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


twaza (@wassabeee on twitter) said...


I have been looking for sometime now for a full-on, out-of-the-closet, interactor-model human primate social groomer. And today I found one.

Are there any others?

You are spot on with the social grooming; the interactor/operator distinction lit a big light bulb; and the "do no nocicepting" is quite plausible.

I would like to follow your blog, but the RSS feeds work only for the comments. IE complains "Internet Explorer does not support feeds with DTDs." Google reader just gives up and says I can't cope. :-(

Diane Jacobs said...

Hi twaza,

There will be more of us, by and by, if I have anything to do with it. It isn't as though this social grooming instinct were dead - it's very much alive in people who are treaters. It's that what we are "taught" gets in the way of what we should "learn."

Whether I would know about any where you live depends on where you live.

About the feed, etc., I apologize for my ineptness - I don't have a clue how to set the blog so it can be more social-media-friendly. I've tried exploring the bowels of the pages about settings, on more than one occasion, and had to give up.

You found me, so I guess it can't be completely invisible.

twaza (@wassabeee on twitter) said...

Thanks Diane

I don't think that the social grooming instinct is dead, just that education, training, and political correctness conspire effectively to suppress it.

My personal experience leads me to think that awareness of the social grooming instinct is quite rare in treaters. I think that a large part of the explanation for this is that, as a student, your immediate challenge is to become a competent operator. And once you are there, it is hard to realize that becoming a competent interactor should also be part of your personal development plan.

Have you read Iain McGilchrist's The master and his emissary? The metaphor he uses to explain everything is left brain (operator) and right brain (interactor).

You needn't apologise for your ineptness on blogging - it is a design issue that the operators at google need to solve.

My antennae detected a reference on twitter that led me to your blog.

Diane Jacobs said...

No, I had not heard of that book or that anyone beside me had ever come up with those terms.

> "I don't think that the social grooming instinct is dead, just that education, training, and political correctness conspire effectively to suppress it."

Yeah - culture, its dictates, colonizing our own inner primate don't-rock-the-boat, favor-the-troop-over-self-in-order-to-survive default mechanisms.


dantheman22 said...

Just wanted to say a big thanks for posting your article on Human Primate Social Grooming. Very inspirational and helped me a lot. Thank-you!

I have been a physio for ten years, the last 5 have been in private practice. I can really relate to what you are saying. Just today in fact I had a new patient (no previous history of pain) who came to me after a relatively minor whiplash injury. She received 20 sessions of “rough-house physio" and exercises that made her more painful. Countless specialist visits, swallowing 18 pills a day and not sleeping. Also battling with her most recent diagnosis of "fibromyalgia". She thought a large part of it was due to her initial physio going too hard to early.

So I did a little poll today and 80% of my patients needed only "Human Primate Social Grooming". Nothing too complicated. Just some gentle hands on "without causing nociception". (Love your rule there by the way, that is a big help, thank-you).
It always amazes me how effective simple, proper education can help most people. I really think it’s the most important thing for people in pain. The Human Primate Social Grooming approach fits nicely because it gives us a chance to talk to our patients and “massage their brains” or perceptions if you like, whilst providing some non—threatening input. Dare I say, I also like using ultrasound because it gives me a few minutes to really talk to them and hammer home some important truths about their pain.

In the past I have been frustrated because there are so many treatment options for clinicians, that we each have our own little interpretations and idiosyncrasies. As a student I was totally confused and couldn’t really buy into anyone’s concept wholly.
Sometimes I think it would be easier to just to have a very defined, purely anatomical base to what we do (operator). For example a surgeon performing a TKR. But then again, we are dealing with people and I guess that's what makes our job so interesting and satisfying; the interactor component.
I really like your statement about some people trying to be more operator models and complicating treatment. I can finally say after 10 years of being a physio that I am really over paying lots of money to so called “gurus” for their complicated concepts. In fact I am heading the other way, keeping it as simple as possible. I normally keep quiet when in the physio tea room everyone is debating about the exact location of pain in sinus tarsi syndrome, or how bad an MRI report is on someone’s lumbar spine or how someone had an upslip in the innominate.

I was supervising a 4th year physio student recently and I wasn’t sure how much of this to share with her (was still grappling with it in my own head). My treatments are so uncomplicated that I almost felt like a fraud. Luckily I still seemed to get decent results without using fancy, complicated techniques. Being gentle and not producing nociception was a little hard for her to grasp. I did give her some good pain type articles, Explain Pain and she also read the pain chapter from “the brain that changes itself” which I think she got a lot out of. But as a student, to be able to “pass” you do need to “tow the line” and comply with certain operator standards.
But I think now, thanks to you Diane, and knowing that there are others out there who think along the same lines, that I can feel ok about the way I treat my patients. It was a nice feeling to know I am not alone.

dantheman22 said...

Ayurveda the ancient Indian system may have had it right all along. They use warm sesame oil massage all over the body, sometimes with two practitioners applying it, one either side of the body. The effect of four hands massaging you is supposed to “disarm the nervous system” into total relaxation. They consider the skin to have a direct relationship to the nervous system (they call it Vata). But there is no inflicting of nociception, it is more about relaxation and nourishing the skin. Specific foods can help reduce Vata or nervous energy are interesting to read about too, well worth “googling” if you have time.
Anyway, I think I am a much better clinicians from having read your article. Certainly more thoughtful and reflective about what it is that I actually do. I forwarded your message onto a colleague who is a massage therapist and we now compare notes about how many people we have “socially groomed” that particular day, (much to the bewilderment of our other workmates.) On the other hand, another senior physio wasn’t that impressed, in fact he seemed a little offended………I guess it comes down to trying not to get too attached to our concepts and certainly not to mistake them for reality.
Keep up the good work!

Diane Jacobs said...

Thank you for your very thoughtful reply, dantheman22. Music to my eyes. Indeed, you are not alone.

I think the somatosensory cortex would get very jazzed indeed with four hands massaging it, simultaneously. And the insular cortex would probably love not having to deal with processing added nociception.

And you keep up your own good work too! :-) Maybe someday our work, and whatever sense we can make of it, will vindicate itself.

Michelle Wald said...

Thanks to Walt Fritz blog post about feeling what is under your hands, there are some good points - especially cause no nocioception. I do believe you have some good points in treating as a human primate social groomer and I also believe we can effect different structures albiet through the skin and in addition to the nervous system. I am a PT turned social groomer when I found a body of work which was not painful and honored the whole of the person and not just their parts. It is called Aston-Kinetics and encompasses assessment, movement and bodywork with this perspective of wholeness and rightness about what is going on. The work feels like a good hug for the painful area, and give support in a minimally invasive way . I am on a mission as it appears you are to change the touch of PT and more aggressive techniques. Have a more thoughtful caring and intelligent approach to healing.

Diane Jacobs said...

Thank you for your comment.