Thursday, August 09, 2018

About CKS (crabby knee syndrome)

I have a story about my right knee.

Picture the following scenario: I am a 67 year-old, overweight, under-fit female, in a foreign city (Barcelona), in the ladies room of a teaching venue. The 3 stalls are little rooms, with complete privacy, ordinary doors, not the kind we are used to here which are just partitions. I quite like this foreign version of toilet privacy, but it's a bit off topic so I'll head back to the point: when you gotta go you gotta go.
I use one of the little rooms, and completely forget that the little room is up a step that is about 4 inches high. I presume the plumbing had to be accommodated or something, but before I wander off topic yet again, let me just say I didn't notice myself stepping up to go into the stall (jet-lagged probably), and my brain did not account for the height-of-floor-difference coming back out again.

Long story short, I made a predictive motor error. Or at least my brain did. I thought the floor was all one height, and when it suddenly wasn't, I landed pretty hard when finally the floor came up to meet my descending foot. My foot that descended surprisingly farther than anticipated. With all my considerable overweight jolting down an extra 4 inches to stop more abruptly with a lot more gravitational force than I had expected. Four inches in which apparently a lot of acceleration can occur, within mere nanoseconds.

I didn't fall over or anything.. I carried on.
The knee felt weird though. Not right. Like it wasn't quite me. Stiff and unnatural. Like there wasn't any room for "me" in it. Like a mechanical thing more than an alive thing. The interoception felt cloudy, and the proprioception seemed to be missing. My brain didn't trust it anymore.  It didn't really hurt at first, but I could feel machinery running in the background of my awareness as though my brain was trying to figure out where it had gone wrong. And the knee acted slow and stiff. But I hobbled around for the next 5 days, teaching, sightseeing on foot (slowly). The best thing to do with stuff like this is ignore symptoms and keep moving, right? Treat whatever it is as though it were normal, make normal demands on it, don't baby it, just keep going. And that is exactly what I did.

Pain set in during the long flight home, but I just kept going. I had to go to Taiwan, then Winnipeg. Then Minnesota, just last week. Four months have elapsed since the bathroom floor predictive error encounter.
It has been variable, with entire days pretty much nociception free, but it would wake me up at night, pain shooting through my knee. I would have to wake up fully to change position. I did not let this worry me. I would just go back to sleep, easily enough.
Some days it really hurt, so I would baby it with some stretchy tape and keep on going.
It was always worse after sitting for a long time.
Like on airplanes.
And a number of different people helped me by treating it, which always made it feel better, for a little while at least. 


It did not slow me down at all, really, except when descending stairs. Then I knew I still had a knee pain problem. I live on the fourth floor. Three flights of stairs. About 60 steps in total. Going up was easier than coming down. Yes, there is an elevator. Yes, I took it, but I tried to make myself do stairs as much as I usually do, which is about half the time going up, and all the time going down. So, I worked it under load.

.........

The backstory: I had a terrible time getting paid for the work I did in Barcelona.
Finally, after a lot of back and forth and several attempts (according to the party that had hired me) to wire the payment through, I got paid through good old Paypal, at my suggestion.
I was in Minnesota when the money from Barcelona finally came through; I emptied the Paypal wallet into my account, mentally heaved a sigh of relief that that particular psychosocial worrisome bothersome irritation was over with, crossed off my list of things to be dealt with.

......

Here's the weird part, the gist of this whole story, the juice in the blogpost: Almost immediately with the experience of relief of this formerly noxious situation, I felt a reduction in pain, like someone flushed a toilet in there, and "me" gushing back into my own knee, able to "re-inhabit" it physically, much much better. Such a peculiar feeling.
Slept through the entire night that night, didn't wake up once.
So.
Cool.
The psychosocial aspect of pain perception.

....

I'm back home now, and 8 or 9 days later, I can feel my knee getting better with each day. (FINALLY!)(After 4 months!)
I can do stairs normally now, descending straight down without needing to have a hand on the handrail. I even noticed, today, I led with my left leg! Unconsciously! I could not do that for the entire 4 months the right knee was being a pain. There are still little twinges in it, but I can fully flex it now, just as far as the other knee, and the twinges feel a lot more superficial, medial knee, saphenous nerve, not throughout the entire joint as though it were made entirely of wood and discomfort. Now it's time to work on squatting.

So much more space inside it for "me."
I love endogenous opioids, so much. Especially when they hit at the precise representations in the various somatosensory cortices where they've been dried up for however long an accompanying situation has been grinding along, unresolved. Another neurotag bites the dust! 





Monday, August 06, 2018

DNM 2.0

Totally exhausted, but in a good way, after being in Minneapolis for a week attending a 6-day long seminar that Jason conceptualized and organized, such that all the people out there in the world who are explaining their manual approaches using the stretchy framework of dermoneuromodulating could have a chance to build a new community.

DNM has stretched from standing for dermo, neuro, modulating, to also include everything from "deconstructing/demolishing nonsensical methodologies," to "deep 'n meaningful."

Too many highlights to list everything from every topic or every person, but overall:

1.  I appreciated the inclusion and emphasis on cognition and psychosocial aspects, like Robert Rex's inclusion of narrative medicine, and Erik Ouellet's emphasis on cognitive biases and perceptual fantasies/illusions.


2. I absolutely loved the examination and treatment directed toward cranial nerves, by Julie Porter and Jeff Rockwell. This was a bio part I've been missing all my life, and I think, a missing part for most of us probably. We have plans to bring together a new book, written by Julie and Jeff, with some art provided by me. It will be a separate book for now. (Maybe later, as in someday in the far distant future, a new inclusive edition of the original DNM book will emerge in which EVERY nerve will be included, and the head and body will finally be reunited in manual therapy examination and deployment. But that will have to be a long way away. Meanwhile Julie and Jeff deserve the first round of royalties from all their hard work placing all these cranial and superficial nerves into DNM context, so a separate book will come first.)

3. Brian Rutledge, a Feldenkrais practitioner, spoke for about 10 minutes in a very metacognitive fashion about how he sees cognitive/bio integration.

4. Jason Erikson always thinks in a way that is social first, psycho next, and bio eventually. He spoke about how to integrate change in culture as manual therapists, the manual therapy culture that currently exists, promoted the idea of joining organizations that improve social acceptability of our work, make it more visible. Some of the participants were moved to speak about social inclusion/exclusion, their experiences of having personally felt the impact of discrimination, how they deal or have dealt with it. The feelings were big and traveled through the room, as they usually do when the topic is about the experience of personal injury or harm. I had several thoughts initiated by this, outlined further along in this blogpost.

5. One event stands out in particular: One of the participants had a longstanding inability to flex forward to touch her toes. In fact she couldn't reach much past her knees. Julie asked her to hum while flexing, and she did. Suddenly, while humming, she reached way past her knees all the way to the floor.
It was stunning.
Julie did a little victory dance, and the participant was astonished. Having successfully reached the floor while humming, she did it several more times to make sure it wasn't a one-off, that she would be able to repeat it from then on.
It was the most fabulous example of a distraction technique I have ever seen.
The participant "believed" she could not forward flex her trunk in a standing position. Her brain was kept busy by humming (novel input and output) while bending. Her predictive motor control was interfered with. Her belief that she couldn't flex her back was disconfirmed. Her next job was to integrate all the new information and realize she had successfully crossed a chasm of sorts, a chasm that had existed only inside her own competing neurotags.

6. Such wonderful partying. This is what my own social life consists of, mostly, as I am generally a hermit where I currently live, and because I'm a big-time introvert it suits me just fine these days. But I do love me a good round of being with other people, in a suitable context, where there is deeper meaning and purpose, enjoying rounds. :)

7. It really did feel as though Jason created a context within which DNM is about to go to the next level. I couldn't be more content about that.

..........

I love that DNM is a stretchy enough conceptual container that just about every form of manual therapy (but only the interactive kinds, not the coercive kinds) can find a home in it. It is essentially about:
1. embracing human primate social grooming at its most fundamental, i.e., be kind, purposeful, slow, responsive, intelligent, with physical touch;
2. incorporating widespread biopsychosocial principles which boil down to listening first and talking after (minimally, without nocebo);
3. deliberately dis-including all conceptualizing about any tissue but skin and or nerve;
4. promoting nervous system awareness and handling.

I sit back and think, wow, here we are/here manual therapy is, at the bottom of society's ladder, really, without a lot of respect or acknowledgement for our efforts, which in the end doesn't really matter anyway, because human primate social grooming doesn't require much more nod to society other than a basic license to touch people and it sort of returns the favour. Yet, YET, here we are in all our multiple professional designations, called to them for whatever reason, trying to figure ourselves out and fit in somehow, the non-pharmaceutical, non-surgical alternatives to helping people with pain problems. We are in a similar clinical boat as the psychologists that way, except that we also have the advantage of being licensed to touch people.

All people.
Every person who asks.
This is a huge advantage.

We get to cherry-pick and be as evidence-informed as we could possibly want to be because we know how to read, think, and use scihub to look up all the latest information and scientific literature. We get to freely make up new conjecture, simultaneously weeding out anything ridiculous because now we know we can't just make shit up - we have to be from the start at least scientifically plausible and, if not completely bias-free, at least bias-reduced, because we know about fallacies and all the cognitive biases that exist and can appreciate how science itself is in a similar boat, and that science exists to prune back airy assumptions. We can trust it, and trust ourselves to be better off than we were before we were science-literate. We can deploy science-based consideration of every idea that pops into our head, and weed out all the mutually exclusive ones. We can be Occam's Razor all we want. We can place our work on a platform that is more solid, therefore.
We still get to be as jazzy as we like - but we aren't on crumbling ground conceptually or perceptually anymore.
And pain science and neuroscience are proving to be our best way forward into the future.

Just think: this might be the freest least-confining and simultaneously most challenging field of endeavor any human could possibly choose: we each have a human brain to use - the human brain, thought of as the most complex object in the known universe.
And what do we do with ourselves? We access and work with human brains all day long.
Is that not awesome? The most complex objects in the known universe taking on the most complex objects in the known universe as our daily work.

And here we are, asking those people inside those brains to change their pain perceptions by providing them with a bit of novel stimulus, getting them to disconfirm their beliefs about their pain by a little or a lot.

Picking back up on the thread of the inclusivity of DNM, as I sat back and observed a bit of acknowledged social pain ricocheting round the room for a little while, I reflected on how much stretchier I have become in my own life - in the past I might have squirmed and judged. Some thoughts that might have arisen may have been along the lines of, wait a minute, I'm not here for this - what does this have with learning how to use my hands - this is taking up too much oxygen and is not the focus we should be having - that guy does not know how to keep the room contained, etc.
I might have become impatient and annoyed and blamey.
I watched myself watching and listening and was pleased to note I felt or thought none of those things whatsoever, and instead just waited for the tension to conclude on its own, which of course it did.
I had some political thoughts too.
As a Canadian watching people interacting so close to the bone in an American context close-up, I marveled at how in Canada this would probably never happen. I extrapolated on that thought, comparing the US to all the other more hidebound countries - basically, all the other countries - where tradition dictates everything and freedom to invent new ways to be human don't really exist, although we love to pretend we're just as hip as US people who are constantly inventing new language and new things like internet and new music.
It occurred to me that after the US dumped the monarchy it built a pressure cooker for its citizens, politically, and although it is probably hard to live in it, it has innovated very cool stuff. Furthermore, without all the huge effort people in the US make in terms of social interaction, there would be no social progress anywhere else in the world, or there might be but it would be a lot slower to evolve. For example, as a queer woman (and I have my own definition of that, but totally identify with queerness in general and consider myself part of the queer community) I wouldn't likely have enjoyed my life as much as I have, so far, or come to know myself as well as I've managed to, and in Canada I would never have had access to anything social outside my white-bread rural upbringing and the rather conservative social conditions that accompany it (of which I am acutely aware, having gone back to live in it again, at least for now, but could never succumb to ever again).
So, thank you US people for all the discomfort you endure, having the courage to be vulnerable, speak your truth even though it takes a lot of nerve to do so, living in your social pressure cooker of a country, raising the boiling point so the cognitive and social interaction food can cook faster and be more delicious for everyone including all those who see it then duplicate it (social progress for all formerly dis-included people or groups) in our own respective, probably slower-moving, slow-cooking countries. 
And I sincerely hope that you will manage to deal with the orange menace appropriately when your time comes to vote.

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: https://docs.google.com/document/d/1FJ9jWwUIcEr7kJ07DJMitYW3C0nLHJU_cJoO_U2Rx28/edit#


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) APTEI.ca

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.
Seriously.
Apparently there was a big meeting recently, and this appeared on twitter:


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

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

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

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


I have many thoughts about this:

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

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

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

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

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

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

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

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

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

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

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













Monday, May 14, 2018

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

Earlier today I posted about starting in the middle.

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

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

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

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

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

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

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

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







Starting in the middle


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

From the blogpost:

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

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

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

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

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

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

Thursday, April 26, 2018

Ann massaged me

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

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


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

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

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

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

........

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

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

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

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

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

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

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


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


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

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






Tuesday, April 24, 2018

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



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

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

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


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

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

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

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


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








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




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



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

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






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

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

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

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