Thursday, March 31, 2011

Hu/manual therapy: "Intention"? "Intent"?"Intending"?

"There's no load I can't hold
The road's so rough this I know
I'll be there when the light comes in
Just tell 'em we're survivors"-Tom Cochrane

The discussion rages on the Facebook page, on several different threads simultaneously.

One discussion that is from oh so earlier in the week and is nearly buried, is one around Todd Hargrove's blogpost, More Deepities: Does Intention have Power?

People involved in manual therapy will have noticed that quite a few streams of it are almost religious in their fervor. The term "deepity" came my way from a lecture by Daniel Dennett, called the Evolution of Confusion, a great watch at about an hour long. Out of that lecture came "deepity"(see clip about 3 minutes long, an extract). Todd explains that a "deepity" is a "somewhat ambiguous statement that precariously balances between two possible meanings. One potential meaning is true but trivially obvious, while the other would be earth shatteringly profound if true, but is in fact false."

Manual therapy is full of these deepity things. Which is kind of Todd's point in writing his blog posts - he's trying to deconstruct belief-based nonsense (I think) to see if there is anything meaningful (actually solid enough to believe) in manual therapy conceptualization. Todd's posts on deepities: 

1. Is the “Mind Body Connection” New Agey or Scientific?

2. More Deepities: What is “Energy Work”?

3.  More Deepities: Does Intention have Power?

After I linked his latest blogpost to the Facebook page some puzzlement arose: What was truth? People with materialistic viewpoints think they know and that people who don't (have materialistic viewpoints) are wrong and stupid. It's all philosophical/debatable. The poster did not want to discuss her implication that not buying into ideas of "chi" etc was an ethnocentrist attitude and withdrew her post before it could be challenged. A quantum entangler arrived and discussed actions at a distance, which didn't really move the conversation along much.. Finally the idea emerged that "intention" might mean applying mental faculties to manual movement of hands in treatment. It prompted me to write this: "

"The discussion is not about the verb "to intend" - rather the discussion is about the noun, or construal, named "intention" - which as a noun (i.e., reification) can refer to whatever mental construal happens to be drifting through somebody's head. The argument is "some construals are more science-based (i.e., more objective, more reality-based, biologically-congruent) than others." The project is to slowly wean one's own mind off mental junk food onto ideas that are healthier. The goal is to save manual therapy from sloppy thinking and therefore, oblivion."

On another thread, in a post which I can no longer seem to find (dang you Facebook..) I posted a link to Manual therapy models: Operator or Interactor.  It was noticed by a poster that the definition I proposed for interactor models of manual therapy included the word "intended". And it does:
Interactor model: A physical therapy handling model which consists of therapist and patient, minus or with deliberately minimized objectification or reification; both parties choose to directly deal with patient pain and nervous system function, in a process intended to be therapeutic.

I pointed out that the word "intended" appears in my definitions of operator models as well:

Operator model
A physical therapy handling model which consists of therapist and patient, plus some pareidolic, reified objectification chosen by the therapist and implicitly agreed to by the patient, intended to be therapeutic.

A physical therapy handling model which consists of therapist and student, plus some pareidolic, reified objectification chosen by the teacher and implicitly adopted by the student, intended to be therapeutic.

There is no escape from intending or intention. There is only a choice about what set of ideas one moves or "intends" from. Moving strictly from a fixed set of ideas while in contact with another human being within a manual therapy context will not allow interaction. Interacting with another human being within a manual therapy context, and having the interaction become the focus, leads to a much different kind of "intending", more interesting process, and hopefully a greater sense of having attained and retained locus of control by the patient. The definition I propose for manual therapy itself, models aside, is:
                 Proposed definition for Manual Therapy:
A legally contracted, paid interaction, consisting of physical and verbal therapeutic contact, between a person trained and licensed to perform physical treatment to assist movement and/or relieve pain and a patient seeking such paid service.
Something like this might remove us from the messy sphere of arguing over what kind of model is better than anyone else's favorite model and how one model is better than another because it's more spiritual and less materialistic, more quantum entanglementle and less materialistic, more energy and less physical, more ethereal and less biological.

I'll probably spend a bit more time delineating the argument (some construals are more science-based [i.e., more objective, more reality-based, biologically-congruent] than others), the project (slowly wean minds off mental junk food onto ideas that are healthier [or at least more neuroscience-based]), and the goal (save manual therapy from sloppy thinking and therefore, oblivion), in future posts. It's good to have all three, clearly in one's mind, no? That, and only that, is my tripartite "intention" in most anything I write, pretty much. And it applies to me as much as anyone else.

Vancouver weather

This is from Oatmeal, and is about Seattle weather, but really, Vancouver and Seattle are conjoined twins when it comes to weather.

The 4 Seasons of Seattle Weather

(Today in Weyburn, brilliant sunshine.)

Wednesday, March 30, 2011

Ooh... my my. That does not look comfortable at all.

The time: 1936
The place: Somewhere in the UK, I guess.

Sir Herbert Barker's manipulative technique Part 1

Background information

Sir Herbert Barker's manipulative technique Part 2

Background information

Note the tension level exhibited by the patient throughout the manipulative ordeal. This is exactly why I have never learned to appreciate ortho manual therapy. It's too hard to relax when your salience detectors are on full blast working overtime pouring on the coals in the insular cortex. If the patient does not have any opportunity to practice having or experiencing an internal locus of control, he or she will never learn to use it.

Harriet Hall on toothfairy science

Ever since the most recent news (i.e., that it is a nonstarter) about acupuncture appeared in the journal of the International Association for the Study of Pain, aptly titled, PAIN, protest has erupted in the land of the true believers, in Facebook land, for sure, likely other places as well.

Here is a quick descriptive list of the publications creating the uproar:

1.  Ernst E, Lee MS, Choi TY; Acupuncture: Does it alleviate pain and are there serious risks? A review of reviews. Pain. 2011 Apr;152(4):755-64.

2. Hall H; Acupuncture's claims punctured: Not proven effective for pain, not harmless. Pain. 2011 Apr;152(4):711-2. Reproduced in full in Acupuncture Revisited, Mar 29 Science-Based Medicine blogpost.

3. Ingraham P; The last word on acupuncture? If only! March 29/11 

On the Facebook discussion a Tcm ("traditional chinese medicine") poster left a link to a rebuttal article:

4. "A response to "Acupuncture: Does it alleviate pain and are there serious risks? A review of reviews" by E. Ernst, Myeong Soo Lee and Tae-Young Choi, PAIN®, Volume 152, Issue 4 (April 2011)". The authors are not listed. The Journal of Chinese Medicine appears to be an online publication, and the rebuttal appears in a special section called "Drum Tower", which is described as "Informed news & opinion on the latest hot topics in Chinese medicine" 

What are they trying to drum up?

Anyway, much flapping, feathers and fur flying. 

My final link is to an entry about Harriet Hall's remarkable deconstruction of nonsense with the concept she originated, namely "Tooth Fairy Science". If ONLY people would just stop, and breath, and read this, and take it in, a little bit at a time, until they get it, they would see what their own fuss is about and would stop being so defensive. Everyone would be able to get ourselves onto the same page.

The Tooth Fairy Science entry makes several points (see 1, 2) and highlights several foibles common to humans, being, and thinking, and getting through life (see 3, 4, 5). 

1. Prior plausibility: "doing research on a phenomenon before establishing that the phenomenon exists."

"Fairy Tale science uses research data to explain things that haven't been proven to have actually happened. Fairy Tale scientists mistakenly think that if they have collected data that is consistent with their hypothesis, then they have collected data that confirms their hypothesis."

"You could measure how much money the Tooth Fairy leaves under the pillow, whether she leaves more cash for the first or last tooth, whether the payoff is greater if you leave the tooth in a plastic baggie versus wrapped in Kleenex. You can get all kinds of good data that is reproducible and statistically significant. Yes, you have learned something. But you haven’t learned what you think you’ve learned, because you haven’t bothered to establish whether the Tooth Fairy really exists."
2. Occam's Razor: "there may be a simpler, more plausible explanation for your data." 
"(Most readers will not find it arduous to devise an explanation for those gifts that have replaced teeth that were placed under a pillow.)"
3. Circular reasoning: the case of Ian Stevenson: "he used his data to support a belief in the reality of reincarnation and he used reincarnation to explain his data."
"a psychiatrist and head of the department of psychiatry at the University of Virginia, spent years collecting stories from people who claimed to be reincarnated. His data is extensive and he used it to make a case for present-life calamities in terms of past-life experiences. Stevenson exemplifies the circular reasoning of many Fairy Tale scientists: he used his data to support a belief in the reality of reincarnation and he used reincarnation to explain his data."
 4. Pareidolia: John Mack and UFOs
"Whatever else Mack believed about his abductees, he saw their experiences as spiritual and as fitting well with his own beliefs regarding spiritual transformation and larger environmental issues."
5. Alt Med:
"if the data shows that the CAM therapy doesn't work any better than a placebo, the CAM folks claim that proves their medicine is effective!"

Thursday, March 24, 2011

Life, post rabbit trap

These are excerpts from a letter I sent in to the instructor when I withdrew from the Pain Management Certification Program late last week, about various of our discussion points. They are tidied, organized, edited for clarity, and headings are added. They summarize the main disagreements we have with each other (and may continue to have on into the indefinite future). They touch on our perspectives on where we see the profession headed, how those perspectives differ. They may or may not represent deeper overall tensions within the profession. 

I would like to stress that just because I personally am turned off about the program, this does not reflect on the program itself. Objectively, it is a fine, well-constructed program, and should be able to turn out graduates who can go on to "manage" (on behalf of the health care system) patients who have hard-for-themselves-to-manage pain, which doesn't/can't/won't respond, for one reason or another, to simple measures found easily in the community, such as all the kinds and flavors of human primate social grooming that exist, for example.

The nervous system itself
The main topic in the first class was the afferent system and what can go wrong with it. She thought I had somehow misunderstood one of the fine points about this (Aβ sensitivity in the system) and became stuck on it. After 20 emails and no clarification forthcoming, I decided to exit the circular holding pattern. Instead I explained how I see the nervous system.

I am (and always will be) fascinated by the fact that ectoderm builds everything, that 98% of the body is not electrically excitable, that 2% of it is, that ectoderm turns directly into brain and skin, that neural crest builds the sensory and autonomic peripheral nerves, that there are 72 km of nerves spanning a human body from skin cells that can transduce all the way to sensory cortex all the way back out, that electrical signals travel 120 meters per second on average, that to maintain such ferocious signalling speed the NS consumes 20% of all the body's available metabolic energy, even though it comprises only a measly 2% of the total mass. I love reading how this system has evolved. How it isn't monolithic, that it has different systems, that evolved at different times, that synapses have proteins in them (as many as 1400 in humans) some of which we still have in common with yeast. That signaling is what the nervous system is all about, to maintain an organism's coherence. All the things this might mean. Humans as evolved primates. Manual therapy (or any kind of human interaction, really) as human primate social grooming. Biopsychosocial models [e.g., neuromatrix model] and their implications... It may come as a shock, but I'm pretty disappointed in our profession and would like to see it move past ideas as erroneous as "muscle pain." Pain is something the brain experiences, not something muscles make.

The Neuromatrix Model of Pain
From our earlier conversation an issue about "muscle pain" had arisen. She had sent me a link to a video which had guidelines in it for managing acute low back pain. Although there was nothing wrong with the advice as such, the therapists in the video talked about pain as if it came straight up from the body to the brain, the famous and now-finally-slowly-being-debunked Cartesian model. Earlier she had indicated that in her opinion the neuromatrix model was "just another hypothesis" about pain which had yet to be tested. We had locked horns a wee bit on that - I stated that in my opinion it was more a theory from which hypotheses could be derived, then tested, to see if the theory would stand. 

Frankly I had been a bit surprised that she had never looked at it that way, nor seemed to want to.

I copied her a passage from page 906 in the Texbook of Pain, by Marshal Devor: 

"Sensation, including pain, is the domain of the nervous system. Although it may seem trivially obvious, it is sometimes forgotten that stimuli delivered to skin, muscle, bone and viscera give rise to sensation only by virtue of the nerve fibres that end within them. Completely denervated tissue is numb. On the other hand, sensations that feel as if they originated in peripheral tissues can arise from impulses generated in nerves, sensory ganglia or the CNS even if the tissue itself is completely numb or even absent. Examples are anaesthesia dolorosa and phantom limb pain."

About it, I had this to say:
This is the main issue, about tissue: I.e., tissue doesn't "feel" anything or "report" anything: only the neural tissue embedded within it can depolarize, mount an action potential, and message from tissue: NON-neural, NON- electrically-excitable "tissue", itself, or rather, the cells that comprise it, can only exocytose, secrete substances that excite afferents (which can and do electrically signal).

I have a real problem with the fact that the common language in PT is all about how we have muscle pain and joint pain and ligament pain. Such language is a disservice to the profession and all the individuals in it. The actual neurobiological and neuroscientific information remains completely (and conveniently!) ignored, misunderstood; conveniently heuristic but erroneous and misleading ideas are instead reinforced at the level of the entire profession.

 So, do we actually feel "pain" coming from the body? I come down on the side of 'No."
My understanding is that it would be more neuroscientifically congruent (a bit awkward at first, perhaps, but in the long run, less messy, incorrect, or intellectually costly for the profession to modify/upgrade as new information emerges), to reinforce the idea that, while we can feel nociception which our brains tell us seems to be coming from our body, that what we experience consciously, as "pain" (often conflated with nociception, which is sensation, but not yet a pain experience) only comes to our awareness from several representational maps combined in the brain itself, and in fact has to be computed there and produced before it can even reach conscious awareness. If nociception doesn't not reach conscious awareness we simply and non-consciously and reflexively withdraw from a stimulus and that's that. We respond to nociception without having to become involved, without having to think about it. Smack the mosquito and forget about it. Shift our position when we become uncomfortable.

But pain, not so much. Hard to escape.

Labelled-line research, while it is very good at investigating neuronal behaviour, including nociception, seems to have never been very good for investigating or understanding what
pain was about. There were puzzles that just would not be solved. So Melzack said, OK, we need a new theory, and built one, based on his four conclusions about why label-line investigation was inadequate for investigating, describing, or coming to terms with treating "pain", in conscious people (see note 2). One conclusion was about phantom limb pain, which shows up not only in people who have had amputations, it also turns up in people with congenital aplasia of a limb, completely bypassing the nociceptive input system - entirely.
Another is the body-self puzzle - virtual body and rubber hand illusion work is being done on that - so easy to dislocate sense of self over to a mannequin.

My understanding is that such investigations have so far supported the neuromatrix model
[and separation of ideas of nociception cleanly from those of pain] but knock over Cartesian label-line "theories" about pain.
I do not see any of this [research on hypotheses deriving from the neuromatrix model] as dogma. I see it as a way forward. I think our profession is lagging way behind, hiding behind biomedical coattails, to its own detriment. It can do plenty with measurement but it has never decided that it's a grownup, that it will measure what is important to measure (i.e., that which would keep it congruent and updated with the rest of biological science), [as compared to] what might be measured for fun and intellectual exercise but won't help it evolve in the long run.

Misrepresentation and dogma
Another of her issues was that she thought pain science was being packaged for sale and delivered in a manner that was too simplistic, did a disservice to all the shades of grey it contains, and was too easily turned into dogma.
Learning that "nerves" themselves can "hurt", about 12 or 13 years ago, gave me a completely new entry point as a clinician [into understanding the world of "hurt" that my patients inhabit, and that I also inhabit from time to time. It gave me ways to reassure people and all sorts of treatment ideas I'd previously never even considered.] Frankly, I've never slowed down ever since, because suddenly I had a story that was congruent with my actual clinical work, not some string of ideas awkwardly cobbled together by a profession that still doesn't really make any sense, even though I still think it still retains huge potential.

What goes on at the interface of one human nervous system, and another nervous system, in a treatment context, be that context hands-on or hands-off, is fascinating. I will always be motivated by that.
I think the packaging [of the profession] is wrong, and riddled with dogma, and weighed down by it, and would love to see it decluttered one of these days. Not more added.
I'm talking about the whole profession, the one that won't hire pain researchers, the one that talks about muscle pain, the one that only will focus on motor control and doesn't appear to care about afferent systems, or how they blend, or pain; the profession that refuses to consider developing a neuroscientifically congruent basis for the importance of context and afferent input in manual therapy; the one that won't let in manual therapy unless it's full of pareidolic notions that are either biomechanical (which have never interested me much) and over the last couple decades, mystical unsupportable indefensible concepts, which I can't stand to see happen anymore. It's time for de-hoarding IMO. I want to get RID of dogma.

About the pain science division in Canada
She seemed quite suspicious about the pain science division and its motives, using the word "marketeering" on more than one occasion.
Now, about people who teach workshops, for money. What is the problem? I mean, why [do you think] this is [an appropriate] issue [to be raised in a student-instructor consult]? I don't think it should be.  
In PSD we are very careful to keep the hats on different shelves, and the money and tracking it is a very transparent process. 
Every division has this issue and deals with it. PSD actually has something relevant TO teach. And yes, the individuals involved teach workshops about pain, because: 1. information about pain is what we think is important, salient; 2. no one was reaching clinicians with solid information in any sort of organized fashion through a structure; 3. most of our patients are coming to us with pain !! 
I don't personally enjoy teaching as much as the others do, but I am motivated to facilitate the others' teaching of pain concepts to clinicians, because otherwise they end up stuck with outdated ideas about where pain arises! 

Informed clinicians in a profession make for a better-informed profession. A better-informed profession might create a demand for more pain researchers and more jobs in schools will arise. Win win.

Seriously, you would shudder to see some of the JUNK that is taught out there in the world, to clinicians, for huge piles of money. Clinicians teaching other clinicians about pain is a wonderful service for the profession - for the clinicians in the profession, who, unless they are exposed to updated information, are going to continue to perpetrate misinformation that turns out to be anti-scientific and neuroscientifically incongruent and biologically ungrounded. 

These instructors aren't telling people what to do - they are explaining what might be, is likely to be, going on in a nervous system which is having a pain experience; they are trying to balance the information flow so that clinicians have better concepts to work with. Yeah, so they throw in a few treatment concepts too. It's all OK.
They teach clinicians about being interactive with people, not operative.
Something tells me this would be a better direction for the clinical chunk of the profession to move toward.
There were many more items I could have touched on, about appropriate boundaries, about clinicians teaching, subject matter being taught, teaching workshops for money, what motivates clinicians, to learn, to think, to treat, to study. But I didn't think there would be enough room on the internet or enough time left in my lifespan to say all of it, so I let it stop there.
2. Melzack's four conclusions

Monday, March 21, 2011


My motivation wasn't hiding, it was all piled up waiting for the email from the course coordinator, always a swell guy, which informs me about the withdrawal policy. His lovely perfunctory note reads (identifiers deleted):
Thank-you for your email.  I’m sorry to hear that the course is not meeting your expectations. 
In answer to your query about refunds - the date for obtaining a full refund has passed.  However, you are still eligible to receive a 50% refund if we submit an add/drop form to .... before March 31st, 2011.
If you decide that you would like to drop the course please let me know and we can get the process started.  As you have already completed .....  you will receive credit for that course and it will appear on your .... transcripts.  However, only individuals completing all three courses in the series would receive the certificate issued through the .....
Please let me know if I can help in any other way.  Hope all is well with you!

It feels like the trap is off my foot now, and I'm pleased to report that virtual feet on virtual rabbits heal instantly with good news.

So, what WAS this all about, anyway? For sure, this latest (and hopefully final) move away from the actual program was about a visceral response to an irritant.

Some of the irritant was the course content, some of it was my own lack of adaptability, some of it was how I couldn't figure out how to consider this chunk of it important - for me - and some of it (a lot of it, actually) has to do with how I was treated when I asked for some help to clarify some things.

Instead of a boundary being maintained around the student-teacher issue by the instructor, the conversation derailed, got personal and political about all sorts of things that were not directly about any "student-having-a-problem-with-the-material" issue. I might be a bit of a handful from time to time, but I think the real train wreck, for me, in terms of developing an allergic response and getting irrevocably turned off her and the program, happened when she decided to take an opportunity to talk about all the other stuff that she had on her mind. I think that really weighed down the cognitive dissonance issue with which I was already struggling.

Furthermore, I felt my intelligence being insulted about A beta fibers, and about "muscle pain" which she apparently accepts holusbolus as a heuristic, and with which I have a problem, and support for objecting to, right in the Textbook of Pain, on page 906. Rather than clarifying the issue in a couple sentences in one email, over several emails it was implied I was an unteachable crummy golfer with a closed mind.

Anyway, that's what happened, in vague terms, so as to protect identities of those involved or discussed by us. So, I have lost confidence and trust in the instructor in terms of being able to relate to her as a student. I don't agree with where she thinks the profession should end up (i.e., stay in the same holding pattern intellectually). I don't want to continue under these circumstances.

And what WAS my motivation in the first place for taking on a project like this, at this age, and without having any practical objective reasons for doing so? I was in a lull, needed stimulation, needed brain food, needed to see what it was all about, needed to find out if my brain still worked.. was bored, needed something different to do for awhile.. a post-midlife minicrisis, or at least doldrum, maybe... looking back I'm not really sure anymore.

I guess something useful will come from it. Anytime a compost bin gets accidentally tipped it makes a mess, but in the process the compost itself becomes aerated. 

Nothing ventured, nothing gained.
Just because I didn't survive the program doesn't mean I didn't learn a great deal, and education is never wasted. I understand more about research and reading papers. That's got to be good. I've listened to lectures from excellent people in the field and have made copious notes. I now know who I don't want to hang out with, in my profession, and why. I now see the shape of the battle we all face together more clearly. That's always strategic.

I was a dead woman (in terms of having any influence over anything important) to begin with; I'm still just as dead as ever, so it doesn't much matter that I drop out of this particular battle, whatever it's about. I concede defeat. I now have my rabbit foot out of that steelclaw trap though, and feel way more comfortable.

While all this was happening last week I couldn't sleep, found myself up at 2:30AM, shopping online looking at treatment tables. It could well be that part of me is stirring once again, the part that likes having a location defined by me, where I control the ambiance and decor and cleanliness, that is warm and bright and comfortable, where I can treat people at my leisure without any pressure. It's the human primate social groomer motivation stirring again. I can feel it. It had a nice long rest, and I think it may be wanting to wake up and get busy again one of these days, have a defined practice again. That's always been my one and only motivation, since I was a child. It's the one I'll take with me to the grave.

Sunday, March 20, 2011


Currently managing all my physiology again after dealing with the dreaded online quiz about measurement theory. I raced through it heart pounding and palms sweaty, anxious to have it over with. I ended up with 39 out of 50, according to auto-eval.

Yeah..., I think I'm a bit too worn in the tooth to be doing all this cortisol stuff to myself.

It isn't only that the material is alien to my personal proclivities and unattractive to my mentations, it seems to be something my brain finds outright aversive, crosses some sort of sense of order my cognitive capacity has developed over decades, forces it to adapt to a set of goggles that make the world look like Bizarro world, upside down and inside out. The effect is kinda nauseating, suggesting a protective response arising in the insular cortex.

That might seem like emotional over-reaction, but I'm merely reporting the opinion my insular cortex has about the matter. It's my affective motivational system talking to me. Or through me. (My cognitive evaluative system is busy right now, trying to pour water on hot exposed fuel rods, from dorsolateral prefrontal and medial prefrontal helicopters. I hope it works.)

My insular cortex is my Tiger mom. Truly, if there is anything intrinsic I have to be terrified about, it's my own insular cortex's reaction to anything it doesn't like. Amygdala schmamygdala. That I can deal with. My own insular cortex, not so much. It has never dished pathological pain out to me, fortunately. But it has a lot to express about anything novel, and I sure don't like when it activates and stomps around all over my brain. If it does, usually I can have a chat with it, and usually it goes back to normal levels - with repeated exposure to something disconcerting, it usually calms down.
Example: the first time I ever tried teeth whitening strips, my teeth burned, my mouth filled instantly with foamy saliva, and I couldn't stand the exposure. My insular cortex clearly hated them and my teeth hurt for days. When I tried again, years later, the strips did not provoke (I did not experience) the same reaction. I wondered if the strips were past some kind of expiry date as they seemed to have no afferent effect. The teeth did lighten up however, as they were supposed to.

That was a peripheral afferent stimulus, though. This is a cognitive-evaluative afferent stimulus. I don't have much experience with this. My efforts to grapple with learning measurement theory isn't mere graded exposure to a novel noxious stimulus, it's Graded exposure, exposed, judged, measured and scaled scholastically, to an entire set of information about exposing, judging, measuring and scaling - a quite different kind of critter and something that sets all my salience detector alarm bells off with Tiger mom insular cortex acting quite unilaterally, arbitrarily, and terrifyingly.

Do I really need this stress? At my age? With no real requirements to complete it in order to make a life? I guess I'll find out. Foot is still caught in the trap. Lots of time to think about how it all feels.

Saturday, March 19, 2011

What's my motivation?

The class I have been struggling with is going from bad to worse: I am learning my limitations.

I do not personally have any real attraction to the geeky side of research, whether it be learning how to measure abstract things like pain, or even learning ABOUT the geeky side of pain research, such as learning what a criterion concurrent validity is compared to a convergent construct validity. Never have had. I simply have no hooks built in my brain, that could grab that information to work with it, even if I wanted to. Never went there. Never did that. Never was attracted. So, right now I'm asking myself how and why I ended up in this situation.

Ooh. The pain. I do not like finding out I do not have a nimble enough mind to even process the information let alone mentally manipulate the information let alone do assignments and exams about it. I feel trapped like a rabbit with one foot in a steel claw. I want to get out of here. If I make a move I just hurt myself and go nowhere.

So, I ask myself, why did I sign up for this?
I think I wanted to know about all of it, but I didn't really want to have to learn how to do it.

The instructor insists that this is the right way to learn to manage pain patients, and she may well be right, but managing pain patients this way is not really and never will be my focus.

I had an enormously long email conversation with her, and slowly, it has emerged as to what my focus might really be... It certainly differs from the one she has.  There is a certain clash of perspectives. In the end, all I am is a human primate social groomer who is always inquisitive about learning anything that will help me do my human primate social grooming better or more effectively by being able to explain. Furthermore, I'm convinced that having the story in the right ball park is also important, in the clinican mind and the patient mind.

Basically, to me, this boils down to being at least on the right kind of tissue, at least conceptually, i.e., somewhere in the nervous system, when discussing pain problems.

She is teaching a class on how to administer tests to patients to figure out what kind of pain they have. To do that, there are dimensions of testing one must learn about before administering.

It gets even more dicey than that. Here is the really scary part, from my point of view. The impression she gives me is that she would love to turn the whole PT profession into people like her. She has huge judgment against any use of pain science for information value only. She seems to want it to stay pure and unsullied, to boldly go into all the shades of grey, to measure them, to develop new conceptual tools that will calculate one colour of grey against another and measure them precisely in such neutral light that back in the sunshine one can still be confident that the scale one uses to gauge the grey shade one is looking for will still correctly identify it, even when its context has changed.

She said "nothing in research is black and white. Everything is grey. Clinicians want black and white all the time, but there isn't anything black and white." (Um, yeah... we already knew that, but we have to make decisions, and the best decisions are made when we can access the best information. Hello? Withholding information isn't helpful! And just because it will never be perfect or because it's only provisional or because it's still just a theory doesn't mean that it isn't closer than what we were working with before! LIFE IS A VERB, not a NOUN!)

She was discomfited at the very idea of pain research being distributed by people who are a lot less close up to it than she, who knows all about how many shades of grey there are and still may be. (Um, sorry, that started a couple decades ago. There was no spigot in place, so somebody built one. The amount of information that had piled up around pain, that was not getting into the minds of clinicians, was threatening to burst the dam and flood the profession far below. Some people thought it better to build some ways to drain some of it out to use to grow new food for thought. Um, so the profession could remain relevant on the ground and in the clinic and be more congruent with how science looks from there.)

She was discomfited by the idea that people were selling pain information to clinicians in workshops for money. (Um, you should see some of the other JUNK being sold - at least this is useful stuff, not JUNK!)

Everything in brackets, italicized, bolded and exclaimed, is my own emotional frustration with everything she expressed frustration about.

I can see her point - she loves the geeky side, and doesn't like to see any situation develop which could possibly misrepresent the careful effort she makes on behalf of the profession. I get it. I do. I think it boils down to intrinsic academic reluctance to take a stand or make a decision. I think some of that gets trained into people. Some of it is probably a character trait. It's good..., I mean, if we didn't have that, we'd have no science at all - all we'd have would be religion (and that would not be a good thing).  She says she is against dogma, so, another point for her.

On the other hand, we have a profession full of clinicians who need better information about what it is we do and better stories with which to line our minds such that we can slide the better information out to patients. And the stories better be scientifically congruent with the information and congruent with the delivery by the profession to clinicians and by clinicians to each other and by clinicians to patients, or else the profession ends up anachronistic, or worse, deceiving the public.
EXAMPLE: I do not see any point in keeping clinicians in the dark about the nervous system and how it works. We aren't children. We shouldn't still be going around talking about something called "pain" as coming from muscles or bones or joints. It doesn't. Pain is something the brain makes out of raw data coming up from the body, but only if it has a "mind" to. It loves to tell itself stories. It can invent pain without sufficient information or even any information coming up from the body. (And no, don't go using that to blame patients for having pain. It's not them making it up. It's their brain, and they are trapped inside that brain, feeling the pain story, perceiving it even as their brain projects it.)

Anyway, here I still am, lying here with my little rabbit foot in the trap. I could chew the foot off, and would still have three feet left to run away on. I'd rather not lose a foot. Don't like making sacrifices.

There is a part of me (an ego part probably) freaked out about failing this class. After scoring an A (!) in the first class, which was all about learning what's going on in the nervous system. Learning the stories about what's going on in the nervous system. That's what I love learning about. Those stories are the ones I can explain to patients. That kind of thing I am definitely motivated to learn. This abstract, dry dull measurement stuff, not so much. I don't want some poor mark on my (pathetically irrelevant in any case) academic record. At least this ego part doesn't. It thinks people could come along and use it to judge me later. Now I remember why I hated going to university even though I loved learning information.

So, I'm forced to consider my options. Cognitive dissonance is so frickin' painful. Ow, my foot!

Lacking natural motivation for learning geeky methodological verificatory statisticality, I could force myself and could probably learn the material, but it would take me a lot longer than the time frame of 13 weeks. Even if I apply myself diligently 24/7 to nothing but the material (which I HAVE BEEN doing), I'm still going to lose. I don't know how to even begin to tackle the assignment, "Critical evaluation of a measure specific related to pain management". It's due at the end of March. No matter what I do, I'm convinced at this point that I'm gonna lose. I'm a dead woman.

From March 18, News Research UPDATES: How to Make Practical Sense of Pain Research

Wednesday, March 09, 2011

Fibromyalgia - Rompecabeza? Casse-tête?

In English, the literal meaning of "rompecabeza" is "head breaker." Generally the English translation is more benignly listed as "jigsaw puzzle." On my kitchen table is a BigBen 1000-piece jigsaw puzzle, in a box, on which appears, "1000 piezas de rompecabezas", and "1000 pièces de casse-tête", following after "1000 piece puzzle."

Rompecabeza: (Spanish)
- Romper: "Separar en partes o pedazos, usualmente con violencia; destrozar" 
(My English translation: "separate into parts or pieces, usually with violence; destroy")
- Cabeza:  head

Casse-tête: (French)
- Casse: "Dans les arts martiaux, la casse est l'art de briser des objets solides (tels que des briques ou des morceaux de bois) à des fins de démonstration, de compétition ou d'entraînement." 
(My English translation: "in martial arts, the chop is the art of breaking solid objects (bricks or blocks of wood) in competition or training.")
- Tête:  head

"Jigsaw Puzzle" seems so ... underwhelming compared to these terms in other languages. Doesn't it?

A recent article appears in WebMD, by Bret Stetka MD, about fibromyalgia, entititled What is Fibromyalgia? Medscape Readers Weigh In.

Six pages of reportage of differing opinions from different branches of the medical practitioner family ensue; then, on the last page:
"Not surprisingly, in the end reader consensus was lacking. We were left with an assortment of theories, conflicting etiologies and symptoms, and severe brain drain from trying to piece it all together."
Every kind of medical doctor still each has a perspective about fibromyalgia born of having attached him or herself to a particular discipline that matches his or her particular world view or health care perspective or set of characteristics, and fibromyalgia just seems to stubbornly resist any easy definition. 

Right now, I'm struggling with the second class in the U. of A. pain management certification program. I'm feeling my cabeza being romped pretty hard. Or my tête cassed.

Not literally, OK? More the symbolic, jigsaw puzzle kind of way.

I'm learning about all the biopsychosocial models of pain commonly used. I don't feel at home, quite, because, for whatever reason, the neuromatrix model (the one I love the best) is not among them. Maybe it isn't a good "management tool"? I am learning about managing my own stress levels while not turning around and just leaving the scene. I find the whole class a bit daunting because I've never been much of a "team" type in the first place. I've always been more of a "leave me in peace so I can focus all my attention on the human primate social grooming of my patient, thank you" type of healthcare practitioner. I'm finding out there is a lot I don't even have a clue about, mostly to do with how the social troop of health care socially "manages" patients who don't fit any convenient medical slot.  It also manages disparaging attitudes, by naming them as counterproductive, which is kind of reassuring.

Monday, March 07, 2011

Lorimer Moseley

Lorimer Moseley from Australia is a PT and pain researcher who has published dozens of papers investigating pain, rubber hand illusion, and all sorts of motor imagery ideas.

It's great to find this interview from last year on YouTube. There is no video, as it was a radio interview, but it's on YouTube nonetheless. About an hour altogether.

Part 1
Part 2
Part 3
Part 4.

WELL worth a listen, if you have pain, deal with it, and don't quite fathom it.
WELL worth a listen, if you are a clinician who treats people who have it.