Wednesday, February 22, 2012

New treatment encounter V

New treatment encounter I
New treatment encounter II
New treatment encounter III
New treatment encounter IV
New treatment encounter VI

I decided to add one more post to this series, to illustrate a few of the key ideas I use to help a new patient develop new cognitions regarding pain.

In Part I I described talking to the patient about the nervous system as a whole. This post could be labelled Part Ia.
But it's OK that it's Part V.

I draw ridiculous pictures very fast to show people what I'm talking about, usually scritchy little things on a piece of paper with a ball point pen. I made a series of drawings in photoshop, using more than one colour, to bring here. I'll go through them one at a time.

1. So, first I draw a brain with a little ponytail of a spinal cord hanging down. I tell them, let's say this is your brain, and spinal cord hanging down inside your spine. It's called the central nervous system.

2. Then I add nerves sticking out of the spinal cord. I tell them, these are your 72 kilometers of nerves, your brain's "feelers", going everywhere and doing everything, and reporting back to the central nervous system. Collectively this is called the peripheral nervous system.

3. All around the nervous system is a physicality, with its layer of skin the brain is very interested in. (Yeah, this picture usually does end up looking sort of like a gingerbread cookie.)

4. I tell them, most of the front part is the human part.

5. But all vertebrates have a "critter brain". The critter part is old, the part that runs everything and keeps us alive. It's like a big loyal dog. It's been around a lot longer than the human part, and it will take over if it feels threatened. This is the part that has become a bit freaked out, the part that we have to learn how to deal with, teach, train, impress, reassure, help work more appropriately again. It's trainable, like a dog. It needs a job, like a dog. So, how do you deal with it? Same way you might deal with a real dog, probably, that you could see was scared or misbehaved. You would try to understand it, try not to scare it or spook it, but observe it, remain calm around it, try to figure out what it needed and provide it with that, be around but give it space, wait for it to trust you, wait for it to wag it's tail and come over to lick your hand and roll on its back. 
This usually helps patients get started thinking - everyone (mostly) likes dogs, likes to think they would know how to relate to one, rescue it from a neglectful owner. Here is this misunderstood "creature" right inside them that they can immediately do something about. The important part of this metaphor is two-fold: people will often be more willing to take a project looking after somebody or something "else" before they'll take on looking after themselves. Even if that "other" is right inside them. Second, they realize right away that were this true, they would need to learn how to relate to other creature pretty fast if they want to live comfortably again. There are some ways this story makes no sense, but in terms of motivation, it's usually an idea that can help people move out of seeing themselves in a victim role into a caretaker role. I think that's what is the most important thing - stewardship of one's own nervous system, taking responsibility, seizing the locus of control. 

Exteroceptive input via skin
ascends through fast dorsal columns,
bypasses dorsal horn/spinothalamic tracts

6. To further the metaphor, my job becomes helping people get their "dog" back under control; the first step is to learn how to be the alpha dog to the inner dog, and help "owners to better understand how to see the world through a dog's eyes." I.e., help people learn to gain some control of, or at least, emotional distance from, their own critter brain. One thing real dogs respond to, crave even, is physical contact. So, manual therapy has a role here. I explain to the patient that I can provide their human brain with some sensory input that will be exteroceptive, in through their skin, that it's important that it NOT hurt; because it will not hurt, it will go straight through the critter brain without stopping, all the way to the human brain, where maps of the body are stored. This will make the human brain start to go to work influencing, in a good way, the critter brain, from the top down. Not that the critter brain won't know someone is touching its organism - the one thing that both brains have, and use in common, is the peripheral nervous system - but the contact won't be uncomfortably nociceptive.
Patient learns to detach from feeling helpless and watch events unfold calmly
7. Their job will be to allow stuff to happen. What they feel in their nervous system will be their own human brain getting out of the way, becoming an observer, and letting their critter brain self-regulate and change its behaviour. This is known as "descending modulation." 

The critter brain is thus deliberately placed between two coordinated forces: 
A) On the one hand, it can "feel" that something touches its organism directly. This will mildly threaten it, or at least get its attention such that it will need to check for any potential threat. Recall in Part IV, the diagram of the internal regulation system, and the descending modulation system parts of the nervous system. That's what we're talking about when we think "critter brain", including insular cortex and anterior cingulate cortex, which develop much earlier in life than the prefrontal "human" brain bits. We need to get the critter brain's attention, bearing in mind that it's already so adept at nocicepting, firing up a barrage of upregulated nociceptive stimuli, that we don't need to give it any more of that - just touching it will get its attention enough to get it to check out the novel stimulus. 
B) Meanwhile, at the same time, it has a calm human brain now engaging with it from upstairs, at the other end, watching it, expecting different behaviour now, not reacting the way it used to. 

These two things together are enough of a new situation that it will be stimulated to adapt. Provided it's a normal intact nervous system that only has a behaviour glitch, it will be a fast learner. 

With good preparation, a patient can be taught how to think about things differently, step outside the problem, observe it in a more detached way, be interested in it in a different way, not "How do I escape from my own body that has betrayed me in this awful way?" but rather, "Ah, I see - I've been treating my own nervous system all wrong! To have to have a better relationship with it, I have to take charge - I get it now. Very interesting! I think I can take it from here. :-) " 

The patient still needs to be made aware of all the usual stuff, how to avoid getting stuck in the same place again, to move (motion is lotion, "dogs" need exercise), strategies for self management, all that. But the big piece is that they'll be motivated from inside - they'll end up with locus of control. 

One last thing - if this didn't start to happen inside a couple or three visits, I'd suspect that the patient and I were not a good therapeutic fit, and would not want to continue to take their money. I would teach them all about the neuromatrix model, and let them go away to think about things for awhile, with the option to come back if they had some new insight, but I would not provide them with more manual treatment that was clearly not landing anywhere in their brain such that their brain could produce different output. 

LINK to WCPT 2011 slide show presentation, 90 minutes: TEACHING PEOPLE ABOUT PAIN; Moseley, Butler, Louwe, Thacker

Out-thinking Pain: How the Mind can Control Pain with Catherine Bushnell, video, about an hour.

Saturday, February 18, 2012

New treatment encounter IV

New treatment encounter Part I
New treatment encounter Part II
New treatment encounter Part III
New treatment encounter Part V
New treatment encounter Part VI

The sturdy treatment relationship you make with a new patient should be like a new well-caulked boat to help them across their river of feeling Doomed by Diagnosis. You are the distraction while they supply their own motivation, usually enough to get themselves out of pain.

There are some rivers, sometimes, that just can't be crossed, however.

There will be some people, rare fortunately, who just can't seem to muster up the inside strength to even get into the "boat", even with you helping them, and explaining how ferrying works.

Don't ever take people like this personally, or get mad at them, or blame them for not getting you. It's not their fault they don't get you. It's not about you! It might be something to do with how their brain:

  1. Was wired up at birth, or
  2. Became wired up after, through life. 

Each person who walks in your door is an unknown quantity. You have no idea what they've been through or what they're like until you interact with them a bit. Even then, you'll only ever know a vanishingly small amount about them, only what they let you know. When you interact directly with their nervous system you'll get more of a clue, but even then, if they can't light up their own kindling inside themselves, nothing you do TO them will make a pick of difference, probably.

So we could call this post in the series, troubleshooting.

When somebody has yellow flags sticking out all over, a very useful picture to show them, and discussion to have with them, is the "neuromatrix model of pain" discussion.  I keep one of these diagrams around just in case - mostly I keep my pain education superficial and peripheral, because that suffices for most of the people I see. But once in awhile, my oh my, I see someone who really needs to know about the neuromatrix model of pain. See this post from a few years back, about a patient I saw that I called "Rosie".

To use it effectively, first of all, ponder it yourself, deeply, until you understand it thoroughly. Tape the diagram to the fridge, to the wall beside your computer, keep one near the toilet, one beside where you relax in the evening, one near your bed in case you wake up and need to look at something for awhile before you can go back to sleep. This effort will pay off, big time, in terms of your self-respect as a human primate social groomer, if ever you have a yellow flag person walk in and your ordinary approach is futile. With a diagram of neuromatrix model of pain, you can sit down with your patient and explain, without ever blaming them, how pain is made by the brain as an output by the brain's own machinations. Brains are like churns - they take inputs (everything on the left side of the diagram, including all your own efforts as therapist) and churn it around, and produce outputs, one of which is "pain" perception. Pain perception is NOT the patient's fault. It's coming from parts of the brain that are old, more primitive threat detector zones. It's a normal process, and usually people can turn that off one way or another, even if they require a bit of help in the process, which is why we human primate social groomers are around in all our vast numbers. We let people use us so they can get themselves better.

The best description I ever have seen and read to date of the part of the brain that handles nociception is in Mayo Clinic Medical Neurosciences 5th Edition. The authors call it the "internal regulation system".  Here is a little picture of a slide I made of it. It regulates stress, emotion, threat, is covered in opioid receptors throughout, operates quite autonomously, is ubiquitous in vertebrates, runs everything physiological, and (this is the interesting part) can be heavily influenced, trained even, by more "rostral centers".

"Rostral centers" is code for "frontal lobes", the thinking, socially conscious, cognitive-evaluative parts of the brain: Here is a very nice, short little video of how the brain processes social stimuli.

Social cues in the brain (Scientific American)
 Social cues in the brain (Scientific American)

It's very, very easy for people (i.e., human primates with a great big focus on watching/interacting with the rest of the "troop") to be so caught up in their own psycho-social brain activity that they have no clue, really,  how to attend to their own bio-psycho aspects. And pain is biopsychosocial, not nociception, not only "bio", not only "psycho". I happen to think that it arises when functional, firing, awareness-driven relationships between different systems inside the brain are a bit out of whack with each other, for example if the "person" in the brain has no awareness of physical discomfort until all of a sudden, it's too late, and they're stuck in a bunch of bad movement habits, or more specifically, a bunch of bad lack-of-movement habits! Just a hunch. However, conscious awareness is the only lever in there for PTs to pull, really. Never underestimate the ability of a good therapeutic relationship, one that can capture attention appropriately, using those already well-worn, socially attenuated processes in a patient's brain, to help them get off the square they are stuck on, pain-wise. Usually. Or at least move on in life with less dis-empowerment. Above all else, avoid disempowering patients. It's very noceboic. Negative expectations are associated with cholecystokinin being released in the brain stem, with the overall effect of enhancing ascending nociception. Which brings us back to the descending modulation system.

Anyway, this internal regulation system/descending modulation system is in the core of the brain. It's already working at birth, keeps us alive, regulates our heart, lungs, hunger, all drives, all resolutions, dampens all our nociception for us. Usually!

If (for whatever reason...) the frontal lobes, in particular the prefrontal cortex, which doesn't fully myelinate until into our third decade (!) ... if for some reason, it doesn't hook up properly to this internal regulation system, our patient may not have the means by which their brain can learn to conquer pain from inside itself. If that's the case (and remember, we have no way of knowing - it's all a guess) ... if that's the case, then all your fancy-schmancy multiple kinds of therapies are completely useless, and the treatment container boat you built will sink, unless you keep on trying to teach this patient what they need to do, and hope they can figure out how they can manage to do it.

The other possibility is that they may have some sort of bio issue, maybe a receptor problem or a protein problem or something their nervous system needs but can't make or a system that makes way too much Substance P in the cord or wildly enthusiastic microglia in their spinal cord or something. There are so many ways things can go wrong biologically and developmentally that it's amazing that usually everything turns out so well. 

Anyway, don't ever lie to them. They will have been through many practitioners and will have been disappointed by all of them. So the last thing they need is heroics. Do not become another person in their biopsychosocial existence who has promised them some kind of operator model magic in the form of a gizmo or a tool or a magic technique, and then not delivered. If you've explained the nervous system to them, then it should have been clear to them all along that only they have control of the magic wand, not you.

They need solid information! It won't matter if they don't suck all of it up instantly - you will at least have held up your end of the therapeutic relationship as best you could, by giving them excellent food for thought. All you can do is provide it and hope their brains will work toward being able to use it some day.

Nocebo Effects, Patient-Clinician Communication, and Therapeutic Outcomes 

New treatment encounter III

See Part I
See Part II

This series is all about container building. You are constructing a treatment relationship with a new patient, and you only ever have one shot at it. It's important for each of us to learn how to do this properly, from scratch, every time, and not screw it up.

This is the only thing you are entirely responsible for.
Everything else about getting better is completely up to the patient, and whatever sort of "relationship" they can then go on to build with their own nervous system. (Their brain will use the one you are building with the patient as a template for the relationship that emerges two nanoseconds later between the patient and the patient's own nervous system, the very same one that brought them in with a pain issue. And it will let the patient think it was all his or her own idea! How clever is that?)

Can you see now why it's important to talk to them about all this? In Ectoderm-ese? Brains do nothing but predict, construct and test models. They construct a version of "reality" and try to get it to match what's coming in every second of their existence. And they are pretty good at doing their job - brains have been around a LOT longer than humans have. So, your patient's brain will automatically model something new based on what you are saying, so whatever you're saying better be something half decent: truthful, relevant, science-based. Otherwise you'll just (at best) confuse them more, and (at worst) alienate them further away from themselves, from their own survival machine, operation system, threat detector, their own nervous system. You have to figure out how not to do that! They NEED that system, and they need to learn to befriend it, help it, instead of blaming their meat body for pain, the usual story that has gone on far too long in the Mesoderm-ese language that evolved outside the understanding of what a nervous system is and does and needs.
In the treatment room, everything you are, say, do, think, every way in which you respond, act, dress, smell, becomes some sort of raw material for the patient's brain to throw into its predictive machinations. Therefore, I cannot stress enough how important it is to simultaneously remain contained, responsive, and be strategic, and thereby as effective as possible with your teaching.

Anyway, we've explained in broad brush strokes to our patient the story of this operating system they have/that has them, what it consists of, what it does, and what it needs. We moved the story out to the periphery, out to skin, where we'll be working. The patient has new pictures in their mind, now, about what's going on in their "body". When you handle them, they will be much more aware of their sensations and will be able to help guide you. You can fill in more detail as you go along, after you start treating, but you and the patient are not quite ready to start just yet. There is an assessment to conduct, and a few more pictures to look at.

The assessment should be done in Ectorderm-ese as well: this means, when you look at the patient standing and moving, all the usual asymmetries commonly noticed by human primate social groomers will no longer be viewed as defects in mesoderm. Instead, they will be viewed as outputs, or defenses, of ectoderm, of the nervous system, trying to protect itself from its own meat suit.

Let's get one thing straight here, because this is a common mistake therapists make all the time - viewing meat or any other kind of mesoderm as some kind of bad guy, troublemaker, villain, root of all evil. Mesoderm is NOT a bad guy, most of the time. It is space filler, anti-gravity-suit, often usefully contractile, but it has no "behaviour" of its own, particularly..  - it's an E-ffector puppet way at the far end, the output end, of a nervous system which (usually) has learned to use it improperly, to its (the nervous system's) own detriment, for whatever reason. In Mesoderm-ese, it is suspected of having committed all sorts of crimes that have resulted in "pain" right off the bat. In Ectoderm-ese, we know better - we know mesoderm is to be considered innocent unless/until proven guilty. Which is really rather rare.

It's likely a good thing to explain this to your patient. It is usually welcome news to them.

The assessment will give both nervous systems involved, your own and your patient's, more time to get to know each other on a level that is much less verbal, way more visual, and kinesthetic. All the senses will be wide open. Your patient's brain will be acutely aware of you looking at it. It's a precarious time for a new patient - they are coping with tracking you intently, trying to understand what you're saying, feeling a bit weird perhaps, because your language is so unfamiliar to them, yet so interesting and makes so much sense on so many levels that they want to know more. You must never ever ever breach this tender trust they are extending to you. Ever. Be careful. Be honourable. Be gentle. Together the two of you are setting out to tame some frantic creature the patient never even knew existed, and your next job is to show them how. So be kind, move slow. Always have smooth warm clean light intelligent responsive and effective hands.

At some point you will get a sense of what you need to do, which nerves you will want to address first. Often they will be the ones in the zone the patient has complained to you about already. There might be others elsewhere, maybe on the other side of the body that you also want to look at (with the little eyeballs at the ends of your fingers), but it's usually a wise (and courteous) move to physically examine the part the patient is most worried about, first.

Before we start treating, though, I pull out another binder full of pictures of nerves to show the patient, pulled from anatomy books. I want them to know that each nerve has a name, a place in the body, that maps of them exist, that they come out to skin, that when I touch them, I'll be visualizing these yellow (usually, in anatomy texts) noodle-y looking strands that are woven through their meat and around their joints and out to their skin and down to their hands and that they are layered, like shingles on a roof. I tell them which one I'm going to visit first, and why, so they know. Then we start.

I treat horizontal people. I want my patients relaxed into gravity. I want them comfortable. I want them warm, so I offer them a light warm fleece blanket, which they accept unless they protest because of feeling too hot. Most people who have persisting pain feel cold, so they are usually happy to have a warm blanket. I tell them "a warm nervous system is a more cooperative nervous system", and they usually agree.

I land carefully. Remember what I said about their nervous system being on high alert. You are a new person to them, so there is a lot of anticipation mixed with a lot of novelty mixed with some dread, probably. Try to make life easy for them - they've got a lot of mixed-up emotional stuff to stay on top of, to stay contained in their end of the treatment relationship. Plus, their nervous system is going to have to check you out again, this time using its kinesthetic capacities. Who is that touching my organism? Is it a bear? Do I need to get ready to fight? Flee? What?

If you have set up the treatment relationship properly, the patient doesn't have to fight any urge to flee, or hit you. You have told them to tell you if any contact you are making, any way you are gripping them or handling them is uncomfortable. You've explained why that would be counterproductive, how this acutely sensitive learning machine called the nervous system already is way too good at constructing something called "pain" out of something else called "nociception", so you do NOT want to add more nociception to the mix. They feel they can trust you, that if they indicate discomfort you'll back off. So they're calm. Instead they can focus inside themselves on their own interoception, appraise their own sensations and the turmoil from a detached calm place, let it roll by. They will be able to observe their own nervous system running its own threat detection operation without getting involved in it, or flooded by it.

More to come, suggestions about what to do "if".. 
New treatment encounter Part IV
New treatment encounter Part V
New treatment encounter Part VI

Friday, February 17, 2012

New treatment encounter II

In Part I in this series, I explained how I set up a bit of dissonance in a new patient to get them out of what I call their "Misleading Mesodermal Misery Movie" - the one where they imagine themselves to be falling apart, broken, degenerating, discs bulging, tendons frayed, bone spurs stabbing them, a body turning into a train wreck, burying them in disaster. You have to act quick to get them to break up such a movie playing over and over in their head, provide them a new screenplay for a new movie, one in which they are the lead actor, and producer, and director, all at the same time, where the ending is not written yet, and where you play only a minor supporting role. 

You only get one chance to make a first impression, and the first session is your best chance.

I explained how introducing a third player (the nervous system itself) is useful - it makes a bit of room inside people, introduces the possibility that all may not yet be lost.  As their therapist, we want them to reach a new level of understanding of pain, that it's just an opinion the brain has about the state of the body, and that, strictly speaking, it doesn't correlate very well at all to actual tissue damage

Where we left off last post was at the end of the 4th statement: 
"I want to get back to the part about how the nervous system needs so much energy for its puny size." 

Lundborg 1999
I take them over to another part of the room where I keep a thin binder with some precious pictures in clear plastic sleeves. One of them is this one from Lundborg, 1999, in this open access paper, Pathophysiology of Nerve Compression Syndromes: Response of Peripheral Nerves to Loading (pdf). It shows how, on the inside of a nerve, neurons are bundled up like fiberoptic cables. 

I say to the patient:

1. "This is a blow-up of one of those nerves - remember the 72 kilometers of nerves in the body need a lot of oxygen too. They are the brains "feelers" out into its body, and out to the edge of the body out to the world beyond. The brain is very interested in who or what might be touching its organism. But these nerves all have "feelings" as well. (Usually the patient will want to know how big nerves actually are. I tell them their size varies, most of them are about half the girth of a ball point pen, some like the sciatic is the size of a rope, the ones to skin are about the size of a thick thread. I've dissected these so I know their size.)  
2. "The thing that upsets them most is any possibility that they can't get enough fuel. Really, that's what the nervous system is most sensitive to - it's own environment. Seriously, it doesn't really care about much else. You may have heard stories about guys being shot in war, but being so focused on fighting they don't even notice they've been shot - they might feel a bump or something, but unless they see blood they don't really realize they were shot or have tissue damage! Another example is a football player determined to get a ball down the field who twists his ankle but gets up and keeps going, doesn't realize it's sprained or even maybe fractured until the game is over. It happened to me - I twisted my foot once at a basketball game in first year university, and it hurt a bit, but there was a dance I was determined to go to, so I just ignored my foot, figured it would get better, went to the dance, danced, walked home (well, limped home), went to bed. Next day it had swelled up and I couldn't walk, got an xray, turned out I had fractured head of the fifth metatarsal, and had to use crutches for a few weeks. Bottom line is, nervous systems don't much care what's going on with meat or bones, particularly, until you've settled down a bit - then it gets busy and gives you pain to keep the part still so it can heal. There are lots of documented examples of this. (The patient might remember a story of their own about this, and tell it to you. Your job is to let them tell you about it. This allows the patient to feel they are contributing to the screenplay you are now building together.) 
From here
3. "That's at one end of the spectrum. At the other end, the nerves need movement so their circulation system, right inside the nerve itself, and stimulated by movement, can work properly. So if you sit in the same position for 20 years, you might get pain starting up somewhere, seemingly out of nowhere, with no injury. (I show them another picture, one that shows the capillary plexus around the neural bundles). I say, you know, if you took one of these white dots here, which represent single neurons, and made its cell body the size of a tennis ball, the axon, this long skinny part in the nerve, would be a half mile long, and the size of a garden hose*! It needs a lot of support, all the way out to skin. So that's why it has its own circulation system - it's like a deep cave explorer needs an oxygen tank and a lifeline up to the top. Except that neurons are stuck in the cave for life, with just one job - reporting from their far end. Anyway, sometimes part of that capillary system can shut down like if the nerve is under tension for too long, if a movement is too repetitive or a certain position is held for way too long for too many years. (I keep a Chinese bamboo finger trap around so people can feel for themselves how a nerve feels when it's under tension. They get it, really fast. They want their nerves to not feel compressed under tension! The bamboo finger trap has to be squished from both ends so the fingers can be extracted; it's a pretty good teaching/learning tool to have around, actually.)
4. "Which brings us to my job. I figure the physical part of my job, where I touch you, is to help these nerves breathe easier, get the oxygen and fuel they need, so that the brain can stop worrying about them and being all frantic over them. All that worrying it's been doing has made the alarm system too efficient so that it goes off too easy. It's kind of like a motion detector that goes off if it sees someone innocently walking down the sidewalk on the other side of the street, instead of trying to climb in the window! We want it to work, but appropriately, not all over-sensitive the way it does right now. Make sense? (Patient will usually nod along, very interested. They will usually ask how you plan to do that. I say, well, I'm going to explain how right now.) 
Lundborg 1988
5. Next picture: (another from an old Lundborg paper, depicting how the inside bundles of neurons can kind of slide on each other.) "See how these bundles can slide against each other a little bit? This gives them the ability to tolerate a bit of lengthening, and even better, the lengthening can stimulate those capillaries! If they open up, the older used-up blood will be able to escape and the way will be cleared for fresh grocery delivery! Did I mention there isn't any other way for blood to get out? The rest of the body has a lymph system, but  it's thought that nerves don't. Which means they can back up. Swelling that presses on a nerve whether from the outside or from the inside will make it feel pretty cranky after awhile. So, my job will be to move the nerves, anyway I can, so they can breathe better and stop "hurting". Since they all end up plugged into the backside of your skin, so your brain can read your environment, it's quite easy, really, to move them by moving skin itself. And it doesn't hurt! Once your system gets the idea, it will start to help by changing volumes and lengthening muscles and all sorts of reflex activities, because it really would rather not hurt, probably. So, in the end it's not a bad guy, it's just misunderstood and was doing the best it could under the circumstances. So, we'll see if we can help it get a good feed, and see what happens. OK with you? (The patient is usually ready to start, and anxious to help.)

So, we've got a new screen play, we have a patient who is cooperative because they have new pictures in their head to think about, and someone who is going to do everything she can to help them, who has made it clear that they will not have to endure any more nociception during treatment. They relax! They anticipate. They have hope again. This is the match that can light the descending modulation their brain needs to rev up in order to get better chemistry happening in the spinal cord. 

All the other stuff has to be in place - assessment of movement, quality and difficulty and amount of their movement/range of motion. Reassessment after each strategic intervention. But the patient doesn't have to struggle.  Everything that happens will be at the nervous system level itself, and the patient's job is to let it happen, tell you if they experience any discomfort (so you can remain in therapeutic contact with them, change what you're doing, or respond in some reassuring way so they get that you get what they are experiencing). 

Remember, it's the relationship you have constructed and have invited the patient to inhabit that is going to make the biggest difference, in the end. The contact should be minimal, only what is sufficient and necessary to get things going. They will usually need to perform some kind of homework, but it needn't be a struggle. It might be as simple as practicing sitting at the other end of the couch when watching TV, leaning on their other elbow, so their physical neural array might be angled or sheared inside their body at some other, opposite angle. It might be a bit fancier, like some neural gliding. Depends entirely on the patient and their presentation. 

More to come. 

If the cell body of a motor neuron were the size of a tennis ball, its dendrites would fill a room and its axon would extend, like  a 0.5 inch garden hose, nearly 0.5 mile.”
             ~ Jack Nolte, Neuroanatomist
                p. 335 Vol 3 Encyclopedia of the Human Brain


New treatment encounter Part I
New treatment encounter Part III
New treatment encounter Part IV
New treatment encounter Part V
New treatment encounter Part VI

New treatment encounter I

On SomaSimple, somebody asked about the best time to inject pain education into a treatment session, as if pain education were in a foreign language. I understand the problem. So let's look at pain ed. as being in an unfamiliar language. These days we have the option of continuing to speak the old (hopefully about to be obsolete) language while painfully trying to learn and translate in the new one, or we can plunge right in and use only the new one. I recommend switching completely to the new one. 

What languages am I talking about? 

Generally a patient speaks haltingly in Mesoderm-ese*. This is the language they will have recently assimilated from their doctor or from previous health care providers, or learned from the internet. All PTs were raised in this language. It used to be the only language around, but there was no clear word for "pain". Instead, there were only nouns for body structures and parts. And pain was assumed to be some kind of bottom-up thing. It's clunky language that doesn't fit modern times or new understandings. It's a bit like as if we went around saying "thee" and "thou" and "yea verily" in ordinary life. It sounds awfully dated. 

Now, we have Ectoderm-ese**! There are many ways to discuss "pain" in this new language. I'm going to write a series of posts to explain how and why I teach patients Ectoderm-ese. Several useful things are accomplished simultaneously, as we will see.  

There is a small window of opportunity available to teach your patients this new language. Very small, unfortunately. During the first session, people tell you about their pain, what they imagine it's from, all that. The window is: 

1. after they are done explaining as best they can, and..  
2. before you examine or treat them. 
This is your best chance, your one shot, your only hope, really, to get a foot inside the door, and expose them to Ectoderm-ese, in the context of explaining to them what you intend to do, what you're like, how you think, because this is when they will be the most receptive, right at this moment: to them, you are still an unknown quantity and they want to know more about what you think and what you do. They need to build up a picture of you they can carry away after. Know full well they have a filter up about whether they can trust you not to hurt them, so take full advantage of the opportunity to dispel their fear in advance of touching them. It's a precarious moment. Handle it well - explain to your new patient how you intend to handle them, well

I invite them to come over and take a look at the only poster I have up; it shows the nervous system all by itself. 
  • I point out the complete lack of meat, or bones or joints. 
  • I tell them this is the only part of the body that can produce "pain" for them. 
  • It's the nervous system, and "it comes all the way out to skin, which makes it easy to work on". (This is the first big hint I give them about how I work.)
I tell them a few choice details about it, just like I'm telling a story. I tell them...
  1. ... it's comprised of 72 km of nerves, a brain 5 times bigger than it needs to be to run a critter "our size". (I stay deliberately vague here - lots of people have 'size' issues no matter what size they happen to be, so I just ballpark all us humans into the same size category to help a therapeutic relationship establish itself.)
  2. ... even with all this length, even with the huge brain, it's tiny, only 2% of the whole body, but because it's busy 24/7, even when we're asleep, and because it runs all operations, it sucks up an amazing 20% (!) of all available oxygen and glucose, all the time, at speeds of about 270 miles per hour, so it's a big energy suck. 
  3. ..."you are part of it. It's not part of 'you', the way we usually think of our body parts. You are part of it. 'You' are the human bit in there, but most of it we have in common with all the other critters out there that have vertebrate nervous systems. It runs 'you'. It looks after 'you'. It keeps 'you' alive. It puts 'you' to sleep at night so it can do other things, but it keeps your heart beating and your lungs working, right? It's your survival machine and your threat detector. It wakes 'you' up in the morning because it needs you to get it something to eat. It never shuts off !"
  4. ... it's your operating system. It's an old evolved thing, and some parts are really old while other parts are quite new, and they're all hooked together, and sometimes it can get itself into a glitch. Usually that's all that's the matter. So, we do a systems check and help it fix itself. I'll explain how we can do that in just a moment, but first, I want to get back to the part about how it needs so much energy for its puny size. 
All of this is done in just a minute or two. Most peoples' attention spans are long enough to last through this little orientation. Especially when a lot of "you's" are thrown in, with references that track back to their ailment, how their brain might be perceiving it. You are laying, in plain sight, a trail of bright markers for them to follow. 

The main goal here is to recruit the patient to working with you, by introducing a new character into the drama - the nervous system. Put a mustache and black eye mask on it if you want. It can be our provisional villain, if you need one, or it can take on any role the patient needs it to take. You want the patient to realize that they and their own nervous system, although inseparable, are not exactly one and the same thing.  They quickly realize they can be agents, they can have a bit of leverage at their end - you have made it clear it's not their fault, this will be a team effort, that there is a possibility it will be "you and them" on one side, against their nervous system's undesirable behaviour on the other side. This prevents any potential "oppositional defiant disorder" from occurring on the part of the patient at the outset, and seals a treatment relationship into committed existence - the patient has been let in on the scoop, and realizes s/he has a job to do, a role to play. You will build more layers on top here eventually, but this moment is when and where and how a foundation crucial to the successful unfoldment of the therapeutic encounter can be laid. They start to understand that they are actually in charge, that you are there to help, not take over. They have locus of control, inside themselves - it's not beyond them, out in you or in the room - it's inside them. They don't quite have full access to it yet, but at least they now know that it's inside them somewhere. Their brain will go to work on that little bit of news as you move them onto the next piece of information. 

More to come.

*Mesoderm: (noun used in place of "embryonic mesodermal derivative") - Refers to the 98% of the body that is structural and non-signalling: bones, joints, muscles, tendon, ligament, fascia
**Ectoderm : (noun used in place of "embryonic ectodermal derivative") - Refers to that 2% of the body that is the nervous system and can mount an action potential: brain, spinal cord, nerves and receptors in the outer layer of skin

Pain. Is it all just in your mind? Professor Lorimer Moseley - University of South Australia
You tube video, about 49 minutes

Friday, February 10, 2012

Another quality

Ruth Gendler wrote a very nice little book, the Book of Qualities. There are about 100, beautifully described. But Gendler missed a few. Here is one she missed:


Containment was born to a woman named Merry, who finds most everything about herself so amusing that she laughs all the time. Containment grew up perplexed because Merry never found having a daughter like Containment amusing at all. In fact, Containment wondered quite often if she had perhaps been mixed up at birth with some other baby.

Containment is older now. One of her few friends is Determination, who she met when she was a teenager. Containment might look buttoned-down, but inside her simple style she feels safe and free. She has grey hair, dresses in black, white, and neutral colors, but loves the warmth of an extravagant red cashmere scarf wrapping her neck in winter, peeking out from under the big collar of her warm black coat. She also loves warm practical snow boots that close with Velcro.

She lives in an apartment high up like a bird's nest, facing a big west sky, full of sunshine in late afternoon and frequently riotous sunset just a bit later. It's walls and floors are white, the space uncluttered, her furniture the colour of bark.  The neighbours are friendly but quiet. When she first moved in they made overtures, but without her having to say very much at all, they soon understood that Containment prefers solitude, and they have left her alone except for greetings in the hallway or elevator. 

She spends peaceful days working on solitary projects, taking whatever time they require. In late afternoon, she likes to change into blue silk pajamas, watch TV, and plan what she will do the next day. Her favorite smell is sandalwood.

Thursday, February 09, 2012

Exercise incentives

Stark picture making the rounds on Facebook lately:

Also, from this link:

I like to think I'm taking myself from the middle situation above, and becoming the bottom situation, adding more meat to myself, and that that's why my weight is hard to lose - meat weighs more. Size hasn't changed much over the last couple months.. so, I don't know what's going on exactly in this hexogenarian humanantigravitysuit. The first ten pounds came off the first month. It took 2 and a half months for the next 10 pounds to come off. Now I'm on my last ten. It might take 6 months to get those off, at this rate. Resting pulse has dropped, which I guess is healthy.. Slow though. Really really slow. And staying under 1200 calories for months and months and months is becoming ... well, I shouldn't complain - elsewhere in the world people are lucky to get one meal a day. Also, I'm pleased that my knees are in great shape. They handle the elliptical easily, remain painfree and fully bendy. Thank you, yoga that I did 40 years ago.

Monday, February 06, 2012

Pain is an emergent phenomenon

SomaSimple member and moderator, Kory Zimney is putting his thoughts down in this thread: Pain is an emergent system.

Yesterday (while the superbowl was on and I was ignoring it, watching a movie instead) I conversed with a couple Facebook Folk. I've conversed with them several times, and generally we come to virtual blows. This time we may have gone round some kind of corner.

Link to the FB thread: Central Sensitization:  "I dare anyone to read this and then try to declare that "muscles" somehow spontaneously start developing "trigger points", then need to be "needled", which somehow, one is led to believe, magically stops them from such misbehaviour. Or something. Ludicrous idea. Really."     

I think you have to be a FaceBook member and have "liked" the page, to be able to view it.

Saturday, February 04, 2012

To sum up..

A cartoon in wide circulation, adapted by me

This cartoon sums up the whole problem of operator models, in my opinion. They are based on shortcuts in thinking (belief systems) that leave science-based reasoning completely in the dark. Not that such models aren't efficient - they usually are! People get treated, usually quite effectively (provided they have no actual medical problem), whether they or their practitioners understand what they are doing or not. The physical skill set is not the issue. The issue is, what do they think they are doing, and why? Maybe this issue isn't important to most people. Maybe in the end, none of it matters. I don't believe that however - I think it matters a lot. Which is why I'm fascinated and continue to write and argue over these things. They matter to me. I think they matter to anyone who thinks and reasons and tries to integrate themselves, which is what this whole blog is - one ordinary female humanantigravitysuit, her attempt to figure out her own existence, human organisms in general, especially the various human primate social grooming groups/troops. So many operator models rest so precariously on so little. So many are based on nothing but a conceptualization impossible to prove or disprove, like religions/cults.

Like cult thinking, the only way to free yourself from operator models is... well, to free yourself from them. Not that they will go anywhere. Unfortunately you can't call 1-800-GOT-JUNK to take them away - you have to wait for them to wither and die on their own, but they will, if you stop feeding them, stop propagating them, stop watering them.

Unfortunately, for every individual who does this pruning effort, this selective weeding effort on his or her own mind, there are a thousand who don't. And another thousand who tried, but gave up and maybe became real estate agents instead.

Lately I've written a bunch of posts about trigger points. Here are the links.
1. Why I don't buy the idea that "trigger points" are in muscle  (July 2011)
2. Letter to a biomechanically-minded therapist (July 2011)
3. Trigger point model deconstruction, models in general (Jan 2012)
4. Yet another "trigger point" discussion (Jan 2012)
5. Projector? Or movie screen? (Jan 2012)

I'd like to add the essay on abductive thinking written by Barrett Dorko a long time ago, which describes the process in more detail, and more eloquently too.

Please read, and more importantly, digest, this review paper on central sensitization from 2010, by Latremoliere and Woolf. Central Sensitization: A Generator of Pain Hypersensitivity by Central Neural Plasticity

Friday, February 03, 2012

Projector? Or movie screen?

In "Yet another trigger point discussion" I discussed some of the comments in the long long comment section in Mike Reinold's blogpost about dry needling.

The trigger point true believers and dry needlers seem to think sore spots in the periphery are the "cause" or "source" of "pain."

This is a flawed mental trajectory, backward, inside out, upside down, and, well, just plain wrong. It supposes the following:
1. Set of tissue circumstances (not yet shown to be "real) --> "pain".
2. Solution: jab the tissue --> reduces "pain"
3. Mechanism? I don't know. Punishment of the body for merely existing?

A different (better-informed by pain science) mental trajectory is as follows:
1. Nervous system affects tissue; nervous system gets stressed, tells tissue the "wrong thing", tissue tightens up, possibly via efferent capacity of visceral afferent neurons into somatic tissue, especially cutis/subcutis (which is very thick) and neural tissue itself (peripheral nerves contain a lot of non-neuronal tissue).
2. Sore spots can be found on palpation.
3. They are the result of "pain" processing (i.e., they are areas of hyperalgesia secondary to central sensitization), not primary "causes" of pain.

Blaming tissue for pain is like blaming the screen for a bad movie, instead of the projectionist. Then poking holes in it to try to change the movie. It seems.. I don't know.. sort of futile, superstitious even.

Not to say peripheral soreness can't be "treated" however - a sore spot is just the peripheral end of a continuously looping verb called the nervous system - it usually will respond to exteroceptive attention paid to it, take advantage of novel stimulation to self-regulate/improve output behaviour. It can be projectionist, screen, movie, all the actors and directors and producers of any given movie, all at the same time.

Tissue though, tissue is just a surface acted upon from within. It does not act unless instructed to do so. And it is entirely innocent where pain is a problem.


90 minute slide presentation by Lorimer Moseley, David Butler, Mick Thacker and Adriaan Louw, from WCPT 2011.

I took a look around in the abstracts from WCPT, and found an interesting poster abstract under "Pain Management" (see image). Here is a better link to it.

I'd like to point out a simple concept known as "mutual exclusivity". This means, two ideas can be so incompatible, so contradictory, that they can't both be true at the same time.

So, what is a person supposed to believe? A meat theory that has at its core a bunch of ritual behaviour, i.e., poking at never-proven-to-exist "trigger points" in "muscle" with needles? Or a nervous system based theory that has demonstrated its veridicality as seen in the screenshot of this abstract, where results from needling are obtained whether the needles are put into a real hand or a rubber hand? They cannot both be right.

Look. Here's the thing: if you took the entire human nervous system and laid it out in a straight line, it would be 100,000 miles long (Angvine). If you are a manual therapist or a needler of some persuasion or other, you would be at one end of that long line, the "affective" end. At the other end would be the "effector" function of that nervous system, which consists of output to muscles, joints, tissues, everything. Anything you might do to it has to go through the whole long system before any change can happen in the tissue you hope to "affect". In other words, you can't "do" ANYthing directly to tissue, without the nervous system's permission. The only reason a nervous system doesn't look linear is because it's all cleverly folded up into something that looks like a human organism.