Thursday, September 10, 2015

Pathokinesiology instead of kinesiopathology

Pathokinesiology: Faulty movement patterns result from some process or problem going on within the organism, perhaps within its nervous system. Find out what the problem is, address the problem (which is usually only pain, but could be something else actually pathological), then watch to see if the faulty movement pattern disappears. Use movement output as a clue, a symptom only. Always see deeper than the surface. 

Kinesiopathology: The movement patterns themselves are the bad guys, to be corrected. If you move badly for long enough, you'll end up in pain, because.. muscle. Sarcomeres. Or something. Something to do with tissue. You the patient are the bad guy because of moving badly. You're ruining your body. Your pain is your own fault. Move differently and it will go away. Plus you won't destroy your body. Plus I can bill for treating a condition (a noun) instead of for interacting with a patient (a verb). 

I have John Ware on SomaSimple (post #48) to thank for clarifying and historically contextualizing the difference.

He says, 

"Actually it was Helen Hislop who came up with the term "pathokinesiology" waaaay back in 1975. Nothing really ever came of it because, in my opinion, modern healthcare systems aren't designed for- and won't pay clinicians to provide- interactive treatment. It's all about procedures, interventions, injections, operations, etc... We can thank Shirley Sahrmann for defining and popularizing the term kinesiopathology within the PT profession.... We should use a pathokinesiological perspective when treating patients with persistent pain problems. The movement disorder is persistent mechanical deformation; the essential diagnosis is abnormal neurodynamic."
... Which puts us squarely into the realm of the nervous system, some glitch in the software aspect of its function, some positive feedback loop thing, some sort of input that blew up into a pain problem coupled with motor output problem, maybe at entirely different times, maybe from different parts of the NS trying to solve a problem it couldn't handle with whatever hard drive it ended up with, so the "problem" moved more rostral.

Nothing is simple to work out, but for sure, the conceptual tools we were given in school were mostly blunt stone axes. I'm all for upgrading the conceptual tool kit, even in the face of opposition (which is out there. Lots of it. From corners you would never have anticipated.) 

I twittered this back to him, "I guess you would prefer we went back to this?" : 
Image by Sigurd Mikkelsen PT

Learning to use two eyes is way better than being equipped with only one:

Here is the thing: a therapist with no awareness of/ interest in/or desire to learn about all things brain and nervous system, has only one eye that has to see two things, at the same time, at different focal lengths; 1. a patient, and 2. the body attached to them, full of all sorts of lurking orthopaedic ailments. Now, *that's* dualism, right there.. 
You can treat people that way, but it's really clunky.
Clunky. And often very noceboic.

After one has developed a working knowledge of the afferent nervous system (not just the motor output system), and what the brain does with afferent input, it's like suddenly you have gained TWO eyes, binocular vision, stereoscopic vision. The best part is, you no longer have to drag fresh patients through that ghastly noceboic morass of all All Things Ortho That Are Wrong With Them, Completely Speculative, Based Entirely On Pain Presentation or Provocation Testing, Bad-looking Biomechanics, etc. Instead, you can explain pain to them, treat them kindly, wait and see.
If it's a tissue thing, it will show up.. later. 
(As long as the patient is reacting to a pain presentation, you can't ever know for sure.)

Besides, people live with all sorts of tissue stuff they never ever knew they had. When it comes to pain, correlation definitely does NOT equal causation.
So let's not focus on tissue so much.

It's like developing (cognitive) depth perception, finally, later in life, seeing depth and space in the world; it turns one's professional role from moving flat cardboard cutout images around, into real interaction, real therapy.
Dualism is replaced by (cognitive) binocular vision. Two cognitive "eyes" working together from two slightly different perspectives, does NOT equal "dualism". It equals depth perception.

When you teach binocular vision, this way of appreciating their brain, to patients, stress goes down and they stop being so bothered, worrying that they are going to fall apart.

So, this toothpaste (me) is never going back in the tube.

Tuesday, August 25, 2015

The busy-ology of physiology

This morning I started thinking about physiology yet again, when I saw a full-text paper by Benedetti posted to facebook. Recently I had listened to a podcast interview of Bud Craig. He's the interoception guy. Here is a link to some notes I made re: a video of his I watched a few years ago. Fascinating.

Both these items, fresh in my mind, reminded me of Jorge Fuente's work, coming at it from a different angle but still trying to show the world that really, it's all about the therapeutic relationship, not whatever ritual might be being performed within it. I remembered David Butler, at least 12 years ago, saying, "We don't treat anatomy, we treat physiology."

I thought of my recent plunge into a rethink of metaphor in culture, instigated by Mike Stewart, and Keiran O'Sullivan's video about Ally who in the middle of a full-on stressful life fell and broke her tailbone, and developed chronic pain which was very hard to live with until someone (him) started to listen to her, empathically, as though she were a competent human instead of a "case" (discussed/blogged about here). I bumped (yet again) into my own self, my own bumps and snags and realization that I can demonstrate good listening and empathy, but probably only in short bursts. Probably because I really don't enjoy being around people much, except for in short bursts. 




I thought of the cartoon I made of the evolved nervous system (see below), how in order for it to get a grip on itself, it requires communication/social input. Imagine that.
Humans have been designated the "neotenous ape". This means, adult while still in juvenile form.
You can see it, can't you? How dependent we are, on each other, on the systems that emerge, like a bunch of large babies? Big brains that are not fully myelinated until age 25? The way we have rampaged all over the planet, wrecking it, and fighting with each other like a screaming bunch of wild toddlers with no day care lady to keep us cookied and juiced and napped and meaningfully distracted?

I think, once we've been born, and we're stuck here anyway, we should try to help each other get through life to the end with as minimal damage as possible. Personally I'm against reproducing very many more of us, even as I can empathize with the biological need to reproduce (.. that I managed to completely escape being gripped by, thank goodness..).  


But back to physiology.
Bud Craig, the neuroanatomist says he discovered a new pathway in the brain that had previously been overlooked: It joins up the interceptive fibres with the cognizing brain, so that we can be aware of our body states. These are pathways that are essential to homeostasis. I don't recall if he said these are just human or if they are more broadly primate. I'd have to listen to the whole interview again (I've ordered the book. Can't wait!). I think he said they are in primates, but no other kinds of (studied) mammals, and greatly increased in humans. (I really appreciate that he discusses these pathways and homeostasis, in general, as being energy conserving. That makes sense to me. Our brains are such monster fuel hogs..)

Homeostasis is all about physiology. Remember that in the beginning was the nerve net. The human brain came later. 
Remember that the nerve net is bi-directional, and enclosed within tubes where it can get itself into some big, echo-chamber, positive feedback loop trouble. 

From "Neuritis


All of this was on my mind, then I saw the Benedetti paper, Placebo and the New Physiology of the Doctor-Patient Relationship. 
The coin dropped again.
Yup, our poor overly big sorta helpless human primate brains need external validation before they can turn around the physiological problems inherent in pain production, for example. Possibly.
At least that's true for me, even though I hate that I "need" anyone to help me, therapeutically, physically, sometimes.. at least, my brain does..


I remembered Jorge Fuentes when someone on SomaSimple posted a link to all his publications. I remembered I had even blogged about him a few years ago. I found the post again. He is definitely somebody to watch carefully. Maybe he will be someone who can lead this profession out of the post hoc ergo propter hoc forest it got lost in, decades ago, and is still lost in..


Be sure to register for the San Diego Pain Summit, Feb. 2016. Benedetti will be speaking there!!
Robert Sapolosky too, the fabulous primatologist and stress researcher. 

Friday, August 21, 2015

The mobiusity of it all..

"Pain is an all-consuming interior experience that threatens to destroy everything except itself and can only be described through metaphor" ~ Biro 2010. Quote from Mike Stewart's blogpost, BEYOND WORDS

Sometimes we're up, sometimes we're down.
Sometimes we have pain, sometimes we don't.
Whether we're on the painfree side of the line or not (and all of us, or at least virtually all of us, will end up having tasted both sides), we still have to keep on doing life. What is life? Walking around on that mobius strip until we die, I think..
We're all here together, doing life, doing time, until our time is up.
And no matter where you go, there you are. 

I made this image inspired by a conversation on Facebook, with Mike Stewart of KnowPain, and Joletta Belton, of MyCuppaJo

Here is the conversation. LINK.

Part of it was about the word "management", which I have an instinctive dislike toward.
If I have pain, I do not want it "managed" by anyone but me, thank you very much.
If I am a provider of help for pain, I don't want to "manage" your pain - that's your job - I want to help you/you nervous system to learn your/its way out of it if I possibly can. 

But if I can't, I can't. It should be clear within one or two sessions if anything I do helps or doesn't help.


I've met Jo in person, just a few weeks ago in San Diego. We dined out with Rajam Roose at a lovely restaurant, beside a large pond alive with huge goldfish. 

Joletta Belton (nearest), and me (across the table), San Diego, August 2015

She takes absolutely gorgeous pictures of nature, wild and free. She is keenly interested in pain. She ended up with some of that herself, through circumstance.


I have not had the pleasure of meeting Mike yet, in person, only on twitter and facebook. He caught my attention the other day with a post about metaphor, how pain, that uniquely private interior experience, is understood or shared metaphorically, and therefore demands a creative response. His slide contained cultural contrast in metaphor to do with headache. The "west" or English language, and therefore mindset, is all aggressive and warlike and as he puts it "mechanistic and invasive" with descriptors such as stabbing/ shooting/ lancinating/ pounding/ burning/ crushing/ pinching. Some Japanese metaphor he offered up from The Story of Pain by Joanna Bourke, were by contrast, "natural and environmental" - comparing pain to an animal, e.g., an octopus headache (sucking) or a bear headache (like heavy steps of a bear).  I liked the Japanese metaphors - way less personal somehow. More space around the pain. More detached.
I realized, yet again, on the one hand, how hard it is to describe a pain to anyone else, and on the other, how culturally embedded metaphors are. 

Yes, I do think English is a war-like language. 
So many nouns, so few verbs.

Pain is a verb, not a noun. Well, OK.. it's a verb that is pretending to be a noun. It tries to stop one from moving, is what it does.


About being a pain carer, a carer of others in pain.. I really really get that pain is entirely personal. I've been there. I really really get that it's massively important to leave people with hope, AND locus of control. I really really get that the pain they have is theirs and theirs alone.  I think I get a bunch of other stuff too, about how the nervous system evolved as a biological learning app. When I have one in my hands, I do try, as well as I possibly can, to communicate appropriately with every level it has to offer, from the most abstract to the most kinesthetic, trying to help it feel seamless again.


Another inspiration to write a blogpost came today via Pain-Ed. A wonderful video of Keiran O'Sullivan sitting with a woman he treated, who fell and broke her coccyx. I was riveted the whole time as she told her story. Definitely worth a good listen.

What I got from this was: 
1. Don't ever become addicted to stress. And yes, stress can be addictive. The money-chasing type of stress is the worst, because then if you fall on your tailbone and it breaks and you are in pain, you can't work as hard, which, if you are addicted to making a lot of money by working really hard, is doubly stressful because hello? now all of a sudden you feel impoverished on top of everything else!
2. She went to a pelvic floor therapist who made her worse by asking her to tighten harder. Pelvic floor therapists are wonderful, but I would pick mine very carefully, because they have to know who to teach tightening to and who to teach relaxing to.
3. It sounds like almost everyone she went to see for help treated her as a "condition", not as a person. She needed help as a person, so that she could deal with her condition, not the other way around. 

Wednesday, August 12, 2015


It's been awhile.. I've been very busy trying to get the manual I wrote into shape for publication. I've worked on it for a good 6 hours every morning since May. Still not done. Getting there though. And a cover is ready, an isbn number.. once the publish button is ready to hit...

I just arrived back from teaching in San Diego, hosted by my amazing friend there, Rajam, who organizes the San Diego Pain Summit. Be sure to attend the one she's organizing for 2016. Robert Sapolsky will be speaking! He's awesome. So are all those other speakers! Don't miss out or you'll kick yourself.
There are only 2 weeks left to register at the early bird rate. I kid you not. After that, it's going up. 



You know how ideas can chase each other around and around in one's head until they make a hole in your thinking?
I think that has happened to me again fairly recently. The idea I had turned into a cartoon. 

I really do think the NS is still pretty much like this. It seems seamless in its operation most of the time, as a communication system, but that danged old ancient physiology can derail it and then the seams show.
And pain is the clue. At least, according to me. And bear in mind, I'm no expert. I just like to read, and think. 


I made another cartoon, this one about the physiology of tissue healing. I threw in a few ideas about how as long as you have enough blood flow, you won't have any nociception that will "hurt" you, as long as you don't bang that sore toe or whatever... 

This is all well and good. Things resolve, discomfort ebbs, eventually disappears, all is well once again eventually.


What happens if this process occurs INSIDE A NERVE?

1. Nerves are loaded with nociceptive neurons innervating their walls, and the vessels that pierce through them to feed neurons. 

2. Nerves are long narrow cylinders, very self-contained. 
3. They have lots of circulation - neurons need lots of oxygen and glucose to function. 
4. The circulation gets in, and out, of nerves, through narrow regional vessels, which are highly subject to mechanical deformation. 
4. The circulation to nerves is easily distorted. At any given point in time, some part of the peripheral neural tree is being somewhat deprived, while the rest enjoys abundance. As long as one moves about and or rests in enough varied ways, no harm befalls any part of the neural tree. In fact, it needs the challenge and the stimulation of being affected mechanically.


What happens if you develop bad stationary resting habits?
What happens if you always...
1. sit with the same foot tucked up under the other leg?
2. carry your bag on the same shoulder?

3. sleep on the same side?
4. stand with one hip up and the other down? 
5. wear a toolbelt dragging you down on only one side? 
6. lean on the same elbow all the time?
7. have your head turned the same way watching TV for a couple decades?
8. sit with the same leg crossed, and have for the last 25 years? 

These things we do can really take a toll after awhile. If circulation is skewed too long one way for too long and too repeatedly, I can see how the products of nociceptive activation WITHIN A NERVE might not be cleared away in a timely fashion.
Then, "silent" nociceptors might activate, part of a positive biological feedback loop. Not good, those positive feedback loops...

The signs of inflammation are rubor, calor, tumor, and yes, dolor.  Loss of function is considered a fifth cardinal sign. 

Imagine inflammation occurring inside a nerve. 

It can. 
It's called "neuritis". 

Now, put that together with the fact that a nerve is a very enclosed structure. How can the products of inflammation be swished away, from an enclosed space like the inside of a nerve, if fresh blood can't even get in there because of swelling? Or because regional vessels that drain the nerve have been tensioned and become narrowed or occluded, aka "mechanical deformation"?  Mechanical deformation secondary to some muscle guarding the spinal cord has given rise to because it's trying to help, reflexively? 

How can you move, in order to bring fresh blood into an inflamed nerve, if you can't, because of reflexive motor inhibition because the spinal cord got way too excited and is trying to protect you with reflex inhibition/spasm?
We can't get rid of nociception or peripheral hyperalgesia or neurogenic inflammation because tissues need all that "nerve net" behaviour, to become healthy again if injured. We can't lose that. But inside nerve trunks, it can all turn into an echo chamber!! Lotsa neurons all covered in sensitizing debris from other neurons, all of them raw and screaming! Like babies in wet diapers with their diaper rash stinging their undercarriages! Nothing cleans up nerves like fresh blood flow washing away the physiological byproducts of inflammation, but fresh blood can't get in, because... well... swelling. Tumor. And the old blood can't get out.
And it is not obvious swelling, because it's inside a nerve. 

And not only all that, but also, the neurons will think they're starving because fresh blood can't get in with new supplies. It's a perfect storm. 

I've checked the IASP site for this, and found out that neuritis is indeed a "thing".


"Note: Neuritis (q.v.) is a special case of neuropathy and is now reserved for inflammatory processes affecting nerves."
Again.. : "Neuritis is a special case of neuropathy"
Even though nociception is involved, in terms of nociceptors' ability to create and add to an inflammatory response, IASP is clear that neuritis is not nociceptive "pain". Nociceptive pain is:  

"Pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors."
I don't think I agree entirely, because I know that nerve coverings are derived from mesoderm. Which makes them "tissue".
However, I won't quibble about it.
Mesodermal derivative is usually an innocent bystander - I blame ectodermal derivative for everything pain-related, including neuritis, because of all that ancient nerve net (the clay tablet and stylus) hooked up to the state of the art smart phone type central NS we all enjoy (or don't enjoy, depending on what is going on inside the whole enclosed system).

OK, so the question remains: How can we get rid of something like this that is excruciatingly painful, comes along seemingly spontaneously, and we can't just shake it off, because (hello?) we can't move that bit? 

Well, we have to make an appointment and go see someone we hope will have some answers.
Hopefully, if it's medication, it will be effective and not mind-numbing.

Hopefully, it won't be an appointment for imaging, where all sorts of perfectly innocuous grey hair and wrinkles on the inside of the body might show up and be conflated with this awful pain experience.
Hopefully it won't be a surgical recommendation in the absence of actual life-threatening pathology. 

Hopefully it will be a good human primate social groomer who:
1. Understands physiological processes and pain mechanisms
2. Can reduce stress by providing clear explanations and pain education
3. Can move the nerves carefully without adding more nociceptive input, enough that..
4. He or she can help some of it go away immediately, restore hope, reduce stress
5. Recommend safe and stress-free and easy movement homework
6. Cares enough to inquire about habitual postures and body-useage and can advise the individual in pain on how to change their own behaviour to avoid any relapse in the long term. 

Thursday, May 28, 2015

Muscle guarding, and so on..

From a Facebook thread started by Taylor Sun, in Skeptical Massage Therapists group:

>> "I would love to foster a discussion around the idea of "muscle splinting" or "guarding" as a protective mechanism that the organism is engaged in due to perceived threat or repeated exposure.... Can we think of muscle splinting as one of these plastic-stimulus-responses that as manual/massage therapists we can interact with in a site-specific manner order to give the organism a new engram or encoding to work with?"

(What follows is my reply:)
"I think this is a great question. I have many thoughts on it.

"In no particular order:
1. I think "muscle" is an innocent victim, too often blamed for shenanigans the NS gets up to. As long as it's not frankly diseased, muscle is just being obedient to whatever it's told to do by NS motor output.
2. It makes sense to me that the spinal cord (along with its assorted intrinsic, or more rostral but bidirectional, nuclei) is a "first responder" to nociceptive input. It dangles out there into the "body" with all its array of PNS coming out of it and into it; it's the oldest part of the CNS so it has seniority. The rest of the CNS came along a lot later, with one of *its* big jobs being to inhibit spinal cord reflexive activity.
3. Nociception is a stimulus to the spinal cord which may or may not be processed at more rostral levels of CNS, but for sure, the spinal cord (plus the nuclei it came with) will notice it.
4. The spinal cord operates reflexively. Smooth muscle is contracted by the ANS (cell bodies in lateral horn) and striate muscle is contracted by lower motor neurons (cell bodies in anterior horn). In comes nociceptive input. There are lots of interneurons, glia, all sorts of things in the spinal cord extending many segments. All of them affect each other. They get excited over nociceptive input if not discouraged from doing so by descending inhibition.
5. A nociceptive input doesn't even have to reach the brain before it will be dealt with reflexively by the spinal cord. (E.g., touch a hot stove by accident and the hand jerks away before any sensation arrives to conscious awareness.)
6. Nociception is occurring constantly. But tonically, not phasically. The spinal cord actively deals with it all the time.
7. Our more rostral centres adapt easily to stressful inputs of any kind, as long as they are spaced, and not too intense. This is the way graded exposure works, when it works. The brain gets used to fleeting discomforts, weird positions, gait disturbances, whatever. These are defenses (mounted by the spinal cord, reflexively), not defects of structure (most of the time anyway). (Asymmetric resting positions, combined with external mental focus, are the two biggest contributing behavioural factors to nociceptive input that goes under the radar, IMO)
8. Anyway, spinal cord takes care of business, unless and until some of its striate motor or smooth motor or both at the same time output, pulls some other portion of the 72km/45 miles of peripheral neural array, or any of its connected vasculature, into "mechanical deformation". Then, oops! we have something that could act just like a tunnel syndrome.
9. The literature on tunnel syndromes all says the same thing: the sensory system will be affected first, and pain felt in a region that's neuroanatomically plausible (same as the new description for neuropathic pain) will be the predominant complaint.
10. So, an evolutionarily conserved strategy, reflexive tightening/contraction, deployed by the oldest bossiest part of the CNS, the spinal cord, which doesn't have much more hard drive than when fish invented it in the Devonian period 500 million years ago, which seemed reasonable at the time (if we were still fish maybe), has led to a situation where *more* nociception, stemming from somewhere else, occurs. (Bear in mind that the oldest parts of the NS have been dealing with it this way since the beginning of the NS, and nature never gets rid of anything that works.)
11. But eventually something's gotta give, and descending inhibition doesn't work automatically anymore. Nociception has become so tonic and from so many more afferent nerves, that glia have glee-a-fully arrived to augment the process, and the entire input becomes a positive physiological feedback loop. Central sensitization has tipped the NS into "every movement hurts".
12. If the NS is normal, and if associated vasculature is normal, the possibility exists that the NS can be hacked successfully so it can reboot. But the reboot has to happen from rostral areas, backward. Thank goodness for yes-ciceptive exteroception and fast dorsal columns, that can bypass all the flood waters and cars in the ditch within the dorsal horn, and get some new fresh regional info up to the brain so it can have something novel and pleasant to work with and make new body schema/representations from.
13. Non-specific FX and descending inhibition must be juiced up as much as possible. If the attached human brain knows what's going on, because the person in it has been successfully recruited to the effort and is willing to do their part, hacking such a NS can proceed in a clinically successful manner, i.e., improved ROM and decreased pain on movement. Then movement homework can take care of the physiological details over the next few days until peace prevails in the entire NS.
14. What I find quite fascinating is how little the CNS gives a fig about the "person" who has to ride around inside it, feeling/dealing with all the pain nonsense it can generate. Not entirely sure about this, but it seems to me that the bigger/more connected the brain, the more suffering its conscious awareness may have to endure when pain arises.
15. It pays, big time, to explore all the movement corners of one's own body, well in advance of any pain problem, so one can stave off most of it through simple movement hygiene. Especially, avoiding consistent asymmetric sleeping on one side only or other default resting positions, stances, leg-crossing, bag-carrying, etc., is a good investment of whatever "will power" one may possess, to avoid a world of dumb hurt.

16. Barring some frank disease, or being hit by a truck, simple movement awareness could keep most people, mostly out of pain-treatment offices like mine, most of the time. If everyone practiced Feldenkrais for example, most of us would be out of business."


None of this answered the question, of course... But the question stimulated a bunch of thoughts that had been roiling around in my brain for a long time, and acted like a spigot for me to splash them out onto an existing thread. So, thank you Taylor.

Sept 22 2015: Text correction. I had the terms tonic and phasic backwards. Text reads correctly now.

Monday, May 04, 2015


This is the title of a very good piece in the NewYorker by Atul Gwande.


It's a perfect complement to the last blogpost, Like a Bridge Over Diagnosis.

Here are a few choice excerpts:

"Bruce’s father had a stroke during the cardiac surgery. “For me, I’m kicking myself,” Bruce now says. “Because I remember who he was before he went into the operating room, and I’m thinking, Why did I green-light an eighty-something-year-old, very diseased man to have a major operation like this? I’m looking in his eyes and they’re like stones. There’s no life in his eyes. There’s no recognition. He’s like the living dead.” .. A week later, Bruce’s father recovered his ability to talk, although much of what he said didn’t make sense. But he had at least survived. “We’re going to put this one in the win column,” Bruce recalls the surgeon saying...“I said, ‘Are you fucking kidding me?’ ”His dad had to move into a nursing home. “He was only half there mentally,” Bruce said. Nine months later, his father died. That is what low-value health care can be like."

"Overtesting has also created a new, unanticipated problem: overdiagnosis. This isn’t misdiagnosis—the erroneous diagnosis of a disease. This is the correct diagnosis of a disease that is never going to bother you in your lifetime. We’ve long assumed that if we screen a healthy population for diseases like cancer or coronary-artery disease, and catch those diseases early, we’ll be able to treat them before they get dangerously advanced, and save lives in large numbers. But it hasn’t turned out that way. For instance, cancer screening with mammography, ultrasound, and blood testing has dramatically increased the detection of breast, thyroid, and prostate cancer during the past quarter century. We’re treating hundreds of thousands more people each year for these diseases than we ever have. Yet only a tiny reduction in death, if any, has resulted."

Atul Gwande; Overkill: An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it? The New Yorker, May 11 2015

Thursday, April 30, 2015

"Like a bridge over diagnosis"

Or, if you prefer,  Like a Bridge Overdiagnosis. 
Anyway, this link crossed my path, about how verbs of clinical observation are turned into "nouns" of diagnosis, and how this can be a real disservice. 
Because as soon as an event or a verb or a set of symptoms floating by in awareness are turned into a "noun" that has a "name" it is then regarded by our human brains as a "thing". 
This is called "reification" - treating an abstraction as if it were a real thing. 

Then the instinct to go after that thing, hunt it down and nail it, switches on.  Especially perhaps in the medical world, because of the momentum for preserving "life" by fighting anything that has been labelled a "disease". 

For your listening and viewing pleasure:

A few days ago I blogged about some papers indicating that yes-ciception (or, as I like to call it, social grooming) can trigger growth of new neurons in the spinal cord that inhibit nociception.

I think this is a wonderful start to a vindication of keeping manual therapy (or as I like to call it, human primate social grooming) in our scope. 

I included a video of Martin Hey speaking at a conference about the state of the profession

PT is kind of a mess these days, everywhere, not just in the UK.
Every so often though, I see something that cheers me up again. 

I had not seen Nancy Zimny's paper before, but I like the gist of it.
Nancy J. Zimny; Diagnostic Classification and Orthopaedic Physical Therapy Practice: What We Can Learn from Medicine. J Orthop Sports Phys Ther • Volume 34 • Number 3 • March 2004 (FULL TEXT)

This paper comes even closer to taking Occam's Razor to all the clutter of orthopaedic overdiagnosis.
RenĂ© Pelletier, Johanne Higgins, and Daniel Bourbonnais; Is neuroplasticity in the central nervous system the missing link to our understanding of chronic musculoskeletal disorders? BMC Musculoskelet Disord. 2015; 16: 25.  (FULL TEXT)

Finally, because it is so engaging and brilliant, 
Arnold C; Ants Swarm Like Brains Think. Nautilus April 23 2015

(It's basically a reprint of her article from about a year ago, by the same title: Ants Swarm like Brains Think, April 24 2014 with the idea of positive feedback loops extracted/emphasized, and blogged about here: The ants go marching one by one.)

It seems to me that positive feedback loops operate at societal levels too, maybe even easier than they do at ant levels or neuronal levels. 
Maybe that's why medicine and especially orthopaedic medicine and certainly the app to orthopaedic medicine, known as PT, has succumbed to overdiagnosis. 

Isn't it all long overdue for some social inhibition?

Sunday, April 26, 2015

Yes-ciception inhibits nociception in the spinal cord

At last. 

Finally a paper has come along that provides a bit of solid evidence for gate control theory of pain. It only took 50 years (..for petesake!), so I guess we shouldn't get all downcast over how hard it is to get physiotherapy to change course. (I just hope this doesn't turn into some huge TENS revival..)

But I digress..  
I'm thrilled. My confirmation bias bells are all going pingpingping
Why? because this supports manual intervention/human primate social grooming. 

1. Here is Mo Costandi's piece on the topic (the word "pain" should be replaced by the word "nociception", as usual..) :

2. Here is a link to the actual paper. 

Foster, E., et al. (2015). Targeted Ablation, Silencing, and Activation Establish Glycinergic Dorsal Horn Neurons as Key Components of a Spinal Gate for Pain and Itch. Neuron, 85: 1289-1304 [PDF].
Here is the abstract: 
SUMMARY The gate control theory of pain proposes that inhibitory neurons of the spinal dorsal horn exert critical control over the relay of nociceptive signals to higher brain areas. Here we investigated how the glycinergic subpopulation of these neurons contributes to modality-specific pain and itch processing. We generated a GlyT2::Cre transgenic mouse line suitable for virus-mediated retrograde tracing studies and for spatially precise ablation, silencing, and activation of glycinergic neurons. We found that these neurons receive sensory input mainly from myelinated primary sensory neurons and that their local toxin-mediated ablation or silencing induces localized mechanical, heat, and cold hyperalgesia; spontaneous flinching behavior; and excessive licking and biting directed toward the corresponding skin territory. Conversely, local pharmacogenetic activation of the same neurons alleviated neuropathic hyperalgesia and chloroquine- and histamine-induced itch. These results establish glycinergic neurons of the spinal dorsal horn as key elements of an inhibitory pain and itch control circuit.
My bold.

3. Here is a link to the original gate control theory of pain paper. 
Melzack, P. & Wall, P. D. (1965). Pain Mechanisms: A New Theory.Science150: 971-979 [PDF].

MORE:  Here is a link to a great great set of very short and wonderful videos of David Krakauer discussing intelligence, genius, whether or not stupidity is the opposite of intelligence (spoiler alert - it's not..) and all sorts of things. It's great. I can't recommend it highly enough. 

"...what genius does is it just changes the rules of the game. It doesn’t just make it better, or easier, or more efficient. And one of the very interesting characteristics of genius, as opposed to intelligence, is it looks a little crazy. Because an intelligent solution is almost always—and I gave some examples of stupidity—clear to most people that that is a better way of doing things. Yes, that is a better way of doing things. But when you change the rules, you make a lot of people uncomfortable, and it looks a little crazy. So in some sense, my diagnostic, my litmus test for genius as opposed to extreme intelligence is it made everything simpler, but the people, when they first saw it thought it was lunatic; because formally, it’s changing the basis set. It’s just changing the nature of the representation of the problem so completely that you get the kind of vertigo of unfamiliarity. So that for me would be genius."

My bold. There is no way to classify Melzack and Wall's work other than they are genius and so was/is their work. They pushed back the boundaries of pain research. They changed the rules. There was pushback - bitter pushback. Even nowadays Melzack remarks on what a surprise that pushback was, in some ways, and shakes his head. 
I bet he feels vindicated, a bit at least, by this new paper.

MORE:  I just today spotted a video of Martin Hey, head of the WCPT pain network, presenting an overview of pain physiotherapy in the UK. It's about 40 minutes long, was filmed in Seville in October last year and a Pain and Physiotherapy conference, and uploaded to Youtube in December 2014. 
It's very good. 
Hey describes most aspects of the mess PT is in, without actually calling it such..

Martin Hey of WCPT's Pain Network

YET MORE (courtesy of Fred Wellens):   

Shechter RBaruch KSchwartz MRolls A.;  Touch gives new life: mechanosensation modulates spinal cord adult neurogenesisMol Psychiatry. 2011 Mar;16(3):342-52


"The ability to respond to a wide range of novel touch sensations and to habituate upon repeated exposures is fundamental for effective sensation. In this study we identified adult spinal cord neurogenesis as a potential novel player in the mechanism of tactile sensation. We demonstrate that a single exposure to a novel mechanosensory stimulus induced immediate proliferation of progenitor cells in the spinal dorsal horn, whereas repeated exposures to the same stimulus induced neuronal differentiation and survival. Most of the newly formed neurons differentiated toward a GABAergic fate. This touch-induced neurogenesis reflected the novelty of the stimuli, its diversity, as well as stimulus duration. Introducing adult neurogenesis as a potential mechanism of response to a novel stimulus and for habituation to repeated sensory exposures opens up potential new directions in treating hypersensitivity, pain and other mechanosensory disorders."


Thursday, April 23, 2015

Dear Motor Vehicle Insurer, I want a divorce

Yeah... I know, I should never have led you on.. I should never have hooked up with you in the first place. I had divorced all the other ones I was ever hooked up to, a decade ago, and was living happily ever after.
Then, you came calling, and at first I said no, but then I thought, what the heck, making myself available to see clients of yours who are traumatized after being in an MVA and needing help getting over the emotional and physical shock of it all and pain problems resulting.. heck, I've been there and I know how it feels..
And you were all accommodating of me at first - I was clear about my boundaries and described how I work - one patient at a time, an hour of treatment, no programs, no testing apart from range of movement recording, no questionnaires.. just interacting verbally and non-verbally with another human nervous system, giving it a chance in a quiet space to develop a different way of handling physiological regulation and reducing its own pain output, after having shared some information about the nervous system and what it needs and wants and likes.
You said yes. You even said I could bill and be paid for an hour at the going rate.

Time passed, and we grew used to each other. I didn't see clients of yours very often, but the ones I did got better in a timely way and you seemed happy with my work and paid me well for it.
Things seemed to be working out.

Until now.

One of your agents contacted me. Let's call her Stacy. That is not her real name, but I wanted to use a name that would evoke all the qualities of an alpha female who works out hard at the gym and is upwardly mobile and authoritative, who has that chirpy, energetic, extraverted no-nonsense sort of voice. So I'll call her Stacy.

Stacy wanted to know what was going on with Lucy. OK, here's the backstory on Lucy (also not her real name, but I wanted to pick a name that evoked the sort of quiet honest thoughtful earnest individual Lucy is). She's a grade 1 teacher.
She was walking (in a crosswalk for petesake) in December (cold, snowy, but in daylight) meeting friends for lunch. In the crosswalk she was struck by a truck. Yup, a pedestrian minding her own business, hit by a truck. Fortunately the truck stopped in time. Lucy remembers being struck on her right side, holding out her right arm to try to stop the truck, and yelling at the driver. There was physical contact of Lucy by the truck.
The driver got out and apologized.
Lucy proceeded to have lunch with her friends, a few of whom were nurses. They were concerned for her. She filed a claim. The claim covered her. The adjustor assigned to Lucy was nice. Let's call her Julie. (That's not her real name, but I want to call her something that evoked boundaried and professional but still friendly concern and caring.)
Julie told Lucy that the Insurance Company would keep her file open for 6 months, which sounds reasonable...

Lucy came to see me shortly after her injury with arm and neck pain. She had low back pain too which she had had for a long time and got massage for.
I treated her and we made a followup appointment. She was leaving the province to visit family for holidays, and wouldn't be back until the new year. I saw her again in the new year. She was 80% better, she said. I worked with her again, and said, come back if there is anything more I can help you with.

Time passed, she did not make any more appointments.
About a week ago, Stacy called me about Lucy. Stacy wanted to close the file, which had been given over to her when Julie took another spot in the company. Where Julie had been people-smart, Stacy was all corporate, this-is-the-way-we-do-things smart. She wanted that file closed and she wanted a discharge note, now.
I replied, well, I want to call Lucy first and just make sure everything is OK with her.
I called Lucy and Lucy said, I feel better, but yes, I would like to make an appointment (about the low back stuff, as it turned out..).

I told Stacy that Lucy had made another appointment and that I would hold off on the discharge note until after I'd seen her. Stacy said, OK, we'll pay you for that visit but then I'm closing her file for non-compliance. I asked what non-compliance are you referring to? Stacy said, people go into programs. Lucy hasn't been in any program so she's non-compliant with treatment. I said, I don't put people in "programs" - you should be glad I save you all that money by not treating people unnecessarily. Stacy said, no, people have to be in programs or we don't cover them. I said, what about what Julie said about leaving the file open for 6 months? Stacy said, no, we don't do that. People go into programs and when they are finished the program we close their file. We never keep files open just in case. We don't work that way. We're an insurance company. Julie was new and made a mistake.

Oh. I see. I said.

Then why (I asked) did you say you would pay me for that final visit Lucy made and that you wanted a discharge note, but then you closed her file anyway, and when I submitted request for payment I couldn't access the e-pay system? I do have a billing number..
Stacy said, you do? What is it? I gave it to her. She said oh, it's under your name and not your clinic's name? I said yes, it was a small practice, not a corporation, and I and Sensible Solutions Physiotherapy were the same. She found that very odd. I could hear her brain filing this new information under That-is-not-how-we-do-things-here.
I was getting increasingly angry; Stacy could hear it in my voice, so she accused me of being rude. I wasn't rude, I was angry. Those are two completely different things, but she had decided I was rude, and tried to change the conversation to it being about that, instead of about the client and the situation.
So I told her I wanted my name removed as a "partner" of the company. She said I'd have to contact Kathy (not her real name) to do that. I said fine. And hung up.

Then I called Lucy, and asked her if she wanted copies of anything in case she wished to pursue the company further, but she declined.. she was willing to let go of the whole ordeal with the change of adjustors and all the drama. Plus, she felt fine now, including her low back which had plagued her for a long time, since way before the MVA.

I said, it looks like I won't be paid for that last visit, but it's OK, because I'm just glad to not be their "partner" and having them shove me around and shove you around and not let me have my preferred style of interaction with their clients which is more 'catch and release' - instead they seem to think I need to have you come in three times a week for useless treatment and waste all kinds of money on that and have you be treated unnecessarily and me be bored trying to treat you even when you don't need it as if the "program" were the most important thing in the world instead of your sense of wellbeing back out in the world not needing to be a "patient" of mine... I'll take the bite for the treatment you had that they won't pay for because it wasn't your fault.

Then Lucy said, no, I'll pay you for that last visit.. I can send the receipt into my work insurance - they cover PT. If my workplace didn't have good insurance I might be more willing to fight the Motor Vehicle Insurance company, but really, I just want it to be over.

Fair enough Lucy, fair enough. And thank you for being you. And Stacy, go perch on a pivot. And MV Insurance company, I divorce you as of today. Our little adventure together is over.

UPDATE: April 27
I just got off the phone with an official smoother-outer person from the insurance company who called, left a message, asked me to contact her, please (!), and begged me to return, expressed how much the company doesn't want to lose any PT partners out in the hinterland, wanted to hear the whole story. Sort of the relationship counsellor from the company side. Nice woman..
We talked. She listened more than talked. She asked me to return if I could possibly see my way clear to do so.
I agreed to be reinstated. As long as I don't have to deal with the Stacy's of the world. (Actually, I should have given her the name Rocksy.) I was told that Stacy would be chatted to/with as well.
So, the marriage is back on, insurance company.  It's all good, for now at least.