On being badass, when called for

I have a little horror story to share. 
File under, "No matter what, do the right thing, and be badass if it's called for."

The story goes like this: me, age 30-ish, working in a hospital. Chugging along, routine ortho rotation. Three months of respite from all the other routine rotations.
Get a new referral from the psych ward of all places. Woman admitted for depression, won't eat, says she can't lift her arm, mobilize shoulder.

So, I have the patient brought into the department. Asked her to tell me what she thinks the problem is. She says, well they put a tray out for me, but I can't eat, because I can't use my arm. 

I ask, can you tell me what the problem is with your arm? She says, I fell and broke it a year ago. The doctor put pins in it, but it still doesn't work. 

I say, really! Can you show me? 

She says, sure. She uncovers her arm. She is a thin woman, sixties, smoker. The heads of the pins poke out visibly under her skin. 
She says, I can move the shoulder, if I do this..  (she contracts her shoulder girdle muscles and her shoulder externally rotates, while her arm stays still, against her body) - I can move the shoulder, but it feels like the arm isn't attached. 

I am aghast. She is exactly right. 

I ask, what did the doctor say about this? Has he seen it? 

She says, no, he told me it was healed. He said the surgeon told him it was healed. 

My jaw is on the floor. What? he hasn't examined you? She says, no, he told me I was depressed and admitted me here. But I can't eat from the tray... 

By now I'm mad. I don't get mad very often, but this makes me outraged. I say to her, it looks like the pins didn't do their job. I'm going to phone your doctor and see if I can get this straightened out. He should at least take a look!

So, I send her back to the ward, and I get the doctor on the phone. He is the scaredest doctor I have ever talked to on the phone, before or since. 
I want answers and he has none. 
I ask him why he didn't examine his patient - she has a non-union for PeteSake. 
He says, yeah I should have, but I trusted the surgeon's word. 
I ask, who read the xray? He says, the surgeon. I ask (because I'm so mad I can't remember), who was the surgeon? He tells me. 

Oh FFS. The worst one in the city, maybe the planet - behind his back everyone calls him Dr. Abscess. Plus he is the head of the provincial medical association and Dr. Scaredy is terrified of upsetting him by contradicting him in any way.

Dr. Abcess is an idiot. And a socipath to boot. And Dr. Scaredy is willing to put Dr. Abscess's version of taking and reading his own xrays, and playing let's-pretend-this-fracture-is-healed, ahead of even examining his patient. 

So now we're dealing with two idiots, and here is this poor woman who is being told by them both that her arm is fine, and healed, and by the second who hasn't even examined her that the reason she can't lift her arm is because she's depressed! (Yeah, I'd be depressed too if I couldn't lift my arm or eat and a couple of idiots certified as real doctors were telling me that night was day.) 

This display of cowardly obsequiousness infuriates me even more. I ask, what would it take to get you to change your mind and examine her? How about if you order some new xrays? He says, I can't because Dr. Abcess is gonna know. I ask him, if I can get somebody else to do a new set of xrays and read them, will that convince you to examine your patient? He says, yes. 

Aha. The magic word. 

Then he says, what do you think I should do?

Imagine. Asking the lowly PT what he should do. He's up to his nasal septum in imaginary political doodoo and paranoia and it clearly has distracted his brain from even being able to think about duty of care.

So (madder than ever) I say something, slowly, like, look, if you cared about this patient, you would have examined her. You would not have taken Dr. Abcess's word about anything! You would take her off that psych ward and put her on the ortho ward and you would refer her to Dr. Genius (not his real name - a wonderful ortho surgeon with a black belt in karate who understood the body, even under anesthetic, and whose patients always got better with no complications). 

He says, OK, if you can get me new xrays, I'll do that.

So I did. I called xray, explained the problem, named names, was invited to bring the patient down.

I went and got her, wheeled her down to xray. 

I asked her to show the new doctor what she could do with her shoulder. 
He watched her spin her shoulder around on top of her humerus, and his eyes widened. 
Then he said, I'll order the new set of xrays myself. And he did. And the new report stated "nonunion". 

I call Dr. Scaredy with the news. 

By the next day she is moved to the ortho ward and put under the care of Dr. Genius. 
By 2 days later her arm has been reentered, the ends scraped off, re-approximated, repinned, and put in a big coil that delivers electric field therapy of some kind to the bone, a short-lived medical fad back in those days.

I saw her once more just to make sure she was OK. She expressed thanks for having successfully kicked stagnant hospital and medical butt on her behalf. 

I normally kept my head down, got along to get along, but in this case I felt pretty righteous about bossing stupid doctors around. Then I went back to normal.
No one said a word and no one got in trouble, even the incompetent physicians who should have.

Then I moved to a new province to start a new life as a manual physiotherapist, away from hospitals and all their chaos and interpersonal machinations. 

Anatomy of a peripheral nerve root

It's embarrassing to admit that even though I've been a therapist for over 40 years I still have to go back to review the basics on a regular basis.

I'm a visual learner when it comes to learning the nervous system. If I can't "see" it, I can't make a memory for it.

Most images out there are so complicated and cluttered they don't really help.

I decided to make my own, post them around on the internet, as files, and here, as a sort of comic strip. The images and any content they contain are a compilation from many sources, greatly simplified. I made these images, and I'm showing them to you. My hope is that they can help a viewer learn the wiring diagrams more easily.
The images are not copyrighted in any formal way - I would hope and trust that no one would stoop to stealing them or not attributing them or trying to sell them...
I made them myself. Feel free to use them, but please link back to this blogpost, at least..



1: The basic plan

The junction between CNS and PNS is a foreign land to most manual therapy practitioners. They know it exists but don't understand it very well. So they default to imagining they can affect tissue directly with their hands.
Even more alarming perhaps, in the long ago past, a certain cargo cult mentality emerged in which human primate social groomers imagined they could affect this junction directly by bouncing around on the spine forcing noise to emerge from it. The spine houses this intricate system, but since when did a computer ever work better by banging around on the housing of it, as if it were a reluctant coke machine?

The fact is, this junction houses very long neurons that talk to each other and to the CNS/brain at many levels. These long neurons come all the way out to skin. You can touch them there. You don't have to try to bang the housing around like some kind of home renovator/carpenter. Instead, just hack into the nervous system itself - metaphorically of course. So much easier and kinder.


2. Spinal nerve components

There are a few names to learn. Do not confuse them.

Posterior (dorsal) root
Anterior (ventral) root

Those are the bits that plug straight into the spinal cord, before the peripheral spinal nerve is even a nerve. They are closest to CNS. There are no postganglionic ANS fibres in these. Our peripheral nerve isn't ready for distribution quite yet.
.......

Dorsal ramus
Ventral ramus

These are the two divisions that occur right after all the circuitry is in place, after post ganglionic fibres have added themselves, after all the fibres have sorted themselves out and are ready for the long trip to wherever they are going to end up.
The dorsal ramus heads for the back. It innervates paraspinal muscles and skin on the back of you, from the top of the head down to the tip of tailbone.
The ventral ramus innervates everything else in the whole body (below the head), all four limbs, muscles and skin. It innervates a body wall that surrounds the whole body, including the back of the body.
Wait a minute: didn't I just say the dorsal ramus innervates the muscles of the back? Yes, but not the neck and limb muscles that cover the back and enclose it, shutting it off from the world.. only a little of them, close to the spine.
Trapezius covers the back of the neck all the way down to T12.
Latissimus covers the back all the way from T6 down to the sacrum.
The cutaneous portions of the dorsal rami must pierce through both these huge flat muscular sheets to reach the skin organ. By then all they have are sensory and autonomic fibres. I think this anatomical arrangement poses a dilemma for them, could account for some portion of back pain in the population.
But I digress.


3. Ganglia

There are a whole bunch of these located just outside the spinal cord (DRGs), inside the body (chain ganglia), some of them in front of the aorta (preverebral or preaortic).
They are so interconnected that when you look at an anatomical image of them, it's bewildering, and the eye can't take in the information the first million times you try to look at it and understand it visually - there is just too much information - it looks like a big net covering up stuff. And it is. It's the body's internet. Sort of. It's necessary to slow way down, make it really simple, visually, in order to understand its workings, first. That's what this series is. A step-by-step breakdown of a cluttery looking system. It might help to visualize this horizontally, the way it is oriented in fish, in quadrupeds.

What's kind of awesome is the fact that these ganglia, this system, predates the CNS, predates the spinal cord. Fish invented the spinal cord a half billion years ago - up to then, it is thought that this nerve net was all there was. In fact, invertebrates are distinguished from vertebrates in that they do not have a CNS (spinal cord/brain).. which doesn't mean they aren't smart - octopi are quite smart according to most accounts.
Apparently a PNS suffices for a very large percent of the population on the planet.

Please note that the DRG is not to scale in this picture. In reality it's way smaller than it looks here. And it's not right up against the anterior root.

We will find out what these ganglia are for. But first...


4. Some basic spinal cord areas

As vertebrates, however, we do have a CNS. As humans, we are inordinately proud of ours, mostly of our brains. This is where the PNS, the oldest critter brain portion of our nervous system, joins the CNS, in the spinal cord, the oldest part of the CNS, or what I like to think of as the fish brain.

I always think of the spinal cord as a land spit stretching out into the ocean of the body, festooned with little docks on each side. It seems weird that the spit was there before the continent formed at one end. But it was.

5. Peripheral outflow (efferent)

A lot of people confuse efferent and afferent. Personally, this has never been a problem, but I can understand the problem. The words are pretty close in how they look.
You just have to memorize them. Ponder them until the meanings and the distinction sink in. They are opposites.

There are two kinds of "Efferent" from the spinal cord. One is from the critter brain further upstairs, and the other from the human brain (well, at least we'd like to think we are... human I mean.. )


6. Peripheral outflow (efferent)

Here are the two kinds. Basically, one is for striate muscle and the other for smooth.

The kind for smooth muscle basically runs all the physiology for the body. The brain needs to be able to intervene and change things in a big hurry, sometimes. That's what the sympathetic NS is all about.


7. Peripheral outflow: Voluntary movement

We will tackle the easy stuff first, get it out of the way. Unfortunately this is usually all that we learn in PT school. When I try to remember PT school, I'm also pretty sure this is all that was ever taught, too. 

Maybe it's different nowadays.

8. Peripheral outflow: Voluntary movement

This system lets you execute everything from the playing of Chopin, to knitting, or breakdancing, or winning the 100 meter dash in under 10 seconds. You were a lot more aware of your voluntary movement when you learned to walk, learned your first lessons about gravity. You were a lot more aware of your voluntary movement when you learned to talk, and learned what sort of effect vocalizing at various decibel levels had on those in your social environment.

Striate muscle is amazing, but it's good to remember it's just an effector tool at the end of an executive central nervous system that wants to output something to its environment through its anterior horn neurons.


9. Peripheral outflow: Autonomic

Let's take a look at the autonomic output system now.  Yeah, I know you've been dreading this. But it's not that bad. Not really. Baby steps now, baby steps...
The CNS outflow neurons for the ANS live in the lateral horn of the spinal cord.

(Yes, there are parasympathetic neurons too. They are in the top end [brain] and tail end of the spinal cord. None of them end up in the skin we ordinarily contact in manual therapy, so I'm more interested in sympathetic outflow.)


10. Peripheral outflow: Autonomic

So, first we trace the preganglionic neurons to their destinations. These are CNS neurons, and they go to ganglia. Period. Full stop. Only a short way. Not that they don't travel through a few ganglia up and down the chain until they decide to hook up with a post ganglionic fibre.. they certainly do.

They are a little bit myelinated. Therefore the communicating ramus between the anterior root and the chain ganglion is called the white communicating ramus, or white rami communicantes if we're speaking Latin, and in plural.


11. Peripheral outflow: Autonomic

Eventually they synapse somewhere, be it in a chain ganglion or a prevertebral ganglion, and then the PNS takes over, taking the info from the brain further out and down into the ocean, oops - I mean body.


12. Peripheral outflow: Autonomic

Here's the thing: if a preganglionic fibre synapses with a postganglionic fibre in a chain ganglion, it's going to head off down a familiar peripheral nerve for the soma. This is the musculoskeletal system and all the smooth muscle cells there, including all the glands and immune cells and blood vessels. This includes running all the thermodynamically obedient, heat-regulatory, heat-dissipatory layers and layers of vasculature in the thick skin organ/blubber layer that vertebrates evolved.

If a preganglionic fibre does not stop in a chain ganglion, projects further, and synapses with a post ganglionic fibre in a prevertebral ganglia, it will send info to the smooth muscle of viscera instead. Not that viscera doesn't have its own nervous system. It certainly does. It's called the enteric nervous system, and it works quite well all by itself without any help from the sympathetic nervous system, thank you very much. However, if a bear is coming at you, the sympathetic NS will intervene to stop the enteric NS so that blood flow can go into muscle instead, so you can run away from the bear. Cool eh?

It will also divert a bunch of blood from the skin organ into the muscle layer, for the same reason.
Got to escape.
Don't worry, we can cool you down later. Right now it's more important to get outta here.

But I digress.
The grey communicating ramus, or grey rami communicantes, contains only unmyelinated neurons. No myelin, no white, more grey.


13. Peripheral inflow (Afferent)

This is my favourite part of the PNS. My bias is because this is the part I can send kinesthetic messages to somebody else's CNS through, by touching their skin in the course of treatment.

People can give themselves feedback through this system, through proprioception from striate muscle. This is how you learned to play Chopin, and breakdance, in the first place, remember?

This is a very very old old old part of the PNS. It takes info to the CNS along a wide variety of sizes of fibre. The bigger and thicker and fatter and more myelinated the fibre, the faster will be the input.

Without feedback the system does not have a clue what to do. You wouldn't know where your limbs are with your eyes closed. You wouldn't know your butt is tired from having been sat on for too long.

The visual system can be hijacked into overthrowing this input, to a certain extent, through rubber hand illusions, etc.

Mostly though, I like accessing peoples' brains through their skin.
I like remembering that somatosensory fibres are so long, and so accessible, all the way out to skin, that there are only six cells between my brain and the consciously aware brain of somebody I'm treating. Three on their side and three on mine.


14. Peripheral inflow (sensory): meningeal nerve

This is a nerve we all hope never becomes sensitized.
It gives the CNS information about its own three-layer overcoat.
It's pretty short. One can't get their hands directly on it. I don't think manipulating spines in a high-velocity fashion does this nerve (or any other nerve for that matter) any favour, long term.


15. Peripheral inflow (sensory): somatosensory nerve

This is my favourite input channel - especially those fat fibres that go all the way, from skin contact, up to dorsal column nuclei in the medulla before they terminate, synapse with another neuron. There are other cool neurons in there, however - C-tactiles, thin C's in skin that transduce only pleasant sensation, or what I like to call yes-ciception, a term coined by Jason Erickson, a massage therapist.

One should remember, though, that fibres in these nerves are sending info in from everywhere inside the body, including all the nerves themselves, and the back of the head. Here is the last slide, and it shows that.


16. Peripheral inflow (sensory): from everywhere

That's it. That was easy, right? 

............

Happy holidays

Dec. 23/2014: Edit
1. Picture of meningeal nerve corrected to depict fibres arriving to more superficial area of dorsal horn

2. Picture of viscerosensory neurons corrected to depict their arrival through white communicating ramus instead of grey, and destination in more distinct areas of dorsal horn

(See? I worked really hard to get it right, and I still didn't get it quite right the first time. It's at least improved this time.)

Endurance

I moved my office this week to a new location, patients booked for Monday morning.

This morning (Friday) it's all about the phone/internet install. The installer showed up at 8am, as did I.. full of anticipation that the process would be relatively quick & painless.

It's an old building, probably from the 1950's. Probably the same age I am, roughly.. The phone lines are in an office on the other side of some firewall (a physical one, not an internet one) that bisects the building. Neighbouring office doesn't open until 9-ish. The installer went away, scheduled himself to return at 9:30 after the neighbouring company arrives at work and opens their office.

Not so quick and painless after all. Luckily I can kill time here at home until 9:30 rolls around, in about an hour from now.

I used to be able to distract myself easily from hurrying up and waiting. There was always something I could be doing.

Now, I can't, so much. Over a lifespan I've taught myself to focus, and like anything that becomes a positive feedback loop, it feels, in circumstances like this, uncomfortably runaway.

I can feel each second float slowly by, slowness like some kind of punishment for existing, a seemingly endless succession of seconds forced to be beholden to some process outside myself, dependent on external conditions.

I guess that's what I get for painting myself into the corner of life I chose to paint myself into.. trained my brain into. Usually it's more interesting to me, because at least I can feel something moving, some succession of this "now" being slightly different from the now that came before it, and the one before that.. I can feel unseen rivers moving under my hands, placed on somebody's physicality.

This kind of waiting, more social, more dependent on other people in their social realm of existence, I have less capacity to endure gladly. I have to trust that their ordinary lives will fall into place so that mine can.

So, I write about stuff, even about being bored, because it kills outside time just a little bit easier.

.........

Top-down causation and the emergence of agency

Top-down causation and the emergence of agency

A fabulous blogpost by Kevin Mitchell, in Wiring the Brain. 

Rarely does one see entire whole nervous system function, from peripheral to frontal lobes, explained in all its hierarchical glory, linked to reality and thermodynamics and evolutionary biology, all in one easy-to-read beautiful blogpost. Thank you Kevin Mitchell.
Not that there aren't quibbles. See the comment section.

The assemblage art of Bernard Pras is a good visual metaphor for how brains work, for watching how one's own brain works.

Bear in mind this happens with every sense, every kind of input, not just visual. Mostly there is a big moving pile of junk coming in all the time; the brain tries to figure out how to make sense of it, and succeeds enough of the time that life and events seem seamless and natural. Pretty cool trick when you think about it. It's had plenty of time to develop the ways of doing this, a good 500 million years. Ever since Devonian fish first invented spinal cords. 

............................

Is the process intelligent? It certainly feels that way. Especially in us.

However, is it really? or is it just a well-honed, most-efficient way to transform physical energy within the constraints of the laws of thermodynamics?

I found another video yesterday that depicted a gob of some sort of goo ingesting a magnet, and immediately thought of macrophages in the body. They probably are about this intelligent. Life isn't necessarily required for this sort of behaviour. Just some sort of gradient.

"Nature abhors a gradient",  a quote by Dorion Sagan and Eric Schneider, from their book, Into the Cool: Energy Flow, Thermodynamics and Life, one of the best books I have ever read in my entire life.

Here is the goo video. 

...................

On the other side of the neuroscience universe, people are building neurons these days in order to better study them. See Blanchard et al 2014, and this news story, Scientists convert human skin cells into sensory neurons.   Ignore the usual foible, nociception conflated with pain, while reading Pain and itch neurons grown in a dish, about Clifford Woolf's group, who just published Modeling pain in vitro using nociceptor neurons reprogrammed from fibroblasts. 

..................

Let's never forget that as therapists, we input new sensation, new "junk" for our patient's brains to sort. We have to wait long enough for those brains we treat to sort through new junk.

The good news is, this process is completely automatic. 

Check out the video of Alan Watts, discussing how to not fight nature, instead, how to work with it.
Instead of rowing, which requires a lot of effort, just throw up a sail and wait.
The brain of your patient is the wind, and your contact with their physicality is the boat: let that person's brain move that boat itself.
Don't wear out your hands trying to row their boat for them. 

........

One last thing, a new paper on the insula, by Lucina Q. Uddin.
In the critter brain metaphor, insula is quite the chooser of which raw input to pay attention to and why. Very picky.
I like to think of it as a mid-level stage processor of raw data in, from every sense.

I try to make sure I'm not displeasing the insula of the brain of the patient at any stage along the way.

Not that it doesn't happen from time to time, despite my best efforts.
I live in a conservative small prairie city. Most people are religious, or at least go to church to see their friends, and quite a few think "evolution" is an idea from the vice category. I've lost a few people on that alone. The thing is, none of any of this information about how brains make sense of things, or might end up in pain, makes any sense without that key piece of reason in the story line.

Fortunately the bell curve here contains enough people who don't care one way or the other, that I continue to make a living, a reasonable living, no matter how science-based I choose to be. 
Yes, I chose the word "reasonable" deliberately, for both its meanings, in that sentence.

..................................

1. Joel W Blanchard, Kevin T Eade, Attila Szűcs, Valentina Lo Sardo, Rachel K Tsunemoto, Daniel Williams, Pietro Paolo Sanna, Kristin K Baldwin. Selective conversion of fibroblasts into peripheral sensory neurons.  Nature Neuroscience (2014)

2. Brian J Wainger, Elizabeth D Buttermore, Julia T Oliveira, Cassidy Mellin, Seungkyu Lee, Wardiya Afshar Saber, Amy J Wang, Justin K Ichida, Isaac M Chiu, Lee Barrett, Eric A Huebner, Canan Bilgin, Naomi Tsujimoto, Christian Brenneis, Kush Kapur, Lee L Rubin,Kevin Eggan, Clifford J Woolf. Modeling pain in vitro using nociceptor neurons reprogrammed from fibroblasts.  Nature Neuroscience (2014)

3. Lucina Q. Uddin Salience processing and insular cortical function and dysfunction Nature Reviews Neuroscience 19 November 2014

"The brain is constantly bombarded by stimuli, and the relative salience of these inputs determines which are more likely to capture attention. A brain system known as the 'salience network', with key nodes in the insular cortices, has a central role in the detection of behaviourally relevant stimuli and the coordination of neural resources. Emerging evidence suggests that atypical engagement of specific subdivisions of the insula within the salience network is a feature of many neuropsychiatric disorders."

Pain results in motor impairment, not the other way around.

Pain results in motor impairment, not the other way round. 
"Our study demonstrated that simply inducing experimental pain over the posterior sacro-iliac ligaments in painfree people resulted in the kind of findings often reported in patients with pelvic pain; a positive active straight leg raise (ASLR) and muscle guarding. This indicates that pain alone, regardless of the position or mobility of the pelvic bones, can mimic the clinical findings previously associated with ‘pelvic instability’ or lack of ‘ force closure’. The findings have implications for how we interpret what we find among patients in the clinic. It has often been assumed that these findings when present in patients with pain are the cause of their pain. In contrast, these findings suggest the opposite – that simply experiencing pain causes the body to move in slightly unusual ways, and these are signs of pain, not necessarily the cause of pain."

"This study demonstrates for the first time that pain and hyperalgesia arising from a structure superficial to the sacroiliac joint complex increases the subjective effort, activity in stabilizing muscles, and lifting quality during the active straight leg raise test. Moreover, the pain caused by hypertonic saline is related with the increase in perceived difficulty and muscle activity during the test. These data indicate that pain and hyperalgesia per se can give similar responses to the ASLR test as seen in different clinical groups and challenge the diagnostic value of the test." 

I *love* when my confirmation biases find outside confirmation! 

Now, substitute "pain caused by hypertonic saline" for "nociceptive input from a nerve, cutaneous or motor, but probably cutaneous, that can't drain and is backed up with its own metabolites because of mechanical deformation of its venous drainage coupled with the fact nerves have no lymphatics", and I think this paper is onto something.





Also, don't miss the brilliant chiro-turned-PT, Greg Lehman's, presentation (see above) which deftly deconstructs the biomechanical model in a way that it doesn't even know that it's been sliced to ribbons until it tries to stand up and falls down in a million pieces.








Palsson TS, Hirata RP, Graven-Nielsen T. Experimental Pelvic Pain Impairs the Performance During the Active Straight Leg Raise Test and Causes Excessive Muscle Stabilization. Clin J Pain. 2014 Aug 12.

Just in case you may have missed the point:

Downfall of the biomechanical postural structural model

The Lovely Waitress

Last week I travelled to Los Angeles to teach a workshop. The workshop went well and the visit was fun, but I'll spare you a detailed account of the double decker bus tour with the tour guide who pointed out all the hotels and nightclubs where stars had fallen from suicide, or drugs, or had been kicked out for being rowdy. Instead, I want to tell you about an inner experience at breakfast, at a nice little hole-in-the-wall bakery shop.

The twenty-something waitress came to take our order. She seemed sweet and had a beautiful smile. Her smile was nice, but hey, lots of people have beautiful smiles, and hers was no more beautiful than usual.

I was with the guy who hosted the class. We ordered lattes and something to eat.. we were busy chatting about this and that when the waitress arrived back with the lattes, and magic happened.

Suddenly, I became acutely aware that something beyond the usual was going on inside me. Something in there was responding to the waitress, or rather, to her movement. Suddenly 100% of my conscious awareness was watching her as she unbelievably, beautifully, placed two broad shallow cups of brimming latte on the table, gently, as though they were sleeping babies, not spilling one drop; the surface tension held the edge.

She smiled through this. Clearly this required making an effort, yet she graciously cancelled out any sense of this being effortful as she slowed and steadied her body to accomplish this feat, this feat which in the moment suddenly seemed as difficult a feat as anything Cirque has ever required of its performers.

Maybe the proximity was a factor as well - her arm was only a few inches away from me. Perhaps there was a small element of danger: had she lost focus, the coffee would have slid over the edge of the cup. It likely would not have spilled completely in my lap or anything, but it would have dripped off the edge, and that would have been mildly unpleasant. Instead, she rode that razor's edge of possibility, masterfully interacted with gravity in a most pleasing manner, and pulled off the impossible - laid that latte down with grace and style, but not in any way that could have been misconstrued as showboating. It was a beautiful moment.
Then she did it again, for my host.

But she wasn't done yet - she had flatware to put down. You know how waitresses usually lay down flatware after doing it a couple thousand times - kinda perfunctory, letting the weight of the flatware have its way, saving themselves a bit of energy by letting gravity win a bit too soon..
Not our waitress. She floated those six pieces down as carefully as though she were landing six small jet planes filled with precious breakables, merging them into gravity, not giving up until the very last nanosecond. She floated those pieces down. She succeeded in forcing time itself to elongate, slightly, just long enough to give my critter brain time to experience something in the outer world on its own terms, for once, and mount a surprise emotional response.

What was this response? It was awe, joy, appreciation. I actually could feel tears come to my eyes. She had created a moment of beauty with her movement that was remarkable for having occurred in so banal a setting, extraordinariness framed by ordinariness, the juxtaposition of which was extra delight in itself.
I do not feel that way very often. I have never felt that way while being served coffee by any other waitress, ever.
Both of us felt her.

I asked her name - it was Antoinette. I remarked how marvelous it was that she had managed to not spill a drop. She said, "I'm studying dance which is kind of funny because the reason I chose dance is that I'm naturally quite clumsy. In fact a lot of dancers are clumsy, and that's why we choose dance, so we can learn how to overcome it."

Well, Antoinette, all I can say is thank you for the amazing, unforgettable, closeup experience of witnessing your use of your physicality to create a moment of beauty. If you ever audition for So You Think You Can Dance, I'm pretty sure the judges will see your talent, your "it" factor, feel moved by you, and pick you for one of those tickets to Las Vegas.
You made me feel a moment of pleasure in this world, for free! - a world in which it seems I spend most of my life fending off displeasure, and I liked it. I really, really liked it.
If I had another life to live, I'd want you for my mom in that next life.

........... 

Can manual therapy be made antifragile?

While I'm sure there are some who would like to see manual therapy destroyed and outlawed altogether, there are some, like me, who only want to see it cleaned up, objectionable explanatory models (noceboic to patients, intellectually offensive to therapists who have decluttered ourselves) removed, and practices which could maim people (high velocity or even just heavy neck manipulation, I'm looking at you..) outlawed.

I want to keep manual therapy, itself, alive. I want it to be antifragile. Well, in fact.. I think it already is solid. It's solid when defined properly. Here is the little list of antifragility principles I'd like to see manual therapy associated with. Many of them are the opposite of what the professions/culture/insurance companies demand.

Stick to simple rules
Don't try to be doctors of it - just go about helping people with their stress&pain, with physical contact, and kinesthetic reassurance.

Build in redundancy and layers (no single point of failure)
It is only what it is, nothing more. Nothing fancy. You can't lose anything by trying it, a few times at least.

Resist the urge to suppress randomness
Serendipitous ways of handling a problem will come to you in the moment, if you let it. Together you and the patient and both your nervous systems are 4 artists, physically making a work of art, in the moment. Let creativity come and play if it wants.

Make sure that you have your soul in the game
I'm not somebody who thinks in terms of "soul".. I do think in terms of critter brain, however. I'm pretty sure the two are indistinguishable. One is a human conceptualization of a set of qualities and behaviour and the other is a giant chunk of nervous system we share with all other vertebrates and without which we would be dead. So I would say, keep your own critter brain in the game. You have got to know your own, interact with it lots yourself before you can trust it to play nice with somebody else's.

Experiment and tinker — take lots of small risks
Make sure they are risks devoid of future harmful consequences, that's all. Usually smaller = slower and/or lighter.
We are connecting with nervous systems in other people. The surface of the body is so lively with info processing and conveying that you can pretty much get any message across to another nervous system without having to push hard, or fast, or perpendicularly.

Avoid risks that, if lost, would wipe you out completely
E.g., high velocity maiming, poking patients full of needles and collapsing a lung.

Don’t get consumed by data
Especially data on manual therapy, which just about always turns out to have effects that are nonspecific, at best, or else just random.

Keep your options open
As in, for example, the option to avoid certain bits that seem way too sensitive. Load in skin contact elsewhere instead. For example, a very sore or swollen ankle - you don't have to touch or "treat" the actual tender malleolus right off the bat. Twist the skin around the heel or do a balloon technique or something, stretch the skin somehow, by pulling skin toward the opposite malleolus instead. You'll get the human brain's attention without aggravating the critter brain.

Focus more on avoiding things that don’t work than trying to find out what does work
Absolutely. And the older you get the less you'll find yourself doing, and the better will be your results in the moment.

Respect the old — look for habits and rules that have been around for a long time
As far as I'm concerned, what has been around longest is that tendency vertebrate creatures have to conduct conspecific and interspecies social grooming, as long as there have been vertebrates. More recently primates took social grooming to a whole other level when they started exchanging it for not only bio (picking off bugs) reasons, but psychosocial ones as well (bringing individuals back into the troop, reducing stress after fights or someone got bossed unfairly, demonstrating caring behaviour). We are human primates and if we remember to do human primate social grooming first, that's all we usually have to do.

None of the above is the least bit incongruent with pain science.
I think we should be first responders to pain as expressed by another. Most of which is secondary to stress. Much of which is associated with muscle tension also secondary to stress, because spinal cord was the first part of the central nervous system to evolve, is the first responder to nociceptive input, and the spinal cord has never been famous for having much hard drive.
In fact the spinal cord hasn't changed a lot since fish invented it 500 million years ago. Come to think of it, that could be why vertebrates invented social grooming in such a cross species fashion.

Claustrum? Consciousness?

The claustrum is being associated with conscious-"ness".

A decade ago, Christof Koch and Francis Crick (before he died) wondered, What is the function of the claustrum? (pdf).

Here is a new news story about this part of the brain: What the Claustrum Does—How One Makes Up One’s Mind

Excerpt:

The claustrum consists of a thin yet broad sheet of neurons buried in the depths of the brain. Until recently its function has been obscure. Because it is directly connected to nearly every other region of the brain – especially the cortex – Francis Crick and Christof Koch suggested a decade ago that it might have something to do with consciousness...perhaps the claustrum gets it all together and acts, as Crick and Koch suggested, as the conductor of the brain’s orchestra... Recently, my colleagues (Smythies and Ramachandran) and I have suggested that the claustrum operates by strengthening the synchronized gamma frequency oscillations in the cortex that play a key role in coordinating the brain’s input and output. For example, two different sensory inputs will activate and set-up synchronized oscillations in two particular zones within the claustrum. These will be subject to further modulation by saliency mechanisms that signal the importance (i.e., significance and reward value) of what is going on. These two groups of cortico-claustro-cortical oscillations then compete on a “winner-takes-all” basis. The winner gets to activate the motor cortex (in essence, to “make it so!”) and a particular behavior results.

We should probably not get too excited though. As Robert Burton points out in BrainSciencePodcast 96, and in his book, "A Skeptic's Guide to the Mind: What Neuroscience Can and Cannot Tell Us About Ourselves", using the mind to study the brain is one thing, but using the mind to try to study the mind is an exercise in futile circularity, and there is simply no way out of the trap. 
Not that people aren't going to keep on trying. 
And telling stories.

Also, meanwhile, there are other bits involved that surely have something to do with something, e.g. the dorsal medial habenula (a part that is likely somewhat dysfunctional in me), that manages mood, motivation, desire to exercise.

Maybe everything influences everything.
Maybe, as soon as one wakes up in the morning, everything is a repeatable/repetitive neurotag.
Maybe everything is a verb, not a noun.

Rationality - attainable goal or vanishing horizon?

Some days the blogposts just write themselves. It's Monday morning, a bleak and rainy day after an entire bleak and rainy weekend. Perfect weather for
a) a heavy sigh and 
b) a depressing blogpost. 

SOURCE

Theme: The work to become rational/promote rationality is never done.

Supporting links:

1. The most depressing news about the brain, ever. Sept 2013 This is about American voters, but it could be about any group of humans probably. 

"Say goodnight to the dream that education, journalism, scientific evidence, or reason can provide the tools that people need in order to make good decisions."

Even if tools are provided, people don't seem to pick them up.  

"When people are misinformed, giving them facts to correct those errors only makes them cling to their beliefs more tenaciously."

Backfire effect.

2. Keith E. Stanovich, Richard F. West, and Maggie E. Toplak; Myside Bias, Rational Thinking, and Intelligence. Current Directions in Psychological Science 2013  22(4) 259–264 (FULL TEXT PDF)

"AbstractMyside bias occurs when people evaluate evidence, generate evidence, and test hypotheses in a manner biased toward their own prior opinions and attitudes. Research across a wide variety of myside bias paradigms has revealed a somewhat surprising finding regarding individual differences. The magnitude of the myside bias shows very little relation to intelligence. Avoiding myside bias is thus one rational thinking skill that is not assessed by intelligence tests or even indirectly indexed through its correlation with cognitive ability measures."

Take-home point: Myside bias will operate as a default mode of thinking unless instructions are explicitly given to set it aside; it has nothing whatever to do with intelligence.

3. Rationality vs. intelligence 2009, by Keith Stanovich

"Intelligence tests measure important things, but they do not assess the extent of rational thought.  This might not be such a grave omission if intelligence were a strong predictor of rational thinking. But my research group found just the opposite: it is a mild predictor at best, and some rational thinking skills are totally dissociated from intelligence."

4. Conflict as thinking: Margaret Heffernan at TED Global 2012: An epidemic hidden in plain view. 

People don't want to rock boats. It's a long learning curve for them comfortable with disagreeing, but without objective thinking, we get exactly nowhere.  

5. Against all reason: Effects of acupuncture and TENS delivered to an artificial hand. 

6. Common misconceptions about back pain in sport: Tiger Woods’ case brings 5 fundamental questions into sharp focus  Peter O'Sullivan, Aug 22 2014. 

Hat tip to Carol Lynn Chevrier, Todd Hargrove, Sigurd Mikkelsen, Barrett Dorko, and Rick Carter for these links. 

Many thanks to Peter O'Sullivan for such a rational (and hopefully, rationality inducing) blogpost.

................

I don't know what to do about any of this. I'm as guilty as anyone. 

Meditate I suppose.
Kill time until the end comes. 

Breathe in and out. Become fascinated by that. 

I'm not up to going off into the woods and watching the moon become the minute hand and the seasons become the hour hand. I guess I'll just keep plugging away at making pictures instead, getting them published some day. Treating patients with every minimalist bit of myside bias I can manage to muster. And continue to add links to this list.