Here is a great article from Paul Ingram-

Those scary spine models • How hopelessly obsolete clinical ideas persist for years, even decades

Anatomical models of lumbar spines almost all include a herniated disc — in spite of the fact that the last quarter century of scientific research has consistently shown that herniated discs are of minimal clinical significance in the vast majority of back pain. The niftiest science fact about herniated discs is that so many people have asymptomatic disc herniations — at least 25% of people, many more according to some research, are walking around with diagnosable disc herniations … and yet they have no symptoms at all.

And so, although herniated discs do happen, they are typically much less common and much less serious than most patients, doctors and therapists believe. Meanwhile, several respected experts have made strong statements about the extreme importance of reassuring low back pain patients and not scaring them with ominous-sounding and diagnoses like “herniated disc.” Such diagnoses are usually wrong, or hopelessly oversimplified at best, and needlessly scare the wits out of patients … which is a known risk factor for low back pain.

Nervous low back pain patients tend to have more pain for much longer.

And yet it remains nearly impossible for a clinician to buy an anatomical model of the lumbar spine that doesn’t have a little rubber disc bulging ominously from the spine … invariably coloured bright red, just to hammer the point home! It is also nearly impossible for a patient to look at such a model without worrying.

Model of doom and gloom

Lumbar spine models like this almost all show a herniated disc. Some go a step further and show discs slipped so far they’ve completely left the spine! (Hat tip to Dr. Moseley.)

That little bulging disc looks bad. Or, God forbid, a disc that has “slipped so far out it’s sitting on its own?” Here’s pain researcher Lorimer Moseley making this point in a great TED talk. He’s talking about how pain is always worsened when you believe that there is danger … and plastic anatomical models of slipped discs are much too persuasive.

Any piece of credible evidence that they are in danger should change their pain … And they are all walking into a hospital department with models like this on the desk: what does your brain say when it sees a disc that’s slipped so far out it’s sitting on its own? If you’ve ever seen a disc in a cadaver, you can’t slip the suckers — they’re immobile, you can’t slip a disc — but that’s our language, and it messes with your brain. It cannot not mess with your brain.

Lorimer Moseley, from his surprisingly funny TED talk, Why Things Hurt 14:33

(I laughed out loud at that, and then cheered. I’ve been bitching about these blasted models for years. Long before I’d ever heard of Lorimer, I’m proud to say.)

Such models undoubtedly also influence professionals. Even if they accept that it’s an oversimplified model, the prominence of herniated discs in most models and anatomical drawings constantly exaggerates their importance.

Anatomical models aren’t cheap, and once a clinician has purchased one, it is likely to stay in his or her office for years, probably even decades. I’m sure there are probably hundreds of thousands of them in offices around the world that are at least twenty years old, and clinicians are still buying new ones right now!

And so this is a great example of how hopelessly obsolete clinical ideas persist for years, even decades, after the field has moved on.

Here is a great article from my colleague Todd Hargrove:

What is the arthrokinetic reflex and what does it have to do with strength, mobility, flexibility and joint mobility drills? Here is a (very) quick explanation.
The arthrokinetic reflex defined

Arthro means joint. Kinetic means movement. Reflex means involuntary movement in response to a stimulus. Put them together and you have a term coined by researchers in the 1950s as a way to describe the idea that sensory input from joint movement can reflexively cause activation or inhibition of certain muscles.

This theory was proposed as way to explain the results of an experiment where scientists deactivated a cat’s brain but were still able to effect muscle tone changes in the legs by moving the knee. Similar results were found in a different study involving the muscles of the jaw. The researchers concluded that abnormal jaw positions resulted in mechanoreception that reflexively created abnormal (and dysfunctional) patterns of muscular activation.
The arthrokinetic reflex and strength

Dr. Eric Cobb, the creator of Z-Health, uses this term as a way to explain why joint mobility drills may be a quick and easy way to increase strength, flexibility or coordination. The idea is that moving a joint alters the mechanoreceptive information coming from the joint, which can reflexively alter the activation of the muscles attaching to the joint. For example, there is at least one study where hip mobilization led to immediate increases in hip abductor strength.

But is this the result of the arthrokinetic reflex or some other neural mechanism? I don’t know if there is any answer to this question, but personally I don’t care that much. Mechanoreceptive information might end up talking to many different areas of the spine and brain, all of which might have some sort of influence, reflexive or otherwise, on how the muscles around that area should be activated in the near future.

If the sensory information basically conveys the idea that movement in the joint is safe, we should expect the nervous system to loosen its governor on strength, speed and range of motion. If the information suggests that the movement in question involves danger, we should expect increased protective activity, such as stiffness, pain, weakness, and altered coordination.

Certain foods are hyped as anti-inflammatory and certain dietary supplements are marketed with claims that they are anti-inflammatory. Integrative medicine guru Andrew Weil promotes both foods and supplements. Unfortunately, it is not clear that they can actually reduce the kind of inflammation that is associated with chronic diseases, or that such reductions actually prevent or improve the clinical course of those diseases. It is conceivable that they might lead to harm as well as benefit. If they really diminish the body’s ability to mount an inflammatory response, wouldn’t that also tend to impair wound healing and response to infection? Fortunately, most of the anti-inflammatory diet recommendations are consistent with consensus recommendations for a healthy diet (lots of fruits and vegetables, etc.). Anti-inflammatory medications like NSAIDs and steroids do reduce inflammation, but they have had limited use in treating diseases associated with chronic inflammation, and they have problematic side effects. In fact, steroids make people more vulnerable to infection.

For the present, we have only hints. Research like Dr. Ozcan’s will help us better understand the risks, benefits, and complexities of inflammatory processes. Meanwhile, it’s a mistake to oversimplify and to assume inflammation is always a bad thing, and trying to prevent or treat it with special foods and supplements is little more than a shot in the dark, a gamble based on speculation. Eat your vegetables and stay tuned!

Interesting thoughts on Pain by Gatchel:

There is a common belief amongst some people involved in pain and pain management that a person with chronic pain should be consistent in their presentation. That is, be consistent in various settings, and consistent across various measures. This assumes that if inconsistencies are present there must be something going on to cause suspicion about the validity of the person’s presentation.

Returning to yesterday’s post, I discussed the distinction between nociception (activation of receptors in the nervous system), pain (the experience produced by the brain once it has interpreted the nociceptive action), disability (the changes in functional performance attributed to the experience of pain), and impairment (tissue changes). These are not the same! Today’s post refers mostly to pain and disability.

Pain is, as I keep spouting, a personal, subjective experience – you and I can’t share our pain except through our behaviour. And even when we describe it, we can’t actually experience what it feels like to have each other’s pain. What this means is that our behaviours, or what we do, are what conveys our experience to others but only to a certain extent.

While our experience of pain remains individual, our behaviour is shaped by all the influences around us. And just to make things more complex, the meaning of our pain experience is shaped by what we learn and believe about pain from interactions between ourselves and all those influences that shape our behaviour. Complicated? Oh yes.

So if I grow up in a family that is generally stoic, where my complaints of pain are ignored and I see that others in my family don’t generally cry or stop doing things when they are hurt, it’s likely I’ll also be less demonstrative about my pain than another person in a family where this is not the norm.

We also learn to behave differently in different contexts. It’s common to say a few choice words when we hit our thumb with a hammer in the garage on a Saturday afternoon, but we usually wince and gasp quietly if we thump that same thumb in Church the next day!

What this means in terms of consistency is that people often do different things in different settings when they have pain – maybe when they drive from home to a clinic they’re a bit anxious about what the consultation might mean. They get out of the car and walk quite carefully into the clinic and sit down rather gingerly. They’re not sure whether they’re going to hear good news, or not. They go through the examination and consultation, and get told they’re going to try a new medication that might help. Oddly enough, as they walk back out to the car someone looking out the window might see them moving fluidly and getting into the car quite smoothly. Suspicious minds might start to wonder if they really had “that much pain”.

Turning to assessment of pain now, it’s been said that pain assessment should incorporate a number of different dimensions. At the very least, assessment needs to consider the location of pain, the intensity and quality of pain, and some sort of measure of the interference pain has with everyday activities. Some commentators consider pain assessment should also make a diagnosis of the type of pain disorder present (or the cause of the pain), while others also think that psychological aspects of pain need also to be included (such as pain catastrophising, measures of avoidance and measures of mood and anxiety). And of course, assessments of range of movement, strength and reflexes are also often part of a pain assessment.

Should these measures all present a “consistent” picture?

Where we hurt and what it feels like (the quality of pain) don’t directly correlate with the amount of interference a person experiences from their pain. If I’m a pianist I might be really bothered by tingling and burning fingers, while less bothered about the same pain qualities in my feet. If I’m really anxious about my future as a nurse, I might be really concerned about my low back pain. If I’ve developed some effective coping strategies for managing my overall body aching, I might not be particularly anxious or have low mood despite having quite intense pain.

Inconsistency between various aspects of a person’s presentation doesn’t mean they’re faking, or that their pain is not real. It does mean we need to generate some hypotheses about the relationship between the various factors that could be influencing the person’s behaviour. To decide, on the basis of our own experience (which is always limited!) that another person’s pain is not real just because we don’t understand why they are doing what they’re doing, is a judgement call we can’t make, in all honesty. More than that, it doesn’t help work out what to do next to move the person from being disabled (or getting a benefit they don’t “deserve”) to returning to function.

Gatchel, R., Kishino, N., & Minotti, D. (2010). The Three Major Components of Behavior Used for Assessing Pain: Problems Faced When There Is Discordance Among the Three Psychological Injury and Law, 3 (3), 212-219 DOI: 10.1007/s12207-010-9081-0