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


ben said...

Hi Diane
bad news that the course was amenable to being challenged. I've always found your writings and musings to be provocative and reflective. Two qualities that I would expect from an expert clinician.

Ben (NOI UK)

Anonymous said...

Thank you Ben.


Tracy said...

Different topic... I have just watched Neil Pearson's three presentations, was not very impressed. Felt like typical BS of mixing well known science factoids with pseudoscience. The way he presents his information is very typical of infomercials and me very sceptical of what he says. I see you have those three videos in your sidebar, do you approve of his ways? In the past year I've had to quit a lifelong practice of yoga and cycling because my back injury became worse, success at pain management has been intermittent. Right now I'm not dealing with pain, only limited range of motion. My PT suggested I watch his vids, but I'm less than impressed.

Diane Jacobs said...

Hi Tracy,

I wonder if some other kind of help would be more appropriate than simple pain education. You state that pain isn't the issue for you - limited range of motion is. Maybe you would benefit from some form of movement therapy.

I completely approve of the content in the videos (and Neil), or they wouldn't be linked here.

All the best.