The busy-ology of physiology

This morning I started thinking about physiology yet again, when I saw a full-text paper by Benedetti posted to facebook. Recently I had listened to a podcast interview of Bud Craig. He's the interoception guy. Here is a link to some notes I made re: a video of his I watched a few years ago. Fascinating.

Both these items, fresh in my mind, reminded me of Jorge Fuente's work, coming at it from a different angle but still trying to show the world that really, it's all about the therapeutic relationship, not whatever ritual might be being performed within it. I remembered David Butler, at least 12 years ago, saying, "We don't treat anatomy, we treat physiology."

I thought of my recent plunge into a rethink of metaphor in culture, instigated by Mike Stewart, and Keiran O'Sullivan's video about Ally who in the middle of a full-on stressful life fell and broke her tailbone, and developed chronic pain which was very hard to live with until someone (him) started to listen to her, empathically, as though she were a competent human instead of a "case" (discussed/blogged about here). I bumped (yet again) into my own self, my own bumps and snags and realization that I can demonstrate good listening and empathy, but probably only in short bursts. Probably because I really don't enjoy being around people much, except for in short bursts. 

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Anyway...


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I thought of the cartoon I made of the evolved nervous system (see below), how in order for it to get a grip on itself, it requires communication/social input. Imagine that.
Humans have been designated the "neotenous ape". This means, adult while still in juvenile form.
You can see it, can't you? How dependent we are, on each other, on the systems that emerge, like a bunch of large babies? Big brains that are not fully myelinated until age 25? The way we have rampaged all over the planet, wrecking it, and fighting with each other like a screaming bunch of wild toddlers with no day care lady to keep us cookied and juiced and napped and meaningfully distracted?

I think, once we've been born, and we're stuck here anyway, we should try to help each other get through life to the end with as minimal damage as possible. Personally I'm against reproducing very many more of us, even as I can empathize with the biological need to reproduce (.. that I managed to completely escape being gripped by, thank goodness..).  


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But back to physiology.
Bud Craig, the neuroanatomist says he discovered a new pathway in the brain that had previously been overlooked: It joins up the interceptive fibres with the cognizing brain, so that we can be aware of our body states. These are pathways that are essential to homeostasis. I don't recall if he said these are just human or if they are more broadly primate. I'd have to listen to the whole interview again (I've ordered the book. Can't wait!). I think he said they are in primates, but no other kinds of (studied) mammals, and greatly increased in humans. (I really appreciate that he discusses these pathways and homeostasis, in general, as being energy conserving. That makes sense to me. Our brains are such monster fuel hogs..)

Homeostasis is all about physiology. Remember that in the beginning was the nerve net. The human brain came later. 
Remember that the nerve net is bi-directional, and enclosed within tubes where it can get itself into some big, echo-chamber, positive feedback loop trouble. 

From "Neuritis" 

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All of this was on my mind, then I saw the Benedetti paper, Placebo and the New Physiology of the Doctor-Patient Relationship. 
The coin dropped again.
Yup, our poor overly big sorta helpless human primate brains need external validation before they can turn around the physiological problems inherent in pain production, for example. Possibly.
At least that's true for me, even though I hate that I "need" anyone to help me, therapeutically, physically, sometimes.. at least, my brain does..

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I remembered Jorge Fuentes when someone on SomaSimple posted a link to all his publications. I remembered I had even blogged about him a few years ago. I found the post again. He is definitely somebody to watch carefully. Maybe he will be someone who can lead this profession out of the post hoc ergo propter hoc forest it got lost in, decades ago, and is still lost in..

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Be sure to register for the San Diego Pain Summit, Feb. 2016. Benedetti will be speaking there!!
Robert Sapolosky too, the fabulous primatologist and stress researcher. 

The mobiusity of it all..

"Pain is an all-consuming interior experience that threatens to destroy everything except itself and can only be described through metaphor" ~ Biro 2010. Quote from Mike Stewart's blogpost, BEYOND WORDS. 

Sometimes we're up, sometimes we're down.
Sometimes we have pain, sometimes we don't.
Whether we're on the painfree side of the line or not (and all of us, or at least virtually all of us, will end up having tasted both sides), we still have to keep on doing life. What is life? Walking around on that mobius strip until we die, I think..
We're all here together, doing life, doing time, until our time is up.
And no matter where you go, there you are. 

I made this image inspired by a conversation on Facebook, with Mike Stewart of KnowPain, and Joletta Belton, of MyCuppaJo. 

Here is the conversation. LINK.

Part of it was about the word "management", which I have an instinctive dislike toward.
If I have pain, I do not want it "managed" by anyone but me, thank you very much.
If I am a provider of help for pain, I don't want to "manage" your pain - that's your job - I want to help you/you nervous system to learn your/its way out of it if I possibly can. 
But if I can't, I can't. It should be clear within one or two sessions if anything I do helps or doesn't help.

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I've met Jo in person, just a few weeks ago in San Diego. We dined out with Rajam Roose at a lovely restaurant, beside a large pond alive with huge goldfish. 

Joletta Belton (nearest), and me (across the table), San Diego, August 2015

She takes absolutely gorgeous pictures of nature, wild and free. She is keenly interested in pain. She ended up with some of that herself, through circumstance.

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I have not had the pleasure of meeting Mike yet, in person, only on twitter and facebook. He caught my attention the other day with a post about metaphor, how pain, that uniquely private interior experience, is understood or shared metaphorically, and therefore demands a creative response. His slide contained cultural contrast in metaphor to do with headache. The "west" or English language, and therefore mindset, is all aggressive and warlike and as he puts it "mechanistic and invasive" with descriptors such as stabbing/ shooting/ lancinating/ pounding/ burning/ crushing/ pinching. Some Japanese metaphor he offered up from The Story of Pain by Joanna Bourke, were by contrast, "natural and environmental" - comparing pain to an animal, e.g., an octopus headache (sucking) or a bear headache (like heavy steps of a bear).  I liked the Japanese metaphors - way less personal somehow. More space around the pain. More detached.
I realized, yet again, on the one hand, how hard it is to describe a pain to anyone else, and on the other, how culturally embedded metaphors are. 

Yes, I do think English is a war-like language. 

So many nouns, so few verbs.

Pain is a verb, not a noun. Well, OK.. it's a verb that is pretending to be a noun. It tries to stop one from moving, is what it does.

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About being a pain carer, a carer of others in pain.. I really really get that pain is entirely personal. I've been there. I really really get that it's massively important to leave people with hope, AND locus of control. I really really get that the pain they have is theirs and theirs alone.  I think I get a bunch of other stuff too, about how the nervous system evolved as a biological learning app. When I have one in my hands, I do try, as well as I possibly can, to communicate appropriately with every level it has to offer, from the most abstract to the most kinesthetic, trying to help it feel seamless again.

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Another inspiration to write a blogpost came today via Pain-Ed. A wonderful video of Keiran O'Sullivan sitting with a woman he treated, who fell and broke her coccyx. I was riveted the whole time as she told her story. Definitely worth a good listen.

Ally's story: "My life was busy, it was hectic and it was very stressful".  

What I got from this was: 

1. Don't ever become addicted to stress. And yes, stress can be addictive. The money-chasing type of stress is the worst, because then if you fall on your tailbone and it breaks and you are in pain, you can't work as hard, which, if you are addicted to making a lot of money by working really hard, is doubly stressful because hello? now all of a sudden you feel impoverished on top of everything else!
2. She went to a pelvic floor therapist who made her worse by asking her to tighten harder. Pelvic floor therapists are wonderful, but I would pick mine very carefully, because they have to know who to teach tightening to and who to teach relaxing to.
3. It sounds like almost everyone she went to see for help treated her as a "condition", not as a person. She needed help as a person, so that she could deal with her condition, not the other way around. 

Neuritis

It's been awhile.. I've been very busy trying to get the manual I wrote into shape for publication. I've worked on it for a good 6 hours every morning since May. Still not done. Getting there though. And a cover is ready, an isbn number.. once the publish button is ready to hit...

I just arrived back from teaching in San Diego, hosted by my amazing friend there, Rajam, who organizes the San Diego Pain Summit. Be sure to attend the one she's organizing for 2016. Robert Sapolsky will be speaking! He's awesome. So are all those other speakers! Don't miss out or you'll kick yourself.
There are only 2 weeks left to register at the early bird rate. I kid you not. After that, it's going up. 
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Anyway:

You know how ideas can chase each other around and around in one's head until they make a hole in your thinking?
I think that has happened to me again fairly recently. The idea I had turned into a cartoon. 

I really do think the NS is still pretty much like this. It seems seamless in its operation most of the time, as a communication system, but that danged old ancient physiology can derail it and then the seams show.
And pain is the clue. At least, according to me. And bear in mind, I'm no expert. I just like to read, and think. 
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I made another cartoon, this one about the physiology of tissue healing. I threw in a few ideas about how as long as you have enough blood flow, you won't have any nociception that will "hurt" you, as long as you don't bang that sore toe or whatever... 

This is all well and good. Things resolve, discomfort ebbs, eventually disappears, all is well once again eventually.
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But.
But.
But.

What happens if this process occurs INSIDE A NERVE?

1. Nerves are loaded with nociceptive neurons innervating their walls, and the vessels that pierce through them to feed neurons. 
2. Nerves are long narrow cylinders, very self-contained. 
3. They have lots of circulation - neurons need lots of oxygen and glucose to function. 
4. The circulation gets in, and out, of nerves, through narrow regional vessels, which are highly subject to mechanical deformation. 
4. The circulation to nerves is easily distorted. At any given point in time, some part of the peripheral neural tree is being somewhat deprived, while the rest enjoys abundance. As long as one moves about and or rests in enough varied ways, no harm befalls any part of the neural tree. In fact, it needs the challenge and the stimulation of being affected mechanically.

But.
What happens if you develop bad stationary resting habits?
What happens if you always...
1. sit with the same foot tucked up under the other leg?
2. carry your bag on the same shoulder?
3. sleep on the same side?
4. stand with one hip up and the other down? 
5. wear a toolbelt dragging you down on only one side? 
6. lean on the same elbow all the time?
7. have your head turned the same way watching TV for a couple decades?
8. sit with the same leg crossed, and have for the last 25 years? 

These things we do can really take a toll after awhile. If circulation is skewed too long one way for too long and too repeatedly, I can see how the products of nociceptive activation WITHIN A NERVE might not be cleared away in a timely fashion.
Then, "silent" nociceptors might activate, part of a positive biological feedback loop. Not good, those positive feedback loops...

The signs of inflammation are rubor, calor, tumor, and yes, dolor.  Loss of function is considered a fifth cardinal sign. 

Imagine inflammation occurring inside a nerve. 
It can. 
It's called "neuritis". 

Now, put that together with the fact that a nerve is a very enclosed structure. How can the products of inflammation be swished away, from an enclosed space like the inside of a nerve, if fresh blood can't even get in there because of swelling? Or because regional vessels that drain the nerve have been tensioned and become narrowed or occluded, aka "mechanical deformation"?  Mechanical deformation secondary to some muscle guarding the spinal cord has given rise to because it's trying to help, reflexively? 
How can you move, in order to bring fresh blood into an inflamed nerve, if you can't, because of reflexive motor inhibition because the spinal cord got way too excited and is trying to protect you with reflex inhibition/spasm?
We can't get rid of nociception or peripheral hyperalgesia or neurogenic inflammation because tissues need all that "nerve net" behaviour, to become healthy again if injured. We can't lose that. But inside nerve trunks, it can all turn into an echo chamber!! Lotsa neurons all covered in sensitizing debris from other neurons, all of them raw and screaming! Like babies in wet diapers with their diaper rash stinging their undercarriages! Nothing cleans up nerves like fresh blood flow washing away the physiological byproducts of inflammation, but fresh blood can't get in, because... well... swelling. Tumor. And the old blood can't get out.
And it is not obvious swelling, because it's inside a nerve. 
OW!! 
And not only all that, but also, the neurons will think they're starving because fresh blood can't get in with new supplies. It's a perfect storm. 

I've checked the IASP site for this, and found out that neuritis is indeed a "thing".

Furthermore:

"Note: Neuritis (q.v.) is a special case of neuropathy and is now reserved for inflammatory processes affecting nerves."

Again.. : "Neuritis is a special case of neuropathy"
 
Even though nociception is involved, in terms of nociceptors' ability to create and add to an inflammatory response, IASP is clear that neuritis is not nociceptive "pain". Nociceptive pain is:  

"Pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors."

I don't think I agree entirely, because I know that nerve coverings are derived from mesoderm. Which makes them "tissue".
However, I won't quibble about it.
Mesodermal derivative is usually an innocent bystander - I blame ectodermal derivative for everything pain-related, including neuritis, because of all that ancient nerve net (the clay tablet and stylus) hooked up to the state of the art smart phone type central NS we all enjoy (or don't enjoy, depending on what is going on inside the whole enclosed system).
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OK, so the question remains: How can we get rid of something like this that is excruciatingly painful, comes along seemingly spontaneously, and we can't just shake it off, because (hello?) we can't move that bit? 

Well, we have to make an appointment and go see someone we hope will have some answers.
Hopefully, if it's medication, it will be effective and not mind-numbing.
Hopefully, it won't be an appointment for imaging, where all sorts of perfectly innocuous grey hair and wrinkles on the inside of the body might show up and be conflated with this awful pain experience.
Hopefully it won't be a surgical recommendation in the absence of actual life-threatening pathology. 

Hopefully it will be a good human primate social groomer who:
1. Understands physiological processes and pain mechanisms
2. Can reduce stress by providing clear explanations and pain education
3. Can move the nerves carefully without adding more nociceptive input, enough that..
4. He or she can help some of it go away immediately, restore hope, reduce stress
5. Recommend safe and stress-free and easy movement homework
6. Cares enough to inquire about habitual postures and body-useage and can advise the individual in pain on how to change their own behaviour to avoid any relapse in the long term.