Friday, February 12, 2016

What is PT, really?

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

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

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

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

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

Tuesday, February 02, 2016

One of those patient encounters you never forget

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

Friday, January 22, 2016

A new pain

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

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

Contributing factors: 

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

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

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

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  2. Flavia Mancini, Thomas Nash, Gian Domenico Iannetti, Patrick Haggard; Pain relief by touch: A quantitative approach. PAIN Volume 155, Issue 3 , Pages 635-642, March 2014 (FULL TEXT)
  3. Olausson H1, Lamarre Y, Backlund H, Morin C, Wallin BG, Starck G, Ekholm S, Strigo I, Worsley K, Vallbo AB, Bushnell MC.; Unmyelinated tactile afferents signal touch and project to insular cortex.  Nat Neurosci. 2002 Sep;5(9):900-4.
  4. Lundblad LC1, Olausson HW, Malmeström C, Wasling HB.; Processing in prefrontal cortex underlies tactile direction discrimination: An fMRI study of a patient with a traumatic spinal cord lesion. Neurosci Lett. 2010 Oct 15;483(3):197-200.
  5. Edin BB and Johansson N;  Skin strain patterns provide kinaesthetic information to the human central nervous system. J Physiology 1995 487.1 243-251 (FULL TEXT PDF)
  6. Meira, Eric; Getting Rid of Something Positive. PT Podcast Network blog, April 9 2014
  7. Quintner, John L. & Cohen, Milton L. Referred Pain of Peripheral Nerve Origin: An Alternative to the “Myofascial Pain “ Construct. The Clinical Journal of Pain 10:243-251 1994 Raven Press, Ltd, New York. (FULL ACCESS)
  8. Jeannette Hofmeijer, Hessel Franssen, Leonard J. van Schelven,and Michel J. A. M. van Putten; Why Are Sensory Axons More Vulnerable for Ischemia than Motor Axons?  PLoS One. 2013; 8(6): e67113. (full text)
  9. Michael J. Joyner; Cutaneous blood flow: uncomfortable in our own skin? American Journal of Physiology - Heart and Circulatory Physiology 1 January 2009 Vol. 296 no. H29-H30 (FULL ACCESS)
  10. Kapitzke D, Vetter I, Cabot PJ; Endogenous opioid analgesia in peripheral tissues and the clinical implications for pain control. Ther Clin Risk Manag. 2005 Dec; 1(4): 279–297 (FULL TEXT)
  11. Stein C, Machelska H; Modulation of Peripheral Sensory Neurons by the Immune System: Implications for Pain Therapy. Pharmacological Reviews December 2011 vol. 63 no. 4860-881. (FULL TEXT)
  12. Christoph Stein, Michael Schäfer, Halina Machelska; Attacking Pain At Its Source: New Perspectives on Opioids. Nat Med. 2003;9(8) (FULL TEXT)
  13. Stein C; Opioid receptors on Peripheral Sensory Neurons. Madam Curie Bioscience Database. 2000-2013, Landes Bioscience. Bookshelf ID: NBK6242

Thursday, January 07, 2016

Slowly, steady..

I think I finally figured out how to structure the manual, which to me is how to climb up out of this chasm, which feels like such a relief.

I will put all the heavily referenced deconstruction and reconstruction at the end instead of at the beginning. 

At the beginning I'll put all the 'hey-ho, here's the nervous system, isn't it lovely? treat it first' stories, 'here is the way DNM is different from other stuff' (at least 7 different ways), 'here are at least 3 important treatment concepts'; then, in the middle, bam - here are the treatment suggestions, all visual; and finally, at the end, all the heavy plodding argumentation. It isn't that it isn't important, it is. It isn't that it doesn't need to be in there, it does. It's just that it's still such a plod, no matter how I try to slice it or make it interesting and enticing.

Human cognition, especially in manual therapists, it seems, and definitely in me, works best when motivated by learning how to do, and then doing, something useful. There will be many others, however, I suspect, who won't be interested unless they can read the argumentation first. So for any who need it, it'll be there and they will be directed to it. It's bedrock. Under the surface stuff. In it's rightful place, under all the topsoil. To be dug straight down to, or to end up at eventually, after playing with the stuff at the front of the book. 

Saturday, December 12, 2015

If science were sandpaper

Yes, I'm still dangling in the chasm.
I'm still procrastinating. But I do think I'm making a little progress.

Not that I didn't write several more heavily referenced pages, an entire new intro chapter, not that I didn't include all the ideas I wrote about that I wanted to include, not that I haven't farmed it out to people I know who not only can write but who can edit too.. so, not that I haven't made some progress, because I think I have - but the timing is lousy because, time of year, and only one person has got back to me with lots of lovely suggestions.

So, to kill time I'm watching videos.
Not just cat videos.
I've watched almost all Harriet Hall's excellent video series on science-based medicine. As I listened to her methodically demolish all quackery on face of the planet, I applauded all the medical people and scientific hard work that has gone into making life more physically bearable for humanity over the last century. Oh yeah sure, there is a long way to go and there are inherent contradictions, but every day I wake up grateful that, since I had no choice but to endure physical existence as a female human primate, I was born in a place and time where I have had legal access to vaccinations and antibiotics and public health and 
and general anesthetic and birth control.

It made me think that if medical science were sandpaper, biomedical science would be the roughest, toughest grit size. And you need that, if you are trying to remove hardened goop or paint from a board or something...  or if you're trying to get humanity in general to wake up from all its inherent bias.

However, there are other grades of sandpaper that work way better for other jobs. Like polishing lacquer, or jewelry... 


I read Engel's wonderful 1977 paper arguing for a new biopsychosocial model of disease and illness, The need for a new medical model: A challenge for biomedicineReading it word for word really made me think.

In that paper, speaking from a psychiatrist's perspective, he discussed the biomedical model as a scientific model that, in the process of making huge progress, understanding disease and finding solutions, became a cultural dogma of reduction and exclusion which considers anything that doesn't fit the model as heretical, and anyone arguing for anything else as heretic. So, he embraced himself/his profession as heretic, I guess, and argued for a new model. Thank you, Engel.

I feel a bit that way myself - like manual therapy was hung out to dry in the chasm, put into the heretic category, become an 'unmentionable' or something, even though every PT on the face of the planet, just about, uses it without thinking about what it really means or how to resolve its contradictions. It doesn't have a very good evidence base. What evidence base does exist is kind of flimsy. Just about every intervention model that osteopaths and chiropractors, for example, invented or have heavily promoted, once it has been studied, has pretty much gone down in flames. 

So, as a manual therapy (as currently understood) atheist, as a heretic, I argue for a new model.

Barbara Gibson wrote a great blogpost recently on disability, quality of life, and the various tools that have been designed to "measure" it: "Whither 'Quality of Life'?" She points out that: 

"Quality of life measurement has exploded in the last several years. Myriad tools have been devised to measure the quality of life of populations, groups and individuals; and quality of life arguments are advanced in momentous decisions such as withholding or withdrawing ‘futile’ medical treatments. These developments have not only changed research and health care practices, they have helped structure how we think about what it means to be ‘healthy’ and ultimately what it means to be human (Gibson 2016; Rapley 2003). Quality of life is a useful concept that has contributed to moving healthcare away from a disease model but QOL judgements are always necessarily relational, reproducing social ideas of what constitutes a good or deficient life. Given the complexity of life quality, it is crucial that we tread very carefully with measurement and its interpretations. As Annemarie Mol (2008, p.75-6) notes:‘It is important to do good, to make life better than it would otherwise have been. But what it is to do good, what leads to a better life, is not given before the act. It has to be established along the way. It may differ between lives, or between moments in a life.' "

My bold. Who is to say what quality of life really means, except to those who either have some or don't have some?

Her post reminded me of how the body-beautiful fitness enthusiast people have been dictating since for-fricking-ever what "health" and "attractiveness" is, according to how well-defined a six-pack one sports. 

Culture imposing itself on individuals.


Any-hoo, what does any of this have to do with manual therapy, you might ask?
I don't know yet. Other than I think we've probably been using the wrong kind of sandpaper to try to understand what it is good for.
So, still wrestling with existence. And uncertainty. 

  1. Engel, George L. (1977).  The need for a new medical model: A challenge for biomedicine. Science 196:129–136.
  2. Gibson, B; "Wither 'Quality of Life'?" Critical Physiotherapy Network,  December 2015

Sunday, November 08, 2015

Dangling in the chasm

I should be finishing up my manual and sending it in to be published, but the project got derailed at the end of July, and I just have not got back to it. It's 85% done, too, which is even more maddening - it would only take about a week of concentrated effort to get that thing done
But I procrastinate. I have procrastinated for years, and lately for months. 

I think it's because I still don't "like" it enough. It's still not the manual therapy book I would buy in a flash and read cover to cover and refer to endlessly. Not in its current state.
The problem is the introductory chapter.
So far it's about 16 pages, with about 40 references, and it's still not right. I still don't have that satisfying sense of accomplishment about how it's structured. It needs yet more work.

The rest is just images and explanations of how to do the "moves." That was the easy part, even though it took years of fiddling around learning how to do photoshop to meet the need for it to be visually appealing.

What is lacking is the right mental frame. I've got the content down, but I don't have the right shaped container. Not quite. Not quite yet


I have an anecdote that might make some people gag,  others laugh maybe, but I'll share it anyway. 
Even as I was still going through school, I could feel that there was a massive chunk missing completely. I wasn't being taught what I really needed to know. I was not being taught any people skills. 
I flailed around a lot after graduating, all through my twenties (during the 1970's), trying to make my "marriage" to my profession work; leaving it for a time, going back to it after awhile, trying on other lines of work to see if I could love them more, but always returning to PT, and eventually settling down with it as my "life." 
One of the extra"marital" alternate-profession "affairs" I had, was, I went into real estate for awhile. 
I lasted about 6 months. RE sucked, and so did I. I actually sold a property, even, but I wound up hating RE even more than I hated PT the way it was, and the way I was..

I did learn various sets of people skills.
These were crude and cartoonish by today's standards, and I still loath that they were established ways of getting to "yes", getting people to part with their money, buy a house they maybe didn't even need, but at least they were something. I appreciated that they were in place and taught didactically, even though I hated being in "sales" and went back to PT right after. 

Meanwhile something that happened over the past few decades is that PT has turned itself into "sales." 
Maybe I should have just stayed in real estate! Kidding.. kidding.. I could never have been happy doing that for a lifetime. 


This morning I learned about "Ethics of proximity," something that Scandinavian PTs are onto lately.. 
I've got to say, I love the basics (from a non-related open access source (1) ): 
1. When interacting with another, we have an ethical obligation to help the other.
2. What constitutes “helping” can be defined through discourse but must always respect the other’s self-determination.
3. To interact authentically with the other is to risk ourselves and give up some of our control over where the dialogue between us takes us.
4. Do what works in the particular situation, taking from any other ethical field (especially discourse ethics, but also virtue, utility, or duty) but always respecting the other as the primary virtue.
5. In bringing preconceptions and prejudgments to our interaction with the other, we dismiss his needs.
6. When in a position of power over another, we are obliged to act in his best interest, not our own.
7. A relationship of caring has as its goal that of helping the other to gain his autonomy

I think these are gold. 
I am so disappointed that my profession stopped being a profession and turned itself into an "industry."
I so very much hope it can turn itself around before it hits the iceberg.
I so want my humble manual to include these values and be truthful.


Todd Hargrove wrote a good blogpost recently about treatment models, and three reasons why it matters what we think and say about what it is we think we're doing when we treat, explanations we offer up. 

1. If you get on the right track you can improve. >>>"...if my target was breaking up fascia or muscle knots then indeed I wouldn’t care how they felt. And I wouldn’t do as good of a job." [.. or getting some presumed stuck joint to move.. or jabbing needles into "trigger points" as if those were actually things]

2. False beliefs have unintended consequences. >>>"...false beliefs, no matter how small, are like viruses - they multiply, get passed to others, mutate to form super bugs, and can eventually cause disease. Don’t spread them people!" [Look how pervasive the mirage of perceptible joint movement is in our profession! Look how the profession turned itself into a mechanics shop!]

3. Truth matters. >>>"Every step away from misinformation and confusion is a step in the direction of the truth." [Egggggggzactly.]

I really want my manual to be about how to handle people who hurt. How to touch their nervous systems by letting them express themselves, by touching/trying to help their nerves. Nothing else.
Yet I know that currently it looks like just another how-to recipe book of ideas for manual therapists to copy. It doesn't have a unifying theme yet. It's still lacking soul.


Also this: 
"We like to think our senses can give us unbiased, truthful information about the external world.... that's utter nonsense - we are not driving the bus. By the time we are aware of a sensation, that sensation has already been filtered and edited and combined with our expectations and our emotions and our personal history so in the end there is no sensation without emotion, there is no sensation without personal history without evolutionary history - it's all combined into a mush and that's what we have to deal with." 
This is David J. Linden, speaking in a podcast he did with Ian Sample at ScienceWeekly, back in March 2015.

This is important to grasp - i.e., as manual therapists we're dreaming if we think we are doing anything "specific" - everything we do, every sensation we provide, is subject to filters by a patient and their past, all bundled in their neuromatrix, churning endlessly, trying to predict its own future. We need to get over ourselves and stop trying to do things TO people, instead just be WITH them. Which circles back around to what the point is, of even bothering to put out yet another manual therapy manual, if it doesn't explicitly state all this somehow? How can I get across the point that manual therapy is a ritual that kills time while people spend time in your presence letting their brains figure out at subcortical levels how to get over themselves? While you busy yourself doing innocuous things, rather specifically? (Well, we hope "innocuous" things..) It's one of those chasms in which I am stuck simply not being able to cross at the moment. ................
One thing that gives me hope though: This past week I got some feedback from the "system" in which I do not participate, in fact stay out of for the most part, quite deliberately. Back to the "marriage" analogy, it's like my profession and I sleep not only in separate bedrooms, but in separate wings and floors of the house. We meet once a year when I renew my licence. Anyway, back to the point, I got two documents from a very-much-in-the-system facility in a far away city. The backstory here is, a woman called to see me who had been in a lot of back pain for a very long time and had been way overtreated and biomedicalized and pathologized, and finally they stopped, referred her out to another therapist who lived closer, because she lived a long way away and had to travel recumbent. The therapist they referred her to had not wanted to deal with such a sensitive nervous system and had mentioned my name. When the patient called, I said sure, come on in, we'll see what's what and if I can help you. Anyway, she did well, could even travel sitting upright in the vehicle after a few visits. She returned to the first clinic for closure. They were sort of surprised, I think, that she tested very well after all their own efforts hadn't worked. The discharge note was like, hurray, she's better thank goodness.. don't know what Diane did but whatever it was, yay.  In retrospect, I think they had inadvertently taught her to be more worried about her back than she had ever needed to be, and worry/stress was her main obstacle.

I really want my manual to explicitly contain values and people skills and convey how important it is to put the responsibility onto the patient and divest oneself of any responsibility other than positive encouragement, including by doing careful manual therapy of a most superficial kind, a set of tricks really, and how to give the patient full rein to get themselves better. I give people a little speech before I ever lay any hands on them, that puts them in charge of my touch/handling. I make it clear they can feel themselves better than I can, that I need their help to help them with their pain problem, that treatment shouldn't hurt at all, that hurting them is counter-productive when pain is being treated, that if they experience any discomfort of any kind they need to tell me right away so I can change what I'm doing right away - we want their nervous system to work, yes, but work normally, not in this hypersensitive way, and provoking it won't get us where we want to go.
This does a couple things - it makes them the boss over me - if they have locus of control they will feel less stress about being touched. It's built-in that the whole point is about coming off the table in less pain than when they went on the table. It also takes responsibility of being the "fixer" off me completely, and puts it on them. I'm just a helper. I'm just holding up a kinesthetic flashlight so their nervous system can see what it has to do to get over itself.
I call that person-centered treatment.
I want my manual to get across the idea that person-centered treatment is where it's at and anything else is a great big fail waiting to happen. 

Denna Hintze , Knut Are Romann-Aas , and Hanne Kristin Aas; Between You and Me:A Comparison of Proximity Ethics and Process Education. International Journal of Process Education (June 2015, Volume 7 Issue 1)