Additional birthday thoughts

Whenever I try to think of ways to deal with this kind of issue directly, I remember all the failed attempts, and also how old she is, and how she has never changed, and... well, why should she, now? ever? She doesn't have much lifespan left, and this seems to be solely my problem, not "ours", not hers - everyone else seems to get a positive vibe from her. It's me being picky, I guess... I would have thought if you're going to become somebody's mom (something I have never wanted), surely the first order of business is to fall in love with that baby and teach them through your physical presence how to fall in love with you. I think there are supposed to be hormones and pheromones that help with that. I must have missed out on transcribing receptors for those, or something, because all my life I've been horrified by the idea of bringing yet another human into the planet minus that good start.

All I have ever sensed in my own daughter-mother relationship is a Chasm, my own yearning for it to never have existed, all the bridge-building materials over on her side of it, and her not ever even having had a clue that such a chasm ever existed in the first place or that I had to learn to communicate with her myself, from the far side of it. I do not have enough objective perspective on this to know if it's just my own idiosyncratic Chasm, or if such chasm-ness is commonplace within the whole human primate species. (Something tells me it might be commonplace and that a lot of what passes as "culture" is supposed to hide it or veil it or distract it from awareness.)

This used to bother me a lot more than it does anymore, having had plenty of mom-related therapy, to do with surviving/coming alive after having been her punching bag as a child - this was known as 'spare the rod, spoil the child' in my parents' farm culture/time era. (Religion was all mixed up in it - this was a big motivation for my learning how to live without such ubiquitous mind-f***.)

Our relationship only ever bothers me on occasion, like this time of the year, the most overlapped part of the Venn diagram comprised of my birthday, my mother, me, our very carefully mapped out relationship; all the essential boundaries installed by me quaver a little bit, I feel that quaver more intensely than I should, because maybe I am more vulnerable than usual. There is no escape from this time of the year, or from the uncomfortable juxtaposition of factors. Not while she's alive. Nor while I am, probably. It's insoluble. I deep breathe, feel my/our feelings, keep moving.
 ................

I love this poem, via Art of Europe, sent me by a friend in Scotland.

This be the verse, by Philip Larkin

They fuck you up, your mum and dad.
  They may not mean to, but they do.
They fill you with the faults they had
  And add some extra, just for you.

But they were fucked up in their turn
  By fools in old-style hats and coats,
Who half the time were soppy-stern
  And half at one another's throats.

Man hands on misery to man.
  It deepens like a coastal shelf.
Get out as early as you can,
  And don't have any kids yourself.

Happy birthday. I guess.

My 60th. Today.
So, my spry, almost 87yo mother invited me to her place for a quiet, uneventful Christmas dinner on Saturday, which only lasted a few hours (thankfully) and tasted pretty good. She invited me out for a brunch on my birthday, an invitation I accepted, which was today.

No exact time had been set, but I was ready by 10-ish... that's what I'm used to as brunch time.
About 11:30 AM I finally got a call from her;

Her: "Are you all set? I'd like to wait until the mail comes - the mail lady is late today - the last time the mail came was on the 24th, and all there was was a Christmas card from the MLA."

Me: "OK, no problem."

The next call was shortly after 12 noon:

Her: " Are you ready to go? I'm hungry, and the mail hasn't come yet. Let's go."

Me: "OK." 

So off we went for the anticipated Belgian waffle with strawberries and whipped cream at Smitty's. As we ate, I heard all about how she cut her finger, how it felt, how it bled and bled and hurt and hurt, what she ate the day before, plans for New Year's eve (a card party at the neighbour's), what day my brother and his family might come to town for a visit/holiday meal. All the burning topics at the top of her list that she wanted to chat about.

I asked her if she'd heard any rumor about Doctor X (her own doctor) retiring.  She said, no, asked where I'd heard that rumor. I told her nothing about where (from whom) I'd heard the rumor but that I'd heard it, and that it was just a rumor - whereupon she launched into the entire scene with the doctors in the city - who had come here, who had gone, their reasons for leaving, who was married to who, all their children, etcetcetc.

She asked me if I had found a doctor yet. No, I replied. I hadn't. In fact the last time I'd been to see one was in 2004. She seemed a bit shocked.

I was about to tell her why, about how the last visit had (by total fluke) coincided with a routine mammogram which had coincided with a bit of arm pain I'd been having from too much typing, which was partly breast pain (intercostobrachial nerve, lateral cutaneous branch of T2, which splits, and the posterior branch goes down the medial side of the arm while the anterior branch innervates cutis/subcutis of the breast), how the mammogram tech and the MD had freaked out about this and had insisted on a second (MUCH more painful) mammogram, and ultrasound exam, plus a clinical exam, all of which turned up absolutely exactly nothing, but which had irritated me a lot. Especially because I knew exactly what was (benignly) wrong already, but no one would listen to me. So I had decided to look after my own health care observation for awhile.

Anyway, I had only just begun, with a first introductory sentence about how I had had a sore arm from typing, when along came a waitress, not even our official waitress, but one who has seen my mother in there often, and who apparently didn't register that my mother and I were having a conversation (and it finally had become my turn to speak), wanted to make small talk with her, didn't seem to have any boundaries around what was appropriate waitress behaviour, i.e., be discreet, don't interrupt guests who are talking.

My mother responded to the situation the way she always has (and no doubt always will) - she opted for the novel, more superficial and therefore safer topic/opportunity, gave the waitress her full sunny attention, as if the waitress were some old dear friend she had not seen since forever, while I, and the thread of the conversation we were having, completely ceased to exist.

Conversationally shot down, bumped by a waitress on my birthday.

Story of my life with mom. Social invisibility. Interruption by waitress (or it could have been anything - a cloud pattern, a leaf blowing against the window) takes precedence; any conversation in which my mother has tried to, or has pretended to, listen to my contribution or story for more than a fleeting moment or two, is severed, aborted, never re-engaged. Even back in the car for the short 5-block drive home, she kept the air filled with casual chatter. She has never wanted to know anything about what I think or feel - thinks she already knows everything. Or she finds me hard to listen to. Or both. 

Other than setting up that unfortunate (for me) dynamic, she looked after me pretty well from babyhood to adulthood. I was supposed to be the passive doll and as long as that's how I was/am/acted/act, everything between us is fine just fine just fine and dandy.

I guess every introvert has likely experienced this dynamic in the company of an extroverted, therefore more socially dominating human, be they family member or anybody; only visible when that person decides it's time for one to be visible and then, if they can get some sort of reflected glory out of the deal somehow. I'm used to this. I grew up with this.

I've got a lot more patience with her and a lot less resentment toward her than I used to; but every so often... like, for example, a day when it's my 60th birthday (about which I'm not that excited in the first place) and I suddenly am made socially invisible by a waitress intrusion, and a mother who in a flash decides that small town chitchat is more important in that very moment, and I sit there reeling from being made suddenly invisible for the billionth time in my life, can think of no slick cool way of re-railing the conversation and/or shooing away the waitress ... I am reminded how much I still hate this particular dynamic, in this case, mother/daughter on top of everything erosive and corrosive it already encompasses.So why do I not deal with it directly? The way I do other things in life?

I normally just stay away from people who vex me and with whom I have no business dealing or who have no business dealing with me; but what do you do when it's your own mother, to whom you were born at emotional disadvantage of cosmic proportions, with whom you've been dealing all your life, sometimes more successfully than at other times? I guess if it hasn't killed me by now it has made me stronger - at least I hope it has. I can hold my own in almost every other non-mother circumstance.

Two years in review

I've never done one of these year-in-review things before, and because the last two years have blurred into each other I'm going to do 2009 and 2010 as conjoined.

So, two years ago I was in Hawaii rethinking my existence on the planet while soaking up rays into my sunstarved self. I decided the sun felt so good that I needed more. I knew I didn't need it on my skin as much as I needed it in my head, so I resolved to get it together enough to move to a different life/place.

2009
The first half of 2009 was about getting ready to move and moving and dealing with the life that was ending so I could move on to the one that was still unknown. To help me stay focused and slide through the transition, I started a Facebook page which just rolled over 4000 members a few days ago, and has close to 2000 links.

The second half of 2009, after I moved, was about recovering from the previous 25 years of light deprivation and the toll it had taken on me cognitively. I couldn't do much but I did whatever I could while I let my brain fluff back up.

2010
The first half of 2010 was about enjoying the spring and delving into new projects, like traveling, teaching, presenting, signing up for a uni program, and trying to figure out how to get back into the working world.

The second half of 2010 has been about immersing myself into study with a bit of webinaring on the side, and starting a bit of a practice seeing people in their homes.

I have to say, I still miss the life I had in Vancouver, which was tailor-made for me/by me, but in the wrong place for me micro-neuro-physiologically/biologically. My mistake. Oops. We move on.

Dealing with depression every winter had started to feel more like "They Shoot Horses, Don't They?" than I could bear.
Recently I found this, Depressive Illness - Curse of the Strong, a fresh package for an old problem, one that sits better with me; I liked this part:  

"This illness nearly always happens to a certain type of person. He or she is strong, reliable, diligent, with a strong conscience and sense of responsibility, but is also sensitive, easily hurt by criticism and has a self esteem which while robust on the outside, is in fact quite vulnerable and easily dented. This is the person to whom you would turn to in times of need, and they would never let you down."

That is a great description of the ideal human primate social groomer, right there. Not saying it's how I am, but rather that I think it's what human primates ordinarily aspire to be before we have to admit we fail at it and have resign ourselves to said failure. Serial failure. Waxing and waning of hope while trying to become some ideal version of a human.

I have to say, while my outer life still feels shrunk compared to how it played out in Vancouver, on the inside of me I feel SO much better, more "normal", more energetic, motivated, etc. I guess a year and a half with no saddle on, grazing about in sunshine will do that for ya.

Looking forward
I just got back from Saskatoon last night, Solstice eve, from a preliminary review committee meeting. A young woman is setting up a project in conjunction with a Master's degree in PT. She wants to study dermoneuromodulation. I'm a member of said review committee, and would be providing the physical treatment. I provided a demonstration for them, pre-organized by them, on the husband of one of the members. We hope to find a way to measure effects of manual treatment on the peripheral, spinal and brain nervous system, using some sort of molecular trace - without my having to learn to touch and treat actual lab rats of the rodent kind, I mean - so we have a molecular pain scientist on the committee.
Very interesting meeting. Very unusual solstice in my experience - lots of questions, no answer, but feels like lots of movement happening. 
My birthday is in another week. Happy birthday to me. If we can come up with some sort of study that can show that manual therapy has a physical effect on the nervous system, and we can measure it (in some non-invasive way), and not just imply said effect based on outcome measures that are ridiculously hard to validate/be completely objective about, it might be a step forward for manual therapy.


Happy solstice and new year - I mean that sincerely. Happily.

Seasonal affective disorder, SAD, depression

Posts that discuss or mention depression, seasonal affective disorder, or SAD:

Winter 2005
 November

Winter 2006
More teaching

Winter 2007
"Rage Against the Dying of the Light": A Survival Plan for SAD
SAD progress report
Surfacing from SAD
Not so SAD anymore

Winter 2008
Barry Beyerstein on Pseudoscience and other related matters
Thoughts on Solstice Eve on Life's Absurdities
Happy people and unhappy people

2009/10
Does depression have an upside? 
Nucleus Accumbens
Robert Sapolsky on depression
Fresh spring, fresh start
Lull
Noticeable improvement

Posts about moving away from Vancouver

1. Insular winter wallowing
2. Making progress
3. Adrienne and my cranky leg
4. Progress toward "impeccabilization"
5. Oozing toward the move
6. From the waterfall to the desert
7. The first lap
8. Ready for the next lap
9. Nothing yet
10. Might have an offer
11. Sold
12. Huge blue
13. Letting go
14. Selling the practice
15. Final day at work
16. Monday monday
17. Wednesday Wednesday
18. Friday
19. The silent auction continued
20. Mini-vans
21. Aloft
22. The final weekend
23. Tonight, tonight, won't be just any night
24. Made it.
25. July 27/09 - first day of the rest of this life

All the Hawaii vacation posts

This post is just a collection of all the blogposts I made about or while I was in Maui.
There is no new content here.

1. First day of vacation
2. My old friend Sleep! Welcome back!
3. Photon therapy
4. same shot different day
5. Scary road in Maui
6. Day 6
7. Ocean at dusk
8. tourist shot
9. Kona Storm
10. Luau
11. Luau 2
12. Luau 3
13. Vacation time share pitch
14. Vacation time share pitch II
15. Vacation time share pitch III
16. Gecko invasion
17. palm tree picture
18. turquoise and purple ocean
19. Day thirteen
20. lavender dawn
21. lavender and lace
22. Dawn day 14
23. Thoughts on Solstice Eve on Life's Absurdities
24. Solstice Greetings
25. Solstice Greetings II
26. Solstice greetings III
27. Solstice greetings IV
28. Solstice greetings V
29. A touristy day in Lahaina, Maui, Part I
30. A touristy day in Lahaina, Maui, Part II: Monster of the plant world
31. A touristy day in Lahaina, Maui Part III: my salute to the Hawai'ian flag
32. Exercising permeable boundaries
33. Surf's up 
34. Last day  

Things are moving fast (relatively)

So, last week my mother (who has decided to be my agent, on her own advisement apparently) called up the local media and arranged for a reporter to call on me. One did. I gave an interview and prepared to burrow back into my intensely interesting studies.
Then, the story was published on Friday (if you really want to view, go to Weyburn This Week).  Since the story was published - front page no less -  I've had 4 new patients call me. I feel such a business crunch!

Really, I'm joking. I have such a sweet laidback life now. But with this sudden minor avalanche of patients I suddenly found myself faced with the necessity of having to get a car again, after nearly 3.5 years of not driving or needing to or having to own a car and endure the hassle and expense of licensing, insuring and maintaining one. It's been a fabulous car-free existence, but now I need to get around in winter and carry some items to peoples' homes, so a car is in my immediate future. My brother, a trained mechanic and service manager for Saturn, an ex-GM make, found me a nice bright yellow, cheerful sporty used Saturn that he has personally inspected, serviced, recommends highly, and will fit with a set of new all-weather tires. It will be yellow like the car in the top picture, but with funny back doors like the red car on the bottom. The back seats fold down for ginormous trunk space. I sort of look forward (as much as I don't want the bother) to driving this little car around town. I might even get a sign for the door - Sensible Solutions Physiotherapy. (Registration of the name is in process. Once I've been registered I can get business cards made, etcetc.)

So that's me, this is my new life, juggling being a home-visit therapist/uni student/writer/human primate social groomer/neuroelastician/aging daughter of a very vigorous elderly parent who still runs my life every chance she gets. I kinda don't mind though - I've got a lot more patience with her now than I used to- I know she's only trying to be helpful. I'm all too acutely aware that she doesn't have that many more years left in which to be bossy.

Noticeable improvement

A lot of what this blog is about is to be a place where I can roar and kvetch and indulge myself when I need to, and track my own state.
I don't mind if others read this stuff, but it's not polished and I make no apology. It's a journal for petesake.

Anyway, I have noticed as November slogs on, a wonderful and welcome relief from seasonal affective disorder this year. Last year, I had already moved back into the light but I don't think my brain adapted immediately to the absence of Dreariness - it was still anxious and all hand-wavey and -wringy for a long time, even though it didn't feel as disabled as it had in previous Novembers.

This year I'm burrowed in and have my mental canines embedded in a juicy course which (while some of it gives me fits, as I've expressed in the post previous to this one) I am really loving;  and I love the way my brain is sucking up this stuff as though it were starved for it, and I'm loving the feel of the motivation it has for the project. My brain works properly again! Yay! And it's November 20! And I don't care! I don't feel it! I'm happy for a change in November, cognition not buried by some uncontrollable natural light level. There is plenty of light now. And I could not care less that it's minus 15 Celsius, because I'm warm and comfortable in my high-up condo from which I can see the sky and all its light and the backdrop it provides for wicked blizzards or sparkling frozen water vapour or intense sunsets. I love to attack the snow on my balcony, fight it, keep it swept away. I feel like such a hero cleaning off my deck - during the recent blizzard I cleaned it off three times in one day - no way is snow going to win! - I am the captain on my deck! (Yeah yeah, I know, it's lame, but hey, a woman about to be 60 in a few weeks still needs to feel victorious about something so chooses her battles effortlessly and only the ones she knows she will win. Schmutzhaken is my snowhook. )

I feel vindicated for having moved at the right time to (apparently) the right place or at least "a" right place. I moved before it was too late to extract myself. Good on me.

Neonates and nociception

So, I'm feeling all queasy right now. And angry.
I've got to get this dealt with so I can continue studying in the cool online Pain Management Certification Program that started 7 weeks ago. 

All was well until I got to a fabulous lecture by a UBC OT, Liisa Holsti. I want to stress it is not her fault I've gone off-track and need to rant here for a bit. Not at all. In fact, her lecture is exemplary for being low-key and even-toned and academic and non-emotional and factual and supported by the literature, etcetcetc. She couldn't have presented anything more correctly or beyond reproach.

No, my anger is not at her, not even a bit.

The bile I can taste in my mouth has to do with all the stuff going on in the world that she is describing and studying. The fact that she has to study it in the first place. The fact that medical obliviousness to nociceptive capacity in full and preterm babies, in the first place, has led to such a socio-cultural adaptation of the medical system, that preemies get heel-poked 15 times a day, their little immature neural crest peripheral sensory neurons do their best but fail to handle all the stimulus successfully way upstream in time (because they aren't even developed yet!) such that downstream, after descending inhibition systems have hooked up, those descending systems have way more to deal with than they ever should have had. The fact all this came about a few decades ago all coincides perfectly with the chronic pain epidemic we're now in, and no one seems willing to point fingers at the iatrogenic components of it. It makes me very, very cross to learn about this; maybe I should have stayed ignorant. Wait, no, that's not usually a great way to be... so, for now, bear with me as I continue to swim, academic rope still between my teeth, into a large area (how large, I have no idea) that feels and smells a lot like culturally produced human cesspool.

Some basic factoids:

Image from http://www.frontlineint.com/

1. Humans are neotenous. We are born way early compared to other mammals and primates, whose nervous systems are developed enough to be able to move independently long before human systems are. We have to be, because our brains end up 5 times larger than the size usually required by mammals our size. If we stayed in the womb as long as it would take to be able to run around shortly after birth, our mothers' pelvises wouldn't be wide enough for them to successfully squeeze us out. The human/evolution compromise was to remain physically helpless a lot longer, dependent on a mom.
2.  Neural crest (sensory neurons, autonomic system peripherally, cranial nerves, glia, Schwann cells),  neural tube (brain, spinal cord) and epidermal derivatives (skin and sensory receptors) are like a three-ring nervous system circus; these three broad populations of cells that will eventually coordinate nervous system business arise independently from each other and don't braid together properly until at least a couple weeks after birth.  This is a critical window of time for a sensitive nervous system, and most of us just squeak by - with luck, no premature birth, and good careful responsive sensitive maternal handling, our sensory systems catch up without getting too overstimulated, without too much harm done. But... but....
3. What if we're born so young that all sorts of genius human primate grooming of the medical sort intrudes itself on our fragile little systems? Think about it. (I did and my mirror neurons made me want to scream and go fight somebody.) Think of a baby this tiny getting poked in the heel as many as 15 times a day.
4. Sensory neurons are present in an embryo on day 12 - DAY 12! of gestation. In gestational week three they already start to hook up to the spinal cord. C-fibers, which can't carry as much information and have a higher threshold if they are nociceptors, don't hook up in the spinal cord until 5 days after a normal term delivery. This means that the fibers nature provided us with, to convey nociception, are lagging behind actual nociception, and big fast accurate sensory fibers that are supposed to carry ordinary sensation have to carry, and are being sensitized to, inappropriate (for them) noxious stimuli instead. An analogy might be something like child rape - a human system is forced to have to endure something long before it's ready. (Maybe that's what's so sickening here. This analogy bothers me even though it's an appropriate one - the very existence of child rape makes me feel exactly the same, like I want to plow somebody in the face.)
5. The brain isn't fully grown up until the third decade of life. It can feel noxious stimulation  (Slater et al 2006; Bartocci et al 2006) - but it can't do anything about it yet. How much does that suck? This is all evolutionary hangover. The peripheral nervous system and spinal cord evolved before the brain did. Tough darts - that's just the way it turned out. Now human embryological development is stuck with it.
6. There is a surplus of neurons present at birth. More bad. They get pruned by a few weeks postnatal, but until then, it would be better not to rile them, because they can totally sculpt and script a bunch of cord plasticity, and not in a favorable way. Argh! Sigh. 
7. The system is more excitable than inhibitory, the receptive fields are much bigger, skin is thinner with (excess) sensory neurons right out to the edge of it ("hyperinnervation"), and look at the relative size! (see picture). A baby heel is much tinier, plus it's packed with 20% more large sensory neurons, sensory neurons that can "feel" all sorts of stuff but are in a system that still doesn't have anywhere "absorbent" to receive their overstimulated info into! So all that nociceptive noise goes into the spinal cord, dorsal horn (the very very innocent and undeveloped and as yet incapable dorsal horn), up dorsal columns too, maybe, some of it, and the reverb in there is terrible. The dorsal horn can't contain it and it just echoes around, spreads all over the place to lots of other inappropriately receptive spinal segments, scuplting the system as it goes, because the system is oversensitive AND undermature.
8. Yeah, I realize that a preemie might die without all the medical attention. I realize anxious helpless-feeling parents want and need all the help they can get from whoever they can get it from. But I gotta say, if I were a preemie nervous system, I'd want to tell the world to butt out, let me snuggle with my mom for as long as I could and let me die (if that's what the future had in store), relatively happy - I would not want to face a great long human life span with a nervous system that had been primed by well-meaning but blundery medical intervention to potentially hurt me for the rest of what could be a long and otherwise fairly healthy life. What about my sad parents? Well, yes, all this would indeed be sad for them, but they are the supposed adults, my life isn't supposed to be a sacrifice for them - I didn't ask to come to endure it, they invited me to their party, and I should be allowed to leave if I can't find it put-up-withable. Shouldn't I?

Nov 8 Postscript:
I'm back in this post today to let people know I'm over being angry, and back to merely being depressed about this and about the over-all medical, business-as-usual assumption that babies feel less pain/feel pain less because they are underdeveloped.

I'm over it. What makes me ongoingly, grindingly, perpetually mad, mostly, in PT or medicine or anything else to do with health care and its delivery, is the observation that people seem to easily give over their own primate-given ability to use good sense and sensitivity, to mindless human  protocolization, what I call "zombification" of treatment, through wrong-headed reliance on or worship of "standardization". In my opinion this makes the working grind easier on people but at the same time I think it dulls people to the feelings of others, of patients - it really does. It makes them do things in a ritual way rather than in a way that would connect them to that patient's process, or if it seemed to be "nocicepting" somebody, decide to not do the thing at all or figure out a way to do it that doesn't hurt. And what do humans have an abundance of? Love for ritual for the sake of ritual. That's REALLY what P's me off, but about humans in general, and about the way the working world turned itself into factory and then the hospital world turned itself into a caricature thereof. I don't know how to deconstruct that, but I hate the feel of it, always have. Poor wee babies. 


Nov. 12: Another postscript: This just in: Reducing Neonatal Pain during Routine Heel Lance Procedures by Carla Morrow et al. 

Abstract

Purpose: To measure the difference in pain scores for newborns who were held and swaddled while undergoing routine heel lance procedures compared to newborns who were lying on their backs and not swaddled during heel lance. Additionally, we sought to compare the total amount of time it took to collect the specimens in each group.

Design and Methods: A total of 42 neonates recruited from a large tertiary hospital were enrolled in a randomized controlled trial. Infants in the experimental group (n = 22) were swaddled and held in an upright position during routine heel lance procedures while neonates in the control group (n = 20) remained in a standard care position. Pain was measured with the Neonatal Inventory Pain Scale (NIPS) at two points in time for each group (just before the heel lance procedure and at the completion of the heel lance). Total collection time was measured using a stopwatch accurate to 1/100th of a second. Specimen quality was measured based on the number of rejected specimens for each group. Descriptive statistics and t tests were used to analyze the data.

Results: The mean NIPS score for neonates who were swaddled and held during the procedure (experimental group) was significantly lower (M = 1.3, SD = .9) than the score for infants in the standard position (control group) (M = 2.7, SD = 1.3), t (40) = -4.48, p < .001. Although the total collection time was lower for infants who were swaddled (2 minutes and 17 seconds, SD = 59) versus (2 minutes and 47 seconds, SD = 85) for controls, this was not a statistically significant difference (p = .45).

Clinical Implications: Swaddling combined with positioning neonates upright during routine heel lance procedures offers nurses a nonpharmacologic method of neonatal pain reduction for heel sticks. This technique can be easily implemented on any unit independent of facility protocols. Furthermore, the technique is not associated with any cost or policy development, making it more likely that nurses can use it in practice.

I found it here:  Hold the patient; help the pain?
(Nice. It still makes me shake my head, however, at what strange versions of primates we've become as humans that we have to bother constructing expensive research to prove to each other/funders/medical business-as-usual that something as simple as holding a (likely) existentially-terrified (anyway) baby will have it register less noxious stimuli or reactivity by holding it. Sheesh... other primates would likely already have this all figured out - instinctively.)

Ronald Melzack: Pain Pioneer

 I attached this to the Facebook Page, Neuroscience and Pain Science for Manual Physical Therapists, and now here. Very nice little video about Melzack's life and work.

New bursts of energy

I think going to school is good for me. My brain seems to be working better again.

Lately I had thoughts about going back "to work" - i.e., treating patients again. I mentioned to my mother at Thanksgiving that I had been thinking about something simple, something that would leave me in control of my time, something like doing home visits. I even told her the name I picked - "Sensible Solutions". I don't have business cards yet, but I know a place where I can get some made, and I went out during the week, picked out a file cabinet, had it delivered, moved my office all round and repositioned and reorganized all my book shelves, moved the desk to make more room but still get a lot of light from the window, made a space for my computer setup - two large screen computers in a nice little semi-circular nest, for "going to university"; I still had room for a small oak roll top desk which will become the place where I sit to write patient files. Today I went out and bought bright yellow file hangers to put in the new file cabinet. It has three large drawers. Lots of room to expand if/when my new "practice" takes off, and meanwhile, lots of storage. :-)

If it does take off, I'll have to get a car soon. Drat. :-[
But I'll think about that if/when.

I got my first official call this morning, and first appointment arranged today at 5PM - a friend of my mom's, 83 with back pain. She had surgery last year to remove no-longer-useful organs which were growing cells that no one thought would do her any good in the long term, but allowed none of this to stop her from participating in the senior Olympics here in Canada and taking home all the gold medals in her category... she is the only entrant in her category, but that's kind of beside the point. She goes to the lovely rec center here and trains several days a week, so I know she's motivated.

Now, at last, so am I.
Whatever my brain needed a rest in order to go off and do, it looks like it's close to being done, and after having had an opportunity to marinate in sunshine for the last 15 months, is getting ready for a new life, mental molt finally over with.

I've got two bags to carry over to her place (she's only a block away) - one contains a foam bolster and the other my treatment gadgets - block wedges, foam rubber square to give me more traction on skin, stretchy tape and scissors. I will take a treatment gown along. Got lots of those.

A flow chart for alt therapy

This is the funniest thing I saw all day today. From Science, Reason and Critical Thinking blog, A Handy Alternative Therapy Flowchart. Thank you for this, Crispian Jago.

"Touch is good" - HumanPrimateSocialGrooming manual

In a recent SBM post, Mark Crislip discussed reflexology among other things.

He said,

“Monkeys, and other animals, groom each other often with a marked reduction in stress. Touch is good, and one doesn’t need to wrap it up in pseudoscientific nonsense for it to be beneficial.”

To which I replied, in the comment section,

"Thank you for saying that Mark; I’ve been saying the same thing for years. I call it “human primate social grooming.” Most human primate social grooming professions/professionals dislike the term, for some weird reason. Oh well.

Diane, human primate social groomer and manual therapist with a PT license to touch people."

Another commenter suggested that it was more succinct to use the term "pedicurist", which I took as an opportunity to explain the difference between operator model of human primate social grooming and interactor model of social grooming. So, I replied,

"Well, strictly speaking, any profession that is licensed to touch human beings for whatever reason including hair dressers, dentists, pedicurists and medicine, could all be considered human primate social groomers, I think.

It’s the “WHY-we-touch” that shakes the idea into layers, I think.

Those who touch to get a specific job done, like get a tooth out, get a toenail clipped or a callous scraped off, or hair cut, or appendix out etc., i.e., have an obvious, clear, objective purpose for both patient and practitioner to focus on; these practitioners have the option of being ’something more than just’ human primate social groomers. We could call these people “operator model” human primate social groomers.

Those who groom humans specifically to help them with nebulous perceptions and experiences of stress/pain, are (fundamentally) practitioners of what I would call the “interactor model” of human primate social grooming.

Could a desire to be more “operator” than “interactor”, to have some externalized reason for treating no matter how imaginary, i.e., a treatment “concept”, be a big reason *why* human primate social groomers (and now I’m talking about only the ones like me, interactor-model ones who touch to relieve stress and reduce pain perception/experience) made up (and still make up!) crazy ideas like acupuncture meridians? Trigger points? Subluxations? Untestable and unprovable? then go on to develop complicated ways of treating them?

I’m content just treating human primates with pain problems nowadays, supported by pain science and neuroscience, rather than trying to learn to treat crazy concepts some other groomer(s) invented once-upon-a-time for fun and profit. I guess this makes me a full-on, out-of-the-closet, interactor-model human primate social groomer on the lowest possible rung of the human practitioner hierarchy; oddly, though, I find it the most comfortable place to be, the most science-based, with the least distance to fall.

Diane, human primate social groomer and manual therapist with a PT license to touch people/many opinions on the matter"

I would add, any idea about anything anyone thinks they can affect below the surface of the skin must be put carefully through Occam's Mental Meat Grinder before being adopted as verifiable fact.

* The truth is, we can't literally touch anything but skin.
* The truth is, skin (cutis/subcutis, the actual organ of "skin") is thick. (It's also rubbery and full of physiology, busy-ology)
* The truth is, we can bend things around a bit, things that are located inside, beneath skin, but we cannot "touch" them - only if they are exposed, as in an operation, can we literally touch them.
* The truth is, we are probably mobilizing neural structure a lot more than anything else with manual therapy


Which means, when we treat, we are using our imaginations a LOT.
It's ok to use imagination, but it's not OK for one group of PT or manual therapy imagination users to claim higher scientific turf than some other group of PT or manual therapy imagination users.
Get real.
What do you think you're testing/treating? What you imagine you are touching/affecting, instead of what someone else imagines they are touching/affecting?? How is your science based on whatever you think you can "operate on" under the skin ever going to be more than more tooth-fairy science, based on some hypothesis which is implausible because you can't get your hands literally on the thing that you are trying to affect with your hands, and you cannot rule out the fact that the patient's brain/neuromatrix is being very attentive to you and anything you try to do to it with those same hands? Give me a break.


Adoption of an interactor model would slice the matter in several novel directions.
a) we would be more science-based.
b) it would place neuromatrix and biopsychosocial models of human pain/function/dysfunction ahead of orthopaedic and biomechanical and other (also largely pseudoscience) operator models.
c) it's already pretty hard to design experiments that can test aspects of manual therapy.
d) adopting an interactor model would make things even harder.
e) we would, however, as clinicians, be on much firmer scientific ground.
f) why strive so hard to build an evidence base, based on operator models of treatment that contain such implausible tissue-based hypotheses (biomechanical, craniosacral, myofascial, triggerpoint, joint-based, reflex zone, acupuncture, you name it) in the first place?
g) adoption of an interactor model would make things harder but also easier. We could work toward improving what already works, i.e., the verb of therapeutic contact, as a new social element of that individual's biopsychosocial, pre-existing landscape, the entry of oneself as a therapist, with a social-grooming interactor role, into that person's neuromatrix. Not have to try to substantiate the noun (and therefore, myth(!)) of some system for
- supposedly pushing a joint sideways and thereby supposedly decreasing nociceptive afferent stimuli, or
- supposedly bending a suture somehow and thereby supposedly squishing cerebral spinal fluid around thereby supposedly decreasing nociceptive afferent stimuli, or
- supposedly physically stretching fascia (of all things!), a tissue whose job is to keep an organism and its layers from falling apart..
- etcetcetc.....
h) what is the element common to both the operator model (even though the operators won't admit it) AND the interactors? Skin.
i) Which takes us all the way back round to the question, "What are we really handling?"

Answer: The surface of someone's body. All the representational maps stored in the brain of the individual we are touching. All the feelings, thoughts, beliefs, impressions, perceptions that individual has stored up over a life time. The person has the pain problem. We don't. The person has to fix his or her own pain problem. We have to try to help them.

It's that simple.

It's a grooming encounter and they have a pain nit they can't reach by themselves. They need someone outside to verify it, so they can begin to downregulate it. Maybe it's a little, buried, default primate social need our human primate brains still have. I don't know. But I know we don't have to press very hard for that. We only have to apply a bit of judicious and NON-nociceptive stimulus to that person, at the right speed, for the individual. They need to become more aware of their body and simultaneously less aware of their pain.

It's that simple.

Handling skin properly is simple: Do anything to it you want, just avoid hurting the person through it, and the person's brain will take care of all the rest. Bear in mind what I will now call the...

First Law of Human Primate Social Grooming: Do No Nocicepting

Stick to that law even if the patient seems to have a high nociceptive threshold, even if they "think" they should pay for gain with more pain, even if they kid around and act tough, even if they've been told by countless other treaters that it's OK, just suck it up. Don't get sucked into that movie, people. Stick to the First Law and you will never have to hold yourself responsible for having created a new chronic pain patient.

They are out there, you know... Life is a verb, not a noun. The brain is a verb, not a noun. It interacts continuously with its environment, both inner and outer. Those whose nervous systems aren't organized quite normally, who perhaps lack the means by which their cells can produce that absolutely crucial opioid receptor in quite the right synapse, or whose systems go haywire and produce way too much Substance P or some other excitatory substance which can jimmy the ordinary downregulatory system... those people are out there. Yes, they are rare, and yes, they might instinctively already "know" they don't tolerate rough-house well, but some of them may find their way into your clinic regardless. They only want what any patient wants - some professional interactive human primate social grooming from someone who will take them as a person and all their possible baggage into account while being in therapeutic contact with them, and leave them explicitly with the locus of control over the treatment. If it happens to be you, and you didn't interview them enough to pick up they aren't appropriate for your kind of manual treatment (or manual handling, period), don't set the context correctly, or you wander off into your own operator mentations inappropriately or at the wrong moment, or you haven't told your patient to tell you when your handling feels uncomfortable... congratulations![not] - chances are pretty high you may have just initiated another person to the (already too high) chronic pain population. Oops. You (and your treatment idea) became their tipping point. Now you'll have to live with that, and (much) worse, so will they. No one starts out thinking they'll end up in chronic pathophysiological pain - they just do. Don't play any role in making worse problems for people than they already have.

If you're going to be a human primate social groomer, for goodness sake be an intelligent one - think about stress reduction - get that person's stress levels down before you ever begin - set the stage. Make it easy for yourself, and for them. Make it clear they are in ultimate veto charge of you and your handling. Make it a habit to give them cognitive material in the form of pain education to work with. Human primates need that as part of the human primate grooming process; those big frontal lobes need information to chew on throughout the process. With stress levels down, the individual will be more apt to incorporate you and your contact into his or her body schema, and good things will have a better chance to result. Go slow - the slower you go the more that person's brain will be able to take in what's going on and use it best to help itself.

Additional reading:

1. Bennedetti: The Placebo and Nocebo Effect: How the Therapist’s Words Act on the Patient’s Brain

Pain management certification program

So, I'm into the second week of this post-grad university certification program in pain management out of U of A that I signed up for in June. I am loving the feel of having an academic rope between my teeth, swimming swimming swimming through oceans of information, pleased with myself for learning how to use the university's RefWorks reference manager and make automated bibliographies (the waterwings and flippers and mask provided). The university librarian who is connected to the class even made herself available by phone to support me through the hugely stressful process of learning how to use it (how to actually swim with the wings and flippers and snorkel mask). It's a lot different than regular, nose-barely-out-of-the-water sort of swimming I am more familiar with. It's a lot more three-dimensional and you can stay underwater a long time, build all sorts of underwater storage bins for the sea shells you collect - they stay alive but you can restrain them. Move them around however you want.

A lot of the information I already have investigated, so the content isn't really very hard so far - this gives me a chance to play endlessly with shaping it and investigating it from all sides.

I'm really glad I moved out of Vancouver and the struggle to survive there. It sort of sux that I needed a whole year to recover, but that's likely just my brain doing its thing. It feels like it works a lot better now than it did a year ago, and even though it still reacts to stress with overwhelm at times, the stress seems more manageable and the brain seems to recover a lot faster, like one good night's sleep.

I haven't been idle. Looking back over the past year, particularly the last 6 months, I've done more traveling than I, within the same time frame, ever did before in my whole life, have gone to new places and done new things, have stretched out lots of capacities that would never have been stretched had I sat in Vancouver and slowly rotted beneath the cloud cover, feeling like my mind was covered in green mold.

Now it feels perfect to be stretching in yet another new way, going back to school after 35 years of not going. I always loved going to university - went just for fun, studied the darnedest things just because I was curious. I love that the whole thing is online and the classroom is both synchronous and asynchronous - I don't have to get organized to leave the house, don't have to waste time commuting! I just wish I could go for free. I'm fifty-nine, and I think the university should cut people over 55 some slack the way UBC does (or at least did once - I don't know if it still does..)

Look out world. Diane might be ready to grow some new wing feathers one of these days. She said optimistically.

Dream

Along with all the rest of humanity, I watch as a gigantic sphere approaches, slowly. It is very far away and hazy, but as it comes nearer it looks like a huge mirror ball, twisting and glinting, its surface reflecting from billions of small facets.

Oddly though, the closer it comes, the more it sizes itself down to human scale; finally it lands, softly, small enough to fill a small room, easy enough to approach now.

I approach, fueled by my own curiosity, without any fear.

Once up close I realize that what looked to be small mirrors from a distance are actually face-sized windows, through which one can peer in. I find a window. I peer.

I see nothing but a big slow swirl. My sense of disappointment tells me that I must have picked the wrong window. Others are peering in and have become fascinated by something, riveted to their view. I conclude that there must be a certain window for each human, a unique view for every individual. Yeah, that's it - I simply haven't found "my" window yet. Nobody is fighting over windows, so there must be one for everybody, there must be one for me somewhere. I move about, examining available windows, looking for the window through which I'll be able to see whatever is in there that people are exclaiming over.

Finally I find my window. When I look in through it I see all of human history and past that all the way to the beginning of time. The view is strangely telescopic and wide-angle at once, and I can see all the way in to the center, the start point, and all the way out to the surface, the present moment; I can stop at any focal length to examine any point in time I want.

This must be it. This must be what others see, and are busy looking at.

I see a species called human, which has evolved and took its place recently and to which I belong. It is unbearably maladapted to the planet, physically and emotionally maladapted, yet has spread all over it.

I see when it lost its fur. This was a very pivotal wrong turn. At least, as I see it, through my window, that's how it looks. From that point the expansion was more than just gustatory survival - it looks as though it was a starting point for what follows, a planetary expansion that has been based on need, greed, and in more recent days, making the earth bleed by sucking out as much oil as humanly possible. The liposuction of the planet until it begins to heat, and cave in on itself. Pretty gross.

I see that religion might have started out as a well-meant coping mechanism, a cultural adaptation to try to keep peoples' minds off their own individual fates, a distraction from the pain of realizing that once born, we're all stuck here until we die, forced to scratch out a living by using up a planet. It looks like it accelerated along with everything else though, and, from my perspective, through my window, backfired; it turned into an accelerant instead, serving to zombify rather than merely assuage, justify rather than clarify, lubricate the "descent" of humanity as it continues creating "hell" on earth, rather than support individuals as it was intended. I see science as a cheerful, determined attempt to mop up, but mostly after the fact and mostly also having become another accelerant. It seems no matter what humans try, what seems like maybe it was a good idea at the time becomes institutionalized and exploited to turn the process into more and faster destruction.

I wake up.

Life at a basic bio level

So, today as I surfed around I fell into reverie about life at its basic biological unit, the cell. Not just the human cell, 300 kinds on the spectrum from most structural to most signally (i.e., meso to ecto, meat/bone to brain), but this time, how foreign bits of life invade, how our culture assists this to our occasional individual detriment, how we are basically just walking condos for microbial life, how apart from just an occasional sense of dismay, I've learned to accept all this and mostly roll with it.

This story from Superbug blogger Maryn McKenna, about brain amoebas contracted by innocent transplant recipients from organs obtained from a donor who had died from encephalitis got me started. Then, I tracked through a few of the other Superbug blogposts and found this: Outbreak of superbugs: The Singing Doctors (a youtube video). Apparently these guys go on tour, putting on musical shows about the US health care system. This seems absurd to me; but then, I'm a Canadian and there are many, many things US that seem absurd to me.

If you haven't thrown up enough yet, check out this: picture of baby licking pig's snout - eyeeeeeew. Talk about exposing your immature immune system to all sorts of adventure so that it can develop itself into something robust...

Microbes certainly have a way of having their way. I have a feeling long after we're gone (as a species) they'll still be around, no doubt inventing new forms of warm, anaerobic habitat they can drive around and symbiose with, completely supported by evolution, respecting all the laws of thermodynamics.

Ronald Melzack and the Canadian Physiotherapy Pain Science Division

It's good to have long term goals, right? One of mine is that every PT on the planet eventually be exposed to Melzack's neuromatrix model of pain (5 page pdf), and learn to see being a PT as equivalent to being a neuromatrician. Another goal is to have every manual therapist realize the two main input domains* of a neuromatrix they can favorably influence, and why it's important to be careful what is put into them, and how. A third is that each therapist would operate from a working knowledge and awareness of his or her OWN neuromatrix while working on another's (interactor model of treatment), and not merely from recipes and protocols and paradigms that elevate structural tissue above signaling tissue (operator models of treatment).

With this as the backdrop I attended a reception at the recent IASP Congress in Montreal, to celebrate the lifetime contributions of one of Canada's most famous if not THE most famous of pain researchers anywhere, Ronald Melzack.

He had not met us before (except perhaps Dave), although he wrote a message of support at our request back when we were trying to organize a proposal to become a Pain Science Division of CPA. A line of people were wishing him well as he made his way out of the room after the reception. He was moving toward a larger brighter lobby for some pictures with all the grad students he had worked with over the years. I positioned myself at the end of that line, introduced myself and told him who we were, thanked him for all the work he has done in his life, remarked that I would like all physiotherapists to become neuromatricians, asked him if he would be willing to let us have a picture with him. He was very gracious and more than willing. It was the highlight of the trip to Montreal and perhaps my whole life. I can now die, anytime, a happy woman.

* Cognitive-evaluative and Sensory-discriminatory

Snippets from IASP

Luggage finally arrived home yesterday. This is good, because all my notes and materials from the Congress were in it.

Pain Mind and Movement Symposium
A whole day of presentations, lots of science, lots of graphs, lots of dark slides of graphs in a dark room. I gotta say, there wasn't as much zip as I would have preferred. Some presentations stood out, like that of Michael Sullivan who is looking at how to test for a sense of "perceived injustice" in injury cases, teasing out the manner and degree to which it impacts a pain experience. He used video clips - much more interesting than plain old power point. Maureen Simmonds showed video clips of her movement lab - she uses virtual landscapes projected onto walls and tries to determine if illusory surroundings have any effect on perceived pain or effort while walking on a treadmill. Catherine Sabiston talked about mastectomy patients and dragon boating, and something called post-traumatic psychological growth, but not pain specifically. It sounded like if everyone would just bond while being active no one would care if they had pain or not. I don't know - I'm sure there's something to this but I'm also pretty sure that not everything emotionally or physically or socially painful is due to dragon boating deficiency.

There was a break for lunch, which turned out to be lunch from a box, not the most inspiring lunch I've ever enjoyed. Several of us gathered round large round tables. I sat with some people I knew from being online and a young woman from England I had just met. The conversation roamed around and landed on the topic of pain and biomechanics, something I have done some thinking about. As we talked about how to uncouple the two ideas to free the minds of PTs from the shackles of conflated thinking, the English girl said, well, wait a minute, I have a foot pain, and it goes away when I slide T12 to the right over L1. I couldn't let it go by: Really? I asked; Do you think that's the only thing going on in your body that matters, is that you move a few bones relative to each other? How do you "know" you are even doing that? I was questioning her assumptions but she responded as though I had punched her in the gut. She replied that that's what she did, and it took away her pain. I looked at the others and said, mesodermalist. A lively discussion followed but the English girl might as well have been listening to jabber from an alien planet, because she knew what she knew and what she knew was fine by her. Or something. I think she's another meme victim of "motor control." I checked around and see that she wrote a chapter in a book about movement published in 1998. She's been attending congresses like this, one presumes... maybe she still imagines that other innervated tissues in the body, besides bone and muscle, don't matter to the brain. Maybe she's never considered that physically therapeutic ways to approach the problem of pain exist, might include a bit of, but are in no way restricted to, "motor control". It's the 'blinkers attached to the side of the head' problem I've seen ever since I started up in this profession 40 years ago.

The afternoon session included more dark powerpoints in a dark room. The final session was a "roundtable" - a refreshingly lively microphone session where anyone who wanted to take the mike could. Steve George started off with a confession that he was a recovering biomechanist. He had presented earlier but I probably had zoned out by then on all the powerpointage - my ears were sharp now however. He was followed by a bunch of other fed-up people, all on a similar page about the state of PT and what could be done about putting pain further forward in the focus of the profession. I didn't get up at the mike - I'm more interested in what others more eloquent and extroverted than I have to say, and I'm better at writing than talking. It was great to be there and realize how not alone I am in my disquiet.

The wine and cheese slated to follow the day had been canceled.

IASP in Montreal - post event snippets

This is a series of little personal and professional snippets, vignettes, from the IASP Congress, held in Montreal Aug. 29-Sept 2 2010.

Lost luggage (again..)
I got back Friday afternoon (Sept 3), minus my luggage, lost somewhere in the bowels of Toronto airport by Air Canada in connector flight limbo, for the second time in 4 months. It has yet to arrive - the first time it was lost by Air Canada as I came home from Brazil, it arrived the next day. This time the wrong bag appeared at the bus station. Someone else must be in Air Canada luggage hell with me, our suitcases delivered to each other. This is getting very stressful. No more Air Canada for me I'm afraid. I'm already going through a mourning process more severe than should be necessary - especially once I realized I had packed my notebook FULL of scrawled notes taken at all the presentations. That really sux. The clothes? Meh. The shoes? Meh. Replaceable. But the two hard cover books, a dental pick, favorite scratchy Japanese bathing towel, MUCH harder to replace; the bamboo back scratcher that was my dad's before he died, and the note book (!) - irreplaceable!

The Melzack reception
It was the first time I'd ever been to an IASP Congress, ever. I knew they occurred but this time I wanted to go specifically to attend the reception for Ron Melzack. I not only was in the same room as he was, but I got to meet him, shake hands, and have a picture taken with him and the other members of the CPA Pain Science Division who attended. The photographer is a retired neuropathologist married to a Canadian pain physio we know, who said he'd email the photos but hasn't so far. When he does I'll post one. This event is the highlight of my life so far.

John Loeser presented a slideshow of Melzack's life and work, lots of photos of his childhood, family, vacations he was on, people he met and worked with, with lots of hair and without, all the way from age 10 to now. I was previously unaware Melzack had written books of stories of the indigenous peoples of the far north. He was there with his wife in her wheelchair, gracious and charming, shorter than I had expected. There were probably close to a hundred people gathered, beautiful food, plenty of wine, lots of huddle around the guest of honour.

I really wanted to say hello to him, saw that there was sort of de-reception line had formed as he tried to make his way out the door into a larger foyer for a planned photo with his "family" of grad students. I walked over and waited a turn. When he got to me it was clear on his face he had never met me before. He extended his hand anyway. I rapidly introduced myself and reassured him we had never met previously but that I was very pleased to meet him, that I was with the physiotherapy Pain Science Division, that I wanted to thank him for his life's work, that it was already having a large impact on my profession and that if I possibly could I would want all PTs in the world to become conscious neuromatricians. I asked him if he would be willing to have his photo taken with those of us from PSD who were there, and he graciously nodded. And then it happened, out in the lobby, after the more official photos were taken.

SomaSimple thread
A SomaSimple thread was started while IASP Congress was happening, to which we posted highlights (and some photos) when we had time.

More to come. Much more.

Yet another level

In manual therapy one is taught that one can push bits of body around, and that this makes them feel better to the person whose bits one is pushing.

I call this the "operator model" of manual therapy.

One quickly learns (or should) that manual therapy is much less about the bits one thinks one is pushing, much more about one's speed and force, mostly minimalizing thereof, waiting for the opening, waiting for the person's physicality to let one in.

I call this the "interactor model" of manual therapy.

However, it's quite possible to remain stuck in the operator model for good.
As one proceeds through life one begins to realize that it is impossible to prove to oneself or anyone, through any method, specifically scientific but also logical or philosophical, that what one "thinks" one is doing has any bearing on reality. I.e., you cannot prove, even to yourself, that the SI joint, actually is what you are "feeling" with your fingers, as you perform what has been taught to you as a "test" of its "function." Yes, you can feel stuff... stuff is moving, or not moving, but what one feels moving or not under one's fingers, from on top of skin, has absolutely NO bearing on whether or not a buried SI joint is literally moving. There are many layers and structures all moving on each other between skin and joint, even inside "skin" (cutis/subcutis) itself.

It's merely a convenient assumption. It's a belief. There is absolutely no way to show that it is or isn't moving, or that people can or can't palpate it clinically.

In this case, what do you do? You realize (with a sickening feeling) that you've managed to paint yourself into a conceptual corner. There is no way out, except:

1. ... tromp out over wet paint, spreading dirt and paint.

This is the equivalent of insisting that it's possible, it must be, you've always thought so, your patients' results have always verified your magic-hand ability to ferret out movement/non-movement in the SI (except for when they didn't), therefore the premise must be right. Right? (Those patients who don't fit, well, there are always a few patients who don't fit, outliers, right? We can ignore them, can't we?) Wrong.
Trying to set up tests to "prove" you are right/how right you are is a version of what Harriet Hall calls, tooth fairy science.

2. ... admit defeat, stop thinking about escape, sit in the corner, deal with your feelings, and wait for the paint to dry, however long that may take.

This is the equivalent of waking up yet another rational level on the manual therapy mesodermal mesmerization coma scale, reconfiguring/allowing reconfiguration of your own mentation to accept the facts as they are, including that you were a victim of your own conceptual hallucination, perceptual fantasy, that you were dreaming your own bad-logic dream. But it's OK, you're more awake now, and can move your mind differently, more reasonably. You can now reinterpret your work more correctly as interactive with somebody else's neuromatrix, and whatever it is you think you felt in the past, can go ahead and just be whatever it is/isn't, a mystery of function/dysfunction, not having to have any anatomical identity whatsoever. It will change anyway, just like patterns in clouds change. Continuously. That's a good thing, especially when the patterns are associated with something feeling 'wrong'.


Especially freeing is to know you don't have to prove anything, because there is nothing to prove. Instead from now on you can sit back and disprove, which is a heck of a lot more fun.

Accepted

I found out that I've been accepted into a pain management certification program at U. Alberta in Edmonton. This online post grad program would count a bit toward a masters degree at U. of S. (if I decided to pursue one).

Also, plans are afoot for an RCT for me to be involved in. It's still tentative, but if it becomes reality, I'll be making a lot of bus trips back and forth to Saskatoon, 4 hours each way. Fortunately, buses have wifi these days. :)

Still no big urge to "work" (as in, for money), but I've been dreaming about working lately, treating people, so maybe my brain is working up an appetite for doing that once again.

Meanwhile, I look forward to seeing Ron Melzack and meeting some people I know but only from online.

Montreal and Melzack

I finally came up out the long summer torpor I've been in since coming back from St. John's, to get ready to go back east, this time to the IASP World Congress on pain, in Montreal at the end of this month. One of the items under "related events" is a reception on Aug 28 for Ron Melzack, my hero. I managed to get two tickets, one for me and one as a hostess gift for the friend I'm staying with, also a PT and also in our CPA Pain Science Division.

I'm actually excited about this. Feeling pleasantly excited instead of feeling stressed and anxiety ridden is a welcome change. I'll be able to see him in person, and even if I do not get to meet him in person, at least I'll be able to say I was in the same room.

More clothing angst, however, had to be battled - what does one wear to a reception in Montreal? It's a bit like going to Brazil - Montreal is the fashion capital of Canada after all. Therefore motivated by the unfamiliar-to-me default female flap of having 'nothing to wear', plus actually caring about the fact I have nothing to wear (for the second time this year in probably 20 years or more), I went out and bought some black shoes that actually have heels!! (- not high, but still, in order to not break an ankle I'll have to practice walking in them), and a few items of clothing that I think may help me escape fashion police disapproval. Get this - I even bought a necklace! That is how determined I am not to look like a complete fashion schlub at a reception for my hero, Ron Melzack. I'm hoping a) I get to meet him in person and b) that I don't stand out as not dressed properly for the meeting.

Honestly, I can hardly believe that buried under all the years and decades of being depressed and not giving a rip about how I look, as long as I smelled OK, I'm actually going to try to look like a female from across a room. Wearing a necklace and shoes with heels. I feel like such a female impersonator! Nothing motivates my inner fembot, it seems, more than a chance to see Melzack up close and in person. :^)

Have we overlooked the skin in manual therapy?

In a recent post I showed some pictures of slides I would be using for a presentation a few days later. Since then I've been to Newfoundland, gave the talk, and have returned. Here is a google doc containing the slide show for anyone interested. It's a bit heavy at 37 MB, but anyone interested can download a pdf at this google link. Have we overlooked skin in manual therapy?

Cortical processing of somatosensation

I wrote here about a conversation I had with Paul Hodges of PT motor control distinction, while bumping around in a minivan and while enjoying fabulous food and drink in Brazil. If only I had had this series of slides at that time, there might have been less quibble. Anyway, I found materials and have made them subsequently for a talk I'm giving this coming weekend called "Have we left the skin out of manual therapy?" in which we'll be presenting the results of our pilot project measuring the effects of skin stretching treatment on pain. The two sources for this 7-slide segment were:
1. Smith CUM; Biology of Sensory Systems
2. Keysers C; Somatosensation in social perception

Points to ponder:

1. It would appear there are 4 functioning somatotopic maps up there, not just one.

2. It looks like only one area (about 25% of the cortical real estate dedicated to somatosensory processing), BA3a, deals directly with muscle spindles. The other 75% directly deals with tactile (exteroceptive input) and secondarily with whatever BA3a has already processed.

3. Each of the tactile processing areas deals with a specific sort of mechanosensitivity.

4. It looks like (to me, at least for the moment) that the brain is more concerned (based on how much of its cortex is involved) with somatic exteroception than with somatic (muscular) interoception; might this relate to examining potential threats from the environment?

5. According to the Keyser paper a lot of socially evaluative areas pour their information into the mix as well.

6. As a manual therapist I'm concerned with creating an environment and a therapeutic relationship in which all social threat is reduced, and in which a non-nociceptive, non-noceboic, kinesthetic input will be "added," so that the brain has something to work with to down-regulate pain felt in a "region," while otherwise permitted to be peaceful/safe. I think this information provides a bit of science base to support that inclination.

Biomechanics and the virgin Mary in a piece of toast

Position statement
My profession has become ever more insistent (since its takeover by fundamentalist orthopaedic specialists) that its members see the world of patient problems as biomechanical in nature and keep treatment concepts "corrective" of "faults" such as "weakness," "asymmetry,""imbalance" and "poor posture."

Biomechanics
These exist. People are physical, and biomechanics are basically what peoples' bodies do to hold themselves up against gravity and move around. They are patterns of movement, nothing more. They are measurable, sort of, and a science does exist around them, but clinically there is not much point in measuring them - they can change radically, depending on how people feel, whether someone is experiencing pain or not.

I definitely look at biomechanics. We all do. They are useful as feedback to our own therapist visual cortex to gauge if our treatment is being effective or if we should change course.

But biomechanics are like cloud patterns. They will shift anyway, should not be made into more than what they are - sudden changes should not be assumed to be "proof" (explicit or implicit) that "I, therapist," am therefore great.

Patterns on toast
These also do exist, although there is no science as far as I know. They are a natural function of burning a piece of bread. They should not be made into more than what they are - burnt spots. Neither should biomechanics.

Pareidolia
This is the name of a well-recognized perceptual fantasy: people read faces or pictures into patterns on toast or in clouds or whatever, see something that isn't there and which has no bearing whatsoever on the nature of the material they are gazing upon.

Finding "fault"
This is a common human trait. Sometimes "fault" actually exists. Lots of times it does not, and "fault"-finding is mere perceptual fantasy, like pareidolia, i.e., visually projecting onto an external object something that has nothing to do with anything but one's own personal (usually incorrect and off-target) mentation.

Finding things in biomechanics, then labelling them as "weakness" or "imbalance" or "poor posture" is value-judgy. Considering value judgments worthy of categorically diagnosing and treating is to somehow believe that value judgments can be objectified - they are not objectifiable, scientifically, IMO, because value judgments are not objective to begin with. Nevertheless they persist as a collective pareidolia, and people keep trying to couple them with biomechanics, keep cranking out papers full of implicit and explicit linkages. Excuse me - I think there is something wrong with that.

This is me, finding fault.

Prior plausibility
This is something that scientific investigation requires in order to even be scientific. There is no prior plausibility in linking biomechanics (expression of motor output or expression) to fault-finding; correlation is NOT causation, it isn't scientific, instead it leads to conceptual hallucinating all over the place. Conceptual hallucination often results in something known as pseudoscience.

Ritual
This is common human behaviour done to restore order to a universe that seems to go cockeyed viewed from a subjective standpoint. It's magical behaviour in that:

• there is no discernible connection in natural law between cause and effect, only in the mind of the conductor
• it helps the ritualist feel better; when conducted excessively, this attempt-to-feel-better behaviour is known as OCD (obsessive compulsive disorder).

When done regularly in a group setting, this is known as "religion" (e.g., Roman Catholic)

What does this have to do with PT?
There are different camps within PT. Using the religion metaphor, there are:

• Hard-tissue fundamentalists - these are the orthopaedic specialists who are convinced that orthopaedic manual therapy is the most smiled-upon. They have taken over the profession, pretty much. People practically bow as the high ortho priests pass by. There are systems in place wherein you can work your way up a hierarchy and earn a black belt in ortho manual therapy. Each stage requires one to drink ever-stronger Koolaid. There are tests to pass. Orthos are identifiable by their strict adherence to biomechanical concepts conflated with value-judgments about joint movement, elaborate rituals devoted to improving joint movement/mobility/function which they suppose will lead to heaven - er, I mean, better movement/less pain. In the last couple decades there has been an influx of dry needling as an added ritual. If cracking it or jiggling it doesn't work, poke it. There are many sects/gurus/professions with this stance outside PT.
  
• Soft tissue-ists: these are everyone else, mostly the stretch/strengthen/exercise crowd but their numbers include all manual therapists who don't do manipulation of a high-velocity kind. They might have different rituals but they still all see Mary-in-toast: they still all think various mesodermal derivative the source of all evil (pain), that the altar is whatever gym ball or equipment they put their patient on, or machine they hook them up to, and that their hard work to strengthen/lengthen/massage/release it (magically, from the outside of someone else's body, and continuing the "fault-find" in toast patterns) is the way to proceed (make an appropriate sacrifice/make a living).

Then there is me. What makes me different?
I checked out the two main sects of PT, but liked neither of them. Became an atheist PT and manual therapist/atheist/heretic/apostate beside being an ordinary atheist, even while continuing to practice hands-on therapy, which I reframed as human primate social grooming, in order to

• make it more palatable to myself
• make it more "scientific" to myself, more in line with evolutionary biology
• make it more compatible with neuroscience/pain science

Did fewer rituals, less and less of the time. Mostly wandered around in the desert. Found the oasis - neuroscience and pain science. These tell me that biomechanical patterns aren't important (which suited my own confirmation bias) and freed up even more hard drive to examine what the humanantigravitysuits standing in front of me every day really needed from me in the way of understanding and treatment.

Not much, as it turned out. No rituals, really. Just a bit of engagement, handling, education, reflection, support, encouragement, help, reinforcement, suggestions for pain management.