A Q&A about DNM with Maggie at Embodia

 Here is a link to a transcript I finally finished of the Q&A which took place Sept. 21/'23.

LINK

So, I transcribed it for anyone interested whose first language is not English and who might be interested. 

I had a lot of opportunity to observe myself talking about something that used to take up a lot more of my personal mental hard drive than it does now since having retired over three years ago, formally, but before that, operationally, because of Covid.  

Shockingly, I couldn't remember the former name of a condition now called CRPS. The former name came to me later, after the Q&A was over. Reflex sympathetic dystrophy. Here is the video with Jonathan Fass, and Brendan, the person Jonathan worked with and in which DNM was mentioned by name. 

It's shocking to me that it would not easily come to mind as it likely would have back in the day before I retired. C'est la vie I suppose. Getting older, different interests these days. 

Something else I botched up during the session was a memory I had about hyperpathia, a mechanism about it that Simon Beggs had proposed that I remembered from a pain class I took in 2010. It was in a recorded video that was part of the class, so no wonder I was pretty foggy on details. Later I remembered he talked at length about P2X4 receptors, and that it was an issue with an electron on that particular receptor (I think). Anyway, here is an open-access paper, with Simon Beggs as lead author, for pain nerds, that is all about P2X4 and neuropathic pain because of microglia in the spinal cord exacerbating the situation.  

P2X4R+ microglia drive neuropathic pain 

I hope this helps.  

............... 

 

Leonard's view of the future of rehab

Here is Leonard's website. https://hrfhome.com/

I have only just started to examine/ingest it. There is so much there, and like eating feels at my age (72) it's best done in small meals spaced out. 

Right on page 1, we see the project all laid out. Kind of breathtaking really. 

It'll take me quite a while to wade through each of these ideas and fully comprehend how they connect and how far back they go and who all the people were and what they showed about themselves and what they hid from history. 
It's a very big site. There is much to read and ponder through. It's sort of like wandering through a new world, worldview. 

But let's just start with the video and some highlights from it. (I made notes.)

Leonard's intro
(I love how he starts out, bright and bold:) 

 “Today we speak of embracing a new era of rehabilitation, or what we like to consider, the journey toward human rehabilitation.” 

(Psst: It's for everyone who deals with the entity known as a human. And who wants a better way to do so. Be you an analytic type or a humanist or both combined. You are human also, and you just may want to level up yourself.)

He points out that it's for any/all allied health professionals. That he's able and willing to mentor any professional from any profession:   

"The reality is this might come off a little bit more clearly to physical therapists, OTs, and speech therapists, but this was designed for professionals across all disciplines in medical allied health, mental health, behavioural health, fitness and wellness industries in mind."

He talks about "functional understanding" which we can get to later. There's a heap of stuff about that in the "whitepaper" (I don't know why public papers were ever designated as "white," but I do not want to get sidetracked here). The whitepaper is free to read by signing in on his website. 

"... the HRF is an open source project."

... Which means, he hopes it will travel by itself through interested parties out into the wider world. 

The situation we face/rehab faces

This is the situation we find ourselves in as professionals in a profession which looks like chaos, faced by people coming for treatment who are told all sorts of contradictory things by different people, left with no way to make sense of it except what they are told, feel left out of the process with their personal experience invalidated, with no way to make sense of any of it, their problem stuffed into some grouping or other that was designated by someone else a long time ago or maybe a week ago, and varies by profession. I would call it a tyranny of nouns and operations that were designed to manage all the nouns, but not the actual people themselves. Huge boundary problems resulting from science that framed us as professionals wrong from the start. But I digress.      

He talks about the biomedical model: 

"...what we have to embrace first off is that you know, we live in this biomedical model, and this model has a number of achievements but it certainly has a number of shortcomings especially when it comes to dealing with health. So where did it start? Well it was this focus on biology exclusively and its become again our dominant model for healthcare. It gained its prominence in the 1800s and has saved a lot of lives. I mean if we think about what it’s done for infection and disease, many more people are living today than in the past because of advancements in the biomedical model. But as we’ve learned, when it comes to health and well-being, it’s been falling short quite significantly. So these significant shortfalls include this excessive reliance on interventions that are targeting biology in isolation, separation of the psychological and social factors from the biological aspects; this idea that somehow they can be separated really is quite illogical and unscientific on so many levels. It really overlooks the true complexity of human health and well-being."

Enter the biopsychosocial model from Engels 1977. He explains the BPS model has certain shortcomings and drawbacks. And that he would like to improve it. Make advancement. He says taking a functional contextualist worldview and treating humans from its standpoint would work better. How? 

"It embraces human complexity. It comprehensively appreciates the history and context of the person and considers each person’s uniqueness and ability to change as a part of the bigger picture. What we really appreciate about this kind of functional contextualistic worldview is that it sees humans as having infinite potential to successfully make things work with whatever problem they face. We believe that’s a really helpful lens if we’re going to be dealing with complexity and we’re going to be dealing with problems that are human in nature. We propose that we need to transition from fixing machines to working with humans, which means we have to develop approaches that highlight human resilience and adaptability rather than treating them as machines that wear down and break down and have to be repaired and you know things can be permanent and unchangeable. In this process, we have to emphasize the dynamic, multi-level, multi-dimensional nature of human challenges as well as what that means for their potential for growth. We also need to acknowledge that people can learn and adapt even while they are in the middle of a health crisis or struggle. In doing so and in concentrating on supporting the individual where they are and working with their health issues, rather than merely trying, attempting to “fix” them, we truly believe we have the potential to make a much greater impact on human health and wellness as a whole."

Sounds good to me, I'm in. 
He talks a bit about how what works better is to stick with a beginner mind, process-oriented, N=1 approach with every single person who comes into the clinic. And it makes sense because each human is a world unto their own self. And he says, importantly... 

"Processes of change are independent from the treatment methods themselves."  

This fits with everything I've read that says that it's not about having some magic method, it's about relating. He introduces the names of the pioneer psych researchers who have developed this new worldview and who have informed his vision so valuably. He says they looked at their own profession, found 600 different ways of going about their business,  and developed an overarching meta-framework with 6 dimensions, called the Extended Evolutionary MetaModel, or EEMM, to which he added (with their support and encouragement) 3 more dimensions to cover return to human physical wellbeing. I really like that two-thirds of this work was already in place already. 👍
He says, around minute 13, 

“What we have found is that by partaking in this journey along with the psychological pioneers, we already are able to speak across the psychological discipline and domain and our hope is by adhering early on to a kind of unified language for process-based thinking that we’re going to truly be able to embrace a transdisciplinary approach to care.”

How does this process approach work? Well, helping people get to psychological flexibility is the goal, really. Not just for the clients, but for the clinicians too. Network theory can provide a tool to navigate complex processes. It can be applied to rehab, can give a picture of interconnected processes within each individual. He has some numbers to share.

1. over 84% of our client base are high complexity cases which means they have at least three factors or comorbidities. They have a central senseitization inventory that is at least 30 points. Their history and their psychosocial and social determinants of health clearly indicate that they are stuggling and this is a more complex case. 

2. Over 25% of our patients utilize Medicaid. 

3. Over 40% of our auto and workman’s comp cases are in active litigation. 

"So, needless to say if you’re looking for a challenging environment to test something, we have that." 

He gives a little rundown of results so far from 250 clients. 

"With HRF, trans-diagnostic FX include: 

• Psychological flexibility improved 15%

• Mental health quality of life up by 5%

• Client satisfaction: 99% - clients feel validated and heard 97%,  and confident 92%."

He's going to be publishing his work with (by the sound of it) some new statistical tools the psych people are coming up with. 

He talks about the financial implications for clinics, always a hot topic, especially for big corporate clinics: 

"The national average rehab cancellation rate for low complexity : 12-25% 

Pain speciality >30%

No show rate ~10% 

For HRF: cancellation rate 7-15%, 1-2% no show rate."

 He talks about "transdiagnostic and social outcomes of learning psychological flexibility skills."

• "Clients come off opioids, reduce overall medicating, reduce imaging, cancel surgeries.

• Come off disability and start meaningful careers

• Parents teach these skills to their kids

• Spouses and caregivers learn the skills

• Teachers and professors add it to their curriculum

• Clients use the skills to go to substance abuse and eating disorder rehab"  

I gotta say, all this seems pretty impressive to me. And I had not dug into the white paper yet. So, there will be more to come. Before I forget, here is the improved https://dermoneuromodulation.com/ website where all my stuff has been given sanctuary by HRF. 😊

  

Back again

SOME BACKGROUND

So, I left off writing thoughts here a couple years ago.  I had accepted being newly retired, for real. Had landed that particular plane. Still had runway left. 

I had accepted that I was retired, and deliberately wasn't going to worry about physiotherapy anymore. I was going to edge away from it. Not put any more energy into trying to help it improve. I pivoted. 

I had committed to scouting around on youtube to find things that were interesting. Something I could deep dive into and luxuriate in learning, ponder from all angles, watch develop. 

I settled on Ukraine. It wasn't hard. I mean, there is a war happening there because Russia decided it had the right to believe its own BS and invade its neighbour after having signed treaties, twice, agreeing to borders established between the two countries way back in 1992 or whenever. So, it was as good a way for me to pass the time as any and was very attention-attracting, served to keep me interested in the world, the whirled world. Which is also a verb, not a noun.  

I committed myself to Timothy Synder's excellent Yale education series, The Making of Modern Ukraine. I watched every single class all last fall as soon as it was uploaded. Then I started all over again, and am up to Class 16 of 23. It's a full semester of history. Timothy Snyder is a great teacher, and I take copious notes, but that's not what this particular blog post is all about. 

No.

An email came along one day last month from the Weebly people who had offered free websites and from whom I had built two, one for my former physio practice and another for Dermoneuromodulating. I had let go of the practice site already and decided I would let go of the DNM site too because it was no longer going to be hosted by Weebly for free. They were going to start wanting to be paid. Why keep it? I was no longer teaching. I let people in the DNM Facebook group know that soon it would be gone, along with the very incomplete international directory I had been maintaining there for people who had taken the workshop and wanted a listing. I announced to the Facebook group members that they could grab whatever they wanted from it before it went dark. 

A few people salvaged it, and one guy in particular volunteered to maintain it all on his own site! I agreed, because he gave me a look at the content, all beautifully and functionally reformatted,  and offered to maintain and update the directory and everything, so how could I say no? And I turned over the url to him because he offered to pay for it, off into the distant future. It was like he was carefully lifting an albatross from my neck so I could retire even more! I asked him why he wanted to do me such a service and he said because it lined up well with his own vision for the profession, Dynamic Principles, and his Human Rehabilitation Framework. Here is his introductory video, Clinical Overview of the Human Rehabilitation Framework (HRF).

We talked. 
The more I learned about Leonard Van Gelder and his company the more it started to feel like home there! This is a screenshot of the principles he has, and I agree with them all. 

So, I'll be blogging more about this. It's all quite wonderful, and I feel very congruent with it all, and I'm not promoting Leonard just because he was kind enough to take responsibility off me by hosting accumulated DNM content, I'm promoting both him and his mission because it's like the freshest air I've ever had the privilege of breathing when it comes to physiotherapy. If the profession manages to change and save itself from becoming a dinosaur, it will be thanks to his vision, I'm pretty sure.  

Next post: Leonard's vision for evolving rehab science. 

Life is a verb, not a noun.

 I'm in the process of truly adapting to retirement, for real. 
After I returned from Saskatoon at the end of August, and the workshop card started filling up for the coming year, I started to recognize in myself a feeling of panic. 
It became abundantly clear that something or someone in me reallyreallyreally did not want to teach anymore. Felt horror at the very thought of teaching while the coronavirus is still around, with its sped-up evolution, its bursting forth of creative forms, each potentially more deadlier as a result of faster transmissibility.
No end of the tunnel in sight. 

My panic manifested somato-sensorially as a sinking feeling through the chest, one that felt heavy and simultaneously cold, and spikey, like an anchor. It was close to a feeling of dread.
I have surmounted many moments like that, though, never dropped down dead from them; but this was a bit different. It came over me more suddenly. I was less prepared. I was on automatic pilot but suddenly the plane I piloted was signalling that it was in trouble. Alarms were sounding, lights were flashing. 

In this case, I had no valid argument against quitting. The existence of the virus, my age, and the fact that I really do not need to continue making an income, all converged to argue for quitting. 

Long story short, my inner demands to NOT teach/travel anymore were discomforting enough that I canceled my plans for 4 workshops, all here in Canada. 
Which kind of sucked for everyone involved. 
And I regret having had to ever be a volitional agent of suckage of any sort or to any extent for anyone. 

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

It felt so final. 
And solemn. 
Like a sacrifice. 
The final decision hurt, and delivering it hurt. I felt like I imagine my dad must have felt, saddled with the the responsibility and no doubt, existential angst, that surrounded his "job" of killing chickens and steers and excess numbers of kittens and chicken-killing skunks and badgers, etc., on the farm I grew up on. I imagine it contributed to his dying on the rather young side of old age, at 77. 

But now, I must digress for awhile. 

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

Since I retired, I've been watching a lot of Iain McGilchrist videos, and planned to buy his new book.
The actual book. 

Which is 1500 pages long. 

The Matter with Things. 

But another part of me is inhaling the wisdom it contains, just by watching videos, and is arguing against buying the book. 
I'm already pretty convinced about what is in it, so I would just be exercising confirmation bias by owning a copy, and is that any reason for buying the book?
Another part of me argues, life is short and then we die, and I would enjoy reading all his words and ideas and arguments. I have the right to amuse myself, it says.  

Anyway, here is my take so far.
Life is a verb, not a noun.
Two verbs, actually. Because the brain has two sides, two hemispheres. Each one has its own personality, in effect. 
Sometimes these two come into some dissonance. 

The right hemisphere gets that life is a verb, not a noun. But it doesn't talk. 

The left one is very gabby. It loves words. It can talk.
It's like a four-year old though.
Lots of energy but no wisdom.
Lots of content but no container. 
Very pushy. 
Needs a lot of handling and carefully boundaried coaching to get it off all the squares it gets stuck on. 

Now, (bearing in mind that the verbal hemisphere is like the 4-year-old), every time a word is used, it is a "thing." The left hemisphere uses words to describe something that it considers to be a detachable aspect of the world, something specific. It turns the verb of the world and life and consciousness into a bunch of nouns, manipulates them, builds ideas from them, creates structures with them, conquers continents, pretends money is real, grabs as much of it as possible, turns competition into a fun game to be played on top of the bones of everything that is not itself.  Self-flattering, self-aggrandizing monuments to heroic events meant to make the nouns it has created in its own image, permanent. Anything that steals life itself. De-verbs it. Noun-izes it. Thinks it can stop entropy by slowing down life's very creativity, which doesn't work and only accelerates entropy instead.
Lovelessness. 
A perfect example of this is all the plastic the world is currently drowning under. 
The rubbish heaps that poor people all over the world scavenge for bits to reuse or recycle or sell.  Or eat. 
The community in India that lives on top of a below-ground fire that has burned for a century already, and occasionally breaks above ground to consume this house or that one. (These people can't move - there is nowhere else for them to go.)  (https://www.aljazeera.com/program/people-power/2017/1/5/india-the-burning-city)

His book is about where, when, and how all this went so very wrong.  All from a very highly educated white Brit male, whose cultural container is the same as that of some of the most virulent colonialism the world ever saw. 
He is trying to undo the worst of the worst, examine and point to the places where wrong choices were made ideationally. Go back to source, and provide a different perspective. Backed by (I don't know) something like 40,000 references. 

He places himself in the middle of it all, able to argue both sides of most dogma and convention.
Not sure how many non-white, non-male voices he has listened to though. 

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

I like to think that my hemispheres communicate fairly successfully with each other. 
My left hemisphere listens to the feelings in my body that the right hemisphere generates to warn it of things. It responds. It does the job of interacting with the outside world.
It's like an inner marriage I guess. 

For years and years, decades really, my two hemispheres had their relationship worked out just fine. If their relationship was tested by circumstance, they usually worked out what to do in the background somehow, and allowed me to enjoy the illusion of being integrated. 

However these days I can more clearly see the outlines of each of them having their independent thoughts and feelings and motivations. 
They are connected by and through, my body. 

At the same time, I am far less bothered by this now than I might have been earlier in life.
Nowadays I view these two hemispheres of mine who have come so far together as an Amaryllis,  that tall, red, two-headed (or more) flower that blooms around this time of the year, whose Greek name means "to sparkle." 

 

A Saskatoon adventure

This whole past weekend I was in Saskatoon staying with a friend and her family in their home; I volunteered to be rapid-tested a couple times in the process to make sure no covid bugs were present in the posterior wall of my nasopharynx. 
I did my own swabbing, which although it did not hurt in the slightest, was exceedingly tickly. 
I do not think I could have tolerated anyone else doing that to me - so ticklish. 
It brought tears to my eyes as it was. 
I expect that one's sensory nervous system would easily adapt to repeated testing, however. 

The snot-drenched swab is put into the little test tube and five drops of reagent is added, left for a short period of time, then dabbed on the tester. The strip at the bottom turns pink, which disappears, and a line is left. Or if you are positive for coronavirus infection, two lines are left. 

The kit set up

                                           My negative test result.                  Two lines would indicate a positive test. 

...........

So, why was I in Saskatoon, invited into somebody else's personal covid-free bubble? 
This particular friend had proposed a reshoot of my entire online dermoneuromodulating class at Embodia with a professional film company. She found a space, handled all the logistics, food, everything, including looking after me, most spectacularly and efficiently. She made sure that all who attended the presentation/overview were double-vaxed and masked, including the camera people. 
There was a brief moment of concern when one of the attendees notified her that his girlfriend had tested positive (which is why I took a second test) but as it turned out he tested negative, so we carried on and completed the entire shoot over the 3-day period. 

The camera guys were great, and their lighting and camera equipment impressive. The mic was clip-on, very tiny, and the battery box so small that it and the cord fit easily inside the front of my bra, totally invisible. They used to work for a TV station. It was evident that they were pro, the way they moved around completely silently and signaled to each other with just hand signals.   
On occasion, a train would go by out back, and they would stop me until it had passed out of earshot. But remarkably (and thankfully) that did not happen very often. 

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

I have come to realize (with slowly growing horror) the extent to which my own profession (physio) is in the process of being taken over by the chakra belief system. A glimpse was gained when an individual I was chatting with used a chakra framework to discuss her neck issues.
A physio. A yoga physio. 
I don't care what people do with themselves or their own brains on their own time, or what they "believe," but I really do not think their belief systems should be imposed on my profession. I want my profession to be science-based. Maybe it never will be.  
I guess I must have been unaware until just this past weekend how deep chakra talk has permeated into the way (probably all yoga-physios) think and speak. Such a slippery slope from there into operator notions of "energy" and "healing." Exact same BS as the massage profession is up against. I have intense disturbing visions of physio becoming awash in crystals and all the other crap that goes with chakra BS.

I don't know how to deal with it.

I mean, I guess it's less (overtly) harmful than the way my profession was taken over by the bone-cracker mentality 40 years ago.

But it may be ultimately MORE harmful in that it uses the same mental shortcut pathways (exceedingly UNcritical thinking) PLUS, it comes all draped in gauzy "spiritual" flowing robes of metaphor, more insidious, less easily dismantled/disconfirmed by scientific investigation.

Sigh. 

Yet more weeds. 

I may need a new and better cognitive weed-whacker.  

Thoughts on authoritarianism

Every so often on Facebook you see frames pop up that can be added to one's profile picture. I saw one I liked and added it - programed to go bye-bye in a month. 

It made me think a lot about authoritarianism when somebody pressed me on science being authoritarian. I pushed back because I haven't seen evidence of science, or actual scientists, being authoritarian. Rather I've seen authoritarians trying to justify their authoritarianism by using science to try to justify themselves. 

If any group of humans understands that life is a verb, not a noun, it's actual scientists. 
They get that things, like viruses, like life itself, evolve. They try to keep up, they don't impose. They know they'll never be completely right about anything but they always strive to be less wrong about everything. 

The ones who impose, the ones who are authoritative, are those we elect to lead us. Hello? WE elect them to lead us! 

And from whom do they seek information on how best to lead during a pandemic? From effects of climate change? 

From science, we hope! 

That way we can all stay together and move as a large group in hopefully the right direction at the right times, stay nimble against threats to our human collective existence. It's a pretty good system, democracy is - it allows authority/authoritarianism to spread out and be dilute as possible among as large a group of individuals as possible while protecting the body politic from as much die-off as possible. Because you see, authoritarianism is always in there as a default brain thing - but how we organize ourselves in groups will either ameliorate or exacerbate it. 

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

Speaking of authoritarianism, I also made this little picture: 

The pic at the back is of soldiers from the famous Star Wars movie, and the one at the front was taken just yesterday or the day before, of the new regime in Afghanistan. To me, there is a striking resemblance.  

Both were/are authoritarian. 

There is nothing on this earth more authoritarian than a collective of males banding together to save themselves from the verbs of life by trying to turn everything into nouns to be defended or vanquished. 

By them. 

They keep for themselves alone the right to be verbs and everything else becomes a noun to be manipulated.

Meanwhile they are "salvationed" from having to think for themselves because they take orders instead from whoever feeds them and gives them uniforms to wear. They can go back to being dependent babies in some ways. 

They crave certainty. 
Insecure people don't see existence as a human as being an active agent who has learned to surf on a moving body of water. Instead, they want solid ground. They want to turn everything into rocks that they can pick up and throw. They are vulnerable to wanting authoritarianism to dictate to them what to do with themselves. They want religion to tell them the answers to life's conundrums. They want to blame the world and everyone else in it for their own personal existential angst. Especially they blame females, because perhaps they just can't reconcile with the fact that they came out of one of those "others" and find the very thought rather horrifying.
...............

So many examples of this tendency in the human primate brain - well, for sure the male human primate brain, because males are very homosocial and they love to dress up all the same so that as a group they look more foreboding/less human.
Women perhaps not as much. We prefer to remain individuals I suspect. 

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

A third thing I saw today that reminded me of authoritarianism was a post from Adam (Manual therapy sux!) Meakins, who I've spoken of before here and here. 

 

I enjoy this guy and his take on the world, even though it's so opposite my own, and even though he is so "authoritarian" with his stance or maybe adamant is a better word. 

(Right, adamant is a way better word! It contains his first name even!)

There is nobody on the planet probably, as wedded to the idea that tissues are the cause of back pain than Stu McGill. There is nobody on the planet probably, as prepared to openly confront and contradict him on this than Adam! 😄 

So, who's the authoritarian here? 
What is the background to all this? 
In my mind, I put Stu McGill and all of chiropractic and all of orthopaedic manual therapy and most of orthopaedic surgery all in the same boat: those who subscribe to it want nouns they can manipulate, not messy changey verbs that are like water that they cannot grasp.
They are transfixed by skeletons. They love bones. They sit there and puddle around with individual vertebrae in front of them on the desk, fitting them together, pondering for hours on how they move, what stops them moving, trying to design systems of thinking, algorithms for manipulating them, and assuming (this is the important bit) that somehow those bones not moving on each other is what pains people, not that pain might be something (in the nervous system!! Hello??) that stops them from moving. 
And from that, they built themselves quite the authoritarian world to inhabit. 
One that I examined for a time, quite casually, then, in the end, rejected as pseudo. 

In case you haven't figured it out yet, I am anti-authoritarian in most aspects of life. But not in a meaningless way. 

I got the shots and I wear a mask when out and about. 

I enjoy freedom but not free-dumb. 

 

The battle continueth, part 2

⁠A couple weeks ago I wrote about the fun tennis match between Adam Meakins (manual therapy sux!) and Chad Cook (manual therapy is unfairly demonized even though I have taken great scientific pains to point out its shortcomings).
See part 1 here. 

Edzard Ernst has given the Cook paper a good looksee: Here is his take. 

Here is my favourite excerpt: 

"Cook’s defence of manual therapy is clumsy, inaccurate, ill-conceived, misleading and often borders on the ridiculous. In the age of evidence-based medicine, therapies are not ‘demonized’ but evaluated on the basis of their effectiveness and safety. Manual therapies are too diverse to do this wholesale. They range from various massage techniques, some of which have a positive risk/benefit balance, to high-velocity, low-amplitude thrusts, for which the risks do not demonstrably outweigh the benefits." 

My bold. 
I like to think that the kind of manual therapy that I spent the last 35 years of life practicing and the past 20 developing into a nervous system and pain-science-based approach to treating patients, and also decluttering minds, falls at the positive tip of the spectrum of effective and safe, as far as possible away from the orthopaedic manual therapy uncomfortable pop-em end. 😎

The battle continueth

I watch this battle with interest and enthusiasm not because I personally have anything to gain or lose anymore, but because I just enjoy it. I get why people flock to tennis games and things like that. 

Recently a paper by Chad Cook came to my attention on twitter: The Demonization of Manual Therapy,  
in response to a years-long blog siege by Adam Meakins, a physio in England, who argues that manual therapy deserves to be taken down by a few or by many pegs in our world. 

Some disclosure on my personal perspective. 
I am (rather was) a licensed physio in Canada for 50 years. I am no longer licensed but I still consider myself a physio, recently retired. 
I saw a lot in 50 years. I felt the Big Wave of orthopaedic manual therapy hit in the 1980's. I wanted to be a manual therapist but found I was allergic to the frank discomfort of the clunky procedural learning, plus I found the biomedical, biomechanical premise, "pain comes from joints,"  kinda stupid, really. So I plowed on with what was called at the time "soft tissue" techniques. 
A great deal of snobbishness went on - those who became "certified" as orthopaedic manual therapists within the profession looked down their noses at those of us who dropped out. We were considered non-scientific and less qualified. Our bottom-up "soft tissue" propositions were pooh-poohed and scorned, even though theirs were equally suspect. 
The gestalt of it all, the momentum of it was understandable - they wanted to create something, they wanted to scientifically examine manual therapy, which was good, I guess... Cook's paper exemplifies that attitude I think. The flip side of that, though, is that the dubious snobby attitudes of OMT, buttressed by a bit of added 'silk purse from a sow's ear' type of academic prestige, held strong even as good research came along to disconfirm said propositions! We can't afford to lose any ground in our social climb! A fortress has been built and must therefore be defended, dammit! 

For me, the entire purpose of manual therapy was to help people with pain problems they were having, more importantly, that they were worried about, anywhere along a scale of being annoyed by but not really disabled much by their ache or pain, all the way to being terribly anxious and physically impaired by it. 
The central organizing principle around which I revolved for most of my career was pain relief. Period. 
I was happy to embrace:
1. pain science and the growing wave of research dedicated to its relief or at least self-management 
2. research that supported a biopsychosocial attitude toward MSK pain to replace the clunky biomedical biomechanical one we had been saddled with since Descartes 400 years prior

The war rages on. People get upset at Meakins, who is seen to have started the fight. He doesn't care. He's quite ready to be a martyr. His perspective is that it's a righteous fight and that he is a warrior doing Something Good for the profession. He wants to wake people up. He cheerfully lobs his catapults at the fortress, which he knows like the back of his hand. He gets captured, brought to "court," then released because he is as good a science-based arguer as he is at getting under people's skin!  
Waking up is uncomfortable.
I get it. 

I have always lived outside that manual therapy fortress, even though I know a lot of the tunnels into and out of it. My strategy to get through life was to argue for a new version of manual therapy because I decided based on pain science that none the old ways deserved any respect, based as they had been on faulty premises and narratives.  

Cook defends the fortress. Most of the defenders of any fortress are those who would feel very psychosocially uncomfortable living outside it. I think in the manual therapy world fortress defenders still entertain delusions of grandeur, the possibility that one day, manual therapy will gain the respect they feel deep inside themselves that it deserves. But he took the bait and fought back in the literature, instead of just grumbling and trying to take Meakins out politically. And for that, I applaud Cook. 

Meakins cheerfully rebutted Cook's paper in this most recent blog post. 😀

To know what these two are like in person, in real-time debate, watch this podcast hosted by Jared Powell. 👍

More about insular cortex and pain: Musings, Part 2

A few months ago I had a dopamine spurt of some kind, and published a blog post to do with brain lateralization and insular cortex and implications about pain. Here is a link: A few new musings about pain and brain. 
Consider this a follow-up post to that one. 

Firstly, I want to include a link to the Tucker paper from 1984, the one I found buried in a book about brain and self/no self.
Tucker, D. M., & Williamson, P. A. (1984). Asymmetric neural control systems in human self-regulation. Psychological Review, 91(2), 185–215
(Obviously, I forgot to include this particular link at the time, even though I linked to all the other things that are connected and that mostly just swim in a school, like fish, in my mind somewhere. That's lock-down brain for you. It misses a few things.) 
Looks like I did link it in this old blogpost from 2012 though, about Iain McGilchrist's book on brain lateralization. Asymmetry of brain sides: size, structure, neurochemistry

Here is the abstract: 

Reviews the literature on the neurotransmitter substrates controlling motor readiness, showing that these substrates produce qualitative changes in the flow of information in the brain: Dopaminergic activation increases informational redundancy, whereas noradrenergic arousal facilitates orienting to novelty. Evidence that these neurotransmitter pathways are lateralized in the human brain is consistent with the left hemisphere's specialization for complex motor operations and the right hemisphere's integration of bilateral perceptual input. Principles of attentional control are suggested by the operational characteristics of neural control systems. The affective features of the activation and arousal systems are integral to their adaptive roles and may suggest how specific emotional processes dynamically regulate cognitive function. (4½ p ref) (PsycINFO Database Record (c) 2016 APA, all rights reserved)

This morning a member of the Dermoneuromodulating group posted an abstract to a paper about the insular cortex and pain from way back in 2010 which somehow escaped my attention at the time: 
Wiech K, Lin CS, Brodersen KH, Bingel U, Ploner M, Tracey I. Anterior insula integrates information about salience into perceptual decisions about pain. J Neurosci. 2010;30(48):16324-16331. doi:10.1523/JNEUROSCI.2087-10.2010

Here is the abstract:

The decision as to whether a sensation is perceived as painful does not only depend on sensory input but also on the significance of the stimulus. Here, we show that the degree to which an impending stimulus is interpreted as threatening biases perceptual decisions about pain and that this bias toward pain manifests before stimulus encounter. Using functional magnetic resonance imaging we investigated the neural mechanisms underlying the influence of an experimental manipulation of threat on the perception of laser stimuli as painful. In a near-threshold pain detection paradigm, physically identical stimuli were applied under the participants' assumption that the stimulation is entirely safe (low threat) or potentially harmful (high threat). As hypothesized, significantly more stimuli were rated as painful in the high threat condition. This context-dependent classification of a stimulus as painful was predicted by the prestimulus signal level in the anterior insula, suggesting that this structure integrates information about the significance of a stimulus into the decision about pain. The anticipation of pain increased the prestimulus functional connectivity between the anterior insula and the midcingulate cortex (MCC), a region that was significantly more active during stimulation the more a participant was biased to rate the stimulation as painful under high threat. These findings provide evidence that the anterior insula and MCC as a “salience network” integrate information about the significance of an impending stimulation into perceptual decision-making in the context of pain.

Now, it's true that this 2010 paper is specifically about nociceptive pain, and we must bear in mind that there are a few other kinds now formally acknowledged by IASP.  

Also it talks about "activation level of bilateral anterior insular cortex." So it would seem that these researchers weren't interested in sifting out any info about lateralization in their study. Oh well... c'est la vie. 

I was prompted to dig up a 2015 Scientific American Mind article by Lydia Denworth on the connection between touch and insular cortex, mostly for the amazing illustrations of representative maps for somato-sensory cortex and for insular cortex. (Note: the link does not contain these images but the original does.)

Note that the insular cortex map is "hypothetical" - I guess this means that the researchers didn't go directly into the brain with probes the way Wilder Penfield did for the somatosensory cortex. However, I am willing to accept that it represents C-tactile afferents, those lovely little pleasure sensors all over the skin that the somatosensory cortex doesn't map very well for. 
In fact, if you compare the two maps they are like opposites. Big mouth, small mouth. Big hand, small hand. Small body, large body. Small head, large head. 

Anyway, I'm all out of dopamine, so, time to stop. 

Musings about a grumpy book review

I wrote a book a few years ago, and reviews are still coming in. One of the most recent ones made me laugh. 

And you still gave it 4 stars. So thank you. 

I can see that you are cognitively dissonant and feeling disturbed by that, but still interested. I appreciate that. 

.................................. 

I want to parse this out just a little bit. I presume this person is an osteopath, and if so, was steeped fully in anatomical relationships and tissue types and taught an operative mindset, taught that they would end up with magic hands and be able to change tissue with them. 

Even if they weren't an osteopath, even if they were from any other branch of the human primate social grooming tree, they would likely still think that way. 

I am from the physiotherapy branch and was fully indoctrinated in muscles and bones. I systematically pondered through all the different kinds of tissues there are in the body, practiced my moves, and still couldn't figure out WTF I was doing or why things I did worked. I felt I was conceptually stuck in a mental ghetto, yearning to be free. Going to countless cont. ed. classes only helped a tiny bit. 

Finally, I found one that helped me free myself from the mental ghetto. It was David Butler's class in Vancouver, in 2000. He taught nerve physiology. How pain might arise from nerves becoming trapped. How they might recover by targeted handling.
Beautiful.
Like music to the ears. 

I graduated in 1971. How stupid I believed I was, to have gone that long - three decades!! - without ever considering that the nervous system might have something to do with something, or that less doing, less provisional acceptance of implausible explanations, and more actual thinking might be in order, and that one could trust the nervous system to do its own self-correcting and that the manual part of manual therapy might be just to help it remove its own obstacles from its own self.  I wrote that book to help other practitioners avoid all those pitfalls. 

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

John Vervaeke, a cognitive scientist and cognitive psychologist at U. Toronto, has many, many youtube video lectures out, explaining how the mind works and his favourite topic, relevance realization. His quest is to figure out how the brain chooses what to pay attention to and why. He wants to help the world awaken from "the meaning crisis." He wants to attain wisdom. He wants to lay out a path that is scientifically valid, grounded in reality, existentially non-threatening, and will eventually circle back to Plato, his favourite ancient philosopher, with touches of Socrates along the way. 

What I have done with these lectures is try to understand them by making PowerPoint notes of some of them. 

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

Iain McGilchrist is famous for his book, The Master and his Emissary.  

He has been interviewed countless times.  I recently watched him interviewed by Rebel Wisdom in 2018. He described, as usual, how early impressions about the divided brain left implications that were quite wrong, designating entire human beings as either right-brained or left-brained, when in fact all people use both sides of the brain together at all times.  

Things I took away were that actually the two sides inhibit each other, usually successfully, until agreement is reached and a mutually satisfactory solution to a problem is produced. He talked about the main functions - that both sides perceive and comprehend, but that the right side is dealing with whole landscapes, both inner and outer worlds, while the left side, the one that can speak and grasp, is fast and smart, but highly procedural, more like a functional appendage of the right side (the right side's emissary),  but likes to control, and gets angry when its power is constricted or if it feels its worldview has been contradicted. (There are many nuances I've left out here but are really worth the bother of watching the entire video.)

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

Anyway, here are a few thoughts for whatever they're worth. 

1. Manual therapy is taught as procedural knowing, for the most part. I presume that most people, like myself, are interested in having our procedural knowing backed up by accurate propositional knowing. The sad truth is, most of the propositional knowing that our procedural knowing came saddled with is easily refuted with relatively basic testing. Almost none of these propositions - OK, none that I know of - have held up under scrutiny. E.g., palpation (or any of the things people claim to be able to palpate correctly) has no interrater reliability. 

2. Perspectival knowing (putting oneself in another person's shoes vis a vis their lived life) or participatory knowing (being intensely interested in how they feel and being able to feel their feelings, however inexactly, but possible given such phenomena as mirror synesthesia) have been ignored. 

3. Personally I favour manual therapy as an avenue for growth in all four areas, but only when certain boundaries are established. 

a) prodedurally: do no harm, be that harm nociceptive or noceboic

b) propositionally: get into the right basic science. Science exists to disprove, not "prove." Accept that your favourite "method" may have been disproven long ago. What follows after that is accepting one's role as being that of interactor, not as operator. This may be the hardest thing of all: to take a backseat to someone else's nervous system. Manual therapy as a two-way street between two nervous systems, not just one doing some "procedure" to another, not being a "magic hands" person, not being "the great healer." You have to learn be receptive, and carefully be prepared for feedback through your hands even as you might be doing things with them. Long periods of quiet stillness will permit it to get through. 

c) perspectivally: do a lot of reading about life, about other people, other cultures; read a lot of literature, or if you wish, listen/watch a lot of podcast interviews (my favourite way of learning others' perspectives these days).  Stay out of the social media bubbles. They can trap you into wrong ways of thinking. 

d) participatory: anyone who possesses interpersonal sensitivity will likely have enough of this to get by on. Psychotherapy is as full of "methods" for counseling as manual therapy has "methods" of treating for this or that kind of pain felt in a body part. Even if you lack intrinsic capacity for sensory empathy or mirror synesthesia, where you can for a brief period of time feel someone else's "pain" in your own body, you can still learn compassion; compassion, like wisdom, can take a lifetime to develop. However, there are ways to learn the basics of almost anything from books or from other people, through communicating and reflecting. 

4. I think all the bits of propositional knowing that go with standard conventional manual therapy training, even though they are largely incomplete and/or completely wrong in the light of modern neuroscience, are still passed on because it's convenient for the schools to do so and because the left brains of all teachers and students get rattled and angry if they aren't. To be fair, it's true that we learn to do by doing. I mean, I learned that as a child in 4-H class in a farming community. However, nuances must be examined and contradictions pondered, in any walk of life, perhaps especially in a walk of life like manual therapy in which so much that is obsolete must be tossed.  

We might start out this way..... 

But we have to tweak it until it gets to be more like this.