Tuesday, September 11, 2012

Deep versus shallow models of treatment

Last week I posted "Deep versus shallow models of manual therapy", but, as we all know, "therapy" isn't necessarily "manual." In fact, most therapy isn't manual at all. So, I'm going to expand the idea of deep versus shallow a bit more, to include therapy in general. This will encompass all the other kinds of treatment out there that has nothing to do with manual or physical contact. 

Joe Brence, in his Open Question to PTs... asks, "In your opinion, what is the one thing you would change about PT and why?" This effort is an answer to that question, I suppose...

But permit me to digress.

This past weekend I spent two days immersed in the small, 7-person think tank known as the executive of the Pain Science Division of CPA, in the beautiful and comfortable home of Dave Walton, current chair, who led the meeting. Almost all have been involved in research of some kind, spanning the range from me, with one paltry case series, to Tim Wideman, our chair elect. Out of 7 people, 4 have PhDs. We turned ourselves into a team. Out of our meeting emerged 1-year, 3-year, and 5-year plans. We intend to be unstoppable. 

General Effects
At that meeting I learned of the work of Maxi Miciak, a colleague of Geoff Bostick from U. Alberta, who is our division research representative. She has written a paper called: 

A review of the psychotherapeutic 'common factors' model and its application in physical therapy: the need to consider general effects in physical therapy practice.

In it she examines the idea that "general effects" count for far more than any sort of skilled technical expertise when outcomes of treatment are examined and put through a detergent cycle of statistical scrutiny. She mentions work done by someone named Jerome Frank*:   

[Jerome Frank's] "..conceptual framework includes four common features: (i) an emotionally charged confiding relationship with a helper, (ii) a healing setting where there is belief the therapist can help and is acting in the client’s best interests, (iii) a rationale, conceptual scheme or myth that plausibly explains the symptoms and prescribes a procedure for resolving the symptoms, (iv) a ritual or procedure that requires active participation of both patient and therapist and is believed by both to be the means of restoring health."   
* Frank JD, Frank JB. Persuasion and Healing: A Comparative Study of Psycho- therapy, 3rd edn. 1991, The Johns Hopkins University Press, Baltimore.

Don't you think, realistically, that manual therapy is mostly "ritual" procedure? It seems to me, after a lifetime of being a therapist, and for most of that time, being a manual therapist, that it's a way to fill up time while the patient's brain changes itself. Hey, you gotta kill time doing something. Hopefully something useful. Hopefully something that will make sense to both of the two people in the treatment dyad, therapist and patient person experiencing pain. 

In other systems, e.g., Peter Levine's Somatic Experiencing (which I attended in 1992), time is killed by just sitting there calmly. Peter Levine referred to this as paw-licking, something cats do a lot when they are just sitting, thinking, cogitating (or whatever cats do in those feline brains they have..), basically just passing time. The point is, you don't want to interrupt while your patient or client or consultee is busy doing what they have paid you good money to facilitate. The other thing to remember is, their brains will do their own changing, automatically. You don't have to "do" anything at all, if you don't want to. You can just sit there and watch. All the facilitation is purely social. Your job as therapist is to stay out of the way, for the most part. Just like siphoning - get the water to come up against gravity by sucking on the hose a bit, recruit normal air pressure to assist, then you can sit back and watch it flow uphill. It will work fine as long as the output end of the hose is a bit lower than the intake end. (In the brain, this has something to do with its finding more efficient metabolism, I think.)
The skill set is to know when to intervene slightly, and when to back off. Like steering while driving. You do not have to devote much hard drive to steering after awhile. The skill set of keeping a car on the highway, between the lines, while avoiding other moving vehicles, becomes completely automatic, implicit knowledge. 

(The challenge as far as I'm concerned, as a manual therapist, is how to keep the process alive and dynamic and fresh with each patient, how to stay tuned in so it doesn't get stale and turn into automaticity.) 

Putting the SOCIAL into biopsychosocial (finally!)
Serendipitously, this little gem turned up: PAINWeek 2012 Conference Keynote Address: The Realities of Pain as a Public Health and Social Issue. In it, 
"Daniel B. Carr, MD, of Tufts University School of Medicine delivered a keynote address titled “Have We Been Backwards, Upside Down, or Both?” at the opening session for PAINWeek 2012."
It's great! He can see how all this time we've all been looking at pain through a telescope backwards! If we start at the social end of biopsychosocial, instead of always at the bio end, we could do better

The social end is where all manual therapy starts. It's interactive, not operational, no matter HOW resistant manual therapists might be to that idea. We are not treating stretchy corpses, we are not treating tissues, we are treating people who have pain. We are treating brains in pain. We are treating nervous systems in pain, nervous systems that span the entire distance, both physically and conceptually, between skin cell and sense of self. 

So, Joe, in answer to your question, I'd say, let's be less physical, more therapist. 


Miciak MGross DPJoyce AA review of the psychotherapeutic 'common factors' model and its application in physical therapy: the need to consider general effects in physical therapy practice. Scand J Caring Sci. 2012 Jun;26(2):394-403

Thursday, September 06, 2012

Deep versus shallow models of manual therapy

A long time ago, shortly after I moved online and joined discussion groups (way back in 2001), I encountered Barrett Dorko, who was the first PT I had ever met who differentiated between what he called deep models of manual therapy versus shallow models. It made sense to me. 

Deep models seem to line up well with knowledge of science in general, understanding of neuroscience in particular, and logical deconstruction of the pretence that we, manual therapists, can actually have any direct physical impact on somebody else's (i.e., a patient's) tissues that would result in a therapeutic outcome. 
I could relate. In my mind, deep models equate with what I call "ectodermal" models - "interactor" models. It's where I've always wanted to see PT go - more emphasis on "therapy" - less on "physical". 

Shallow models line up with everything I detested (and still detest) about manual therapy - a tissue is chosen as a target, then an entire world-view built around it, including a whole set of ritual interventions directed toward said tissue target. 
Tissue targets range from the most deep (spinal joints) to the most superficial (fascia, head sutures); muscles, ligaments, tendons - pick some part - any part - of the movement conglomerate, or passive elements that are there to keep it from falling apart! - then have at it. 
Build an entire religion around "correcting" it. 
A large vocabulary is invented, based on pareidolic assessments of biomechanics which are asymmetric and therefore "faulty". These observations are welded to pain manifestations. Therapist "corrects" the "faulty" biomechanical appearance of a person's posture, or position, or movement, and voilá, if the pain diminishes, it has "proven" the therapist's religious-like world view about what was "wrong" in the first place. It's like driving forward while looking in a rear view mirror. 
These are the shallow models.  These line up with what I call "mesodermal" or "operator" models. 

I recently devised a flowchart of sorts, exposed it to my peers, got good feedback, revised it a few times, and posted it to Facebook, where it went out into the world a little way. Here it is again. (Click on it to make it big.)

In my opinion, the problem stems back to language, and particularly to the human brain's difficulty with recognizing that as soon as nouns are applied to treatment, the life gets sucked out of treatment as encounter between two human beings. Life is sucked out of the verb of the encounter, out of the encounter as verb. As process. As something that has a beginning, and a middle, and an end. Like a story. Like a story built by two people, interacting, not by one person who thinks they know everything about everything and treats the other like an object

More information:

1. Beyond the technique- from Operator to Interactor BlogTalk radio podcast interview with Diane Jacobs and Jason Silvernail

2. "Touch is good" - HumanPrimateSocialGrooming manual

3. Manual therapy and its treatment models (google doc)

4. Diane F Jacobs*, PT and Jason L Silvernail, DPT, DSc, FAAOMPT; Therapist as operator or interactor? Moving beyond the technique.  J Man Manip Ther. 2011 May; 19(2): 120–121. (*FYI: This is my only pubmed publication - any other "Jacobs DFs" out there are not me)

5. New Treatment Encounter (I-VI)

6. DNM in a Nutshell

7. Boiling down the problem

Saturday, September 01, 2012

More about Olausson

I have talked about Olausson before, many times (see list of blogposts at bottom of page). 

Last night, late, this piece by Sabrina Richards, writing for New Scientist, came in: Pleasant to the Touch.  (Which meant it was 1:32 AM before I could even think about going to bed!)

There were other great stories to read in New Scientist last night - there was one called A Nose for Touch, by Kenneth Catania about star-nosed moles, all about what incredibly sensorially-well-appointed little feeler-like noses these small mammals enjoy, with a great deal of information about sensory processing in general; Missing Touch by Meagan Scudellari is about the quest to give prostheses haptic capacity. Good Vibrations by Cristina Luiggi is about mechanoreception in all sorts of creatures. The Pliable Brain by Christina Karns is about how deaf peoples' auditory cortex might be used by them, outside awareness, to process mechanoreceptive information. 

A bit outside the exteroceptive sensory processing ball park, but still about feeling, this time interoceptive processing of one's own stress response, is a piece by John Coates, A Story Biological: Coates is a former stock trader, and neuroscience investigator - he wrote a book. "The Hour Between Dog and Wolf: Risk Taking, Gut Feelings and the Biology of Boom and Bust." I happened to catch this CBC interview with him while driving home from CPA Congress in May. It was brilliant. He proposes that in men, a positive feedback loop between excitement and risk taking grows and grows until either victory or devastating defeat occurs. I.e., men just don't feel their growing stress response as anything with warning bells attached - instead they feed on it. (He thinks women and old guys should take care of the money, as they are way more risk aversive.) 

But anyway, back to Kenneth Catania's piece about star-nosed moles... 


"Exquisitely sensitive touch
The star-nosed mole’s “nose” is not an olfactory organ, but a skin surface that mediates touch. Innervated by more than 100,000 sensory neurons, the star is probably the most sensitive and highly acute touch organ found on any mammal. Under a scanning electron microscope, the skin surface resolves into a cobbled landscape covered with tens of thousands of tiny epidermal domes. Each is about 60 µm in diameter, and each contains a circular disk in its center. Known as Eimer’s organs, these sensory protrusions cover the entire surface of the star’s 22 appendages. In total, a single star contains about 25,000 domed Eimer’s organs, each one served by four or so myelinated nerve fibers and probably about as many unmyelinated fibers.1 This adds up to many times more than the total number of touch fibers (17,000) found in the human hand—yet the entire star is smaller than a human fingertip."
So, thinking as a manual therapist, if we could make a human hand that contained the sensitivity of a single star nose, we'd need ... let's see.. a hand that was 6 times bigger and just as sensitive as it already is! If you  think of visual data, that would be WAY too big and too fuzzy a "picture"! The pixel size needs to be dense to get such great resolution. 

We could die from all the pleasantness, maybe: (Pleasant to the Touch)
"Scientists hope an understanding of nerve fibers responsive only to gentle touch will give insight into the role the sense plays in social bonding."
"The C-Tactile Story 
When Håkan Olausson and his colleagues at the University of Gothenburg began studying light touch perception in the early 1990s, most researchers in the field rejected the idea that humans might have slow-conducting nerve fibers sensitive to gentle pressure. “Nobody really thought they existed in humans,” Olausson explains. Textbooks at the time acknowledged that humans had slow-conducting nerves, but asserted that those nerves only responded to two types of stimuli: pain and temperature. Sensations of pressure and vibration were believed to travel only along myelinated, fast-signaling nerve fibers, which also give information about location. Experiments blocking nerve fibers supported this notion. Preventing fast fibers from firing (either by clamping the relevant nerve or by injecting the local anesthetic lidocaine) seemed to eliminate the sensation of pressure altogether, but blocking slow fibers only seemed to reduce sensitivity to warmth or a small painful shock. 
In contrast to the work in humans, experiments in cats, rats, rabbits, and even monkeys found that unmyelinated, slow-conducting nerve fibers were indeed sensitive to light touch, but were found only in hairy skin. Some researchers speculated that humans had lost such fibers to evolution as they shed most of their body hair. While a few isolated studies suggested that facial skin retained the fibers, those studies were often dismissed as merely demonstrating the existence of a vestigial type of nerve fiber, says Olausson...
Then, in 1999, the group looked more closely at the characteristics of the slow fibers.They named these “low-threshold” nerves “C-tactile,” or CT, fibers, said Olausson, because of their “exquisite sensitivity” to slow, gentle tactile stimulation, but unresponsiveness to noxious stimuli like pinpricks... Unlike other types of sensory nerves, CT fibers could be found only in hairy human skin—such as the forearm and thigh... To address the question, Olausson’s group sought out a patient known as G.L. who had an unusual nerve defect. More than 2 decades earlier, she had developed numbness across many parts of her body after taking penicillin to treat a cough and fever. Testing showed that she had lost responsiveness to pressure, and a nerve biopsy confirmed that G.L.’s quick-conducting fibers were gone, resulting in an inability to sense any pokes, prods, or pinpricks below her nose. But she could still sense warmth, suggesting that her slow-conducting unmyelinated fibers were intact... G.L. also afforded scientists the opportunity to observe which areas of the brain respond to the gentle brushing. Sensations of touch stimulate two different brain areas, says Vaughan Macefield, a neuroscientist at the University of Western Sydney who researches how the brain processes pain. The somatosensory cortex registers the quick signals sent along myelinated nerve fibers and tells us where on our body the sensations originate. Slow, unmyelinated fibers send signals to the insular cortex—a section of the brain that processes taste and pain, as well as emotion. Most of our touch perception mingles information from both areas, says Macefield. 
Olausson used functional MRI studies to examine which areas of the brain lit up when G.L.’s arm was gently brushed to activate CT fibers. In normal subjects, both the somatosensory and insular cortices were activated, but only the insular cortex was active when researchers brushed G.L.’s arm. This solidified the notion that CT fibers convey a more emotional quality of touch, rather than the conscious aspect that helps us describe what we are sensing. CT fibers, it seemed, specifically provide pleasurable sensations.Reading these studies while sitting on an airplane some 15 years ago, 
Francis McGlone, whose research at the time focused on pain, had an epiphany. “I said, I know exactly what they’re for: grooming behaviors,” he explains. 
McGlone had already begun hypothesizing that certain behaviors, like applying face creams, were motivated more by an underlying pleasant sensation than by any anti-aging benefits the creams might be providing. People repeat these behaviors, McGlone theorized, because they stimulate a subtle, positive, possibly unconscious sense of reward. CT fibers offered the perfect explanation of how this positive sensation was being transmitted to the brain.
These studies, taken together, led McGlone to think about how touch informs social interaction. In his view, it’s clear that pleasant touch is important during both infant development and adult social interaction. Although rigorous human studies have yet to be performed, anecdotal evidence in humans and studies on rats nurturing their pups supports the role of touch in brain development."

My bold.
References under Richard's story:

  1. Å.B. Vallbo et al., “A system of unmyelinated afferents for innocuous mechanoreception in the human skin,” Brain Res, 628:301-04, 1993. 
  2. Å.B. Vallbo et al., “Unmyelinated afferents constitute a second system coding tactile stimuli of the human hairy skin,” J Neurophysiol, 8:2753-63, 1999. 
  3. H. Olausson et al., “Unmyelinated tactile afferents signal touch and project to insular cortex,”Nature Neurosci, 5:900-04, 2002. 
  4. L.S. Löken et al., “Pleasantness of touch in human glabrous and hairy skin: Order effects on affective ratings,” Brain Res, 1417:9-15, 2011. 
  5. I. Morrison et al., “Reduced C-afferent fibre density affects perceived pleasantness and empathy for touch,” Brain, 134:1116-26, 2011. 

Old blogposts re: Olausson:
1. Dermoneuromodulation: Ascending Pathways (March 2012)
2. Dermoneuromodulation: Ruffini Sensory Endings and Dorsolateral Prefrontal Cortex (March 2012)
3. More Insular Matters (May 2008)
4. "Somesthesis" (April 2008)
5. SomaSimple Pain Consensus (Jan 2008)
6. Manipulation and the Brain (Feb 2007)

Also, about grooming behaviours and how they relate to manual therapy: