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Ideomotor Movement in Pain Management

There are numerous approaches to hands-on treatment used by the manual therapy professions. In osteopathy, manual manipulative techniques are often broadly defined by the terms ‘direct’ and ‘indirect’. Direct technique refers to the application of external force to engage a restrictive barrier and includes mobilisation with impulse technique, MET, articulation and soft tissue massage. In contrast, indirect techniques, such as functional technique, strain-counterstrain and facilitated positional release, are generally unconcerned with restrictive tissue barriers and attempt to bring about change via reflexive somatic responses.

Movement of some kind is usually an integral feature of manual therapy for the treatment of pain. While many manual therapies consist entirely of passive movements, increasing evidence suggests that over-reliance on passive treatment or coping strategies is a strong predictor of chronicity and increased risk of disability. Active management approaches and manual therapies which incorporate active components usually involve prescriptive movements and exercises aimed at addressing specific functional goals, or at specific impairments suspected to be relevant to the clinical presentation.

American physical therapist, Barrett Dorko, has proposed a unique approach to indirect manual therapy for pain problems that has led to the development of a method described as Simple Contact. Although this approach uses similar manual handling to other common indirect osteopathic manipulative techniques, the model does not rely on hypothetical pathophysiology or detailed assessment of the patient for subtle dysfunctions that are difficult to substantiate. The intent of the method is not to introduce passive movements to the patient’s body, or to direct active movements, but to provide an environment and opportunity for the patient to explore greater expression of spontaneous, self-directed movements. Dorko’s premise is that in people with mechanically induced or maintained pain, active movement designed to reduce the mechanical deformation of the involved tissues will emerge as an instinctive and effortless movement response. This inherent activity is called ideomotor movement, or ideomotion.

A Short History of Ideomotion

Descriptions of ideomotion have been present in the medical and psychology literature since 1852, when a lecture by William Carpenter was reprinted in The Proceedings of the Royal Institution of Great Britain. Carpenter identified ideomotion as a third category of non-conscious, instinctive behaviour, which also includes excitomotor activity (e.g. breathing and swallowing) and sensorimotor activity (e.g. eye blinking and startle reactions).

Ideomotion can be described as instinctive, automatic expressions directly coupling dominant mental representations to action without intermediary volition. Ideomotor theory suggests that motor patterns can be automatically and intimately associated with their internal and external sensory effects and will occur in the absence of any other cognitive representation or efferent motor command. Although ideomotion has been commonly associated with involuntary movements, ideomotor theory also provides a compelling explanation for the generation of goal-oriented voluntary actions.

Ideomotor movements include the involuntary and unconscious movements that make up our non-verbal communication behaviours, such as facial expressions and changes in posture. Ideomotion contributes to complex tasks, such as operating a car while we focus on the road, and to write or speak the beginning of a sentence while we are mentally constructing the end of it. In addition to its expressive functions, ideomotion also has homeostatic or corrective functions, such as shifting in one’s chair or changing posture to relieve discomfort, yawning, and forward motor planning to ensure end-point comfort. Ideomotion is also responsible for many illusory perceptions, such as those experienced in dowsing, the ouija board and pendulum diagnosis, the observations of applied kinesiology, and some palpatory experiences in manipulative therapy and ‘energy work’.

The most frequent reference to the ideomotor effect in relation to common indirect manual therapies is explication of the potential error in associating palpatory confirmation of hypothetical physiology with substantiation of a theory. Some indirect manual treatment methods presuppose unsubstantiated physiological or pathophysiological mechanisms, and suggest that palpatory confirmation can offer sufficient evidence of these mechanisms. However, in accordance with the ideomotor principle, the anticipation of a sensory consequence itself can act as the stimulus which directly and involuntarily prompts the muscular movements that will produce it. Thus, expression of a desire or expectation to perceive hypothetical body functions, such as cerebrospinal fluid rhythms, tissue ‘unwinding’ or ‘energy’, can result in the practitioner subconsciously generating internal movements and sensations that match the practitioner’s envision.

However, in the absence of anticipatory projections from the practitioner, gentle, non-provocative palpation can reveal a great deal of subtle, involuntary movement within the patient. Considering the fact that expressive and corrective ideomotor movements, large and minute, can occur almost continuously in humans unless consciously suppressed, it is possible that ideomotor activity is responsible for a significant proportion of the subtle tissue alterations observed by practitioners using some indirect techniques. Knowledge of the presence and purpose of ideomotor activity should inform our understanding and interpretation of such observations.

Ideomotion and Pain

According to the contemporary neuromatrix theory of pain, the sensations of the pain experience and accompanying motor responses coexist simultaneously as two dimensions of a multi-system output response. The perception and localisation of pain sensations occur concurrently with the generation of motor output responses designed to resolve the perceived threat to tissues. Patrick Wall has proposed that the resolution of pain thus requires an appropriate motor response, and that such a response may proceed as the result of inherent mechanisms. If this instinctive process is interrupted then guarding, altered posture and continued pain may ensue. Dorko has noted that ideomotor movements constitute the predominant expression of instinctive movement response to both internal and external stimuli in humans during their daily activities. He suggests that enhancement of the expression of ideomotion should lead to the reduction of mechanical pain in patients whose instinctive responses have been inhibited or suppressed, and are thus experiencing continuing symptoms.

Ideomotor movements are expressed to their maximum degree unless there is an antagonistic motor representation present simultaneously in the mind. In his 1890 text, Principle of Psychology, William James explains that unless conditions are simple, full ideomotor expression is often dependent on a mental consent, or permission. Dorko argues that spontaneous bodily expression may be inhibited in the context of culturally acceptable expressions of movement or suppressed by prescriptive body expression, for example, postural correction training. Such external demands may result in the generation of simultaneous ‘antagonistic representations’ that distract authentic, spontaneous expressions of movement and thus manifest as isometric muscle contraction. Dorko has suggested that such muscle activity is commonly misinterpreted as a lack of appropriate relaxation, and may then be subjected to various forms of stretching, manipulation or choreographed exercise, rather than being encouraged to complete the motor response for which it was activated. The method described by Dorko endeavours simply to provide a context of ‘permission’ in order to encourage greater expression of ongoing ideomotor activity.

During ideomotor movements the sensory effects, such as the kinaesthetic and interoceptive sensations that may accompany each movement, are directly coupled with the generation of the movement itself. Thus a kinaesthetic representation of a position that may be associated with reduced pain sensation, or stretch of a stiffened tissue, will be automatically coupled to the movement that produces the represented sensation. The pathway from sensory effect representation to movement may also involve feedback from the peripheral sensory apparatus at levels below attention, and this sensory input may facilitate the elaboration of motor patterns at higher levels. Alterations in motor output during the movement may be generated by continuing sensory effect representations and may be influenced by both conscious and non-conscious peripheral sensory feedback, thus resulting in the complex movement patterns seen during the many expressions of ideomotor movement. Since varying interoceptive sensations may be perceived with even minute alterations in motor output (e.g. muscle relaxation), in some instances movements may not be visible, though they will often still be palpable.

Ideomotion as Therapy

Ideomotion is the somatic expression of mental imagery, attention or thought; therefore, it is always present in conscious patients. The goal of ideomotor therapy is simply to make the patient aware of this spontaneous internal activity and then allow it to proceed unhindered. Thus the patient is not directed to do any particular movement; rather they are encouraged to cease restraint of any ongoing ideomotor activity. Manual contact from the practitioner need only be just enough to be felt and draws the patient’s awareness to the slightest indication of ideomotor activity. Following the patient’s body with very light contact encourages more pronounced expression of these movements. It is suggested that the attitude of the practitioner toward the ideomotor movement should be one of quiet acceptance and interest, maintaining contact but avoiding inhibition or guiding in any way.

The expression of ideomotion during treatment may be quite striking, involving very slow, arrhythmic, large-range movements of the trunk, neck or limbs. This response is particularly common when the patient is standing or seated. In the supine position, movement is restricted in many directions and the response is not consistently perceptible from a visual point of view; however, palpable movements and changes in breathing and muscular tension are frequently observed. One of the dominant characteristics of ideomotion is a sense of disassociation with conscious volition behind the movement. Patients often express surprise that their body has begun to move and will either assume that the practitioner is moving them or express a sensation that some internal mechanism separate to their ‘will’ is responsible. It is possible that a significant advantage to the use of non-volitional movement in the treatment of pain is that subconsciously generated movement may bypass conscious fear-related cognitions responsible for some functional movement impairments resulting from pain.

simple contact osteopathy

Barrett Dorko facilitating ideomotor expression though gentle manual communication

Many patients experience a rapid onset of warmth throughout the skin over the spine, face, upper limbs and/or the feet, accompanied by pronounced sweating during treatment. Adoption of a deep breathing pattern may also be noted. These phenomena often commence early during the treatments and suggest a marked alteration in sympathetic tone. Such observations are considered typical by practitioners using this approach. It has been noted anecdotally that these overt reactions are commonly associated with favourable outcomes.

Rationale for Ideomotion in Manual Therapy

Motor output as a dimension of pain generally serves to both promote evasion and to limit provocation of the painful area. Evidence from PET studies suggests that cortical and subcortical motor mechanisms become activated in anticipation of movements intended to escape the noxious stimulation. For example, the premotor cortex has been shown to be significantly activated during noxious stimulation, even though the patient is stationary. However, modulation of nociception occurs at all levels of the neuraxis, generating the multidimensional experience of pain involving sensory-discriminative, affective-motivational, cognitive, autonomic, and motor components. While ideomotor responses to pain may primarily serve to decrease or resolve noxious mechanical peripheral input, additional central mechanisms may be involved in producing pain modulation during the therapy.

Nociceptive inputs can be modulated in the CNS by other sensory inputs or by descending inhibitory influences. Facilitating mechanically non-aggressive, large-range novel movements could have therapeutic effects on central mechanisms of pain on the basis of threat reduction. The application of non-threatening and supportive touch, the emergence of novel movement patterns or the unusual sensation of non-volitional movement may facilitate inhibitory modulation via the sensory-discriminative pathways of pain. The patient-oriented approach and non-threatening context of ideomotor therapy, as well as the learning of a new self-management technique might alter affective-motivational and cognitive components. Commonly observed clinical changes, such as pronounced warmth, sweating, muscle relaxation, and deeper breathing, suggest that autonomic modulation is also involved. Non-specific and placebo mechanisms must also be considered.

Since chronic musculoskeletal pain infrequently presents at a single site of the body. Carnes et al. (2007) have suggested that in the presence of non-specific pain at multiple-sites, assessment and intervention targeted specifically at a single pain site may be inappropriate and may fail to have a significant effect on overall pain and disability. Patients presenting with multiple-site pain may gain greater benefit from less site-specific interventions. Ideomotor-based treatment typically precludes attempting to isolate treatment to a single area of the body. Although further investigation is necessary, ideomotor-base physical therapy may be a more reasonable alternative to more traditional compartmentalised manual treatments for complex, multiple-site pain presentations.

Further, it is evident that assigning the acquisition and maintenance of skills necessary for functional independence to patients rather than practitioners is highly beneficial. Although the ideomotor-based therapy involves manual contact, the resulting movements are entirely active. Once a patient has become familiar with the process of permitting spontaneous, non-prescriptive movements guided by their own kinaesthetic and interoceptive experience they can proceed independently. Consequently, it is possible for the patient to achieve similar effects from the manual intervention process on their own as they do in the presence of the therapist, thus reinforcing active coping and self-efficacy.

References:

1. Ward R (Ed). Foundation for Osteopathic Medicine. 2nd Ed. Lippincott, Williams & Wilkins, Baltimore. 2003.
2. Dorko B. The Analgesia of Movement: Ideomotor Activity and Manual Care. J Osteopathic Med. 6:93-95. 2003.
3. Dorko B. (n.d.) Without Volition: The Presence and Purpose of Ideomotor Movement. Retrieved 13th March 2006 from: http://www.barrettdorko.com/articles/ideomotor.html
4. Carpenter WB. On the Influence of Suggestion in Modifying and Directing Muscular Movement, Independently of Volition. Proceedings of the Royal Institution of Great Britain. 1852. 1:147-53.
5. James W. Principles of Psychology. Holt, New York. 1890.
6. Dorland WAN. Dorland’s Medical Dictionary. 30th Ed. WB Saunders, Philadelphia. 2003.
7. Spitz H. Nonconscious Movements: From Mystical Messages to Facilitated Communication. Lawrence Erlbaum Associates Inc, New Jersey. 1997.
8. Lehmann HD. Yawning A. Homeostatic Reflex and its Psychological Significance. Bull Menninger Clin. 1979. 43:123-36.
9. Rosenbaum DA, van Heugten CM, Caldwell GE. From Cognition to Biomechanics and Back: The End-State Comfort Effect and the Middle-Is-Faster Effect. Acta Psychologica. 1996. 94:59-85.
10. Hyman R. The Mischief-Making of Ideomotor Action. Sci Rev Alternative Med. 1999. 3(2):34-43.
11. Hall H. Wired to the Kitchen Sink: Studying Weird Claims for Fun and Profit. Skeptical Inquirer: May 2003.
12. Hartman SE, Norton JM. Interexaminer Reliability and Cranial Osteopathy. Sci Rev Alt Med. 2002. 6:23-34.
13. Weigelt M, Kunde W, Prinz W. End-State Comfort in Bimanual Object Manipulation. Exp Psych. 2006. 53:143-8.
14. Keller P, Wascher E, Prinz W, Waszak F, Koch I, Rosenbaum DA. Differences between Intention-Based and Stimulus-Based Actions. J Psychophysiology. 2006. 20:9-20.
15. Kunde W, Elsner K, Keisel A. No Anticipation-No Action: The Role of Anticipation in Action and Perception. Cogn Process. 2007. 8:71-78.
16. Stock A, Stock C. A Short History of Ideo-Motor Action. Psych Research. 2004. 68:176-88.
17. Melzack R. Pain and the Neuromatrix in the Brain. J Dental Ed. 2001. 65:1378-82.
18. Moseley GL. A Pain Neuromatrix Approach to Patients with Chronic Pain. Manual Therapy. 2003. 8:130-40.
19. Wall P, Melzack R (Eds). The Textbook of Pain. 4th Ed. Churchill Livingstone, London. 1999. 1305-6.
20. Wall, P. Pain: The Science of Suffering. Columbia University Press, New York. 2000. 146-52.
21. Gove PB et al. (Eds). Webster’s Third New International Dictionary of the English Language. Merriam-Webster Inc, Springfield. 2002.
22. Wyman-McGinty W. The Body in Analysis. J Analytical Psych. 1998. 43:293-60.
23. Steckler LH. Somatic Soulmates. Body Mov & Dance in Psychotherapy. 2006. 1:29-42.
24. Dorko B. (n.d.) The Origins of Simple Contact. Retrieved 13th March 2006 from: http://www.barrettdorko.com/articles/origins.html
25. Butler DS, Moseley GL. Explain Pain. Adelaide: NOI Group Publications. 2005.
26. Crombez G, Vlaeyen JWS, Heuts PH et al. Pain-Related Fear Is More Disabling Than Pain Itself. Evidence on The Role of Pain-Related Fear in Chronic Back Pain Disability. Pain. 1999. 80: 329-40.
27. Casey KL. Forebrain Mechanisms of Nociception and Pain: Analysis through Imaging. Proc National Acad Sci (USA) 1999. 96:7668-74.
28. Svensson P, Minoshima S, Beydoun A, Morrow TJ, Casey KL. Cerebral Processing of Acute Skin and Muscle Pain in Humans. J Neurophysiol. 1997. 78:450-460.
29. Riedel W, Neeck G. Nociception, Pain and Antinociception: Current Concepts. Z Rheumatol. 2001. 60:404-15.
30. Kerr CE, Wasserman RH, Moore CI. Cortical Dynamics as a Therapeutic Mechanism for Touch Healing. J Altern Comp Med. 2007. 13:59-66.
31. Zusman M. Cognitive-Behavioural Components of Musculoskeletal Physiotherapy: The Role of Control. Physical Therapy. 2005. 10:89-98.
32. Mercado AC, Carroll LJ, Cassidy JD, Cote P. Passive Coping Is a Risk Factor for Disabling Neck or Low Back Pain. Pain. 2005. 117:51-57.
33. Blyth FM, March LM, Nicholas MK, Cousins MJ. Self-Management of Chronic Pain: A Population-Based Study. Pain. 2005. 113:285-92.
34. Furlan AD, Brosseau L, Imamura M, Irvin E. Massage for Low-Back Pain: A Systematic Review within the Framework of the Cochrane Collaboration Back Review Group. Spine. 2002. 27:1896-910.
35. Gross AR, Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, Bronfort G. A Cochrane Review of Manipulation and Mobilization for Mechanical Neck Disorders. Cervical Overview Group. Spine. 2004. 29:1541-48.
36. Kay T, Gross A, et al. Exercises for Mechanical Neck Disorders. Cochrane Database Syst Rev. 2005. 20:CD004250.
37. Brooks C. Sensory Awareness: The Rediscovery of Experiencing. The Viking Press, New York. 1974.
38. Fortrat JO, Formet C, Frutoso J, Gharib C. Even Slight Movements Disturb Analysis of Cardiovascular Dynamics. Am J Physiology. 1999. 277:H261-7.
39. Cole J. On the Relation between Sensory Input and Action. J Motor Behav. 2004. 36:243-44.
40. Knoblich G, Prinz W. Linking Perception and Action: An Ideomotor Approach. In: Freund HJ, Jeannerod M, Hallett M, Leiguarda R (Eds). Higher-Order Motor Disorders: From Neuroanatomy and Neurobiology to Clinical Neurology. Oxford University Press, Oxford. 2005. 80-81.
41. Carnes D, Parsons S, Ashby D, Breen A, Foster NE, Pincus T, Vogel S, Underwood M. Chronic musculoskeletal pain rarely presents at a single body site: results from a UK population study. Rheumatology. 2007;46:1168-70.
42. Blyth FM, March LM, Nicholas MK, Cousins MJ. Self-management of chronic pain: a population-based study. Pain. 2005;113:285-92.
43. Mercado AC, Carroll LJ, Cassidy JD, Cote P. Passive coping is a risk factor for disabling neck or low back pain. Pain. 2005;117:51-57.
44. Butler DS, Coppieters MW. Neurodynamics in a broader perspective. Manual Therapy. 2007;12:e7-8.

osteopathy treatment

Tackling Pain in People Living With HIV/AIDS

Pain management doesn’t end with medication. Education, empowerment and self-care are equally important factors in effective pain management.

Pain is very common in people living with HIV, with self-reported pain rates across different settings ranging from 35% up to 91%.1 While there is evidence supporting a relationship between increased pain and decreasing CD4+ T cell counts a significant number of people with an undetectable viral load also experience pain.1 Pain remains a serious problem in HIV management despite effective antiretroviral treatment (ART) and some types of painful conditions are associated with increased prevalence with ART, especially peripheral neuropathy. Other risk factors for increased reports of pain are alcohol consumption, smoking, IV drug use, depression and anxiety, and co-illnesses like diabetes and hepatitis.2

People living with HIV can experience pain from a variety of different causes. The most common problems reported include pain associated with peripheral neuropathy, headache, abdominal pain, chest pain, generalised muscle pain, joint pain, anorectal pain and oral or pharyngeal pain.3 Women with HIV may experience pain more frequently and, similarly to the general population, more intensely than men.4

Early treatment era studies suggested that health providers often underestimated pain in patients, however, the burden of chronic pain in people living with HIV has since become increasingly acknowledged within HIV/AIDS healthcare guidelines. Despite this, a solid body of evidence for the effectiveness of pharmaceutical pain management based on current guidelines is still lacking and while this is still the mainstay of pain treatment for people with HIV many report only modest relief from pain medications.1

Pain is Complex

The challenges of providing pain relief are not unique to HIV+ people. Around 20% of the general population suffers chronic pain. The frustrations in ensuring effective pain management provision in Australia have lead to the development of a National Pain Strategy, published in 2011.5

The complexities that patients and health providers face in getting chronic pain under control are largely a consequence of the complexities of pain itself. The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience, associated with actual or potential tissue damage, or described in terms of such damage.”6 One of the main intentions of this definition is to make it clear that pain is an entirely individual and subjective experience. Pain is now understood as a category of complex experiences involving a composite of sensory, motor, autonomic, endocrine, immune, cognitive, emotional and behavioural components. The experience of pain is produced by our brain in response to a perceived threat to the safety of the body as a whole: it is not simply just an awful sensation in response to damaged tissues.

The last two decades of research into the nature and causes of pain have demonstrated very strong support for a model of pain and its treatment that considers the physical, psychological and socio-environmental dimensions of pain. This is commonly referred to as the ‘biopsychosocial’ model. Brain imaging studies supporting this view of pain have shown that diverse areas of the brain are activated in different ways in different people experiencing apparently the same physical stimulus.5 The biopsychosocial model also indicates that the assessment and treatment a person suffering pain must both acknowledge the individual experience and carefully address each of the relevant dimensions contributing to the pain. The National Pain Strategy document highlights that “this often means that more than one category of health professionals will be required to make a full assessment and to communicate with each other to weigh up the relative contributions, enabling selection of the most appropriate treatment or treatments in an interdisciplinary approach.”

Taking Control

There is also now convincing evidence that when people suffering with chronic pain, and their supporters, are educated and empowered they experience less pain and psychological distress.5,7 Self-management approaches encourage patients and their supporters to take an active role in the management of their condition. When people are engaged in ‘active’ self-management programs they tend to suffer less pain and associated disability than those receiving only ‘passive’ treatments.5 For example, in a randomised trial comparing the use of a targeted symptom specific strategy manual with general information manual for symptom management in people living with HIV, the researchers reported a significantly greater decline in symptom frequency and intensity in the group using the symptom specific management manual.8

Self-management strategies offer important and effective approaches to limiting pain and other negative effects of HIV.8 While it is critical to treat both the disease and secondary illnesses underlying ongoing pain directly, there is also evidence that effective symptom management can improve virologic suppression and adherence to treatment.2 Self-care strategies may also have more direct health benefits, for example, in a systematic review of massage therapy for people with HIV/AIDS conducted in 2010 the reviewers concluded that in addition to improving quality of life scores there was preliminary evidence that massage therapy may have a positive effect on immunological function.9 Regular aerobic exercise can result in significant improvements in cardiopulmonary fitness, body composition, and psychological health and depression – a significant amplifier of pain-related distress.10

Self-Care That Works

Three surveys of self-care strategies and symptom management used by people with HIV-related painful peripheral neuropathy have shown that a broad variety of approaches may be helpful in relieving pain and discomfort.11 The most commonly used strategies were taking a hot bath, rest, elevating the feet, walking and massage. The surveys also asked people to rate the effectiveness of self-care strategies. Those with the highest rating of effectiveness included taking a hot bath, rest, walking, exercise, massage and meditation. Interestingly, while taking over-the-counter pain medications is also a frequently used strategy, this was not as effective as the above approaches. Although it was only used by 20% of the respondents, meditation was consistently rated as the most effective strategy.

In addition to standard pharmacological treatments, how do these commonly used self-management strategies square with other evidence of effectiveness in the management of pain? Ideally, assessing the evidence of effectiveness of a treatment should take into account the people to which the results are intended to apply. Unfortunately, there isn’t enough research in HIV+ people available to make conclusive recommendations; however, several of these approaches have been studied extensively in other chronic pain populations.

Meditative movement therapies like tai chi and yoga have been strongly supported in evidence reviews for pain management in chronic pain syndromes.1,13 Aerobic exercise is also an important component of self-care for people with HIV.10,14 There is moderate evidence in support of various forms of massage for some of the pain problems that people with HIV may suffer.1,9,14 Nerve massage and mobilisation of the peripheral nerve tissue has been shown to help people suffering diabetic neuropathy15 and may also be appropriate in HIV-related sensory neuropathy. This is best performed by a physiotherpists or osteopath with training in neurodynamic manual treatment. A growing body of research is showing that practising mindfulness meditation can be immensely helpful for people with persistent pain.12 Meditation can even be as effective as participating in multidisciplinary group pain rehabilitation programs in improving coping ability and other functional outcomes.16

Catalysts to Patient Empowerment7

• Knowledge
• Understanding
• Information (including side effects of treatment or medication)
• Right environment
• Right attitude (mutual trust and respect, and collaboration)
• Availability of resources (including time)
• Healthcare professionals who have been educated in chronic pain management

Getting pain under control is challenging, and often it’s a moving target. Because your pain is unique to you, effective management will be unique to you too. Understanding pain, being educated and empowered, and taking an active role in your health is the best place to start.

(Article originally written for Positive Living Magazine)

References:

1. Newshan G, Staats JA. Evidence-based pain guidelines in HIV care. J Assoc Nurses AIDS Care. 2013; 24: S112-26.
2. Merlin JS et al. Pain and physical and psychological symptoms in ambulatory HIV patients in the current treatment era. J Pain Symptom Manage. 2012; 43(3): 638-45.
3. Hewitta DJ, McDonald M, Portenoya RK, et al. Pain syndromes and etiologies in ambulatory AIDS patients. Pain. 1997; 70(2–3): 117–23.
4. Richardson JL, Heikes B, Karim R, Weber K, Anastos K, Young M. Experience of pain among women with advanced HIV disease. AIDS Patient Care STDS. 2009; 23(7): 503-11.
5. Available at: http://www.painaustralia.org.au/the-national-pain-strategy/national-pain-strategy.html
6. Merskey H, Bogduk N. (eds). Classification of Chronic Pain, Second Edition. IASP Task Force on Taxonomy, IASP Press. Seattle, 1994. Available at: http://www.iasp-pain.org/Content/NavigationMenu/GeneralResourceLinks/PainDefinitions/default.htm
7. Barrie J. Patient empowerment and choice in chronic pain management. Nursing Standard. 2011; 25(31): 38-41.
8. Wantland DJ, Holzemer WL, et al. A randomized controlled trial testing the efficacy of an HIV/AIDS symptom management manual. J Pain Symptom Manage. 2008; 36(3): 235-46.
9. Hillier SL, Louw Q, Morris L, Uwimana J, Statham S. Massage therapy for people with HIV/AIDS. Cochrane Database Syst Rev. 2010; 1: CD007502.
10. Nixon S, O’Brien K, Glazier RH, Tynan AM. Aerobic exercise interventions for adults living with HIV/AIDS. Cochrane Database Syst Rev. 2005; 2: CD001796.
11. Nicholas PK, Voss J, et al. Prevalence, self-care behaviors, and self-care activities for peripheral neuropathy symptoms of HIV/AIDS. Nurs Health Sci. 2010; 12(1): 119-26.
12. Reiner K, Tibi L, Lipsitz JD. Do mindfulness-based interventions reduce pain intensity? A critical review of the literature. Pain Med. 2013; 14(2): 230-42.
13. Langhorst J, Häuser W, et al. Complementary and alternative therapies for fibromyalgia syndrome. Systematic review, meta-analysis and guideline. Schmerz. 2012; 26(3): 311-7.
14. O’Brien KK, Nixon SA. Evidence-Based Management of an Individual Living with HIV. Physiother Can. 2010; 62(3): 202-5.
15. Kumar SP, Adhikari P, Jeganathan PS, D’Souza SC. Immediate effects of nerve sliders and nerve massage on vibration and thermal perception thresholds in patients with painful diabetic peripheral neuropathy- a pilot randomized clinical trial. Physiother Occup Ther Journal 2010; 3(2): 35-49.
16. Reiner K, Tibi L, Lipsitz JD. Do mindfulness-based interventions reduce pain intensity? A critical review of the literature. Pain Med. 2013; 14(2): 230-42.

The Pleasure of Learning

According Irving Biederman of the University of Southern California and Edward Vessel of New York University, the process of acquiring new knowledge might actually be analgesic. Beiderman and Vessel believe that humans have an innate drive for information–we are ‘infovores‘–and they think that the same brain mechanisms which control pain and reward are responsible.

The brain is wired for pleasure

That the human brain has information-acquisition mechanisms which reward us for learning about our environment should not surprise us – such mechanisms would have an obvious evolutionary advantage. If ‘infovorous’ behaviour is advantageous it would follow that the brain has developed mechanisms which actually encourage information-seeking behaviour.

Beiderman and Vessel explain that mu-opioid receptors, which are involved in the modulation of pain and reward, are found in increasing density along the neural pathways responsible for visual and auditory processing, perceptual association and memory. Neural activity in these areas results in the release of endomorphins and subsequent stimulation of the mu-opioid receptors, which causes feelings of pleasure. Since the density of mu-opioid receptors increases along the processing pathway, information that contains lots of interpretable information will result in the greater stimulation of opioid receptors in the later stages of association processing and will therefore provide the greatest pleasure.

Understanding new information is key

Unless we are satisfying hunger or sexual drive, avoiding harm or are engaged in some other goal-directed behaviour our hunger for information is active, and boredom sets in pretty quickly when this drive is even moderately starved. We crave a constant supply of new and engaging information. When we are repeatedly exposed to the same stimulus pattern, like watching a movie for the fourth time, only a fraction of the same neurons active the first time will respond and the potential for pleasure diminishes.

Although humans have a preference for experiences that are both novel and richly interpretable, we can also derive increased pleasure with repeated exposure to the same information if we have not yet understood it. Beiderman and Vessel suggest that the pleasure derived from new information peaks at what they call the “click” of comprehension. According to the researchers, “the click corresponds to the release of endomorphins in the association areas as the brain makes rich connections with stored information”. Once we have understood the subject our preference for ongoing exposure declines, which reduces endomorphin release on the next exposure.

Maximise the pleasure of your addiction to learning

The brain’s craving for pleasure has ensured that the infovore system is designed to maximise the rate at which we absorb information. However, to maximise the pleasure derived from acquiring new information we need stimuli that are both novel and highly interpretable, and we need it as fast as we can comprehend it. This “preferred rate” of information exposure may correspond to the maximal release of endomorphins, explaining why information that is presented much more slowly than the rate of comprehension typically causes boredom or frustration instead of pleasure. Remember surfing the web with a dial-up modem? Information may also be presented faster than we can comprehend it, which is common when learning something complex, but anticipation of the rush when you ‘get it’ presents a powerful incentive to keep plugging away.

 

If Beiderman and Vessel’s work is accurate, then the human craving for information might compel the creation of a media that is immediately available, offers an endless variety of new and engaging information, provides ample opportunity for interpretive challenge, and can be delivered at rates according to individual preference.

Sounds a lot like the internet to me.

___

Ref: Biederman I, Vessel E. A. Perceptual pleasure and the brain. American Scientist. 2006;94:247-53.

Placebo: the Meaning Response

Understanding which components of the therapeutic encounter are valuable in producing positive responses to a health care intervention is an important responsibility of every health profession. The ability to produce specific treatment effects that intervene directly with the presenting dysfunction or pathology is the conventional aim of health care practice, and maximising these effects is usually viewed as providing optimal care.  Positive responses that are unrelated to these specific effects, or even occurring in the absence of them, are often also present but these are dismissed as the result of placebo effects.

Although the potential for placebo responses is a ubiquitous feature of all health care practices, placebos are usually referred to as irrelevant and unintended side-effects. It is only by subtracting the magnitude of change produced by placebo responses that the ‘real’ value of any treatment may be revealed. When ‘real’ effects are considered an impossible consequence of the intervention, the intervention is designated a sham-or a scam. However, placebo responses often result in very meaningful for changes for the patient, and since meaningful positive change is the primary motivation for seeking care, this must reconciled with the professional responsibility to provide definite therapeutic inputs.

It is now well recognised that placebo effects occur in response to the contextual components of the therapeutic encounter and the patient’s individual interpretation of these. Unless we intend to resurrect Cartesian dualism, placebo effects must be understood as arising from brain effects, i.e. processing within the central nervous system has changed in some way. Therefore, placebo is not something that is ‘administered’. It is a response that emerges from the patient.

The clinical potency of therapeutic responses dependent on the contextual components of therapy is malleable. For example, Ted Kaptchuk’s team have demonstrated that sham acupuncture is associated with significantly greater reduction in pain intensity and symptom severity than placebo pills for repetitive-use arm pain. Culture, social circumstances, personal history, individual predilections and expectations all shape the patient’s interpretation of the significance of the illness experience and that of the particular treatment process. According to Moerman and Jonas, placebo responses occur when the meaning of the illness experience has changed. They have even proposed that the placebo response may be more accurately termed the meaning response.

Meaning is enhanced via story, and the stories we tell patients about their illness and the treatment we prescribe can have a significant effect on the perception of these experiences. A classic example of this was seen in a study by Moseley et al., which demonstrated that teaching patients about the neurophysiological mechanisms responsible for their pain, particularly the tenuous relationship between pain intensity and tissue damage, resulted in immediate improvements in functional performance. The same education has been demonstrated to result in widespread alteration of brain activity characteristic of the pain experience.

Although there is no doubt that any story and subsequent treatment that is consistent with an individual’s expectations and/or is sufficiently convincing as an appropriate intervention will increase the likelihood of meaningful placebo responses, many argue that stories and accompanying treatments that are inconsistent with objective understanding of human function are unhelpful at best and dangerous at worst. Moerman and Jones write,

“by focusing on placebos, we constantly have to address the moral and ethical issues of prescribing inert treatments, of lying, and the like. It seems possible to evade the entire issue by simply avoiding placebos. One cannot, however, avoid meaning while engaging human beings.”

However, giving inert treatments is not identical to using the meaning response therapeutically. One need not give sugar pills. Providing intervention that is both consistent with objective understanding of human health and illness and seeks to enhance the significance of the therapeutic process may maximise positive outcomes without compromising ethical and moral responsibilities.

Placebo responses are not sufficiently potent to resolve all health problems. Conditions that are the most amenable to placebo responses are those associated with psychological distress and sympathetic arousal, e.g. anxiety, depression, hypertension, angina, stress-related immunosuppression, addiction, functional digestive disorders, headaches, and especially, pain. John Medina explains that psychophysical stress responses occur when a negative situation is interpreted as beyond one’s control. Positive changes in the meaning of these experiences may occur when a person:

  1. receives an explanation that makes sense to them
  2. feels safety in the presence of aid or the expression of care and concern
  3. experiences an intervention they expect will resolve the problem as they understand it
  4. gains skills and knowledge that allows control or mastery over the experience.

The following list was presented by Walach and Jonas in their paper, Placebo research: The evidence base for harnessing self-healing capacities. These methods have been demonstrated in the medical literature as effective for enhancing placebo responses:

  • Use more frequent dosing (or treatment) rather than less frequent dosing (up to a limit).
  • Apply therapies in therapeutic settings such as hospitals and clinics.
  • Attend to the route of administration.
  • Deliver therapies in a warm and caring way.
  • Deliver therapies with confidence and in a credible way.
  • Determine what treatment your patient believes in or not.
  • Be sure you as a therapist believe in the treatment and find it credible.
  • Align all beliefs congruently: patient, doctor, family, culture.
  • Deliver a benign but frequent conditioned stimulus along with the effective therapy.
  • Use the newest and most prominent treatment available.
  • Use a well known name brand identified with success.
  • Cut or stick the skin or poke into an orifice whenever it is believed important.
  • Inform the patient what they can expect.
  • Use a light, laser, or electronic device to deliver and track the treatment when possible.
  • Incorporate reassurance, relaxation, suggestion, and anxiety reduction methods into the delivery.
  • Listen and provide empathy and understanding.

and an easy one for manual therapists…

  • Touch the patient.

Check out this great interview with Nicholas Humphrey on contextual therapeutic responses from an evolutionary perspective.

Sacroiliac joint fusion and the implications for manual therapy diagnosis and treatment

Assessment and treatment for sacroiliac dysfunction is common in manual therapy management for spinal pain and is based on the assumption that small movements occur at the sacroiliac joints (SIJ). SIJ dysfunction is often addressed using manipulation techniques, usually involving the application of manual forces to the joint complex. Considering the fact many of these treatments rely on the hypothesis that SIJ motion is directly alterable by such forces it is important for practitioners to be aware that producing movement at the SIJ may not be possible in many individuals due to the presence of joint fusion.

Dar et al.1 have recently conducted a study with aim of determining the prevalence of SIJ fusion using 3-D CT imaging. The study examined 287 consecutive patients (159 male, 128 female) referred to a hospital radiology department for a variety of abdominal complaints. The patients ranged from 22-93 years. Patients with spinal diseases, such as spondyloarthropathy and diffuse idiopathic hyperostosis (DISH), were excluded. Unfortunately, information on low back pain status was not reported. 3-D images of pelvises were obtained using a 64-slice CT scanner, and volume rendering sections of 1-2mm thickness. Multiplanar reformation was used to detect whether the fusion was intra- or extra-articular. The SIJs of each image were divided into six equal areas and the presence, side and location of fusions were recorded. Assessment was made by two radiologists who were blind to each others results and the interexaminer agreement was substantial.

SIJ fusion was found in 16.7% of subjects and was far more prevalent in males (27.7%) than females (2.3%). All fusions were extra-articular. Fusion in males was strongly correlated with age: 5.6% in the 20-39y.a. cohort, 15.85% in the 40-59y.a. cohort, 31.1% in the 60-79y.a. cohort, 46.7% in individuals aged over 80. Fusion among females was not significantly correlated with age. Fusion was present bilaterally in 11.9% of males. Diffuse fusion was present in 7.5% of males, four cases were bilateral. The superior region was involved in all male individuals manifesting the phenomenon. No fusions were isolated to the inferior part of the joint. Fusion of the females was at just above and under the arcuate line at the most anterior point of the joint.

The results of this study accord with previous skeletal and cadaver studies and demonstrate that SIJ fusion is common. Further, it is clearly an age and gender biased phenomenon. The authors suggest that manual therapists who frequently utilise manipulation techniques aimed at addressing sacroiliac articular mobility or that result in forces across the sacroiliac joint should be aware of the limited potential for compliance at this joint in older males. The risk of injury may be far greater than the potential benefits of manually applied forces during the treatment of SIJ dysfunction in this population.

1.    Dar G, Khamis S, Peleg S, Masharawi Y, Steinburg N, Peled N, Latimer B, Hershkovitz I. Sacroiliac joint fusion and the implications for manual therapy diagnosis and treatment. Manual Therapy. 2008;13:155-58.

Myofascial release: an evidence-based treatment approach?

Myofascial Release (MFR) is an extremely popular manual therapy approach used by therapists in many professions treating neuromusculoskeletal problems. It is so popular, in fact, that the most well known MFR educator, John F. Barnes, claims to have instructed over 50,000 therapists worldwide in his approach. With so many therapists using MFR and, according to Barnes, “the consistent, profound results of myofascial release are so impressive, even when all else has failed, critics have said it is impossible because it breaks the laws of science.”, the results of a systematic review published by Remvig et al. are somewhat surprising.

The researchers conducted a literature search on PubMed, the Cochrane Library and on www.fasciaresearch.com. They also conducted an assessment of the rationale for the treatment within the studies. The search on PubMed resulted in 71 references, but only 23 were about manual MFR. A similar search in The Cochrane Library gave 13 hits, 5 about MFR and all of these already included in the 23 PubMed references. No futher supplements were found at www.fasciaresearch.com.

According to their results:

No studies were found with which to determine reliability of the diagnostic method. Four randomised controlled studies of the treatment were identified. Two of the efficacy studies comprised several different modalities of treatment, so that no conclusions could be drawn. In one further study, the numbers were too small to allow safe conclusions; in the other, the myofascial release treatment was inferior to an isometric contract-relax technique. Overall, no good evidence of efficacy has been shown.

The current evidence did not allow conclusions on the diagnostic criteria and methods or demonstrate any efficacy of myofascial release. Remvig et al. strongly recommended that “reliability studies be performed on diagnostic tests for myofascial dysfunction (tightness/looseness), so that efficacy studies can be performed on a more solid diagnostic foundation”.

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The father of Osteopathy in the Cranial Field: Sutherland or Swedenborg?

William G. Sutherland’s cranial osteopathic concepts are arguably the most cherished and guarded ideas within osteopathy. No other topic engenders the degree of debate, controversy, defense or criticism that a discussion of Osteopathy in the Cranial Field (OCF) will invariably spark. In fact, a recent study published by myself and three French colleagues resulted in the most letters to the editor for a single article in more than 10 years.

In the latest issue of the International Journal of Osteopathic Medicine there is fascinating article discussing the likely origin of most of Sutherland’s cranial osteopathy concepts. According to the author, Theodore Jordan, in 1744 a well known 17th century physician-turned-mystic, Emanuel Swedenborg, published a text titled The Brain, which described ideas similar to the first four of the five components of Sutherland’s cranial concept.1 It is known that Sutherland had a copy of a 1882 translation of this text, and on a few occasions he had made reference to Swedenborg’s ideas, even comparing Andrew Taylor Still’s anatomical study of “the handiwork of his Maker-the body” to Swedenborg’s search for the “seat of the soul” within the human brain. It appears that Sutherland integrated a significant portion of Swedenborg’s anatomically-based paradigm of rhythmic brain-body interaction into osteopathy as he developed cranial osteopathy.

This knowledge will be a revelation to many osteopaths, as it was to the editors of IJOM. However, it appears that it is not unique. A quick search on Google revealed a free access copy of the annual address delivered at the Annual Meeting of the Swedenborg Scientific Association on April 26, 2008 by David B. Fuller. This 32-page paper details a comprehensive overview of Swedenborg’s paradigm of the brain and nervous system and a comparison to Sutherland’s cranial concept.

For many osteopaths, the extent of anecdotal evidence supporting both the descriptive model and clinical outcomes is interpreted as sufficiently compelling to justify continued use of OCF treatments in clinical practice. Unfortunately, substantiating evidence of the commonly accepted explanatory models of OCF is yet to be established. In this regard, Jordan’s closing comment is worth careful consideration:

“Critical dialogue regarding cranial osteopathy is a crucial component that can only strengthen the osteopathic profession. The PRM model has been part of osteopathic thought for over 60 years. To understand that it is based on an abandoned eighteenth century physiological hypothesis will hopefully propel the osteopathic profession to open a dialogue that will serve to advance our science.”

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1. Jordan T. Swedenborg’s influence on Sutherland’s ‘Primary Respiratory Mechanism’ model in cranial osteopathy. International Journal of Osteopathic Medicine. 2009;12(3):100-105.

Mechanical or inflammatory low back pain. What are the potential signs and symptoms?

Non-specific low back pain (NS-LBP) is commonly conceptualised, categorised and treated as inflammatory and/or mechanical in nature. There is no universally accepted definition for mechanical or inflammatory LBP, however, there is evidence to support the involvement of both mechanical and inflammatory factors in its generation. Following from this nosological separation, there are two distinct approaches to treatment for LBP: treatment involving “mechanical” intervention, such as mobilisation, manipulation, traction and exercise are contrasted with ‘‘anti-inflammatory’’ treatments like non-steroidal anti-inflammatory medications and corticosteroid injections.

In an effort to identify common symptoms or signs that may allow discrimination between inflammatory low back pain (ILBP) and mechanical low back pain (MLBP), Walker and Williamson recently surveyed experienced health professionals from five professions using a questionnaire listing 27 signs/symptoms. Of 129 surveyed, 105 responded (81%). According to their results, constant pain, pain that wakes, and stiffness after resting  were generally considered as moderate indicators of inflammatory LBP. Intermittent pain during the day, pain that develops later in the day, pain on standing for a while, pain bending forward a little, pain on trunk flexion or extension, pain doing a sit up, pain when driving long distances, pain getting out of a chair, and pain on repetitive bending, running, coughing or sneezing were all generally considered as moderate indicators of MLBP. There was, however, no consistency of agreement either between or within professional groups.

While the general absence of agreement regarding signs and symptoms of ILBP and MLBP does not invalidate the pathophysiological paradigms of mechanical and inflammatory pains, it does, however, signal the need for further research. This research should be aimed at testing the indicators identified in this study for their ability to predict the outcome of mechanical and anti-inflammatory treatments of LBP.

Walker BF, Williamson OD. Mechanical or inflammatory low back pain. What are the potential signs and symptoms? Man Ther. 2009 Jun;14(3):314-20. Epub 2008 Jun 13.


Placebo analgesia is augmented following prior observation of successful treatment

It has long been known that psychosocial factors play a crucial role in placebo responses. According to Colloca and Benedetti, no attempt has been made to understand if social observation shapes the placebo analgesic effect. To address this question, they compared placebo analgesia induced through social observation (Group 1) with first-hand experience via a typical conditioning procedure (Group 2) and verbal suggestion alone (Group 3). In Group 1, subjects underwent painful stimuli and placebo treatment after they had observed a demonstrator (actually a simulator) showing analgesic effect when the painful stimuli were paired to a green light. In Group 2, subjects were conditioned according to previous studies, whereby a green light was associated to the surreptitious reduction of stimulus intensity, so as to make them believe that the treatment worked. In Group 3, subjects received painful stimuli and were verbally instructed to expect a benefit from a green light. Pain perception was assessed by means of a Numerical Rating Scale (NRS) ranging from 0=no pain to 10=maximum imaginable pain. Empathy trait and heart rate were also measured.

The researchers found that observing the beneficial effects in the demonstrator induced substantial placebo analgesic responses, which were positively correlated with empathy scores. Moreover, observational social learning produced placebo responses that were similar to those induced by directly experiencing the benefit through the conditioning procedure, whereas verbal suggestions alone produced significantly smaller effects. These findings show that placebo analgesia is finely tuned by social observation and suggest that different forms of learning take part in the placebo phenomenon.

Colloca L, Benedetti F. Placebo analgesia induced by social observational learning. Pain. 2009 Jul;144(1-2):28-34. Epub 2009 Mar 10.


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