Tuesday, September 17, 2013

Skin as a (therapeutic) social organ, and the nerves of my knee.

I've been WAY too busy to be able to blog on the paper, but before I return to it, decided I want to pour down a few reflections in a lull here, in a hotel room in Regina, awake from a heavy sleep after returning from Madrid where I taught this weekend. So I got in at about midnight, after leaving the nice Hotel Confortel at 7:30am, fueled by a couple or three cafe con leches, and comida.. from there to the aeropuerto, sitting for awhile to await boarding, flying to Charles de Gaulle in Paris, admiring the airport!, finding my new gate (always a couple kilometers between gates and a security check/passport check with the snaking lines, having to drag luggage.. ), boarding the cross Atlantic flight (I gotta say, the food was really good!), arriving in Toronto with customs, security check, snaking lines, take a bus, find the checkin counter, sit and wait for the next plane to Regina..

Anyway, long story short, I was upright for another Very Long Period of Time. Counting the 8 time zones with an hour lost every time, plus the three airport experiences, I'd guess it was more than 24 hours. Going to Spain was even longer. I'd already been traveling 14 hours by the time I got on a plane that would fly me to Europe out of Toronto.

So OK: Why am I telling you this? More moaning from the woman who hates traveling? Well, partly, but this time is not just a long sad moan: this time there is a point.

The point is, I had knee pain for a couple months previously, couldn't walk well, couldn't access smooth biomechanics, and now I can. Yay!

Even after all that sitting, snoozing, not moving, fast walking, pulling luggage, going up and down short steps to and from aircraft, no knee pain anymore. I'm delighted. So, that is really what I want to talk about.

In the beginning
On a previous flight in July, to teach in Minneapolis, which is a short flight, not even two hours, I sat with my left leg crossed, foot on knee, balanced an iPad on it, played games non-stop to kill time. I should have known better, but my urge to kill boredom and stress overwhelmed my good sense about taking care of nerves, and any nociceptive input that may have been coming from my knee. As I recall, that entire weekend, I felt some stiffness in my knee, but not pain. It didn't really bother me. A few days after arriving back home, though, huge pain developed along the inside of the knee, across the front. along the medial calf, and at the back, it felt like a thick short bungee cord took up space and prevented full flexion. It was worst standing up after sitting for any period of time.

It hurt a lot. There was swelling. I did exercises for sliding nerves, I used tape, I managed the pain, and managed to do everything (badly..) except be able to use stairs. I had to use those one by one, unless I wanted to feel pain... Sometimes I capitulated to it and went one step at a time. Other times I thought, no, hurt doesn't equal harm. I'm going to act as if my knee were normal, even if it hurts.

Facing the ordeal
I kind of dreaded having to go back on a plane, especially a long trip like to Spain, but some part of my
Class in Madrid Sept 14-15, organized by Zerapi
brain decided it would ask for help once I got there, and at an appropriate moment. (see class photo at the right - a wonderful class! people with hands like butter.)

When I arrived, I was in about the same condition as before I left. The class was a ten-minute walk from the hotel, but carrying computer, etc., and my knee, and stairs, and cobblestones, it took me about 15 minutes. The second day was the workshop on  lower body/leg. I had the guy who translated, whose name was Julio (see picture), perform the treatment for entrapment points for saphenous nerve, patellar plexus, and fibular nerve. That took care (immediately!) of all the biomechanical problems. After I could even use the knee for jumping. I could handle a few steps smoothly, even carrying a load. I could walk evenly, no limp. I could feel my knee lock and unlock smoothly and appropriately with each step back to the hotel. Yesterday morning I woke up with no awareness of knee pain for the first time in at least 6 weeks. I did that huge plane trip. Today I woke up with even less discomfort. It's getting even better! With normal use, and normal biomechanics, the nerves will receive normal mechanical input. The neurons will be fed by movement. The residual soreness will vanish.

The treatment
Saphenous nerve exit point:
For the saphenous nerve I laid prone and had Julio put both his arms on the back of my leg, elbows apart, so he could elongate the skin along the back of the leg away from the knee crease. Then he located the "punta dolorosa" at the medial knee. Using both hands, he gently pulled the skin around the knee into more medial rotation around the leg. The point softened and was no longer tender. I felt extreme heat as if it were coming from his hands; actually it was coming from my leg itself as the sympathetic nervous system reacted. 80% of vasodilation occurs thanks to the sympathetic nervous system, and about 20% thanks to afferent C-fibres in the vascular plexus of cutis/subcutis. He could barely hold on to the skin, as a lot of sweating arose at the same time. But he did.
Patellar plexus:
Over the patella a bunch of nerves, cutaneous ones from the femoral nerve, all anatomose and form something called a rete. It contains lots of vasculature as well. The treatment for that is in supine: the therapist gathers as much skin circumferentially as possible, and lifts it up toward the ceiling, holding it there for a long period of time. This feels really good to the brain.
Fibular nerve:
The therapist sits beside the table, with the leg off the side of the bed, foot resting on their lap. The hip is in about 45 degrees abduction, full extension: The knee is in about 45 degrees of flexion. The therapist locates the "problem child" behind the knee. It might be a nerve, a vessel, a muscle.. I don't know for sure. There is a hard spot, anyway, large, and it feels tender.  The therapist places the other hand on the skin atop foot and the lateral side of the fibula at the lower end of the leg. They pull that skin obliquely away and into more internal rotation. The lower leg itself wants to move to follow the skin to which it is attached, into more adduction, but the top of the tibia can't move because the edge of the table is a fulcrum preventing that. But the bottom end of the leg moves slightly into adduction and internal rotation. This lengthens the fibular nerve slightly where it winds around the head of fibula, and maybe pulls it out of some deep grommet hole behind the knee at a branch point. Anyway, something in behind the knee lets go of the spinal cord reflexive guarding it was doing, or rather, was being told to do by the spinal cord. Intrinsic rotary movement at the knee restores itself. The position is completely comfortable and with the added pressure from the therapist results in a wonderful yes-ciceptive response experienced in the knee part of the body schema in the brain.
Today, my body schema is absolutely delighted with the outcome we obtained.


There wasn't enough time to present the lecture I have about operator vs. interactor models, unfortunately - translating everything means a class takes twice as long. I really really want to get across the point though, that implements are not necessary for treating anything in the periphery that has to do with pain. Only careful hands. The nervous system is absolutely self-corrective, as long as it's intact and has the ability to make any and all proteins, receptors etc., that it needs for its own maintenance. I saw this paper (full text) posted this morning and want to share it - Flexible Cerebral Connectivity Patterns Subserve Contextual Modulations of Pain.  Can you imagine the detriment to this sort of brain function if it has to put up with gouging tools, needles and high velocity manipulation? From a certain subset of practitioner who has decided they Must Be In Control of the Situation? And don't want to allow a nervous system have its own natural response? (To me, this is like a subset of rape culture.)

Another very short comment appeared in a wonderful blogpost by David Butler today, who apparently has been in Paris, visiting Pasteur's home: 
"I came out thinking “this man has saved far more lives than the Mona Lisa ever will, and why are scientists hardly revered these days – adulation goes to politicians, sportsmen and Kardashian types”. I am sure most people think the term “pasteurized/pasteurised” on the milk carton means the milk came from a pasture. And too many of my colleagues think they have to be doctors to get anywhere."

Oh yes. 
Such nonsensical and completely beside-the-point puffery. Egos walking on hind legs. I'd much rather be a SomaSimpleton.  

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