Saturday, October 16, 2010

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.

Wednesday, October 13, 2010

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.

Monday, October 11, 2010

"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

Tuesday, October 05, 2010

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.