Saturday, February 10, 2007

Manipulation and the Brain

This entry is a more edited version of a post I made on NOI in a discussion regarding manual therapies. I have included some references.

One of the participants asked, “If we discredit manipulation are we not at risk of undermining other manual type techniques for the same reason (myofascial, massage, mobilizations etc)???”

I answered with a prior version of this:
I don't think so. There is a layer of "brain" all around the outside of the body, a.k.a. skin, with fibres that go straight up to the insular cortex.1,2,3,4 We could consider manual therapies as altering the nervous system through THIS organ - I think all of the manual therapies you named do this anyway to a large extent, yet there is a conceptual void that needs filling; long ago manual therapies were named for the mesoderm (deep to the skin sensors) they were supposedly targeting (e.g. myofascial) or the sort of physical movement needed to perform them (e.g. massage, mobilization). These sorts of archaic designations deflect accurate therapeutic understanding from including the perspectives that patients' own unique nervous systems may have, keep our constructs off track, bias our self-image toward being PHYSICAL therapists instead of being physical THERAPISTS.

I doubt the actual therapy procedures, the physicality of them, are discreditable. These seem to be something humans evolved doing in order to help/comfort one another, cognitively consolidated action memeplexes that appear to stem from some deep ancestral well of primate social grooming. However, the constructs that attempt to explain and inform their use do nothing but describe such treatment as something we the treatment heroes "do" unto others. This perpetuates confusion, maintains invisibility/disregard of the highly variable nervous systems at the receiving end of the interactions as passive recipients, does nothing to consider or include the highly active role that nervous systems play in their own recovery by first accepting as non-threatening, then responding to, exteroceptive input.

Manual therapy ranging from skin touch only to active skin stretch to deeper pressure into underlying bones, muscles, neural tunnels, what have you, at varying speeds, should always be kept within our scope, but framed instead as varying kinds of exteroceptive input into a living perceiving system. Rather than being framed so strictly in biomechanical language, with its attendant and unavoidable misconceptions of cause and effect, the effects produced by manual therapies should be more carefully read as responses by the patient's living perceiving system. This necessitates seeing a patient's nervous system as more of a verb than a noun. This necessitates developing abilities to stay one step ahead of that nervous system, guiding it toward better behavior/output, not overtreating the mesodermal anatomy of it, or holding that foremost in our minds.

I'm all for retaining, but renaming, all forms of manual therapy interventions as a necessary part of their long overdue upgrade; new manual therapy names should include and reflect modern pain and nervous system concepts, and a sense of the interactivity of two nervous systems working together at every level to help one of them reduce pain and improve function/freedom. I would predict that as the perception of them shifted in us, the users of these therapies, the balance of usage of them would too; I think a trend more toward less intensive and slower forms would develop.

1. Unmyelinated tactile afferents signal touch and project to insular cortex; Nature Neuroscience (2003); H. Olausson, Y. Lamarre, H, Backlund, C. Morin, B.G. Wallin, G. Starck, S. Ekholm, I. Strigo, K. Worsley, Å.B. Vallbo, and M.C. Bushnell.
2. Pain Mechanisms: Labeled Lines Versus Convergence in Central Processing, Annu. Rev. Neurosci. 2003; A.D. (Bud) Craig.
3. Antero-posterior somatotopy of innocuous cooling activation focus in human dorsal posterior insular cortex, open access 2005; L.H. Hua, I.A. Strigo, L.C. Baxter, S.C. Johnson, A.D. (Bud) Craig.
4. The Integrative Action of the Autonomic Nervous System: Neurobiology of Homeostasis 2006; W. Jänig.

I see the understanding of how to treat live people as inversely proportional to the amount of force used and the speed of its delivery. I see the misunderstanding of how to treat live people as directly proportional to the amount of force used and the speed of its delivery. I guess nothing will ever be able to make me change my mind on this, ever.

Monday, February 05, 2007

Graded Exposure

In this Feb. 4th entry, painonline blogger Kevin McHenry discusses Mt. Everest.

...can SEE the top of Everest and the fact they can SEE it makes them think they can climb it. Everest is only the equivalent of 2229 stairs. Surely we can do it. Yet, fairly frequently, we may die trying. It is not just mountains which give this illusion. A windsurfer on Maui who could see Molokai clearly from Kannapali Beach disappeared on a day of rough weather, attempting to make the crossing.

The Everest principle then is letting the eye overcome reason. Being able to SEE the top of Everest is no assurance at all that one can climb it. A slight worsening in the weather can spell the end of life. Mallory's story is one such example. In other words, unexpected troubles change everything and we should not take chances with survival. Ed Viesters, a survivor of the 1996 disaster, went up Everest, slowly, without oxygen. He claimed the reason so many die is that they go up too fast, misled as to their abilities by carried oxygen. When the climbing is tough, as in bad weather, they use too much oxygen, and when they run out, they are dead. He felt that slow acclimation was a better protection for him and has managed to prove it. Viesters has climbed most or all of the world's most dangerous peaks without oxygen. His idea, don't risk taking on more than you are really ready for.

This is a very apt comparison for what it takes to slog along through life when in pain, the sense of physiological demand embedded within. In a pain state, it's just as if someone took ordinary life and turned it upward at a steep angle, with less oxygen available. Thank you for the great analogy Kevin McHenry - good example of something called "graded exposure" - going along toward a goal, but in slow enough and small enough stages that there is no overshoot, no physiological payback, no fall into defeat.

By climbing that mountain slowly, Viesters' physiology was able to adapt. He was able to build hemoglobin levels that could cope with the altitude and decreased air pressure. His heart had time to "try out" and "learn" new strategies to maintain his blood pressure within normal range. In short, he gave himself time to adapt. He gave his physiology time to learn how to maintain homeostasis in the face of increased allostatic load from the environment.

Graded exposure is a cognitive behavioral therapy tool used by psychologists to help people overcome phobias. For example, let's consider people afraid of spiders, to the point where ordinary life becomes absolutely narrowed and imprisoned by fear. A patient wants to overcome the fear, which is step one. It has to be, obviously. The patient is so uncomfortable and trapped by this fear that they don't have much of a life.

A psychologist teaches the patient to recognize the earliest symptom of fear, a speeding up of heart rate perhaps, cold clammy hands, what have you.. Gradually and gently, the patient is taught how to experience tiny bits of this overwhelming fear, before it gets to the point of overwhelming them. By learning to approach and retreat from something they "know" can't hurt them, like a picture of a spider, they are taught to modulate their own fear. Eventually this modulation will become "downregulation" - their own nonconscious brain, through consistent, steady, successful cognitive self-input, guided by another factor in the environment, i.e., the psychologist, takes over the job of inhibiting the fear that was formerly all encompassing.

Graded exposure has been successfully used to teach people, and peoples' brains, how to downregulate pain, as well. Lorimer Moseley has done several studies showing long term pain relief measurably improves with education about pain, about the physiology of it and by practicing graded exposure. In cases of central pain, in fact, there simply is no better way to deal with it than for patients to learn to regulate their own physiology, much in the way Viesters did on the mountain. He went up and came back down without oxygen and with his life intact according to McHenry, and that certainly suggests something done right.

See my list of links to the right for the painonline main blog link.