Friday, May 20, 2016

Society vs: culture vs: chronic pain

It is not without a bit of trepidation I tackle all this awkwardly, for I barely know what I'm talking about... it's been a very very long time since I've sat in a sociology class soaking it in or have involved myself in political aspects of life. However, I have opinions after being alive this long. And this is my ancient blog that no one reads so I'm safe to express my klutzy ideas here.

Part I: Prelude: 

Lately I've been pondering the difference between society and culture. There is a difference. It's political.
The one demands conformity to be able to perpetuate itself, and it does so by oppressing the other. If it cannot oppress it covertly, by persuading its members there is no difference between the two, then it oppresses overtly. It doesn't really care.

For example, society and state usually overlap, completely.
Society goes on forever until or unless toppled.
Voting is actually the way the state maintains itself; it doesn't matter who you vote for - the government will win. So, allowing voting was a clever move: it is a way for the state to pretend it is a democracy, so it doesn't get toppled.

To be sure, toppling the state would mean generations of anarchy and turmoil and maybe a series of dictators or militarist gangs or a theocracy springing up. Most of the culture and subcultures, e.g., women, anyone who is coloured differently than the dominators, has a different set of values, language, religion, etc.etc., would be worse off than ever. State-toppling is not a good alternative.

The rules are in place to keep everything running smoothly, and in our society, to keep money flowing away from producers and toward hoarders, who generally can change the rules to suit themselves, and who are generally old white males.

Culture is ever-changing and growing from the grassroots; it is forced to adapt to society. If your culture doesn't fit the society, or adhere to its values, you are by definition an outsider.

Political parties (the old established ones, at least) represent the poles of differences between society and culture. For example, conservative parties, when in power, squelch down on culture and anything related to the well-being of ordinary people by pulling back on funding or else refusing to fund it at all. Example: Here in Canada, conservatives were in power for a decade, and managed to cripple state-funded health care, research, and a lot of other benefits to taxpayers. They massively propped up the oil economy. They did not manage to get Canada completely out of debt, the thing they had decided well in advance was the most important thing. They seemed eager for war.

Ordinary people who vote for conservatives think they are the most rational; they want to preserve social order and maintain or improve status quo. They usually place any needs of heterogeneous groups of people way down on the list. They fear change. They tend to view themselves as parents who support the state as ultimate parent, and anyone else who is, or thinks, or votes any other way as childish. They are a bit like the stern dad, who goes for the gusto and to hell with anybody who gets in his way.

In Canada, last fall, they got booted, and the other pole was elected. Liberals are now in power.

Liberal parties do promote culture as well as state. They are two-faced that way. Which is why conservative voters don't trust them much. On the bright side, they operate from an egalitarian position - that everyone is equal and adult with varied concerns. Like the mom, they want everyone to be as happy as possible.

Liberal voters are often immersed in a let's-feel-good-now way of existing and living. They do have a point - life is short and then we die, so there should be something to help slide us along easier than pointlessly sacrificing and suffering while we're here. They tend to see the state as a parent and themselves as dependents.

They managed to convince the public they would move the country forward by removing cultural obstruction that had accumulated the previous decade. They would shift the cultural landscape. They would restore funding to everyone. They would right old wrongs and heal rifts between state and cultures. They would make sure everyones' social well-being was not only restored but their interests furthered. To cut them some slack, for sure, they got right to work on a lot of projects to soothe cultural feelings and relieve some of the cultural oppression, some of which have been accomplished and others that are still being worked on. Here is the Trudeaumeter that makes it easy for regular people to keep track of the progress being made by the Canadian government. They are planning to legalize marijuana, for example.

One of the things that had piled up, that the conservative party had put way way down the list, was right to die legislation. Which leads us to the next part of this post.

Part II: Right-to-die

Now in my mid-60's, and part of the baby boom that strained every resource the state ever had in place and ever had to install to accommodate such a large increase of an age demographic, I got kind of used to the state accommodating me and not the other way around.

My personal fantasy is that by my end of life, there will be little kits you can just order at the drugstore, whether by prescription, because let's keep doctors inside the loop, or over the counter if doctors don't want to be kept in a loop. I will be done. Not imaginary thy, I.
I might not be sick, but I will be done. With living.

I will be able to go get a kit, or else, if I'm disabled somehow, I'll be able to get one delivered.
I'll call the ambulance, or whatever societal transportation method is officially in place by then, somebody aboard with rights to pronounce death, to produce an official death certificate that will tell society I'm gone and to stop sending electrical bills to my address, notify my relatives, etc..

I'll tell the transport what time to come and pick my body up. I'll leave the door unlocked for them. I'll crawl into and lie down in the tub: in case the ambulance is late, I don't want any body fluids to leak onto my condo floor and ruin its resale value and leave a lot of bother for my indirect (as in, I have no direct) descendants to have to deal with. I will take the potion. I will go immediately unconscious and won't feel a thing. I'll simply go dark.

The transport will take my carcass off to the crematorium.
No mess no fuss.
No huge medical bills.
Low carbon footprint.

I realize this seems macabre, a bit; it seems that way even to me. But in another 20 years? A lot of us will be dying off all at the same time, and it seems reasonable to try to think of ways to save society money in advance. Think of all the children.

Part III: Drama in the house

So, the other day, the government and the parties in the house were all faced with having to parley through all the stressful taxing hugely socially responsible topic of having to come up with something on the issue of right to die for the Supreme Court of Canada, who had struck down the law against assisted dying, earlier, and had imposed a deadline for new legislation.

This is something the conservatives would not ever have come near with an eleven-foot disinfected barge pole. But the liberals? it is a cultural thing, something they had already promised to deal with, so it was theirs to stickhandle.

The deadline was the rock, conservative opposition was the hard place, and the Liberals were up against the clock. Yes, the NDP, the party of progress, was involved as part of the hard place too, but here is why. The Liberal party, the official government with a massive majority of seats, had looked at the situation, the deadline, all the other stuff they still had to get to, and decided to do this thing that the governing party can do if it chooses, which was to close debate and move on.

But: opposing parliamentarians did not like that idea. They wanted to slow things down a bit. The NDP behaved kinda badly by forming a physical crowd barrier to a conservative who had to get to his seat before discussion could resume. I have no idea if that is even legal. But they did it. And Trudeau got a bit annoyed.

Trudeau is not an old white guy. He's a guy, and he's white, but he's young, and he's a boxer.

Maybe he comes by his reaction to being stalled, and what came next, honestly: His father was somebody who gave the public his middle finger when he became annoyed. He swore at other constituencies, then later claimed he had said "fuddle-duddle."

So maybe it was genetic. Or maybe J. had a testosteronic moment, was a temporarily so stressed alpha male human primate that he lost it. Maybe it was all the boxing. Maybe it wasn't.

Whatev' the case, he got mad, he marched down and broke through the knot of people, went after the conservative. He knocked a female NDP MP in the chest accidentally in the process, with his elbow.
For more re: the kerfuffle that followed, see Trudeau's elbow neither the beginning nor the end of Liberal troubles, by Chris Hall.

To the public, and to the media, it was like mom and dad were having a fight, and it had got a bit physical. Needless to say the issue of the blocking and whatnot mushroomed and completely eclipsed the business of dealing with legislation. Maybe nobody was really ready to get on with dealing with something so fraught with opposing viewpoints, soul-searching, and the pressure of time, as legalizing assisted dying is. For more, read Know what's deeply traumatic, Elbowgaters? Needing assisted dying.

Part IV: Dying of pain

OK, finally the topic has meandered around to something I'm keenly interested in and have been since forever, the topic of pain, how the issue of chronic pain is woven into a societal tapestry, and suffering from it therefore if it counts as enough of a "thing" to be a legitimate reason for assisted dying. The topic is starting to be addressed by PT bloggers. See Tim Cocks' post, The ultimate pain killer. 

One of the biggest aspects of pain is that is feels like it will kill you, yet it never will. Because it can't. Because it's only a perception of a sensation. It's not a real "thing" - i.e., it's not an actual medical condition stemming from an actual problem with an actual tissue, the way the biomedical model assumed it was, and would still like it to be.

Yes, there are biomedical aspects to it, physiological glitches, genetic components, neuroanatomical peculiarities sometimes, perhaps: but they aren't diseases and they don't kill you either. Pain makes you feel like shit. Then (if it won't go away on its own, or you can't find someone who can help you by using a variety of placeboic, non-specific tricks, like manual therapy, which only works for the most basic kind anyway, which fortunately is also the most common), have to learn to deal with it. Live life in spite of pain. There are LOTS of helpers to help with that.

While I am somebody who does my best to alleviate pain, with my life, and work, and advocating, I think there are things definitely worth thinking about:

  1. The risk of un-assisted suicide in the chronic pain population is high. See Completed suicide in chronic pain. 
  2. The rate of un-assisted suicide in the chronic pain population is high, by opioid overdose. See Depression, chronic pain, and suicide by overdose: On the edge. 
  3. 50% of chronic pain patients have depression. See Suicide attempts in chronic pain patients. A register-based study. 
  4. Migraine, back pain, and psychogenic pain (whatever that is) are linked to higher suicide risk in vets. See Certain chronic pain may raise suicide risk.

Part V: What should I make of all this?

OK, here goes:
  1. I'm more of a liberal than a conservative. (But I do not vote liberal - I'm more leftoid than that.) 
  2. I can see the point of there being an ebb and flow in society, with conservatism being in power once in awhile. But not too much for too long, thank you. (I do not vote conservative, I'm way more leftoid than that. )
  3. Still, I hate when society oppresses cultural flowering. I'm a member of a few oppressed groups in society, myself. With the help of institutionalized white privilege, though, and women's rights groups who made a lot of societal progress before I was born, and while I was still a child, I made it through life reasonably well as a single female who was never turned into a uterus with arms and legs, whether by societal expectations or cultural trap. 
  4. While I've never been, and never will be, rich, I don't care: to me that is not the point of living, and as long as I can pay the bills and save enough to live on for when I become feeble, it will all be fine. 
  5. I think the point of living is to work hard to figure out how to live without harm to self and others, and try to leave the world a little better than you found it, if you can. And not by merely reproducing and just hoping for the best. If you are going to have children, raise them without harming them in the process. (Frankly, I'm glad I never had any, because global warming.)
  6. I appreciate forethought and planning by society to keep societal services intact. I do not mind paying taxes to those objectives. I could never live in a country that did not look after its citizens' hospitalization and health care, that instead does not care if they become impoverished by accident. 
  7.  I do not have any political or moral objection to assisted dying. I would want "society" to care for my suffering the same way I cared for my beloved cat's old-age suffering; I arranged for her to be put down. 
  8. I do think that pain drives people to kill themselves. 
  9. I do not think pain is very well understood, yet, by society itself, or by any of the cultures oppressed by society, or by very many of the unfortunate members of oppressed cultures under a dominant society who experience pain chronically. 
  10. If you have chronic pain and are a member of an oppressed group, your pain may be worse and you may receive less help for it. Like if you are female. Because biomedical studies are usually done on male mice and human males. 
  11. If you are female and do not have white privilege,  you are doubly unfortunate, probably. 
  12. Once marijuana is legal, there will no doubt be a lot of studies on its effects on pain. 
  13. Maybe once it has been made legal and people are free to smoke it, pain will either be decreased, or else people will be distracted enough from pain, among other things like social oppression, that they won't commit as much suicide for all the reasons they currently do, un-assisted.
  14. Maybe the issue of assisted suicide for chronic pain will go away, because a legal tool (marijuana) that allows people to space out and assists them to invent then have a life in spite of pain, will cancel out their wish to cease living before they are done, physically. Then assisted suicide can be in place, less tendentiously, for actual already-recognized diseases that people want to die to get away from. 
  15. Maybe everyone will go even more nuts than we already are. But perhaps we'll be less stressed out about all of it. 
  16. It has never ever been easy to be a self-aware human primate and juggle all this hierarchical social structure and find a way to live with it all. It never will be. 
  17. Meanwhile, global warming. Trudeau is working on that too, or at least, promised he would. 

Here is what I think might help them all get back up on track: Trudeau (and his wife along to chaperone), arrange to visit her office to (hopefully) meet with her, or if she won't meet with them, drop off flowers and a beautiful handwritten note apologizing yet again, asking her forgiveness, etc., for the final time.
Then get back to business.

ADDED MAY 21: 'Elbowgate' has made mountains out of molehills.
I agree: "Jack Layton would not be pleased."

Wednesday, May 18, 2016

Dangling no more

Done with dangling

At last. 
Way behind the imaginary schedule I had in mind but failed to live up to. A year behind, actually. 
I finished the book slash treatment manual slash deconstruction of tissue-based operative treatment models and have sent. It. In.

Not that there won't be dozens of little mistakes and tweaks needed and maybe even rewrites. But at last, I found the flow that was so elusive. And I managed to get everything in that I wanted to say.

That inability to follow the schedule I thought I should stick to is OK, because it had been arbitrary in the first place. I satisfied the main itch, which was more important: to say what I wanted to say and how I wanted to say it. 

Thursday, April 07, 2016

Evidence vs: plausibility in manual therapy

About "evidence-based" vs: "plausibility-based" - here's the thing. At least, here's the thing the way I see it.
You cannot prove any specificity with manual therapy. None that I know of, anyway. By that I mean, you cannot prove any cause-effect relationship. You can't prove that when you do x, y always happens. Sometimes y happens, and sometimes z happens. Sometimes nothing happens. The point is, you will never EVER 'know' what's going to happen. It's a crap shoot. N will always equal 1.
Take stroke following neck manipulation. That's pretty specific, right? Seems to happen a lot, right? An ER nurse I talked to once said that in her ER alone, she saw at least three per year, strokes following neck manipulation, by chiro. But let's not stroke out the chiros by talking about stroke *from* chiro, even though nearly 100% of the reports of death and maiming are about chiro neck manip. In fact that's the only time chiros seem to want to dissociate themselves from manip, instead of conflating themselves with it .. but I digress.
A manipulation event occurs, followed shortly thereafter by stroke. You would think it would only take one or two of these before the law would catch on and declare neck manipulation a kind of assault and battery. Especially since it leaves the patient mad and angry and feeling betrayed, and often litigious.
But no, neck manipulation is still allowed, probably because it cannot be "proven" to be causal! (see Roger Kerry's paper, Cervical spine pre-treatment screening for arterial dysfunction: out with the old, in with the new -  which lists a bunch of red flags for neck manipulation. Also see Harriet Hall's latest on the topic of no evidence, Chiropractic and Stroke: No Evidence for Causation But Still Reason for Concern.

We get nowhere in manual therapy, trying to find "evidence."
In fact, the DNM group page on Facebook was started by the researcher I was working with, years ago. She left the group after the study went down in flames. I remember her explaining about P values, confidence intervals, trend lines... talk that still gives me a dull headache. See the link Keith Eric Grant provided re: P values and how slippery it all seems to be,  Scientific method: Statistical errors.

In the end we had to toss the study because the subjects had backfilled their data books - one thing statistical analysis was good for - picking up on patterns that looked too perfect!
I don't want to sound negative about science - I love science. In the broad sense, I mean. A wide-angle view on the world, reality-based. And who knows? Maybe some day somebody will figure out the right question to ask, and put the right frame around it, and be capable of demonstrating some sort of direct causal connection between human primate social grooming and pain relief.
But I will not hold my breath waiting for that to happen:
If you can't "prove" that manual therapy (the stupid kind) is specifically causal for maiming and killing by stroke, I will bet the farm that you will never be able to "prove" that your light, slow, kind, interactive, responsive and *intelligent* ways of working at the surface of the body are specifically causal for pain relief.
It will always boil down to "non-specific effects." I.e., the patient's brain hacked its own self (in some smart, specifically unrepeatable, non-lethal way!) and changed its opinion about the state of its body, because, context.
So, that is why I prefer to think of a dermoneuromodulating approach as being plausibility-based instead of evidence-based.
We are already where we want to be, which is as far as we can get anyway, if we go with plausibility instead.
So, when you treat around the head and neck, please don't press hard on ANYthing there. And no jerking, K?
Set a favourable context, embrace uncertainty, let your fingers and hands be receptive, not blunt weapons, do no harm, and hope for the best.

Michael Leunig's brilliant cartoon.
It sums up the reality of the non-clarity of manual therapy.

Saturday, April 02, 2016

Pain does not equal nociception

Reading about pain can be very confusing. Why? Because those who are writing unconsciously or deliberately, from a biomedical standpoint, continue to conflate nociception and pain.
Once you learn the difference it is not so bad. Your brain will grow an automatic translation program that kicks in all by itself.

Here is the one I use:

1. Pain is a perception, perceived as a sensation.
2. The nervous system is separable, for mental exercise sake, into "central" and "peripheral"
3. Spinal cord is "central" nervous system, as is brain.
4. Once a signal reaches the first synapse in the dorsal horn, bam! it has reached the central nervous system.
5. Up to then, a noxious signal is merely nociception.
6. After that, if it makes it past that first hurdle, up to the thalamus and beyond, it may contribute to a pain experience.
7. Note that I said may contribute, which leaves space for a lot of other processing and inhibition before something else, called "pain," might be even potentially experienced.
8. Pain is multifactorial. Which means, experiencing it depends on a large number of factors.

It is good to know something about general features of sensory systems, the difference between tonic and phasic firing, and the difference between temporal and spatial summation, the difference between interoception (which, as far as I am concerned, includes proprioception) and exteroception. It's also good to know about the skin organ and where neurons came from. But none of those is what this blog post is about.

Thursday, March 03, 2016


I thought I had invented this word, dogmasphere, recently, at the San Diego Pain Summit, while conversing with old friends and new, but somebody else beat me to it, it seems. Always good to google your ideas and new words to see if someone else has invented them before you.

Anyway, when I use this word, I am referring to a spherical world of opinion divorced from any grounded thinking. It's round, like a ball. It floats, detached from reality. It has layers, accreted over time. People live inside them. Manual therapy is full of them. The inside is reflective, lined with mirroring, inside just as shiny and reflective as the outside. You can't see out but you and all the people who agree with you are reflected on each other in so many ways that you start to think, that's just life. 

It's like small-town life where everyone knows what each others' opinions are just by looking at their face. Or, like high school. Same kind of deal. Social intimacy leads to being able to read each others' thoughts and feelings just by looking their way. Everyone keeps up mainly through gossip. It's the human condition, I'm afraid.. we are primates in troops. Forever.

If you want something else, you have to escape the bubble of the dogmasphere and go looking for real-ity. Something not opinion-based. A firmer foundation. Not just a bunch of ideas promoted by a few prominent alphas then adopted uncritically by generations and multitudes of betas.
See Ravensara Travillian's slide for why it's important to have a referent that is reality based. Here is the dogmasphere, without a referent:

Ravensara's slide, messed with by me. 

It's hard.
Manual therapy is full of dogma and closed-off ideas. Breaking up those cozy but hard dogmasphere balls by trying to get people to be excited about reality is kinda hard to do.

Sunday, February 28, 2016

Post summit ponderings

I just got home from the second San Diego Pain Summit, #sdpain 2016.
My brain is still reeling around from all the extroverting I did, and all the great info that poured into it from all sides, for three days straight. Wow. A lot of familiar faces from last year and a lot of brand new faces.

The take home highlights:

1. Sapolsky was polished, fast, funny and straight up fabulous. I knew he would be. I could hardly hang on to anything he was saying, I was such a fan girl, sitting right in the front row. 

Fangirl with grey hair front row => me
San Diego Pain Summit 2016
Every paragraph ended in a hyperbolic punchline, something that will be familiar to anyone who has ever watched any of his youtube videos. 
He said lots of pertinent things, mostly about stress. 
He said one thing about social grooming which was this: it does relieve stress in both groomee and groomer, but in primate troops, at least half the time, stress is relieved best not by grooming someone but but kicking or sinking canine teeth into someone further down the hierarchy, especially if you are male.
Oh well.
I expect human males attracted to grooming work are mostly nice guys who wouldn't go around kicking or biting others for stress relief. I do wonder about high velocity manipulation though, and "deep tissue" massage, and any kind of poke-you-puncture. All those seem a bit abusive to me. Maybe they are veiled aggression. 

2. Kevin Vowles had a great experiential exercise. He had us stand up and put a finger up in front of our faces. One's attention is immediately drawn to the finger. All else not focused on becomes blurry. Then walk around with all the attention and focus on the finger and notice how hard it was to not bump into others all milling around likewise focused on their fingers. Then try again - this time de-focus from the finger and focus on the surroundings of the finger. Ah, much easier to navigate.
The finger = the pain, and everything else = your life.
The difference between acceptance and commitment therapy and cognitive behavioural therapy, according to him, is that CBT starts with cognitions - change those and behaviour will change, whereas with ACT, focus on what holds value, let value motivate new behaviour.
Quality of life can go up independent of pain. Activity and satisfaction can go up without there being any change in pain.
And I love that he used finger traps as a metaphor for wiggling oneself out of a stuck situation!

3. Bronnie wants us to be like water: flow all around our patients and support them without any sharp edges. She quoted Bruce Lee many times. 

4. Ravensara Travillian spoke about the need to anchor the massage therapy profession in reality. I don't have a photo of the slide that very much appealed to me, but I'll describe it: a triangle. Bottom left corner, labelled "referent" - i.e., a corner of reality that has been objectively, scientifically described. Next corner, concept. Last corner, symbol.
She explained that a lot of the ideas in massage therapy are symbolic and conceptual, and totally missing is the referent, the anchor. Which leads to a lot of misunderstanding and misleading ideas about "energy" and "quantum" etc. She says that pain science might be a great anchor point. I do too, because a) it's science, and b) we treat people who have pain, most of the time.
Her talk applies to every allied medical profession you could name (yes PT, I'm looking at you..). And the medical profession itself sometimes. Especially the orthopaedic branch of it, which refers patients to surgery for a lot of pain situations that would likely respond to things much less invasive. See "
Back pain? Try some placebo surgery".

5. ALL the speakers were great. Seriously great. I mean, Benedetti for petesake!! Yes, he followed on the heels of Sapolsky, who admittedly is a tough act to follow, but he's only the world's foremost researcher in placebo and nocebo effect! Nice coup, Rajam Roose. Nice coup. 

You can order and purchase videos of the entire event, of course (but for Sapolsky), 
but for a full three-D experience, do not make the mistake of not coming out next year. Nothing can replace being there, being part of a troop of human primates celebrating advances in pain science and figuring out, together, how to integrate them into our separate clinical lives. 

Spikey pain ball metaphor, credited to Tim Wideman

Not connected directly to the summit but something that appeared serendipitously today, on Facebook, was Dave Walton's series of videos about pain assessment. Dave Walton, some of you may recall, is a former chair of the Canadian Physiotherapy Pain Science Division.
Anyway, the current chair, Tim Wideman, has developed the coolest image for pain and pain assessment. The. Coolest. Ever!

The inner grey part is the aporia, the subjective place that only the patient can access, the actual experience of having the pain.

All around that, the blue part, is the part the patient can describe using metaphor.
The spikes on the ball are measurable through qualitative means. The tips are pain-related physiological changes, which can be measured more objectively.

I think this metaphor is mesmerizing, fantastic, hugely valuable.
I think Dave should be a speaker at the next summit.

There is a ton more, but for me, those were the highlights. I loved every second of the summit and all the speakers, the smaller events like the art show and podcast panel, the networking event, all the lunches and snacks and conversations. My brain is still full and I am tired, so I'll stop here. Maybe more will surface and I'll say more but for now, this feels like a good place to stop. :)

Postscript Feb 29/16:
1. Ravensara loaded her slides up onto Facebook! Here is the slide I was talking about earlier. 

This applies to so many situations. If we keep these three things clear when we discuss, it makes life so much easier. 

2. Todd Hargrove had us rolling around on the floor on and off for about 4 hours, as he explained Feldenkrais methods of being in a body better. I remembered something from a long time ago that I actually had considered using as a book title: To feel better in your body, learn to feel your body better. But I discarded the idea as it was way too long. However, I kept a version of it for exercise suggestions I uploaded for people to do at home.

Friday, February 12, 2016

What is PT, really?

What follows is a side conversation on a Facebook thread, about acupuncture.
Bronnie Thompson said,
My main worry about acupuncture is that even if it helped with pain unless the person can learn to do it themselves there is an ongoing need for seeing a clinician, taking time out for appointments and the person will not have a chance to think about no longer being a patient. The opportunity to learn to be confident to self manage pain gets lost when people receive ongoing treatments.
A few replies later, Bronnie added,

Thanks guys. I used to believe there was no good from hands on therapy, but revised my opinion after meeting you lot and the like minded people on here. Now I can see that hands on has a place but it's that old thing about deciding when to stop seeking a pain reduction approach. At some point life is limited more by the ongoing pursuit of treatment than learning how to live well despite the pain. There's no easy way to work it out but my research found that people need to know their pain will remain before they're ready to get on with life and I worry that people lose opportunities for quality of life and fulfilment because healthcare providers don't want to talk about the reality that pain is not always completely removed. Tough questions to ask!
I replied,

I think our hands on works well (confirmation bias) but is usually short-lived. Behaviour that contributes must be uncovered and challenged (gently) for long term comfort in one's own physicality.
>> I see you sit with your right leg crossed. Do you ever sit with your left leg crossed? [Hmmnn. I don't know. I've never thought about it.] Would you like to see how it feels to cross the other leg, just to find out? [OK.] (Patient crosses left leg.. funny look appears on her face) How does it feel to you? [Weird.] Go back and forth a few times. Check how it feels to you, on the inside, each time. (Patient goes back and forth, a couple times each side.) Is there one leg that when it's crossed makes you feel more "at home" in your body than the other? [Definitely the right leg feels "right" and the left leg feels weird.] Like you have to work a lot harder to relax? [Yeah, kind of.]Note: psychotherapists are the worst for this! smile emoticon

And so on. 
You can still use your well trained biomechanically nit-picky eyeballs. But you can convert them over from spotting "biomechanical defects" into spotting motor output stasis habits that put diagonal shears into the peripheral neurovascular tree (metacognition?). 
Habits. Default resting positions. They are detrimental. A small force over a lifetime can be just as annoying to a nervous system as a big force over a short period of time. 
You can help people become aware of their habits. Then you can invite them to change them. 
Homework is simple - ask them to consider watching themselves (metacognition?) and intervening every time, to practice the exact same behaviour on the other side of themselves (just a few minutes at a time) (graded exposure), until it feels just as easy and natural to them as the habit does. They can symmetricalize themselves with way fewer visits, way less expenditure, and stop or at least cut way back on irritating their own peripheral nervous systems. 
How long does it take to feel comfy doing an unfamiliar yet easy motor output task? Surprisingly, not very long, maybe 3 or 4 days, same length of time it takes for receptor turnover. Like any kind of learning slope, it should be as low-angle as possible.
I call that a kind of cognitive behavioural therapy. I don't know that it would count as such, academically, but it's the kind I've cobbled up over a lifespan.
She replied,
That is exactly CBT to me. And some people think PTs are working out of scope if they "do CBT"?!!
I replied,

Bronnie, those people must not have a very broad understanding of what PT is really about! To me, that is what it's supposed to be about - helping people learn how not to be patients, and avoid useless surgery by learning how to be in a body better. Of course it will involve teaching and learning. Doesn't everything involve teaching and learning? I was so ecstatic when pain science came along, because it helped me make sense of my entire profession. Not everyone in my profession agrees this is what it's about though! They think it's an industry in which they can pop stuff or poke holes in people and hand them "pain education" in a pamphlet! OK, rant over.

Tuesday, February 02, 2016

One of those patient encounters you never forget

The time: afternoon, typical work day, 1994. I had opened my first ever solo practice a few months earlier. It was autumn. My practice was still slow, still building. Even when it was busy, I had it organized so that I only ever saw one person at a time. This was completely against all ordinary practice in PT at the time, in that province.
The place: my work space, a quiet large airy office, upstairs in a busy funky artsy retail neighbourhood in Vancouver. It was a large room with a desk at one end and a screened off treatment bed closer to the windows, which faced west.
Dappled afternoon light beamed in.
For a change.
I mean, it was Vancouver. The only time the sun ever comes out there, usually, is just for a few hours before it slides into the ocean for the night.
The guy: He was a Middle Eastern refugee, sent by a doctor. I actually can remember his name, which is unusual for me and an indication of how our encounter left a groove deep in my brain, but to protect his identity I won't reveal it. He was in his thirties. I can't imagine what he'd been through in his life. We never got into it.
His situation: He could speak English very well. He had been in the country for only a few months. He told me he had arm pain, so bad he couldn't move it. He was visibly anxious and cradled his left arm carefully with his right. He said that a couple weeks earlier he was getting off a bus through the rear door. The bus driver had closed the door on his arm, and then started to drive off. He was dragged a few feet. Ever since then, he had not been able to move his arm, or sleep very well, because, pain. The doctor had told him nothing was broken inside his arm. The doctor had told him to come to see me. Earlier that year I had visited doctors and told them I was a manual physiotherapist who treated pain. The doctor who had sent him had taken a chance. A welcome chance, because I needed referrals.
The treatment: I did not have the faintest clue what to do. I told him I wouldn't hurt him, that I wanted to feel his arm. Assessing it was impossible, as he could not move it voluntarily. He was apprehensive, but agreed. I invited him to lie down on his back on the table. I carefully slid my hands under and around his arm. I don't even know what I thought I would accomplish. I guess I must have been thinking I would assess to see if he had passive range available. But before I could even start, the guy started sobbing. Out loud. Hard. Body shaking. Head lifting. Abs contracting. I froze, his arm still suspended by my hands, not even off the table yet. Everything in his body shook violently with his sobs, yet his arm stayed perfectly still, and I stood perfectly still, holding it gently, trying to figure out if I was hurting him somehow, and deciding no, I was not, best to wait until the storm cleared.
He went on with this for what seemed like an hour, but was probably just a couple minutes.
He stopped sobbing just as abruptly as he had begun. He looked surprised, and said, it feels better.
Really? I asked? Really, he said. He sat up, and, remarkably to me, moved his arm all around as though he had never had any pain at all. He smiled. Thank you, he said. For what? I wondered to myself, as I smiled back.
That was it.
Aftermath: I saw him about a year later as we crossed the same street in different directions. He recognized me, smiled and moved his arm all around at me. I smiled back.
It was the easiest treatment I ever gave but has been the absolute hardest to figure out. And it's been 22 years. Clearly all the drama, pain, angst and all its resolution was inside his own nervous system. My role was so vanishingly small it amounted to nothing.
Probably all we ever are is catalyst no matter how we like to imagine we possess technical prowess and skill. When kindling is ready to burn it practically self-ignites. When it's wet, it needs to be blown on for awhile. And lots of manual therapy is nothing but a lot of hot air.

Friday, January 22, 2016

A new pain

Latest pain episode confirms all my biases about treating pain, in myself at least...
Complaint: Dull back pain, inter-scapular, left side, some at lateral border of scapula. Sometimes the lateral pain is worse than the medial one.

Onset: Started about five days ago, upon waking after having fallen asleep in recliner.

Contributing factors: 

1. Long (hideously long) hours at the computer (bio), stewing and stressing over the writing project, for months now, feeling more by myself with the stress of all that than I have felt alone about anything since forever, probably.. (psychosocial).

2. Falling asleep in recliner while watching whatever is on TV at 11pm in my time zone (these days, Colbert) is normal, has been for years.
3. No mechanism of injury. When I woke up, deciding to go to bed, it had appeared/was there.
Nature of pain:
I could fall asleep OK on either side, but it would come back and wake me up. It wouldn't let me sleep on my back. If I got up and moved about, or sat and went online for awhile, it would go entirely away. Full range, no pain on movement, so, obviously not a "deep" nerve tunnel syndrome..
Things I tried:
Floor work: This made the rest of me feel pretty good, but the pain returned as usual, at night, forcing me to get up.
Different positions? No luck there. I'm very inventive with sleep positions and pillows, but no joy. Bear in mind I could go to sleep without pain, but it would visit and be the thing that would wake me up.
It felt naggy and dull and deep, and bad enough to wake me... But it would go away easily by getting up and distracting myself.
Thing that finally "worked":
After four nights of this I got out the stretchy tape yesterday and managed to apply two strips to myself, vertically, stretched upward, one along the lateral border of the scap and one along the medial border (see diagram).
The naggy pain went away instantly. (Yay!)
I wasn't going to be convinced, though, unless I got good sleep. Last night, I slept through the whole night without any pain, with the tape on. Not that I didn't wake up occasionally, because I do anyway, but the back felt good, nice, warm, tingly, no matter which position I was in, or went in. Feels good to have had almost 24 hours without that annoying pain.
So, yay!
Confirmation bias: it must have been only cutaneous rami hurting me/my brain. Yay for peripheral sensory neuron opioids secretion (and probably some in the brain too). Tape will stay on until those rami have readapted themselves, and receptors have turned over.
Even though pain at night is usually red flaggy, I didn't worry myself or run off to become medicalized, as this pain did not feel sinister or intractable; Making more effort (getting up, raising my blood pressure, moving around) made it better, not worse.The fact that tape helped so much last night reassures me that it's no big deal (so far anyway..). I'll see what happens tonight: if I get two good nights in a row, my bias will enjoy more confirmation. Self-management, baby, self-management. My sedentary lifestyle may well kill me eventually, no doubt, but so far, so good; my pains in life have all been merely annoying body wall nerve being cranky, not visceral/referred. I've still got every bit I was born with, and most of those seem to still work OK. I will increase my activity level slightly (do more floor work, play more with my barbells, and try to avoid becoming diabetic (I'm 65 and something will kill me eventually) (but did I mention my mother is 92, still with all her bits, and still in good health despite having never done any actual exercise her whole life?) The last thing I want to do is to put myself in the hands of those who would want to perform a scapulectomy or something and try to talk me into that. I live in a pretty orthopaedic-surgery-happy province these days. The other thing, they might want to stent every blood vessel just in case. They like doing that around here too.
[Added Jan 23: I wish I could report that I had two nights painfree in a row, but my confirmation bias
can no longer be supported, as alas, the pain returned and woke me up as I lay on that side. The good news is, it did not come back medially, only laterally, and furthermore, I was able to sleep OK on the other side with a great fat pillow behind me, and my arm back on top of it. My new hypothesis is, the pain medially that seems gone for good was cutaneous dorsal rami kvetching about something that bugged them, in particular, and the lateral cranky bit is possibly a) coming from a deeper tunnel syndrome, maybe, like lower branch of subscapular nerve, or b) posterior branch of one of the lateral cutaneous nerves where it emerges, right there at the side of the trunk, then splits at a horrible angle, kvetching about something that bugs it in particular, but differently. I can reach it well enough but can't quite treat it the way it needs. I'll have to figure out a plan B this weekend. If all else fails, I can go next week to see a local massage therapist who came all the way out to Vancouver last fall to a workshop I taught.
I managed to get both pieces of tape off by myself, so yay about that.] 

Added Jan 25: Update: The lateral scapular pain disappeared on its own. I was able to sleep on either side, totally comfortably. I still had pain medially if I tried to sleep on my back. What nerve is in there? Why, the dorsal scapular nerve, of course.. It's too deep to be hacked with mere tape. The acute crankiness of the cutaneous nerves had been well beat back by the tape, it felt like.. But there was still a very small, dull discomfort medially. All righty then. It's easy to feel dorsal scapular nerve being cranky on other people, and treat it: I had to figure out how to confirm it was "the one," then try to hack that one on myself. Easier said than done. The test was to press the medial interscap. area into a door jam. Yup, it was tender compared to the other side. Now what? I usually treat it on others by having them lie prone, then taking the arm gently into full shoulder elevation (to widen and shorten the neural tunnel), then rotate it externally (to twizzle the nerve inside its tunnel). Much harder to treat on myself. The attached cartoon shows how I managed. Happy to report, no pain of any kind all night long in any position. Yay, back to normal. At least for now. Confirmation bias, back up to 100%.

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