Mirror therapy for central pain in paraplegics

Please check out Neurotopian's latest blog post.

What a gorgeous idea this is. Thank you Neurotopian. Your smashingly good idea (and of course Dr. Moseley's test, and future clinical trials on every continent) could go a long way to save future generations of paraplegics from a great deal of pain.

Pain as aporia

One of my favorite article writers on pain, Dr. John Quintner, has a site, www.creativepain.com . He is one of the pain world's foremost deconstructionists. I admire his ability to cut through all sorts of erroneous nonsense about what pain is and isn't. I like that he prefers to regard peripheral pain as pain from nerves themselves, not from mesoderm of one sort or another, admirable especially in that he is a rheumatologist and one would expect, be all about "joint pain".

Anyway, if you read his webpage you'll discover that down near the end he states that pain is an "aporia". I became fascinated by the concept and spent a bit of time looking up what is meant by the term.

Here are some useful links to "Aporia":
1. Wikipedia
2. Literary encyclopedia
3. Postmodern terms
4. About.com Grammar and Composition

The gist of "aporia" seems to mean, a way that is blocked; "poria" must be the "way" and "a"-poria, the blockage of that way. Note that there is a subtext here, of movement, frustrated in its expression.

I did my own little deconstruction, working backwards from the wikipedia definition, following a few of the links. I know beans about philosophical discourse, but here's what I think I found out. First, I clicked on the word "elenctic", attracted by the novelty of a word I'd never before seen in my life. It went to a page about some long-dead guy I'd never heard of, Elenchus. From there I looked up "dialectic", which seemed interesting, a word I had heard in poly-sci circles long ago..

There it was. Sublation. A way to get around, over, through, out of the "a" part of "poria", past the impasse. Go Hegel:

"Sublation is an English term used to translate Hegel's German term Aufhebung. The German word Aufhebung literally means "out/up-lifting."

But what does any of this have to do with pain, an astute reader might wonder?
Everything, I would answer. Consider this.

"...the term Aufhebung has the apparently contradictory implications of both preserving and changing (the German verb aufheben means both "to cancel" and "to keep"). The tension between these senses suits what Hegel is trying to talk about. In sublation, a term or concept is both preserved and changed through its dialectical interplay with another term or concept. Sublation is the motor by which the dialectic functions."

Just as continuing dialogue helps to move a conflict past its flash point, or an argument towards resolution, so does having a kinesthetic "conversation" - an inner dialogue, help a person in pain's brain move past pain. It is at least a three way conversation. The therapist supplies a small amount of kinesthetic input to help the patient's brain settle and focus. Most of the dialogue however, is completely internal, between the patient and the various levels of his or her own nervous system. Eventually the impasse is surmounted, sublated, and pain resolves. Or doesn't. Usually it will, but sometimes it doesn't.. so, no guarantees can be be ethically made....

Neurotopian, would you concur? You are both German and a nervous system treater. Did I get the meaning of "aufhebung" correctly translated into Kinesth-ese?

Mirror therapy

It looks like the effectiveness of mirror therapy for phantom limb pain has been independently verified yet again.

Kent has sent a link to a video featuring Ramachandran.

He says, "This is a link to a TED talk by V.S. RAMACHANDRAN. In the middle of the half hour talk he describes stumbling on the mirror box as a means for dealing with phantom limb. It is a very engaging video. Thought you and your readers might be interested."

Thanks Kent. Thumbs-up.

Everything Oscillates

.... even the genome apparently. Scientists at Vanderbilt University have noticed that chromosomes contract in daylight and loosen their coils at night. Just a really interesting factoid - nothing to do with the gist of this blog. Except that everything eventually has something to do with everything else, in biology.

Anyway, the word "oscillation" in the article reminded me (yet again) of György Buzsáki's work.

Michael Merzenich, On the Brain

I've been exploring a site called On the Brain.com, a blogsite hosted by Michael Merzenich:

Dr. Michael (Mike) Merzenich is the Francis Sooy Professor in the Keck Center for Integrative Neurosciences at the University of California at San Francisco. In parallel with the landmark studies of his UCSF team in the science of neuroplasticity, he has worked with other scientists, medical specialists, psychologists, engineers and other technical specialists to develop training programs based on this science, and designed to improve the behavioral capacities and neurological abilities of children and adults in need of help. Almost a million individuals have now benefited from the use of these programs.

On his site I found a video about a man with traumatic brain injury whose cognitive function became improved via some mental exercises. I was impressed - thought I'd share it here.

Place cells and Grid Cells: Part II

You do not have to dig very deep to find good descriptions of place cells. (It is starting to become a bit more clear to neuroscientists how the brain works together as an entirety, to conduct "thought". No more dualism, please.)

It's interesting that both place and grid cells are at/in the hippocampus. György Buzsáki discusses hippocampal "theta" rhythm as fundamental to all brain function in his book "Rhythms of the Brain".

Grid cells were discovered more recently and are not quite as famous yet. Blakeslee discusses grid cells next: These map space too, but differently - they do not use external markers to orient you - they let you know where you are in space based on your own movements. These were discovered in 2005 by scientists in Norway.

The discoverers say,

Imagine coming up from an unknown subway station. You immediately look for a landmark to figure out directions and your position. The moment you find it, your cognitive map is calibrated, and things fall into place,” explain Edvard and May-Britt Moser. They reveal the secrets of memory.

Grid cells do this calibration. Blakeslee says,

"Located just one step higher in the cortical hierarchy from place cells, in a region called the entorhinal cortex, each grid cell acts as though the surface of your local environment had a triangular grid painted all over it... A grid cell is active when you are at the vertex of any of the triangles in the field in front of you but inactive for locations between the vertices. The grid persists like graph paper spread as far as you can see, or like the Holodeck on Star Trek before scenes are projected onto it. When you move through space, grid cells mark your position independent of context. Place cells "say" I am in the store, I am in my house, I am in a strange plaza. Grid cells keep track of where you are in all contexts, in all kinds of places, as if they were a property of the environment itself and not cells in your brain.... Moser, when asked, is willing to venture a guess that great athletes have highly developed place cells and grid cells. Yes, they need fast reflexes, trained muscles, great eyesight, and developed brain networks to compare different trajectories; but when Ronaldinho looks down a soccer field, he is mapping the entire field in his brain. He has an effortless, innate sense of where he is in space and time, thanks to how well his brain maps that space. Every time he takes a step, an entire new geometry of action is created within his brain. In ten seconds, Ronaldinho will see at least one hundred alternatives and will make choices that draw on his...place cells and grid cells."

I've done some traveling, enough to know that I get lost easily, turned around, hardly know up from down, don't have a clue which way is west without a good map. I've traveled with others who effortlessly (maddeningly) "know" where to find a site. They stand in the middle of a foreign city, gaze around for about 3 seconds and say, "over there" - and take off toward the place we've decided to go to. They are almost always right. My strategy when alone is to use a map, and double check my progress by stopping local people, asking them, to "feel" sure I'm going the right way.

Place Cells and Grid Cells: Part I

I spoke of Sandra Blakeslee's new book, The Body Has a Mind of it's Own, here and here.

On page 128, at a nice little section called "A Sense of Where You Are". The authors describe the eerie way certain basketball players and other athletes have of knowing exactly where they are in space, how balls go through hoops precisely even with backs turned. They duly note the advantages top athletes are born with: fast-twitch muscles, long limbs, high anabolic thresholds, extraordinary hand-eye coordination, lightning fast reflexes, excellent vision (including peripheral). They describe how certain athletes look at everything, focusing on nothing until the last moment of commitment; due respect is paid to the thousands of hours of accumulated practice manipulating ball and body in space. Then they go on:

"But there is one trait among great athletes especially those whose game is played on open courts or fields (like soccer, basketball, American football, rugby, lacrosse and hockey), that has not been described on ESPN or elsewhere. It explains why some people have an extraordinary sense of where their bodies are located in space, as well as the fast-moving bodies of all their teammates and opponents. Namely, the very best athletes have really great "place cells." And maybe even more important, they have spectacular "grid cells.

Place cells and grid cells are space-mapping neurons linked to a memory-forming region called the hippocampus. The hippocampus is evolutionarily much older than the cortex. So despite the amazing power and flexibility of our cortical space and body maps, this ancient system of place and grid cells is still very much with us - you could say it was "grandfathered in." Instead of mapping personal space from an egocentric point of view, as your parietal and premotor circuits do, place cells and grid cells are what scientists call geocentric."

The rest of the section is what they are, how they differ. Place cells were discovered in 1971 by researchers John O'Keefe and John Dostrovsky, who studied the hippocampus and memory. They appeared to encode parts of a maze the researchers' rats explored. Thousands of place cells combined in millions of ways to give the rats endless place-learning capacity.

The authors remark:

"You have place cells too. When you walk into your kitchen, certain place cells fire when you are standing in front of your refrigerator. As you move toward the sink, a different set of place cells will mark your new position in the room. If you walk into your dining room or living room, another combination of place cells will mark your spot in space."

Place cells help you navigate around your home if the lights go off, help you find a candle. They internally map where you keep your objects in relation to one another, and in relation to your body as you move through space. Some keep track of where your head is turned and update you about your balance and your body schema. If you spin in place you'll be lost until you find an object you recognize - then you'll 'know' where the door is.

"place fields are calibrated according to fixed reference points - sofa, chair, table, window, door - that do not usually change. If you move your furniture around, your place fields reconfigure your map."

More to come on this. Much more.

Now back to function... Part II

2. UN-clear metaphor

In Part I, I introduced scenarios related to clear metaphors people use to describe pain. I used "icepick" and "fish hook" examples. When someone says they feel like they have a foreign object lodged somewhere, and it's perfectly obvious they don't, the comparison is at least acceptably clear as metaphor, even if the solution to the pain isn't yet clear.

What about if the metaphor used is not about a foreign object, but a body part that truly does exist inside the body? Suddenly comparisons are much less clear. Suddenly structures are blamed for misbehavior that is actually functional. Suddenly something that feels LIKE a "locked joint", becomes in a patient's mind, or in a therapist's mind, or a doctor's mind, a possibly 'real' locked joint. There are a million of these. Examples are, "I must have a bone out of place." "A muscle is cramped in my foot." "This tendon is too short - look". "I was fine until I lifted that couch, then my (whatever) seized up on me."

These are still metaphors, but now the issues the patient feels in the tissues are not clearly metaphoric at all. In fact, there has been nearly perfect reflection of metaphors like these, a verbal and investigative ping pong match of pain memes and memeplexes going on ever since humans have had pain and human primate social groomers have tried to help.

But.

Slowly it has begun to dawn on some of us who are fascinated by all the little tricks of the brain and the habits it has of setting up simulations of reality, that pain is something of a perception itself. A great example is phantom limb pain. This is pain that an amputee feels vividly and to his or her consternation, in the missing limb. It can't be the limb hurting, because the limb no longer exists.

But.

A representation of the limb does exist, in the brain. A brilliant neuroscientist/brain researcher named V.S. Ramachandran figured out that using a mirror box could help. The patient places the remaining limb in the box in a way that creates an illusion of a missing limb being present, and able to move freely. Even though the patient knows full well it's just a mirror image, moving freely and painlessly, some important part of the visual cortex actually will record this information and send it around the brain in such a way that pain is relieved in the "missing limb", the phantom of the missing limb, the virtual body part, the representational map of the part located in the brain. It's as if the brain thinks to itself, hmm, I must have made a mistake. It looks like that part can move ok.. Alrighty then, I'll take out the pain signal.

It gets even more strange - it turns out we all have these maps - everyone has them. And we all can feel pain in them, just as amputees do. Ready for more strangeness? Pain is usually in the brain map part instead of in the actual part. I know - this is where "what everyone knows" bumps into new science. Such apparent heresy! But not so strange if you accept the idea that the brain is a great big simulation producer. It can make you have a pain in a part that is not at all "damaged", just because it senses a threat to that part. Yes, you read that right. Nothing has to have happened to the part for the brain to make a pain in it. From my blogpost of September 4th, "Rhythms of the Brain" by György Buzsáki:

The short punch line of this book is that brains are foretelling devices and their predictive powers emerge from the various rhythms they perpetually generate. At the same time, brain activity can be tuned to become an ideal observer of the environment, due to an organized system of rhythms.

I really want you to know I did not make this up - György Buzsáki wrote an entire book about how this is not just possible but likely.

What can decrease pain? Helping the brain sort, refine, redraw its maps. How? Create an illusion for the brain in regular 4-limbed people in pain that is as powerful as the mirror box is for phantom limb pain. How? Well, movement is the key here. The brain needs to perceive some kind of movement before it can get off the square it is stuck on, pain-wise.

One can create a kinesthetic illusion of movement, through skin stretch. Simon Gandevia is the researcher who came up with this while studying cutaneous receptors. He is a lot less famous than Ramachandran is, but no less important to those of us who work with new ideas on how to pare back erroneous metaphor in our own thinking about pain. True, Simon Gandevia hasn't linked his own research yet to pain relief itself, specifically, but he has provided a huge clue. Putting this clue together with Patrick Wall's idea that pain is a "need state", and that pain relief follows a "consummatory movement", and bearing in mind the success of mirror therapy for pain in limb representations, is it really that hard to draw a line connecting the dots? Treating people who still have all their parts is much easier because you don't need a mirror, you just need to get on their skin and give their brain a movement illusion.

To me, this cuts through all the confusing metaphoric mesodermal tissue based wild goose chases that practitioners go on, led originally by convincing descriptions of pain given to them by patients, which they then go on and foist on other patients, and all of which becomes some version of gravely mistaken treatment orthodoxy. I am fond of saying three things to patients on their first visit:

1. There are people who have things on x-rays like degeneration (etc.) who don't have any pain
2. There are people who have pain, and have no x-ray changes
3. Pain and x-rays (or, pain and body weight, pain and posture, pain and... [etc.]) don't necessarily have anything to do with each other

(Truth is, I'm haunted a bit by all the years I worked as a PT, diligently and inadvertently contributing to peoples' pain experience by choosing wrong words, like, "looks like a disc problem", "Sudek's Atrophy? You'll need to wear this brace to keep your fingers from curling into your palm", "This looks like a tendon rupture", etc etc... I'm haunted by a past filled with thousands of faces of patients who intersected with my life, in pain, with ordinary nervous systems and intact tissue, looking at me as some sort of keyholder of relief for them, me having official human primate social grooming status and license but no key, no clue!- to how to really help them at all, other than temporary accompaniment and a set of protocols on how to get them to move anyway, even if it hurt, social manipulation/motivation. Cheer leader stuff. It makes me cringe nowadays - if I were in a patient's shoes I would want to shoot some kid fresh out of school who had the audacity to think she knew the first thing about what my brain and body were going through. But apparent sincerity and earnestness kept me alive, I suppose... Plus, to be fair to my former self, there was not all this nice research available back then, in the 70's. There is no excuse for continuation of perpetuation of inappropriate metaphor in my profession (or the medical profession) anymore, other than pure ignorance/being too busy to read/relying on the schools to have taught what is necessary to know to do the job. The schools are only just learning about this stuff themselves! It'll be awhile more before they figure out how to do the requisite "knowledge translation".)

Certainly there will be some hips that still need replacing and some knees, and so on, but the pain felt in those parts which have been sacrificed might not be relieved by the sacrifice, might not have been from those 'parts' in the first place!

Does it not make more sense to deal with pain first, provide the simulating brain with a movement illusion, see if it really is cranking out pain for no particularly good reason? If the pain goes away, great! Show the patient a few exercises to keep pain at bay. Another knee or hip or (insert name of structure) saved from sacrifice. If pain doesn't go away/stay away, then think about replacing the part.

Now back to function.. Part I

In the Butler blog is a post about painful words, how they conjure up horrible imaginings in peoples' minds, create needless stress and worsen pain. A comment from a reader of this blog about his knee pain, knee replacement, his surgeon's words reflecting insecurities about not being able to "fix" his patient's pain, and the reader's battle to withdraw from heavy pain meds came to mind immediately.

...I realized after months of difficult recovery from my joint replacement that one of the key things my surgeon said to me was "I am worried about our ability to control your pain". He is a great surgeon, and meant well. But he played directly into strong fears that I had about the surgery already. I obsessed on the idea that my pain might be uncontrollable. I believe that contributed a lot to me winding up on 350 mg per day of oxycodone.
I'm doing much better now and have been off the oxycodone for 5 weeks.

A battle is being fought by a tiny group of people in lots of ways, including through blogs (like this one), comprised of practitioners (myself among them) whose main agenda is to deconstruct pain for the sake of having less of it around perpetuating useless suffering. We are fighting an abstract battle, one of memes: the mindless and needless enticement of persistent pain into permanent suffering, through simple correctable things like word choice. We are trying to change this by presenting, studying, arguing, pointing out current pain science, science which refutes an entire historical mind set not only guilty of permitting needless suffering, but also of giving rise to a professionally reinforced sense of helplessness and avoidable drug use in patients.

There are at least two layers to this:

1. Clear metaphor

Some of the metaphors patients use are easy enough to understand as such: when someone says something like, "It feels as though I have an icepick through my shoulder here and a fish hook stuck in it back here", it's obvious both to them and to the practitioner that they have no such thing really - instead they are explaining how their pain "feels" to them. The practitioner response is often a little smile at the colorful language; if the patient is insistent after a few treatment attempts (based on having diligently tried to find and treat the offending tissue) the practitioner rapidly begins to feel helpless and either refers on or else decides the patient must be crazy with all that icepick talk.

At least three scenarios can ensue from here:

a). With any luck the patient will be referred to a PT who understands pain, and can reassure the patient that perhaps that's really all it amounts to. A few little manual therapy maneuvers, voilá, some cranky neural tissue somewhere in the vicinity has more oxygen, the brain maps all overlap perfectly again, the protective motor reflexes dissolve, needless ion channels vanish, stress is gone, all is well, patient can move the shoulder just fine again. Metaphoric icepick and fishhook are gone as if they had never been there, even as "just" a feeling or sensation that was turned into an image in the patient's mind to help him or her communicate verbally something ineffable like pain that has no words of its own.

b). In scenario two, the patient may be referred for further imaging and possibly surgery. Diligent medical practitioners will diligently look for and usually find some aspect of the patient's body that they decide must be responsible for the pain, and will schedule a surgical intervention. They may be referred before or after to a PT who closely follows the medical tissue-based model for pain. The PT will do all sorts of things to try to help, but if their word choice is not careful, they will merely reinforce pain while trying to get the patient to do all sorts of activities in spite of the pain.

c). In scenario three, the patient is referred to a psychiatrist.

Stay tuned for Part II, Unclear metaphor.

OK, back to structure for just a minute...

I'm so pleased to announce (with Michael Shacklock's permission and blessing) that he will soon be re-publishing portions of a classic text of great interest to all nerve-o-philes, namely Alf Breig's book, Adverse Neural Tension in the Central Nervous System, long out of print.

The new release will be called Biomechanics of the Nervous System Revisited. It will explain to all manual therapists new to thinking about this particular structure called the "nervous system", the physicality of it, how it slides around inside the body, how to treat it (respectfully, we hope). It will contain many of the original photos taken by Breig himself, during surgical procedures, and published in the original book in 1978, which clearly show how nerves move, especially nerve roots.

Breig's book, very scarce, out of print, attained near-mythic fame. The pioneers of neurodynamic treatment had obtained copies nearly three decades ago, but not many books had been printed, and no one else in later waves of interested neural treaters could lay hands on it, or on any of these pictures, much to our collective frustration. This sad fact created a bit of a dip in the understanding of nerve mechanics for a long time. Until now. Make that until soon. Until January 2008.

Michael made trips to visit relatives of this recently deceased surgical explorer, and the explorer himself before he died, and was able to obtain rights to reproduce much of the content. Thank you so much for this, Michael. What a gift you are bringing manual therapy.

Deconstructing and rehabilitating the concept "placebo effect"

We have the conventional definition of "placebo" versus the Patrick Wall definition, which is the same definition used by PTs interested in treating pain.

For anyone who still doesn't know who Patrick Wall was, he and Ronald Melzack combined efforts to research pain for over 4 decades. (Tip: Read the paper linked to Ronald Melzack. It explains his neuromatrix theory of pain. It's the best pain theory in existence to date, in my humble opinion.)

But now, back to placebo. Placebo is a loaded word, charged with centuries of flimflam, misunderstanding, and exploitation. Patrick Wall figured out what placebo response really is, how that works, and worked together with PTs to determine how it could be harnessed ethically for relief of pain.

I count myself among this slowly growing cadre of PTs who are laying aside our old tissue-based belief system based on 3 or 400 years of ignorance about pain, in favor of instead understanding the science that has developed around pain. Patrick Wall said (paraphrased), "Placebo is not something administered TO a patient, it is something to be elicited FROM a patient." He went on to describe the perfection of a placebo response. It was something the patient's brain made by itself, a chemical substance, antidote, precise in dosage and specific to the problem, which went straight to the receptors in need of it. It was allowed to exist in the brain for only as long as necessary, whereupon the brain would dismantle it by itself. In other words, one sort of nature (placebo response) taking care of another kind of nature (pain response).

After a brief nervous system explanation, it's a lot easier to explain effects that are "placeboic" in a way such that people will be more inclined to think of "placebo" in a positive light rather than negative - at least they catch a glimpse that it will be good for pain, that you don't think it's undesirable, that you want to help them make their very own, and begin to see achieving it as a victory not a defeat. It must be reframed/ redefined as a treatment effect that is desirable and unique to them, something that is produced naturally as a consequence when a "team" (comprised of patient and therapist) develops a temporary third entity (the interaction of nervous systems) to help a fourth entity (the patient's own nervous system) wrestle with and overcome a fifth, the "foe" (pain output). When people have the Wall definition of placebo explained to them they are not at all disinclined to go for it. They are willing to set up a treatment improv mini-drama with you in which all these entities can exist on their own for a short while, and change places, play musical chairs until all the chairs are taken and pain has nowhere to sit. They become co-conspirators in the development of a "placebo" effect that will fix their own system, in fact they get that it is up to them, by doing very little except waiting patiently and tracking processes. The right frame around that charged concept, "placebo", is everything.

The team can be dissolved. The patient can go off with new strength derived from new cognition around the problem, a new understanding that while their nervous system includes "them", it is not "them" entirely. Instead it is something they can successfully interact with, as one might find oneself interacting with an unruly child or a screaming baby. Do not abuse the nervous system. Do not permit anyone else to abuse it. Figure out what it needs (usually some form of movement developed slowly and carefully, with close attention to a sense of timing), then supply it, and be patient. Do this for short periods of time (minutes), frequently (as one would feed a starving baby, perhaps every hour or two). It will take a good three days for abnormal and too numerous receptor sites (associated with pain sensitization) to dismantle and (hopefully better ones) to reform. Allow time for improvement to establish itself. Get on a better track and find ways to enjoy the rest of your hours per day while waiting optimistically.

More on Michael Shacklock

I've had Michael Shacklock linked to my website for years, and decided it was high time to link him to this blog, where I spend more time now.

I wrote about Michael a couple years ago ( see archives for November 2005). At the moment, he is working hard to get a book republished. It will be very exciting for all of us who are human primate social groomers of the "functionalist" persuasion, and wonder about what bits of "structure" we really need to bear in mind (thank you to Neurotopian Matthias Weinberger for clarifying the two broad camps of debate) ... you'll get a hint or two about this by reading his newsletters.

I don't want to spoil the surprise, so that's all for now - over and out.

Boiling the flimflam off human primate social grooming

Every so often something crosses my path which cheers me up. Recently I found this blog by an ex-chiropractor who no longer tolerates wool pulled down over his eyes or his mind. Good for him. Here's another.

The sooner hucksterism leaves my field of endeavor the sooner I'll be way more happy. To get hucksterism out of this field requires that individuals like this begin to save themselves from replicating it, and then talk about it.

Really, it comes down to just this: Someone in pain, Person A, goes to see someone, Person B, about it. Hopefully Person B has been trained to be ethical and scientifically respectful. Hopefully Person B does not take on a hero's role. Hopefully Person B has been around long enough to have discarded uselessness in favor of honesty. Hopefully Person B is current with pain science.

Person B will do what he or she can to provide a favorable no nonsense context for the patient to conduct his or her own exploration. There will be usually some provision of exteroceptive input of some kind. There will be no funny business - Person A will be told what is expected of them, taught what to look for, asked to proceed at their own rate. It will have been made clear, one way or another, in some way Person A can understand, that it's their job to get themselves better, and that Person B is a helper.

Person B will realize all along that he or she is nothing but a catalyst. Person A will be doing all the hard work of sensing and learning, changing their own nervous system (or rather, allowing their own nervous system to change itself) to something more optimal. The desired reaction occurs entirely within the patient, and the only reagent is the patient and all their inTRA-relationships. None of this is a simple thing to understand at a scientific level, but progress is being made and the science base is growing; maybe one day the physical contact aspect of human primate social grooming will be not only stripped of flimflam but will have vindicated itself.

Changes occur, usually in the direction of improved function and decreased pain. But not always, and not in any sort of predictable way or speed. All this depends on the patient, the context, and on the quality of therapeutic contact within a treatment room.

Let's discuss "crucible". On the surface it means a container such as the ones used in chemical labs, able to stand high heat etc. A deeper level of meaning (without being religious in any way) is "cross", an intersection or crossroads, a place where a change of direction can take place. Other words contain the same root, words such as "crucial", or something that is the "crux" of a matter.

A treatment room is, then, a metaphoric crucible. As such it should be able to stand the metaphoric equivalent of "high heat" - the patient should sense that the room they are in is safe for them to be who they are, express whatever they want. And they may well need to.

Not only should the room be designed to take the "heat", the therapist should be "fireproof" as well, able to tolerate whatever sorts of pain offerings a patient might bring, emotional or physical, without flinching. Flinching is a non-conscious, mirror-neuron, socially connective, social behavior. To NOT flinch and still retain good therapeutic contact is definitely a learned behavior. Here, I must confess, I am still working on getting the right proportions of non-flinch combined with solid connection during the interview. I'll never be perfect - no therapist will ever be perfect. It keeps one humble and honest. I would like to add, however, that not very many people are "high heat" people - most cases of persistent pain are very straightforward.

The therapist will have tried to eliminate as many distractions and noceboic elements as possible from the crucible. He or she will have made it as clear as possible that the pain issue is something the patient must permit themselves to work through. This needn't mean having to experience more pain. In fact, the less the process "hurts" the better. No point in reinforcing the pathways associated with the very thing the patient has come in to try to learn how to deal with, get rid of.

Eventually the time will come for the reaction. I usually spend a half hour or so, interviewing, examining, explaining, which leaves a half hour for the patient to experience a sample of what happens on the table. Subsequent visits are much more tabletime. Usually at least two visits, sometimes as many as 4, are required to complete the process. (A few of my patients come in long term for various reasons, but very few indeed. It is not encouraged.)

Hands-on is definitely involved - for most people who come. Anything that sounds like wind-up pain, I like to leave alone, at least in visit one. I've had people leave disappointed, people who just didn't get that they would require more prep time, and who didn't return. C'est la vie. Better they leave in the same shape they came in, than feeling worse. I'm happy to say this is so rare it's only happened twice. I learned my lesson with a patient one time whose pain flared suspiciously with the sort of hands-on I do, so I learned to spot the signs, and do not use manual therapy in the first visit with a patient who says something like, "I've always noticed, whenever I get an injury and it heals, even just a scratch, it always feels painful after that - the pain never goes away." Fortunately these sorts of patients (highly sensitized ones with abnormal pain processing) are pretty rare. Most people just have regular persistent pain, good processing, but need some assistance so they can connect dots within their own nervous systems.

Finally, the hands-on part is nothing more than contact with skin, at varying pressures and angles, but mostly lateral stretch. This does nothing TO a person's "body", or TO any of the mesodermal derivatives that lie within it, rather it sets up volleys of firing sequences that have been mapped and studied by neurophysiologists and other curious people, and documented scientifically (by Simon Gandevia and others). One can predict that if one has chosen one's patients wisely, and guided the therapeutic relationship appropriately, Person A will let their own non-conscious system take over all the heavy lifting, let it will change itself/its output into something easier to live with, something less mechanosensitive, less painful, with easier movement to follow.

Like any catalyst, the therapist will have added nothing to this reaction, will have only functioned to help speed it up, and will leave nothing of themselves in the final product.

Ineffability

Speaking of ineffability, there is a manual therapist essayist who is very very good at writing about the kinesthetic kinds of ineffability from a therapist point of view. Please check out Barrett Dorko's essays (listed in the menu to the right).

Right Front Insula

I am about to read Sandra Blakeslee's book, The Body has a Mind of its Own for the second time.

Chapter 10, entitled "Heart of the Mandala", discusses a part of the brain I am particularly interested in because of my work as a manual therapist, the insular cortex. It registers all "incoming" from the body including interoception from organs. You could say it monitors 'business as usual' and remains alert to any fluctuations. It reads the body surface as well. It is both threat detector and interpreter. It is very important in my work to realize this region exists, that it is reading one's interventions continually, and to not trigger it the wrong way.

This region is found in other mammals, but in a rudimentary form. In primates it is much more developed, and humans alone have a level of integration nonexistent in any other animal:

From p. 186:

After reading off the internal state of the body from both the left and right insulas, the human brain - and only the human brain - performs yet another level of integration. The information from both your insulas is routed to the right frontal insula, the same region Critchley found corresponding in size and metabolic vigor to a person's empathic talent.

Your right front insula "lights up" when you feel all the quintessential human emotions - love, hate, lust, disgust, gratitude, resentment, self-confidence, embarrassment, trust, distrust, empathy, contempt, approval, disdain, pride, humiliation, truthfulness, deceit, atonement, guilt.

One's touch, one's handling conveys all manner of conscious and non-conscious intent - the best one can do is intend to be as helpful as possible.

One of the hardest challenges is describing something that has no words, something ineffable. Many years ago while writing a pamphlet describing to potential patients what to expect during a visit, I struggled to describe that elusive interface of manual treatment, that completely subjective zone where hands touch person and physical boundaries disappear for awhile. I wanted to reassure potential patients that I knew how to be helpful without being overwhelming. Finally I came up with a sentence describing my hands. I used the words "slow, light, kind, intelligent and effective". Looking back, I'm quite sure now that the feeling those terms encompass came up from my right frontal insula via the left cortical hemisphere and out through my typing fingers. In fact I'd lay odds that if an fMRI were done on me while writing, it would show that zone never shuts down - it's both my biggest impetus and harshest editor, for better or worse.

David Butler Blogs

David Butler is a PT pain pioneer from Australia. He is researcher, clinician, university professor, and author of three books, two for therapists and one for people with pain. His website is www.noigroup.com ; there is a discussion forum attached to his site which has, alas, been closed for some time now, although it can still be accessed for reading.

This fall he began to publish three blogs. One of these is on Neuromatrix Training. The other two are linked into the banner of this one. I've also linked David's blogs into the menu on the right. Pay him a visit - he has much to offer.

I met David about 10 years ago as a participant in one of his dozens, possibly hundreds, of workshops he has taught all round the world. He certainly lit a fire under my brain, but I seriously doubt I'm the only PT to have been so affected. Carry on David, carry on.