Saturday, November 15, 2014

Pain results in motor impairment, not the other way around.

Pain results in motor impairment, not the other way round. 
"Our study demonstrated that simply inducing experimental pain over the posterior sacro-iliac ligaments in painfree people resulted in the kind of findings often reported in patients with pelvic pain; a positive active straight leg raise (ASLR) and muscle guarding. This indicates that pain alone, regardless of the position or mobility of the pelvic bones, can mimic the clinical findings previously associated with ‘pelvic instability’ or lack of ‘ force closure’. The findings have implications for how we interpret what we find among patients in the clinic. It has often been assumed that these findings when present in patients with pain are the cause of their pain. In contrast, these findings suggest the opposite – that simply experiencing pain causes the body to move in slightly unusual ways, and these are signs of pain, not necessarily the cause of pain."

"This study demonstrates for the first time that pain and hyperalgesia arising from a structure superficial to the sacroiliac joint complex increases the subjective effort, activity in stabilizing muscles, and lifting quality during the active straight leg raise test. Moreover, the pain caused by hypertonic saline is related with the increase in perceived difficulty and muscle activity during the test. These data indicate that pain and hyperalgesia per se can give similar responses to the ASLR test as seen in different clinical groups and challenge the diagnostic value of the test." 

I *love* when my confirmation biases find outside confirmation! 

Now, substitute "pain caused by hypertonic saline" for "nociceptive input from a nerve, cutaneous or motor, but probably cutaneous, that can't drain and is backed up with its own metabolites because of mechanical deformation of its venous drainage coupled with the fact nerves have no lymphatics", and I think this paper is onto something.

Also, don't miss the brilliant chiro-turned-PT, Greg Lehman's, presentation (see above) which deftly deconstructs the biomechanical model in a way that it doesn't even know that it's been sliced to ribbons until it tries to stand up and falls down in a million pieces.

Palsson TS, Hirata RPGraven-Nielsen T. Experimental Pelvic Pain Impairs the Performance During the Active Straight Leg Raise Test and Causes Excessive Muscle StabilizationClin J Pain. 2014 Aug 12.

Just in case you may have missed the point:

Downfall of the biomechanical postural structural model

Thursday, October 30, 2014

The Lovely Waitress

Last week I travelled to Los Angeles to teach a workshop. The workshop went well and the visit was fun, but I'll spare you a detailed account of the double decker bus tour with the tour guide who pointed out all the hotels and nightclubs where stars had fallen from suicide, or drugs, or had been kicked out for being rowdy. Instead, I want to tell you about an inner experience at breakfast, at a nice little hole-in-the-wall bakery shop.

The twenty-something waitress came to take our order. She seemed sweet and had a beautiful smile. Her smile was nice, but hey, lots of people have beautiful smiles, and hers was no more beautiful than usual.

I was with the guy who hosted the class. We ordered lattes and something to eat.. we were busy chatting about this and that when the waitress arrived back with the lattes, and magic happened.

Suddenly, I became acutely aware that something beyond the usual was going on inside me. Something in there was responding to the waitress, or rather, to her movement. Suddenly 100% of my conscious awareness was watching her as she unbelievably, beautifully, placed two broad shallow cups of brimming latte on the table, gently, as though they were sleeping babies, not spilling one drop; the surface tension held the edge.

She smiled through this. Clearly this required making an effort, yet she graciously cancelled out any sense of this being effortful as she slowed and steadied her body to accomplish this feat, this feat which in the moment suddenly seemed as difficult a feat as anything Cirque has ever required of its performers.

Maybe the proximity was a factor as well - her arm was only a few inches away from me. Perhaps there was a small element of danger: had she lost focus, the coffee would have slid over the edge of the cup. It likely would not have spilled completely in my lap or anything, but it would have dripped off the edge, and that would have been mildly unpleasant. Instead, she rode that razor's edge of possibility, masterfully interacted with gravity in a most pleasing manner, and pulled off the impossible - laid that latte down with grace and style, but not in any way that could have been misconstrued as showboating. It was a beautiful moment.
Then she did it again, for my host.

But she wasn't done yet - she had flatware to put down. You know how waitresses usually lay down flatware after doing it a couple thousand times - kinda perfunctory, letting the weight of the flatware have its way, saving themselves a bit of energy by letting gravity win a bit too soon..
Not our waitress. She floated those six pieces down as carefully as though she were landing six small jet planes filled with precious breakables, merging them into gravity, not giving up until the very last nanosecond. She floated those pieces down. She succeeded in forcing time itself to elongate, slightly, just long enough to give my critter brain time to experience something in the outer world on its own terms, for once, and mount a surprise emotional response.

What was this response? It was awe, joy, appreciation. I actually could feel tears come to my eyes. She had created a moment of beauty with her movement that was remarkable for having occurred in so banal a setting, extraordinariness framed by ordinariness, the juxtaposition of which was extra delight in itself.
I do not feel that way very often. I have never felt that way while being served coffee by any other waitress, ever.
Both of us felt her.

I asked her name - it was Antoinette. I remarked how marvelous it was that she had managed to not spill a drop. She said, "I'm studying dance which is kind of funny because the reason I chose dance is that I'm naturally quite clumsy. In fact a lot of dancers are clumsy, and that's why we choose dance, so we can learn how to overcome it."

Well, Antoinette, all I can say is thank you for the amazing, unforgettable, closeup experience of witnessing your use of your physicality to create a moment of beauty. If you ever audition for So You Think You Can Dance, I'm pretty sure the judges will see your talent, your "it" factor, feel moved by you, and pick you for one of those tickets to Las Vegas.
You made me feel a moment of pleasure in this world, for free! - a world in which it seems I spend most of my life fending off displeasure, and I liked it. I really, really liked it.
If I had another life to live, I'd want you for my mom in that next life.


Sunday, October 12, 2014

Can manual therapy be made antifragile?

While I'm sure there are some who would like to see manual therapy destroyed and outlawed altogether, there are some, like me, who only want to see it cleaned up, objectionable explanatory models (noceboic to patients, intellectually offensive to therapists who have decluttered ourselves) removed, and practices which could maim people (high velocity or even just heavy neck manipulation, I'm looking at you..) outlawed.

I want to keep manual therapy, itself, alive. I want it to be antifragile. Well, in fact.. I think it already is solid. It's solid when defined properly. Here is the little list of antifragility principles I'd like to see manual therapy associated with. Many of them are the opposite of what the professions/culture/insurance companies demand.

Stick to simple rules
Don't try to be doctors of it - just go about helping people with their stress&pain, with physical contact, and kinesthetic reassurance.

Build in redundancy and layers (no single point of failure)
It is only what it is, nothing more. Nothing fancy. You can't lose anything by trying it, a few times at least.

Resist the urge to suppress randomness
Serendipitous ways of handling a problem will come to you in the moment, if you let it. Together you and the patient and both your nervous systems are 4 artists, physically making a work of art, in the moment. Let creativity come and play if it wants.

Make sure that you have your soul in the game
I'm not somebody who thinks in terms of "soul".. I do think in terms of critter brain, however. I'm pretty sure the two are indistinguishable. One is a human conceptualization of a set of qualities and behaviour and the other is a giant chunk of nervous system we share with all other vertebrates and without which we would be dead. So I would say, keep your own critter brain in the game. You have got to know your own, interact with it lots yourself before you can trust it to play nice with somebody else's.

Experiment and tinker — take lots of small risks
Make sure they are risks devoid of future harmful consequences, that's all. Usually smaller = slower and/or lighter.
We are connecting with nervous systems in other people. The surface of the body is so lively with info processing and conveying that you can pretty much get any message across to another nervous system without having to push hard, or fast, or perpendicularly.

Avoid risks that, if lost, would wipe you out completely
E.g., high velocity maiming, poking patients full of needles and collapsing a lung.

Don’t get consumed by data
Especially data on manual therapy, which just about always turns out to have effects that are nonspecific, at best, or else just random.

Keep your options open
As in, for example, the option to avoid certain bits that seem way too sensitive. Load in skin contact elsewhere instead. For example, a very sore or swollen ankle - you don't have to touch or "treat" the actual tender malleolus right off the bat. Twist the skin around the heel or do a balloon technique or something, stretch the skin somehow, by pulling skin toward the opposite malleolus instead. You'll get the human brain's attention without aggravating the critter brain.

Focus more on avoiding things that don’t work than trying to find out what does work
Absolutely. And the older you get the less you'll find yourself doing, and the better will be your results in the moment.

Respect the old — look for habits and rules that have been around for a long time
As far as I'm concerned, what has been around longest is that tendency vertebrate creatures have to conduct conspecific and interspecies social grooming, as long as there have been vertebrates. More recently primates took social grooming to a whole other level when they started exchanging it for not only bio (picking off bugs) reasons, but psychosocial ones as well (bringing individuals back into the troop, reducing stress after fights or someone got bossed unfairly, demonstrating caring behaviour). We are human primates and if we remember to do human primate social grooming first, that's all we usually have to do.

None of the above is the least bit incongruent with pain science.
I think we should be first responders to pain as expressed by another. Most of which is secondary to stress. Much of which is associated with muscle tension also secondary to stress, because spinal cord was the first part of the central nervous system to evolve, is the first responder to nociceptive input, and the spinal cord has never been famous for having much hard drive.
In fact the spinal cord hasn't changed a lot since fish invented it 500 million years ago. Come to think of it, that could be why vertebrates invented social grooming in such a cross species fashion.

Thursday, August 28, 2014

Claustrum? Consciousness?

The claustrum is being associated with conscious-"ness".

A decade ago, Christof Koch and Francis Crick (before he died) wondered, What is the function of the claustrum? (pdf).

Here is a new news story about this part of the brain: What the Claustrum Does—How One Makes Up One’s Mind

The claustrum consists of a thin yet broad sheet of neurons buried in the depths of the brain. Until recently its function has been obscure. Because it is directly connected to nearly every other region of the brain – especially the cortex – Francis Crick and Christof Koch suggested a decade ago that it might have something to do with consciousness...perhaps the claustrum gets it all together and acts, as Crick and Koch suggested, as the conductor of the brain’s orchestra... Recently, my colleagues (Smythies and Ramachandran) and I have suggested that the claustrum operates by strengthening the synchronized gamma frequency oscillations in the cortex that play a key role in coordinating the brain’s input and output. For example, two different sensory inputs will activate and set-up synchronized oscillations in two particular zones within the claustrum. These will be subject to further modulation by saliency mechanisms that signal the importance (i.e., significance and reward value) of what is going on. These two groups of cortico-claustro-cortical oscillations then compete on a “winner-takes-all” basis. The winner gets to activate the motor cortex (in essence, to “make it so!”) and a particular behavior results.
We should probably not get too excited though. As Robert Burton points out in BrainSciencePodcast 96, and in his book, "A Skeptic's Guide to the Mind: What Neuroscience Can and Cannot Tell Us About Ourselves", using the mind to study the brain is one thing, but using the mind to try to study the mind is an exercise in futile circularity, and there is simply no way out of the trap. 
Not that people aren't going to keep on trying. 
And telling stories.

Also, meanwhile, there are other bits involved that surely have something to do with something, e.g. the dorsal medial habenula (a part that is likely somewhat dysfunctional in me), that manages mood, motivation, desire to exercise.

Maybe everything influences everything.
Maybe, as soon as one wakes up in the morning, everything is a repeatable/repetitive neurotag.
Maybe everything is a verb, not a noun.

Monday, August 25, 2014

Rationality - attainable goal or vanishing horizon?

Some days the blogposts just write themselves. It's Monday morning, a bleak and rainy day after an entire bleak and rainy weekend. Perfect weather for
a) a heavy sigh and 

b) a depressing blogpost. 

Theme: The work to become rational/promote rationality is never done.

Supporting links:

1. The most depressing news about the brain, ever. Sept 2013 This is about American voters, but it could be about any group of humans probably. 

"Say goodnight to the dream that education, journalism, scientific evidence, or reason can provide the tools that people need in order to make good decisions."
Even if tools are provided, people don't seem to pick them up.  
"When people are misinformed, giving them facts to correct those errors only makes them cling to their beliefs more tenaciously."
Backfire effect.

2. Keith E. Stanovich, Richard F. West, and Maggie E. Toplak; Myside Bias, Rational Thinking, and IntelligenceCurrent Directions in Psychological Science 2013  22(4) 259–264 (FULL TEXT PDF)
"AbstractMyside bias occurs when people evaluate evidence, generate evidence, and test hypotheses in a manner biased toward their own prior opinions and attitudes. Research across a wide variety of myside bias paradigms has revealed a somewhat surprising finding regarding individual differences. The magnitude of the myside bias shows very little relation to intelligence. Avoiding myside bias is thus one rational thinking skill that is not assessed by intelligence tests or even indirectly indexed through its correlation with cognitive ability measures."
Take-home point: Myside bias will operate as a default mode of thinking unless instructions are explicitly given to set it aside; it has nothing whatever to do with intelligence.

3. Rationality vs. intelligence 2009, by Keith Stanovich

"Intelligence tests measure important things, but they do not assess the extent of rational thought.  This might not be such a grave omission if intelligence were a strong predictor of rational thinking. But my research group found just the opposite: it is a mild predictor at best, and some rational thinking skills are totally dissociated from intelligence."
4. Conflict as thinking: Margaret Heffernan at TED Global 2012: An epidemic hidden in plain view. 

People don't want to rock boats. It's a long learning curve for them comfortable with disagreeing, but without objective thinking, we get exactly nowhere.  

5. Against all reason: Effects of acupuncture and TENS delivered to an artificial hand. 

6. Common misconceptions about back pain in sport: Tiger Woods’ case brings 5 fundamental questions into sharp focus  Peter O'Sullivan, Aug 22 2014. 

Hat tip to Carol Lynn Chevrier, Todd Hargrove, Sigurd Mikkelsen, Barrett Dorko, and Rick Carter for these links. 
Many thanks to Peter O'Sullivan for such a rational (and hopefully, rationality inducing) blogpost.

I don't know what to do about any of this. I'm as guilty as anyone. 
Meditate I suppose.
Kill time until the end comes. 
Breathe in and out. Become fascinated by that. 

I'm not up to going off into the woods and watching the moon become the minute hand and the seasons become the hour hand. I guess I'll just keep plugging away at making pictures instead, getting them published some day. Treating patients with every minimalist bit of myside bias I can manage to muster. And continue to add links to this list.

Friday, August 22, 2014

Writing, but mostly reading

A number of months ago I joined a writing group here in Weyburn. When everyone attends, there are eight members - mostly women in our 50's and 60's, and one guy who looks about 18.

Several of the members have written and published for years - novels, children's books, articles in magazines. Weyburn, lest we forget, was the childhood home of one of Canada's favourites, W.O. Mitchell. Maybe it's something in the water. I hope.

Anyway, there are assignments. This month the assignment is nice and vague - write an essay about something that interests you. 

Good grief, where to start..

Earlier in the month I decided to take a stab at learning the basics of how to write. I found a site that discussed 8 important elements, without which, stories won't fly. I would learn how to stitch a story together from Alice Munro. Might as well choose someone at the top of the heap, right?

Lots of her short stories are online. I picked one called "Train." My self-assignment was, parse out the Munro story and decide which twist of the story fits each element.

Easier planned than done. I haven't finished this task yet. Truth is, I find her stories a little boring. I do not know why. I just do. I like Margaret Atwood's take on her stories more than I like the stories themselves. Oh well.

She didn't get the Nobel prize for literature this year for nothing, however, so I'm sure there are important things about writing I will learn by studying "Train", dissecting it, savouring it, learning to like it for its structure.

Writing that got my attention
Yesterday I read two pieces that captivated. The first was posted to Facebook by a friend of mine. (Not just some anonymous Facebook friend - an actual friend who I first met there.) 
It was a BrainPickings blogpost about the writing of Alan Watts. Suddenly I was re-inhabiting my own youth. Yeah, I remember that depressing song about "all the houses on the hillside made of tickytacky and they all looked just the same."

I grew up with his ideas. Well, not from childhood - rather when I finally achieved the right to read whatever I wanted anytime I wanted, in my twenties. I ate up everything that decade. It was the seventies. Didn't understand a lot of it yet, but ate it up anyway.

The part my facebook friend quoted is so good I'm going to quote it here, too. 
We suffer from a hallucination, from a false and distorted sensation of our own existence as living organisms. Most of us have the sensation that “I myself” is a separate center of feeling and action, living inside and bounded by the physical body — a center which “confronts” an “external” world of people and things, making contact through the senses with a universe both alien and strange. Everyday figures of speech reflect this illusion. “I came into this world.” “You must face reality.” “The conquest of nature.”
This feeling of being lonely and very temporary visitors in the universe is in flat contradiction to everything known about man (and all other living organisms) in the sciences. We do not “come into” this world; we come out of it, as leaves from a tree. As the ocean “waves,” the universe “peoples.” Every individual is an expression of the whole realm of nature, a unique action of the total universe. This fact is rarely, if ever, experienced by most individuals. Even those who know it to be true in theory do not sense or feel it, but continue to be aware of themselves as isolated “egos” inside bags of skin.
I love the idea that the universe "peoples" the same way the ocean "waves." That we come out of it, like leaves come out of a tree, then after a little while, after we've caught some sun, done our job, we drop off.  Then life goes on as though we were never there. 
Perfect.  Exact.  Bare. 
And I love that this perfect, exact, bare idea is congruent with reality, science, what is known. We are all stardust, and eventually, after we've burned through life, the universe takes back its elements to itself, and we go back to being the way we were before we were born.

More writing that got my attention
I found another article linked by yet another facebook friend that I've actually met in life,  a magazine article about a hermit who had lived in the woods in central Maine, and managed to elude people for almost three decades, living from food and cooking supplies he stole from a nearby summer resort community.  
And books he stole.  Hundreds of books. 
He was finally caught after being spotted with some fancy surveillance equipment, and put away in jail. He could barely speak anymore, but when he did, what came out of his mouth was fabulous. This:  
"I did examine myself," he said. "Solitude did increase my perception. But here's the tricky thing—when I applied my increased perception to myself, I lost my identity. With no audience, no one to perform for, I was just there. There was no need to define myself; I became irrelevant. The moon was the minute hand, the seasons the hour hand. I didn't even have a name. I never felt lonely. To put it romantically: I was completely free."
The moon was the minute hand, the seasons the hour hand.

After you've been alive for several decades, that's exactly how fast life does start to feel.  Time itself, perfect, exact, bare, ticking by, each year whacking your head against that rubber brake on your way around, on the wheel of fortune to which you are glued, spread-eagled, every year feeling as though the wheel has sped up instead of slowing down.

I remember reading something said by a woman over a hundred years old, who, when asked how she was enjoying life in her senior's home,  remarked, "It's fine, but it feels like breakfast is served about every twenty minutes." 


Thursday, August 14, 2014

My take on the role of manual therapy in the treatment of pain

1. Manual therapy is not a "thing" - it's an intrinsic behaviour evolved from social grooming in vertebrates and conceptualized by human primates, taught from the time humans could talk, bottom-up/operator style.

2. Manual therapy should be about pain and pain relief.

3. Pain, and relief of pain, is strictly a top-down phenomenon. It occurs only in ectodermal derivatives, specifically the brain. Nerves and spinal cord are antecedent, and very important physiologically, to a emergent pain production.

4. Manual therapy models must adapt, teach about pain, teach top-down, not just bottom-up, and interactively, not only operatively.

5. The senses are the only way into any patient's brain. Talking/education are paramount; furthermore, touching is allowed us; skin receptors have the fastest highway into the brain (DCML), and to its output mechanisms, by any manual therapist, so these should be in sharp focus.

6. People who get stuck in a bottom-up mindset because they ponder far too hard about what deep receptors are where, how to affect them, are going to lose sight of the whole point of touching somebody on their skin, i.e., stress and pain relief.

7. Nociception is mostly irrelevant to the brain and is handled immediately, effectively, automatically, by the internal regulation system, without ever becoming or having to become pain.

8. If anything out in the periphery needs moved, by a manual therapist, it's nerves themselves: neural anatomy is unique, crossing many tissue boundaries, and the connection to accompanying vascular supply is vulnerable to mechanical deformation (e.g., simple inactivity, habitual resting positions, or repetitive strain); enough signalling from these, over a long enough period, will challenge spinal cord cell interaction/immune cell physiology enough to change it, which can give rise to an actual pain situation.

9. Worrying or perseverating about anything else, i.e., receptors that may lie in deep tissue other than nerve tissue, or arguing to include them/it in a treatment or in an explanatory model of manual therapy, is a massive waste of time, and would serve to keep the profession mired in mesodermal mutterings, whereby we see misled therapists misleading ever more therapists into the fogbound foreseeable future.

From this thread at SomaSimple:

Wednesday, August 13, 2014

Kafka and me

Another invitation to teach in England
A couple years ago I visited England for a few days and taught a workshop. I had problems at Heathrow airport (which are chronicled here, in case anyone wants to read a big long moan about how much I dislike travelling in general, Heathrow in particular..).

Anyway, several months ago I received another invitation to go to England to teach, this time near London. This would mean dealing once more with Heathrow, and the border guards, and that hideous huge immigration room with its herringbone lines of travellers and visitors, moving slowly, very very slowly, into the country.

I hated the experience so much 2 years ago that I swore I would never go through it again, that I would rather swim to england towing my luggage in my teeth, and drag myself up the white cliffs of Dover or some other rocky shoreline to enter the country, rather than deal with the crazy-making nightmare that was Heathrow. 

My stance on that softened considerably as time went by.

Optimism bias
This seems to be the way women's brains work, e.g., re: childbirth: after going through it with the option of confining it to having been a off-time unpleasant novel experience, they seem willing to repeat it.

When given the opportunity to deal with Heathrow once again, I thought,
1. "Ah well, it can't possibly be as bad as it was the first time - after all, I have prior experience to draw on now" and

2. "This time I can get a visa - I won't turn up there without one and have to sit there being interrogated for 40 minutes about that while having to pee."
3. "I survived it once - I can survive it again. After all, I am now aware of its foibles, and can navigate around easier." 

The foibles are: massive size with terminals scattered all over the entire city of London, terrible signage, very few toilets, toilets accessible only by stairs, no wifi, long tunnels that bend and twist without moving sidewalks, miles and miles of luggage dragging, poor service, perfunctory and only accessible by direct pleading. Apparently no anticipation of the needs of travellers, jet-lagged, hungry and grumpy and completely lost.

This time, I thought, I don't even have to find the gate for a connecting flight. I just go through immigration, and then I can exit, and someone will be meeting me right at the airport. I'll be whisked away to Surrey. I think that's near Stonehenge. I might even get to see Stonehenge. Hey, it will be fall equinox!

That is how the female brain works, I guess. Sees the upside of things. Optimism bias.

Getting ready
Anyway, I explained to the new host the issues I had had with immigration. As the months passed, he and his colleagues worked closely with me. The visa must be applied for online. For the life of me, I could not work out what kind of visa I needed. It's a Byzantine site, nothing but rabbit holes leading to more rabbit holes. 

The hosts could not have been more helpful. They took a long look and decided the visa I should apply for was a Permitted Paid Engagement Visa.

I dutifully spent all Canada Day holiday filling out the application (all nine pages of it) with a couple false starts, and mistakes, which meant deleting everything and starting from scratch. But I got it done, printed, submitted, got an appointment to be processed.

I felt on top of my game, halfway there.

The trip to submit the visa application
Getting processed meant that I had to book an appointment online in Edmonton, book a flight to Edmonton, go there and back the same day. I had to be physically there to be "processed" which meant fingerprints, retina scans, giving over my documents which included passport, letters of invitation and verification of details of how long I'd be staying and where, and why, and six months worth of bank statements so they could know I had the means by which I would be able to support myself for duration of stay and not be a drain on their economy, or health system, etc.

Anyway, I got wanded, fingerprinted, all that - my iPhone and computer were not permitted in the office space, and had to be sequestered in a (unguarded) closet across the hallway. It cost an additional $112 to have my personal physicality invaded and documented. My stuff all got put into a big envelope, with a return envelop addressed to me, to be sent to New York, where Decisions On Visas Are Made By Somebody There.

The result: Utter disappointment
I made it home - twenty consecutive hours of my life I'll never get back, and a lot of expense (half of which the company organizing me agreed to pick up) - all for fricken nothing. The application was rejected because the company who hired me didn't fit the criteria for an advanced learning institution or something. They would have to be a university. They aren't - they are a continuing education company.

The company has decided to work on the problem at their end, postpone the courses for now, see if they can find a lawyer who can figure out the website and what category everyone belongs in and what sort of visa I should try to apply for next.


I think this whole situation fits the definition of a Kafkaesque nightmare:

"Kafka's writing has inspired the term "Kafkaesque", used to describe concepts and situations reminiscent of his work, particularly Der Process and "Die Verwandlung". Examples include instances in which bureaucracies overpower people, often in a surreal, nightmarish milieu which evokes feelings of senselessness, disorientation, and helplessness. Characters in a Kafkaesque setting often lack a clear course of action to escape the situation. Kafkaesque elements often appear in existential works, but the term has transcended the literary realm to apply to real-life occurrences and situations that are incomprehensibly complex, bizarre, or illogical."

Tuesday, August 12, 2014

Manual therapy "Operator" hypotheses laid to rest

For whatever reason, google docs is being cranky this morning, and won't let me share the actual doc. So I'm going to share it in this blogpost instead. It's a start, a new addition to the much more lengthy DNM References doc that is already public. I will add more as I see them and have time to add them. Enjoy.



1. Hans Chaudhry, PhD,  Robert Schleip, MA,  Zhiming Ji, PhD,  Bruce Bukiet, PhD,  Miriam Maney, MS, Thomas Findley, MD, PhD;  Three-Dimensional Mathematical Model for Deformation of Human Fasciae in Manual Therapy.  J Am Osteopath Assoc August 1, 2008 vol. 108 no. 8379-390

2. Robert Schleip; Fascial plasticity - a new neurobiological explanation: Part 1.  Journal of Bodywork and Movement Therapies Volume 7, Issue 1, January 2003, Pages 11–19

3. A Joseph Threlkeld;  The Effects of Manual Therapy on Connective Tissue.  Physical Therapy December 1992 vol. 72 no. 12 893-902

4. Cynthia Holzman Weppler and S. Peter Magnusson;  Increasing Muscle Extensibility: A Matter of Increasing Length or Modifying Sensation?  Physical Therapy March 2010 vol. 90 no. 3 438-449

5. Owen M. Katalinic, Lisa A. Harvey and Robert D. Herbert;  Effectiveness of Stretch for the Treatment and Prevention of Contractures in People With Neurological Conditions: A Systematic Review. Physical Therapy January 2011 vol. 91 no. 1 11-24


6. Adit Chiradejnant, Christopher G Maher, Jane Latimer,  Nicholas Stepkovitch;  Efficacy of “therapist-selected” versus “randomly selected” mobilisation techniques for the treatment of low back pain: A randomised controlled trial.  Australian Journal of Physiotherapy Volume 49, Issue 4, 2003, Pages 233–241

7. Rafaela L. Aquino, Priscila M. Caires, Fernanda C. Furtado, Aline V. Loureiro, Paulo H. Ferreira, Manuela L. Ferreira;   Applying Joint Mobilization at Different Cervical Vertebral Levels does not Influence Immediate Pain Reduction in Patients with Chronic Neck Pain: A Randomized Clinical Trial.  J Manual & Manipulative Therapy. Volume 17 Issue 2 (01 April 2009), pp. 95-100

8. Jochen Schomacher; The Effect of an Analgesic Mobilization Technique When Applied at Symptomatic or Asymptomatic Levels of the Cervical Spine in Subjects with Neck Pain: A Randomized Controlled Trial. J Manual & Manipulative Therapy Volume 17 Issue 2 (01 April 2009), pp. 101-108

9. Menke JM.  Do manual therapies help low back pain? A comparative effectiveness meta-analysis. Spine (Phila Pa 1976). 2014 Apr 1;39(7):E463-72.

10. Artus M1, van der Windt DA, Jordan KP, Hay EM; Low back pain symptoms show a similar pattern of improvement following a wide range of primary care treatments: a systematic review of randomized clinical trials. Rheumatology (Oxford). 2010 Dec;49(12):2346-56

11. Kent P1, Marks D, Pearson W, Keating J; Does clinician treatment choice improve the outcomes of manual therapy for nonspecific low back pain? A metaanalysis. J Manipulative Physiol Ther. 2005 Jun;28(5):312-22.


12. Wolfe F1, Simons DG, Fricton J, Bennett RM, Goldenberg DL, Gerwin R, Hathaway D, McCain GA, Russell IJ, Sanders HO, et al.;  The fibromyalgia and myofascial pain syndromes: a preliminary study of tender points and trigger points in persons with fibromyalgia, myofascial pain syndrome and no disease.  J Rheumatol. 1992 Jun;19(6):944-51.

13.  Hsieh CY1, Hong CZ, Adams AH, Platt KJ, Danielson CD, Hoehler FK, Tobis JS;  Interexaminer reliability of the palpation of trigger points in the trunk and lower limb muscles.  Arch Phys Med Rehabil. 2000 Mar;81(3):258-64.

14. Nice DA, Riddle DL, Lamb RL, Mayhew TP, Rucker K;  Intertester reliability of judgments of the presence of trigger points in patients with low back pain.  Arch Phys Med Rehabil. 1992 Oct;73(10):893-8.

15. Lucas N, Macaskill P, Irwig L, Moran R, Bogduk N.  Reliability of physical examination for diagnosis of myofascial trigger points: a systematic review of the literature. Clinical Journal of Pain 2009; 25(1): 80-89.

16. John L. Quintner and Milton L. Cohen; Referred pain of peripheral nerve origin: an alternative to the "myofascial pain" construct. Clin J Pain. 1994 Sep;10(3):243-51.


17. Zegarra-Parodi R1, de Chauvigny de Blot P, Rickards LD, Renard EO.  Cranial palpation pressures used by osteopathy students: effects of standardized protocol training.  J Am Osteopath Assoc. 2009 Feb;109(2):79-85.

18. Downey PA1, Barbano T, Kapur-Wadhwa R, Sciote JJ, Siegel MI, Mooney MP.  Craniosacral therapy: the effects of cranial manipulation on intracranial pressure and cranial bone movement.  J Orthop Sports Phys Ther. 2006 Nov;36(11):845-53.


20. Zusman M. Forebrain-mediated sensitization of central pain pathways: 'non-specific' pain and a new image for MT. Man Ther. 2002 May;7(2):80-8.

21. Zusman M. Structure-oriented beliefs and disability due to back pain. Aust J Physiother. 1998;44(1):13-20.

22. Zusman M; The meaning of mechanically induced responses.  Australian Journal of Physiotherapy Volume 40, Issue 1, 1994, Pages 35–39 (FULL TEXT PDF)

Friday, August 08, 2014

Collection of references

Since I haven't been inspired to blog in over a month, I feel like I should take advantage of the teeny spark of dopamine that seized me today.

I've had my mind on other things lately - joined a local writer's group (we've met three times since I joined), started running (yeah I know - shock), tried (and failed) to procure a visa for teaching DNM workshops in the UK (not my bad - the Brit gov. for having such a Byzantine website that none of us on either side of the pond know what the eff is up or how to pick the right kind to apply for). 

Plus I've been making many nice pictures of the neurovascular system in all zones of the body. Here is one:

I want people to learn how interconnected nerves (green) are with the vascular system. It travels everywhere in the body, joined together, as the neurovascular bundle. This is the physiological tubing upon which everything else depends, for life. Without it, gangrene would set in.

The nervous system, including 72 kilometers of nerve, brain, spinal cord (oldest part of the CNS), is only 2% of the whole body. Two percent. Tiny in mass, but mighty in that it manages everything. Every little thing. Uses 20-25% of all available fuel to do so. Day&night, 24/7. Which means, it needs blood flow, needs it now, must have it or it will think it's dying. Nerves must have constant access to fresh blood and constant drainage of used blood, or they'll complain. Bitterly.

According to Sapolsky, the cardiovascular system is only 5% of the body, but is so finely divided and distributed that no body cell is more than five cell-widths away from a capillary. The fuel lines to and drainage lines away from nerves are delicate and subject to kinking. Nerves do not have lymphatics, according to most sources. So, "sewage" backup can occur. Not good for neurons - they hate that.

Vessels need nerve supply. If they don't have nerve supply they deteriorate, because neurons supply the tissue of vessel walls with necessary trophic factors. Plus, the vessels wouldn't be able to constrict or widen without neurons to ask the smooth muscle cells in the vessel walls to act.

So, they are completely co-dependent systems, traveling everywhere together and depending on each other.
When you do manual therapy, please keep in mind that all this tubing is in there, and monitor your pressure carefully. Maybe try working smarter by taking advantage of reflexive behaviour of the NS instead. It's not about you, it's about it.
On Facebook recently this was posted: Therapist as operator or interactor? Moving beyond the technique, my one and only (probably forever) citation in pubmed.

It was added to with this radio interview: 

Moving beyond the technique: From Operator to Interactor

A bit further on I added the foundational paper I wrote that it was based on:
Operator/ Interactor - Google Docs: Manual therapy and its treatment models

This wonderful blogpost at Body In Mind was included: Starting conversations - has Jason hit the silvernail on the head?  It referred to Jason's thread on SomaSimple,  Enough is Enough, about joint heads, disc heads, fascia heads, all that.
Great commentary under the BIM blogpost.

Great review in general.

Add to that, Adam Meakins blogpost, There is no skill in manual therapy..? 
In it, he lists several references to papers that combined, support everything Jason had to say about how we can leave tissue-based reasoning in the waste basket. 

"I learnt you can't break down scar tissue, adhesions, 'release' a muscle or fascia (Chaudhry 2008,Chaudhry 2007Schleip 2003Threlkeld 1992)"I learnt that by stretching a muscle in a certain fashion, in a certain way, for a certain amount of time doesnt effect it's structure (Solomonow 2007Weppler 2010Katalinic 2011)"I learnt that you don't need to mobilise or manipulate a joint in a specific direction, based on a pattern of pain or specific assessment of movement and joint feel (Chiradejnant 2003Aquino 2009Schomacher 2009Nyberg 2013)"I learnt that palpation of muscles, joints, trigger points are all unreliable and leads therapists to misdiagnose often and direct treatment down wrong and ineffective pathways. (I have done a blog on this topic recently with all the supporting evidence here.)
"I learnt that when all the methods and techniques of manual therapy are examined through the process of systematic reviews and meta analysis most of the research is poor and even the good research shows that it doesn't do much (Menke 2014Kumar 2014Artus 2010Kent 2005)"
Thank you for your well-organized reference list, Adam! 

I would like to add a list of my own, that I file under "Skin is the outside of the brain" in my google doc of dermoneuromodulation references

1.  Walsh LD, Moseley GL, Taylor JL, Gandevia SC. Proprioceptive signals contribute to the sense of body ownership. J Physiol. 2011 June 15; 589(Pt 12): 3009–3021. (FULL ACCESS)

 2. Tomás J. Ryan and Seth G. N. Grant; The origin and evolution of synapses. Nat Rev Neurosci. 2009 Oct;10(10):701-12. Epub 2009 Sep 9. (FULL ACCESS)

3. Valeria Gazzola, Michael L. Spezio, Joset A. Etzel, Fulvia Castelli, Ralph Adolphs and Christian Keysers; Primary somatosensory cortex discriminates affective significance in social touch. PNAS 2012 ; published ahead of print June 4, 2012,doi:10.1073/pnas.1113211109 (FULL ACCESS)

4. Gallace A, Torta DM, Moseley GL, Iannetti GD; The analgesic effect of crossing the arms. Pain. 2011 Jun;152(6):1418-23. Epub 2011 Mar 26.

5. Carsten Dahl Mørch, Ole K. Andersen, Alexandre S. Quevedo, Lars Arendt-Neilsen, Robert C Coghill; Exteroceptive aspects of nociception: Insights from graphesthesia and two-point discrimination. PAIN Volume 151, Issue 1 , Pages 45-52, October 2010

6. R Shechter, K Baruch, M Schwartz and A Rolls; Touch gives new life: mechanosensation modulates spinal cord adult neurogenesis. Molecular Psychiatry 16, 342-352 (March 2011) | doi:10.1038/mp.2010.116

7. Desmond J. Tobin; Biochemistry of human skin—our brain on the outside. Chem Soc Rev. 2006 Jan;35(1):52-67. Epub 2005 Oct 26. (FULL ACCESS)

8. Paul L. Bigliardi, Desmond J. Tobin, Claire Gaveriaux-Ruff, Mei Bigliardi-Qi; Opioids and the skin – where do we stand? Experimental Dermatology Volume 18, Issue 5, pages 424–430, May 2009

9. Aaron L. Williams, Gregory J. Gerling, Scott A. Wellnitz, Sarah M. Bourdon, and Ellen A. Lumpkin; Skin Relaxation Predicts Neural Firing Rate Adaptation in SAI Touch Receptors. Conf Proc IEEE Eng Med Biol Soc. 2010; 2010: 6678–6681. doi:  10.1109/IEMBS.2010.5626264 (FULL ACCESS)

10. Scott A. Wellnitz, Daine R. Lesniak, Gregory J. Gerling, and Ellen A. Lumpkin; The Regularity of Sustained Firing Reveals Two Populations of Slowly Adapting Touch Receptors in Mouse Hairy Skin. J Neurophysiol. 2010 June; 103(6): 3378–3388.

11.  Lumpkin EA, Caterina MJ; Mechanisms of sensory transduction in the skin. Nature. 2007 Feb 22;445(7130):858-65.

12. Boulais N, Misery L.; The epidermis: a sensory tissue. European Journal of Dermatology. Volume 18, Number 2, 119-27, march-april 2008, Review article (FULL ACCESS)

13. Björnsdotter M, Löken L, Olausson H, Vallbo A, Wessberg J.; Somatotopic organization of gentle touch processing in the posterior insular cortex. J Neurosci. 2009 Jul 22;29(29):9314-20. (FULL ACCESS)

14. Hansson T, Nyman T, Björkman A, Lundberg P, Nylander L, Rosén B, Lundborg G.; Sights of touching activates the somatosensory cortex in humans. Scand J Plast Reconstr Surg Hand Surg. 2009;43(5):267-9.

15.  Rotem Ben-Tov Perry, Ella Doron-Mandel, Elena Iavnilovitch, Ida Rishal, Shachar Y. Dagan, Michael Tsoory, Giovanni Coppola, Marguerite K. McDonald, Cynthia Gomes, Daniel H. Geschwind, Jeffery L. Twiss, Avraham Yaron, Mike Fainzilber; Subcellular Knockout of Importin β1 Perturbs Axonal Retrograde Signaling. Neuron Volume 75, Issue 2, 26 July 2012, Pages 294–305 (Also, see news story about this: Long-Distance Distress Signal from Periphery of Injured Nerve Cells Begins With Locally Made Protein, and Crucial Protein for Peripheral Nerve Repair Manufactured Within Axon Near Injury Site)

16. Edin BB; Quantitative analysis of static strain sensitivity in human mechanoreceptors from hairy skin.  J Neurophysiol. 1992 May;67(5):1105-13.

17. Collins D et al;  Cutaneous receptors contribute to kinesthesia at the index finger, elbow, and knee.  J Neurophysiol. 2005 Sep;94(3):1699-706 (FREE ACCESS)

human central nervous system. J Physiology 1995 487.1 243-251 (FULL TEXT PDF)

Seriously, there are still way too many people who discount the effect that distorting skin (and the nerves that plug into it from beneath) will have on the central nervous system, as it frantically tries to make sense of novel exteroceptive kinesthetic input, to deal with any possible threat, and in the process might dismantle some positive feedback loops that are counterproductive.

For more about positive feedback loops, see another great blogger, Erik Meira, on the topic: Getting rid of something positive. 

Getting rid of conceptual clutter (another kind of positive feedback loop) is an issue in human primate social grooming in general. OK, make that, in the whole culture.
I saw this great little piece this morning on Bigfoot, science, and approaching truth through the null hypothesis: Why we can't rule out Bigfoot.

 You can't ever prove Bigfoot does not exist, but you can come very very very very close, close enough to jump that tiny gap and take a principled stand against nonsense.
In our varied and multiple human primate social grooming professions, we could do the same, as Adam Meakins has done.
Then we could rule the nervous system of the person we are treating, in.

That's all we have to do.