Thursday, June 21, 2018

Ortho Division in Canada is taking a look at itself, finally.




Is it ever about time, too.
Seriously.
Apparently there was a big meeting recently, and this appeared on twitter:


(Did I miss something? Did someone imply we were?)
It seems like a response to certain individuals on SoMe who are especially voluble about the way manual therapy continues to conduct its affairs in ways that have been mostly debunked. Alas, the ortho div. seems to want to bolster its fortress instead of coming out of it to join with the rest of us.

"...the OD provides a layered educational system that works for many people in terms of time commitment, cost and structure. It provides a solid framework with which to approach clinical interactions, starting at the tissues and working through whole body regional interdependence."

And that might just be the problem, right there folks. Too tissue-based, too peripheral. Like looking through a telescope backward, such a perspective does not let you see much. Learning about human functioning starting with tissue does not lead to much understanding of humans or of their pain problems.

How about starting with nervous systems first? What they do, besides run commands out to muscles? What they want and need? Is that really so impossible?
.........


I have many thoughts about this:

1. Not only that the entire edifice of ortho PT is built around issues supposedly existing in tissues, but also the huge emphasis on (accurately!) palpating joints/joint movement, which has been found to have little if any interrater reliability. Yet to get your black belt in ortho, you had to have your palpation accuracy given the nod by your instructor. (I remember Bahram Jam admitting that even with his three black belts he still couldn’t really feel anything.)

I went to ortho school many years ago: an instructor described how hard it was to feel joint movement in "dumpy middle-aged women with cellulite." I dropped out about 5 seconds later, because what was the point of learning all this tissue-based, biomechanical joint-based minutia if you could only treat thin people with it? If it did not address pain problems being suffered by moderately overweight people who constitute about half the population? Were we supposed to just leave them out? What nonsense. I knew I could help people with pain problems already, no matter their size.

2. The obvious nocebo inherent in blaming "tissue" for pain problems. Check out Adriaan Louw’s work for more on that. Also Peter O’Sullivan’s.

3. Lack of evidence for what constitutes "good" movement as opposed to "bad" movement.

4. Discomfort (as a recipient) with having one's joints moved instead of one's sensitized(!) nerves considered, then handled carefully.

5. Joints are the deepest thing in the musculoskeletal system. Why go there first? This seems exactly backward. This is a touching profession; we touch the outside of the body first, so why not think about physical contact from the outside in rather than inside out? The outside is actually the most sensitive! Furthermore, movement does not only happen at joint surfaces - it happens throughout all layers and structures and tissues.
.......

"Yes, we still learn about biomechanics (joints do move, after all) but also about the neurophysiology controlling joint and muscle function, movement screening, pattern recognition, pain science and exercise dosage. We are taught to clinically reason, to think in terms of the biopsychosocial model and to treat according to those influencers. It certainly isn’t all mobs and manips. The syllabus has come a long way."

Maybe you are evolving, Ortho Div., but it still looks to me like something that started out the way this did is still going to have all the same problems. Joints are still the centre of the universe in this system, seems to me.  And the whole thing, like the ortho biomedical model, is still resting on top of a Cartesian model of pain. Why oh why do you insist, Ortho Div., on putting the body before its operating system, the brain, and why do you insist on emphasizing motor neurology ahead of sensory neurology? Manual therapy might want to re-think itself in light of the fact that new sensory information is coming in from a well-meaning manual therapist and that brains might be able to use that info to self-correct output, both motor and sensory (ever heard of the Neuromatrix theory of pain by Ronald Melzack?). That would both take the load of responsibility off the therapist AND be more meaningful from a person-with-pain perspective. Please see my humble effort at distinguishing between operator mindsets compared to interactor mindsets.

"The update is now underway and the new manuals will be released in early 2019. Would it have been nice to have them sooner? Sure. But the OD is a large not-for-profit organization, founded and run by volunteers – it’s a big ship to mobilize and refurbish."

About refurbishing the ship, maybe the ship should never have been expected to sail on dry land in the first place. Maybe we need to build a vehicle with wheels. And if it's a cart, the horse should be in front of it, not behind.
Alas, putting the structural body before the sensory nervous system
 in manual therapy training
makes about this much sense.
 

I have gone to some trouble and no small pains to develop a model for manual therapy that makes more sense. To me anyway. Here is a list of some 85 pages (at this point) of references to support my point. Oh, and wrote a book as well, linked to the top of the page.













Monday, May 14, 2018

Starting in the middle of the mobi-"us" strip that is the human nervous system

Earlier today I posted about starting in the middle.

I have always been fascinated by how the nervous system is like a mobius strip, in that it seems to effortlessly turn everything coming into it into everything that goes out of it, including all the bio into which it is embedded.

In Todd's blogpost (find link in mine) he included a nice picture of a nesting doll to illustrate how complex systems are composed of simpler subsystems.

I have taken his image and have tried to illustrate how the brain and everything it can do in terms of predictive processing, can mobi-"us" everything, including a sense of self, then project that out onto the surface of the skin through its ability to create representational maps.

This image is still pretty crude. It would work way better as an animation, but I don't know how to make one of those, so just try to imagine this thing in action, the way the brain is, always, always more a verb, not a noun. Not a noun until it's dead.

I have tried to include the way a mobius strip turns everything inside out and outside in.
To me, that's what the neuromatrix is like: a mobius strip, constantly in motion, churning through life like a weird looking egg beater, trying to turn everything into Meaning.

So, you can read it bottom up or top down.

Top-down would be the biopsychosocial aspects of a human brain.
Bottom-up would be bio aspects, constantly and continuously feeding into the mobius strip. Until it's dead.

The middle is where that mobius strip crosses over itself. I think if I had to pick an anatomical location to represent that, it would be brainstem. Fastest way to get to the brainstem from the bottom up is through low-threshold mechanoreceptors and their attached giant big heavily-myelinated very fast fibres.  They will work best, though, when top-down has been prepared properly, first. 







Starting in the middle


Todd Hargrove wrote a new post based on his talk in Oslo recently, in which he described systems thinking, and how it can be helpful for complex problems like treating pain; here is a link:
The Big Picture of Pain

From the blogpost:

"At the “lower” levels, you can view the health status of cells and organs like muscles, tendons, discs or nerves. For example, maybe your foot hurts because of a stress fracture. This is where you can find "issues in the tissues", which is where traditional pain treatment has focused most of its attention. This is often called the "biomedical approach" or the "bio" part of the biopsychosocial model. You find the structure that is damaged and work to repair it.
"At the “higher” levels of analysis, such as the person or the environment, you are looking at more complex phenomena – the role of thoughts, emotions, or social relationships. These are the “psychosocial” issues that are known to have very important effects on chronic pain. Problems in these areas are often relatively subtle, more about dysregulation or imbalance than something being broken or injured. These issues are also invisible if you look for them at a lower level. For example, you can't see catastrophising by assessing a foot - you need to talk to a person."
In between "lower" and "higher", there are threads that must connect. After all, people are individuals, aren't we?
Undividables.
What about "middle" levels?
As a PT I aim mostly at the middle levels, which I define as how someone habitually inhabits their own "bio", and which give me options of exploring to either side, either bio* or psychosocial. 
*(And when I consider "bio" I'm really only thinking about the 72 km of peripheral neural tree, most of the time. The fact that neurons need physiology to get their groceries and drainage. Neurodynamics.) 

Lest we forget, people are physical entities. They have mass.
They are constantly being operated on by the "environment," which, to make life simple, let's reduce to the most basic of physics, air pressure and gravity.

Most of the time, they can re-arrange their relationship to these two things, by simply arranging their bodies differently with respect to them.

People adopt default resting positions, that IMO have a lot more to do with eventual mysteriously-arising "pain problems" than anything else in life, be it strictly bio or strictly psychosocial. (I like to stay away from these two polarized extremes. I always have.)
 

Sometimes the reasons people do what they do with their own body stem from psychosocial reasons, sometimes for clear bio reasons, most of the time for reasons that are probably completely innocuous and seem to have been lost in the fog of time. 
Examples: why someone crosses their left leg over their right, but never the right over the left. Why someone leans on the right elbow on the couch, but never their left. 
In the case of leg crossing, it could be a bio reason (one hip is actually shaped differently than the other), or it could be a choice (perhaps the patient is a psychotherapist and "learned" or taught herself or himself that crossing one leg, not the other, led more easily to a sense of security and boundary between them and whatever their client was saying to them). 
In the case of leaning on one elbow, there might be a bio reason (the patient has only one elbow!), but usually there is a psychosocial reason (territorialism at home "this is my spot on the couch") or a context reason ("The way I have my furniture arranged, this is the easiest way to watch TV"). 

Helping people spot their own physical behaviours (mostly lop-sided usage) is often a revelation for them. They have been mostly unconscious about these, all their lives. Becoming aware (of anything) is the first step toward change (of anything).

Thursday, April 26, 2018

Ann massaged me

Yesterday I arrived in Taiwan for the first time. First time ever in Asia, in fact.

I found my way through all the corridors and immigration lines to the exit, where I saw a long line of signs with names on them, arriving people being met by locals.
Two smiling young women held a large blue sign with my name on it.
We greeted each other, posed for smiling pictures under a large sign that said Welcome to Taiwan.
Someone's phone rang before we got a taxi - it was another host who informed me she would be waiting for me at the hotel and that they had booked me for a massage at a nearby spa. 


By now I had been up longer than 24 hours without being horizontal, one of the least good things about traveling. I also felt like I needed a shower. Taipei is hot. They reassured me that it didn't matter, I could go get the massage without needing to take a shower first.

We got to the hotel. My hosts, by now numbering 4 young women, escorted me up to my room, made sure I was connected to the internet, made sure everything was OK.
I'm not used to having so many people taking care of things for me. Very luxurious.
The room itself is very luxurious, a giant kingsize bed, a large bathroom with heated toilet seat, a washlet that can spray at least four different ways, a large walk-in shower and and deep soaker tub, both, gold faucets...

Anyway, I had no time to enjoy any of that because there was a massage therapist waiting for me, and they seemed very determined that I go meet her and let her do her thing. My impression was that they could not imagine anyone who might not be attracted to the idea.
I had not received a massage since... about 1994 I think.
I've never been that crazy about massage, getting it from a stranger, even though I learned to do it in physio school, and remember that I liked it a lot at that time.

In any case, I complied, caved to peer pressure, and off we went.

........

We walked halfway around the block to the spa.
I was given slippers to put on. Shoes and socks sat in neat rows in the front lobby. The place was quiet, smelled good, was full of quiet smiling people serving ginger tea.
My massage therapist, Ann, ushered me into a room at the back; a raised bleacher-style bench was punctuated at intervals by large round crocks. She asked me to sit in front of one of them. She sat at a low stool on the other side. Slippers came off. Feet went into the crock. It was filled with lovely hot water. She proceeded to massage my feet and lower legs up to the knees with some oil and some gritty stuff that felt good. She even filed away at my calloused heels. I was glad I had been doing that for myself, so that someone else handling my 67 year old feet would not find them as cracked and rough and thickened as I had, a couple years ago... Amazing how time takes a toll on foot epidermis. I use foot cream on a regular basis, which helps a lot.

As she worked on my feet I noticed that the floor behind her had a long strip of large glass panels, under which swam live goldfish.

When the foot treatment was finished, slippers went back on and she escorted me to the toilet, indicated that I should use it. So I did.
When I emerged she took me to the massage room, a lovely room with a sliding door. We went in. She opened up a small package, and pulled out the smallest pair of panties I've ever seen in my life, a g-string really, made of the same stretchy material as panty hose are made of. There did not seem to be any point in putting them on, but she wanted me to, so I did, to help her maintain her own professional boundaries. She gave me lots of time to get my clothes off and get comfortable face down under the blanket with my face in the hole. Lovely quiet spa music was playing.

She came in and went to work. My awareness became completely kinesthetic. First, she made complete contact with my entire back and back of hips and legs through the blanket. Just some lovely pressure. She would make contact slowly, then accelerate. Like she knew what my brain needed, how it liked being contacted or something.

She put hot wet towels onto my back. Something inside me melted when she did that. A bunch of spinal tension I had had when I first lay down, and when she had first pressed through the blanket, went poof and just.. disappeared.

She uncovered the entire lower left limb. First she massaged it in its straight position, then she bent it up like a frog's leg and worked on it some more. She did not leave out the foot, even though she had already worked on it in the room with the fish and the big crock pot.
Then she did the right leg.
Then each arm.
Then the neck and back.
The table was very wide. Clearly, she was up on it, and working very symmetrically with both hands. Yet I never felt her touch me with any part of her body except her hands.
I thought to myself that she must be very strong and agile, and that this was hard work. That she must be pretty tired by the end of a day.
Then she said, lie here for a moment, and left the room. After awhile she came back in, and covered my back with hot wet towels. She used some sort of hot sandbags on it also.
When she was done she asked me to roll over onto my back. Which I did. As she held the blanket up in front of herself like a curtain, to preserve my modesty.
The blanket came down over me.
She moved behind me and worked on my neck some more. She rolled my head to one side, massaged my head and ear. Then the other way. I was pretty limp by then. I can't even remember the last time someone was able to turn me into a cooked noodle like that.
She asked me to sit up, worked on my shoulders some more, then let me know we were done.
I turned to look at her, and saw she was wearing a face mask!

This is something I have seen a lot of people wearing here.
The woman who processed me at immigration was wearing one.
I don't think they are sick. I think they are protecting themselves from inhaling other people's germs probably. 


The entire massage encounter had lasted about two and a half hours. But it all had gone by in a flash. So nice to feel a different sense of time, to experience each moment as a Now, not be sucked into either the past or the future.
I got dressed and exited the room. She was there to guide me up the hall. She gave me her arm, in case I stumbled. The hall was basically a set of railway ties, painted black and heavily varnished and impeccably clean, quite close together with white rocks in between. But you do have to walk on the ties, not the rocks. I guess that was a way to make people's brain come back into focus - give them a small predictive motor task.
I was taken back to the tea room. It had floor seating all round the wall, flat foam cushions with wall cushions for leaning back. I was given a plate with ginger tea and some sesame cookies. When I was done with the tea, I went back to the front lobby and put my shoes and socks back on. 


My hosts had vanished, and it was now about 6 pm. I didn't wait long though - they arrived en masse to walk me back to the hotel - Joanna, Rainbow, Livia and Tina. 

After a quick shower I joined them downstairs - another host had joined us - Poppy. We went out for a lovely dinner at a restaurant just across the street, and I had the opportunity to remember how to use chopsticks. 






Tuesday, April 24, 2018

Yeah... about burnout. Been there, done that.



Rajam, my San Diego friend and CEO of the San Diego Pain Summit, posted a thread to Facebook and linked a blog post by a recent physio grad who was fed up and had decided to quit physio. She is planning to include a workshop in the coming 2019 SDPS that will explore this topic.

It reminded me of my own episodes of burnout, how they felt, how I navigated them. I posted the following:

"I graduated very young (age 20) and flamed out completely several times right away (mostly because of being so immature). Most of the time I left PT behind completely and did something else for awhile, always knowing: 
1. That I could go back to it if I wanted; 
2. That I really didn't want to right then. 
I would throw myself 100% into something else. Nothing else I did ever worked out, not the way I wanted it to anyway. And always (bizarrely!), I would start to miss physio after a year, or two, and I would go find a job somewhere and start over. I started over So Many Times. Mostly because while I liked the work I hated the jobs and the work environment (hospital). 
Things I escaped to:
1. University (several times)
2. Tried to be a real estate agent for awhile. Which was way worse. 
Things I assiduously avoided:
1. Marriage
2. Children 
After about 13 years of going back then quitting again then going back, I left the province I had grown up and worked in (Sask) for an entirely new life (B.C.). I managed to adapt and reconciled burnout as being not about the physio but about the physio JOBS, and did a lot of locum work to get by. Locum work suited me perfectly. I had no responsibility, didn't have to "fit in" anywhere, didn't feel obliged to participate in longterm work relationships, just parachuted in, handled patients for somebody, then left a few weeks later when they came back. And I did some travelling, learned Spanish (sort of). 
I bumbled along through life for a couple decades that way, until I finally felt ready to have my own practice. After that I settled down quite easily, and it was about 15 years later I got itchy feet again, moved back to Sask. almost a decade ago. Took a two-year sabbatical. Opened a new practice. Have bumped that one around three times before finding it a forever home.
It's been a crazy pothole filled road full of sharp bends and several times in the ditch, but no serious accidents. I managed to do it my way, which happened to not have been the usual way, that's all. Me and physio, we've been married for 47 years but not monogamous (at least I wasn't), and eventually I think we simply got used to each other. It has always taken me back, so that's something good right there. I've seen other careers not last nearly that long. 
And I've moved personal (home) location about 30 times in that 47 years. I can't even begin to remember how many different places I've worked. Lots and lots, enough to see the grim underbelly of both private and public practice. I only really "loved" physio after I got my own practice together, which looks way more like a massage practice, really. But I like it. Nowadays I call it my retirement practice. About a half-hour away, there is an old osteopath, in her 90's, who still works, still sees patients out of a trailer. I often think to myself, that will probably be me, working with people in pain until I drop dead, because why not? Life blows by and then you die. So why not do whatever you most desire at the time, whatever turns your crank for awhile, all the way through it?"


Looking back, I realize that burnout is mostly just a brain's way of signaling that it needs novel stimuli, a change, a rest, a chance to spread different wings, try new tricks, to take a break. By caving into my own brain every time I got that signal, I hope I managed to preserve most of it for my old age. Or maybe I simply had social attention deficit disorder. Not biological, because I can focus like a fiend on anything if, and as long as, I want to.
Wanting to. That's where the rub lies.
Other people's expectations may not be, may never have been, congruent with my own.

Life is not for sissies. I have come to appreciate (especially after reading Damasio's book!) that most of my own personal conscious awareness became locked up in navigating boundaries between 'self as authentic individual' and 'self as member of the human primate troop', locked down into the delicate psychosocial navigation needed to live life (on the one hand) according to my own psychobiological drives and demands, and (on the other) the human intricacies needed to dance with the rest of the people I had to work with and deal with, neverendingly. Which is always hard, but especially for an introvert.

In the video called The Quest to Understand Consciousness, Damasio briefly described various sorts of self, and a quick superficial tour through the brain.

I built a few slides of screenshots I took. These slides will be in the presentation I am scheduled to make in Taiwan. Thanks, Damasio. I cannot wait to see you live in person, Feb 2019 at Rajam's conference.


1. All the major action in our nervous system has to funnel back and forth through the brain stem. When I refer to "nervous system" I include the peripheral nervous system; enteric, sensory, autonomic. So does Damasio. 








2. A close-up of the brainstem reveals that it has a dorsal part and a ventral part. The dorsal part (red) contains many closely and heavily interconnected nuclei that regulate survival and homeostasis, including the periaqueductal grey (PAG), which as we know, is crucial in pain regulation. 




Note that it is also connected to the cerebral cortex.
Ah-ha! Thoughts and perceptions can influence our physiology. See?
AP = Area Postrema (controls vomiting)
NTS = Solitary nucleus (regulates gustatory things among many others)
PBN = parabrachial nuclei (more about food intake, also breathing and cardiovascular regulation)
SC = ? not sure. Maybe superior colliculus, to do with vision
hypothalamus = regulates everything to do with everything. 



3. If the dorsal part is damaged, say by stroke, you lose your mind. Your body will carry on for awhile all by itself, and later with a lot of help from caregivers, but you won't have awareness, be able to form thoughts, nothing. No volition. Total oblivion.
If the ventral part is damaged, say by stroke, you can get locked-in syndrome, where you have plenty of volition but no access to your body. None. Unable to moooooooove. Unable to communicate. (Seriously, can you imagine anything worse? Which is why I will go to my grave denouncing high neck manipulation. But that's for a different blogpost.)

The colliculi are for vision and hearing. The brain itself will take in visual and auditory stimuli and make sense out of them, concoct a story long before "we" (the "I"-illusions riding around in the same nervous system that is the boss of us, not the other way around) can possibly become aware of said story. 






4. Then I made a slide of the remainder of his talk, about all the different "selves" we have thanks to evolution. (This is what his entire new book is all about.)
Every animal (including smart invertebrates, probably) have proto and core selves. In fact, in the book he talks a lot about bacteria and how they get along with no nervous system at all. How they operate as individuals (un-divide-ables) and also when in a group.

Autobiographical selves are a lot fancier. I think he should have included elephants, but that's just my opinion. He jokingly included dogs, which I left out.
Their main claim to fame is they have access to past events, and future possibilities, the ability to imagine different scenarios, and the capacity to make meaning out of all of it.
At once.

The human species is off by itself in a text box, because of the way we have become so utterly dependent on culture to regulate us.

This is what I was referring to earlier, re: burnout. So much psycho-social hard drive seems to get burned through simply adapting to each other, other people and their ways, starting with family and the culture itself and its history, our society and what "it" (whatever it is) expects in terms of behavioural homogeneity from its citizens. We all have that hypothetical cross to bear.
For introverts the cross seems extra large and heavy.
So.
Much.
Work.
So.
Tiring. 




















Thursday, April 12, 2018

Damasio's "The Strange Order of Things"

I just finished my first read-through of this new book.




It's so good.

Rarely does a single book include the evolution of nervous systems all the way from single cell organisms forward to humans. But Damasio doesn't leave out a single thing. He includes all the functions of nervous systems as well as all their bits, in order of their appearance, and manages to line them up appropriately with different stages of nervous systems in evolutionary time. I appreciate this because it's what I try to do in my own lectures; I figure that if you can understand the nervous system as a movie through evolutionary time, you can understand its function better.

His organizing theme is that homeostasis is the driving force and anchor point for everything that living organisms, with or without nervous systems, can do.

It's such a great book that I want to go through it carefully, blogging all the way. I want to sift through each idea (and there are a LOT of them, including ideas about pain that are brand new to me), and ponder how they relate to our profession.

I guess we shall find out if I have the time and the energy both in sufficient quantity to fulfill such an ambition or if the ambition is just a fleeting dream. Right now I still have jet lag, and I can't make a firm committment in such a state.

While I consider the pros and cons, here is a recent (2017) video of Damasio speaking about the same subjects he discusses in his book.




Here is a recent review of his book. LINK 

.

Tuesday, April 10, 2018

Into everyone's life a bit of knee pain may fall

I have just returned from teaching a class in Barcelona.
Lovely city.
Glad I finally had an opportunity to see a bit of it, namely the Gaudi architecture.

In Europe, the bathroom stalls are like small rooms. They are floor to ceiling, with doors that close completely - no gaps.
They also often have a small step up.

So, the first day at the teaching venue I went to visit the ladies' room.
I blame jet lag. I blame the fact it was the first teaching event of the season and I was adrenalinized.
I blame myself for forgetting there was that small step.

On the way out of the stall my brain made a stupid motor prediction error.  The floor was about 3 or 4 inches lower than I expected. My brain did not account for the step. The floor wasn't where it was supposed to be. My foot hit the actual floor and jarred my whole body. 


From then on the knee was very crabby with me. 

It's getting better now, 5 days later, and it felt fine the day of the incident, but the next day, it refused to climb or descend stairs smoothly, and after I had sat awhile, getting up and asking it to move felt quite painful. Medial knee, saphenous nerve, of course... 
I taped it, which helped me feel it much less so I could focus on the people and not on myself.


In younger years there would not have been pain associated with a dumb move like that; I know because I've made dumb moves like that in the past, and they didn't used to bother me. I wonder if, when we get past 60, 65, if the immune system doesn't get grumpier and stronger? Quicker to throw mast cells at anything? For any excuse?

Or the whole spinal cord? Maybe as the brain starts to falter, the spinal cord seizes the opportunity to do what it tries so hard to do against all that built-in descending inhibition, which is to be an amplification system for nociceptive input. 


I have this fantasy that the spinal cord sits in there, resentful and fuming that the brain grew big out of one end of the brainstem while it, the spinal cord, stayed the same. 

That it struggles all its life to take precedence again, as it still does in fish, and be The Main Event, the star of the central nervous system.

I fantasize that it plots a takeover, or more accurately a takeback, gradually erodes the system, makes small gains, and eventually (in aging mammals, primates, humans) succeeds to a certain extent. That it does this by making nociception much bigger and more dramatic than need be and the spinal cord glia stronger/more facilitated, which go on to sensitize the sensory branches of a peripheral nerve, whichever one received the most mechanical force during some predictive coding mishap.
Positive feedback loop.
Spinal cords, doing their protective thing but at the same time hastening physical entropy! 


Maybe the reason for doing deliberate daily exercise/movement/strengthening is simply to activate all large fibre sensory input from muscle, in order to keep spinal cord function locked safely in its cage. (See Foster et al 2015, my favourite paper so far about stimulating glycinergic interneurons in the spinal cord that inhibit nociceptive input at the first synapse in the dorsal horn.)


This is me, age 67, pondering and probably trying to talk myself into exercising more regularly again.
I have always said aging is not for sissies. 

..........



Friday, March 30, 2018

Hey hey, ho ho: Those bogus outdated ill-informed egotistical operative tissue-based treatment models have got to go

It's so effing simple really...

1. Humans are social
2. Humans can end up in pain

3. Pain is biopsychosocial
4. Manual treatment for pain is human primate social grooming (yes, we are fancy primates. Human, but still wired as primate). 
5. Brains are predictive. Especially human brains, because the "I"-illusions in there can remember the past and predict the future (see Triple Threat blogpost)
6. When we do manual therapy, we play with people's sensory nervous systems, and somatosensory cortices. And these cortices are full of all sorts of responses that have to do with that individual's psychosocial history. 

7. There is sufficient bio in there that most of the time, we don't have to delve into every detail of any of that. Unless the person really needs/wants to.
8. We have to allow time for their brain, and them, of course, as part of their own brain, to sift with lightening speed through all the cargo they have accumulated over their lifetime, and permit new hierarchical and parallel processing to occur, such that old bits of brain and newer (more recently evolved) human bits can negotiate new communication pathways. 

9. Many of those old bits regulate physiology.
10. It might take a few minutes, but eventually, new orders from rostral areas of the brain will inform the integration areas inside the spinal cord to re-organize autonomic output, and sensory input. Mostly through inhibition.

We, the therapists, must avoid taking credit for ANY of this. It's all nature operating, not us. We are merely interacting with the most complex object in the known universe, the human brain. The reason we can become good at it is due to the fact that we have one that is equally complex and sophisticated, neurologically speaking.

Other attributes that are helpful in our line of work:
 - Patience
 - Curiosity

 - Willingness to get up every day and go do it all over again
 - Good interpersonal boundaries
 - The right mix of respectfulness and playfulness and empathy
 - A bit of fearlessness doesn't hurt
 - Not blame ourselves too hard for all the failures we will encounter, or mistakes/logical fallacies we have made in our own thinking in the past
 - Determination to not fall prey to hubris or narcissism or heroics, or even entertain such notions or behaviours secretly inside our own minds. 

Thursday, March 15, 2018

Triple Threat

.
.
.

This is spurred by a facebook conversation yesterday, here.

The theme was Daniel Dennett, his assertion that consciousness is an illusion, in this review by Thomas Nagel of Dennett's new book, From Bacteria to Bach and Back: The Evolution of Minds.
I've always appreciated Dennett's take on life - he confirms my own bias every time.

Anyway, the conversation rolled along, and someone asked, "..illusion to who? Who is the user?"

I replied, to the "I"-illusion. I first encountered the idea of an I-illusion reading Deric Bownds' Mindblog. Such a handy little idea!

So, there is nothing to stop two illusions interacting in our human brains, is there?

Someone else pointed out he had no problem with consciousness being illusory, or with self being illusory, but what about all that subjective experience that accumulates over a lifespan? Surely that's real.

But wait, what if it's all illusory as well? Then we have the triple illusion, the big three-headed dog, the Cerberus we must all learn how to deal with while staying sane at the same time. Cerberus guards the gates of Hades to keep the dead from leaving but I bet he also keeps the living from entering.


No wonder we get so tired

That idea excited the bejeebers out of me and I rolled with it.

I'm pretty sure one could argue this using Damasio for support, and Sapolsky.
I happen to be reading both of their new books at the same time.
Sapolsky's is Behave: The Biology of Humans at Our Best and Worst.
Damasio's is The Strange Order of Things: Life, Feeling, and the Making of Cultures.

Someone in Scandinavia sent me a link on Twitter, a piece by Galen Strawson about how Dennett is not on track. I read it, but found Strawson wasn't exactly on track either: he ended with:
"If (Dennett's) right, no one has ever really suffered, in spite of agonizing diseases, mental illness, murder, rape, famine, slavery, bereavement, torture, and genocide. And no one has ever caused anyone else pain.This is the Great Silliness. We must hope that it doesn’t spread outside the academy, or convince some future information technologist or roboticist who has great power over our lives."
Really? That seems unnecessarily fear-mongerish. I would call it a strawman from Strawson.
Humans are going to continue being humans, regardless.

Sapolsky studied baboons for many years and laid a strong foundation for good ideas related to stress, stressors, what makes us humans, what sort of primate dominance business we still get ourselves up to. I think he would point out that alpha males have the hardest time self-regulating stress, and tend to deploy it outward by beating up on other members of the troop and thereby end up as dominant. The rest must simply suck it up and go on as best they can, and try to stay out of his way.

Damasio places everything inside the frame of homeostasis, (including stress-regulation probably!) in his new book "The Strange Order of Things". I haven't read very far into it yet, but he lays careful groundwork by pointing out that even bacteria, who no one could accuse of being conscious, nevertheless form communities and jostle for position within them and between them.

Another piece I read recently was Physics Makes Aging Inevitable, Not Biology. I loved it!
Here is the intro:
"The inside of every cell in our body is like a crowded city, filled with tracks, transports, libraries, factories,
power plants, and garbage disposal units. The city’s workers are protein machines, which metabolize food,
take out the garbage, or repair DNA. Cargo is moved from one place to another by molecular machines that
have been observed walking on two legs along protein tightropes. As these machines go about their business,
they are surrounded by thousands of water molecules, which randomly crash into them a trillion times a
second. This is what physicists euphemistically call “thermal motion.” Violent thermal chaos would be more apt.
How any well-meaning molecular machine could do good work under such intolerable circumstances is
puzzling. Part of the answer is that the protein machines of our cells, like tiny ratchets, turn the random energy
they receive from water bombardment into the very directed motion that makes cells work.
They turn chaos into order."
Now we are getting into thermodynamics.
Seriously, we are matter, there is no denying that.
Matter is subject to the laws of thermodynamics whether we like it or not.
We're all gonna die.
At some point.
Everything has to go to entropy. Thermodynamic equilibrium. Our brains, self-stimulating though they are, and giving rise to all those illusions we call "self," and "I", and "consciousness", and "subjective experience", all turn off at the same time the brain does. Because it just stops keeping itself, and them, going.
I am reminded of another great book I read years ago, Into the Cool: Energy Flow, Thermodynamics, and Life. 

"Working from the precept that "nature abhors a gradient," Into the Cool details how complex systems emerge, enlarge, and reproduce in a world tending toward disorder. From hurricanes here to life on other worlds, from human evolution to the systems humans have created, this pervasive pull toward equilibrium governs life at its molecular base and at its peak in the elaborate structures of living complex systems. Schneider and Sagan organize their argument in a highly accessible manner, moving from descriptions of the basic physics behind energy flow to the organization of complex systems to the role of energy in life to the final section, which applies their concept of energy flow to politics, economics, and even human health." 

I'm pretty sure Damasio would like that book.

Anyway, lots of food for thought. I just can't help myself, I'm a reductive materialist I guess. Or a neutral monist. Depends what mood I'm in and what time of day it is. So much self-regulating to do all the time.






Monday, January 08, 2018

Nervous systems, getting old.

.

Once in awhile I pick up a book I've had for ages, that I bought long ago because it looked interesting and I thought it might be useful someday, but never actually cracked.
Lately I picked up Aging of the Autonomic Nervous System, edited by Francesco Amenta, published waaaaaaaaaay back in 1993. 

(Gee, that's the year before I finally opened my first solo practice in Vancouver!)

Anyway, Chapter 2 is "The Peripheral Nerve." Given that there are 72 kilometers of this in the human body, and given that I try to treat this in people, and given that I just had a birthday and am definitely aging, it made sense to start there.

There are some very nice sections on what happens to entrapped nerves/neurons over time. In particular, section D, "The Vasa Nervorum in Aged Nerves" stands out. 

To me. 
We are as old as our cardiovascular system. 






Read Chapter 2 here.


...

Thursday, September 28, 2017

Re: Non-specific FX

Re: non-specific FX:
You know how all the literature on manual therapy says, when you read between the lines, is that it's "no better than placebo" ? Well, that's a good thing. It has taken away all the dreams from the dreamers, those who 
imagined their way of doing manual therapy was BETTER than any other way. Mostly this has deflated the orthopaedic manual therapy community, because of all the manual therapies out there, the practitioners (and studiers it must be emphasized) of OMPT were among the most strident about how much better their ways were than other kinds. Mostly though they were riding a wave of confirmation bias that sort of looked as follows:
1. People in pain often have impaired movement. Movement is important.
2. Movement is best measured at joints. Let's study the FX of our work by measuring ROM
3. Move the joints, bring back the movement. Pain should go away.
4. Voila, we have confirmed that pain comes from joints.
It became one of those closed loop ideas, self-referencing and self-confirming.

I never bought it, because in order to do OMPT properly you had to be able to feel joints and joint movement, so you could only do it on thin people, which a) left out all the fat people with pain and movement problems, and b) I knew I could help people of any size with their pain and movement problems without ever having to feel their joints, because I was working on their surfaces, not their depths, in the first place. In other words, I always found OMPT illogical.
In the end I feel vindicated because studies show there is no interrater reliability for palpation or diagnosis (too many type I errors). Good science shot down the myth that had grown that OMPT was superior.

We are straight back to non-specific FX again (of which placebo is just one kind, but not the entire story), which makes me glad. I embrace non-specific FX, because the hunt for specific FX from manual therapy has been futile.

Studies are starting to look like even orthopaedic surgery (for pain) is 'no better than placebo' for a lot of things.
If people are going to do things to other people that are 'no better than placebo', at least be kind! at least don't mess up their body even more!
On the other hand, there are all those studies that show major confirmation bias, like ones for needling and acupuncture showing good results. And just as many that say the results are NOT specific. Again, why be poking through skin with needles when toothpicks work just as well? 

Taking the long view, that all manual therapy is non-specific, and that measuring an outcome does not prove an effect, I am more relaxed about doing this work than I ever was in the preceding 40 years, more willing to sit back and do non-specific things somewhat specifically, and let peoples' nervous systems do all their own heavy lifting to get themselves out of pain.

I'm totally willing to teach other people my set of tricks, that have sufficed for all these many years, plus new ones I have made up more recently, all the while telling students that they need to be adaptable and can make up their own new tricks, they have my blessing. Not that they need it. But they must FIRST sit through a very long lecture about the nervous system, its care and feeding, all the info I have about pain and brain mechanisms that pertain to manual therapy, with all the emphasis on the sensory portion, all the cutaneous nerves, so they will know what they are touching. And that they will be affecting the person, not the person's "body." And that they will accomplish more by doing less, and being kind while doing it, not hurting people more than they already hurt, unloading sore spots, not loading them more.

I'm totally willing to help people but I'm no longer willing to worry hard about trying to fix anybody. I do my best and that's all I need to do. I don't charge for results, I charge for my time. And inside the time people buy from me, I focus 100% on them, try to disconfirm all their noceboic beliefs, touch them very carefully and slowly and lightly where they hurt, load into them quite heavily where they don't hurt, and give their systems enough time to adapt until I can feel responsive changes in their physiology slow down and stop. Then I move on. Until the hour is up. 

My results/outcomes have not been formally measured, but I would lay odds they are just as good as anyone else's.

.........
Old posts about non-specific FX:
Oct 20, 2012
May 15, 2014
May 20, 2014