If science were sandpaper

Yes, I'm still dangling in the chasm.
I'm still procrastinating. But I do think I'm making a little progress.

Not that I didn't write several more heavily referenced pages, an entire new intro chapter, not that I didn't include all the ideas I wrote about that I wanted to include, not that I haven't farmed it out to people I know who not only can write but who can edit too.. so, not that I haven't made some progress, because I think I have - but the timing is lousy because, time of year, and only one person has got back to me with lots of lovely suggestions.

So, to kill time I'm watching videos.
Not just cat videos.
I've watched almost all Harriet Hall's excellent video series on science-based medicine. As I listened to her methodically demolish all quackery on face of the planet, I applauded all the medical people and scientific hard work that has gone into making life more physically bearable for humanity over the last century. Oh yeah sure, there is a long way to go and there are inherent contradictions, but every day I wake up grateful that, since I had no choice but to endure physical existence as a female human primate, I was born in a place and time where I have had legal access to vaccinations and antibiotics and public health and and general anesthetic and birth control.

It made me think that if medical science were sandpaper, biomedical science would be the roughest, toughest grit size. And you need that, if you are trying to remove hardened goop or paint from a board or something...  or if you're trying to get humanity in general to wake up from all its inherent bias.

However, there are other grades of sandpaper that work way better for other jobs. Like polishing lacquer, or jewelry... 
......................

I read Engel's wonderful 1977 paper arguing for a new biopsychosocial model of disease and illness, The need for a new medical model: A challenge for biomedicine. Reading it word for word really made me think.

In that paper, speaking from a psychiatrist's perspective, he discussed the biomedical model as a scientific model that, in the process of making huge progress, understanding disease and finding solutions, became a cultural dogma of reduction and exclusion which considers anything that doesn't fit the model as heretical, and anyone arguing for anything else as heretic. So, he embraced himself/his profession as heretic, I guess, and argued for a new model. Thank you, Engel.
I feel a bit that way myself - like manual therapy was hung out to dry in the chasm, put into the heretic category, become an 'unmentionable' or something, even though every PT on the face of the planet, just about, uses it without thinking about what it really means or how to resolve its contradictions. It doesn't have a very good evidence base. What evidence base does exist is kind of flimsy. Just about every intervention model that osteopaths and chiropractors, for example, invented or have heavily promoted, once it has been studied, has pretty much gone down in flames. 

So, as a manual therapy (as currently understood) atheist, as a heretic, I argue for a new model.
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Barbara Gibson wrote a great blogpost recently on disability, quality of life, and the various tools that have been designed to "measure" it: "Whither 'Quality of Life'?" She points out that: 

"Quality of life measurement has exploded in the last several years. Myriad tools have been devised to measure the quality of life of populations, groups and individuals; and quality of life arguments are advanced in momentous decisions such as withholding or withdrawing ‘futile’ medical treatments. These developments have not only changed research and health care practices, they have helped structure how we think about what it means to be ‘healthy’ and ultimately what it means to be human (Gibson 2016; Rapley 2003). Quality of life is a useful concept that has contributed to moving healthcare away from a disease model but QOL judgements are always necessarily relational, reproducing social ideas of what constitutes a good or deficient life. Given the complexity of life quality, it is crucial that we tread very carefully with measurement and its interpretations. As Annemarie Mol (2008, p.75-6) notes:‘It is important to do good, to make life better than it would otherwise have been. But what it is to do good, what leads to a better life, is not given before the act. It has to be established along the way. It may differ between lives, or between moments in a life.' "

My bold. Who is to say what quality of life really means, except to those who either have some or don't have some?

Her post reminded me of how the body-beautiful fitness enthusiast people have been dictating since for-fricking-ever what "health" and "attractiveness" is, according to how well-defined a six-pack one sports. 

Culture imposing itself on individuals.

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Any-hoo, what does any of this have to do with manual therapy, you might ask?
I don't know yet. Other than I think we've probably been using the wrong kind of sandpaper to try to understand what it is good for.
So, still wrestling with existence. And uncertainty. 

1. Engel, George L. (1977).  The need for a new medical model: A challenge for biomedicine. Science 196:129–136.
2. Gibson, B; "Wither 'Quality of Life'?" Critical Physiotherapy Network,  December 2015

Dangling in the chasm

I should be finishing up my manual and sending it in to be published, but the project got derailed at the end of July, and I just have not got back to it. It's 85% done, too, which is even more maddening - it would only take about a week of concentrated effort to get that thing done. 
But I procrastinate. I have procrastinated for years, and lately for months. 

I think it's because I still don't "like" it enough. It's still not the manual therapy book I would buy in a flash and read cover to cover and refer to endlessly. Not in its current state.
The problem is the introductory chapter.
So far it's about 16 pages, with about 40 references, and it's still not right. I still don't have that satisfying sense of accomplishment about how it's structured. It needs yet more work.
The rest is just images and explanations of how to do the "moves." That was the easy part, even though it took years of fiddling around learning how to do photoshop to meet the need for it to be visually appealing.

What is lacking is the right mental frame. I've got the content down, but I don't have the right shaped container. Not quite. Not quite yet. 

.......

I have an anecdote that might make some people gag,  others laugh maybe, but I'll share it anyway. 
Even as I was still going through school, I could feel that there was a massive chunk missing completely. I wasn't being taught what I really needed to know. I was not being taught any people skills. 
I flailed around a lot after graduating, all through my twenties (during the 1970's), trying to make my "marriage" to my profession work; leaving it for a time, going back to it after awhile, trying on other lines of work to see if I could love them more, but always returning to PT, and eventually settling down with it as my "life." 
One of the extra"marital" alternate-profession "affairs" I had, was, I went into real estate for awhile. 
Yup.
I lasted about 6 months. RE sucked, and so did I. I actually sold a property, even, but I wound up hating RE even more than I hated PT the way it was, and the way I was..
But. 
I did learn various sets of people skills.
These were crude and cartoonish by today's standards, and I still loath that they were established ways of getting to "yes", getting people to part with their money, buy a house they maybe didn't even need, but at least they were something. I appreciated that they were in place and taught didactically, even though I hated being in "sales" and went back to PT right after. 
Meanwhile something that happened over the past few decades is that PT has turned itself into "sales." 
Maybe I should have just stayed in real estate! Kidding.. kidding.. I could never have been happy doing that for a lifetime. 

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

This morning I learned about "Ethics of proximity," something that Scandinavian PTs are onto lately.. 
I've got to say, I love the basics (from a non-related open access source (1) ): 

1. When interacting with another, we have an ethical obligation to help the other.
2. What constitutes “helping” can be defined through discourse but must always respect the other’s self-determination.
3. To interact authentically with the other is to risk ourselves and give up some of our control over where the dialogue between us takes us.
4. Do what works in the particular situation, taking from any other ethical field (especially discourse ethics, but also virtue, utility, or duty) but always respecting the other as the primary virtue.
5. In bringing preconceptions and prejudgments to our interaction with the other, we dismiss his needs.
6. When in a position of power over another, we are obliged to act in his best interest, not our own.
7. A relationship of caring has as its goal that of helping the other to gain his autonomy

I think these are gold. 
I am so disappointed that my profession stopped being a profession and turned itself into an "industry."
I so very much hope it can turn itself around before it hits the iceberg.
I so want my humble manual to include these values and be truthful.

.........

Todd Hargrove wrote a good blogpost recently about treatment models, and three reasons why it matters what we think and say about what it is we think we're doing when we treat, explanations we offer up. 

1. If you get on the right track you can improve. >>>"...if my target was breaking up fascia or muscle knots then indeed I wouldn’t care how they felt. And I wouldn’t do as good of a job." [.. or getting some presumed stuck joint to move.. or jabbing needles into "trigger points" as if those were actually things]

2. False beliefs have unintended consequences. >>>"...false beliefs, no matter how small, are like viruses - they multiply, get passed to others, mutate to form super bugs, and can eventually cause disease. Don’t spread them people!" [Look how pervasive the mirage of perceptible joint movement is in our profession! Look how the profession turned itself into a mechanics shop!]

3. Truth matters. >>>"Every step away from misinformation and confusion is a step in the direction of the truth." [Egggggggzactly.]

I really want my manual to be about how to handle people who hurt. How to touch their nervous systems by letting them express themselves, by touching/trying to help their nerves. Nothing else.
Yet I know that currently it looks like just another how-to recipe book of ideas for manual therapists to copy. It doesn't have a unifying theme yet. It's still lacking soul.
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Also this: 

"We like to think our senses can give us unbiased, truthful information about the external world.... that's utter nonsense - we are not driving the bus. By the time we are aware of a sensation, that sensation has already been filtered and edited and combined with our expectations and our emotions and our personal history so in the end there is no sensation without emotion, there is no sensation without personal history without evolutionary history - it's all combined into a mush and that's what we have to deal with." 

This is David J. Linden, speaking in a podcast he did with Ian Sample at ScienceWeekly, back in March 2015.

This is important to grasp - i.e., as manual therapists we're dreaming if we think we are doing anything "specific" - everything we do, every sensation we provide, is subject to filters by a patient and their past, all bundled in their neuromatrix, churning endlessly, trying to predict its own future. We need to get over ourselves and stop trying to do things TO people, instead just be WITH them. Which circles back around to what the point is, of even bothering to put out yet another manual therapy manual, if it doesn't explicitly state all this somehow? How can I get across the point that manual therapy is a ritual that kills time while people spend time in your presence letting their brains figure out at subcortical levels how to get over themselves? While you busy yourself doing innocuous things, rather specifically? (Well, we hope "innocuous" things..) It's one of those chasms in which I am stuck simply not being able to cross at the moment. ................

One thing that gives me hope though: This past week I got some feedback from the "system" in which I do not participate, in fact stay out of for the most part, quite deliberately. Back to the "marriage" analogy, it's like my profession and I sleep not only in separate bedrooms, but in separate wings and floors of the house. We meet once a year when I renew my licence. Anyway, back to the point, I got two documents from a very-much-in-the-system facility in a far away city. The backstory here is, a woman called to see me who had been in a lot of back pain for a very long time and had been way overtreated and biomedicalized and pathologized, and finally they stopped, referred her out to another therapist who lived closer, because she lived a long way away and had to travel recumbent. The therapist they referred her to had not wanted to deal with such a sensitive nervous system and had mentioned my name. When the patient called, I said sure, come on in, we'll see what's what and if I can help you. Anyway, she did well, could even travel sitting upright in the vehicle after a few visits. She returned to the first clinic for closure. They were sort of surprised, I think, that she tested very well after all their own efforts hadn't worked. The discharge note was like, hurray, she's better thank goodness.. don't know what Diane did but whatever it was, yay.  In retrospect, I think they had inadvertently taught her to be more worried about her back than she had ever needed to be, and worry/stress was her main obstacle.

I really want my manual to explicitly contain values and people skills and convey how important it is to put the responsibility onto the patient and divest oneself of any responsibility other than positive encouragement, including by doing careful manual therapy of a most superficial kind, a set of tricks really, and how to give the patient full rein to get themselves better. I give people a little speech before I ever lay any hands on them, that puts them in charge of my touch/handling. I make it clear they can feel themselves better than I can, that I need their help to help them with their pain problem, that treatment shouldn't hurt at all, that hurting them is counter-productive when pain is being treated, that if they experience any discomfort of any kind they need to tell me right away so I can change what I'm doing right away - we want their nervous system to work, yes, but work normally, not in this hypersensitive way, and provoking it won't get us where we want to go.

This does a couple things - it makes them the boss over me - if they have locus of control they will feel less stress about being touched. It's built-in that the whole point is about coming off the table in less pain than when they went on the table. It also takes responsibility of being the "fixer" off me completely, and puts it on them. I'm just a helper. I'm just holding up a kinesthetic flashlight so their nervous system can see what it has to do to get over itself.

I call that person-centered treatment.

I want my manual to get across the idea that person-centered treatment is where it's at and anything else is a great big fail waiting to happen. 

....

Reference:
Denna Hintze , Knut Are Romann-Aas , and Hanne Kristin Aas; Between You and Me:A Comparison of Proximity Ethics and Process Education. International Journal of Process Education (June 2015, Volume 7 Issue 1)

Very enteric gut glia

Whoa.. totally sidetracked today by some basic information about the enteric nervous system I previously did not know.  Stumbled across this paper: Imaging neuron-glia interactions in the enteric nervous system, full text (at least for now..).

(I confess to not knowing that enteric neurons had "glia." Well, ok, I figured they likely had very thin (probably) myelination. But "glia"?)  
Turns out that they do. 
From Boesnams et al.: "Enteric glial cells share several features with astrocytes." (Unlike Schwann cells, I guess.)

"The ENS develops from neural crest cells that migrate and proliferate extensively to eventually form a network of interconnected ganglia throughout the entire length of the gut."

From Sasselli et al: "All enteric neurons and glia are derived from neural crest cells (NCC)"

Here is a trust-worthy, basic info page:  Enteric NS. 

Note to self: Live long and learn something new every day.
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1. Valentina Sasselli,  Vassilis Pachnis, Alan J. Burns;  The enteric nervous system. Developmental Biology Volume 366, Issue 1, 1 June 2012, Pages 64–73 (FULL TEXT)

2. Furness JB; Enteric nervous system. Scholarpedia 2007

3. Werend Boesmans, Michiel A. Martens, Nathalie Weltens, Marlene M. Hao, Jan Tack, Carla Cirillo, and Pieter Vanden Berghe; Imaging neuron-glia interactions in the enteric nervous system. Front Cell Neurosci. 2013; 7: 183 (FULL TEXT)

A snapshot down into the chasm

If you look around the internet for images that relate to "chasm", you will find a lot of them that look like this:

Online battles still rage, on facebook and blogpost, mostly polite but not always, about what it is we think we are really doing in manual therapy. Here is a recent example. One of the replies I made there forms the basis of this blogpost.

Operators

Those of us who still imagine we are directly affecting "tissues", and "tissues" are responding, directly, to our tender or not-so-tender ministrations, fall into the "majority" camp, I think. 
Some will remain "laggards" until they die. 
I would categorize both these groups as "operators," because they insert themselves into the process as direct agents of any change. ("It was all about me, and my magic hands, making your tissues behave themselves.")

Interactors

Those of us who think the nervous system is involved and on top of the process, adapting like crazy to everything we are doing to it, exploiting the opportunity offered it physically to create descending modulation that will result in greater movement and less pain (because it's cheaper), fall into the first camp. I would categorize this group as "interactors," because they realize the process of manual therapy is a dance between two nervous systems having a silent but busy kinesthetic conversation. ("It's all about your brain, taking advantage of an opportunity to change all its motor output and ultimately, be able to move you around more efficiently with less effort, in a less expensive manner. My job is just to hold up a flashlight, metaphorically speaking, so it can see what to do next. I'm just a catalyst, leaving nothing behind, as your nervous system "corrects" its own self.")

What's really at the bottom of this cognitive chasm?

A cognitive glitch resting on a mistake about who/what is the real "agent" of change. 



Climbing down to the bottom of the chasm

Regardless of whether we consider ourselves interactors or not, another person's tissue is all supposed to feel "homogeneous"; when we find something under our inquisitive little manual therapy fingers that doesn't feel that way, we are drawn to palpating it; if we aren't careful our heads fill up with all sorts of assumptions, many of which are wrong, based on the fact that the "blumps" we feel tend to go away when handled, and that usually people feel better and can move easier after. Thus do practitioners end up developing operative conceptual hallucinations based on palpatory pareidolia.

How do we get over that chasm?

I don't know for sure, and maybe any bridge over it is completely a fantasy, because I have read that anyone's brain can only have one conscious thought at a time: but I think we can at least swing across that chasm back and forth by being able to think bottom-up (outside-in) and top-down (patient's brain, inside-out) at exactly the same time. 
Sound impossible? 
Part of the cognitive hack I used on myself was to think at a neuro-cellular level instead of a tissue level, i.e., subtract any cells that were not neural. That way I could boil it down to there being just three very fast-conducting neuronal cells between my hand and the patient as person. From skin cell to sense of self. Then from patient's brain back out again, to all end organs of the patient's NS, like "muscles." Like smooth muscle. Like efferent autonomic nervous system. That was my (as an operator) new way in. 

I comforted myself that all the processing going on in there included me/any contact I was making, that the patient's brain was adding my exteroceptive contact with it into all its own body schema, and that its "maps" don't all load simultaneously, because of different fibres and different fibre speeds. That depending how slowly and carefully I loaded, how long I stayed in one place, what angle I used, whether I loaded or unloaded with one hand, some blump or other I could feel with my other hand, the brain would try to take advantage of every little shift and change, and exploit the input to self-correct its output, incuding any pain output. 

Pain is an output. That is something you simply have to accept as valid. It's an idea that changes everything. It goes completely against all models of pain that are bio-medical. It's a verb, not a noun. 

The other part of the cognitive hack was to realize that if there were only three cells between another person's brain and my hand, there were ALSO only three cells between my hand and my brain, and that I had to learn to listen acutely to feedback from my hands to tell me what was going on in the other person's nervous system. I.e., not their "tissues." ... that person's brain was feeling me, and my movement, intention, acceptance, emotion, every bit as closely as I was feeling "it." 

I could still do my job without cluttering up my mind worrying about tissue. Bam, I found myself interacting. Not only interacting with another person's nervous system, but interacting with my own, as well. Then my mind blew even more at the notion that there were four entities all interacting in complex ways - two nervous systems and two people inside them. 

Only after I started becoming aware I was interacting did I see the chasm, that I had crossed over it, and that in retrospect, I'd been "operating." (1)

What do we really "know" about "tissue"?

Probably not as much as we think we do. Take the case of muscle. I don't know how it is out there these days in education, but when I learned about the nervous system, it was taught as an outflow system, with the muscles as end organs. Technically this is perfectly true: However, my PT ed. took place way back when pain science had not yet made it onto anyone's radar, and PT training ended up being all about muscle. How to poke, prod, strengthen, loosen, muscle. Very very bottom-up. Very tissue-based.  All about striate muscle. Smooth muscle was inside the body in organs - we didn't need to worry about any of that.
I honestly cannot recall pain ever being discussed. I endured a very narrow education about treating other humans, with all the emphasis on "physical" - the "therapist" part was not taught in any systematic way. We were supposed to just soak that up along the way by hanging out with more senior therapists during clinical training. They would supposedly "model" being a therapist, and we were supposed to implicitly copy them, I guess. 

Except that some of them annoyed the bejeebers out of me, and I had no intention of ever copying them or modeling myself after them.

Physiology was taught in a disconnected fashion. We took physiology along with med students and nurses, so we were drenched in the biomedical model. I remember there were lots of graphs, and that I had to kill a turtle, both of which did not please me. It was never explained how touching people might affect their physiology. 

From the other side of the chasm, manual therapy models still, to this day, do not seem to care much about physiology. They are still very heavily tissue-based and dualistic.
The sensory nervous system and autonomic nervous system are not regarded as important for being feedback for a brain, trying its best to move its organism around. They are never suspected as having any potential glitches or positive feedback loops manifesting as localized peripheral physiological problems.
...............

Anyway, back to "blumps." 

Smooth muscle cells (e.g., in skin organ for sure, vessels, sphincters, tubes, ducts, even fascia..) will contract (in the skin organ at least) when exposed to products of nociceptive-capable peptidergic neurons, such as Substance P, neurokinin A, CGRP.

It's a cellular function, chemical, that presumably evolved to assist with wound healing.

Normally, these substances excreted in dribble-like, tonic fashion by nociceptive-capable neurons, are used as trophic factors by their target tissue, and any excess cleared away by ordinary circulation. (You will find this explained well in Peggy Mason's book, Medical Neurobiology. (2) )

Presumably the smooth muscle cells *won't* be unduly activated, or stay activated, unless circumstances oblige, such as:

1. A big phasic burst of substances are released: One nociceptor's high threshold is reached and it depolarizes, spewing its products all over in faster, higher-than-usual concentrations, and starts a neurogenic cascade that activates other processes that in turn activates more nociceptive neurons which go on to activate other processes, etc., a physiological positive feedback loop..

2. Maybe a tipping point is reached whereby contraction of smooth muscle cells in fascial tissue occurs faster than any counteracting process that would result in their relaxation, and a mini "compartment syndrome" establishes itself
3. The "compartment syndrome" becomes exacerbated by the paradoxical effect of the smooth muscle in vasculature being relaxed (vasodilated) by the same substances, so that more blood is brought in or else can't escape contributing to more pressure inside the compartment

4. Some minor glitch occurs, whereby the reciprocal efferent "commands" by the ANS (contract, no, relax, no, contract) don't complement each other to smooth out the behaviour of the tissue end organs. And the fascial smooth muscle cells stay contracted. 
5. Maybe nociceptive-capable neurons don't have to be involved at all - maybe it's simply confusion within subsets of sympathetic efferent commands (contract, no, relax) that cancel each other too well and don't allow tissues to change at all.
Oops.

Is that a blump I feel? 

Could "blumps" simply be just small (benign, non-urgent, non-medical, widely distributed) priapic-like* states anywhere in the body and palpable within its thick outer blubber layer?

Do they deserve to be stabbed? Is there not a kinder way to deal with them?

Neuritis
I have not yet found any histological papers that discuss smooth muscle in the connective tissue coverings of nerve trunks; however, there is plenty out there on smooth muscle in vascular walls, and nerve trunks travel along with vessels and are full of vasculature. Drainage out of nerves (which have become mechanically deformed, through adverse use or not enough "normal" movement) can be a big problem: if substances that contract smooth muscle build up within neural tubes and tracts, it seems logical (if they contain smooth muscle cells) the entire 3-tube neurovascular system in any given nerve branch could be affected, contributing to more adverse neural tension, amplified nociceptive input, delayed clearing of substances from the intraneural and extraneural milieu. 
That could be one reason we can feel "strings" and cords. 
I think.

On the other hand, if just the smooth muscle cells in the vasculature that feed and drain nerve trunks were affected, by either mechanical distortion OR by lack of clearing of built-up products of nociceptors inside the nerve trunk (yes, nerve wrappings are self-innervated by nociceptive capable neurons), it would scarcely matter from a clinical standpoint - those palpable bungee cords and strings would still form, probably. I'm almost certain.

Bloated cranky nerves.

Currently I'm trying to find out if smooth muscle cells "let go" as a consequence of

1. being physically stretched  

2. a local spinal cord inhibitory neuronal reflexive process stimulated by contact through non-nociceptive large sensory fibres 

3. descending inhibition by higher centers 

4. All three combined.

If I had to bet..

..I'd bet the farm on smooth muscle deactivation/decontraction being *mainly* by descending inhibitory modulatory control, from more rostral areas, nuclei that Butler refers to as the "drug cabinet" in the brainstem, down to the dorsal horn. Dopaminergic, noradrenegeric, serotinergic, opioidal.

I know that large fiber input does boost spinal gate control of nociception via glycenergic inhibitory interneurons (there is direct evidence for that, at last, after 50 years: see Foster et al. http://www.cell.com/neuron/pdf/S0896-6273(15)00143-9.pdf ); I'm still looking for direct evidence that said inhibition of nociception can therefore lead directly to smooth muscle cell relaxation at a spinal cord reflexive level - that's an extra step.

Until such evidence shows up and accumulates, the 'least wrong' assumption is that good results from manual therapy are due to descending modulation of a favourable kind, and that non-specific effects/ "common factor" effects, are the ones in final charge over pain perception and physiological self-correction.

This lovely paper is just in: Mancini, Flavia; Beaumont, Anne-Lise; Hu, Li; Haggard, Patrick; Iannetti, Gian Domenico D. Touch inhibits subcortical and cortical nociceptive responses. Pain: October 2015 - Volume 156 - Issue 10 - p 1936–1944 - it's full text, at least for awhile.

It proposes that touch affects pain perception at a subcortical level. So, yay!
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1. Jacobs D; Manual therapy and its treatment models 2011

2. Mason, Peggy; Medical Neurobiology. Oxford University Press; 1 edition (May 19, 2011)

* Yes, I went there.