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Hi Ahappiermedium,
I think the forum is now closed unfortunately but feel free to email me directly at [email protected]
Hi Sue, really interesting suggestion about use of tape. I think this is a brilliant example of increasing the safety factor. I work with a physio here in Adelaide who has a really interesting approach that uses an active (vs more passive, like taping) strategy with people with back pain. He does a very thorough objective and subjective assessment and then if he doesn’t find anything that he is concerned about, then he has them do a dead lift/squats on the very first day. To challenge their perceptions and beliefs of their back (obviously ++ clinical judgement needed here!). I interviewed one of his patients on a ABC RN Health Report episode – see here:http://www.abc.net.au/radionational/programs/healthreport/the-brains-role-in-pain/7735610
I think your strategy is great! How do you wean them off the tape?
Yosefa – great comment. There are certainly people who are not very limited despite feeling quite a lot of back stiffness. We had some in our sample that had very low levels of fear and very low levels of disability and interestingly, still exhibited protective behavoiur in terms of their back (thought they were getting much more force than they truly were). I don’t know if increasing one’s ability to use guided imagery would alter feelings of stiffness but it would be very interesting to try this! This could be particularly interesting to test in people that have feelings of stiffness during specific ranges of movement – is their implicit motor imagery less robust in those postures? I don’t know!
Suzanne – yes absolutely! I think this is a critical aspect because many people get their information from social media and from other sources that are not that well evidenced.
Even a look at various supposedly health websites show that people can be misled. For example: https://www.arthritis-health.com/blog/crepitus-may-be-early-warning-sign-knee-arthritis – how terrifying is this for someone?I think that is why education of patients is so important and has to be a key feature of our treatment. I.e., I wonder whether we schedule in allocated time that is literally, “let’s myth bust so that you understand your condition”.
I would argue at the moment that it isn’t an exact science to determine the difference between biomechanical and stretch sensitivity (as termed by eyal). I think a term I am a bit more comfortable with is centrally mediated stiffness.
As I mentioned above, I think there is a central component to all feelings of stiffness, regardless of whether there are literal biomechanical changes that impinge on movement (like ankylosing spondylitis) or whether there are no biomechanical changes. However, I do think that there are people in which the relationship between biomechanical changes and feelings are less robust or absent (as was in our sample). This seems to occur most often with chronicity.
Given the evidence for pain neuroscience education in decreasing things like fear of movement or catastrophising (which can feasibly relate to someone being more overprotective of a painful body part – and thus sensitising the system), perhaps an interesting way to test this is to target these concepts in people and then see what happens to their sensations of stiffness (and their active movement). We have findings that we are currently writing up that show that understanding that pain does not equal tissue damage allows people with back pain to bend and move further than a person that does not understand this. This raises the possibility that an ‘intervention’ type test such as this might be useful.
Sorry that I don’t have a better answer but super interesting question!
Hi Sue, I realised that I didn’t answer your other question following up on detecting the difference between two stiff states. I am going to do this now (in my next post)
Hi Jdarke,
Yes we did find that people that had chronic back pain and feelings of stiffness were more sensitive to changes in pressure applied to their back. That is, they were over-protective (thought they were getting more force than they truly were) but were also hyper-aware. In the acute state this is actually probably a good thing – it helps us to prevent further injury. However, in a chronic state, this may become maladaptive.
So we know that when people better understand what pain is, what affects their pain levels, and that pain doesn’t equal damage, then they often experience less pain with movement (despite nothing changing with their actual back). Often this involves challenging unhelpful beliefs about pain.
So it is interesting to consider, if pain is a protective inference that occurs when we perceive ourselves to be in a dangerous situation (consciously or unconsciously), could other sensations such as stiffness (that relate closely to protective responses at the back) also be able to be modulated. For example, if we told people that the pressure applied to their back was actually helping to promote movement in a safe manner and that any pain that is felt is not representative of any further damage but merely of sensitised tissues, is it possible that we could actually decrease this sensitised response (detecting a smaller change in force)? Maybe! I would love to find out.
Sue – re: question about whether we have to look into consider individual reasons why people may be protective.
YES! I definitely think this is important to do. I do wonder whether some things might tend to always relate to being more protective – for example, if a person’s has high pain catastrophisation, then this may always relate to increased feelings of stiffness. However, it doesn’t meant that every person who feels still is a high pain catastrophiser.
Pain neuroscience suggests that our sensations are created based on input from numerous different sources and we need to explore this within the individual. I think this is where Pain Education (as per Lorimer Moseley and David Bulter) is a nice way to go about this as it directly explores with a person what their beliefs are about their injury, etc..
This is where I would like our further research to go. Thanks for the question!
Hi Ruth,
So we recruited people who reported feeling back stiffness, but in many of them, they had active range of motion within normal limits (some were ++ limited). Our measure of ‘being stiff’ could actually be described as a passive movement – we were applying a posterior to anterior pressure to the L3 spinous process and measuring the resultant displacement of the vertebrae.
But I think you hit the nail on the head that often times there is a disconnect between actual movement (active), possible movement (passive) and feelings of stiffness. This then can further support the idea that these sensations might not reflect the biomechanical state of the tissues.
Hi Matt Brabner – great question! Yes, we have started to look at the impact of words. Specifically in people with knee osteoarthritis, they are often given the explanation of bone-on-bone and wear and tear (implying that activity will wear out already damaged joints) and some of my new work is evaluating hte impact of this. Sorry no result to share yet!
Emma Karran, a PhD student from the body in Mind research group that I work in, is evaluating what happens when you positively reframe imaging results in people with back pain. Again, just under way but watch the body in mind group’s space for the results (www.bodyinmind.org/).
I think it is massively important to think carefully about our words. Especially for patients without any medical background – saying their disc has slipped or their back is out can be taken literally and this can have devastating consequences for activity. Peter O’Sullivan has shared some great stuff about this on twitter, as has David Butler on Noigroup
Hi ekelsey, Yes, we could have also used a neutral sound – but we were interested in seeing if we could elicit opposite effects by a sound that increased the potential need for protection (creaky noise) and a sound that decrased the potential need for protection (whoosh- signifying nice clean movement). We did compare to a control sound. Further we also showed that it wasn’t just the sound itself but it’s context – a creaky noise that decreased over time had an opposite effect on perception as compared to a creaky noise that did not decrease over time.
We were a bit limited in that people could only withstand so many indentations on a sore back!
Hi Trevor,
Great question. I think that we need to positively reframe what grinding, crepitus sounds mean. For example, many times pops or clicks or grinding isn’t painful. This can be used to highlight that it is nothing necessarily going wrong. In some people, they do have pain while they move, but it isn’t necessarily meaning that the crepitus is reflective of why things hurt.
Pain neuroscience supports the idea that pain is a protective response. That is, it is a sensation that occurs when the perceived level of danger outweighs the perceived safety. Thus being scared of the crepitus may literally be sensitising the nervous system and resulting in more pain!
I wonder whether it might be reframing the sounds by explaining that our body is a wonderful adapter. Sometimes when you have injured an area, the body then adapts to help you heal. One of those adaptions can be that bone can be laid down (for example body spurs). This can sometimes then cause noises during movement. However, this isn’t a noise of damage, this is a noise of your body doing what it needs to in order to create a stable, robust joint.
Yes it is a great question and one that doesn’t have a simple answer unfortunately.
I would argue that all the sensations that we have are created, so to speak, in our brains using the available information. I think in the past, we only considered the ‘available information’ to be that which comes from the periphery. However, we know that this information can be modulated both at the spinal cord level and in the brain. It can also be argued that sensations do not come into our conscious awareness until they have reached the brain. As such, numerous other features can then potentially modulate the sensations. That is, perhaps being fearful of movement can have a modulatory effect on the information coming from the periphery. My paper, specifically looked at whether additional congruent sensory information (sound) could modulate perceptions at the back. And what I found was that adding sound information to pressure applied to the back had very specific effects on perception. And also that , in people with chronic back stiffness, a feeliing of stiffness was different to biomechanical measures of spinal stiffness. The evidence suggests that this type of central modulation of sensations can occur with experimental pain, acute pain and chronic pain
In terms of differentiating the two – I do think chronicity can play a role
Do let me know if you have any questions about my study or if there were parts that you wanted clarification on.
Hi Eyal and hello to all who are joining today! I look forward to discussing some of these points with you.