What are good resources for gears models of joint health?

post by Randomized, Controlled (BossSleepy) · 2021-06-06T17:39:50.303Z · LW · GW · 8 comments

This is a question post.

Painscience.com and Hargrove's "A Guide To Better Movement" are pretty good for a model of predictive processing and the roll of the nervous system in chronic pain and movement. I still don't feel like I have a good model of bone and joint health in general, however. Eg, I'm currently nursing a flare up of patelo-femoral pain in my left knee. I've done a number of things over the past few months to deal with it, with some success, including buying and reading Painscience's book length patelo-femoral tutorial. Recently I've had a bit of pain in my foot, possibly in the tibiocalcaneal or tibionavicular tendons. I find that even though I now know a fair amount about PFS and the way the nervous system processes pain, these models don't generalize well to sporadic, idiopathic pain in another joint.

Possibly the answer is: "lol that model doesn't exist", or "lol wanna get a phd?" but if there are good resources, I'd be an eager consumer.

A sub-question that I'm particularly interested in is: what, if anything, is know about the relationship between base line muscle tone and joint issues? I have good reason to think my baseline muscle tone is higher than average.

Answers

answer by ChristianKl · 2021-06-06T19:40:27.138Z · LW(p) · GW(p)

A lot of my related knowledge comes from in person teaching and not from reading books, so I unfortunately can't point you to specific sources for everything.

The best related research does come these days from the people that gather around the Fascia Research Congress. A few Rolfers like Robert Schleip and Thomas Myers decided to give academic science a go and across bodywork discipline and related academia the Fascia Research Congress is the central venue for going beyond the methologies of individual disciplines. 

Tense fascia leads to high muscle tone and that can then make individual body parts tense enough to hurt. When the problem travels between different parts of the body that's often what's happening

From that point it frequently also happens that you get inflammation in that body part which produces additional issues. 

As humans age, bones in various joints grow which results in a loss of flexibility. It might be that this isn't true for a hunter gatherer who uses his joints a lot more then the average Westerner but bone growth does reduce flexbility of joints as people grow older. 

Cartilage like the meniscus for the knee often gets thinner over time which produces joint problems. The old fashioned belief is that such cartilage doesn't grow back. These days we have research at the leading edge that suggest that sometimes some cartilage grows back but we don't have good models about it.

Various other illnesses also lead to joint problems. Lymn disease for example can produce joint pain. 

comment by Randomized, Controlled (BossSleepy) · 2021-06-07T00:14:58.458Z · LW(p) · GW(p)

Fascia Research Congress. A few Rolfers like Robert Schleip and Thomas Myers

I'll look into the Fascia Research Congress and these two!

Tense fascia leads to high muscle tone and that can then make individual body parts tense enough to hurt. When the problem travels between different parts of the body that's often what's happening

Does that suggest that trigger-point release, various forms of massage and something like Paul Ingraham's mobalization prescription are good starting places?

From that point it frequently also happens that you get inflammation in that body part which produces additional issues.

Any suggestions how to tell if you have inflammation and what to do if you do? Ingraham's Patella Femoral Syndrome tutorial is basically a book disquisition about low-level systemic inflammation in the knee cap, and his prescription is: lots and lots of gentle rest. He suggests the knee cap may be an unusual joint in that it it's under a lot of pressure even if just sitting still with a knee bent at 90 degrees, so recovery can be hard, but I'm guessing "lots of rest + standard PRICE treatment" is the typical prescription for other inflamed joints?

Replies from: ChristianKl
comment by ChristianKl · 2021-06-07T01:11:09.417Z · LW(p) · GW(p)

I'll look into the Fascia Research Congress and these two!

Thomas Myers wrote Anatomy Trains two decades ago which is a text book that was important for giving the field form. At that time it was state of the art. The general concept of myofascial meridians is a very useful gearmodel. On the other hand it's two decades old and I have been told that a lot of the book is outdated and Myers himself is not a person who's good at updating.

Robert Schleip is these days seen more as an authority.

Any suggestions how to tell if you have inflammation and what to do if you do? 

Inflammation generally means that the knee starts hurting when you use it and it starts hurting more when you use it more. It's worth noting here that a torn muscle can also hurt if you put pressure on it. Infortunately, I can't tell you much more here. 

Inflammation does mean that the joint needs rest but it's important to move enough to not get more stiff. Ibuprophen can also reduce inflammation. In December after just being inside for a few weeks I went walking and put too much stress on my new. A week of Ibuprophen was what my aunt who's a normal doctor recommended. 

But that wasn't "low level inflammation". When it comes to "low level inflammation" I think it's hard to know what's going on. When it comes to fascia or muscles you have osteopaths you have good feedback loops to understand the effects of their actions by feeling with their hands what happens. When it comes to "low level inflammation" that's a model that you can't directly feel with your hands and thus while bodyworkers might have a theory about it being a cause, they don't have feedback processes to validate that theory. 

While the theory of "low level inflammation" is plausible it's from my perspective problematic that the people talking about it don't have good ways to know whether they are right or wrong.

It's similar to how Todd R. Hargrove is someone who gathered the knowledge he has primarily through feedback loops involves movement and is therefore more trustworthy when he says "I you do these movements, that happens" then when he speculates about what the involved neurons are doing. 

It's always good to ask yourself in a field like this where a lot of knowledge doesn't come out of traditional academia how people know things and whether they are exposed to feedback loops that allow them to know what they are talking about.

Does that suggest that trigger-point release, various forms of massage and something like Paul Ingraham's mobalization prescription are good starting places?

My personal experience with messages by people trained in physiotherapy is that they often don't produce latesting effects, but it depends a lot on the skill level of the person and message is a fairly broad term.

A lot of people who do have skill trained in some particular methology that's not globally available. What's globally available is osteopaths who are generally well trained. 

I don't have much experience with trigger-point release myself nor talked about it with someone who understands how things work. If you do observe that it's a way you can reduce your body tension over periods that are more then a few hours then it's something in favor of it but it seems very indirect to me.

Replies from: BossSleepy
comment by Randomized, Controlled (BossSleepy) · 2021-06-07T15:00:43.166Z · LW(p) · GW(p)

It's similar to how Todd R. Hargrove is someone who gathered the knowledge he has primarily through feedback loops involves movement and is therefore more trustworthy when he says "I you do these movements, that happens" then when he speculates about what the involved neurons are doing.

Are you skeptical of the central nervous system sensitization pain mechanism?

Replies from: ChristianKl
comment by ChristianKl · 2021-06-07T15:29:06.163Z · LW(p) · GW(p)

My general prior is to be skeptical of most neuro-based explanations for phenomena outside of neuroscience. Hypothesis might be true, but it's very hard to check whether they are true. I generally prefer knowledge that's backed by empirics over knowledge that rests on assumptions about understanding of how a black box works internally. 

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comment by leggi · 2021-06-13T05:45:57.662Z · LW(p) · GW(p)
sporadic, idiopathic pain in another joint.

Can I clarify before I spend time writing a long answer - You are looking for a model that explains why you've now got pain in your foot (with a history of knee pain)?

If that's what you want to know, it's not complicated - pain spreads over time.

How I'd briefly explain things:

We alter position to avoid pain.

Positional changes alter the stresses throughout the body (we are connected from head to fingers to toes).

Stresses are unevenly distributed when the body is not in an ideal posture.

Alterations due to pain = not good for posture.

Poor posture = Pain.

One problem area spreads to another as the body keeps adjusting to avoid pain.

https://www.lesswrong.com/posts/gfYdtiJXFXxGeLd9X/a-good-posture-muscles-and-self-awareness [LW · GW]

I've written a fair bit about muscles, connective tissues and pain in this post [LW · GW].


I could write specifics about knee pain if want.


Otherwise, some good resources:

Basic bone physiology, pathology:

http://www.cldavis.org/woodard_bone/text/1_1.htm (veterinary - think "mammalian")

http://www.cldavis.org/woodard_bone/text/4_1.htm


https://www.patellofemoral.org/pfoe/index.html

https://www.anatomyumftm.com/knee

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4295692/


Replies from: BossSleepy
comment by Randomized, Controlled (BossSleepy) · 2021-06-13T17:27:55.726Z · LW(p) · GW(p)

Can I clarify before I spend time writing a long answer - You are looking for a model that explains why you've now got pain in your foot (with a history of knee pain)?

Yup.

I'm also looking to better understand my PF pain.

Poor posture = Pain.

I'd say I'm somewhat confused about this model, based on a reasonable amount of reading. Paul Ingraham, Todd Hargrove and Greg Lehman all point at a lot of clinical evidence that postural and structual models of pain aren't very explanatory, which I think can be 80% pithy sumerized by "there are lots of cases where people have pain in tissues that appear healthy and no pain in tissues that show visible, gross lesions and other damage." I've been working a health coach for the past few months who seems smart and well meaning -- they recommended I make some (reasonably subtle) gait adjustments to help externally rotate the femur while walking. I was quite skeptical of this theory, but I've come across the cue before (ie, to try to emphasize the outer edge of the foot more than the inner), and I've been good-faith trying it to see what happens. I'm about 60% confident that this gait alteration may be involved in the ideopathic footpain -- I've had PF pain flairups before, but never ran into this foot tendon/ligament issue.

Thank you for the resources, I'll definitely spend time with those.

Replies from: leggi
comment by leggi · 2021-06-14T11:45:02.844Z · LW(p) · GW(p)

I hesitate to use the word "posture" due to the various models it conjures in people's minds (slouching, pictures of the spine etc.) Put these images aside for a moment.

Posture = Position of the body.

All the body, at any time.

Good posture = good positioning - the body works well.

Poor posture = bad positioning.

(Bad positioning could be structural or due to inappropriate usage)

Bad positioning is bad for moving parts. Inappropriate tensions, misalignments, friction, stress.

Bad things in the body - detected by sensors, information transmitted by nerves, brain says PAIN!

The body adapts over time. Pain progresses if bad positioning is not corrected.

(One adaptation I propose - physical restrictions in connective tissues form in a response to inflammation, which can be triggered by a multitude of things. Over time these restrict range of movement, apply tension, generate pain. The body is very adaptable. It can take a lot of stress and abuse. The mind can ignore a lot of pain signals. An individual's awareness levels and tolerance affects when issues are noted/treatment is sought i.e. become clinically significant.


I'm about 60% confident that this gait alteration may be involved in the idiopathic foot pain

This is a good example of what I mean by "poor posture" causing pain.  Gait alteration = changing how you move =  altering posture/position.  If these alterations have resulted in pain, I'd classify it as postural pain i.e. pain due to poor positioning. 

Consciously changing your gait involves the activation of different muscle fibres to what you have been using.  Either this is "corrective" (improving positioning with activation of the 'right' muscle areas) or it's detrimental to positioning with increased use of the 'wrong' areas of muscle (causing stress on muscles and a progression of issues.  Myalgia, spasms, fatigue, trigger points → tensions in tissue,  pulling on periosteum "joint pain" which stimulates bone remodelling/osteophyte formation ... ) 

If you are at 60% in thinking a gait change and your foot pain are connected, then I hope you'll give real consideration to my model for otherwise unexplained pain.  (I've taken a very sudden active dislike to the word idiopathic, it's not idiopathic pain - anymore.)

My model fits with all the information I've seen over the years - quote and link to any studies you find relevant and I'll explain how. I joined LW with a "please rip to shreds" about my Base-Line theory of health and movement so please do!  I am p>99.999 confident that what I propose is right.  I'd like that rigorously tested.    Break me, crush me.  Release me from the frustration of knowing (with every fibre in my body) that I'm right ; )


I'm also looking to better understand my PF pain.

Keep studying the anatomy.

Focus on where the pain is coming from. Deep breathing, explore with your mind. 

Bear in mind, dissection photos of pre-prepared specimens are usually designed to demonstrate components rather than showing the natural state of a joint.  Schematic diagrams are just that, ligaments look like strings or ribbons crossing joint spaces at specific points, they don't show that most connective tissues aren't discrete parts, they blend from one named structure into another.  Ligaments being thickened bands within a web of connective tissues around a joint, closely associated with fascia, joint capsule and periosteum, which then blends to tendons and aponeuroses to connective tissues containing myocytes ("muscles").

Have a look at dissection videos of the knee joint. (preferably fresh rather than pickled tissues). After removal of the skin it's obvious how much of everything is encased in connective tissues - a bright white 'bandage' of fibrous tissue (mostly collagen). The ligaments of the knee are thickenings in this web of connective tissue.  A bit of tension somewhere pulls on surrounding areas.

The experience of handling a (skinned) knee brings another level of understanding. Seeing the layers.  Feeling where bits attach tightly to bone. Feeling the bits that glide as the knee flexes and extends.  The change in tension of various thickenings in the tissues around the bones.  The trochlear groove for the patella. There is much to experience.  Goat or sheep knees (known as the stifle) are a reasonable approximation if you do want to really get to know the knee. 


The joints of the leg - hip, knee, ankle, foot offer a lot of potential for movement.  The knee joint is mostly extension/flexion, it has very little medial/lateral movement  - there is almost no slack.   Any issues above or below the knee  (rotations, tensions etc. from the hip/ankle/foot which put the leg in a less than ideal position) will show first in the knee.   (The hip and ankle/foot have much more slack so can cope for longer with mal-positioning/misusage but it will appear with poor positioning).

This has good rather long and I'm out of time, but if you are interested - I could run through a diagnostic process for knee pain.