Guest post at ForwardThinkingPT.com on Dermoneuromodulation

Dermoneuromodulation: What!? ANOTHER "technique"?

This is a copy of a guest post on dermoneuromodulation Joe Brence asked me to write for his blog, ForwardThinkingPT. com published earlier today. It contains the DNM roundup from yesterday.

I want to thank Joe for the opportunity to write a guest post for his blog about dermoneuromodulation. Even though I’ve been writing about it in one way or another for many years, it is hard to encapsulate this in under 1000 words and still be able to convey what I think needs to be conveyed. So, what I've done is present a brief outline, with a list of links at the end to blogposts, which discuss the topics in more detail, and which link to other posts for even more detail. 

HISTORY OF THE TERM: The term originated with a little bit of help from SomaSimple friends in the mid-2000’s as I struggled, as we all struggled, to become more conscious and articulate about manual therapy in general, and discuss problems inherent within it. David Butler’s neuromobilization workshop in the late 90’s, and discovering Melzack’s neuromatrix model of pain in 2003, plunged me into cognitive dissonance from which I have yet to emerge. In 2006 a colleague at the U. of Saskatchewan, and I, began a case series study (scheduled for write-up/ publication this year). Results indicated "weak but statistically significant" results, about what one would expect from a case series on any kind of manual treatment.

MEANING OF THE TERM: The word “dermoneuromodulation” simply means skin/nervous system/change. It does not imply that the practitioner is the one “doing” something called “change” “to” something anatomical in another person. It does not exclude the nervous system of the patient as change agent under its own auspices, thus DNM is as close to being an interactive model of manual care as opposed to an operator model as any kind of manual therapy approach can be, while still handling bodies of other (live, conscious) people. Other than “skin”, the surface all of us touch regardless of whatever else we might conjecture about what we are doing/affecting/handling, sensory endings, and cutaneous nerves, there is no mention of “tissue”. 

OPERATOR VERSUS INTERACTOR MODELS IN MANUAL TREATMENT: I have considered this quite closely, and all I want to say about it here is that I think, in the clinic, one should know when one is in one mode or the other, and be fluent in both. 

CONSIDERATIONS IMPORTANT TO SUCCESSFUL TREATMENT OF ANY KIND:

NERVOUS SYSTEM: Bearing in mind that we are treating live integral humans, conscious, awake, and usually presenting with pain , we have to (I think) consider their nervous system, and focus on creating a context that will favour their ability to change how they think and feel about their pain. We should share whatever information we may have about what “pain” is, how it behaves, with the patient, so we can both be on the same page. I wrote an extensive series of blog posts about developing the therapeutic container, called “New treatment encounter”. I present the nervous “system” as a signalling entity woven throughout the body, derived directly from the embryonic “builder”, ectoderm, continuous in a human adult from skin cell to sense of self. 

NEUROMATRIX MODEL: New Treatment encounter Part VI is specifically about the neuromatrix model, understanding it’s use for treatment, getting clear about our inputs (including manual therapy), and what we want to see happen with outputs. An elaboration of that can be found here. 

TUNNEL SYNDROMES: Pain experienced as persistent or recurrent and relatively localized (i.e., most mechanical “MSK” pain) is conceptualized as nerve pain.

NEURODYNAMICS: Peripheral nerves come all the way out to supply skin, sooner or later, proximally or distally, making them fairly easy to affect mechanically regardless of where or how one makes contact with skin. 

PERIPHERAL DISSEMINATION OF CUTANEOUS NERVES: A dissection of cutaneous rami done in 2007 revealed the macrostructure of cutaneous rami to the underside of skin. 

SKIN CONTACT: Skin is well supplied with exteroceptive receptors of all sorts and fibers that transmit information to the brain using fast dorsal column pathways and non-nociceptive slow spinothalamic pathways, to centers in both the internal regulation system and the primary sensory cortex of the brain. As long as the handling is mostly non-nociceptive, it will be physically safe for most pain presentations. A sensory ending known as the Ruffini ending is particularly capable of transducing lateral stretch to skin. It is slow adapting, which means it will actively fire the entire time a skin stretch is held, allowing the nervous system time and stimulation to alter its motor output and pain output at spinal cord and more rostral levels. 

IN SUMMARY: Research in manual therapy tells us that there is little or no interrater reliability for palpation or application, little or no agreement on what constitutes the overall best approach, and that success in terms of favourable outcomes depends a lot on context and treatment relationship. Applications differ widely in amount, intention, length, depth, angle, and zone of contact. I am of the opinion that manual therapy is optional, yet often may be optimal, to acheiving successful outcome in terms of pain reduction and movement improvement. The real trick in treatment is to leave the locus of control with the patient while still providing them with professional physical contact as required, by them, as individuals, in the moment, and within the context of a therapeutic relationship. I do not know what should be ruled out in order to show the world that manual therapy is useful; I only think that these items I’ve discussed should be left ruled in.

1. Dermoneuromodulation (diagram, gearing up)

2. Dermoneuromodulation: Where it came from

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

Submitted by Diane Jacobs, March 11/2012

AFTERTHOUGHT: 7. Therapeutic Domain

Dermoneuromodulation: Posting roundup

Dermoneuromodulation posts:

1. Dermoneuromodulation (diagram, gearing up)

2. Dermoneuromodulation: Where it came from

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

7. Dermoneuromodulation: Guest post on ForwardThinkingPT blog.
8. Therapeutic Domain

Dermoneuromodulation: The neuromatrix model of pain

I've written extensively about Melzack's Neuromatrix model of pain, here (on a wikipage), and elsewhere in this blog, most recently here.
The main story is to realize, to grok, to wrap one's head around the fact that pain is an output of the brain, not an input. Details are still arriving.

Here is a picture of the updated model.

What we want is to accomplish the following:

DECREASE PAIN OUTPUT, IMPROVE MOVEMENT OUTPUT,
WHICH IN TURN, MAY AFFECT STRESS OUPUT POSITIVELY

Or, this is good too:

PAIN EDUCATION CAN HELP PATIENT FEEL THEY HAVE LOCUS OF CONTROL,
WHICH MAY REDUCE THEIR STRESS LEVEL

Overall, what we REALLY hope we can do (with manual therapy), is this: 

ADDITION OF CONTEXT-APPROPRIATE MANUAL THERAPY, CONSISTENT WITH PAIN EDUCATION

We want our contact to be congruent with our education about the neuromatrix and pain. We want our contact to help, not hinder, the process of resolution of pain and movement impairment DUE to "pain".  We want it to help reduce bad stress, but maybe the patient needs to use their own positive "stress response" (from their own locus of control) to get themselves free from pain. We want to augment the teaching we did (the magnifying glass in the diagram). 


It's best if our physically applied input is kind, light, warm, non-nociceptive, steady. Skin stretching is not a bad way to proceed. If someone has fierce allodynia, you might try a mirror box and a soft sable makeup brush, applied to the skin on the opposite side, or an adjacent part of the somatosensory representation. Give their brain time to figure out the input and respond. Sometimes this means light contact over a longer period of time, not more pressure, or faster pressure. 

Melzack R; Pain and the Neuromatrix in the Brain

1. Dermoneuromodulation (diagram, gearing up)

2. Dermoneuromodulation: Where it came from

3. Dermoneuromodulation: Ruffini sensory endings and dorsolateral prefrontal cortex

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

6. Dermoneuromodulation: Ascending pathways

Dermoneuromodulation: Neurodynamics, tunnel syndromes, cutaneous nerves.

Peripheral neurodynamics

In 1998 I attended David Butler's "Neuromobilization" workshop. I must admit, I was not orthopedic-y enough to be about to translate everything he was teaching into a "spine-out" logical flow. I admit to always having been an outside-in sort of interactor therapist, both physical and manual. I was called on the rug during clinical training for thinking it made sense to work with stroke patients by working with their hands first instead of their trunks. But's that's a whole other story.
Michael Shacklock, another ortho person turned neurodynamic guy, was dedicated enough to bring back to life the original book by Alf Brieg, Adverse Mechanical Tension in the Nervous System. (It's mostly about spinal cord neurodynamics, of more interest to ortho-types of manual therapists, deep into structuralism, steeped by it, than it is to me, who has always stayed more outside the spine, conceptually and operatively. I prefer to affect the nervous system from its sensitive surface membrane, also ectodermal in origin, i.e., the epidermis and related exteroceptive and interoceptive capacity of its many sensory endings.)

Yet, as I sat in Butler's class, I felt my manual therapy worldview cave in - everything he said in terms of nerves, what they were about, how nociception became established, then amplified inside them, inside the system itself, made such sense it took me over completely, and I've been a nerve girl ever since, never gave "tissue" a second thought after that, especially fascia. Everything he said was congruent with another body of knowledge I had examined, embryologic development. You know those pictures that fool the brain into seeing two things at the same time, and you think you see it one way, but suddenly it looks like something else entirely?
That was me. I hadn't seen the rabbit for looking at what I thought was the duck. Abruptly, I graduated from what I call my "mesoderm" phase, and plunged headlong into an "ectoderm" phase from which I'll never emerge. Because at least now we're talking about the right kind of 'tissue' -  skin, nerve, neural container, spinal cord and brain - all direct derivatives from ectoderm, all concerned with "management" of an organism. Not structural space-filler/moveable puppet part and their glued-together connectedness (bone, joint, muscle, tendon, ligament, fascia). It's all a lot more complex than this, of course, with different parts of the nervous system doing different jobs, and different parts of the brain running various subsystems of visceral afferent/efferent function, autonomic function and so on, but at least now, we no longer need to entertain the crazy idea that innocent tissue "causes" anything like "pain" or try to prove somehow that there is any sort of correlation between what we might do with our hands, when working with people, and any sort of pain reduction, based on having magically affected some sort of deeply buried "structure" with some goofy operator model of treatment, whether vitalistic or structuralist - that dualistic Descartes combination. It's about nervous systems interacting with each other, and stress reduction. How simple is that?


In 2007 I was fortunate enough to gain access to an anatomy lab and dissect out cutaneous nerves, which were the ones that interested me! They have feelings too. In live people that is. Michael Shacklock published a few of the photos in his newsletter. I wrote up a paper about it that is yet to be published somewhere. But, at least, it's now been done, and I figure, pulling gently on these little rami likely has some sort of beneficial effect on intrinsic circulation well up into the nerve they are part of, all the way up to the first synapse (neurologically) or into the dorsal root ganglia, maybe (physically, mechanically), especially if you handle body parts simultaneously, and make treatment stress free for the patient by eliminating gravity as much as possible.


Which brings us to the topic of tunnel syndromes.


I think that covers the topics on the right side of the dermoneuromodulation diagram, under "physicality".  These are the considerations I have while treating as a manual therapist. I'm still "operator" model enough to need to think about something physical as I treat. I'm not zen enough to be completely content-free, pure interactor.  Not yet anyway. But I'm a lot less "physical" and a lot more "therapist" than I was, once upon a time.


1. Michael Shacklock Clinical Neurodynamics
2. Dermoneuromodulation treatment manual (first draft) Diane Jacobs

1. Dermoneuromodulation (diagram, gearing up)

2. Dermoneuromodulation: Where it came from

3. Dermoneuromodulation: Ruffini sensory endings and dorsolateral prefrontal cortex

5. Dermoneuromodulation: The neuromatrix model of pain

6. Dermoneuromodulation: Ascending pathways

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

Dermoneuromodulation

I've been asked to write a guest post about DNM for two weeks from now, so I better start thinking about how, I guess. I need 600 words.


I made a picture of the concepts involved a long time ago and never have done anything with it. Here it is:

It contains the topics I address whenever I teach this in workshops. Really, dermoneuromodulation amounts to being interested in and careful about the true physical interface of contact by a manual therapist on a patient's body. Everyone who does manual therapy is already 'doing' some kind of dermoneuromodulation whether they realize it or not (if the patient is alive and unanesthetized at least, as most are!) - dermoneuromodulation is just a more conscious systematic examination of contact with a patient, with no conceptual hallucination of the mesodermal kind. Mostly. Much much reduced, at least.

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.

Have we overlooked the skin in manual therapy?

In a recent post I showed some pictures of slides I would be using for a presentation a few days later. Since then I've been to Newfoundland, gave the talk, and have returned. Here is a google doc containing the slide show for anyone interested. It's a bit heavy at 37 MB, but anyone interested can download a pdf at this google link. Have we overlooked skin in manual therapy?

First leg - Rio

I had to get to Rio by flying to Sao Paulo on Air Canada and catching another local flight. The first flight was all night long (9 hours) and covered over 5000 km. I fussed over my slideshows some more and managed to curl up horizontally to sleep, as I had no seatmate. This nice part about flying north-south or south-north is that no jet lag is involved. It was the first time I'd ever been outside North and Central America. I'd never been south of the equator before. So many firsts.

Dinner (with wine) was served on the plane, and shortly thereafter, breakfast. The coolest part of the trip was that even the economy seats have a place to plug in one's computer so that one's battery stays juiced.

I was nervous landing in Sao Paulo. It seemed to take an hour just to fly over the city through smog cloud to get to the airport. It's 20 million people large, after all. I expected the Aeroporto Guarulhos to be enormous (it was), and I'd learned no Portuguese, hoping my rusty Spanish would suffice. How would I find my way around? I didn't have a lot of time between flights. Fortunately, customs there is a perfunctory matter, one's immigration card is merely glanced at, lines move fast, most of the people in uniform speak a bit of English, and there are many many people in uniform, standing around, changing the cloth bands between stands to facilitate new lines and faster movement. The signage is quite small and the distances huge. I did the default female thing and kept checking with new people as I walked along to make sure I was still going in the right direction. I reminded myself that I was English-speaking in a Brazil airport, not Polish-speaking in a Canadian airport.

Eventually I got to the proper gate in the correct wing of the port and on the TAM plane for the 45 minute local flight to Rio. At the Rio airport, things were even more brisk and easy. Palmiro was there to pick me up, so I could finally relax.

First things first - it took a good 45 minutes to get from the airport to the hotel, through Rio traffic. Rio is another huge Brazilian city, about 12 million. It has a bit of a smog bank too, although Rio citizens choose to downplay it. So beautiful though. In the car I was given a lesson on the social stratification of Brazil, and how to stay safe, not be a target. Palmiro has been around some and has had a chance to observe how life is in North America, so he took great pains to inform me about how in Brazil you can be killed for your cheap ten-dollar watch. He wasn't trying to scare me, just protect and inform me. I listened.

That evening I was introduced to caipirinhas and the sort of steak I can't ever remember tasting in my life. Delicious. Then we went up SugarLoaf Mountain in the cable car, in the dark, to see the lights of Rio way down in the distance. The next day we saw it again, in daytime. The other main tourist spot is Corcovado, on top of which is a giant Jesus statue. Giant Rio Jesus is apparently suffering from acid rain, was covered in restoration scaffolding when I visited.
The mountain is so high and the smog was so dense that I couldn't get any pictures of the city - I could not even see the city.






On the way down I took a bunch of pictures of a very dilapidated but still beautiful and elegant hotel, which is slated to be restored in time for the Rio Olympics, I think.














On the weekend I taught a two-day workshop to 26 people, the largest class I have ever taught. Palmiro had translated my treatment manual in Portuguese himself, ahead of time. A translator had been arranged. It couldn't have been a better organized event and it couldn't have been filled with better, more attentive, gentle students with hands like butter and minds like sponges. By the end of the second day several had already left to make flights etc. Here is a picture of who was left. Palmiro is in the back row, second from left. The translator, Dan, is beside him third from the left.

I learned to do Brazilian cheek-contact air-kissing on this first leg of the journey. I was struck, actually, at how contactful the culture in this branch of my human primate social troop. Such a welcome somatosensory, epicritic input.

Exactly backwards

I had a chance last weekend to travel to Saskatoon and visit the PT school there for a few days, talk with a few of the profs, plan a tentative future. My (not very) lofty goal is to somehow gain permission to dissect, photograph and map out, in broad visual terms, the extensive forest of rami that project out to skin from the numerous cutaneous nerves that run along parallel to and beneath skin - even if I have to suck it up and do a Master's. My friend Angela, who characterizes herself as an obstacle remover, has been extraordinarily kind and generous with her time and hospitality toward me. She and I have completed a research project together, yet to be written up.

Everyone was kind, lent me their ear, but the impression I have come away with is that there is an invisible wall I could sense, that I may never be able to unlock, between what my profession has turned itself into, and what I think it could be.

Take, for example, the nervous system.

I had an opportunity to sit in on a two-hour neuroanatomy lecture, with permission; it occurred to me that these first-year students are getting more information handed to them in one day than I ever did in a year. In the space of two hours, the lecturer covered the embryological origin of the brainstem, its organization, an intro to each of the nuclei within it, all the spinal cord tracts that move rostrally through it and descend through it, the medulla, the cranial nerves and what each does and how each can be affected by traumatic head bangs, the branchial arches and neural crest, and which muscles were formed from which arch, and which cranial nerve was associated with each arch. It's a lot for first-year students, probably.

My question is, Why should they care? How hard would it have been to put an overall frame around that headfacethroatbrain zone, as neurological core sensor, effector, consciousness producer, and (according to some, like Jaak Panksepp, emotion initiator), plus metabolic engine for the entire organism, breathing and swallowing, able to operate bi-directionally?

The prof was kind enough to meet with me for an hour or so following. My impression was that the only real teaching he does regarding the peripheral nervous system is that it is segmented, each spinal nerve innervates all the stuff coming from a particular segment, and that the main important thing about its role in the body is that there are muscle spindles and sympathetics. Other than C fibers and A deltas, the sensory aspect was irrelevant to him, it seemed.

While all that is true, there is so much more to it than that!

But I was reminded yet again, about how physiotherapy, in order to gain permission to evolve as a profession, pretty much focused its awareness of neural matters entirely around motor output, and has been stuck there ever since, child as it is of the greater touch-phobic society into which it is embedded. We are licensed to touch people, but we are not permitted, it would seem, to examine, comprehend, conceptualize or even be taught anything about how our touching might be an interactive source of brain food for the recipient brain. Too .... sexy or something, maybe. Thar be monsters, or something. This potential pitfall could easily be bridged by a single class in transference/counter-transference, a standard issue that must be dealt with up front by the psychoanalytic community. Why let it remain in the subconscious of my whole profession? Why not deal with it up front? A preemptive strike? Forewarned is forearmed.

The profession has structured itself entirely around motor output, and a gaping void exists where understanding of how the brain and PNS reads and responds to kinesthetic input should be. To be fair, it was probably easier in the beginning to follow Cartesian divisions - you bunch of therapists go deal with the mind, and us, we'll stick with the body. Neuroscience has put this idea into total eclipse: there is no separation whatsoever.

Yet, emphasis on the INput side of the nervous system, and learning to understand it, is precisely, according to me, where becoming not just a good therapist, but a great therapist, lies. These are totally uncharted waters for our profession. We could be great therapists if we hadn't got our conceptual trajectory exactly backwards. We have been looking in through the wrong end of the telescope, all along. But we no longer have any excuse for continuing to do that. Not if we look at what neuroscience can tell us about ourselves in a body, and about ourselves treating other embodied people. Other humanantigravitysuits. (We DO have that word "therapist" in our name, not just the word "physical"...)

I'm doing my very best, but may never succeed in making a big enough noise about it to be able to make any difference in the status quo whatsoever. I have to realize this yet not allow it to defeat me.

Oh yeah, he's also an OMPT. Forgot to mention that.

Taking stock

A convergence of sorts has occurred in the new year: today a friend sent me a link to this excellent essay, written by Frank Wildman, on the sad, rather shabby, rather scientifically disjointed state of PT. He was thinking of U.S. PT, I think, and he had his Feldenkrais goggles firmly duct taped to his head while writing, but I'll forgive him for that, because he makes many many good points. I like the way he compares the state of PT to the state of general science before Darwin came along with the unifying theory of evolution. This essay still seems topical, even though it is 22 years old: Learning: The Missing Link in Physical Therapy.

Lately, a New York Times article by Gina Kolata, Treat Me, But No Tricks Please, provided the reading public with a glimpse into the hall of distorting mirrors that is current, American at least, PT. This story has raised comment on a few PT forums/blogs:
1. NY Times: Physical Therapy Useless?
2. Yes, Gina you can tell if your physical therapist is "voodoo less"

There isn't a whole lot to come back with, though.. Frank is still right, I'm afraid.

This short video, "Myofascia," was constructed by a PT student, determined to be a PT who embraces rationality. It's very succinct and immediately was shared by several Facebookers. Facebook really is a networking site, because through it I met a fellow who wanted to counter the video and share that he is helping to organize an entire conference about fascia. He seems like a very nice guy. We struck up a conversation, shared who we are and what we're about. I won't divulge anything about him, as that would be improper, but I'll put here what I told him about me:

"Your enthusiasm for the topic (fascia) is palpable! [/manual_therapy_joke].

Congratulations on helping organize a conference! That's no small task!

I'm a manual therapist too, born and raised in Canada, of physiotherapy descent. ...

Anyway, I moved (grew up in Sask), now have colder weather but WAY more sun, which at my age I need. My interests include deconstruction of faulty treatment concepts, passion for the neuroanatomy, physiological function, understanding, and care and feeding of the human nervous system, and writing. I helped start the Pain Science Division of the CPA. Currently I am on the exec. and run the coast to coast online directory for PSD members/PTs who want to be in it, and for patients who want to find a pain therapist. In my private PT life I have taken what I know about manual therapy, and what I know about neuroscience, and have called the result, "dermoneuromodulation." It's basically skin stretching but with an entirely neurological treatment construct, no mesodermal derivatives involved whatsoever. I've done a pilot research project on this, along with Angela Busch at U. of S, not yet written up. I've done an initial cutaneous nerve dissection (at UBC), took lots of pictures, wrote it up but have failed to have it accepted so far. I'll be talking about dnm, and about Neuromatrix model of pain, at a congress for manual therapists in Brazil in May. Then (hopefully, don't know yet) in St John's at CPA Congress. My life goal is to help develop vast crowds of rationally thinking, compassionate PTs/manual therapists who care deeply about pain and choose to help their patients overcome it in ways and with treatment constructs that are scientifically bullet-proof. Down with woo, IOW. To help that happen my next ambition is to get ensconced in an anatomy lab somewhere and map out the entire cutaneous nervous system so that therapists of the 21st century can realize and visualize and develop treatment constructs around what they are actually touching, and what's actually responding, in the person/body they are handling. I call this an 'interactor' model rather than an 'operator' model. Many therapists learn to do this, but implicitly rather than explicitly. I want self-aware consciousness AND scientific impeccability AND simultaneous, seamless treatment construct. Not too much to ask, is it?..

I run a page here, Neuroscience and Pain Science for Manual Physical Therapists, if you'd like to check it out some time. I also help admin a skeptical PT site/discussion forum called SomaSimple. You are welcome to come, join, discuss there too! We welcome everyone who wants to learn to think more clearly about what we do or who might have light to shed.

Diane"