Saturday, December 10, 2016

Out of gear

Just coasting these days.
One-third of the way through December. Sudden onslaught of winter - a foot of snow and minus 25C weather. A big change to adapt to after the creepy warm November we had, with rain and daytime temperatures that reached plus 20C..

Anyway.. it's a slow time of year, not much happening at work last week. The book has been out for a week and a bit. I have amused myself by looking up the stats on book sales. Definitely not a runaway best seller, but it seems to be steadily moving out into the world. I am pleased with the progress so far, a couple hundred ebooks and dozens of regular books. A guy who attended my class, Jaire, posted a picture of himself holding his new DNM book. So did another guy, William. A woman who blogs at My Cuppa Joe, Joletta Belton, wrote a lovely blogpost about her experience attending a DNM course taught by Rey Allen recently.

What pleases me even more is a sense of the ideas it contains taking root out there in the world, with or without the book. Not many of the ideas in it are original, but I like to think that juxtaposing them to each other my own way has maybe helped give them more pizzazz.

All this is great. The feeling is one of completion, contemplation, enjoyment. Maybe it's similar to that feeling women my age (who reproduced) have when they watch their baby grandchildren or great grandchildren doing adorable things.

Sunday, November 27, 2016

Sacral outflow is entirely sympathetic

The book, Dermo Neuro Modulating, is out on Amazon as ebook only just now.. seems to be selling well based on feedback from twitter and facebook, but really I have no idea of stats, or of when the hard copies will be available, and won't until the coming week when I can converse with the company that helped me self-publish.

For the time being, if anyone interested in taking a look or picking up an e-copy, here is a book link to Amazon.

Time for a nerdy, nerdy interlude. 

In the past week it came to light that researchers got right down to the molecular level and found out that autonomic sacral outflow is entirely sympathetic, that there is no such thing as a parasympathetic cord supplying neurons to pelvic viscera or reproductive or sexual response function. This is huge news. Before I express any thoughts on that, here is Peggy Mason on the topic: 

Here is a blogpost she wrote on this topic! It examines a few of the implications from a science perspective, including the history of the concept and why textbooks will have to be updated.

Peggy Mason works at U. Chicago. I first encountered her brilliance at the IASP congress in Montreal in 2010. She discussed brainstem nuclei involved in micturition. I think that's her specific research area. But she does much much more besides. She teaches an online course for free, through Coursera, Understanding the Brain: The Neurobiology of Everyday Life. I signed up for it a few years ago but it was in May and I underestimated the daunting time factor. I had to run around teaching, myself, so had to drop out. But the amount I managed to assimilate was great, and I recommend it. She's a very engaging teacher.

She has also written a book, Medical Neurobiology. What I love about it is the non-hierarchical format - every single topic and even every little sidebar is connected to bits in other chapters, all the way through. Which means you have to turn a lot of pages frequently in a rather heavy book, but your brain is going to take in the information from lots of sides and angles and directions.

About the sacral outflow thing, clearly this is a big shift in the dogma surrounding neuroscience. I love that she's so excited about it! I know a lot of people whose world if rocked or their worldview pulled out from under them makes them anxious and upset. What does she say? She's excited, and says Whee!!!!

Anyway, here is what the new, more updated picture of sacral outflow looks like, from the Espinosa-Medina et al paper:


OK, so what is the big deal? For manual therapists?
Well, the implications are kind of big, in my opinion.
First of all, there are still plenty of us roaming around imagining that there is some sort of magical elicitation of parasympathetic activity directly stemming from hands-on work. So much so that there is even a kind of guru-based modality empire out there called craniosacral therapy. That set of ideas needs to go. 

Second of all, and more importantly I think, we need to understand that when we do hands-on we are playing with the brain, and that EVERYthing we touch or do is going to excite, for better or worse, the sympathetic nervous system. The sympathetic nervous system has dual control of the entire body wall, and blood flow to each and every bit of it, including to that forest of highly sensitive neural tree comprised of 72 kilometers of passive noodle-y tubing throughout our body. THAT is what it is most protective of, and that extends to the surface of the body, everywhere. Really. Everywhere.
Think about it.
Think about how everything that was ever thought about how sex works (i.e., an orchestrated interchange of sympathetic and parasympathetic outflow), is wrong in light of this new information.
If this is how sex really works, then it must also be how any kind of manual therapy works, also. Because if there is no parasympathetic outflow to genitalia there certainly is none running out anywhere else in the body wall, either.
Which supports the idea that context is everything, and that descending modulation from brainstem nuclei is where it is truly at, for blocking ascending nociception, and (given everything else is level) for pain relief.


1. I. Espinosa-Medina, O. Saha, F. Boismoreau, Z. Chettouh, F. Rossi, W. D. Richardson, J.-F. Brunet; The sacral autonomic outflow is sympathetic. Science  18 Nov 2016:
Vol. 354, Issue 6314, pp. 893-897

2. Adameyko I, Neural circuitry gets rewired. Science 18 Nov  2016 • Vol. 354 Issue 6314, pp. 833-4

Friday, November 25, 2016

The year's not over quite yet.

But it's drawing to a close.

A lot has happened, most of it in the last few months.

1. I finally finished the book. 

It will be available in the coming week I'm told.
Here is a picture of the cover, back to front.

Whew, glad that's done.

2. I moved my clinic. 

Total unplanned surprise. In September I got a call from another physio in town who told me she was opening a new clinic in a renovated school, and would I like to join her?

The deal was,
a) I got to keep my own name and business and patient list and files
b) I got to have lower rent per month, secure for the next five years
c) I got to have a room with a window and could add a sign to it

d) I had to break my lease in the old dilapidated building where my practice was formerly housed

VERY fair terms.
So I did move - I took a big hit because there was still over a year left in said lease, but opportunities like this do NOT come easily in this town. There is almost no new construction apart from residential. So I jumped at the chance.

And I feel like I dodged a bullet, because the same day I moved out, October 3, a giant rainstorm happened, the roof leaked, and water poured down from beside one of the light fixtures in the building.

Lucky me, out of there.
Whew again.

3. The weird election that just happened down south 

It has to have been one of the most bizarre elections humans have ever held since we've been human and since elections became a thing.
I used to think the following, ever since the Free Trade Deal with the US and Mexico, NAFTA:
That Canada and Mexico were like nurses, walking a large demented patient named Uncle Sam up and down the hallway helping him to not fall, and that he was abusive, striking out at both of us even as we tried to support him and look out for his needs.
Now that demented patient has been elected president of the US. He's now going to represent the US in the entire world. Unless some equally bizarre miracle happens..
Nothing he ever said or did in the election run up convinced me that he would do anything but lurch about and break things and hurt people and be thoroughly abusive.

Gad, I'm going to miss Obama.
Whew that I don't live directly in the US.
Quaking because I live very close to the border.

Sunday, October 30, 2016

Dream drama

Bizarre dream this morning, made me wake up at about 5:30 am. Like all dreams, absurd in retrospect.
Still, one of those dreams that is stark, memorable. The kind that twist you a bit, emotionally. Clearly a message from one part of my brain to some other part.

The dream

I'm a teacher in a classroom in an institution. The reason I know this is because it's a home room with those university type desks and a front wall covered in green board, and outside a long hallway with other doors to other classrooms. Apparently I've taught in there forever. (Absurd.)

I arrive to class to see that two other people are in there teaching. Not only have they taken over and are teaching my class, they are teaching them biomechanics. They are not teachers that I know well, but I'm willing to let them complete the exercise.

They have a human skeleton, or rather a vertebral model, about twice human size, a real one I guess, lying on its side curled up on a table. One of them has a percussive implement of some sort. She is thumping each of the vertebrae in turn. Each thump results in a unique movement of the parts of the column.

This is supposed to mean something profound, I guess, because she looks around at each student as if to say, Truth. Case closed.
They all seem quite dazzled by this demo.

I ask, where does this biomechanical demo and tool come from? And she looks at her teaching partner, then says, Scandinavia. (Which might be absurd, but I'm not sure.)

Oh, I say.

She is a large woman, broad shoulders, about 40-ish. Looks like a lifter. Cropped blond hair. Glasses with dark frames.
Anyway, she leaves out a back door, and I turn my attention to the other one, whose looks I can't recall clearly.

I ask, from a pain standpoint, what does this biomechanical movement model have to do with treatment?
He can't answer.
He stares at me for a moment, dumbfounded, as though I'm the incomprehensible one, not him; then, still mute, with an irritated look on his face he strides out the front door and SLAMS it shut behind him.

I and everyone else still in the room startle. Such a passive aggressive thing to do. I hope that lesson is not lost on anyone.

I have my classroom back, and all the people that are supposed to be in it. I try to gauge how mesmerized they have been by the demo, start a conversation with them by asking questions about what relevance they think this has for a real patient with pain. One thing I want to drag out of them is, do they think this movement (which was presented as the only true movement) is true for every individual? Alive? With nervous systems? all sorts of tissue layers burying their vertebral column?
I don't remember how this part goes. It goes on for quite a while.

At the end of the dream, I'm taking the skeleton home in my car with it still dripping a little after having given it a careful shower. (Absurd.)

Tuesday, October 25, 2016

New rumblings in defining and philosophizing pain

Very low rumblings, like thunder far away, but who knows? They could turn into something, right?

1. This just in: Updating the definition of pain. (Full text, at least for a little while..) 

Current def:
>>> An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

Proposed def:
>>> Pain is a distressing experience associated with actual or potential tissue damage with sensory, emotional, cognitive, and social components.

Yes, I think I like the proposed def more.

It seems the world has moved past the general systems theory upon which the BPS model was constructed, into something much more integrated, less objectified, more phenomenological, (more post modern?), so therefore a better model is required.

Gee, and here I thought BPS was soooooooo much better than the odious biomedical/biomechanical/postural-structural models that so many are still working with, when it comes to pain experiences.

How interesting that these two rumblings both arrive in my facebook feed on the same morning and amplify each other.


1. Williams, Amanda C. de C.; Craig, Kenneth D.; Updating the definition of painPain:
November 2016 - Volume 157 - Issue 11 - p 2420–2423

2. Dave Nicholls; Is the Biopsychosocial Model all it’s cracked up to be? Critical Physiotherapy Network 25th Oct 2016

Wednesday, September 28, 2016

Nicole, hair artist

I love my hair dresser, Nicole.
I've only been to her twice; the first time was a year ago, the second time was today, and I put in a whole year of waiting for her; a year ago I had a single haircut from her that satisfied all my hair neuroticism, then she went away, had a baby, has just finished her maternity leave and is now back to work, and I was in there today, back in her care.
During the year she was away I got haircuts from other people, but none of them felt right, not the way my hair felt after that one time she cut it, a year ago; I knew I had found my one and only. I mean, anyone can cut off hair - not that big a deal. But it takes an artist to be able to feel through it and decide on the basis of how it feels, how to thin out the hair where it grows in too thick and feels too bulky, and where to leave it alone because it's the right thickness, and how to leave it thicker over flat spots on the skull (like where one was left lying too long as an infant) so the head looks symmetric and round even if it isn't, and so that when I run my own hands through my hair I'm not painfully aware of how my now aging hair is a lot thinner in some places and by comparison way too thick in others.
The difference between all the other hair dressers in town and Nicole is like the difference between some random kid practicing a cartwheel on the lawn, and someone from Cirque Du Solieil performing in LUZIA.
Nicole is definitely a keeper. She might have another baby some day and I'll have to make do with other hair cutters, but really, she is the only one I will ever feel bonded to.

Friday, September 23, 2016

When autumn leaves start to fall

I'm in a particularly ambivalent stirred-up disquiet mood today. I blame the change of season, partly..
One of those (thankfully rare) windy rainy autumn days out there..
The one and only patient I had booked today cancelled with only a half hour notice. Grrr.

In other news, I am so restless or anxious or something today that I had a hard time focusing on editing. Yup, last edit before my beast of a book gets published. A very nice PT I know wrote a gracious foreword for it, which reinvigorated me for most of the edit this past week.

But today is Friday already, for some reason.

And I've got other things on my mind, alas. I will move my office soon and I still have one travel/teaching gig to deal with this coming month.

Hopefully THIS move will be the last, ever, until I die.

Opportunities like this do not come along every day.

A couple weeks ago I got a phone call from a PT I met years ago while doing a short stint at the local work rehab facility in town. She's a lovely person, young, early thirties, three children, wants to open a new clinic in town. She invited me to join her there, rent a room (WAY cheaper than the outrageous rent I'm paying right now, and which rises each and every year.. in a building that, shall we gently say, has seen better days) for about half what I pay now per month, for the next 5 years. Her new clinic is in a brand new strip mall close to the hospital which used to be a separate catholic school, but has now been repurposed. (Seriously, there just are not enough catholic children anymore to warrant a completely separate school for them.. I guess.)

Anyway, it's lovely, fresh, lots of light, clean, large.
We checked for any conflicts of interest, having two practices in one location, but it seems there is no problem with our licensing body about that.
My soon-to-be PT roomie/landlady who will be subletting to me recently went out and got certified to be a yoga teacher. So the place will be a yoga/physiotherapy center. Which is OK by me, because I asked her if it would mean I would have to put up with any talk about chakras and she said no. :)

So anyway, I have the phone company coming in a week to move my phone number to the new place (yeah I know... old fashioned landline, but gad I hate cell phones and smart phones..); I have atrociously overpriced movers coming the first workday of October, mostly to move my atrociously overpriced hi-lo electric treatment table over, plus odds and ends. My brain is already leaping ahead, planning how to pack and what to pack and what to toss. I will toss the desk, as there will be no room for it in my new room, and my new roomie will let me share her charting area where my file cabinet will sit anyway.

It will be expensive to move and I had to buy out the remainder of the current lease because the property-owners in this city are nothing if not money-grubbing, seems to me.. However, averaged over 5 years,  at half the rent I'm paying now and no increases for 5 years, I'll still come out ahead. Yay me. Plus, it looks like I'll be getting a treatment room with a window! And it's exactly the same size as the treatment are of the room I currently work in, so all the necessities are going to fit.

Saturday, August 13, 2016

Mental models in manual therapy

Our mental models, (ESPECIALLY in manual therapy) need continuous examination, updating, renovating, because if we stay caught up with basic science, especially pain science, we'll notice that it's all quite turbulent, philosophically problematic, scientifically problematic, and therefore, we have to be nimble, like a kayaker in white water, paddle on one side then the other to avoid tipping over and still make our way down the river. (Forgive the analogy, I recently watched the kayaking event at the Rio olympics.)

Our mental models are subject to cocktail party effect, or cognitive conspicuity. We need to be aware of that.

What is the biggest clue we are responding only to cognitive conspicuity?
When we realize we are paying more attention to some movie going on in our own head, and not to the patient or any discomfort they may be experiencing as we impose our lovely mental models on them.

We still need mental models, because that's the human part of our own brain, the most complex object in the known universe, mostly still unknown, possibly unknowable in the ultimate sense.
"Acquiring knowledge can be a very daunting task. If you think of the mind as a toolbox, we’re only as good as the tools at our disposal. A carpenter doesn’t show up to work with an empty toolbox. Not only do they want as many tools in their toolbox as possible, but they want to know how to use them. Having more tools and the knowledge of how to use them means they can tackle more problems. Try as we might, we cannot build a house with only a hammer. 
"If you’re a knowledge worker, you’re a carpenter. But your tools aren’t bought at a store and they don’t come in a red box that you carry around. Mental tools are the big ideas from multiple disciplines, and we store them in our mind. And if we have a lot of tools and the knowledge required to wield them properly, we can start to synthesize how the world works and make better decisions when confronted with problems."

What if the mental models our professions chose to teach us were based on tissue-based, structural, patho-anatomical sidetracks? What if they were modeled after or taught by people steeped in orthopaedic medicine and surgery? What if they are all completely beside the point when it comes to pain? Like the pain being experienced by your next day full of patients? That 50 year old woman who still has neck pain from a car accident when she was twenty? That 16 year old who loves snowboarding but developed knee pain 5 months ago, has been told he "has a miniscus," has been receiving brutal massage therapy that helps for about a week but then the pain returns?

How do tissue-based etc. mental models help people like that?
Are they not swamped by nocebo and subject to the revolving door of treatment?
Have they not probably concluded they are doomed to forever be a patient of one treatment person after another?

Do we (the practitioners) have any shot at all of developing mental models that actually help people recover, get off the merry-go-round, feel normal again, feel themselves in their bodies the way they used to?

I think first of all we have to decide to entertain the possibility that the old models are wrong. Dead wrong. And be brave enough to operate from that assumption. As a test. Of faith? Maybe. Of reality? Maybe.. OK, probably.

As the Farnam Street piece points out,

“...two main factors contribute to our inability to make good initial decisions. First, we don’t have the time to think. And second, we don’t have a firm understanding of how the world really works...”
“We don’t often realize that our first thoughts are usually not even our thoughts. They usually belong to someone else. We understand the sound-byte but we haven’t done the hard work of real thinking. After we reach a first conclusion, our minds often shut down. We don’t seek evidence that would contradict our conclusion. We don’t ask ourselves what the likely result of this solution would be — we don’t ask ourselves “And then what?” We don’t ask what other solutions might be even more optimal.”
“Mental Models allow us to make better decisions, scramble out of bad situations, and think critically. If you want to understand reality you must look at a problem in multiple dimensions — how could it be otherwise?”
“Getting to this level of understanding requires having a lot of tools and knowing how to use them. You knew there was a hitch right?... Luckily there is another path.”
“If you understand the world as it really is, not as you’d wish it to be, you will begin to make better decisions.”
The tools in this case are NOT more courses or treatment systems or actual physical tools, such as expensive equipment, needles or cups or machines that go ping, ding, ring or ting, electronics that zap or zing.
The tool we need in this case is "knowledge that changes slowly over time," but not so slow that it ends up dogmasphere type knowledge that lets the world go by and won't evolve.

Higher-order thinking is recommended in the piece, an awareness and acceptance of the fact that with each action, even a mental action, second and third-order effects ripple out into the world. Each of us in a node of information/knowledge transference. Things we might want to consider: What is the range of possible outcomes? What’s the probability I’m right? What’s the follow-on? How could I be wrong? As a philosophic massage therapist friend pointed out long ago, what about taking care of the future of the neuromatrix of each person who comes to see someone like us?
Understanding how the world itself works is hard enough.
"Understanding how the world works isn’t easy and it shouldn’t be. It’s hard work. If it were easy, everyone would do it. And it’s not for everyone. Sometimes, if your goal is to maximize utility, you should focus on getting very, very good in a narrow area and becoming an expert, accepting that you will make many mistakes outside of that domain. But for most, it’s extremely helpful to understand the forces at play outside of their narrow area of expertise.
Because when you think about it, how could reality be anything other than a synthesis of multiple factors? How could it possibly be otherwise?"
If a human brain is the most complex object in the known universe, a human neuromatrix is its most complex verb.

So, what's the solution? I'd say, don't only learn about paddles or kayaks. Learn to understand the river. Interact with the river. The river.
Interact how?
Well, telling patients all about your great paddle or kayak probably will make you feel like a hot therapist, but won't help them.
Remember rivers get along just fine without you. Unless a river comes in dammed up somehow, and your job is to undam it...
It's not about you, the paddle or the kayak.
It's about interacting with the river, clearing it so it can flow better (now and in the future), and not becoming drowned in the process.

Sunday, August 07, 2016

Waves of thought

A lovely Sunday morning in August.
Idly sitting, watching TV at a time of day I'm not accustomed to.
Watching swimming, Rio Olympics.
Also doing a jigsaw puzzle on an iPad, and sipping coffee. The jigsaw is about water. Lots of wavy turquoise colours.

My thoughts disengage and go inside, which is quite common for me.
Mostly they are forgettable.
This time, though, they hook up in a way that is more interesting, a way that leads to a realization.
Here are the thoughts.

Alberta, swimming
The time: mid-seventies.
I was about 25 or 26 years old, very involved in art school, had won a scholarship to paint intensively in Banff for 6 weeks. While there, I hang out with a small group. One of the group, a woman who lives in Calgary, has logged actual exhibitions. Another woman and I are just students with nothing much to show for ourselves except active learning about perception, and big gobs of enthusiasm.

Woman #1, the accomplished artist, loves to swim. We all go swimming every evening, at the Banff Springs Hotel.
It's a big pool. When I first start, I can make it only about one length, along one side, with frequent rests along the way. By the end of the summer, I can swim 4 lengths with no stops.

Homeward bound
On the way home from this excursion we are invited to this woman's place in Calgary.
She and her husband, also an accomplished artist, prepare simple tacos for a group of 5 or 6.
We are sitting, eating, enjoying: She suddenly develops a severe headache. Out of nowhere. So bad that she starts to cry. She stays put, though, doesn't seclude herself in a bedroom or anything. She is in a lot of pain, and everyone tries to figure out some way to help, but nothing comes to mind.
I sit there.
Even though I'm supposedly a trained professional.
I commiserate, but have no clue what I could possibly offer. I am completely outside my therapy world. I can "be" a therapist, but only when I am in that therapy bubble (which in those days was a hospital setting) do I feel the least bit competent.
Like everyone else, in this situation, I feel helpless.
The other woman in the swim group gets up, stands behind her, and rests her hands lightly on the hostess' shoulders. She attempts some amateur massage, which is better than nothing..
I don't think it helped the headache, but at least she tried to help; I did not.

What I conclude from having this drift up into my mind is that it had an influence on me. A big one, mostly unconscious. Mostly being embarrassed that I was supposedly a trained hands-on professional and I somehow lacked empathy to the point where I felt too inhibited to even try to help somebody who was having a bad time with pain.
Whereas my art student friend instinctively reached out and did her best.
Makes me realize my early PT training actually stopped me instead of helping me to help somebody else, with a pain problem, in a common social situation.
I buried this aspect of this memory until now, but to have it drift up in this new way makes me realize that at least some part of my brain tried to sort it any way it could, by helping to motivate my interest in pain and in what I now like to call, human primate social grooming, that instinctive reaching out to help by touching, feeling, massaging, making some kind of physical contact with any individual who feels crappy. This isn't the ONLY reason, of course, but it definitely helped; I do not doubt that now.
Now I feel competent enough to be fully capable to take a role in any situation, and in many cases, I have.
The woman on the plane sitting beside me who told me why she was wearing a brace on her hand. A fresh ulnar nerve compression syndrome from about 7 hours of unaccustomed mountain biking and leaning too long on one handlebar.  After about a half hour of working with her, she regained use of her hand and could touch her little finger and thumb together again.
The young Swiss guy sitting beside me on the plane home from Europe who had neck pain.
Many other examples that don't involve planes.
Like the wedding I attended in a back yard, where one of the other guests developed sudden horrible back pain, and the bride sought me out to see if I could lend any help; I and the guest retreat into the house to a bedroom, where I do my very best, and after a half hour at least she can walk a little easier.
Live and learn.
If I had enough lifespan left I would want all therapists to feel competent to help with pain problems or weakness problems stemming from nerve problems in any situation anywhere. Without being overly concerned with conventional North American social boundaries.

Wednesday, July 20, 2016

Correlating nociception and pain

I have accepted, over time, that pain and nociception are two distinctly different animals.
Just because my cat eats grass once in awhile, that does not mean that it is a cow.
Yes, nociception can "hurt," but that does not make it pain.

Nociception can be directly measured and pain only indirectly.
And there is enough literature around, drawing the distinction, and slowly dragging us all up out of the muck of biomedical dogma that had the two conflated for so very long, that I seriously doubt there is much in the way of any dependable correlation between the two. OK, I doubt there is any that is relevant to the patient who stands before me. Especially three months in. Three months is the arbitrary length of time, decided by powers that be, when acute pain turns into chronic pain. That's how long it takes soft tissue to heal. (We're talking mesodermally derived soft tissue.) Most of the people I see have had a pain, or pains, for years. Pain is NOT about tissue damage. Pain is about pain. It's an emergent property of the nervous system itself. Nociception might be about tissue damage. Or not. It might only be about tissue danger. Nociception is a signal. Pain is perception, the personal meaning of something perceived as sensation.

Science geeks love correlating things to each other. I'm not much of a science geek. I am not involved in creating any of it.
I love science, but as a consumer, as an appreciator, not a producer.

Correlation has come up as a topic on facebook, specifically correlation between nociception and pain. Some who would proclaim themselves producers, have their hard-won academic black belt, argue with me when I say there isn't any. They think it's laughable, because of course, anything can be forced to correlate to anything else... that's part of the geeky business of it all.
See the Wikipedia entry for spurious correlation.
For some actual spurious correlations, see this link.

As Neil O'Connell PT repeated recently, "If you torture the data long enough it will confess to anything."
Furthermore, about hammering of hands, that demonstrates nothing about how brains respond to nociception, because even hitting a rubber hand that the brain has accepted into its body schema will elicit a protective response, no actual nociceptive input required! Pain (and in this case, protective response) is entirely context dependent!

I get that there is a whole world of measuring and correcting for and determining the Most Precise Measuring and Comparing of Variables that Could Possibly Exist, just as there is for fixing cars. I couldn't be more happy for people who love math and all the patterns they can find in the world, including lovely mathematical patterns in the abstract examination of something as measurable as nociception against something as nebulous as pain.
Nociception is probably causal for pain more than it is correlative. One thing I do distinctly remember from reading science appreciation, is that correlation and causation are also not the same thing, and should not be conflated.

To me, the effort to find a correlation between nociception and pain makes about as much sense as trying to measure the relationship between size of the matchstick, amount of flammable chemical on the end of it, etc. (i.e., nociception) and size of forest fire (pain). Especially when the fire could have been started by an unmeasurable lightning bolt instead. And the size of fire, ultimately, might have been way more about a lack of rain than any other factor or variable, including the match or the lightning. And in terms of pain, sensitization continually adds more fuel. In the end, maybe the creation of a backfire can help stop the spread of the forest fire.

So many variables, that measuring the size of the original match and trying to correlate it to the size of the fire, and seeing that as having any sort of relevance, scientific or clinical, is kinda ridiculous, on the face of it... to me at least.

Furthermore, nociception is not always unpleasant, whereas pain always is.
Here is something I wrote long ago, buried in Facebook somewhere I think, retrieved by Lars Avemarie:
“Nociception is sensation. Pain is a perception. Consider seeing: A sudden flash of light = sensory input. If it gets your attention it might be “sensation”.  But sensory input or even sensation ≠ vision. It does not yet have any assigned meaning. Only context (both inner and outer), considered and added, can provide meaning. A sudden flash of light might be a bomb. Uh-oh, duck and run. A sudden flash of light might be fireworks. Ooh.. pretty. Nociception is not always unpleasant: e.g., rolling around naked in snow, after a 4hr sweat lodge experience. Kinky things SM people do for fun. Nociception ≠ pain. Pain is always UNpleasant.” 


Saturday, July 09, 2016

First ever visit to Norway

In June I travelled to Norway to teach a couple workshops. Of any country I have been to, so far, Norway impressed me most.

I now have more confirmation bias on society vs: culture, fueled by having been to Norway.
My first impression was driving into town in a taxi. Lovely houses, open windows with no bars on them, really, open doorways, even, not even fences, flowers in pots, obviously closely tended, every thing painted fresh. Everything cared for.

After arriving at the hotel, and walking around outside: no litter anywhere. A big glass statue, entirely unmolested, in an intersection, no visible graffiti. Not many people, and no sense of danger. No one lurking. No eyes on the out-of-towner. Safe alleys. No trash. No homeless people. No disrepair anywhere. No signs of vandalism.

What on earth is this place? Did I die and go to heaven?

In Norway, culture and society do not appear to be in opposition. They seem to dance smoothly, together, to the same music. It appears that society grew out of basic culture, naturally.


How babies are treated

Imagine a country with a culture and a society that revolves around its babies. Instead of leaving each family to raise its babies as best it can, there is something different going on in Norway, and maybe other Scandinavian countries as well, as I have no idea how widespread this custom is - what custom am I talking about?
I'm talking about the custom of putting the baby into a buggy, outside the house, for a mid day nap.
That can only be done in a place where there is no fear. And where pitbulls have been outlawed.

One of my hosts who has a young child, 18 months, brought me to his home after I had checked out of the hotel, and before it was time to fly to the next city, to kill some time. I worked on my next presentation while he hung out with his son. In Norway, fathers get government-mandated parental leave. His leave was about to end soon. He and his wife had split up their workdays and time away from work so that each would have time to care for and bond with their child. He was every bit a devoted father, down on the floor in the play area, playing with toy animals with his baby.
This was a very relaxed baby. He mostly ignored me once he had given me a once-over, and had brought me a toy to examine and comment on. During the time I was there, he was played with, talked to, interacted with, and fed lunch, all very calmly. We ate ice cream cones together. I watched this dad nimbly put his infant's entire ice cream covered hand inside his own mouth to clean it off so that ice cream would not end up on the rug, all the while taking a phone call on his smart phone. Fast-thinking, responsive dad. No fuss from this baby. Over anything.
The house became very quiet for a long period of time. I asked where the baby was, and my host said, oh, he's having his nap. Oh, I said.
Would you like to see the rest of the house? my host asked. Sure I said. We went upstairs, me being quiet so as not to wake the baby. He showed me his child's room. I peered in, and didn't see any baby sleeping. Where is the baby? I asked. He's having his nap. But where? I was still puzzled.
Outside, he replied.
Yes, in his buggy... I was thinking, rather than bring him back in here, it will be better to put him straight into the car after his nap, so that he doesn't become stressed by bringing him in, letting him get interested in something, then taking him away from it in order to take you to the airport.
He's outside? (I was still trying to wrap my head around this.)
Wow, it's so safe in Norway that you can leave your baby outside?
Yes, we all do that. It's normal.
Normal? I was trying to grok how a country could be so safe that it was normal to leave a baby outside in a buggy. I must have looked a bit gobsmacked. I asked if he had been left outside in a buggy for naps when he was a baby.
He said, yes, of course. Everyone does that.


After I arrived at my second destination I asked my next host, in a different city, about the baby napping thing, and he said, yes, of course, totally normal.
He added, the only restriction on it is that you are not allowed to put the baby out if the temperature is below -15°C  (five degrees F).


I do not know how this practice evolved, or where it came from.
In my fond imaginings, I like to think it has been around since at least Viking times.
Baby Vikings, left in Nature's loving arms, by themselves, so they can grow up solid, calm, independent, tuned into and bonded with their environment.

I love the idea that Norwegian society organized itself around culture and cultural practices, not in opposition to them. I love the idea that Norwegian society looks after its people, and its people look after it, and that there is mutual respect.


Other little things about Norway that impressed me

1. There seems to be good health care, social programming, and housing for all. I did not see any dumpy or dodgy areas, even though I was touring around by car quite a lot.

2. No pitbull dogs allowed in the country. In fact I did not see any animals of any kind roaming around loose. There were peaceful sheep inside charming low rock fences along the highways, though.

3. Apparently pedestrians are sacred. When out walking, I was struck by the fact that cars stopped, even when the light was green, for pedestrians. In every other country I've ever visited or lived in, pedestrians are considered by society to be on their own and you take your chances. Even when you have a walk light or are in a designated crosswalk, you have to keep your eyes open, because as a pedestrian you are merely potential roadkill - cars don't care and drivers are inattentive. In Norway, there are massive fines for drivers who injure a pedestrian.

4. In Oslo, major highways are underground. So is all the traffic noise. Drivers all have a transmitter attached to their windshield and are monitored. Slowly but surely, the country is moving toward 'no gas vehicles'. Drivers of electric cars have perks - they can park closer to exits in underground parking areas. They have more choice of driving hours and underground streets and highways. Gas drivers can use the freeways, etc., outside their designated hours, but have to pay a toll for it.

5. Norway is not part of the Economic Union. I did not know this, and was caught out at the airport with nothing but Euros to pay the cabbie. Fortunately I had a credit card, and my host loaned me kroners just in case, but I didn't need to use them. Each krone is about 15 cents Canadian.

6. Not part of society, but impressive nevertheless: Norway is pretty far north. I was in the south end, but even so, the latitude was about 60 degrees north, or level with the top of Saskatchewan. It was summer solstice. There were only about two hours of darkness, long long hours in evening and a whole lot of daylight.

7. The official church of Norway is Lutheran, but religion is in rapid decline in general.

8. There is a king, but he doesn't do much. He has a farm, but he doesn't farm it. He has a palace, but he doesn't live there. He was once an Olympian competitor, but doesn't do much of anything anymore, it seems.

9. I saw a Viking ship museum, and a "folk" museum, (which looks after the king's farm), which contained a glimpse into the Sami indigenous culture. The first interactions of these cultures seems to have been about metal spoons, trading for those, as they seemed easier to come by than spoons made from reindeer bone. The Sami people were tromped on by the Nazis, who invaded Norway and the country side, burned the homes and villages, displaced everyone, all so that if the Russians decided to come down through Norway they would have a harder time of it.

10. We climbed the roof of the Oslo opera house. Such a touristy thing to do. But so beautiful. Made entirely of white Italian marble, designed to resemble a glacier.

Oslo Opera House, from

Friday, May 20, 2016

Society vs: culture vs: chronic pain

It is not without a bit of trepidation I tackle all this awkwardly, for I barely know what I'm talking about... it's been a very very long time since I've sat in a sociology class soaking it in or have involved myself in political aspects of life. However, I have opinions after being alive this long. And this is my ancient blog that no one reads so I'm safe to express my klutzy ideas here.

Part I: Prelude: 

Lately I've been pondering the difference between society and culture. There is a difference. It's political.
The one demands conformity to be able to perpetuate itself, and it does so by oppressing the other. If it cannot oppress it covertly, by persuading its members there is no difference between the two, then it oppresses overtly. It doesn't really care.

For example, society and state usually overlap, completely.
Society goes on forever until or unless toppled.
Voting is actually the way the state maintains itself; it doesn't matter who you vote for - the government will win. So, allowing voting was a clever move: it is a way for the state to pretend it is a democracy, so it doesn't get toppled.

To be sure, toppling the state would mean generations of anarchy and turmoil and maybe a series of dictators or militarist gangs or a theocracy springing up. Most of the culture and subcultures, e.g., women, anyone who is coloured differently than the dominators, has a different set of values, language, religion, etc.etc., would be worse off than ever. State-toppling is not a good alternative.

The rules are in place to keep everything running smoothly, and in our society, to keep money flowing away from producers and toward hoarders, who generally can change the rules to suit themselves, and who are generally old white males.

Culture is ever-changing and growing from the grassroots; it is forced to adapt to society. If your culture doesn't fit the society, or adhere to its values, you are by definition an outsider.

Political parties (the old established ones, at least) represent the poles of differences between society and culture. For example, conservative parties, when in power, squelch down on culture and anything related to the well-being of ordinary people by pulling back on funding or else refusing to fund it at all. Example: Here in Canada, conservatives were in power for a decade, and managed to cripple state-funded health care, research, and a lot of other benefits to taxpayers. They massively propped up the oil economy. They did not manage to get Canada completely out of debt, the thing they had decided well in advance was the most important thing. They seemed eager for war.

Ordinary people who vote for conservatives think they are the most rational; they want to preserve social order and maintain or improve status quo. They usually place any needs of heterogeneous groups of people way down on the list. They fear change. They tend to view themselves as parents who support the state as ultimate parent, and anyone else who is, or thinks, or votes any other way as childish. They are a bit like the stern dad, who goes for the gusto and to hell with anybody who gets in his way.

In Canada, last fall, they got booted, and the other pole was elected. Liberals are now in power.

Liberal parties do promote culture as well as state. They are two-faced that way. Which is why conservative voters don't trust them much. On the bright side, they operate from an egalitarian position - that everyone is equal and adult with varied concerns. Like the mom, they want everyone to be as happy as possible.

Liberal voters are often immersed in a let's-feel-good-now way of existing and living. They do have a point - life is short and then we die, so there should be something to help slide us along easier than pointlessly sacrificing and suffering while we're here. They tend to see the state as a parent and themselves as dependents.

They managed to convince the public they would move the country forward by removing cultural obstruction that had accumulated the previous decade. They would shift the cultural landscape. They would restore funding to everyone. They would right old wrongs and heal rifts between state and cultures. They would make sure everyones' social well-being was not only restored but their interests furthered. To cut them some slack, for sure, they got right to work on a lot of projects to soothe cultural feelings and relieve some of the cultural oppression, some of which have been accomplished and others that are still being worked on. Here is the Trudeaumeter that makes it easy for regular people to keep track of the progress being made by the Canadian government. They are planning to legalize marijuana, for example.

One of the things that had piled up, that the conservative party had put way way down the list, was right to die legislation. Which leads us to the next part of this post.

Part II: Right-to-die

Now in my mid-60's, and part of the baby boom that strained every resource the state ever had in place and ever had to install to accommodate such a large increase of an age demographic, I got kind of used to the state accommodating me and not the other way around.

My personal fantasy is that by my end of life, there will be little kits you can just order at the drugstore, whether by prescription, because let's keep doctors inside the loop, or over the counter if doctors don't want to be kept in a loop. I will be done. Not imaginary thy, I.
I might not be sick, but I will be done. With living.

I will be able to go get a kit, or else, if I'm disabled somehow, I'll be able to get one delivered.
I'll call the ambulance, or whatever societal transportation method is officially in place by then, somebody aboard with rights to pronounce death, to produce an official death certificate that will tell society I'm gone and to stop sending electrical bills to my address, notify my relatives, etc..

I'll tell the transport what time to come and pick my body up. I'll leave the door unlocked for them. I'll crawl into and lie down in the tub: in case the ambulance is late, I don't want any body fluids to leak onto my condo floor and ruin its resale value and leave a lot of bother for my indirect (as in, I have no direct) descendants to have to deal with. I will take the potion. I will go immediately unconscious and won't feel a thing. I'll simply go dark.

The transport will take my carcass off to the crematorium.
No mess no fuss.
No huge medical bills.
Low carbon footprint.

I realize this seems macabre, a bit; it seems that way even to me. But in another 20 years? A lot of us will be dying off all at the same time, and it seems reasonable to try to think of ways to save society money in advance. Think of all the children.

Part III: Drama in the house

So, the other day, the government and the parties in the house were all faced with having to parley through all the stressful taxing hugely socially responsible topic of having to come up with something on the issue of right to die for the Supreme Court of Canada, who had struck down the law against assisted dying, earlier, and had imposed a deadline for new legislation.

This is something the conservatives would not ever have come near with an eleven-foot disinfected barge pole. But the liberals? it is a cultural thing, something they had already promised to deal with, so it was theirs to stickhandle.

The deadline was the rock, conservative opposition was the hard place, and the Liberals were up against the clock. Yes, the NDP, the party of progress, was involved as part of the hard place too, but here is why. The Liberal party, the official government with a massive majority of seats, had looked at the situation, the deadline, all the other stuff they still had to get to, and decided to do this thing that the governing party can do if it chooses, which was to close debate and move on.

But: opposing parliamentarians did not like that idea. They wanted to slow things down a bit. The NDP behaved kinda badly by forming a physical crowd barrier to a conservative who had to get to his seat before discussion could resume. I have no idea if that is even legal. But they did it. And Trudeau got a bit annoyed.

Trudeau is not an old white guy. He's a guy, and he's white, but he's young, and he's a boxer.

Maybe he comes by his reaction to being stalled, and what came next, honestly: His father was somebody who gave the public his middle finger when he became annoyed. He swore at other constituencies, then later claimed he had said "fuddle-duddle."

So maybe it was genetic. Or maybe J. had a testosteronic moment, was a temporarily so stressed alpha male human primate that he lost it. Maybe it was all the boxing. Maybe it wasn't.

Whatev' the case, he got mad, he marched down and broke through the knot of people, went after the conservative. He knocked a female NDP MP in the chest accidentally in the process, with his elbow.
For more re: the kerfuffle that followed, see Trudeau's elbow neither the beginning nor the end of Liberal troubles, by Chris Hall.

To the public, and to the media, it was like mom and dad were having a fight, and it had got a bit physical. Needless to say the issue of the blocking and whatnot mushroomed and completely eclipsed the business of dealing with legislation. Maybe nobody was really ready to get on with dealing with something so fraught with opposing viewpoints, soul-searching, and the pressure of time, as legalizing assisted dying is. For more, read Know what's deeply traumatic, Elbowgaters? Needing assisted dying.

Part IV: Dying of pain

OK, finally the topic has meandered around to something I'm keenly interested in and have been since forever, the topic of pain, how the issue of chronic pain is woven into a societal tapestry, and suffering from it therefore if it counts as enough of a "thing" to be a legitimate reason for assisted dying. The topic is starting to be addressed by PT bloggers. See Tim Cocks' post, The ultimate pain killer. 

One of the biggest aspects of pain is that is feels like it will kill you, yet it never will. Because it can't. Because it's only a perception of a sensation. It's not a real "thing" - i.e., it's not an actual medical condition stemming from an actual problem with an actual tissue, the way the biomedical model assumed it was, and would still like it to be.

Yes, there are biomedical aspects to it, physiological glitches, genetic components, neuroanatomical peculiarities sometimes, perhaps: but they aren't diseases and they don't kill you either. Pain makes you feel like shit. Then (if it won't go away on its own, or you can't find someone who can help you by using a variety of placeboic, non-specific tricks, like manual therapy, which only works for the most basic kind anyway, which fortunately is also the most common), have to learn to deal with it. Live life in spite of pain. There are LOTS of helpers to help with that.

While I am somebody who does my best to alleviate pain, with my life, and work, and advocating, I think there are things definitely worth thinking about:

  1. The risk of un-assisted suicide in the chronic pain population is high. See Completed suicide in chronic pain. 
  2. The rate of un-assisted suicide in the chronic pain population is high, by opioid overdose. See Depression, chronic pain, and suicide by overdose: On the edge. 
  3. 50% of chronic pain patients have depression. See Suicide attempts in chronic pain patients. A register-based study. 
  4. Migraine, back pain, and psychogenic pain (whatever that is) are linked to higher suicide risk in vets. See Certain chronic pain may raise suicide risk.

Part V: What should I make of all this?

OK, here goes:
  1. I'm more of a liberal than a conservative. (But I do not vote liberal - I'm more leftoid than that.) 
  2. I can see the point of there being an ebb and flow in society, with conservatism being in power once in awhile. But not too much for too long, thank you. (I do not vote conservative, I'm way more leftoid than that. )
  3. Still, I hate when society oppresses cultural flowering. I'm a member of a few oppressed groups in society, myself. With the help of institutionalized white privilege, though, and women's rights groups who made a lot of societal progress before I was born, and while I was still a child, I made it through life reasonably well as a single female who was never turned into a uterus with arms and legs, whether by societal expectations or cultural trap. 
  4. While I've never been, and never will be, rich, I don't care: to me that is not the point of living, and as long as I can pay the bills and save enough to live on for when I become feeble, it will all be fine. 
  5. I think the point of living is to work hard to figure out how to live without harm to self and others, and try to leave the world a little better than you found it, if you can. And not by merely reproducing and just hoping for the best. If you are going to have children, raise them without harming them in the process. (Frankly, I'm glad I never had any, because global warming.)
  6. I appreciate forethought and planning by society to keep societal services intact. I do not mind paying taxes to those objectives. I could never live in a country that did not look after its citizens' hospitalization and health care, that instead does not care if they become impoverished by accident. 
  7.  I do not have any political or moral objection to assisted dying. I would want "society" to care for my suffering the same way I cared for my beloved cat's old-age suffering; I arranged for her to be put down. 
  8. I do think that pain drives people to kill themselves. 
  9. I do not think pain is very well understood, yet, by society itself, or by any of the cultures oppressed by society, or by very many of the unfortunate members of oppressed cultures under a dominant society who experience pain chronically. 
  10. If you have chronic pain and are a member of an oppressed group, your pain may be worse and you may receive less help for it. Like if you are female. Because biomedical studies are usually done on male mice and human males. 
  11. If you are female and do not have white privilege,  you are doubly unfortunate, probably. 
  12. Once marijuana is legal, there will no doubt be a lot of studies on its effects on pain. 
  13. Maybe once it has been made legal and people are free to smoke it, pain will either be decreased, or else people will be distracted enough from pain, among other things like social oppression, that they won't commit as much suicide for all the reasons they currently do, un-assisted.
  14. Maybe the issue of assisted suicide for chronic pain will go away, because a legal tool (marijuana) that allows people to space out and assists them to invent then have a life in spite of pain, will cancel out their wish to cease living before they are done, physically. Then assisted suicide can be in place, less tendentiously, for actual already-recognized diseases that people want to die to get away from. 
  15. Maybe everyone will go even more nuts than we already are. But perhaps we'll be less stressed out about all of it. 
  16. It has never ever been easy to be a self-aware human primate and juggle all this hierarchical social structure and find a way to live with it all. It never will be. 
  17. Meanwhile, global warming. Trudeau is working on that too, or at least, promised he would. 

Here is what I think might help them all get back up on track: Trudeau (and his wife along to chaperone), arrange to visit her office to (hopefully) meet with her, or if she won't meet with them, drop off flowers and a beautiful handwritten note apologizing yet again, asking her forgiveness, etc., for the final time.
Then get back to business.

ADDED MAY 21: 'Elbowgate' has made mountains out of molehills.
I agree: "Jack Layton would not be pleased."

Wednesday, May 18, 2016

Dangling no more

Done with dangling

At last. 
Way behind the imaginary schedule I had in mind but failed to live up to. A year behind, actually. 
I finished the book slash treatment manual slash deconstruction of tissue-based operative treatment models and have sent. It. In.

Not that there won't be dozens of little mistakes and tweaks needed and maybe even rewrites. But at last, I found the flow that was so elusive. And I managed to get everything in that I wanted to say.

That inability to follow the schedule I thought I should stick to is OK, because it had been arbitrary in the first place. I satisfied the main itch, which was more important: to say what I wanted to say and how I wanted to say it. 

Thursday, April 07, 2016

Evidence vs: plausibility in manual therapy

About "evidence-based" vs: "plausibility-based" - here's the thing. At least, here's the thing the way I see it.
You cannot prove any specificity with manual therapy. None that I know of, anyway. By that I mean, you cannot prove any cause-effect relationship. You can't prove that when you do x, y always happens. Sometimes y happens, and sometimes z happens. Sometimes nothing happens. The point is, you will never EVER 'know' what's going to happen. It's a crap shoot. N will always equal 1.
Take stroke following neck manipulation. That's pretty specific, right? Seems to happen a lot, right? An ER nurse I talked to once said that in her ER alone, she saw at least three per year, strokes following neck manipulation, by chiro. But let's not stroke out the chiros by talking about stroke *from* chiro, even though nearly 100% of the reports of death and maiming are about chiro neck manip. In fact that's the only time chiros seem to want to dissociate themselves from manip, instead of conflating themselves with it .. but I digress.
A manipulation event occurs, followed shortly thereafter by stroke. You would think it would only take one or two of these before the law would catch on and declare neck manipulation a kind of assault and battery. Especially since it leaves the patient mad and angry and feeling betrayed, and often litigious.
But no, neck manipulation is still allowed, probably because it cannot be "proven" to be causal! (see Roger Kerry's paper, Cervical spine pre-treatment screening for arterial dysfunction: out with the old, in with the new -  which lists a bunch of red flags for neck manipulation. Also see Harriet Hall's latest on the topic of no evidence, Chiropractic and Stroke: No Evidence for Causation But Still Reason for Concern.

We get nowhere in manual therapy, trying to find "evidence."
In fact, the DNM group page on Facebook was started by the researcher I was working with, years ago. She left the group after the study went down in flames. I remember her explaining about P values, confidence intervals, trend lines... talk that still gives me a dull headache. See the link Keith Eric Grant provided re: P values and how slippery it all seems to be,  Scientific method: Statistical errors.

In the end we had to toss the study because the subjects had backfilled their data books - one thing statistical analysis was good for - picking up on patterns that looked too perfect!
I don't want to sound negative about science - I love science. In the broad sense, I mean. A wide-angle view on the world, reality-based. And who knows? Maybe some day somebody will figure out the right question to ask, and put the right frame around it, and be capable of demonstrating some sort of direct causal connection between human primate social grooming and pain relief.
But I will not hold my breath waiting for that to happen:
If you can't "prove" that manual therapy (the stupid kind) is specifically causal for maiming and killing by stroke, I will bet the farm that you will never be able to "prove" that your light, slow, kind, interactive, responsive and *intelligent* ways of working at the surface of the body are specifically causal for pain relief.
It will always boil down to "non-specific effects." I.e., the patient's brain hacked its own self (in some smart, specifically unrepeatable, non-lethal way!) and changed its opinion about the state of its body, because, context.
So, that is why I prefer to think of a dermoneuromodulating approach as being plausibility-based instead of evidence-based.
We are already where we want to be, which is as far as we can get anyway, if we go with plausibility instead.
So, when you treat around the head and neck, please don't press hard on ANYthing there. And no jerking, K?
Set a favourable context, embrace uncertainty, let your fingers and hands be receptive, not blunt weapons, do no harm, and hope for the best.

Michael Leunig's brilliant cartoon.
It sums up the reality of the non-clarity of manual therapy.