Me and exercise

Imagine. 

It's fairly early in the morning. You haven't slept very well - you're a bit excited and nervous, because later that day you are going to be flying off to another city where you will be a keynote speaker at a conference for the first time in your life.

The night before, you woke up around 2am and couldn't go back to sleep - instead of tossing and turning you got up and checked your packing, made sure you had everything - passport, clothes, personal item kit, all the cables for all your devices, phone charged, camera charged, everything ready for the workshop you also had to teach later in the weekend. You went through your presentation one last time. You went back to sleep around 3:30am.

You get up around six, get some coffee, do your morning ritual of sitting down and reading email, new posts on Facebook, SomaSimple, Twitter..

The only thing you have left to do is get your presentation off your iMac and onto a stick and onto your laptop. You pat yourself on the back a little bit for being so organized.

You reach around, unplug the printer cable from the iMac port so you can plug the stick in, then plug the stick in.

At that moment, your computer goes dead. Stone cold dead.

Well, it isn't cold yet, but it's certainly dead.
And you cannot get it to turn back on. You do all the usual tricks. Check the plugin. Let it cool down.. decide, I'll deal with this after I have a shower. Have a shower. Dry your hair. Get dressed. Try to revive it. Use the trick they taught you at Apple Hospital the last time your computer went comatose - turn it on, press p, r, option and command all at the same time to make the files all sort themselves out.

Nada. The screen wakes up but stays grey: no reassuring "bonnnnnnng" sound, no apple icon, not even that little bunch of dots circling around. You wait 5 minutes. Still nada.

Uh oh. Now what?

Your mind has already hatched a plan. You know you have enough time to get the beast to the hospital before your plane leaves. Using your laptop you send a distress call to the only other human on the planet who has your presentation - the entire keynote presentation in its final state, and ask him to send it. Your email is titled "Computer disaster". 

He is there! He emails back immediately - no prob - I'll send it. And he is very soothing about all this. Incidentally he's a massage therapist.

One problem solved.

The other problem is, you've lost all the slides you were going to use for the workshop, to which he says, don't worry, just wing it and it will all be fine - same thing happened to me once, computer problems, so I winged it and the class went great.

I go get the box, get the heavy computer into it, drive an hour and a quarter to the computer hospital. I arrive about 10:45 am. I notice this time I can carry it with much less difficulty all the way from the parking lot to the store - about a ten minute walk - with way less stress and strain. Yup, having gone for regular workouts for the last two months has done me some good. No one sees me huff and puff, no one offers to carry my monster computer for me this time, like they did in November...

A tall guy named "Oak" helps me at the store. Excellent customer service. He listens. His brain ticks over. Would I like him to send me the presentation? No, it's OK - thanks, but I've got that covered.. I need you to diagnose the problem and email with me about what is wrong, how much it will cost, all that. He says, let me show you some replacement models just in case. We can do a complete data transfer onto a new unit for $49 dollars. We can give you a discount. You do a lot of photoshop so you would do better with the next grade, this one with... (bells, whistles, trunk space...). 

We agree that will be plan B - plan A will be try to fix the one I have. If possible.

I give him my external hard drive and the guy behind the counter gets all the paperwork organized, and I'm out of there and off to the airport. When I get to the airport, through security, all that, I sit down and open my email and voilá, the presentation has arrived! All will be well. As it downloads I sip my extra large mocha latte. No whipped cream, but only because Tim Horton's has run out of it. Or I would have it. I'm treating myself after having been stressed out.
......

The main point of this long tale is just to set the stage for saying that I'm convinced that this time round, I have less stress and more physical capacity. I was a bit surprised, actually. Exercise really has done me some actual good, it would seem.
In the past, when I did long bouts of exercise, some judgey part of me always stood back, arms folded, waiting to see if it could improve my mood. It never did.

This time, I went back without any expectations at all. I just wanted to stave off decrepitude, see if I would be able to fly long distances without developing ankle swelling, like after travelling home from Brazil in 2010, or a couple weeks of wheezing, like after my last trip in January.

With no expectations, the arm-folding part of me never made an appearance. 
Yet, bizarrely, I think my mood has improved. Imperceptibly.
I mean, it wasn't like I didn't feel stressed out about the death of my beloved computer, or dread the thought of lugging it, after the last time when I vowed I'd get a dolly (I ended up forgetting to buy a dolly). Both stress and dread did happen... 
What was different was that the stress seemed ... smaller, and further away, not as sensorially overwhelming as it has in the past. And the dread was much less because I felt physically stronger.

Stress/anxiety is a horrible experience. It feels so visceral. It feels like the abdominal cavity is being flushed with acid, repeatedly. It feels like everything in the thoracic cavity is being squeezed up into the throat - like there would be any extra room in there for anything extra... 

This time, my stress and anxiety felt like flutters. That's all, just flutters. Like a bunch of tiny black bats with sharp claws on their wings were flapping around inside, but not nearly as painful, and a lot more easily suppressed.
And I was favourably impressed with my improved cardiovascular stamina, carrying that monster computer all that way to the store from the parking lot. Lots of rests, but only for two seconds, and lots of scurries (carrying a heavy load on one side is easier if you scurry with small quick steps, dampening the sinusoidal gait curve all you can); no major out-of-breath-ness. 

Yup, this exercise thing might just finally have made its way into my life in a permanent way. I might just marry it, make it a lifetime commitment. 

"50 Shades of Pain" - Lorimer Moseley quotes, compiled by Lars Avemarie in Sweden

50 Shades of Pain

This is just excellent. Fifty quotes by Lorimer Moseley, compiled by Lars Avemarie from a DVD produced just last year by Laree Draper, available from http://otpbooks.com for the DVD or http://movementlectures.com for download. 

It's one of those labours of love that requires the right mix of slight OCD, desire, determination, dedication, thirst for deepening into a particular topic, all that stuff. Thank you thank you thank you Lars. I've attached this to my blog so that I won't be as apt to lose it in the depths of Facebook.

I have the DVD and it's great. I was always planning to do something like what Lars has done, but have been too busy all year making cartoons in photoshop of nerves and where they go to.

If you want to sample the DVD content, Laree has posted several bits to Youtube. Here is one of them. 

"Joints" that the brain might actually take quicker, closer notice of

A long time ago I wrote about "trigger points" and why I didn't think they were in muscle.

Lately I've been working hard on a bunch of images of the neurovascular array around major joints. Also I've been working on a presentation I'm scheduled to give in a few weeks at the Massage Therapist Pain Conference in Vancouver.

I decided to make a slide that depicts some of the tubing array, and joins between them, and mechanical deformation, all at the same time. 

Here is my effort: 

Green is nerve, blue is vein, red is artery. (Ignore the blue bit in the top right corner - it's part of the slide format, not part of the image.)

Bear in mind that nerves and vessels can never exist very far apart from each other. Nerves need constant access to oxygen and glucose. Bear in mind that nerves don't have (according to current thinking) any lymph drainage. If any connector vessel were to become kinked or flattened by adverse mechanical tension, for a long time, like for example, by constantly sitting and never moving, the nerve, innervated by nociceptors, is likely to complain. This would be because of a high enough threshold stimulus of the mechano-, or chemo-, type (presumably thermo- would not be an issue).  

The thing is, the physiological tubing of the body is attached all the way along. It twines and braids and twirls through the body, sliding through the same or very close "grommet holes" in stiff tissue layers to travel to the surface, into hypodermis. 

By the time it reaches the cutis/subcutis layer, the vessels are small, but still, they remain attached to nerve which although is also smaller, has fewer fascicles and is therefore more vulnerable to compression and/or deformation.

Luckily, most of us have lots of padding. Still, if your hide is always pulled sideways somehow, always the same way, by some sort of contact with a surface, the tubing inside that layer will be pulled too - maybe it won't like it. Maybe the strain will be felt quite soon, or eventually, or be broadcast out along entire branches from related spinal cord segments. Sore spots will turn up before actual pain does, probably. 

What Patrick Wall said about the relationship of nociception and pain

I am looking at a paper Patrick D Wall wrote with SB McMahon:

The relationship of perceived pain to afferent nerve impulses

... published in Trends in Neuroscience in 1986. 

(Gee, that doesn't feel like almost 30 years ago. Time sure flies by.) 

Anyway.. 

In paragraph 1, the authors say this:

"The word nociceptor is a purely physiological term meaning fibre that responds to stimuli that damage tissue or would damage tissue if they were prolonged. The word pain is a purely psychological term defined as 'an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage'. What then is the relation between the physiological existence of impulses in nociceptors and the psychological response? For visceral pain, the question may not even arise, since the existence of specific visceral nociceptors is strongly doubted. But nonetheless, most textbooks of physiology and neurology imply that pain is a unique consequence of impulses in nociceptors by referring to pain fibres, pain cells and pain tracts. For instance, a recent text specializing in neuroscience states 'primary pain afferents terminate in the dorsal horn of the spinal cord', and 'the pain projection pathways are collectively called the anterolateral system'."

My bold. The reference for that is none other than Kandel, E. R. and Schwarz, J. H. (eds) (1985) Principles of Neural Science, 2nd edn, Elsevier. It's a classic. Anyone who wants to know anything about neuroscience has this big thick book on their shelf. I have the 4th edition. It is a good three inches thick and filled with wonderfulness. I don't have the latest 5th edition - something might have changed, but generally what Wall and McMahon said is true - people who write textbooks make that same sloppy error, over and over. 

In the second paragraph the authors refer to Hagbarth and Vallbo, two Swedes who developed single afferent nerve fibre recording in humans in 1968, direct comparisons they made of sensation with primary afferent discharge patterns. 

They say:

"For cutaneous sensations, the results do not support the classical view, which is still adopted by so many. Rather they demonstrate that the threshold, intensity, quality, time course and location of perceived pain is determined by central mechanisms that take into account several specifiable factors in addition to the firing of nociceptors. This article will consider these factors in some detail."

Right there is a good reason to do human primate social grooming - persuade the brain at the other end of those neurons to change its mind about how the world "feels" to it. But I digress. For more about microneurography, you can check out these cited references: Hagbarth, K. E. and Vallbo, A. B. (1968) Exp. Neurol. 22, 674-694, and Vallbo, A. B. and Hagbarth, K. E. (1968) Exp. Neurol. 21, 270-289. 

Wall and McMahon go on about very specific advanced (in the day) microneurography technique "in which they pass current through their recording electrodes and claim to stimulate the same fibre that they had been recording from, and that fibre only." And they cite:  

Schady, W. J. L., Torebjörk, H. E. and Ochoa, J. L. (1983) Brain Res. 277, 249-261 5
Torebjörk, H. E. and Ochoa, J. L. (1980) Acta Physiol. Scand. 110, 445--447 6
Vallbo, A. B. (1976)Acta Physiol. Scand. 97, 66-74 7
Vallbo, A. B. (1981)Brain Res. 215,359-363 8
Vallbo, A. B., Olsson, K. A., Westberg, K-G. and Clark, F. J. (1984) Brain 107,727-740

They continue describing how this approach has been used for a range of tactile cutaneous afferents, how this has led the researchers to conclude that "activation of a single afferent nerve fibre gives rise to a sensation that corresponds to the properties of the receptive field of the fibre." That "these findings endorse the concept that the quality of sensation is coded in specific sensory systems", that "they provide novel evidence that sensory quality, magnitude and localization can be exquisitely resolved at cognitive levels on the basis of input initiated in a single mechanoreceptor unit." The reference provided is Ochoa, J. and Torebjörk, E. (1983) J. Physiol. (London) 342, 633-654.

Apparently Wall and McMahon must have protested the neatness and tidiness and conclusiveness of all this: the arguments they mounted are "fully discussed elsewhere" in Wall, P. D. and McMahon, S. B. (1985)Pain 21, 209-229.

They continue:

"Here we wish only to point out that there are objections to these conclusions and to correct any impression that the work supports the notion that pain is the equivalent of afferent nociceptor discharge. In fact, even the microneuronographers themselves do not make the same claims for pain as they do for touch, although it is easy to see how their general conclusions regarding cutaneous sensibility might be taken to apply to pain."

A bunch of technical stuff follows: tungsten electrodes, who was who and who did what. Comments are made about how the size of the electrode is the same as that of the axon being tested. They remark, "The most likely explanation of these single unit recordings is that the presence of the electrode and its manipulation induces a pressure block of the majority of the nearby fibres allowing only one or a few axons to conduct impulses into the region of the recording tip."

Details reside in  

Hallin, R. G. and Torebjörk, H. E. (1970) Acta Soc. Med. Ups. 75, 277-281
Torebjörk, H. E. and Hallin, R. G. (1970) Acta Soc. Med. Ups. 75, 81-84
Van Hees, H. and Gybels, J. M. (1972) Brain Res. 48, 397-400

Then the discussion turns to A deltas and Cs:

Hallin, R. G. and Torebjörk, H. E. (1970) Acta Soc. Med. Ups. 75, 277-281
Torebjörk, H. E. and Hallin, R. G. (1970) Acta Soc. Med. Ups. 75, 81-84
Van Hees, H. and Gybels, J. M. (1972)Brain Res. 48, 397-400
Gybels, J., Handwerker, H. O. and van Hees, J. (1979) J. PhysioL (London) 292, 193-206

They continue: 

"It might be expected that the onset of firing of one of these types of fibre would invariably coincide with the onset of pain, but this has not been observed. Both groups of fibres begin to respond to pressure or chemicals or heat at stimulus intensities well below those that evoke pain. To take C fibres responding to heat as an example, most fibres begin responding at 41°C while the pain threshold can be as high as 49°C. In this study, the authors conclude that central spatial summation from many nociceptors is necessary before pain is sensed (Torebjörk, H. E., La Motte, R.H. and Robinson, C. J. (1984) J. Neurophysiol. 51, 325-339). Another group show that 'subjective ratings give a better estimation of stimulus size than did the discharge rates of the individual C fibres' (Gybels, J., Handwerker, H. O. and van Hees, J. (1979) J. PhysioL (London) 292, 193-206).
It is apparent that the ability to establish a threshold and to estimate intensity is not determined by the properties of single peripheral fibres or even types of peripheral fibre. Rather the periphery feeds information that is then interpreted in terms of threshold and intensity by central structures."

See what they did? They spotted an inconsistency in the work itself, an oversight, a contradiction between what was actually stated, and how most people went on to blithely interpret it. Then they pointed it out, in writing.

They go on about that for awhile longer, point out how subjects can't tell the difference between hot punctate stimulus or just punctate pressure, how much of a difference there is in pain threshold: "The C fibre firing rate when the stimulus becomes painful is 0.5 Hz for the heat stimulus and over 10 Hz for the pressure stimulus." How the difference is predicted by gate control theory, explained by the fact that pressure stimulus activates both high and low threshold fibres, that low threshold fibres exert inhibition over central excitation produced by small afferents (Melzack, R. and Wall, P. D. (1962)Brain 85, 331-356). How a larger afferent barrage is required in small fibres to produce the same central effect if large fibres are being stimulated at the same time. How this reflects the way the CNS responds to combinations of inputs from many different fibre types. This sort of reflection continues for a good length of time in the paper with minute detail about pain thresholds, size of area being stimulated, what size probe results in what sort of perceived sensation. 

"This evidence shows that the CNS is analysing modality and intensity not only on the basis of firing frequency in particular afferents but also by taking into account the spatial gradient of the stimulus. This contradicts the classical view that modality is determined by the activation of modality-labelled specific fibres that end in local skin spots. Spot-like variations in sensitivity exist but they cannot be attributed to the local presence of special nerve fibres for the following reasons. The spots rapidly move, appear and coalesce. They are not associated with particular types of ending. There are far more endings than spots. The size of the spot depends on the size of the stimulus (Melzack, R. and Wall, P. D. (1962) Brain 85, 331-356; Boring, E.G.(1942) Sensation and Perception in the History of Experimental Psychology, Appleton-Century-Crofts; Johansson, R. S. and Vallbo, A. B. (1979) J. Physiol. (London) 286, 283-300; Johansson, R. S. and Vallbo, A. B. (1976) in Sensory Functions of the Skin in Primates (Zotterman, Y ., ed.), pp. 171-184, Pergamon Press).
"These facts require that the central processing of the afferent barrage take into account which groups of fibres are responding, what is their relative frequency of discharge, and what is the spatial gradient of responding fibres."

Then more technical detail about A deltas and Cs.
Then,  "It is evident that the time course of sensation is determined by central factors other than the arrival of the afferent barrage (Vallbo, A. B. and Johansson, R. S. (1976) in Sensory Functions of the Skin in Primates (Zotterman, Y., ed.), pp. 185-199, Pergamon Press)."

This is true. So very true. Which is why we human primate social groomers need to be careful with our handling. 

They go on about what sort of subjects volunteer for such experiments, and comment that "It is not surprising that the slings and arrows of of the real world produce pain by mechanisms that require more factors for their explanation than the firing of a specific type of afferent. At one extreme, 90% of patients with brachial root avulsions suffer severe pain in the absence of afferents let alone impulses in afferents. At the other extreme, 40% of patients admitted to a civil accident hospital suffered no pain at the time of their injury in spite of being fully aware that they were severely injured. Between these extremes, pain is perceived in terms of injury in the context of the afferent barrage in nociceptors and of other afferents and of analytic processes in the brain."

My mind drifts back to Kevin Ware, who swore he felt no pain when his leg broke and he collapsed on the basketball court last spring, his tibia sticking out a good three inches beyond the skin it tore through, leg bent at a crazy angle, foot dangling helplessly; I am reminded of the guy who suffered acute agony in a construction injury, wouldn't let anyone touch him or the boot from which protruded a large spike, until he was give a big dose of pain meds, but when the boot was removed, it turned out the spike had only pierced the boot, not the foot. 

Wall and McMahon conclude,

"The awareness of touch by itself may be a neutral event without implicit meaning. The labelling of nociceptors as pain fibres was not an admirable simplification but an unfortunate trivialization. The writers of textbooks will continue to purvey trivialization under the guise of simplification. The experimental results show that the final analysis that produces the perception of pain is not monopolized by the peripheral receptor properties of nociceptors. The response of nociceptors is one of the factors incorporated into the central analytic mechanisms that can generate many perceptual syndromes including pain."

My bolds. 

Life grinds on. 

The 'unfortunate trivialization' continues. 

Patrick Wall
1925-2001

By Sigurd Mikkelsen, Norwegian PT

FURTHER READING:
Mechanisms of Pain, Chapter 2 in Recognition and Alleviation of Pain in Laboratory Animals. Very clear straightforward elucidation of the difference between pain and nociception. 

Sitting around in an airport, thinking about critical thinking

I have all this flight delay going on right now - sitting around waiting to take a plane that's two hours late. Bad weather in Denver or something.

Anyway, I've been sitting around all afternoon; what a wonderfully busy day it has been in internet land (Facebook, Twitter..).

Kyle Ridgeway posted a picture I made re: critical thinking, in this very nice blogpost on the topic. 

METACOGNITION, CRITICAL THINKING, AND SCIENCE BASED PRACTICE

I have had not much success trying to include this sort of theme in my own teaching. DNM is what I ended up with after I did a big batch of critical thinking about manual therapy, years ago. It was built from the ashes of what was left after I deconstructed manual therapy to death, had burnt off all the mesoderm, had incorporated Melzack and pain science into my brain.

But... it's slow to catch on. People assume it's just a reorganization of clinical reasoning. They don't understand why mesoderm should be left out. 

Kyle says, 

Because of the focus on evidence based practice, which inherently (overly?) values randomized control trials and outcomes studies over basic science knowledge and prior plausibility, students continue to learn interventions and techniques while routinely asking “what works?” Questions of “how did I decide what works?” “why do I think this works” and “what else could explain this effect?” also need to be commonly addressed in the classroom, clinic, and research. Such questions require formalized critical thought processes and skills.

I agree.
Basic science knowledge I favour is evolution and embryology. Do you know how hard it is to get people excited about these two fields of biology? I'm sure by now Louis Gifford knows.. I think both those fields should be incorporated into formal PT undergrad education. It would make it SO much easier to learn pain science and why neuroscience is so important. Why the nervous system is the thing to target, to think about, to clinically reason about. Not the meat. Not tooth fairy science based on meat theory.

It wasn't me who cracked this code... I had the good fortune to study manual therapy with a DO (doctor of osteopathy) who insisted that these two science fields were foundational. And I'm pretty sure he was right. I remember eating it up. It made total sense. I had had prior exposure to evolutionary biology in university, on one of my many forays there back in the 70's. I trusted it. Embryology was kind of like evolution, it tied in, just speeded up to nine months of unfoldment instead of millions of years. But it was all in there, including the start (the start we all have) as a single cell organism. In the case of human, a fertilized egg cell. Then the mad unfoldment orchestrated by genetic activation and chemo gradients, led by ectoderm, full of cells yearning to be close to, moving toward whatever in that expanding embryo smells so good to them..

It was possible, with this sort of knowledge base, to see a human as an event, not a collection of parts. A verb, not a noun. A development through time, not a done deal at adulthood. It was possible to see pain also, not as a "thing" but rather as a rough patch we all will have to learn to endure, and for most of us, not as a permanent situation.

The DO took great pains to try as well as he could to teach critical thinking AND clinical reasoning, and how to combine them. I think at least some of it must have rubbed off.

Anyway, Kyle's post was one thing that went right today. Thank you, Kyle, for including the picture I made a long time ago.

Yule pondering

Dec. 25th. Temperature a mere minus 5°C.
So calm, so bright. Gorgeous blue sky, white all over the ground, bright white clouds. The best thing - I can see sky from every room in my place, unlike when I lived in Vancouver, every window of my place covered up by hideous huge shaggy photon-sucking trees, and that horrible never-ending thick cloud layer beyond.

I swear I could feel the very second solstice came and went, at 11:11 AM my time, Saturday, 21st.
I felt like a weight dropped away.

Today, the day everyone else gets excited about, is completely beside the point to me, as yet another year circles the drain, takes from Dec 21 to Jan 1 to carry away everything about that year that needs carried away, as by a culturally agreed upon cosmic vacuum.

Really, it's all about the light coming back. For me.

In an other hour or so I'll have to put on some respectable clothing ( I can't wear pyjamas) and go over to my mother's house, hang out, try to be social with an aunt and a cousin. It will feel like suspending freedom for a little while, but it's OK though - she's almost 90, and the way life goes, one of these years she won't be around anymore to fuss and bustle over making a christmas party. When that happens, I'll probably have all the rest of my own christmases to myself, to luxuriate in all the light, blue sky, and white snow that I can see out the window to my heart's content.

The plan is, I'll take my laptop over so that we can all sit down and identify relatives long deceased, photos of whom were put up on facebook by another cousin. My mother has procured a password from a neighbour so that we can do this project. She doesn't use a computer herself.
She is very important to this project, as she is the last sibling standing of five originals. As the oldest member of a shrunken clan, most of whom lived and died in the US, she is the most likely to be able to remember who all these people are/were. Their names at least.

.....

This morning as I worked on an image in photoshop (a picture of quadratus lumborum, of all

My little art effort

things), I listened to Handel's Messiah on CBC.  Once upon a time, long long ago, I was in a big choir for a year, and we sang the whole thing. I didn't like it then and I don't like it now. So frilled and repetitious. Why people still stand up for the hallelujah chorus to this day just because some king stood up back in the 1700's when he heard it, puzzles me.

I became curious and looked up the words online. Really, if I were the king, I wouldn't likely have stood, because the whole thing seems a bit subversive: some baby is born who is killed and then comes back and now will take over the world. Maybe the king stood up because his butt was sore from sitting for so long listing to such repetitious music and singing. The king may well have thought, let the peasants believe any nonsense they want; as long as I run the army and collect the taxes, all the world are belong to me - I don't have to worry about some conceptualized idealized "king" who stands for perfect justice and mercy and love and end to war. Heck, I've worked hard to be where I am. So let them be happy in their little fantasy.

I will never stand up again for that song. I will never go out to hear it live. It's a travesty. The world is not much different 300 years after the fact. People are still fighting and killing each other over imaginary kings and ideas associated with them.

Really, all we need is sunshine for ourselves and kindness for each other. Not as an idea, but as an everyday action.

Loose ends: Welcome back Louis Gifford: David Butler, please, glia are NOT "immune" cells.

It's a beautiful day here in the deep south of the Canadian prairies - the sun is blazing, glinting off wet streets. Yes, wet!
It's mid November, but bits of snow that fell last month disappeared; this month's temp has hovered at zero-ish, with almost no precipitation. Last night it must have rained a little bit. 
Not bad for mid November! No seasonal affective disorder at all! Not a trace. And in only short 5 weeks, daylight will turn around and lengthen yet again.  

Lately I had been all wound up spending hours and hours a day doing new images for yet another draft of my nerve book, also the manual I use for teaching, when the big screen computer died. It's currently in the Mount Saint Apples hospital, an hour to the north, for a dead hard drive ectomy. It will be there for a few more days probably. So I'm at loose ends, kind of.

I'm going to have to get a dolly for trips to the computer hospital. I can carry that beast for short periods of time, but jeepers, the distance between the mall parkade and the Apple service store is very long, involving a short flight of stairs to boot. I had to rest frequently. This time I was offered help by a lady using a wheeled walker: She suggested I put the box on top of the walker somehow, and she would give it a ride to the Apple store. I didn't see this as a good idea, worried the box might fall off or something. Just then along came another woman, a few inches taller, a few pounds lighter, and quite a few years younger than I, who offered to carry it for me. So I let woman number 2 help me. I mean, I would have made it, maybe with one more rest, but hey, she looked capable and acted like she needed to acquire service points for some imaginary merit badge or something, so... what the hey, OK.
Still, a little fold up dolly would do the trick, then I wouldn't be so besieged by helpful strangers. Not that I don't appreciate the offers to help, but just this: You can spend your life thinking you're completely invisible, when really you are totally visible, which is a little disconcerting. And it doesn't take much social ripple for strangers to appear out of the shadows if they see something that bothers them, but isn't a threat, and think they might be able to help restore peaceful calm to the mall.
......


When I'm at such loose ends, I blog. 

......

In the last few days some exciting news from the UK: Louis Gifford has relaunched his wonderful series from a decade ago, Topical Issues in Pain. Maybe this time round, the kindling will catch fire, and his brilliance will not only revitalize, but deepen the profession.
Seriously, my profession has lots of 'splainin' to do: The first time I ever even heard of the neuromatrix model of pain was from Topical Issues in Pain book #3, where Melzack had written a very nice long foreword. Why did I have to stumble across it in Louis Gifford's book in 2003? It had already been out for years! Why had no one presented it or written about it yet in any of our professional publications here in Canada? 
Better late than never, I suppose. But I can't help but think the profession in Canada was still so mesmerized by pushing around mesoderm that it couldn't quite make the leap to considering the effects we have on way more sensitive ectoderm. It was only about a year later that Nick Matheson put a bug in my ear, and a few months later that I contacted Neil Pearson, and the Canadian Physiotherapy Pain Sciences Group  (which eventually became Pain Science Division of CPA) was launched.

.........
Today I found the latest edition of noinotes in my inbox. I love David Butler, the therapist, the teacher, the author... and I love this little professional confessional, but: 

Excerpt: 
"I thought I may have reached nirvana with the brain, but now I realise that neurones are only 10% of the brain and as the rest is immune cells, so there is long way to go."

David, David, David... 
A little bit of me dies every time you say that. It's misleading.
I realize you picked that up from Mick Thacker; I do not know why he continues to assert that, because if he closely read developmental biology, he would see how that statement is not correct.
Immune cells are from way far back in development, before, the body has even started to be built. They come from the yolk sac or something. Microglia are immune cells; hard long rigorous argumentative and painstaking lab bench gruelling research over decades has finally established this.  
There was no controversy as far as I am aware about the origin of all the other glia: glial origin seems to have been recognized quite straightforwardly, early on: no arguments arose. They come from neural tube stem cells, i.e., ectoderm; neural stem cells differentiate into either neuronal cells or non-neuronal cells. If they turn into a neuron, then they do neuron stuff. If they turn into an astrocyte, an oligodendrocyte, etc. (i.e., any other cell termed "glia"), then they can do all kinds of stuff, including (but not restricted to) immune-like stuff. 
I think, therefore, it's misleading to call glial cells immune cells as if the two categories were completely equivalent. I saw it in your latest edition of Explain Pain, too. 
Please, please stop. 

The fall of the postural structural biomechanical model

I saw this gif posted today by Eric Kruger on SomaSimple, and it made my day.

For more, read Eyal Lederman's very good paper, The fall of the postural–structural–biomechanical model in manual and physical therapies: Exemplified by lower back pain, open access.

Some people just can't seem to let go of this model, though...

"Biomusic" and Personhood

Nautilus magazine published this piece today on facebook, and I was immediately entranced by possibility:

What's the Sound of Personhood? 

A boy lies in a coma ward in a hospital in Toronto. He cannot communicate. 

"Thomas didn’t move, and hadn’t for two years. He suffered from a brain injury that left him profoundly disabled. He was incontinent, unable to eat, speak, gesture, or breathe on his own, and dependent on round-the-clock medical care. His parents realized they couldn’t give him the care he needed at home. This is how Thomas came to be in the Holland Bloorview Kids Rehabilitation Hospital in Toronto, Canada, in a hybrid unit that serves as both a permanent home and medical facility to similarly disabled children, who range in age from infancy to young adult. These “silent” children, as they are known, are not in acute life or death situations, but they cannot live without constant monitoring and medical care."

Caregivers look after him, but get no feedback from him. 

This is the fate of a large percentage of people. Babies fare somewhat better, with their big eyes, exaggerated reflexes and possibilities. People at the other end of life, not so much. Care homes for those with dementia are filled with people who once had full lives, but who are now treated as biological "objects" to be "managed." Input, throughput, output. Get them up, clean them up, sit them up, feed them, water them - leave them unattended for hours sometimes, because of doing the same for all the others, toilet them, put them back to bed, roll them over once in awhile. Add to that, the opportunities for abuse by frustrated underpaid caretakers. Language barriers. It can become a horror show.

Back to the article: A woman appears, Stefanie Blain-Moraes, an interesting cross between engineer and musician. She has volunteered for eight years at this facility. She noted the perfunctoriness that sets in after awhile, the detachment, the burnout, the treatment of these patients as objects to be dealt with. That happens naturally, to anyone, after years of never getting any real interaction or feedback.

So, she invented sound feedback - "biomusic"!!

"Biomusic sounds something like avant-garde electronic music. Generated using a Musical Instrument Digital Interface (MIDI), it has an ethereal, other-worldly quality. An underlying drumbeat represents heart rate. Skin conductivity—which varies with sweating—controls pitch. Respiration rate dictates the musical articulation and phrasing. The melody and chords are smooth and flowing through the breath, and soften towards the end of the breath. In the first minute of monitoring, the system takes a baseline reading and assigns the average to middle C. So, every instance of Biomusic begins with the same pitch and moves up or down from there. The overall key signature is determined by skin temperature, which changes gradually about 15 seconds after an emotional or physiological stimulus. States of stress, with fast and jagged breathing, sound different than states of relaxation, when the breath is slow and smooth. More subtle emotions can also be translated into distinct-sounding music."

Whoa! Suddenly, with critter brains able to indicate how they feel, caregivers have instant feedback on how their actions are affecting their charges, and can modulate - themselves! And furthermore, their own critter brains have a way to connect and affect this unconscious person's critter brain directly, without having to go through cumbersome, or non-existent anymore, strictly human brain language based social brain channels.

Brilliant. Freaking brilliant. 
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My brain turned immediately to wild fantasies about how marvelous it would be as a tool for human primate social grooming, manual therapy. Imagine being able to bypass all the conceptual clutter and gaining instant feedback through "biomusic" on how a patient's nervous system is responding to your input. Think how the manual therapy recipient could use the feedback from their own critter brain/ nervous system to enhance their own relationship to it!

I love this idea. Just love it.
Can't wait until we can implement it somehow in our work. Truly interactive. No clunky "thought" objects to navigate anymore. Just hook up, get the music started, then all four brains - the two language-interactive human brains and two critter brains, the nervous systems themselves of both people, could have a nice involved kinesthetic conversation aimed at reducing pain.

Think of all the possibilities: 
1. Easy outcome tracking. You could do a baseline on that patient, in pain, before treatment, during assessment. You could record the whole interactive treatment process. Then another post treatment recording. Then compare. Wow. 
2. No more arguing over what I call "thought" objects (models of treatment). No more need to set up horribly complicated test situations or try to teach patients how to fill out complicated questionnaires and send them in. All the data flows in effortlessly, and can be pooled ongoingly. 
3. Instant feedback during treatment for the practitioner, who can easily and instinctively modulate themselves and what they're doing without having to go through all the "How does this feel?" and get a response you can't be completely sure of, because you have no idea to what extent the person understands what sort of feedback to provide, or might be trying to be nice, and not mention that you're inadvertently pulling their hair or something noceboic.. 
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Another interesting part of this article: a definition of "personhood" that finally makes sense to me. 

"Perhaps it shouldn’t matter that children like Thomas cannot respond or show gratitude for their care.  And yet it does. When the nurse said that the biomusic reminded her that her charge was a “person” she invoked a concept with echoes in law, philosophy, and psychology: “Personhood” is a title for those whom we recognize as being like ourselves and worthy of our concern. The act of caring is a relation, not an attitude; it is a duet, not a solo."

Did you see that? 
"The act of caring is a relation, not an attitude; it is a duet, not a solo."

Personhood is an interaction, not a thing. It's a verb, not a noun. It's buried inside the biopsychosocial exchange. "Personhood" is a word, a concept, or a thought object, that represents this relationship and the connection embedded within it, between critter brains, acknowledged by human brains. It can be either inhabited, or abandoned.

We can provide better care by inhabiting the relationship. Therapeutically.

The Skin as a Social Organ. Part 2h: Social bonding's broader context.

The paper, The skin as a social organ


Previous introductory blogpost to this series.    Preamble: Random thoughts on spas

Part 1: Dual nature of touch: as PTs, do we "get" this? Part 1a: Touch can be pleasant, rilling Part 1b: Vallbo on C-tactiles 

Part 2a: Different kinds of touch Part 2b: Proxemics Part 2c: The sad dearth of manual therapy aspects in reviews of interpersonal touch Part 2d: Learning to sit still, learning to behave, learning to not be connected to oneself Part 2e: Touch early, touch often Part 2f: Human allogrooming Part 2g: Bonding aspects of social grooming. 

Next piece:

"Positive affect and hedonic feelings may be the glue which holds individuals, as necessarily physically separate beings, together in social bonds. Grooming, indeed, may reflect a generalized form of pair-bonding usually seen in reproductive or mother–offspring dyads across numerous taxa (Dunbar 2008). As such it may rely on similar neural and physiological mechanisms as the dyadic cases. For example, in addition to its role in maternal behaviors, the neurotransmitter oxytocin is also an important mediator of grooming (Drago et al. 1986), as demonstrated by the exaggerated grooming behavior that results when it is administered into the cerebrospinal fluid of knockout mice which do not express oxytocin (Amico et al. 2004). Endorphins may also play a central role in grooming. In both talapoin monkeys (Keverne et al. 1989) and rhesus macaques (Martel et al. 1995), opioid receptor blockade results in increased solicitations for grooming. Dopamine may also be important in affiliative behavior and bonding (Depue and Morrone-Strupinsky 2005)."

Dunbar RI (2008) The social role of touch in humans and primates: behavioural function and neurobiological mechanisms. Neurosci Biobehav Rev (Full access pdf)

Drago F, Caldwell JD, Pedersen CA, Continella G, Scapagnini U, Prange AJ Jr (1986) Dopamine neurotransmission in the nucleus accumbens may be involved in oxytocin-enhanced grooming behavior of the rat. Pharmacol Biochem Behav 24:1185–1188

Amico JA, Vollmer RR, Karam JR, Lee PR, Li X, Koenig JI, McCarthy MM (2004) Centrally administered oxytocin elicits exaggerated grooming in oxytocin null mice. Pharmacol Bio- chem Behav 2004(78):333–339

Keverne EB, Martensz ND, Tuite B (1989) Beta-endorphin concentrations in cerebrospinal fluid of monkeys are influenced by grooming relationships. Psychoneuroendocrinology 14:155–161

Martel F, Nevison C, Simpson M, Keverne E (1995) Effects of opioid receptor blockade on the social behavior of rhesus monkeys living in large family groups. Dev Psychobiol 28:71–84

Depue RA, Morrone-Strupinsky JV (2005) A neurobehavioral model of affiliative bonding: implications for conceptualizing a human trait of affiliation. Behav Brain Sci 28:313–395

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I know I'm losing interest in a project when I'd rather spend my time doing jigsaw puzzles on an iPad than blogging. Seriously.

Right now, I have no dopamine for this series. I do so dislike leaving things undone after I've committed myself to doing them.  But I'm also somebody who likes to fully utilize my own critter brain, especially in the motivation department, and right now, my critter brain doesn't want to do this anymore. I think it has become bored.

I won't close the project, but I will meander away from it, turn my back on it completely, blog about other topics for awhile. I don't know for how long. The way my brain recycles, and the way life presents intersecting criss-crosses in bits and pieces read here and there, I'm sure I'll wander back.

Topics in this paper left to cover:
1. Touch as communication
2. Pathways of pleasant touch
3. C-tactile fibres
4. Where pleasant touch lands in the brain
5. Intersubjective representation
6. How it all ties in with empathy.

These are all fascinating, but I've got to go do other things for a little while. I'm waiting for a new book to come, Neurobiology of Grooming Behavior. Well, not "new" - it was published a few years ago, but relatively new, and new to me. It might serve as re-inspiration. Or not. We'll see.