Killing Pain Part II

Yesterday I wrote a florid limbic account of my episode of "frozen shoulder", experiencing the crippling, spreading sort of pain for the first time in my life, how I coped with it, and managed to get my brain back on track, so it could defend properly and not give me a lot of pain noise I didn't need, that no one needs. 

Today, I thought I'd deconstruct it all.
Here is what I've got so far:

This is a slide I made a few months ago for a presentation on the Neuromatrix model of pain. The overall gist of the presentation was rostral mechanisms and how they are involved in pain production and reduction. The subtopic for which this slide (and the next) was used, was Sensory-Discriminative; Descending Modulation.

Here we see flight/fight reponse, whereby an animal, or any vertebrate for that matter, including human, can defend itself to the death by deliberately ignoring cuts/bites/scrapes, with resolve fueled by noradrenaline. I really don't know that it's completely analgesic, but it likely allows the animal to ignore all the nociception with which it is being flooded in the moment. If it's being attacked (e.g., for food), it will try to escape. It still needs its wits to do that.

This descending modulation is activated by the hypothalamus based on input from more rostral centers which are reporting to the animal's brain about the direct context, what's going on in the environment in the moment - the dorsolateral portion of the periaqueductal grey is activated. 

Here, we see a different kind of response, passing out completely.
This is activated when all hope is lost. Much more conserving of the organism's energy.

The ventrolateral part of the PAG is activated instead. The animal "escapes" by going unconscious. I guess enough possums have lived on to reproduce by doing this, that they've evolved this tactic as their primary defense.


Here are the thoughts about the encounter with pain that I've entertained today.

1. I needed a fight/flight response to kick in ("Kill" or "be killed"). My dorsolateral prefrontal cortex knew that I wasn't in any actual danger. It had to access this system however, even in the absence of any real danger.

2. I was in complete control of the process. I had complete locus of control of the event. I directed my therapist and she adapted herself to me.

3. I had a lot of pain education - i.e., I knew pain wouldn't actually kill me, regardless of how threatening it felt.

4. It was, actually, a novel experience to have this magnitude of pain. I'd never experienced anything like it in severity and pain restriction, especially this awful spreading quality. I think the spreading quality concerned/scared me the most.

5. I managed to take fear and change it to fighting fury (elicited a noradrenergic response). I asked the therapist to treat what I figured was the core of the physical bit of the whole problem (exerted locus of control). The pain spread like wildfire - I could feel it but I did not let it deter me (noradrenergic resolve). Then, but only then, I let the part of the threat detector/pain production system that is part of the frontal lobes (anterior cingulate cortex) take over and "run away" immediately following (permitted ideomotor movement), but only after "I" (my dorsolateral prefrontal cortex) showed it who was really boss, by controlling the timing.

6. Although I didn't collapse in an unconscious heap, some part of my brain might have, because the opioids finally kicked in. Perhaps the dorsolateral prefrontal cortex got mean enough (in a controlled environment) that both the dorsolateral part of periaqueductal grey AND the ventrolateral part of PAG were activated simultaneously: the DLPAG fought and snarled and ran, the VLPAG felt sufficiently attacked that it "fainted" and let go of a big gob of all the necessary opioids such that I got the much needed relief I wanted.

7. It all felt very life-and-death dramatic, but I entered the encounter knowing that these centers were the ones that respond to actual life and death stuff, so I didn't mind the heavy emotional powering up that occurred.

8. I was determined to come out the other end feeling better - so the dopamine was clearly flowing from the expectation, probably was a factor, may have helped via various pathways.

9. The therapist was great. No nocebo from her at all - no cholecystokinin was triggered, which would have interfered big time.

10. I was free, and felt free, to manage my PAG and stimulate it from rostral centers using

• emotions (HATING pain, determination, focus, no-nonsense, I WON'T put up with this, I WILL construct a boundary between me and this Pain) as fuel
• information (I won't die if I try this, pain is just my brain being freaked out about something, it's not likely any big deal, it's only pain, I didn't injure anything lately) as message containers
• social context/therapeutic contact (I'm appalled by so much of what I see in the world, and my own body is where I should have the right to feel safe (dammit)/ my therapist is here to help me, I have locus of control) as delivery chutes

11. Even though I'd never done such a thing before, it worked. So I guess it can be done. Sample of one. Now that I've done it once, next time (should there be a next time - there may not ever have to be a next time) it should be easier. (Optimistic thought)

 I've also learned that help is there when I need it.

 Other posts on the topic:

Killing Pain

Killing Pain Part III

Killing Pain Part IV

Killing Pain Part V 

Killing Pain Part VI

Somasimple discussion thread about this post series.  

Scientific American: Anger Gives You a Creative Boost
This article is about interpersonal confrontation, however, I see no difference, from the perspective of the "I"-illusion, whether the perceived "foe" is external or internal. 

Killing Pain

Initiated
OK.  So now, finally, at the ripe old age of 60, I've finally joined the ranks of those who have had a visit from the horrid monster who produces, directs and stars in the horrid movie known as Pain.

Before, I'd only ever seen him only from a distance, across a crowded room, fleeting eye contact. I'd watched him, had tracked him, had stalked him, had found him, had assisted others as they fought him, but had never been formally introduced to or personally invaded by him.


Now I know how he feels.

Now I really, really know how Pain feels. To me. Raped by Pain. In the shoulder.

About 4 days ago I developed hideous pain in my right upper quadrant. Hideous to me, at least. Completely invisible to others.

I'd been noticing crankiness at the shoulder but hey, what shoulder wouldn't be cranky given the amount of typing and mousing I do, and have done daily for the last couple years almost full time, and not much else? I kept going. I should mention that I type completely one-handedly, right hand.

About 4 days ago I found myself suddenly dealing with serious lack of range in the shoulder and acute pain on movement.

Um, I wonder where this is going to go, I wondered to myself. Where it went was into a full-fledged acute Pain experience, with no way to get comfortable, no position to sleep in*, no way to escape, really. I started taking aspirin, which made me feel like I was doing something to help myself, but didn't really seem to change the Pain much.

What does it feel like to be raped by Pain in the shoulder? It feels like hot lava sploots and shoots in every part of the entire upper limb, with every move or breath or change in position. There are moments when it's possible to function and distract oneself, but he's always there, maybe a bit distant, but never not there. When a shift of awareness or focus occurs, bam, he's right there, inside every neuron, every molecule, taking up every bit of virtual space he can in the whole cortex,  spreading inexorably, steadily capturing and controlling more and more of the meat puppet of the body each day. In deliberate fashion, he moves along raping successive nerves and muscles, twisting a spiral point into them, skewering them into submission, leaving them helpless and frozen in agonized contraction.

When I say, entire upper limb, I mean upper quadrant, including the right back, front and side of the neck (superficial cervical plexus) including upper chest and upper back, shoulder (front, back side), and entire arm (front, back, side) and all the major parts (shoulder, elbow, and hand).

He wasn't about to go away by himself. I realized I needed back up and moved as swiftly as I could to get some help.


Background
This is the story as well as I can recall it:
About twenty years ago I had a severe (to me at least) whiplash episode, with major headache and pain on movement and point tenderness, which all went away, brilliantly, in one session of manual treatment by another therapist, inside about 15 minutes. The therapist had taken a workshop in a type of handling which included passively positioning the body part into a painfree, tenderness-free position, and holding it there for a few minutes, then carefully moving the part back out into a normal position again.


This impressed me so much that I built a whole manual therapy practice around doing just that with patients, which sustained me for years.


Details of the crash
I was driving along a Saskatchewan highway, August 1989. About 3 PM, bright daylight, good weather. I'd just gassed up and was driving along, doing the posted speed limit, holding a coke in my right hand, steering with the left.

A truck pulled up to the highway on a side road, from the left side, slowed but didn't stop, even though there was a stop sign.

It was crossing the highway. Right in front of my car. I couldn't believe it hadn't seen me coming. I mean, it was broad daylight. I was driving a small car, white, and maybe the driver didn't spot me, maybe the sun was low enough to have forced him to squint, making my car indistinguishable, invisible.. anyway, he said he never saw me. This was in the days before running lights on cars. People were asked to use their headlights during the day, but it wasn't mandatory. I did not have my lights on - I hadn't turned them back on yet after getting gas, and my hands were full.


I turned left a bit, hoping I could swing around the back end of his truck: I couldn't avoid hitting him, however, so at the very last nanosecond I cranked the steering wheel to the right, so that the impact would be spread out along the side of the car rather than all at the front end.  Then the crash.

I wish now I'd dropped the coke, but instead, as the collision happened, my arm was jolted, still holding the damn coke can, still mostly full. I distinctly remember feeling the jolt in the shoulder. Biceps were contracted because I was holding a stupid coke. Musculocutaneous nerve got jerked. It has never really had enough space in there, ever since.

I ended up with a painless restriction in shoulder movement, specifically internal rotation with arm in 90 degrees of abduction, elbow bent to a right angle. Think of a stick through a straw scarecrow's shoulders, emerging at the elbows; hands pointing up toward the sky is external rotation, and the hands hanging down toward the ground is internal rotation. My left hand could point down, but my right hand stayed up in the air, pointing forward. It was as though it was stuck there.

It didn't bother me much: when I attended ortho school for a brief time in the early 90's, I was told by an instructor that my humeral head was anterior in the socket, and he shoved it back. Very perfunctory. It not only didn't hurt, I felt nothing. Nothing. My brain learned nothing. The restriction was not changed by his heroic.

It didn't bother me much: when it did, once, giving me some minor grief back in 2001 or thereabouts, I went to a friend who was a massage therapist and had him noodle around at the lateral edge of my shoulder blade until it felt like I could move it easily and comfortably again. I was left with the internal rotation restriction, but what the heck. It didn't bother me much.

In retrospect, this was the open window. This was the body bit, the body function, neglected by me, that Pain found, cased, then eventually climbed in through, to invade my personal existence.

Back to present time

So, for whatever reason, whatever the way the moon lined up this month with the planets and stars, the weather, stress from too much recent interpersonal activity, my inexorable aging process, maybe a brain fed-up with a steady diet of mono-movement, maybe a combination - who knows -  Pain found his way into my personal space and invaded my interoception, raped my shoulder, stole my movement, seemed to be threatening to set up permanent residence, was starting to use very creepy torture devices, ones that could only be interoceptively sensed, not seen or prepared for.

I knew I needed help ASAP. I contacted the PT who had contacted me when she moved to town in the winter, had organized the workshop I taught in June. She is quite keenly interested in pain and in helping people deal with it. She was a kindred spirit in that she had tasted ortho koolaid but hadn't gulped the whole glass. Both of us had instinctively known we didn't like the handling that was often involved, or the mindset, or the callous disregard, both interactively and conceptually, of the nervous system of the patients being handled, specifically their interoception and afferent capacities. Both of us were well aware of Pain.

She is also a midwife. She has had 4 children. She has conquered pain from all sorts of angles on several occasions, in herself and while helping others. I respect somebody who has given birth, endured the Pain of it, and lived. I never have. The very thought has always made me feel cognitively dissonant, as in, why would anyone ever willingly go through something like childbirth?, even as I noted that it's normal for Homo reproductus.

The shoulder
Weirdly, even though I realized this exact same presentation was labelled "frozen shoulder" and is common in women, especially older women, and I couldn't do anything with my arm, and pretty much everything hurt it, I continued working. Yes, believe it or not. As it turns out, I was reasonably comfortable while using my arm from the elbow down, and pressing on table tops or my bed or against peoples' bodies with that arm even felt a bit relieving. So I was able to fake my way along through Tuesday and Thursday fairly well. I was really anticipating my session though, yesterday after work.

The treatment
Kirsten allowed me the freedom to do whatever I needed to do in the moment. It was painful to lay on my back, but I knew I wanted her to take my arm off the edge of the table, into shoulder extension, lay it gently and slowly on a pillow, find the core of that monster, Pain, on the front of my shoulder, touch him with one hand, put her other hand behind my shoulder/upper arm, from underneath, at the bend, and press steadily up with the ends of her fingers using her lumbricals. Push him the hell out of me. As soon as she did that, I could feel a shifting going on.

Other nerves screamed as Pain ran around raping them, simultaneously, but I knew this place was his whole tap root, ground zero, the entrapment of the musculocutaneous nerve inside coracobrachialis, from 20 years ago, what the restriction had been all about, right from the beginning. This is what I'd neglected to go get treatment for lo, all these many years. This was all my own fault. This was my battle, not anyone else's. No one could rescue me but me.

I was up for mortal battle - I wanted to full-on murder that rapist bastard, Pain. I was angry, cold, calculating and not in a mood to take prisoners. This was between me and whatever my immune system had decided to dish me. If Pain was a movie, starring him, he was about to be vanquished, by Me, or at least by the "I"-illusion I call Me, because this is my body, my physical existence, my biological real estate, dammit. Life is crappy enough as it is, out there, and this my body is the only place I really ever have felt safe or at home. I own my own body, dammit. No matter what sorts of cultural ideas would try to deprive me of bodily sovereignty. I know them all in detail. E.g., "Right to Life" (whose fucking life? MINE!!)..  

So I endured/ignored all the screaming going on in all the other centrally sensitized nerves - superficial cervical plexus, distributed like the right half of a hijab. All the brachial plexus, the whole hand.

My goal was to keep Pain confined only to where it had already colonized me, not let it get any farther, fight hard to get back my body for me. I took the immediate increase in all the rest of the nerve distributions as confirmation that Pain was trying to fight back.

But I was relentless. I could still breathe. So I focused on deep breathing as the next couple minutes (that felt like hours) ticked by. I know the right length of time to spend on something, from decades of occupying the other end of the treatment dyad.

Kirtsten and I checked in with each other. She felt the softening happening at the front of my shoulder, and I knew that Pain had been stabbed in his heart, by her, by me, by our interaction; I knew that although he would not go down without a fight, or without trying to start more fires, he was eventually going to diediedie.

Finally I decided enough time had elapsed, that death of Pain was certain, and I needed to help the rest of my sensory cortex, indulge the anterior cingulate cortex by letting it express some escape behaviour. I got up on my feet, writhed about, wrestling with myself. Kirsten remarked that I looked like a woman in labour. I remarked that it felt like I was having a baby through my right upper quadrant. I said I was being an ideomotor moron. We both laughed. It was triumphant laughter, because I was letting my anterior cingulate cortex help my sensory cortex escape by giving it complete access to my motor cortex, and it was having me do some pretty remarkable moving. It felt a lot like contemporary dance might look, performed by a very inept and untrained dancer, kinda ugly-like; so, readers, best not to let your mirror neurons become too activated, because visualizing how this interior moving went down could be somewhat painful in and of itself.

But movement had to come out. Just like a baby comes out. Blood, gore (well, OK, no actual blood or gore), messy movement, biological and frighteningly primitive. But natural. And I killed Pain. I killed him with the help of my student, Kirsten, no stranger to any of this in that she has done movement like this herself while giving actual birth. Kind, steady, standing by, putting up with me, engaged, accompanying, permissive, calm, reassuring, letting me do what I needed to do, not interfering, accepting me in the heat of my battle no matter how ugly it was.

Right away, after about 5 minutes of this, the arm pain and superficial cervical plexus pain was much reduced. I could move the arm actively! A few degrees at least. We treated a few more places in a few more positions. I could now tolerate prone lying with the arm dangling. Kirsten sat on the floor and twisted the skin of my arm in slow snake-bite S's for delicious minutes and minutes and minutes. It felt like my arm relaxed and lengthened by inches. When I got back up it was truly better.

I had a great sleep. No more Pain. He's dead now, the miserable rapist bastard. At least for now. At least in me. But he still roams and assaults others, so I will hunt his sorry evil ass and help other people kill him for as long as I have breath.

I have my life back. I almost have my shoulder back. There is still restriction. I still have to use my non-dominant hand for certain personal hygiene which shall remain nameless, and I still have to put on a bra by doing it up at the front then twisting it around, and Kirsten will have at it again next week, but I doubt I'll have to gear up to go full-tilt psycho on whatever dregs still remain. It will be more just a mopping up process. I won't have to be the killer again - I'll be just the cleaner.

Life is painful. We try to keep at least one little corner of it, our own body, pain-free. No one should ever have to endure captivity by pain. People either kill it, or learn to live with it, adapt to its presence, peacefully.
I think people need to be encouraged to kill it anyway they can, if they can. People also have to know it will be entirely an inside job, requiring strategy, planning and often recruitment of someone to assist. They need to have picked somebody carefully, well in advance. It is a truly dorsolateral prefrontal cortex-led inner activity. They must know that they will need a story-line, starring them, that they will need to assume the lead role, and that it will be the role of assassin, if they want to have their life truly back again under their own auspice. They will be faced with win-or-lose, black-or-white, kill-or-be killed/raped/crippled/maimed/paralyzed by Pain. It's a choice, and by now I know, deeply know, emotionally know, that it must be made, can be made, by anyone, including peaceful 60 year-old women who love cats and don't ever try to hurt anyone. The urge to kill is inherent in all biology, all organisms, a birthright. It is the last and final defense for the "I"-illusion against any enemy, real or imaginary, physical and external or sensed, experienced, internal. It is socially forbidden unless sanctioned for use by army or law enforcement. At the personal level, one has the biological right to deploy it for a good reason such as this, engage it  - strictly internally, and fully, without doubt or hesitation.

P.S.: My Kill Pain story-line has specific feminist overtones and undertones running throughout. It's the story I've been angry about all my life - power over, violation of, domination of physical bodies of helpless men, women or children. It's the story that gave me fuel to make myself get mad enough to become capable of committing murder. You'll need to make up your own story: Think of the grossest violation of your own bodily human rights you can imagine, feel how enraged it makes you feel, then fight back with everything you've got. Every claw and every fang. It's your right as a vertebrate with a human nervous system.  

* I finally worked out a position in which I could sleep relatively comfortably, for a relatively long length of time; prone, on top of three stacked pillows, forelegs folded like a quadruped, head turned left. I had to wake up fully in order to move. I had to physically get up to rest from having been in that position for a few hours, then resume that position to get more sleep.

More posts on this topic:
 
Killing Pain Part II

Killing Pain Part III

Killing Pain Part IV

Killing Pain Part V

Killing Pain Part VI 

Somasimple discussion thread about this post series.  

Scientific American: Anger Gives You a Creative Boost
This article is about interpersonal confrontation, however, I see no difference, from the perspective of the "I"-illusion, whether the perceived "foe" is external or internal.

Back in my own life

I realize how addicted to my own life I am. July went by in a blur.

First there was a big chunk that evaporated by attending Congress. Five days shot right there, even though I liked it a lot, actually was stimulated enough to sign up to go to Winnipeg in November to attend Michael Sullivan's PGAP (Progressive Goal Attainment Program) workshop. 

Then there was another 5 day chunk spent in Saskatoon at a large family reunion.
Not that it wasn't enjoyable and interesting. Just that I had no time to be with myself and the internet.

Yesterday I was at work all day, not caught up with myself yet. This morning (day off) I feel like I'm finally getting there. I've been online since 6 AM. So rejuvenating. It's now nearly 11 AM.

I've posted many bits and dabs to the Facebook pages, my own, the Neuro and Pain science page, and the PSD page. Right now I'm watching Wolpert's interview/exposition on the Charlie Rose show from a couple years ago.  Here is his webpage. I love his succinct explanation of the brain:

"Movement is the only way we have of interacting with the world, whether foraging for food or attracting a waiter's attention. Indeed, all communication, including speech, sign language, gestures and writing, is mediated via the motor system. Taking this viewpoint, the purpose of the human brain is to use sensory signals to determine future actions."

 How brilliant is that?

Also, I watched all 50 minutes of this Youtube video of a presentation by Moshe Feldenkrais, from 1981, all black and white and grainy. Thank you yet again, to Carol Lynn Chevrier, a Quebec massage therapist who is also a jazz singer. What a combination. She probably knows all about interactive improv with patients, understands it in its deepest motor sense, probably. Music and singing is motor output making auditory contact, just as manual therapy makes physical contact. With both, basic talent should be present, then motivation, then practice, and maybe, some day, approaching perfection.  

Feels so good to be back to total immersion in all this. Not all "that". 

Deep south of Sask. stories continued

Older stories here.

Maybe I have adult ADHD or something. I got up from the waiting room chair this morning and read all about it, all the symptoms. Yup, that must be it.

Or maybe it was being expected to wait endlessly for my (second, booked) appointment at the Dr.'s office.

I called to find out what happened when the door to the Dr's office was locked at my appointed time, Friday afternoon. Lots of apologies, a new appointment, a confirmation that a sign on the door, letting people know the Dr. had had an emergency to attend, or else a phone call to cancel, would have been welcome. "Oh, yes yes, we will do that next time. Good idea."

So, I gave this guy another shot.
Got there today, 5 minutes prior to appointment time. Not so long before that people suspect me of OCD, but enough ahead of time to ensure that any untimeliness won't be on my account. Simple courtesy.

Forty minutes later, I walked out.

I'd seen him come into the reception area several times, once to help his staff look for some missing file. Another time was a kibbutz with a patient who was just leaving.

I still don't have the Weyburn groove, yet, obviously. Still get mad and fume and steam when someone besides me wastes my time.

Next week the walk-in clinic, just next door, will be open again. I'll try there, see if I have better luck getting my stupid form filled out that has to be signed by a doctor and lets the health bureaucracy feel assured that I'm not some sort of infectious threat to their charges and to other staff.  All so that they can turn me loose one day a week on their persistent pain patients, and make that wait list go down.

Idle thoughts.

I can't find any pattern here, it's just what's going through my head today. Maybe it will turn into something, more likely it won't.

From recently:

Yet more mesodermalism: The fun never stops
This is from a conversation I had on Facebook last week with a mesodermalist devotee. It went exactly nowhere. You'd think I'd learn. But I never seem to.

The Chestnut Challenge
Byron, a member of Somasimple, wanted to get to the essential bits, in under 400 words.

From today:

Dissecting the empathic brain: an interview with Christian Keysers
I'm always interested in how to develop a more empathic brain and simultaneously retain firm interpersonal boundaries. It ain't easy, that's for sure. I think I might have a brain whose somatosensory apparatus can literally feel what's going on in other peoples' somatosensory cortex, and have to try to do something about it using physical contact. Insert myself into their brain loop. Excerpt:  

"seeing activity in somatosensory regions while viewing others being touched is primarily information about ‘where’ the process occurs. But it also shows that you transform what others feel into representations of what you would feel in their stead; ‘where’ becomes ‘how’ you understand others."

Using manual therapy to treat pain

Yes! It's all in there (beautifully laid-out):

"Laboratory and clinical studies have started to identify the physiological changes that occur in individuals undergoing manual therapy. Manual therapy results in a rapid-onset, localised analgesia, increases limb mobility and effects autonomic changes. Animal models have been developed to inform on neuronal mechanisms, and suggest a local action on nociceptors and modulation of central pain-inhibition mechanisms.

Manual therapy is a commonly used treatment modality for managing musculoskeletal pain that has been shown to promote rapid recovery. Localised, manipulation-induced analgesia is routinely seen following manual therapy and is proposed to occur via a number of mechanisms:

·  A local action on nociceptors.
·  Modulating the activity of both descending and segmental pain inhibitory systems.
·  Exerting psychological effects, probably as a result of treatment expectations.

The mechanical hypoalgesic effect occurs within minutes of manipulation, and meta-analysis of clinical studies has confirmed that it is associated with an increase in pressure-pain threshold and limb mobility. In contrast manual therapy does not modulate sensitivity to thermal pain.

In addition to the demonstrable analgesic effects, manual therapy also induces a number of autonomic changes such as increased skin conductance and cutaneous blood flow, increased pulse and respiration rate, and changes in skin temperature. This indicates that, in addition to changes in pain perception, manual therapy modulates central nervous system function in a sympathoexcitatory manner (promoting mobility).

The local analgesia and systemic autonomic changes in response to manipulation have been demonstrated in healthy individuals and those with pain. Manual therapy also achieves motor function benefits; cervical mobilisation in individuals with insidious-onset cervical pain has been shown to promote increased deep neck flexor muscle activity and improve pain-free grip. However, motor function benefit tends to be restricted to individuals with a clinical condition.

These patterns of effect are suggestive of activation of the descending supra-spinal pain systems. Further evidence of a role for descending pain modulation pathways has been generated using animal models. A rat model has been developed in which capsaicin injection induces hyperalgesia in the hind-paw; ipsi-lateral knee joint manipulation subsequently exerts an anti-algesic effect in the entire limb. The model has shown that the analgesic effect of joint mobilisation is inhibited by the intrathecal administration of serotonin antagonists and is partially modulated by a₂2-noradrenergic receptor inhibitors; in contrast opioid antagonists and gamma-aminobutyric acid inhibitors have no effect. This suggests that manual therapy affects the activity of the supra-spinal, descending pain-inhibitory systems that involve seratogenergic and noradrenergic pathways."

(Thank you, Dr. Julie Eastgate, from the U.K. )

Insight and creativity, by Janet Kwasniak.
I agree. They are quite different.
Excerpt:

"creative thinking does not appear to critically depend on any single mental process or brain region, and it is not especially associated with right brains, defocused attention, low arousal, or alpha synchronization, as sometimes hypothesized."

 "insight is represented by distinct spectral, spatial, and temporal patterns of neural activity related to presolution cognitive processes that are intrinsic to the problem itself but not exclusively to one’s subjective assessment of insight."

" [JK]This implies that we can unconsciously notice that we are thinking about a problem in an unsuccessful way, search for an more successful framing, and evaluating the new way of thinking about the problem. To me, this hints at working memory not being required in this search for a transformation. Another interesting result is the gamma increase was in the right hemisphere (rather than left or both). This implies that the usually less dominant hemisphere was carrying the load in finding a transformation.... Insight may or may not be part of any thinking process – creative or not. Creativity is probably so varied and so complex a process that it cannot be correlated with any particular neural picture. "

 

Stories from the deep south of Sask.

There are aspects of living in Weyburn that I do not like. There is a certain structural (I think) lack of accountability, lack of business etiquette.

Story #1:

A couple months ago I looked for office space, found a real estate agent, who showed me a small streetfront space, part of a building housing independently living seniors, right downtown. I decided to take it. I contacted the real estate agent, who said "I think the owners might be wanting more for it than I quoted you." What the..??
I asked him to double-check the cost and let me know ASAP what the new "cost" was going to be. He said, the owners are out of town. I waited patiently, for three weeks. Well, patiently for me, at least. One visit in person (he wasn't in), a couple voice mails and three emails. He never, ever got back.

Nothing.

It was as if he had died and fallen off the face of the earth. No reply. A  couple weeks after I gave up trying, I found out through a completely different source, my mother (who had noticed activity in the space), and directly asking the guy who is the caretaker there, that the owners had rented the space to a different party, people who were were busy jackhammering up the floor, gutting the space, renovating it to turn it into a boutique hair salon.

I could have been notified. Surely a real estate agent's job is to keep all interested parties informed about what is transpiring with a space that's up for rent. Surely.

But, in this town, I'm chopped liver apparently.

It has all turned out OK. I never found the right space, but I do have a working gig with the "big" private PT place in town, two days a week, nice room to work in, private, has a door, a window, space for my small amount of stuff, fresh laundry, someone working there who does laundry.. A bunch of tough cases to treat, no time pressure. I'm working on an application to the other big PT place in town, in the public realm this time, outpatients in a government run facility, right within/part of an assisted living facility for patients who are much higher maintenance, needing skilled nursing care. Which leads me to my second story.

Story #2:
To fulfil application requirements at place #2, I was asked to provide a police check, an immunization list, a medical certificate of health.

OK. Here we go. It's been 7 years since I last visited a medical doctor. The last time I visited a doctor, she freaked out and had checked me out for breast cancer, which involved two (not one but two!) painful mammograms, one of which was exceedingly painful and made me swear out loud. Also an ultrasound and a clinical exam. None of which turned up anything. So I stopped the relationship. I never picked up another. Until now. Because of this application requirement.

So, here I am, in a new place, no medical relationship. I picked out a Dr., which in itself isn't easy here, because they aren't listed under "physicians", here, just medical clinics are listed. Anyway, I walked down the street, found the name I was looking for, took down the phone number because the clinic was closed the day I went looking, called, made an appointment, was ecstatic to find out I could get in today.

Went to the appointment. Was 5 minutes early. Light was on inside, but no one visible, and the door was locked.

I waited until my time. I knocked on the door. Nothing. I waited some more. Ten minutes past my appointed time, I left. I went and picked up some groceries.

On my way back, 20 minutes later, I looked in the window. Now the light was off.

I was stood up again. Chopped liver yet again. I realize, being a manual therapist, that the pattern-seeking and finding part of my brain is extremely well-neuroplasticized. So I'm apt to see patterns where they don't really exist, and make erroneous conclusions from that. I'm way better at NOT doing that than I used to be. Still... I can't help seeing a pattern here: it seems to be a pattern of "Don't-have-to-give-a-sh*t, unless I know this person and my parents knew that person's parents and they all voted the same way and/or went to the same church, and/or they are the sister-in-law of my brother-in-law's cousin, and/or I owe him/her a favour."

Now I remember one of the (many!) reasons I was so eager to escape small town BS 30 years ago, where systems are inefficient and all transactions occur based on who you know, not what you know, or need, or expect, where there are no objective standards of interaction, where business ethics seem to be ... well, the most charitable word I can think of, is wobbly. This aspect, I definitely do not like.

CPACongress11 - Part II

I have been really busy! It's noon on Sunday; I skipped out of sessions today, following breakfast and AGM, to feed my inner blogger with some posting. I can't do it on the fly because unfortunately the conference center down the street doesn't support internetters. They have wifi but no provisions were made to give conferencers the password. Not wanting to lug around a computer for nothing, it has sat in my hotel room idle, most of the time, instead, while I've been out socializing for a change.

Anyway, catch-up time.
Hemispheres
Lara Boyd spoke early on Friday morning. She is a PT/neuroscience researcher with the BrainBehaviourLab at UBC. The talk was fascinating (she should have been the keynote speaker); I don't recall much anymore, but what I gathered is that she looks at transcranial motor stimulation of the cortex of people with stroke. She talked about how the hemispheres inhibit each other all the time, and how in stroke, one hemisphere often shuts down completely and the other gets wildly excited. What I got excited about, was that she said cotico-spinal pyramidal cells don't just originate in the motor cortex, but rather, that they also originate from the sensory, and premotor cortices as well; that the motor, pre-motor and sensory cortices were really not discrete in their function as much as everyone used to imagine they were. She talked a bit about pain, but I forget what she said. I do remember Deb Patterson leaning over and whispering, "That must be why mirror therapy works!" And I remember the two of us, at the back of the room of 500 or so people, breaking out into spontaneous applause. A guy turned around and asked, "Neuro section?" and I replied, "Pain section."

I plan to read every scrap this woman has ever written.

Progressive Goal Attainment Program
One of the big surprises this year was that Michael Sullivan from McGill was invited to present. This is a HUGE step away from the pure mesodermalism I've learned to expect and dislike. He talked about predicting what patients would be less likely to do well with "regular" treatment, and helping patients keep moving along by avoiding therapeutic relational pitfalls common to our profession, common in that no PT school has ever bothered teaching us to be more "therapist" and less "physical." He extends the opportunity for interdisciplinary adventures with his by-now-famous Progressive Goal Attainment Program (PGAP). Which I plan to take one of these days. I think the ortho division brought him in, which is a huge departure from Jay Shah and his muscle needling, from Congress last year.

Pain Science and our (Pain Science Division) chair, Dave Walton
Several workshops this year focused on the pain system, stress, goal attainment, therapeutic relationship, goal attainment, motivational interviewing, and classifications of patient subgroups; Dave was involved in many of them. It was SO good to see. SUCH an evolution away from mind-numbing presentations about elbows and knees and necks. Well, we haven't managed to get away from the necks, quite yet - a lot of stuff was about whiplash; however, much was about yellow flags applicable to any kind of pain, but unfortunately (IMO) because of the nature of science, this body-part issue has to do with the way research is organized and research questions have to be addressed. It's necessary to focus on one bit at a time - no one can ever ask a broad question that would apply to the human organism in general. Apparently PhDs are gained particle by particle.

Dave Walton, new chair of PSD as of Thursday July 14/11, second from right, beside Ronald Melzack

Also in picture: Lesley Singer far left, green dress; me far right

Neil Pearson stepped down as chair (because it's a timed term, not because he wasn't great, because he was), and Dave is our new chair. He is a PT, a PhD, a martial artist, and has been known to do breakdancing at Local Flavour Nights during Congress; it is rumoured he can do full splits. Pretty cool. Go Dave!

Weather report

View from hotel room, Whistler BC, July 15/11

Chair lift in the background. 

Horrible cloud; cold, windy, November weather in mid July

So, here I am at CPA Congress. So far Congress has been brilliant, with great food and fabulous presentations. Can't say the same about Whistler weather. It's like going back into the cave, coming here. Hard to get here, very long trip. Next year I hear Congress will be in Saskatoon. That will be much better. 

So, what am I learning? 

Day I

All day Thursday, Pain Science Division presented "Clinical Chronic Pain Management: Practical Strategies for Everyday Physiotherapy" which was fabulous; Neil Pearson talked about neuroplasticity, how it required 90 minutes a day for a month to change anything in the brain, but that change was indeed possible. He showed a list of pain mechanisms; nociceptive, peripheral neurogenic, central neurogenic, autonomic/motor, and affective; he said that the MDs learn that list, and then they learn from pharmaceutical companies that there is a drug or class of drugs for each (and that that's ... about it). He discussed chronic pain in general, what it meant, etc. There was much more from Neil, but my notes are sketchy and handouts will be emailed out later, so, don't have those to refer to.

Deb Patterson talked about how everything that hinged on change in pain hinged first on developing a good therapeutic relationship and projective goal setting. She explained the SMART (specific, measurable, attainable, relevant, and time-bound) goal-setting model. She had a few videos of patients she had treated, including with DermoNeuroModulation (my thing), and how the therapeutic relationship had turned out. One was a woman whose ends of fingers had been amputated, traumatically, and the woman had developed horrible phantom finger pain. Previous (failed) treatment had been "desensitization" but it had backfired - tapping and stimulating the ends of the finger stumps had revved up pain instead of reducing it.  After Deb had treated her face the phantom finger pain had disappeared, briefly, giving the woman an opportunity to realize she was capable of "no pain." Deb used mirror therapy with her too.  In the video we could see how Deb had moved the woman carefully through just looking at an intact right hand in the mirror box (stimulating visual cortex), to stroking it lightly and VERY gently with a cosmetic brush (stimulating affective somatosensory cortex), to asking the patient to thoughtfully and sensitively move her fingers, watching them move in the mirror (somatosensory and premotor and motor cortex). The swelling and pain went away. Now she could now tolerate wearing her finger prostheses, and as a result was going out, was being a lot more social. Absolutely brilliant clinical intervention.

Lesley Singer talked about having chronic facial pain herself, stemming from surgery to remove a brainstem tumor; what having chronic (centrally generated) pain was like, from a patient's perspective as well as from a clinician perspective, treating other people with chronic pain. 

Dave Walton discussed measuring pain with pain scales, and scales for all things related, such as depression, catastrophizing, anxiety, locus of control, readiness to change, fear, kinesiophobia, coping behaviours and strategies. 

This day long workshop is going to form the backbone of an entire Level II of the Virtual Pain Symposium we put together a few years ago.

Day II

The plenary session this morning was by Lara Boyd of Brain Behaviour Lab at UBC. No time to discuss it right now, must run off to the next event. More to follow.

Letter to a biomechanically - minded therapist

A new member at SomaSimple wrote:

I am still trying to get a grasp on everything I have been reading on this site. I would like to hear the rationale from an Ectodermalist of why I had success this patient.

Patient: 39 y/o female presenting with c/o left lateral knee pain while jogging. No reproduction of symptoms with AROM, joint mobility, palpation, special tests. Onset of symptoms after approx 3 minutes of jogging on treadmill. Patient described symptoms as "deep in the joint" and "sharp". Other objective findings: weak L hip ERs, L midfoot pronation.
Video analysis of running mechanics: excessive L DF and close to full L knee extension at heel strike.
Treatment: decreased patient's stride length by increasing number of steps per minute with use of a metronome; exercise for L hip ERs
Results: patient ran 10 minutes pain free with decreased step length at same visit
Rationale: decreased stride length will decrease ankle DF and increase L knee flexion at heel strike in order to decrease ground reaction force at L knee joint

Name deleted

I wrote back.
Inevitably I missed saying a few things that are probably important for clarity, so this blog post will be an elaboration of that response.

First of all, congratulations on having interacted with, and helped abate, a problem a patient was having with movement and pain. The question you seem to silently be asking sounds like, "because I used biomechanics and biomechanical analysis to help solve the problem, why should I bother trying to learn how to see things ectodermally?" 

This always seems to be the first question people ask. The second one is, how is what you do different from myofascial release? Which used to drive me batty, but doesn't anymore, because it's been so long since I extracted my own brain from entanglement with all the flawed ideas inherent in myofascial release as a treatment concept, But now, back to the letter:

I think that is a fair question. I really do.

I wrote a bit about the focal length of treatment a little while ago. Here is a link; Operator/Interactor.
So, it boils down to biomechanics and biomechanical analysis being a good example of "patternicity", fraught with Type I and Type II error, or pareidolia (seeing the virgin Mary in a piece of toast) or apophenia ("experience of seeing meaningful patterns or connections in random or meaningless data").
Manual therapy is full of pattern seeking and finding, and so is any sort of therapy, really. Psychotherapy is full of this too. A practitioner sees a certain kind of pattern, or sees a pattern a certain way, and starts to explain how he or she sees it, then other people (suggestible as we all are) start to see what he or she means, it all makes sense, and voila, a new institute is born!

 So was medicine for a very long time, and still is to a great extent, burdened by patternicity-seeking.

One of the biggest irritations I still have, actually, is the enormous influence still wielded by the Biggest Mesodermalists of Them All, Orthopods and Physiatrists, over the thinking processes of therapists of the physical persuasion. Why do they persist in knowing nothing about neuroscience? Because they are making a fine living from injecting joints and needling imaginary things called trigger points that they decided arbitrarily are located in muscle somewhere/somehow, and teaching new generations of keeners to think the same way they do about pain problems.

Last summer I sat and fumed for an hour, listening to Jay Shah talk about trigger points and needling them. He admitted upon questioning by Neil Pearson (then chair of CPA's Pain Science Division) in the audience that day, that no one has ever actually found trigger points to exist, but he had gone on for an hour before that, showing zippy video-embeds of naked muscles (skin removed) and needles put into them this way and that, leaving every brain in the room with the overwhelming impression that he was showing us real, anatomical, mesodermal entities that were "pain" generators. Way to mess with peoples' minds, Jay Shah. Way to not help anyone understand pain or the nervous system better. Way to reinforce Cartesian ideas about "pain" (not just nociception) being carried on pain strings inside the body up to the brain. That model is really not that clinically useful anymore. For any of us who don't like needling, for sure. Way to keep allied health professionals separated from a longer conceptual focal length and perhaps wider angle conceptual view of pain and its common persistence. Way to keep us in the dark. Way to reinforce mesodermalism.

But now, back to the letter:

Now, about your patient: You used a very well-established patternicity model to help your patient. There is nothing wrong with helping patients any way you can. However, there is a great deal of information in the last 30 years or so about the brain, about how the body and brain interact, about pain, about how the brain both creates and responds to a pain experience.

This forum, if it is about anything, is about exploring how to connect all that to what we all, in one way or another, do for a living, which in my opinion is human primate social grooming. Human primate social grooming (HPSG), to me, boils down to a wordless kind of interactive, kinesthetic support, fully accessing every affective and afferent channel in that patient that is therapeutically available to us, to help them. Them. Them. 

Them.
This is uppermost on my mind this weekend, because of a recurring fight I always end up in with chiropractors. The latest battle was on Facebook last week. This could be a whole separate blogpost, but briefly, I posted a video of Alannah Myles and immediately had my throat jumped down by a chiropractor who accused her of lying. Yes, lying. About her own experience of being in a body, taking it to see someone she thought would be able to help her, but hurt her instead. I documented the exchange here. To my mind, any profession that doesn't put the patient and his or her well-being, front and center, but instead reinforces victimhood by placing itself first and foremost in the mind of the practitioners it trains, is the exact opposite of what a healthcare profession or professional should be. I consider that to be an unconscionable juxtaposition, completely indefensible, although chiros really really try, reflexively, to defend themselves before any other thought crosses their minds, and end up weeing all over themselves and their (so-called) profession in the process. And they never, ever seem to get how ludicrous they are/it is when they do that.

But I digress. Back to the letter:

What the problem is, with patternicity, is that conceptualizations can interfere with our own brains. Several problems can emerge if we aren't really careful to always keep the patient first and foremost. A few examples, randomly, in no particular order:

1. We can become way too reliant on the tool, instead of what it is we are supposed to be doing with it. There will always be a patient who comes along who doesn't fit your tool/concept. Then what?
2. We can end up being tool collectors which can lead to a lot of confusion.
3. It's really, really hard to study therapy from a patternicity standpoint, because of there being nothing objective to measure, just a pattern in a head that feels real but isn't, because it isn't an object, it's an objectification.

Treating a set of ideas we cart around in our heads in a basket might overlap a good deal of the time with actually managing to help patients, but it can't always, and if we rely on conceptual baskets of ideas only, we will lose the paddle far up the creek on a regular basis.

Back to the letter:

Instead, what some of us old fogies have come to realize, is that we might have saved ourselves a lot of $ and frustration if we hadn't combed carefully through all those patterns, gurus, and institutes out there that are patternicities based on mesodermally-derived tissue. What is mesodermally derived tissue? It's the 98% of the body that is not nervous system (i.e., bones, joints, muscles, fascia, tendons, ligaments, etc.) Instead, we wish we had stuck with key principles.

In this post, Ian Stevens nails the essence of the problem we all face whether we are currently practitioners of one kind or another, or are people in pain (and I can pretty much guarantee that we all will be one day like it or not); ian s, paraphrased:

Quote:

"..illness Pain is not (only and always) a mechanical process. Illness Pain is always multifactorial. That’s part of the nature of complex systems – they aren’t simple! The thrust of the argument is that it’s whole people who get ill pain, body and mind, inextricably interfunctioning, and not only that, but it’s whole people, embedded within the environments of their lives who get ill pain. I use the plural there deliberately. We are embedded in multiple environments, not just physical ones, but also social, cultural and narrative ones. We are meaning-seeking creatures."

I just loved Ian's depiction of nested problems, nested in contexts, several simultaneous human contexts, inextricable from them, rather like the way manual therapists find themselves inextricably bound inside the conceptual worlds they build and pay to have built around their/our own brains. Man oh man, we had better start building in some cognitive nimbleness to avoid being screwed in the left ear by hucksters from our own human primate social grooming troops, and/or in the right ear by 'submission to authority' in the form of actual medical doctors, like Shah (see above), who should be helping HPSGs find a way out of the mesodermal concept quicksand instead of deeper into it. 

Back to the letter:

To sum up, as long as we are putting the patient first, ahead of ourselves, ahead of our professional pride, ahead of being attached to results, ahead of being attached to our favorite patterns, or methods, or anything else, we'll probably do just fine in the long run and work our way out of the conceptual maze and realize that all we can ever know is just how to be just and ever and only one step ahead of our patient. Which is fine, because as their therapist you don't ever want to be any farther ahead than that, or they might lose track of you and you of them. It's only one step, but as long as it's the right step, you'll always go places, and be able to help them, and never hurt them. 

The Expert Mind.
The Patient's Brain: The neuroscience behind the doctor-patient relationship

All the best.

Diane

 

Why I don't buy the idea that "trigger points" are in muscle

This is what happens when vessels to nerves are under tension

We've all heard of trigger points, right? Those things that hurt when you press on them or when someone else presses on them. Right? So far, so good. They are spots, or points, fair enough; and they hurt when provoked, i.e., they "trigger" discomfort. I can accept all this so far. We have something physical, a sore spot, and we have some action, provocation that makes said spot hurt.

It all gets rather smushed together, this (ectodermal) phenomenon called "pain" being generated somehow, then "felt" or perceived as being associated with some (mesodermal) part of the body, with a motor deficit or malfunction of some sort, such that when a certain movement is attempted it is thwarted by a pain signal. I suspect it was the interference with motor output that made it somehow acceptable to leap to the conclusion that muscle was somehow to blame. But it isn't, not necessarily. Correlation is not causation. After all, muscle is just doing whatever the CNS tells it to do. Really. Muscle is just a puppet of the nervous system. It has no "behaviour" other than doing whatever the nervous system decides it needs (non-conscious) or wants (conscious) to do.

Now, why in the first place trigger points were ever blamed on muscle is probably, in retrospect, just sloppy, convenient, heuristic thinking. I can accept that stuff like that goes on all the time. Why such sloppy, convenient and heuristic thinking is allowed to continue when better explanations have come to exist, I don't understand, and sort of resent actually..

THE ANATOMY
First of all, supposed "trigger points" are found/discerned/their existence implied from outside a patient by another person poking at them. Let's bear in mind that there is a thick layer of blubber, even on skinny people, between a patient's "muscle" and a practitioner's finger poke. Let us not automatically mentally subtract the outer layer as inconsequential, the way trigger point diagrams would have us do.

That layer, known as cutis/subcutis, usually a good half inch thick, contains:

1. a huge amount of neural structure, i.e.

• Cutaneous nerves with all their rami to the surface
• All the neural receptors needed to signal the state of the environment to the brain
• All the neural structure required to regulate blood flow in the skin organ which according to Gray's Anatomy, is ten times that required to maintain the skin organ itself.

2. a huge amount of vascular structure, for thermodynamic radiation of heat away from person-as-organism

3. Plenty of smooth muscle tissue, responding not to the will of a person but rather to brainstem exigencies/dictates, e.g. shivering/goosebumps, vascular lumen contraction via sympathetics, vascular lumen enlargement via efferent neuropeptide leakage by afferent sensory neurons, plenty of opportunity for nociceptive afferents to be bothered by sympathetic efferents and vice versa.

Could it be, therefore, that "trigger points" are no more than areas of secondary hyperalgesia? Tell me how it is possible to diagnose "trigger points" in striated muscle, through a half inch of protective cutis subcutis full of all sorts of autonomic behaviour and potential afferent crankiness, plus a dense layer or two of fascial containment around said muscle? I just don't buy it. And I can't buy any diagram that shows red striped muscle with a red "x" on it, indicating a sore spot, with no skin over it or neural structure depicted in the area. I.e., Travell and Simons. To me, all this blaming a muscle for pain is a good example of looking backward through a telescope. It can be done, I suppose, but it doesn't help anyone see or conceptualize anything better. (I realize this all sounds like heresy. So shoot me. But please read on.)

FAULTY REASONING
Several years ago, Quintner and Cohen pointed out some of the logical problems inherent in the 'myofascial' idea surrounding the phenomena of "trigger points", making what I still think is a really good stab at deconstructing the nonsense in which they (still) remain embedded. See their article, "Referred Pain of Peripheral Nerve Origin: an Alternative to the "Myofascial Pain" Construct." I think it's a great article, one of a kind, but still, I wish they had gone further and pointed out or at least mentioned that no tissue other than neural tissue (i.e., neurons, direct ectodermal derivatives) can directly signal the brain (also direct ectodermal derivative) to provoke it into mounting a pain output/perception for our conscious awareness to,.. um, be aware of, consider. In other words, quite apart from the "trigger point" issue, is there really any such thing as "myofascial pain"? I would argue that no, there isn't. Only neural tissue can send sensory-discriminative information to the brain, and only the brain can mount that sort of cognitive-evaluative-motivational-affective-sensory-discriminative display known as "pain". Other kinds of tissue in the body are usually innocent victims, not guilty culprits. (I can hear people thinking, "But what about inflammation? The immune system?" Yes, the immune system can bother the nervous system, terribly, but ultimately, the internal regulation system controls the immune system, so there you go. The only exception I can think of is a channelopathy or other genetic or epigenetic pathology. For regular garden-variety mechanical pain? Not so much. Please read on.)

ALTERNATE EXPLANATIONS THAT MAKE WAY MORE SENSE
A few years ago I started reading about tunnel syndromes. There are more than enough of these described in this book (see below) that I think I'll go with the idea that most of the "pain" (in the mechanical sense) experienced as being located in the body, is likely due to one or more neural entrapments, not misbehaving mesoderm being some sort of causal factor.

TUNNEL SYNDROMES
In the book, Tunnel Syndromes, (Marko M. Pecina , Andrew D. Markiewitz , Jelena Krmpotic-Nemanic, 2001) over 50 different neural tunnel syndromes are described and illustrated. The non-invasive treatment recommended in this book is kinda pathetic, really, but they probably don't realize what manual therapy can do with mechanical pain, and each tunnel syndrome is fully described and its diagnosis differentiated. Here is what the authors say:

1. Tunnel syndromes can occur with no apparent “cause” (e.g., a tumor pressing into a nerve, etc.) - many are “idiopathic”
2. Function of a nerve can be dramatically altered without needing to be compromised in terms of space: diverse factors can adversely affect nerves function, such as: 

• inflammatory changes that thicken a neural wall/reduce blood supply, 
• edema 2° to hormonal changes from pregnancy, menopause, birth control pills, myxedema from hypothyroidism, 
• anatomical variation (anastomoses, other soft tissue variations not visible on x-ray), or 
• repetitive movement.    

3. A nerve that abruptly enters a new tissue produces a fulcrum on which external forces can act.
4. Ischemic changes will first affect sensory fibers; if they continue motor fibers will be affected.
5. Pain (i.e., nociceptive input, nociception) is the most common symptom.

(I would add, pain on provocation, or secondary hyperalgesia, fits in here too, since nerves themselves
a) can "hurt" because of being innervated by nervi nervorum, and
b) come all the way out to skin by way of cutaneous rami sheathed in skin ligaments.)

 

NEURODYNAMICS

So, in addition to repetitive movement, how about not enough movement, or variety of movement? 

I would urge everyone to get a copy of Rempel D, Lundborg G,  Dahlin L;  

Pathophysiology of nerve compression syndromes: response of peripheral nerves to loading.  

J Bone Joint Surg Am. 1999;81:1600-10. 

Check out the wonderful diagram of the microanatomy of peripheral nerve it contains (posted above).

Lundborg, back in the 80's, worked out the microanatomy, how the vascular supply inside a nerve worked,  what assisted it to function (um, movement), what happened to it if it became impaired, the sorts of mini-compartment syndrome effect this could have; he measured all sorts of finicky pressure gradients within a given nerve, and so on. Without lymphatics (although this idea of no lymphatics inside nerves is itself disputed by some), sometimes venous drainage alone can't take care of all the neural needs by itself, in there. Inside a tunnel. Who needs to worry about external compression on a nerve if it can develop problems all on its own inside its own tunnel? From blood flow backed up? I.e., increased volume? Lately Coderre has hypothesized a link between mini-compartment syndrome of blood flow in nerves and CRPS.

Why did Lundborg bother studying all this nerve stuff? Because he was learning how to do nerve grafts, and was trying to figure out what he had to do to keep his grafts from failing. What must have been blatantly obvious to him was that nerves have/are special kind of tissue(s) and require just the right conditions to grow together again.

Why should we as manual therapists care about any of this? Because by knowing about it, by knowing about nerves and the kinds of trouble they can get themselves into, how they can become nociceptive "drivers" themselves, we can drop off a lot of cumbersome and useless hypothetical baggage that forces us to consider and develop extraneous ideas about what tissue we think we are treating when we treat "trigger point" "pain" in people.

If we can get onto the correct tissue conceptually, then we stand a better chance of getting on the right tissue perceptually, too.

As always, it doesn't hurt to remember that the nervous system is only 2% of the body but uses up 20% of available energy, signals itself constantly at an average speed of 120 meters per second, constitutes 72 kilometers of nerve in a single human, and if every neuron were laid end to end, it would be more like 100,000 km.; that if a neuron's soma were the size of a tennis ball, its axon would be a half mile long and the size of a garden hose. The other 98% of the tissue comprising the human body doesn't know, doesn't much care, lives fast, dies young, replaces itself without much fuss. In other words, don't blame mesodermal derivatives for things over which they have absolutely no control. They're just passing through something called a human life, controlled for the length of a life span by something called a nervous system. Treat that instead - it can respond to what you do. From skin cell to sense of self. Continuous and indivisible from a signalling point of view. The other stuff can't.

Two different sources on tunnel syndromes, same information re: mechanism
Note the second source, re: "Ischaemic changes will first affect sensory fibres" 

Conversation with a patient

I've started working again lately. I'm treating people who have persisting pain.
A woman I'm treating told me she has a lot of stress, has anxiety. For sure she does. For sure she does.

I told her we all have to learn to control anxiety. I said it was tied in with stress, and that stress made the hypothalamus send out a hormone that made the adrenals send out juice to make the brain learn. Taking a tip from Deric Bownds (and many others), I said that metaphorically the hypothalamus was a bit like a loyal alpha dog, lead sled dog, very big, very muscular, constantly and consistently protective. We want it to do its job but we have to learn how to not scare it with all our imaginings. That we should always check, then affirm, that "there is no bear in the vicinity".

I told her that the hypothalamus was part of a threat detector system older than humans. That it was an evolved system older than the human part of the brain. That our job as humans was to learn to tame it. That we could do that by:

• being kind to it
• giving it attention
• giving it treats (the way we would with any critter we needed to tame)

Like training any wild, abused, or neglected critter, taming the self's own instinctive protective parts is similar. It requires patience and positive reinforcement. If we don't gain control of the lead dog, it will pull our sled in all sorts of unwanted directions.

It requires treats for good behaviour.

What is the most important thing in the whole world to the internal regulation system? That part of the brain that is responsible for absolutely everything? life itself? Pretty simple actually. Oxygen. Deliberate deep breathing.

That's when we were interrupted by my patient's cell phone, and the conversation ended.

Further reading:
1. Deric Bownds Mindblog Biology of Mind

One of nature's little conversations

Squirrel: (Approaches, shakes tail vigorously and pointedly) "Get away from there get away from there....!"
 Crow: "What the... huh?...?"

Squirrel: (Inspects its spouse's/child's/friend's body) "(Ohno,ohno,ohno...) Hey, you! Back off or I'll point my tail right at you - like a gun!!"
Crow: "Back off? Hey buddy, you're inserting yourself between me and my lunch. That's not nice.. OK, not sure if that's a tail or a pellet gun... But I can tell you're upset...

Squirrel: (Stands up to make itself look more dangerous) "Damn right I'm upset! I'm warning you! Back the ef up!"

Crow: "Ya.. sure, whatever..." (Crow moves out sight range, and squirrel bends down to attend to dear friend, see if it can possibly do anything to help; offers recumbent and unconscious, possibly dead friend a Whiff of Behind, to see if that can revive him or her. It doesn't. Meanwhile, crow circles round to see if it can get closer..)

Squirrel: (Suddenly charges at crow) "I told you to back off!"

(Squirrel hastens back to side of its beloved. It knows there are other crows nearby just waiting for a chance to dine. Squirrel figures out how to apply Whiff of Behind first aid, plus keep an eye on the crow, at the same time. Crows stroll around patiently, looking for an opening.)

Squirrel: (Spits on its hands, charges at crows again) "You guys, back up more! Give me space! I've got a life here I'm trying to save!"

Crow #2: (Hops into frame) "Life? That's not life, that's food! And I'm peckish. And you, my furry friend, are standing directly between me and lunch!"

Squirrel: "Not true not true not true!!! Get away!"
(Crows look at each other.  Squirrel is suddenly overcome, flops prone beside friend; grief surges as it begins to suspect the crows could be right; the accompanying physiological, mammalian bone-chill feeling brings on weakness and sudden exhaustion. Squirrel stands up again) "Well, at least give me a moment to say a decent goodbye then, before you start pecking out eyeballs!!"

....................

Stress? or just dis-stress?

This week I had a chance to contemplate the stressors I've overcome in the last couple years. My mom tops the list probably. That seems to be working itself out.

Another biggie was the relationship I have with my online life, or rather, the relationship I have with the conduits to my online life - the practical stuff, the computer itself, getting it arranged, situated, hooked up, getting a printer that works, getting ink into it. Printing. Believe it or not, knowing what end of what cable to plug into what port. Believe it or not, knowing how to organize pages so I can print them on both sides to save paper and bulk. None of these things seem to bother other people. I figure everyone who just "knows" this stuff is smarter than I am.

I never used to worry about any of that because I had people I could ask. Living in Weyburn means, I've got no one I can ask. I am forced to be a grownup and figure all my computer stressors out myself. And slowly, slowly I'm learning how. Like, right this minute I feel like a big shot, because I figured out how to organize pages so they print on both sides AND stay in order.

Life doesn't have anything to do with how happy one can make oneself, as there will always be those way happier, practically giddy, even, from living. I don't trust people who are too happy. It's like they are permanently on drugs. I think, for me, life has more to do with how much less UN-happy one can make oneself, at least on the inside, at least for a little while.

Therapeutic domain

Click to enlarge

I woke up yesterday morning with this picture in my head. So I got busy and made a slide before it faded away.

Tweaked with the helpful input of several friends since, here's what it depicts:

The top half is the patient, bringing some sort of pain experience, bothersome enough that they have chosen to include another person in their private world. The bottom half is the therapist. Together, they make a treatment dyad, separated by the x-axis. It could be any kind of person or caregiver or social contract, probably, but I decided it's a manual therapist and a patient seeking pain relief through manual therapy this time.

The left half of the image is the inner non-verbal physiological biologically processing interactor(3) world, of both.
The right half is the operator(3) world, the outer, shared, negotiated, verbal, conceptualized, noun-filled world, so pathetically symbolic, so vulnerable to misunderstanding and non-clarity, if we aren't careful. Luckily, in manual therapy, this area can be left quite spacious and airy, able to be used mostly for auditory feedback.

Before then, however, it is the area of sharing and agreeing to a therapeutic contract. It's the space in which each can come into attentional focus about the other. The patient can take some time in that shared space to reflect on how good a listener this therapist is, whether or not he or she can possibly help him or her. The therapist, likewise, can reflect on whether the sort of pain being described by the patient is something he or she can take on with his or her set of skills. They can each size up the other within their own private world, determine their readiness to develop a therapeutic relationship. This might take just a few minutes, or an hour, or take place in a continuous manner over the first 2 or 3 sessions. Or all of the above. As the contextual architect(1), the manual therapist must permit sufficient time for a signal from the patient that they are ready to begin the manual therapy 'ritual', the actual contact part of the visit.

As the therapist, it really helps if we can at least be clear on a set of concepts that can make intrinsic congruent sense to the patient: in trying to explain pain to the patient, one really must include the nervous system itself in the explanation. Explain Pain(2) is a good book for that, quite user-friendly. The nervous system includes the patient from skin cell to sense of self. It might be a tiny thing, at only 2% of the whole body, but it's what keeps us alive, and creates a pain for us to feel somewhere.

The pain is in the patient. No therapist can "feel" somebody else's pain directly. There are, however, correlates of pain, often: part of the pain experience will perhaps manifest as an area of secondary hyperalgesia, or "sore spot", or a tight spot, or something the patient can point to and the therapist can touch. If that's the case, then it's game on. No problem. Physical contact applied judiciously by an experienced clinician can assist that patient's nervous system by a little or a lot. Depending.

Depending on a great deal, much of which is still a biopsychosocial mystery, but most of which, if we're lucky, the patient's brain will decide to set aside in order to take advantage of the current possibility to "form a new opinion".

The y-axis is the treatment action or ritual itself. In my mind, I'm seeing careful handling, focused, non-nociceptive physical contact input, (forever and always indirect) input into the interior "self" construct of the patient, into his or her physicality, reported to/by his or her nervous system and processed, an effect to which the patient's brain mounts an affect, then provides a motor response, which moves back out through physiological change palpable by the therapist: it's a bi-directional dyad system, because the therapist's next shift of contact (ideally) takes this nervous system response into account, then builds upon it, to enhance it, assisted if necessary or if desired by verbal contact/communication as well. 

In this way, the treatment encounter is always a team effort. The resolution of pain will happen only when the patient's brain, on all its non-conscious as well as conscious interactive levels, forms a new opinion of its own state of function and state of its attached body.

NOTES:
1."Contextual architect" - coined by Cory Blickenstaff at Forward Motion 
2.  Review of Explain Pain by Mick Thacker  (2-page pdf)
3. Operator/Interactor