About treatment boundaries

Yesterday, I commented about treatment boundaries in this post. I want to elaborate. I want to explain how explaining pain to a patient can be woven straight into the constructing a safe psychological, social, therapeutic container to work within, while utilizing physical contact.

Guys, especially, seem very reluctant to take on gentle manual therapy. They are concerned they could be misinterpreted. (Maybe this is why they seem to head off in large droves toward ortho and other structural, manipulative technical approaches and away from physiological change approaches - they don't want their physical contact to be misunderstood.)
I say, then, make the situation be completely transparent. Ask for and get permission every step of the way. 

Let's say you had a patient with some kind of pain problem. Let's make you a guy, and the patient female. Let's make her a tough case: anxious, known drug user/abuser. Chances are, you are scared of using gentle manual therapy. You worry that she might cling, rapidly become dependent.

You can avoid any danger of creating dependency by setting a simple but firm treatment boundary: Something like:

Quote:

"We could try to help the part of the brain that is making the pain figure out a way to stop. I'd like to try some hands-on work, if that would be OK with you. (Pause and wait for an indication the patient is interested.) "It may help, although I wouldn't know for sure, without us trying it first - it helps most people in a pretty straightforward way; what I am sure about is that if it we do a few sessions and it hasn't helped yet (changed the pain significantly right away, so that it is less severe, less bothersome, less frequent, stays away for longer periods of time, one of those things or some combination of those things) then it wouldn't be worth pursuing further.

"I'm saying, it's something we could try, and see what happens, and if it doesn't help, we haven't really lost anything by trying. So, what do you think? Would you be interested in seeing if it could help your brain to stop giving you this foot (or back, or leg, or arm) pain?" (Pause and wait for an indication the patient is interested)

The next set of treatment boundaries involves explaining the patient's nervous system and how it mounts a pain presentation. This does a number of things:

1. It explains pain to the cognitive part of the patient's brain, which will give her the idea that you consider her worthy of learning it and capable of understanding it (respect).

2. It creates a conceptualization that "she" is something apart from the rest of her own brain, that you would ask for her cooperation in helping you, so that together, you (plural) can detach from the pain, watch the nervous system (with minimal input from you) solve the "problem" which is something in the rest of the nervous system (recruitment of patient's cooperation, mostly her dorsolateral prefrontal cortex).

3. It also gives her non-conscious brain time to mount reward expectation mechanisms and dopamine (if she has any of her own left), all that anticipation stuff. This wouldn't be a bad place to reassure her that you aren't going to hurt her with your handling, that you want her to tell you if anything you do, any grip, feels uncomfortable to her, because you aren't in there and can't feel her nervous system the way she can, and you certainly can't feel her pain experience, only its manifestations. So you are relying on her to help. You don't think it's prudent to have her nervous system, which is a learning machine, learning to have to deal with more pain, associated with you - your job, as you see it, is to help it learn how to feel less pain.(You are assigning her a job, a role, and indicating that she has locus of control over your handling, are giving her veto control over it, and therefore over all your physical contact with her.)

The third set of treatment boundaries involves explaining the actual physical contact, what position you would like her to lie down in, what you are going to touch, how you are going to land, then what you're going to do once you've landed, what she can expect, what you'd like her to pay attention to, to breath, etc. Then before you actually touch her, ask her permission one more time.

These are little things, mostly good manners, but they add up into setting a treatment relationship/contract that is OK for either of you to walk away from at any time. It's egalitarian and fair. It should not give her any opening to become a cling-on.  It permits the dance between nervous systems to develop to the point of helping the patient get out of the way such that his or her nervous system can resolve its problem, can fix itself, all the while, as you provide it with clear, boundaried messages and feedback, both verbal and kinesthetic, and ask for the same from the patient.

You have the right to end the (manual) treatment relationship if you sense it's not helping, and she knows from what you've said, that she has to carry a lot of responsibility for any success, and her nervous system carries the rest; if she doesn't get this, then I'd recommend stop manually treating her and move to other management methods.

What we don't even know that we don't know

 

LINK ->>>  What Do We Know For Sure, Really? (For therapists)

The blog post is by Alice Sanvito, at www.massage-stlouis.com, a thoughtful massage therapist, interviewed lately by Will Stewart (who calls himself thrill96) on his blog-radio show:  Russian Massage and Neuroscience: Interview w/ Alice Sanvito.

Alice is somebody who isn't afraid to change, who isn't afraid to think about things a bit differently, who isn't afraid of the unknown or of uncertainty. It's a rare quality in a manual therapist - most want to convey the impression that they are experts. Much of the time, I imagine, a patient can feel a level of expertise through their own somatosensory afferent system. If the attitude and the handling don't match, I think it's better that the handling be "expert" rather than the claim.

What constitutes "expert" handling? Well, every nervous system is different. Every pain problem is as unique as the person's fingerprints. So, rather than claiming some sort of "expertise" in some technique or other, i.e., a set of cookbook approaches learned at a class, it's way better to stay humble, let treatment be at the pace of the nervous system with which one's own is interacting, let treatment be more about exploring than performing, watch for settling, watch for deepening of breathing, watch for long periods of silence, encourage the same without being dominating. One lets processes occur until they stop. These are easy to feel through sensitive aware handling - warming, softening, sense of lengthening, pulsing, etc. All these indicate nervous system corrections. Let the patient become fascinated with feeling their own body's life. Let them describe what they can sense. Much of it will be a surprise to them. Give them room to enjoy new afferent experiencing, the feelings that arise when nervous systems self-correct in response to the most minimal and non-invasive input you can manage. 

How does one become "expert" at handling another's nervous system? One learns manners, and boundaries, remembering to "ask permission", not just verbally but also kinesthetically. One maintains these throughout the entire therapeutic encounter. One adapts, matches oneself to the patient. Something as simple as learning to separate one's own breathing from one's own contact with the patient can buffer a lot of unintentional "noise" from a nervous system that is sensitive. This means, literally being aware of your own breath and controlling it, or resting elbows somehow so that breathing motion doesn't travel all the way down your arms to the patient's body. Little things like that. 

Thank you, Alice Sanvito, for being a fellow traveler in the world of deepening into whatever it is we do. I don't think we can, or ever will, know anything for sure, because manual therapy is a verb, in the moment, not a noun, ever, in spite of how many conceptualizations are dreamed up to try to package it or analyze it or measure it scientifically. One thing is for sure, though: we cannot "touch" (directly) anything but the nervous system, as represented in the skin. All the rest is stuff we make up, an "as if" story.

Understanding Pain and what to do about it in less than 5 minutes.

GREAT little video on YouTube - Understanding Pain and What to do about it in less than 5 minutes. on Facebook posted by Sandy Hilton, PT and Noigroup.

"We now know that pain is 100% produced by the brain!"

Unfortunately I can't embed it, can't find the code anywhere. So click on the link to see it on YouTube - well worth the minor effort. ---> LINK

Dunbar on social grooming in primates and humans

The social role of touch in humans and primates: Behavioural function and neurobiological mechanisms

This is a (free access, download 9-page pdf) paper by RIM Dunbar of primatologist fame. Along with Robert Sapolsky I've learned more about human nervous systems from him than I ever knew from studying PT.

Studying PT is being trained in how to use a toy pail and shovel. A lot of effort goes into explaining what shovels do and what pails are for, and how to scoop and dump, but almost no emphasis is placed on the vision of the huge expanse of beach one has been set loose to tackle, or what kind of castle to build, or the nature of sand itself, or how long one can expect to have to dig, or how easy it is for the sand castles to be washed back out to sea. 

Once out on the beach, one generally heads over to where other castles are already under construction, and gets a job helping. Sometimes PTs head off to a secluded part of the beach and figure out how to make their own castle. Some PTs go into the business of making and selling ever more attractive pails and shovels, pointing out the inadequacies of the ones that exist. Many never ever get that building castles is futile altogether. 

Long ago I threw away the pail and shovel, walked down the beach to the water, went into it, and figured out how to swim. I took all the time needed to learn properties of water, learn to float, swim, with and without goggles, learn to avoid sharks and other predators, and how to stay warm even as water sucks at my core temperature. It's been a very engaging life; even if it doesn't look like it has amounted to much from the outside, on the inside I'm very contented and feel fulfilled, all that. I love being a human primate social groomer, swimming around in other peoples' nervous systems, most of the time, most days.

Dunbar points out that (abstract) "Grooming is a widespread activity throughout the animal kingdom, but in primates (including humans) social grooming, or allo-grooming (the grooming of others), plays a particularly important role in social bonding which, in turn, has a major impact on an individual’s lifetime reproductive fitness. New evidence from comparative brain analyses suggests that primates have social relationships of a qualitatively different kind to those found in other animal species, and I suggest that, in primates, social grooming has acquired a new function of supporting these. I review the evidence for a neuropeptide basis for social bonding, and draw attention to the fact that the neuroendrocrine pathways involved are quite unresolved. Despite recent claims for the central importance of oxytocin, there is equally good, but invariably ignored, evidence for a role for endorphins. I suggest that these two neuropeptide families may play different roles in the processes of social bonding in primates and non-primates, and that more experimental work will be needed to tease them apart."

Killing Pain Part VI

Almost back to normal. I can now sleep comfortably on all sides.

I am including a picture of a slide I made for a presentation in June - it contains a very intriguing cylindrical 3-D image of how convoluted a nerve (which just happens to be musculocutaneous) is, inside its tunnel. They really do look like roots.

It's important to bear in mind these are comprised of neurons, each one of which, if its soma were the size of a tennis ball the axon would be a half mile long and the size of a garden hose, according to Jack Nolte, a neuroanatomist. Well, OK, he was talking about a motor neuron, from the spine to the big toe, but you can see the proportion. Maybe in the arm we'd be talking a quarter-mile long. That would still be a pretty long garden hose.

One can imagine that unrelenting stress on a noodle-y system like that would affect its vascular supply adversely. Eventually. One can think of adaptation, I think, as a bunch of nested buckets. The mechanical stress would be like a slow drip into the center smallest bucket; after a time it would overflow and the next bucket would start to fill. It might take a long time, but eventually, the last and largest bucket would fill and spill - then the system would mount an alarm strong enough to get one's attention. I think that's how it went down in my case.

I managed to find somebody to help me empty out the buckets again. Whew.

Killing Pain Part V
Killing Pain Part IV
Killing Pain Part III
Killing Pain Part II
Killing Pain
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 Part V

Aftermath
This is the latest entry regarding my recent adventure on the other side of the mirror, being an acute pain patient with something that I would have instantly recognized in another person as "frozen shoulder".

I hate pain so much that I refuse to put up with it. That's really all there is to say.

I wanted to drop in here to say that I'm doing stuff today which 3 days ago would have been unthinkable:

1. Sleeping on that right shoulder*, my back, my front when I want, all comfortably, without waking up in pain.
2. Using my arm for anything, almost everything. E.g., did a couple loads of laundry, including sheets, made the bed
3. Used the iron (!) no problem
4. Lift heavy objects down out of the microwave.
5. Even carrying a cup of coffee.
6. Still can't get my arm behind my back for those annoying bra clips. Oh well. No pain. I'll get the range back after the neural tunnel syndrome is better and the CNS stops guarding it with movement restriction. Hey, I can actively abduct and elevate the arm, almost fully, and easily.. It feels weird, like I have the shoulder of a diving suit glued on and am painlessly restricted by it. But Kirsten will attend to that sensory delusion, no prob.
7. Personal hygiene behaviour no longer a problem. 

I think there was likely vascular involvement. Coderre talks about mini-compartment syndrome in cases of CRPS. My presentation didn't manage to get that bad, but when one thinks about the complicated twists in the brachial plexus, how the vascular and neural bundles are intertwined, I can see how they could bother each other a lot, just mechanically. I suspect that acute "frozen shoulder" has nothing whatsoever to do with any "capsule" or "joint" issue, whatsoever - that would amount to conceptual hallucination, endlessly perpetrated/sold/taught by who knows who for who knows what reason.


*still can't sleep on the unaffected side - it's still too uncomfortable. Something happens to the nerves in my arm - some sort of adverse tension, so I know they need another go with Kirsten.


Killing Pain
Killing Pain Part II
Killing Pain Part III
Killing Pain Part IV
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 Part IV

In Killing Pain Part III,  I added visual study notes to do with afferent pathways. In this post I'll add visual study notes on descending modulation pathways, made from Ossipov's diagram, found in his chapter in his book chapter, Ossipov MH; Pain Pathways: Descending Modulation. Ed. Larry R Squire; Encyclopedia of Neuroscience 2009 Elsevier Ltd. It's a book I could read for the next hundred years, along with Ramachandran's Encyclopedia of the Human Brain, all four volumes. At the rate I learn, it would take another thousand years to absorb it, probably. Oh well. I don't have that long, so I tear along as best I can visually taking things apart and putting them back together.

(I think what happened with me had something to do with neural inhibition.*)

The first image is straight out of the book. It's nice, but I couldn't follow it as well as I wanted.
The other three are my own deconstructive line diagrams.

Click to embiggen.

Killing Pain

Killing Pain Part II

Killing Pain Part III

Killing Pain Part V 

Killing Pain Part VI

*I was pleased to see the Scholarpedia article on Neural Inhibition was written by Dr. Gyorgy Buzsaki, Rutgers University, whose book, Rhythms of the Brain, I read and absolutely loved a few years ago. I blogged about it in Brain Oscillations: Ten part series.

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 Part III

We're going to drill a bit deeper into some science relating back to the previous post, Killing Pain Part II. I'm a visual learner, so I like to make pictures in PPT and examine them closely, so that I can visualize pathways instead of trying to memorize them. Here are a set of notes I made from DD Price's 2002 paper, Sensory and Affective Dimensions of Pain, on pathways in the brain that are involved with pain production. These are not "pain" centers - really, there is no such thing as a "pain" center. There are, however, pathways associated with pain production and processing. The verb is not the noun. And this is one of the best papers on pain processing I've found so far.

Abstract:

Clinical and experimental studies show serial interactions between the intensity of pain sensation, pain unpleasantness, and secondary emotions associated with reflection and future implications (i.e., suffering). These pain dimensions and their interactions relate to ascending spinal pathways and a central network of brain structures that process nociceptive information both in series and in parallel. Spinal pathways to the amygdala, hypothalamus, reticular formation, medial thalamic nuclei, and limbic cortical structures provide direct inputs to brain areas involved in arousal, bodily regulation, and hence, affect. Another major input to these same structures is from spinal pathways to somatosensory thalamic [ventroposterior lateral (VPL) and ventroposterior medial (VPM)] and cortical areas (S1, S2, and the posterior parietal cortex) and from these areas to cortical limbic structures (insular cortex, anterior cingulate cortex). This indirect cortico-limbic pathway integrates pain-perceptive (nociceptive) input with information about overall status of the body and self to provide cognitive mediation of pain affect. Both direct and cortico-limbic pathways converge on the same anterior cingulate cortical and subcortical structures whose function may be to establish emotional valence and response priorities. This entire brain network is under dynamic top-down (neural effects from higher-to- lower levels) modulation by brain mechanisms that are associated with anticipation, expectation, and other cognitive factors.

I'm putting my notes here for anyone who is interested. Click on image to embiggen.

Lateral pathways

Overview           

Others (slower)

Cortico-limbic

ACC

Killing Pain

Killing Pain Part II

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 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!