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


James Walsh said...

very powerful stuff Diane. I will be stealing some of this stuff for my own practice.

A. Bjerre said...

Oh, I love this! Will be hard not to "steal"... :-)