Monday, June 25, 2018

Critique of traditional non-surgical, yet operative approaches

Some papers I’ve gathered up, on page 79 of 85 at this link:

2. 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.

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

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

6. Lederman E; The myth of core stability. J Bodyw Mov Ther. 2010 Jan;14(1):84-98

7. Hartman SE; Why do ineffective treatments seem helpful? A brief review. Chiropractic & Osteopathy 2009, 17:10 doi:10.1186/1746-1340-17-10 (OPEN ACCESS)

8. Pekka Kuittinen, Petri Sipola, Tapani Saari, Timo Juhani Aalto, Sanna Sinikallio,Sakari Savolainen, Heikki Kröger, Veli Turunen, Ville Leinonen and Olavi Airaksinen.  Visually assessed severity of lumbar spinal canal stenosis is paradoxically associated with leg pain and objective walking ability.  BMC Musculoskeletal Disorders Clinical diagnostics and imaging Volume 15 (OPEN ACCESS)

9. Sutton C, Nono L, Johnston RG, Thomson OP. The effects of experience on the inter-reliability of osteopaths to detect changes in posterior superior iliac spine levels using a hidden heel wedge.   J Bodyw Mov Ther. 2013 Apr;17(2):143-50

10. Pattyn E, Rajendran D. Anatomical landmark position – Can we trust what we see? Results from an online reliability and validity study of osteopaths. Manual Therapy Volume 19, Issue 2, April 2014, Pages 158–164

11. Video, 7:21 Andreo Spina; The easily fooled nervous system: How immediate changes in NS function are misinterpreted Apr. 9, 2015  (I include this because it’s important to stay humble, faced by the overwhelmingly self-corrective capacity of the nervous system in another person. In other words, we shouldn’t let ourselves take credit for successfully interacting with someone else’s nervous system, or as manual therapists, remain married to invasive or unnecessarily violent forms of treatment.)

13. Troyanovich SJ, Harrison DD, Harrison DE. Motion palpation: it's time to accept the evidence. J.Manipulative Physiol Ther. 1998;21:568–571.

14. Tullberg T, Blomberg S, Branth B, Johnsson R. Manipulation does not alter the position of the sacroiliac joint. A roentgen stereophotogrammetric analysis. Spine. 1998;23:1124–1128.

16. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ; The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther. 2009 Oct;14(5):531-8 (FULL TEXT)

17. Joel E Bialosky, Mark D Bishop, Steven Z George, and Michael E Robinson; Placebo response to manual therapy: something out of nothing? J Man Manip Ther. 2011 Feb; 19(1): 11–19. (FULL TEXT)

18. Diane F Jacobs and Jason L Silvernail; Therapist as operator or interactor? Moving beyond the technique. J Man Manip Ther. 2011 May; 19(2): 120–121. (FULL TEXT)

19. Bahram Jam; A new Paradigm in Manual Therapy: Abandoning Segmental Motion Palpation. July 15, 2016 (FULL TEXT)

20. Adam Fehr’s thoughtful blogpost series about manual therapy (the orthopaedic sort) with lots of references:
3. Manual therapy: Treating under contemporary manual framework

Thursday, June 21, 2018

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

Is it ever about time, too.
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?
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.