Tuesday, March 24, 2015

How I cut myself some slack and fixed my TMJ syndrome

When I say I cut myself some slack, I don't mean I pushed aside all care and responsibility and went on a holiday or anything like that. I mean, I cut myself some physical slack.

Let me digress for a moment. 

Life catches up to you in odd little ways. I'm in my mid-sixties now, and my relationship to physical exercise has always been on-again off again. The longest relationship with physical exercise I ever had was in my early twenties, when I practiced yoga every single day for two years solid. I never have regretted putting the time and effort in, and I never have regretted abandoning it and getting interested in other things. Both. At the same exact time. (Yes, I'm a walking contradiction.)

Anyway, I've become a lot more sedentary in the last 5 years or so. Moving back to a place where there is a lot more snow, and where sidewalks are never fully cleared, cured me of a tendency toward compulsive walking. That, plus being online a lot of the time.

Anyway, a month or two ago I was surprised when I felt/heard my TMJ pop, loudly, in my ear, on the left. There was a bit of pain, nothing much, lots of grinding and crunching.
I did all sorts of DNM and movement and even some taping, but no matter, it still popped, snapped, cracked and crunched like some new kind of kid-friendly cereal ad.

One night recently in a fit of insomnia I got up at 3:30 am and stood in bare feet in the kitchen and did some yoga. Just one thing. Complete forward and complete backward bending, three times each way.

I'm happy to report not only was the jaw thing mostly gone by the next day, but a bunch of other naggy wee bits and pieces also disappeared - little things I didn't even realize I had until I did the yoga move. How do I know they went away too? Because this morning I repeated the process, and did not feel them anymore. So, yay about that I guess.

What is the trick? I think taking my 72 kilometers of folded and branched and three dimensional neural tree for a good ride, first one way, then the other, likely got rid of a bunch of accumulated neural tension and mechanical deformation, gave it a chance to mop itself up really well.

You don't have to do much physical exercise to deal with physical discomforts and keep them at bay, but you do have to do a bare minimum. What is the bare minimum? That's for each human to decide for him/herself.

Here is how I do forward and backward bend.
1. Bare feet, firm floor (no carpet). Organize body weight as exactly as possible over the fronts and heels of two feet. Sounds easy, but it can be a real trick. So, even weight as if on four table legs. Keep the imaginary table (i.e., yourself) level. The entire time. Harder than it sounds.
2. Breathe. Slowly. Completely in and completely out. From the pubic bone. Maintain throughout. Again, harder than it sounds.
3. Find the anti-gravity suit and deploy it. This means, grow up toward the ceiling. As soon as you even think that, you will feel your abs kick in, your spine lengthen, your breast bone start to lift, and your neck lengthen. Enjoy the feeling and keep that feeling going for a few breaths. It's a verb, not a noun. When you can't grow up any taller, stay tall as you managed to become, breathe in and out a few times up there, then slowly let yourself shorten again.
4. Now it's time to start the forward bend. Let your head be like a tulip head. Let the neck bones move one by one. Let gravity have your head, but hugely control the descent. Let your arms and shoulder girdle be limp as over-cooked spaghetti. Their angles will change as you descend. Feel how delicious it feels to feel your shoulder blades slide all by themselves over your ribcage. Knees straight, and soft, at the same time. Go as slow as you possibly can while noticing as much as you possibly can about how it all FEELS. If you can, once you've set the agenda, and the very slow speed, let the critter brain do all the rest. Let the critter brain manage the relationship to gravity and angles and descent, and all you have to do is focus on the breathing and making sure the pressure is even through all four contact places of your feet. If you're doing this slow enough for it to do any good, it should take a good three or more minutes to get all the way over. No, I'm not kidding you.
5. Let gravity have all of you it wants. Hang there. Breathe in, and then out. Pause after an exhale. Wait until you crave oxygen before inhaling. You are regaining locus of control over autonomic bits of your nervous system. You are taking charge. You are giving it all the oxygen it could ever want, but you are setting the pace and making it ask first. You are reminding it that you live in that brain too. You are playing frisbee with your inner dog beast. You are giving it your full attention. 

6. When you have dangled for awhile, focused, breathing, feet square, and have stopped noticing any lengthening of your upper body, it's time to come back home. Begin your ascent. Go up just as slowly as you went down. This is a huge project, so notice as much about how it FEELS as you possibly can. Keep the feet square, even weight, maintain the frisbee game of breathing with your inner dog beast/critter brain (inhale -> send the frisbee out, exhale -> the dog brings it back, make the dog wait until you're ready to throw again..). Feel all the fibres figuring out how to lift up half your body weight. Feel the wonderful orchestration as they all cooperate to do this amazing feat. Go very very slowly. It will feel good, not uncomfortable. All sorts of images will pass through the mind as you rise up. A recurring one that goes through mine: a fisherman, carefully hauling up a huge net full of fish, using the side of the boat as a fulcrum, careful to winch slowly so he doesn't catch the net and rip it on anything. Another - a huge crane lifting up over tall rooftops, slowly. All sorts of gears making the mechanics of it be all spread out, long ropes/big pulleys inside making the work be pretty much effortless for any one structure. 
7. Once you're back up on top of yourself, another slow grow up toward the ceiling. You might feel taller this time. Then shorten back into gravity. Time to descend backward.
8. Neck softens, but this time let the tulip head travel back. Let the tulip stem fold back as much like a real tulip stem as you can manage. It's ok to pause at intervals to let more slack cut itself. You are not going to fall over backwards. Your critter brain will do everything it can to not ever let that happen. You are giving it a problem to solve, and its favourite thing in the world to do is combat gravity. It's a human anti-gravity suit, after all. (When I did this, for the first time in decades, probably, in the middle of the night, the first thing I felt was how tight the front of my neck felt, like it was covered all over on the inside with coach tape or something. Then I could feel how tight my abs were, right at the ribcage. I noted everything, but didn't worry about it in the slightest, because I knew my critter brain would be capable of dealing with it, if not right then, later on. It's not about anatomy, it's about physiology.) Go as far as you can. Stay there. Breathe fully in and fully out as ever. Your abs might stutter and shudder a bit. Don't worry about it. Retain control of the direction, the speed, the breathing, the weightbearing. Let the inner dog beast worry about sorting out all the rest, over the next 24 hours.
9. This one is more tiring than forward bending. You likely won't last as long because it feels like way more work. Stay there as long as you can anyway. Then start back up again.

10. Repeat the whole beeswax, times 3. If you're doing it right, i.e., going slow enough, the entire sequence will take about 15-20 minutes. On the second round you'll find yourself able to go further. The third round won't add much more information, but it seems like a third round helps lock in whatever you learned from the first and second round. So, three times is the magic number. Any more than three times is a waste of time in my opinion.

Once you've practiced a few days you'll become way more adept and bendy, and it won't take as long anymore.

What I noticed repeating the entire process a few days later was that the coach tape was gone from inside the front of the neck and the abs lengthened out the way they should, and the shuddering was gone. I succeeded in cutting myself some physical slack. The critter brain had reestablished its own motor control. Good, because motor control is its job, not mine.

Friday, March 06, 2015

Pain and stress in a systems perspective

Today Ian Stevens sent me a link to an old paper (old by publishing metrics) from 2008, Pain and stress in a system's perspective. It's open access and a joy to read, the way it describes the connectivity of systems within a multi-cellular organism such as ourselves.

I bring it forth, not just because it's a great paper, but also because I want to draw attention (yes, again...) to the point that astroglia are not immune cells. 

The paper has this to say about glial cells:
"Microglia, oligodendrocytes and astrocytes reside within the CNS and contribute to inflammation and peripheral injury-induced pain, including the spread of pain. Microglia are immune cells closely related to macrophages that express the same surface markers. Injury and other events that threaten homeostasis activate microglia. These immune cells contribute to hyperalgesia and alloydynia by releasing pro-inflammatory cytokines and chemokines, and they are probably involved in several neuropathic pain conditions. 
"The astrocyte, a non-migratory subtype of glial cell, diversely supports CNS function. Through its direct contact with blood capillary networks, it provides vasomodulation of localized blood flow, metabolic support (e.g., glucose delivery), and control of the blood brain barrier function on micro and macro levels. Subpopulations of astrocytes surround neurons and their synaptic connections, thereby influencing pre-synaptic neurotransmitter release through modulation of synaptic cleft calcium concentration and membrane polarization. In controlling local environments, they functionally organize regional synaptic connections. In addition, they provide the important function of neurotransmitter uptake, thus protecting against glutamate neurotoxicity, which is implicated in several central pathological states."
As you can see, the paper explicitly points out that microglia are immune cells, which is correct, but unfortunately it isn't QUITE as explicit about pointing out that astroglia are non-neuronal neural cells. It doesn't however, SAY that astroglia are immune cells. Which gives me a feeling of relief.
I regret to say that at the moment there is a line of confusion moving along that has astrocytes conflated with immune cells.
Yes, they have certain immune capabilities, but it seems to me, that along with other kinds of macroglia (microglia excluded) their MAIN job is to keep neurons protected from direct contact with blood, even as they extract glucose and oxygen to supply to neurons, which (greedy little hogs that they are) require a vastly disproportionate amount of same in order to function, collectively, as the nervous system. Two percent of the body, using up 20% of its fuel.

At the San Diego Pain Summit, I heard Lorimer Moseley refer to glia as immune cells.
I'm still a fan girl, but I wish he and the others would stop conflating all glia as being immune cells. 

There is a vast difference based on embryologic origin that is easily discernible, and learnable from the most easily accessible source by googling.
"Most glia are derived from ectodermal tissue of the developing embryo, in particular the neural tube and crest. The exception is microglia, which are derived from hemopoietic stem cells. In the adult, microglia are largely a self-renewing population and are distinct from macrophages and monocytes, which infiltrate the injured and diseased CNS.
"In the central nervous system, glia develop from the ventricular zone of the neural tube. These glia include the oligodendrocytes, ependymal cells, and astrocytes. In the peripheral nervous system, glia derive from the neural crest. These PNS glia include Schwann cells in nerves and satellite glial cells in ganglia." Wikipedia 
From: thebrain.mcgill.ca
Understanding embryonic origins of cells helps place them in a developmental tree of most primitive to most recent. I'm pretty sure that a clear understanding of primitive <-> recent helps one understand better how things work together as nested systems in a multicell organism like us, with so many different cell types, all requiring differing levels of fuel, the most outrageous example of which is the nervous system's greedy-pants need for such an overwhelmingly large proportion of whatever O2 and glucose happens to be available 24/7.

1. Chapman CR, Tuckett RP, Song CW;  Pain and stress in a system's perspective: reciprocal neural, endocrine and immune interactions. J. Pain 2008 Feb; 9(2): 122-145 (Open access)

March 15/2015 UPDATE:

After writing this blogpost, a long twitter conversation ensued. I did not buckle. I stand by my opinion: to call astrocytes "immune cells" is categorically incorrect. 

Among all sorts of other deflective offerings, it was declared that using Wikipedia as a reference is wrong because it has errors.
In response to that, I now have a perhaps better reference, that may elicit more respect, full text:

Kessaris N, Pringle N, Richardson WD;  Specification of CNS glia from neural stem cells in the embryonic neuroepithelium.  Philos Trans R Soc Lond B Biol Sci. 2008 Jan 12;363(1489):71-85.
"The nervous system is composed of neurons and glial cells. Glial cells in the central nervous system (CNS) include both the ‘macroglia’, which are derived from the neural tube, and the ‘microglia’, which are derived from haemopoietic precursors. Microglia are the resident macrophages of the CNS and play a key role in immune surveillance and defence." 

Macrophages are immune cells, very primitive, that can move autonomously, are attracted to chemogradients, and will eat up dead things, or any else that moves that they can sense and move toward and ingest. Scavengers. Sea-gulls of the body. Or fly larvae. Yes, the ecosystem of the physical body needs those.

Other glia, macroglia, including astrocytes, are brain cells. OK? Do we really have to argue anymore about this? Astrocytes = brain cells. I.e., NOT immune cells.

Haemopoietic stem cells come from bone marrow and before that, from embryonic support tissue. I.e., not ectoderm/ brain cells.  Immune cells = blood cells. I.e., Microglia = NOT brain cells. Is everyone clear on this? 
Screenshot March 15/2015

One of the biggest jobs glia in both brain and body have is to keep blood AWAY from neurons, by wrapping them, protecting the sensitive little things AWAY fom all the caustic chemical barrage blood has to offer. It's called maintaining the blood/brain or blood/nerve barrier. Not that it doesn't fail sometimes. Not that it's perfect. But it evolved, it's there, and works fairly well most of the time, in most people.
By the same token would it not make sense that astro and other macroglia keep microglia, etc., from sensing/being attracted toward neurons? How could a system evolve that had microglia being attracted to and chomping down on neurons? Wouldn't a creature like that would be selected against, not develop much in the way of brain?
Not that we aren't all gonna die some day anyway, through systems failure. Not that a lot of us won't go down with one kind of dementia or another, or have pain of one sort or another, maybe a kind created by systems failure of a glial sort, even.
No argument from me about that.

But I will go to my grave (earlier than I should have to maybe, because of all the twitter protestation) stating that this sentence is incorrect. 

Sunday, March 01, 2015

Adventures at San Diego Pain Summit 2015

San Diego's first ever Pain Summit, clinical applications of pain science for manual therapists, was the first ever of its kind in the US. Thirteen different professions were represented from 8 different countries and at least three continents. Here is a page with lots of photos of the event.

I've been asked by the Canadian Physiotherapy Association Pain Science Division to write a review, so here it is.

It was Awesome.

Now that the review is done, I fill in the rest of this post with this and that. 

1. Here are other reviews of the weekend. They are way more awesome than any review I could devise, at this point. 

2. I still have jet lag from travelling to Spain earlier in the month and all the stress from that trip. 

3. I was a speaker at #sdpain, the inaugural San Diego Pain Summit 2015, and can't therefore really be objective. 

4. My favourite rock star PT pain researcher was there, as keynote, and I managed to get a picture with him. 
Lorimer Moseley with fan girl, yours truly

5. There were lots of people there from Canada. Neil Pearson was another speaker. He is a past chair of PSD and cofounder of it.

Neil Pearson speaking at SDPainSummit 2015

Susannah Britnell was there - she is a committee member in PSD's communications group, the same one I'm in...
Pretty sure this is Susannah. She was there with her husband, from Vancouver. 

6. There were many many speakers. Here is a picture of us all. From left to right: 

a) Jason Erickson, the MC. Jason is a massage therapist from Minneapolis. I met him on www.SomaSimple.com years ago. He facilitated two workshops I taught at. He teaches mostly on the east side of the U.S. 

b) Lorimer Moseley. Good grief, does he need any introduction? Here is a little writeup I did about him a few years ago. He runs the BodyInMind blog for researchers and clinicians. You will find many many papers there for free download. His talks at #sdpain were great, of course. Stay tuned for DIMs and SIMs. DIM is "danger in me" and SIM is "Safety in me". 
His latest definition of pain is "Pain = (credible evidence of danger) - (credible evidence of safety)  

c) Eric Kruger - Eric is a Next Generation PT, for sure. I met him on SomaSimple years ago too. He is about to do a PhD in psychology. His talk was about plotting a course through uncertainty, mostly by becoming a great listener. Allow for the patient's full expression of pain, answer the patient's question, "Am I alright?", use the patient's expression to have a conversation about values, and align goals and interventions with those values.

d) Below Eric, Rajam Roose. She wasn't a speaker, she was the ORGANIZER. (I'll talk about her a bit more, a bit later.)

e) Joe Brence, NXtGen. He is a SomaSimpler too. Joe spoke while wearing a GoPro camera around his head so he could film the crowd.  He introduced his MIP algorithm. M = Motivation, I = Input, P = Plan. Here is his blogpost about that
Joe Brence
f) Jason Silvernail. For over a decade, since even before Somasimple, Jason, on active duty in the U.S. army, has been posting at least as long as I have..  He spoke about "Crossing the Chasm: integrating pain science and finding your way". He said at first all he thought we'd need was a bridge, but later realized we probably needed a whole navigation system. Why? because the chasm was way, way bigger than he first suspected, with lots of varied terrain. His proposed nav system includes a comprehensive way to make decisions, manage uncertainty and move forward, forget about "tools" - they can't tell you when to use them or for how long, and being "eclectic" is not the answer.  It is a way to make decisions - software, not hardware. It's process, not product. Dump out the toolbox. Get rid of the hoarded clutter. Make sure there is space to integrate new material. A good navigation system will do three things: accurately reflect the ground, recalculate the route if you make a wrong turn or miss one, and give an accurate arrival time. To navigate the chasm, you need to know the science (basic science, published evidence, the context), apply critical thinking, and use claims responsibly. As the system gets more complicated the rules that govern your behaviour need to become simpler. Things you say matter, are a direct reflection of how you think.

g) Neil Pearson - Neil integrated principles from yoga therapy into pain science. He uses yoga as a kinesthetic vehicle for learning/teaching neuroscience and pain science. "Any aspect of your existence can be used to change suffering"

h) Barrett Dorko - he's been posting ever since the internet was invented. I've known him as long as I've been on it, about 15 years at this point. He writes every day on SomaSimple. His message is always "Understand More, Do Less". 

i) Ravensara Travillian - massage therapist in Seattle,  PhD in Biomedical and Health Informatics, works with refugees. She deftly wove into her talk several previous talks of the weekend, and took the Moseley challenge, which was "prove yourself wrong."All the while she worked on her slideshow, she chatted and visited freely. I know, because she and I were staying at the same place all weekend. Plus she was the chauffeur. Clearly, she knows how to multi-task and be focussed on What Must Be Done all at the same time. She treats people who have been through the worst of the worst a human could go through, a ripping apart of their existence and support structures, community, death of loved ones including war and murder, landing in a foreign land with nothing and not speaking the language.  She recounted instances where, had she known some pain science, she might have been of more help to people like this. She is Truly Awesome.

j) Me. What can I say about me? It was a three-hour presentation crunched down into 45 minutes. It included touch, how it's processed. What I wanted to convey was that when you add physical contact, you are holding the entire NS, that messy kludge of an added-onto system, in all its evolutionary glory, from the most primitive C fibre to the most sophisticated human brain function, all at the same time. That I think it appreciates caring contact/attention at every one of its messy levels. That I think it likely helps it to recombine its functions and dispel inconvenient positive feedback loops of which "pain" might be one. That in any NS alive and awake, all we are doing is interacting, not operating. That "operating" (or "curing") is something surgeons do, with their patient under anesthesia, not awake and alive and sensing the way our patients are. That to think we can change ANYthing from the outside of somebody else's conscious nervous system is conceit. That when the ducks line up well the NS changes itself, sometimes readily, sometimes less readily, but without any further ado. That all we can be is a catalyst to a favourable reaction. That catalysts leave no trace of themselves behind. That we can take pride in being the best possible catalysts we can be. Instead, I rambled on about the critter brain and sensory processing and descending modulation and nonspecific effects. Oh well..

k) Cory Blickenstaff - Cory has been on SomaSimple.com as long as I have. I first met him in about 2007, I think.. He spoke about being a contextual architect, and having people learn where their movement edges are, through "edgework", a term he coined. He demonstrated it at the summit. It's about finding the boundary to movement, and respecting it, while exploring it. He brought forth the "OK" scale. More about that.

l) John Ware - John discussed the profession of Physical Therapy, that he thought it was heading in the wrong direction, in the U.S., at least, how he thought it got off track. And he named names. :)

m) Kara Barnett - I met Kara for the first time a year ago, in San Diego where she works in a multi-disciplinary pain clinic. She was attending my humble dermoneuromodulation workshop, hosted by Rajam. This was her first time speaking at a major event, about her work in the clinic, where she sees many chronic pain patients. She was Awesome.
OK, now the story of how I met Rajam Roose.

The Thoroughly Awesome Rajam Roose
Who is Rajam? She is a massage therapist living and working in San Diego. She lives in a house with four cats, two bunnies, and a husband who cooks like a dream. At age 20, she tossed in the towel, her life up to that point, and went hitchhiking. She travelled for three years with a dog, lived hand to mouth, has written a book about her adventures. She settled down in Alabama, where she was born and raised, studied massage therapy, met her future husband there, moved to San Diego where he was from, and where he teaches high school, and went into practice. She contacted me on Facebook A few years ago, I got a private message from this woman, a stranger, who wanted to thank me for allowing a free copy of my manual to be out on the internet. She had downloaded it, quickly taught herself how to use it, and wanted my address, because she wanted to send me a thank you present. She made homemade soap, and asked what my favourite scent was. Sandalwood, I replied. Next thing was a giant heavy box of beautiful homemade soap arrived where I live! It was enough to last about a year. It must have cost a fortune to send by mail, but she swears up and down it didn't cost very much. She hired me I think I was her first gig she ever organized. She recruited Jason Erickson, the MC for the summit, to help her. They shared organizing responsibilities, and in the summer of 2012 I visited San Diego for the first time in my life. Pretty nice place. I met her kitties and bunnies and her husband, who cooks like a dream. She hired me again A year ago I was back in San Diego, teaching a small group of mostly PTs who wanted to learn my version of manual therapy based on neuroscience and pain science. This time I stayed at her home. She let me become attached to her kitties. (I love cats.) She pulled off organizing an entire summit! It was during that visit she decided the world needed her to organize a summit. She immediately contacted Lorimer Moseley to explain her idea and to ask him to keynote it, and he immediately accepted. And last weekend, it transpired. It was a resounding success. Enough people registered that Rajam not only broke even, she even paid for speaker airfare and accommodation. By herself. She is not an organization, she is an individual who made this event happen. And she is already planning the next one. The next one will be even more awesome, I think. Look in the link to see who will be speaking!! 

Edit: March 3 2015: One more picture, the back of the heads of a bunch of SomaSimple members who were also speakers. They sat in what appears to have been an emergent, self-assembled SomaSimple "boy" zone.
The venue and crowd at #sdpain2015