Thursday, March 5, 2015

The Dark Room of Pain

I often describe that dealing with painful movement is a lot like getting out of a dark room. There are some approaches that aren't so smart. For one, standing up and running with the hope that you end up outside of the room is probably just going to end up with you hitting a wall. On the other hand, you can't just sit in the middle of the room without moving. If you want to get out of the dark room you'll have to explore. You would get up and carefully feel for a wall and then gradually feel around until you came to something familiar like a light switch or a door.

This is like painful movement. If you just ignore the pain and go hard, you'll probably hit the wall. At the same time, if you avoid movement altogether, well then you aren't going to get anywhere. You have to thoughtfully explore the edges of your available movements, looking for opportunities for expansion.

For some people, however, the doors are stuck and may even be locked. This is like chronic pain where an exit door has proven elusive. It doesn't mean it's not there, but it's not likely to be found or opened quickly. In these cases it is a good idea to learn to function better in the dark since the alternative is to not function. So practice getting around in the dark room and learn where the coffee table is hidden so you don't keep running into it. Keep exploring too, but gain some skills in the dark because you might be there for a while.

If you live in a house where the lights have a tendency to go out somewhat frequently (recurrent episodes of pain), getting really good at exploring would be a good idea. If you've gotten good at exploring, you'll get better and better at finding the door or the light switch over time. At least you'll gain confidence that it's there.

Both exploring in the dark and learning to function in the dark have their place. Just don't confuse one for the other because they have different purposes.

Saturday, February 28, 2015

Do the Ends Justify the Means?

When people come to an opinion of pain, we can assume that they have moved into the “OK-“ side of the “OK scale perceiving that there is a challenge or threat to their homeostasis, their well-being. It is also safe to assume that their goals will involve a desire to return to “OK” or “acceptable for continued homeostasis.” They come to us for help in achieving these goals.

But what goals should WE have for the manner in which they get there?

As an example, many people in pain worry that they have various spinal misalignments and the like. And despite that fact that we know any improvements seen from care have nothing to do with these misalignments, we also know that it would be SO EASY to just do a spinal manipulation (or whatever other intervention), and let them think that they just got a bone put back in place. If they feel better, does the end justify the means? Is “it worked” enough?

The problem in this scenario is that an erroneous belief has been reinforced that this pain was the result of a bone out of place. So, the next time this person has a similar problem, they will be even more certain that this bone of place problem is real and, what’s more, it gets fixed with a specific method that only those who know the secret handshake can perform. In other words, the result is the belief that their health must be given to them by someone else. If you’re keeping score, this is bad.

 The manner in which they got to “OK” effects both their response to future bouts of “OK-“ and their dependence/independence in dealing with it. This is theft of self efficacy.
Based on the theory of social learning, self-efficacy describes the confidence the person has in his or her own ability to achieve a desired outcome (Bandura, 1977).
Self efficacy exists on a continuum:
In their paper, Self-efficacy is more important than fear of movement in mediating the relationship between pain and disability in chronic low back pain, Costa et al demonstrated that self-efficacy mediates levels of pain and disability at onset and that change in self efficacy mediates change in pain and disability. This is a big deal, folks! From the study:
We found that, when measured at the same time, both pain self-efficacy and fear of movement beliefs partially mediated the effects of pain intensity on disability at the onset of chronic low back pain. However, only improvements in pain self-efficacy beliefs partially mediated the relationship between changes in pain and changes in disability over a 12 months period.
Self efficacy is important. We better serve our patients when we preserve, establish, or even build self efficacy. We want for them to move up the OK scale, AND do so with self-efficacy.

Wednesday, February 25, 2015

The "OK" Scale

In their paper An Evolutionary Stress-Response Hypothesis for Chronic Widespread Pain (Fibromyalgia Syndrome), Lyon, Cohen, and Quintner state that
“all states of affairs salient to the organism are perceived in one of three ways: as acceptable or adequate for continued homeostasis (OK); as challenging or threatening to homeostasis (OK-); or as facilitating enhanced functioning (OK+).”
I’ve created this scale representing it as a continuum:
One such state of affairs would be a circumstance under which the question, “how dangerous is this, really?” is being considered. An answer of perceived OK- , a challenge or threat to homeostasis, would correspond with a response or output of pain along with protective behavior and narratives. The goals of our interactions are always going to be a progression up the scale with narrative and behavioral markers that correspond to the values our patients have identified as relevant.

Monday, October 31, 2011

Demonstration: Edgework for the Knee, Part 2 (Weight bearing)

Another of my video demonstrations produced by Will Stewart of 3D Optimal Performance.

Monday, October 24, 2011

Demonstration: Edgework for the Knee, Part 1

We put together another one. This one demonstrates some applications for knee pain. Enjoy!

Wednesday, September 21, 2011

The "3 Nails" of the Foot

This is a concept that I teach quite often as a way to monitor through the foot. I learned the technique in a tai chi for balance class. This is another production by Will Stewart of 3D Optimal Performance.

Monday, September 12, 2011

Demonstration: EdgeWork for the Foot and Ankle, progression to standing

This is part 2 of the series where I demonstrate the concept of EdgeWork as applied to the foot and ankle. Once again produced by Will Stewart of 3D Optimal Performance.



In case you missed it, here is part one.