Dermoneuromodulation: Where it came from

Introduction
Dermoneuromodulation represents my personal effort to make sense out of manual therapy in general. Manual therapy gradually evolved. 
Given the advances in neuroscience in the last couple decades, and concomitant advances in pain science (although slower), ideas upon which manual therapy bases itself are due for overhaul, in my opinion, by starting further back than mere production of ever more outcome studies. Todd Hargrove, a thoughtful blogger, nails it perfectly in his post, Souless bodies and bodiless souls (3); 

"..vitalism and structuralism are two sides of the same dualistic coin..Vitalism is an example of belief in a “bodiless soul.” Vital energy is considered to be an animating force that exists outside the physical realm and is not reducible to it. And structuralism is the metaphorical flip side of the coin – the tendency to treat the body as a physical object, as opposed to an intelligent agent with feelings, thoughts and intentions." 

Scientific study of manual therapy
Manual therapy teaches a bunch of stuff about "proximate cause (1)." Manual therapists want to, and are taught to, take on the role of "operator(2)", not just humble interactor. 

Examining
the questions themselves 

We seem to think that manual therapy can't be studied scientifically unless it can be isolated and specific effects determined. Problems arise with study designs, and poor interrater reliability seems ubiquitous. Even when separate outcome studies are good, the results don't seem to be able to stand up to statistical analysis very well (16,17). Could it be we asked wrong questions in the first place? 


Rethinking the problem of pain
People who come for manual therapy come because they are experiencing pain (or some sort of discomfort with their body), usually. 
Melzack(5) puzzled over pain for decades and finally concluded it was not an input, it was an output (see neuromatrix diagram here). He at least got us (manual therapists) that far, by separating nociception (an input) from pain, a brain output - he de-Cartesian-ized pain - not an easy task; it meant moving in opposition to 400 years of medical science which claimed pain was a bottom-up phenomenon (and still does, as do most forms of manual therapy). Melzack realized pain was biopsychsocial in nature, something that had to do, perhaps, with being lost in one's own embeddedness into, and ideas about, externalized reality, or not sufficiently aware of one's own physicality, or both, not able to detach from either when desired. His model is brilliant, clinically useful, and best of all, non-dualistic: we treat conscious, living people after all, not anesthetized patients. We are forced to interact - we do not have the luxury of (merely) 'operating' (2). 
Another perspective on the same matter is offered by Quintner(6), who argues that far from being something that can be disassembled into bio-, psycho- or social components, pain is an aporia, which is to say... 

"...a space and presence that defies us access to its secrets. We suggest a project in which pain may be apprehended in the clinical encounter, through the engagement of two autonomous self-referential beings in the intersubjective or so-called third space, from which new therapeutic possibilities can arise."

I see parallels between manual therapy with its attendent problems, and what I found in a revealing blog post interview (about psychiatry) with Richard Marken, discussing Perceptual Control Theory (7): Instead of looking at a human being from "outside" that human being, and his or her own "behaviour" (including pain "behaviour") as a problem of input/output, we could try to look at the behaviour itself as a process of control, by the organism itself/himself/herself. 


So, rather than flailing about with manual therapy as my only tool, a tool, furthermore, honed and contaminated by centuries of Cartesian misunderstanding, I adapted myself to new information. Now I consider manual therapy to be just a tiny part of the process of interacting with people who have come in as patients with pain problems. Providing them with a boundaried therapeutic relationship is far more useful to them in the long term. The hands-on part may be both optional for some and optimal for others. But all  PT patients will benefit by understanding simple facts about the nervous system and pain science (4) (however awkwardly confused, bottom-up, Cartesian such information may still be), couched in a framework such that it lays no blame on them or any of their body parts/mesodermal derivatives for having it, and at the same time leaves them with the locus of internal control they need for extracting their own conscious awareness out of it once more.


Is a new awareness is dawning in manual therapy?
I think maybe there might be (8-15). 
.........................................

1. (Wikipedia)Proximate and ultimate causation

2. Operator/Interactor model (Diane Jacobs)
3. "Soulless Bodies and Bodiless Souls" (Todd Hargrove)
4. New treatment encounter Part I (Diane Jacobs)
5. Melzack R; From the gate to the neuromatrix. Pain. 1999 Aug;Suppl 6:S121-6.

6. Pain Medicine and its Models: Helping or Hindering? (John Quintner et al)

Quintner, J. L., Cohen, M. L., Buchanan, D., Katz, J. D., & Williamson, O. D. (2008). Pain medicine and its models: Helping or hindering? Pain Medicine, 9(7), 824–834. doi:10.1111/j.1526-4637.2007.00391.x


7. Does Psychology Need a Revolution? An Interview with Richard Marken on the Radical Implications of Perceptual Control Theory. 

8. Bialosky JE, Bishop MD, George SZ, Robinson ME. Placebo response to manual therapy: something out of nothing? J Man Manip Ther. 2011 Feb;19(1):11-9. (free access)

9. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model  Man Ther. 2009 Oct;14(5):531-8. Epub 2008 Nov 21. (Open access)

10. Bialosky JE, George SZ, Bishop MD. How spinal manipulative therapy works: why ask why? J Orthop Sports Phys Ther. 2008 Jun;38(6):293-5. Epub 2008 May 27.

11. Lucas N, Macaskill P, Irwig L, Moran R, Bogduk N. Reliability of Physical Examination for Diagnosis of Myofascial Trigger Points: A Systematic Review of the Literature  Clin J Pain. 2009 Jan;25(1):80-9.

12. Maher CG, Latimer J, Adams R. An investigation of the reliability and validity of posteroanterior spinal stiffness judgments made using a reference-based protocol. Phys Ther. 1998 Aug;78(8):829-37.

13. M. J. Hancock, C. G. Maher, J. Latimer, M. F. Spindler, J. H. McAuley, M. Laslett, and N. Bogduk; Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J. 2007 October; 16(10): 1539–1550.

Published online 2007 June 14. doi:  10.1007/s00586-007-0391-1 PMCID: PMC2078309

14. Frédéric Wellens, B.Sc., pht, RCAMPT. The traditional mechanistic paradigm in the teaching and practice of manual therapy : Time for a reality check. 2010

15. M. Zusman, "The Modernisation of Manipulative Therapy," International Journal of Clinical Medicine, Vol. 2 No. 5, 2011, pp. 644-649. (open access)

16. Rubinstein SM, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for chronic low-back pain. Cochrane Database Syst Rev. 2011 Feb 16;(2):CD008112.

17. Rubinstein SM, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review. Spine (Phila Pa 1976). 2011 Jun;36(13):E825-46. 

1. Dermoneuromodulation (diagram, gearing up)

3. Dermoneuromodulation: Ruffini sensory endings and dorsolateral prefrontal cortex

4. Dermoneuromodulation: Neurodynamics, tunnel syndromes, cutaneous nerves.

5. Dermoneuromodulation: The neuromatrix model of pain

6. Dermoneuromodulation: Ascending pathways

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.

Notes:

1. Interactor versus operator model for manual therapy

2. Melzack's four conclusions

Ronald Melzack: Pain Pioneer

 I attached this to the Facebook Page, Neuroscience and Pain Science for Manual Physical Therapists, and now here. Very nice little video about Melzack's life and work.

Ronald Melzack and the Canadian Physiotherapy Pain Science Division

It's good to have long term goals, right? One of mine is that every PT on the planet eventually be exposed to Melzack's neuromatrix model of pain (5 page pdf), and learn to see being a PT as equivalent to being a neuromatrician. Another goal is to have every manual therapist realize the two main input domains* of a neuromatrix they can favorably influence, and why it's important to be careful what is put into them, and how. A third is that each therapist would operate from a working knowledge and awareness of his or her OWN neuromatrix while working on another's (interactor model of treatment), and not merely from recipes and protocols and paradigms that elevate structural tissue above signaling tissue (operator models of treatment).

With this as the backdrop I attended a reception at the recent IASP Congress in Montreal, to celebrate the lifetime contributions of one of Canada's most famous if not THE most famous of pain researchers anywhere, Ronald Melzack.

He had not met us before (except perhaps Dave), although he wrote a message of support at our request back when we were trying to organize a proposal to become a Pain Science Division of CPA. A line of people were wishing him well as he made his way out of the room after the reception. He was moving toward a larger brighter lobby for some pictures with all the grad students he had worked with over the years. I positioned myself at the end of that line, introduced myself and told him who we were, thanked him for all the work he has done in his life, remarked that I would like all physiotherapists to become neuromatricians, asked him if he would be willing to let us have a picture with him. He was very gracious and more than willing. It was the highlight of the trip to Montreal and perhaps my whole life. I can now die, anytime, a happy woman.

* Cognitive-evaluative and Sensory-discriminatory

IASP in Montreal - post event snippets

This is a series of little personal and professional snippets, vignettes, from the IASP Congress, held in Montreal Aug. 29-Sept 2 2010.

Lost luggage (again..)
I got back Friday afternoon (Sept 3), minus my luggage, lost somewhere in the bowels of Toronto airport by Air Canada in connector flight limbo, for the second time in 4 months. It has yet to arrive - the first time it was lost by Air Canada as I came home from Brazil, it arrived the next day. This time the wrong bag appeared at the bus station. Someone else must be in Air Canada luggage hell with me, our suitcases delivered to each other. This is getting very stressful. No more Air Canada for me I'm afraid. I'm already going through a mourning process more severe than should be necessary - especially once I realized I had packed my notebook FULL of scrawled notes taken at all the presentations. That really sux. The clothes? Meh. The shoes? Meh. Replaceable. But the two hard cover books, a dental pick, favorite scratchy Japanese bathing towel, MUCH harder to replace; the bamboo back scratcher that was my dad's before he died, and the note book (!) - irreplaceable!

The Melzack reception
It was the first time I'd ever been to an IASP Congress, ever. I knew they occurred but this time I wanted to go specifically to attend the reception for Ron Melzack. I not only was in the same room as he was, but I got to meet him, shake hands, and have a picture taken with him and the other members of the CPA Pain Science Division who attended. The photographer is a retired neuropathologist married to a Canadian pain physio we know, who said he'd email the photos but hasn't so far. When he does I'll post one. This event is the highlight of my life so far.

John Loeser presented a slideshow of Melzack's life and work, lots of photos of his childhood, family, vacations he was on, people he met and worked with, with lots of hair and without, all the way from age 10 to now. I was previously unaware Melzack had written books of stories of the indigenous peoples of the far north. He was there with his wife in her wheelchair, gracious and charming, shorter than I had expected. There were probably close to a hundred people gathered, beautiful food, plenty of wine, lots of huddle around the guest of honour.

I really wanted to say hello to him, saw that there was sort of de-reception line had formed as he tried to make his way out the door into a larger foyer for a planned photo with his "family" of grad students. I walked over and waited a turn. When he got to me it was clear on his face he had never met me before. He extended his hand anyway. I rapidly introduced myself and reassured him we had never met previously but that I was very pleased to meet him, that I was with the physiotherapy Pain Science Division, that I wanted to thank him for his life's work, that it was already having a large impact on my profession and that if I possibly could I would want all PTs in the world to become conscious neuromatricians. I asked him if he would be willing to have his photo taken with those of us from PSD who were there, and he graciously nodded. And then it happened, out in the lobby, after the more official photos were taken.

SomaSimple thread
A SomaSimple thread was started while IASP Congress was happening, to which we posted highlights (and some photos) when we had time.

More to come. Much more.

Accepted

I found out that I've been accepted into a pain management certification program at U. Alberta in Edmonton. This online post grad program would count a bit toward a masters degree at U. of S. (if I decided to pursue one).

Also, plans are afoot for an RCT for me to be involved in. It's still tentative, but if it becomes reality, I'll be making a lot of bus trips back and forth to Saskatoon, 4 hours each way. Fortunately, buses have wifi these days. :)

Still no big urge to "work" (as in, for money), but I've been dreaming about working lately, treating people, so maybe my brain is working up an appetite for doing that once again.

Meanwhile, I look forward to seeing Ron Melzack and meeting some people I know but only from online.

Montreal and Melzack

I finally came up out the long summer torpor I've been in since coming back from St. John's, to get ready to go back east, this time to the IASP World Congress on pain, in Montreal at the end of this month. One of the items under "related events" is a reception on Aug 28 for Ron Melzack, my hero. I managed to get two tickets, one for me and one as a hostess gift for the friend I'm staying with, also a PT and also in our CPA Pain Science Division.

I'm actually excited about this. Feeling pleasantly excited instead of feeling stressed and anxiety ridden is a welcome change. I'll be able to see him in person, and even if I do not get to meet him in person, at least I'll be able to say I was in the same room.

More clothing angst, however, had to be battled - what does one wear to a reception in Montreal? It's a bit like going to Brazil - Montreal is the fashion capital of Canada after all. Therefore motivated by the unfamiliar-to-me default female flap of having 'nothing to wear', plus actually caring about the fact I have nothing to wear (for the second time this year in probably 20 years or more), I went out and bought some black shoes that actually have heels!! (- not high, but still, in order to not break an ankle I'll have to practice walking in them), and a few items of clothing that I think may help me escape fashion police disapproval. Get this - I even bought a necklace! That is how determined I am not to look like a complete fashion schlub at a reception for my hero, Ron Melzack. I'm hoping a) I get to meet him in person and b) that I don't stand out as not dressed properly for the meeting.

Honestly, I can hardly believe that buried under all the years and decades of being depressed and not giving a rip about how I look, as long as I smelled OK, I'm actually going to try to look like a female from across a room. Wearing a necklace and shoes with heels. I feel like such a female impersonator! Nothing motivates my inner fembot, it seems, more than a chance to see Melzack up close and in person. :^)