Olmi S, Cesana G, Zatti G. Sports hernia and femoroacetabular impingement in athletes: A systematic review. World Journal Of Clinical Cases[serial online]. September 16, 2015;3(9):823-8

Strosberg D, Ellis T, Renton D. The Role of Femoroacetabular Impingement in Core Muscle Injury/Athletic Pubalgia: Diagnosis and Management. Frontiers In Surgery[serial online]. February 12, 2016;3:6.

Thorborg K, Reiman MP, Weir A, Kemp JL, Serner A, Mosler AB, HÖlmich P. Clinical Examination, Diagnostic Imaging, and Testing of Athletes With Groin Pain: An Evidence-Based Approach to Effective Management. J Orthop Sports Phys Ther. 2018 Apr;48(4):239-249. doi: 10.2519/jospt.2018.7850. Epub 2018 Ma

Articles Of The Week January 20, 2019

January 19, 2019/in Article, Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain/by Jamie Johnston

Coming out of college, everything seemed so straightforward! You’ve got a toolbox of techniques and you may even look to specialize in one of them, all the while helping as many patients as you can. Well, things aren’t so straightforward, and the times they are a changing. With it usually taking 17 years for new research to be applied in practice, we need to stay on top of the new and evolving research, along with a strong alliance with those patients.

“Manual Therapists: Have You Lost That Loving Feeling?” – Paul E. Mintken, Jason Rodeghero & Joshua A. Cleland

Patient centred care means different things to different people. Because it has different meanings for different people, there may also be ethical dilemmas surrounding the topic as well. This article delves into some of these topics, while also having you reflect on what this topic means to you.

“‘Patient-Centred’ – What Does It Mean And How Achievable Is It?” – Andreas Laupacis & Jennifer Gibson

Using unstable surfaces for strength training and rehab has been a popular practice for quite some time. However, does it really work? Well, it depends on the patients goals, your scope of practice, and just plain sticking to the basic principles of exercise program design.

“Is Unstable Surface Training A Waste Of Time?” – Nick Ng

He has been at the forefront of pain research over the past number of years and Peter O’Sullivan is always worth listening to. No different with this article, where it shows how he and his team are using ‘Cognitive Functional Therapy’ to treat back pain.

“The ‘Mythbusters’ Of Back Pain Believe They Can Treat It – With Words” – Liam Mannix

We published a post earlier this week about when NOT to treat a patients thoracic pain, but when you can, this is a good post. Dean goes through a few different drills and exercises to help increase thoracic rotation, most of which you can do right in your treatment room.

“Cleaning Up Thoracic Rotation” – Dean Somerset

Using “AIDET” To Successfully Communicate With Your Patients

January 14, 2019/in Article, Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain/by Valerie Bobb

In school, we are taught a list of history questions to ask patients.

But, how often do we allow patients to ask us questions? And should we?

The Journal of American Medical Association Neurology recently published an opinion commentary addressing fundamental questions every patient has but never asks. While the article is geared towards physicians, it is applicable to all healthcare providers. Keeping the patient’s concerns in mind can help solidify the relationships with our patients and improve adherence to the treatment plan.

Research repetitively shows that one of the largest predictors of successful care is the patient thinking the treatment or provider will help.

While it may seem daunting to keep these concerns in mind, many places use a simple framework called “AIDET.” It is a simple acronym that represents an easy but powerful way to communicate with people that improves connection, expectation, and compliance.

Acknowledge (use person-first language and call the patient by their preferred name. Key message “you are important”)
Introduce (who you are and what role you play in their care. Key message “you are in good hands” )
Duration (what can you expect today and in the future. Key message “I anticipate your concerns”)
Explain (who, what, why, next steps. Key message “I want you to be informed and comfortable”)
Thanks (thank the patient for taking the time to see you. Key message “I appreciate the opportunity to care for you”)

How do you think you can implement the commentary or this framework in your practice?

Link to cited article: “Five Questions Every Patient Has but Never Asks”

Articles Of The Week January 13, 2019

January 12, 2019/in Article, Massage, Massage Clinic, Massage Therapist, Massage Therapy, Pain/by Jamie Johnston

Have you ever been wrong? I have been A LOT! The question is, can you be humble enough to admit it and in turn change? Can you have intellectual humility? Well, an argument is being made that science (and healthcare) need to cultivate more intellectual humility to advance. Part of this is having a balance between our convictions and humility because we need to listen to each other.

“Intellectual Humility: The Importance Of Knowing You Might Be Wrong” – Brian Resnick

Keep in mind this post is satire! However, it makes a great point about fads in our industry. I found it funny and I hope you and your patients do too.

“Ask Dr. Dumb: All About Foam Rolling” – Mark Remy

Written by a doctor this article gives some sound advice about most things ‘fad’ in the health and wellness industry. Much of it could certainly be applied to many of the manual therapy groups boasting huge benefits to their new technique (which I have fallen for and taken courses on in the past). Wellness for us and our patients are meant to be a good thing, not a complicated explanation full of pseudoscience.

“Don’t Fall Prey To The Cult Of Wellness” – Margaret McCartney

Early in my career (and I know I’m not alone) I would always use the pain scale of 0-10, with 0 being nothing and 10 being ‘the worst pain you’ve ever felt’. In the hospital setting, doctors and nurses are saying this system doesn’t work and are trying something new. They’re using words instead and asking is the pain ‘tolerable’, having them describe the pain, talking about function, not feeling.

“Words That Matter When Talking About Pain With Your Doctor” – Patti Neighmond

Unfortunately, mental health doesn’t always get the recognition it needs (although it seems things are getting better). This seems to be an issue in sport, as athletes sometimes think they need to ‘tough it through’ a concussion, or other mental health issues. Well, we know this isn’t the case, so the question arises, if there were a simple test that showed a mental health disorder, would we treat it differently?

“What If There Were A Test That Showed The Signs Of A Mental Health Disorder?” – Dr. Tom Ungar

When You SHOULD NOT Treat Your Patients Thoracic Pain

January 7, 2019/1 Comment/in Article, Emergencies, First Aid, First Responder, Massage, Massage Clinic, Massage Therapist, Massage Therapy, Uncategorized/by Valerie Bobb

When I was in physical therapy school, PTs in the States didn’t have direct access.

I figured I needed to mainly focus on differential diagnosis of musculoskeletal issues and not worry about cancer or visceral referral pattern. However, the States slowly has been adopting direct access for physical therapy and I also learned that regardless of having a referral, physicians don’t always spend enough time with patients to properly rule out other causes.

The purpose of differential diagnosis is not to just identify a specific structure involved, but to also help determine prognosis, other psychosocial factors and to rule out serious pathology and identify conditions not appropriate for physical or massage therapy.

My patient was in her late 20’s and 6 weeks postpartum. She had been having mid-thoracic pain and right scapular pain for almost 12 weeks. Her physician sent her to therapy to receive manual therapy and strengthening.

During the examination, I had difficulty reproducing her pain, but she stated her pain was worse at the end of the day after lifting, carrying and feeding her child all day. She had weakness in her extensors and scapular retractors. Even though I couldn’t reproduce her pain, I gave her some stretching and started some scapular stabilization exercises. I figured her pain was from a sudden increase in lifting and carrying, sitting with her child and a change in her chest size.

Admittedly I treated her for 3 follow-up visits (with little change) before I realized what the problem was.

On the third visit, her husband said: “I just don’t understand why the pain is always so bad late at night.” He was more specific than she had been (end of the day). The pain was late (10 pm) and often caused his wife violent vomiting. That minute the lightbulb went on (and according to my patient I shouldn’t play poker because she knew!). I asked her if she had ever had a White or light stool, she denied it, but her husband said: “don’t you remember the one when you were pregnant?” She had a white bowel movement back when she was about 26 weeks pregnant! She had denied pain anywhere else, but the minute I palpated her upper right abdominal quadrant she jumped off the table and reported radiation to her back/scapular area.

There it was….GALLBLADDER!

She was admitted to the hospital an hour later and was in surgery 4 hours later. The surgeon said she was days away from a rupture.

Quite honestly, I felt like an ass.

I had seen her for 4 visits total before the husband had said the words that made gallbladder click in my head. I realize she had seen both her Obstetrician and her Primary Care physicians prior to coming to see me, but that did little to make me feel much better at the time. I had just started treating pregnancy and postpartum and couldn’t believe I almost missed something so important! I went back and reviewed all my red flags and visceral referral patterns after this incident.

I also share this story with every obstetrics in therapy class I teach.

Also, women and men often present differently with visceral referral patterns. For gallbladder, women tend to have more vomiting than men. Also, during pregnancy, the increase in estrogen leads to an increase in cholesterol in the bile and estrogen reduces gallbladder contractions. The decrease in contractions leads to less bile leaving and an increased risk for gallbladder stones. This can lead to severe pain and potential for infection.

Summary of Gallbladder symptoms:

Chills and/or low-grade fever
Dark colored urine
Jaundiced appearance
Light-colored stools
Nausea and vomiting (especially at night)
Stomach pain particularly after a high-fat meal
Right shoulder/scapular, mid back pain

We are never going to be perfect, but the goal is to learn from past patients and pick up on patterns faster the next time. It also helps to share our experiences. So keep these risk factors and symptoms in the back of your mind the next time your patient’s mid thoracic pain isn’t making sense!