Wednesday, May 26, 2010

Conversations, continued

The second conversation, shorter and over only one meal and a couple bus rides, was with Paul Hodges, who did actually attend my second presentation, the one on dermoneuromodulation as a new filter through which to look at manual therapy in the context of the neuromatrix model of pain. I had already presented on the neuromatrix topic earlier, before he arrived.

He's also all about motor control.

He had questions which he took the opportunity to ask following the presentation, and I tried my best to first hear, then understand, then answer. He wanted to know, had I read any of the literature on motor control? If I had, how did I feel about manual therapy in the context of motor control? Something like that.

I replied, I had read some of the literature on motor control, but that because this was a conference on manual therapy, and because manual therapy was what I did, and because I considered motor control issues as mostly self-resolving secondary to pain relief, and because I prepared for a manual therapy congress, I had not covered motor control literature in any thorough way. I stated that motor control was important but unless someone took off the skin, treated muscles, then put the skin back on, I would consider skin input a neurological confound to issues of manual handling in motor control, a cart in front of the horse sort of situation.

As for the second question, if it turned out that motor control (training voluntary efferent output) could trump manual (sensory afferent) input in issues of pain resolution, then manual therapy clearly wouldn't be needed anymore.

This was in front of 1700 people, and both questions and answers had to go through translation.

We continued the conversation later, as I did want to be sure I had understood him correctly. I had. It was as though we talked past each other. I really could not see why, at a manual therapy Congress or anywhere else actually, it seemed so important to negate human contact or any learning somebody's neuromatrix might gain through deliberate skin contact. He couldn't see why I couldn't see why motor control was so vital to understanding the nervous system. Or something.

I said that it was too bad he had missed the first presentation, on neuromatrix model of pain, because this one had been built on that one. He said, I already know the neuromatrix model.

He said that on one of my slides he had seen a reference to Gandevia, who had stated in one of his papers that cutaneous Ruffinis were important for position sense. He said that the range of Gandevia's papers were all about all position receptors in all tissue, not just skin, that muscle spindles were important to the brain... I did a submission gesture about that, saying that I could easily be wrong, that in fact I was usually wrong, that I could have got it wrong even after having read the paper through slowly, twice.. but that I'd been excited to have seen cutaneous Ruffinis mentioned at all. He seemed not to get that a manual therapy perspective should include, at least in my humble, omega human primate opinion, consideration of physical contact, mechanoreception between the sk-interfaces of living humans with threat-detecting neuromatrices. He seemed not to get that from such a perspective, rare as to be practically non-existent other than mine and maybe a handful of other people, any news of any kind about cutaneous receptors being the slightest bit important for anything movement- or position-related was exciting news. It's not my fault that cutaneous mechanoreceptors that fire continuously with lateral stretch of skin, that are found most densely in relaxed skin lines favored by plastic surgeons because incisions along these lines heal better, receptors which Gandevia finally decided to take a close look at, have been pretty much ignored until now. Instead people have been stimulating them without realizing it, and thinking that they are stimulating the fascia or muscle receptors way far within, way deep to skin, way deep to the half inch thick layer of cutis and subcutis that even slender people have encasing them all round, weighing the same as the skelton. Not my fault. This layer and its sensors has never been considered in manual therapy.

That was, and is, my point.

I said I thought biomechanics (joint movements) were usually taught like religion. He said, maybe in Canada, but that in Australia people were taught to palpate layers of the body. I said that was good to hear. I asked him, even if we could treat people without touching them, why would we want to?

I think he agreed we should continue touching people. I can't remember exactly.

However, the impasse between mesodermal and ectodermal concerns and perspectives cropped up over and over and over. We just never got anywhere. He didn't get me, or what I'm on about, or if he did, he discounted it as irrelevant (maybe it's the fallacy of Quantity of evidence substituting for actual Usefulness of evidence in the clinic, for understanding and being able to explain something complex like the nervous system and its care and feeding).

I get him, and what he's about, at least I think I do, and to me it has nothing to do with better understanding and better application of manual therapy for persisting pain in an intact but malfunctioning neuromatrix, or making manual therapy congruent with up-to-date pain models and neuroscience. I don't discount his work - I'm sure it will be important in the long run, but I don't think it's going to help me treat people who hurt, or to understand the nervous system better. And I am definitely not interested in joining any Church of the Transversus Abdominis or any other muscle that he's into - he seems to readily attract large groupie troops who immediately try to build treatment models around whatever his muscle du jour happens to be. I think he recognizes this is a bit of a problem, but not one he allows himself to be concerned with, particularly.

Should our focus be on puppet strings or on puppeteer?

There seems to be no real common ground available with him. Too bad, because he seems like a really nice person, and he IS pretty clear about what motor control training has shown itself helpful for and not helpful for. If only desperate PT people grasping for something, anything that might help their patients, would actually listen to him, and not constantly seize "motor control" as a singular tent pole with which to hold up a whole profession, I'd be a more contented PT human primate social groomer.

He actually does state that too much "stability" (translation: trunk muscles that are too contracted) is just as "bad" as not enough "stability" (based on what I think is an erroneous assumption, of course, or else propagating one unnecessarily, that muscles are bad guys somehow, display defects, not nervous system defenses, that somehow gaining "control" of misbehaving mesoderm will either help pain or else prevent it happening.. a wild goose chase (IMO) that PT has been on ever since its inception).

Too much emphasis on physical, not enough on therapy.

Too much emphasis on the puppet strings and not enough deliberate investigation of or perspective on how to access all the levels, conscious and nonconscious, of the puppeteer, i.e., the entire nervous system including influence of afferent systems and glial considerations.

Too little regard for pain as a neuro-biological phenomenon heavily influenced by cognition; viewing it as a mere abstraction, or distraction, like a fruit fly in the visual field, all importance placed on trying to prove/disprove a profession's mesodermal output control theory. No sitting down and trying to really really understand the nervous system situation first, what a kluge it is, a community of ancient bits and new bits wired together, what it's actually up against in life, where it came from, why it exists, what its role really is, how it operates, apparently ignoring mountains of pain science. Major confusion in the ranks over what our job is/should be, because of all the glare and parade noise from what the profession's over-confident leaders think it should be about. Major ongoing 'Cartesian divide' conceptual behaviour, begun long ago and still continually perpetuated, whether knowingly or unknowingly, by my profession.

I can only hope that one day my profession will take off the damn blinkers that have grown to the sides of its head before the whole parade ends up forced off an intellectual buffalo jump by the knowledge base accumulating all around it. Meanwhile, in the back end of the herd, I'm just a dead woman walking. I might not even be a buffalo anymore. Maybe I never was a buffalo to begin with. Maybe I just got mixed up in the buffalo herd.

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