Abduction and Neurogenic PainThe Problem of Like Goes With Like

The patient says, "I know it's the muscle because I can feel it." Those of us familiar with abnormal neurodynamics know full well that this complaint is due to a nervous irritation and that the muscular nociceptors aren't significantly involved. We also know that our efforts to change this thinking and get the patient to understand and pursue treatment designed to restore normal neurodynamics may prove rather difficult. This isn't because our idea isn't plausible or too complicated. It's just new, and because the meme of muscular pain is fighting for space in the patient's brain and is already entrenched there, there's no guarantee that our idea will win this battle. It may help to throw all of our authority and clinical skills into the fray, but success is never assured.
The root of this problem is explained by Gilovich and Savitsky in a brilliant article titled "Like Goes With Like: The Role of Representativeness in Erroneous and Pseudoscientific Beliefs" (Skeptical Inquirer March/April 1996). The authors describe the use of heuristics, "judgmental shortcuts that generally get us where we need to go-and quickly-but at the cost of occasionally sending us off course" to make connections that appear logical but are untrue. (See "The Fatal Heuristic" elsewhere on this site. Also, read the book "Blink:The Power of Thinking Without Thinking" by Malcolm Gladwell) They use the supposed similarity between the sensation produced by stress in the gut and that produced by a peptic ulcer as an example of a heuristic that led physicians to believe that stomach acid produced ulcers. They were wrong of course, but the doctor's personal, visceral experience hooked that meme powerfully into their consciousness and dislodging it in favor of Marshall 's alternative explanation became an enormous task.
Similarly, the traditional ideas concerning the presence of "musculoskeletal" pain and the role of the contractile tissue as weak or short or lengthened or injured or in spasm or palpably sore is entrenched and encouraged by many wonderful and effective clinicians. It's been my experience that teaching an alternative to this thinking that includes the latest studies in neurobiology has little effect on their theory or practice. Acceptance of the concept of abnormal neurodynamics as the primary reason for chronic discomfort requires that therapists shift the meme of muscular pain from its central role, and this will be allowed only after a major battle; a battle the idea of abnormal neurodynamics may not win.
So how did Breig do it? And, how did those of us who have revised our thinking about chronic pain relinquish the memes imbedded in our brains concerning the traditional attitudes about musculoskeletal pain and replace them with the concepts of neurodynamics and the consequences of its abnormality? I'm proposing that we have engaged in abduction. We have listened to countless patients describe sensations that cannot be explained using the paradigm offered us in school and one day said instead, "If abnormal neurodynamics were present that would account for the patient's complaint-it would explain their story in a way that doesn't violate what we now know to be true about the nervous system."
This sort of reasoning is neither common nor easily done. It requires study, creativity and, most of all, courage.
Do it anyway.

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