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art
1903 Posts |
 Posted - 01/11/2007 : 07:36:08
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Anybody catch today's paper? Very interesting piece on overuse injuries....The prevailing wisdom is changing, and some doctors..orthopods...are changing their recommendations re tendinitis etc....
The new advice is, surprise surprise, continue with your sport because injuries actually heal better when they are under some stress...Doing nothing, in other word resting, is the worst thing you can do unless of course the injury is severe...
Now we all know this of course, but what's genuinely intriguing is that the model invoked is not mind/body, but simply body...It supports Dr.Sarno's approach, but without any appeal to psychology....
Hmmm..... |
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alexis
USA
596 Posts |
Posted - 01/11/2007 : 08:19:43
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Thanks art. I didn't see that one but it meshes with what I've picked up in doing a bit of research lately on what appears to be a real achilles tendinitis issue. The newer research, while it doesn't recommend slamming the thing, does seem to be more use oriented, and less rest. One new method (I'm putting off for a bit) theorizes, with good results, that you have to break down the tendon a bit in order to rebuild it right. [Don't anyone take this lightly, as the results of messing this up are enormous and could haunt you a lifetime.]
The interesting issue to me is how medical liability does and will play into all of this.
It also has been a question to me with my improving RSI how much is psychological (in the sense Sarno focuses on), and how much is just using my hands more. I think a lot does get into deeper psychology, though (therefore making TMS or somatization theories not obsolte), in part because:
a) I've been through the posts here, including one ad hoc survey, and it looks like anxiety disorders are kind of rampant among us TMS types. So I wouldn't want to move away from the psychological approach too fast. I would love to have some hard numbers on what percentage of people who have been helped by a TMS approach have suffered anxiety attacks and how that number compares to that in the general population.
b) So many people have been "cured" just by reading. In this case, they were cured before a resumption of normal activity.
c) It seems from my own experience and from what I've read that psychology plays not only into the creation of some pain, but also how pain, created or structually based, is experienced. And that working on the psychological is just as valuable when it affects the experiece if pain as when it affects the creation of it.
d) As briefly discussed in the Myer's Briggs thread there do seem to be some interesting personality correlations.
So I guess it kind of looks like there are two things going on. There are psychological issues (be they anger or fear or anxiety or whatever). But also the is a possibly misguided idea (influenced by medical malpractice issues?) that rest is the best thing for a variety of ailments. Of course, some things *do* need rest, but it seems this may have gone a little too far in some areas. This makes me wonder if the promotion of "rest" cures is correlated to the risk of medical liability in a particular country or state? I imagine this has been researched somewhere.
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Edited by - alexis on 01/11/2007 10:29:15 |
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MikeJ
United Kingdom
75 Posts |
Posted - 01/11/2007 : 08:21:59
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| That's interesting, art! Do you know if there's a link to this news so we can all read about it? |
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ndb
209 Posts |
Posted - 01/11/2007 : 08:52:12
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Getting back to normal activity may not be the whole picture...for example, perhaps getting back to activity takes your mind away from obsessing about the injury, or perhaps helps in overcoming *fear* of activity. It seems these psychological effects of getting back to activity aren't being taken into account. I very much doubt this makes TMS theory obsolete, even in the case of 'real' injury.
ndb |
Edited by - ndb on 01/11/2007 08:52:55 |
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art
1903 Posts |
Posted - 01/11/2007 : 09:00:14
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You can go to NYT's website and read it///You just have to register...
ND and Alexis.I don't think TMS is obsolete either...I just wanted to give the topic a name that would engender some interest...
I think there's plenty of room for TMS theory...But on the other hand, it does simplify things, especially with respect to plain vanilla overuse injuries for those who don't feel inclined to go the mind/body route...
Alexis, I think you're right re anxiety playing a big role in some of this....I personally think it's more important than Sarno's anger model |
Edited by - art on 01/11/2007 09:04:42 |
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alexis
USA
596 Posts |
Posted - 01/11/2007 : 09:04:56
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quote:
Originally posted by ndb
Getting back to normal activity may not be the whole picture...for example, perhaps getting back to activity takes your mind away from obsessing about the injury, or perhaps helps in overcoming *fear* of activity.
Very good point.
Assuming we are referring to today's NYT article in the health section "When It’s O.K. to Run Hurt", it's unclear whether we are talking about measured physical/structual changes or pain experience, but it seems both. And I think my mostly non-TMS achilles feels better as much from starting a non-athletic class as from walking on it. Not to mention the always open question on the impact of psychology on the non-brain structural issues.
Art, are you from New York? "Today's paper"????  |
Edited by - alexis on 01/11/2007 10:10:31 |
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alexis
USA
596 Posts |
Posted - 01/11/2007 : 09:17:15
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quote:
Originally posted by art
I think there's plenty of room for TMS theory...But on the other hand, it does simplify things, especially with respect to plain vanilla overuse injuries for those who don't feel inclined to go the mind/body route...
Yes, that's another interesting issue. You are actually refering to structural overuse injuries here, but I think it goes, perhaps, further, into people with partially or wholy *not* structual injuries who will never accept at TMS type diagnosis. How do you package these ideas when people don't want to accept them? This actually brings me to a place where I thought Sarno might have misunderstood a Jeffrey Thompson quote (MBP, page 82):
"The word tension suggests that psychological tension or stress may play a role. When the diagnosis is presented in this way, patients are more willing to accept the possibility of psychological influences on their muscle pain disorder and are more likely to take the necessary steps to address them. At the same time, the physician is aknowledging that a psychological disturbance is not the primary cause." --Jeffrey Thompson, with italics by Sarno.
Now, I don't have the original Thompson, though I have tried a quick scan to see if I could find it online. What I question (again, somewhat in the dark) is Sarno's interpretation that this implies that the author cannot accept that psychological factors [may?] play a primary role. As a free standing quote, I rather see it as saying that it must be presented this way to the patient in order for him or her to accept it. But, I really would need to see the full document.
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Edited by - alexis on 01/11/2007 09:26:41 |
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art
1903 Posts |
Posted - 01/11/2007 : 09:33:07
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quote:
Yes, that's another interesting issue. You are actually refering to structural overuse injuries here, but I think it goes, perhaps, further, into people with partially or wholy *not* structual injuries who will never accept at TMS type diagnosis. How do you package these ideas when people don't want to accept them? This actually brings me to a place where I thought Sarno might have misunderstood a Jeffrey Thompson quote (MBP, page 82):
I like to keep things simple to accomodate my simple mind...There seems to be some solid science behind the belief that tendons for example, heal more quickly when they are being stressed...meaning used...
In my case, I've long suspected that there's something more direct going on than the whole TMS dog and pony show when it comes to my own running injuries....I rarely think about or appeal to emotional issues when I have say, a new episode of knee pain...I've just learned that if I continue to run, perhaps cutting down on intensity for a short while, I almost always get better...
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whitris
USA
26 Posts |
Posted - 01/11/2007 : 10:31:47
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text of article:
By GINA KOLATA
Published: January 11, 2007
JUST before the end of last year, a prominent orthopedic surgeon was stretching to lift a heavy box and twisted his back. The pain was agonizing. He could not sit, and when he lay down he could barely get up.
+++++++++++++++++++++++SIDEBAR
What You Can Do When You Are Injured
• Evaluate yourself. Is there redness or swelling? Does one side look different from the others? If not, continue exercising.
• Cross-train in a way that exercises around the area, like cycling instead of running for an injured Achilles tendon.
• Ice the injured area for about 20 minutes after exercising.
• See a doctor if you have severe pain and are having trouble with your daily activities. Otherwise, you can give it time — up to a month or two — to get better before rushing to see a doctor.
• Exercise, and if the pain goes away and is not worse after that exercise, it probably is safe to do it.
• Walk on it; if you can’t do that, you should not run on it.
+++++++++++++++=
So the surgeon, Dr. James Weinstein of Dartmouth College, decided to go out for a run.
“I took an anti-inflammatory, iced up, and off I went,” Dr. Weinstein recalled. When he returned, he said, he felt “pretty good.”
It sounds almost like heresy. The usual advice in treating injuries is to rest until the pain goes away. But Dr. Weinstein and a number of leading sports medicine specialists say that is outdated and counterproductive. In fact, Dr. Weinstein says, when active people consult him, he usually tells them to keep exercising.
The idea, these orthopedists and exercise specialists say, is to use common sense. If you’ve got tendinitis or sprained a muscle or tendon by doing too much, don’t go right back to exercising at the same level.
The specific advice can differ from specialist to specialist. Some, like Dr. Weinstein, say most people can continue with the sport they love although they may need to cut back a bit, running shorter distances or going more slowly. Others say to cross-train at least some of the time and others say the safest thing to do is to cross-train all the time until the pain is gone. You might end up cycling instead of running, or swimming instead of playing tennis. But unless it’s something as serious as a broken bone or a ripped ligament or muscle, stopping altogether may be the worst thing to do.
“We want to keep you moving,” said Dr. William Roberts, a sports medicine specialist at the University of Minnesota and a past president of the American College of Sports Medicine. “Injured tissue heals better if it’s under some sort of stress.”
He and others acknowledge that the advice to keep moving may come as a surprise and that some doctors feel uncomfortable giving it, worried that their patients will do too much, make things worse and then blame their doctor.
“I’m not convinced this is part of every doctor’s training or that everyone is ready to make it part of mainstream medicine,” Dr. Roberts said. “You have to work with athletes a while to figure out how to do it and how to do it well.”
“The easy way out is to say, ‘Don’t exercise,’ ” said Dr. Richard Steadman, an orthopedic surgeon in Vail, Colo., and founder of the Steadman Hawkins Research Foundation, which studies the origins and treatment of sports injuries. That advice, he added, “is safe and you probably will have healing over time.” But, he said, “if the injury is not severe, resting it will probably prolong recovery.”
Medical researchers say that they only gradually realized the importance of exercising when injured. A few decades ago, Dr. Mininder Kocher, a sports medicine specialist and orthopedic surgeon at Children’s Hospital Boston, said doctors were so intent on forcing hurt athletes to rest that they would put injured knees or elbows or limbs in a cast for two to three months.
When the cast finally came off, the patient’s limb would be stiff, the muscles atrophied. “It would take six months of therapy to get strength and motion back,” Dr. Kocher said.
At the same time, in a parallel path, researchers were learning that painful conditions that are essentially inflammation — arthritis and chronic lower back pain — actually improve when patients keep moving.
Now some researchers, like Dr. Freddie Fu, a sports medicine expert and chairman of the orthopedic surgery department at the University of Pittsburgh Medical Center, and a colleague, James H-C. Wang, are studying minor injuries at the molecular level.
Their focus is on tendinitis — the inflamed tendons that are the bane of many exercisers and that affect 15 to 20 percent of all Americans at any given time. The symptoms are all too familiar — pain, swelling and soreness. To study the injury process, Dr. Wang grows human tendons in the laboratory, stretching them repeatedly. In separate experiments, he has mice run on treadmills until their tendons begin to show the tiny microscopic tears that occur in the early stages of tendinitis.
So far, Dr. Wang reports, he and Dr. Fu learned some important lessons: First, forceful stretching of tendons elicits the production of molecules that are involved in inflammation. But small repeated stretching of tendons that are already inflamed leads to the production of molecules that heal inflammation. That suggests moderate exercise can actually speed healing.
And now, their preliminary results suggest that the usual treatment for tendinitis — taking drugs like aspirin or ibuprofen — can help reduce inflammation when the injury begins. But after inflammation is under way, they can make matters worse.
But medical experts caution that people have to be careful if they try to exercise when they are injured.
Some, like Dr. Fu, who is himself a cyclist, Dr. Roberts, and Dr. Steadman say the first priority is to see a doctor and get an accurate diagnosis in order to rule out a serious injury.
Others, like Dr. Weinstein, say that such an injury, a broken bone or a torn Achilles tendon, for example, has symptoms so severe that it is obvious something is really wrong.
“If you had inflammation and swelling that was very tender to the touch, you would know,” Dr. Weinstein said. And if you tried to exercise, it would hurt so much that you just could not do it.
Dr. Weinstein’s advice for injured patients is among the boldest — he said it’s based on his basic research and his own experience with sports injuries, like knee pain and tendinitis of the Achilles and hamstring. Before exercise, he said, take one anti-inflammatory pill, like an aspirin. Ice the area for 20 minutes. Then start your usual exercise, the one that resulted in your injury, possibly reducing the intensity or time you would have spent. When you finish, ice the injured area again.
The advice involving an anti-inflammatory pill, Dr. Weinstein said, is based on something surgeons know — in most cases, a single anti-inflammatory pill before surgery results in less pain and swelling afterward. It also is consistent with Dr. Wang’s research because, at least in theory, it should forestall new inflammation from the exercise that is about to occur.
The icing is to constrict blood vessels before and after exercise, thereby preventing some of the inflammatory white blood cells from reaching the injured tissue.
Dr. Steadman, who works with injured athletes in his clinic, does not advise trying to go back to your old exercise on your own until the pain is completely gone. Play it safe, he said, and cross-train.
But others, like Dr. Fu and Dr. Kocher, are more inclined to suggest trying your old sport. Both also tell injured patients to ice before and after exercising. Dr. Kocher said he sometimes advises taking an anti-inflammatory pill, but worries about masking pain so much that patients injure themselves even more by overdoing the exercise.
His rule of thumb, Dr. Kocher said, is that if the pain is no worse after exercising than it is when the person simply walks, then the exercise “makes a lot of sense.”
It also helps patients psychologically, he added. “If you take athletes or active people out, they get depressed, they get wacky,” Dr. Kocher explained.
Noah Hano knows all about that.
Mr. Hano, 34, a commercial real estate broker in Boston, was competing in marathons and triathlons. Then he developed severe sciatica, whose pain is a direct result of inflammation. He tried physical therapy, he tried acupuncture, he tried massage therapy, but nothing quelled the “nagging, terrible pain” down his leg, he said.
He stopped exercising, but the pain persisted.
“I started getting desperate,” Mr. Hano said. His father, who lives in the same town as Dr. Weinstein, suggested that Mr. Hano call the Dartmouth orthopedist. Dr. Weinstein told him to continue to exercise. Mr. Hano could not wait to get started. “I drove to the gym and ran on the treadmill,” he said. “When I woke up the next morning, I went for a swim and rode my bike. It hurt, but when the doctor told me I wasn’t going to be paralyzed, it made it a lot easier.”
Dr. Weinstein said that Mr. Hano’s problem was a huge, bulging disk, a herniation so severe that most doctors would say he should stop running immediately. Dr. Weinstein, though, thought exercise would help Mr. Hano heal. His treatment was a single injection of cortisone into the inflamed area around his disk. The sciatica gradually went away. And Mr. Hano continues to run.
“I had faith that I was going to be able to work through it,” Mr. Hano said. “I don’t want to not do what I like just because I’m in pain.”
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armchairlinguist
USA
1397 Posts |
Posted - 01/11/2007 : 12:49:11
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Seems like that last example is TMS-type for sure! Active guy gets inexplicable leg pain, etc. But luckily he didn't get locked into the chronic-pain-no-exercise-life-is-hopeless cycle. I can only think that this new recommendation will at least help with that issue a bit.
It's a timely reminder to me too, because I "tweaked" my back the other day and it is a bit sore. Dunno if it's just a little "real injury" or purely TMS, but it sounds like I get to do the same thing regardless -- don't worry about it too much, and keep active. w00t. :-)
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Wherever you go, there you are. |
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art
1903 Posts |
Posted - 01/11/2007 : 14:55:00
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quote:
Dunno if it's just a little "real injury" or purely TMS, but it sounds like I get to do the same thing regardless -- don't worry about it too much, and keep active.
I agree...For runners struggling with lack of trust in TMS, or simply struggling with the, "is it real or is it TMS" dilemma, this greatly simplifies things...
Speaking for myself, I still struggle with that one..Almost all of us do....
Bottom line, this is a very user friendly article...Good news all 'round.. |
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windy
USA
84 Posts |
Posted - 07/23/2007 : 15:41:10
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Wow! I love this article. I've been on the pain - no exercise - resume activity - pain - no exercise cycle for months now.
Fall 2007 I partially tore an ankle tendon. It was swollen and painful but as I have a history of TMS I didn't go to the doctor assuming it would go away. When it didn't after 2 mos. I visited a doctor who suggested it was edema. Then I was referred to a sports med doc who did an MRI that revealed the tear. I was in a cast for 9 weeks. Now I'm into my 3rd month of PT but I keep having a cycle of progress but then backslides as I resume beloved activities. Doc and PT not really sure what to say about it.
However, the doc did tell me that when a tendon is injured, while the collagen that closes the injury is not as good as the body's original collagen, to compensate the tendon grows back twice as thick. yay! go ankle tendon!
I can only assume though, at this point, given the treatment I've pursued and the article above, that my tendon is technically healed (no more swelling) and the pain is TMS finding a fun new place to latch onto.  |
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windy
USA
84 Posts |
Posted - 07/23/2007 : 15:43:32
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err, make that tear occurring in Fall 2006 since Fall 2007 hasn't occurred yet!  |
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weatherman
USA
184 Posts |
Posted - 07/31/2007 : 09:24:01
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Interesting thread since achilles issues are very near and dear to my heart.
Alexis - were you alluding to the heavy-load eccentric calf exercises (Alfredson)? I did some of this some time back, during which my achilles issue improved dramatically. The exercises themselves are counterintuitive, and seem dangerous at first glance. But, there is published research documenting their effectiveness, and no reports of disaster from doing them.
It begs the question, though, as to whether the exercising helped physiologically, or whether the ability to do them just increases one's confidence in the strength of the tendon - since anxiety about causing an injury can surely be a source of pain. This gets back to the age-old question of whether it's a real injury or not - and, as you mentioned, the consequences of pushing and getting a tear are enormous. I should mention that through all my achilles travails, there has never been any visible swelling, nor has the tendon itself been particularly sore to the touch.
The question of diagnosis is most frustrating, as a conventional doc can only verify that you ARE injured, not that you aren't. If you come in with pain within a mile of the achilles area, they will universally diagnose tendinitis, and prescribe rest or decreased activity - even in the absence of tenderness, visible swelling etc. I.e. they will diagnoose a physical injury because of pain alone - and then where does that leave you?
Weatherman
"Good judgement comes from experience. Experience comes from bad judgement." |
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alexis
USA
596 Posts |
Posted - 08/01/2007 : 16:04:18
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quote:
Originally posted by weatherman
Alexis - were you alluding to the heavy-load eccentric calf exercises (Alfredson)?
Yes, those are the exercises. And while counter-intuitive at first the process makes a lot of sense when you delve into the theory of fiber regrowth. And if you think about our nomadic ancestors, only those who could heal common injuries while in motion were likely to survive.
I have the same tensions as you wrt the real vs. TMS injuries, but what's interesting here is how the treatments are in important ways increasingly similar. For some things we can't necessarily know for sure the answer to the real vs. TMS riddle, but the good news is for the tendonitis issues it seems sometimes we don't have to. And as a result some "conventional" doctors (here meaning non-TMS) are actually no longer prescribing rest. How long their insurance carriers will put up with that we have to wait to see. |
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NYT's Article..TMS Obsolete?
