Sunday, February 28, 2016

Post summit ponderings

I just got home from the second San Diego Pain Summit, #sdpain 2016.
My brain is still reeling around from all the extroverting I did, and all the great info that poured into it from all sides, for three days straight. Wow. A lot of familiar faces from last year and a lot of brand new faces.

The take home highlights:

1. Sapolsky was polished, fast, funny and straight up fabulous. I knew he would be. I could hardly hang on to anything he was saying, I was such a fan girl, sitting right in the front row. 

Fangirl with grey hair front row => me
San Diego Pain Summit 2016
Every paragraph ended in a hyperbolic punchline, something that will be familiar to anyone who has ever watched any of his youtube videos. 
He said lots of pertinent things, mostly about stress. 
He said one thing about social grooming which was this: it does relieve stress in both groomee and groomer, but in primate troops, at least half the time, stress is relieved best not by grooming someone but but kicking or sinking canine teeth into someone further down the hierarchy, especially if you are male.
Oh well.
I expect human males attracted to grooming work are mostly nice guys who wouldn't go around kicking or biting others for stress relief. I do wonder about high velocity manipulation though, and "deep tissue" massage, and any kind of poke-you-puncture. All those seem a bit abusive to me. Maybe they are veiled aggression. 

2. Kevin Vowles had a great experiential exercise. He had us stand up and put a finger up in front of our faces. One's attention is immediately drawn to the finger. All else not focused on becomes blurry. Then walk around with all the attention and focus on the finger and notice how hard it was to not bump into others all milling around likewise focused on their fingers. Then try again - this time de-focus from the finger and focus on the surroundings of the finger. Ah, much easier to navigate.
The finger = the pain, and everything else = your life.
The difference between acceptance and commitment therapy and cognitive behavioural therapy, according to him, is that CBT starts with cognitions - change those and behaviour will change, whereas with ACT, focus on what holds value, let value motivate new behaviour.
Quality of life can go up independent of pain. Activity and satisfaction can go up without there being any change in pain.
And I love that he used finger traps as a metaphor for wiggling oneself out of a stuck situation!

3. Bronnie wants us to be like water: flow all around our patients and support them without any sharp edges. She quoted Bruce Lee many times. 

4. Ravensara Travillian spoke about the need to anchor the massage therapy profession in reality. I don't have a photo of the slide that very much appealed to me, but I'll describe it: a triangle. Bottom left corner, labelled "referent" - i.e., a corner of reality that has been objectively, scientifically described. Next corner, concept. Last corner, symbol.
She explained that a lot of the ideas in massage therapy are symbolic and conceptual, and totally missing is the referent, the anchor. Which leads to a lot of misunderstanding and misleading ideas about "energy" and "quantum" etc. She says that pain science might be a great anchor point. I do too, because a) it's science, and b) we treat people who have pain, most of the time.
Her talk applies to every allied medical profession you could name (yes PT, I'm looking at you..). And the medical profession itself sometimes. Especially the orthopaedic branch of it, which refers patients to surgery for a lot of pain situations that would likely respond to things much less invasive. See "
Back pain? Try some placebo surgery".

5. ALL the speakers were great. Seriously great. I mean, Benedetti for petesake!! Yes, he followed on the heels of Sapolsky, who admittedly is a tough act to follow, but he's only the world's foremost researcher in placebo and nocebo effect! Nice coup, Rajam Roose. Nice coup. 

You can order and purchase videos of the entire event, of course (but for Sapolsky), 
but for a full three-D experience, do not make the mistake of not coming out next year. Nothing can replace being there, being part of a troop of human primates celebrating advances in pain science and figuring out, together, how to integrate them into our separate clinical lives. 

Spikey pain ball metaphor, credited to Tim Wideman

Not connected directly to the summit but something that appeared serendipitously today, on Facebook, was Dave Walton's series of videos about pain assessment. Dave Walton, some of you may recall, is a former chair of the Canadian Physiotherapy Pain Science Division.
Anyway, the current chair, Tim Wideman, has developed the coolest image for pain and pain assessment. The. Coolest. Ever!

The inner grey part is the aporia, the subjective place that only the patient can access, the actual experience of having the pain.

All around that, the blue part, is the part the patient can describe using metaphor.
The spikes on the ball are measurable through qualitative means. The tips are pain-related physiological changes, which can be measured more objectively.

I think this metaphor is mesmerizing, fantastic, hugely valuable.
I think Dave should be a speaker at the next summit.

There is a ton more, but for me, those were the highlights. I loved every second of the summit and all the speakers, the smaller events like the art show and podcast panel, the networking event, all the lunches and snacks and conversations. My brain is still full and I am tired, so I'll stop here. Maybe more will surface and I'll say more but for now, this feels like a good place to stop. :)

Postscript Feb 29/16:
1. Ravensara loaded her slides up onto Facebook! Here is the slide I was talking about earlier. 

This applies to so many situations. If we keep these three things clear when we discuss, it makes life so much easier. 

2. Todd Hargrove had us rolling around on the floor on and off for about 4 hours, as he explained Feldenkrais methods of being in a body better. I remembered something from a long time ago that I actually had considered using as a book title: To feel better in your body, learn to feel your body better. But I discarded the idea as it was way too long. However, I kept a version of it for exercise suggestions I uploaded for people to do at home.

Friday, February 12, 2016

What is PT, really?

What follows is a side conversation on a Facebook thread, about acupuncture.
Bronnie Thompson said,
My main worry about acupuncture is that even if it helped with pain unless the person can learn to do it themselves there is an ongoing need for seeing a clinician, taking time out for appointments and the person will not have a chance to think about no longer being a patient. The opportunity to learn to be confident to self manage pain gets lost when people receive ongoing treatments.
A few replies later, Bronnie added,

Thanks guys. I used to believe there was no good from hands on therapy, but revised my opinion after meeting you lot and the like minded people on here. Now I can see that hands on has a place but it's that old thing about deciding when to stop seeking a pain reduction approach. At some point life is limited more by the ongoing pursuit of treatment than learning how to live well despite the pain. There's no easy way to work it out but my research found that people need to know their pain will remain before they're ready to get on with life and I worry that people lose opportunities for quality of life and fulfilment because healthcare providers don't want to talk about the reality that pain is not always completely removed. Tough questions to ask!
I replied,

I think our hands on works well (confirmation bias) but is usually short-lived. Behaviour that contributes must be uncovered and challenged (gently) for long term comfort in one's own physicality.
>> I see you sit with your right leg crossed. Do you ever sit with your left leg crossed? [Hmmnn. I don't know. I've never thought about it.] Would you like to see how it feels to cross the other leg, just to find out? [OK.] (Patient crosses left leg.. funny look appears on her face) How does it feel to you? [Weird.] Go back and forth a few times. Check how it feels to you, on the inside, each time. (Patient goes back and forth, a couple times each side.) Is there one leg that when it's crossed makes you feel more "at home" in your body than the other? [Definitely the right leg feels "right" and the left leg feels weird.] Like you have to work a lot harder to relax? [Yeah, kind of.]Note: psychotherapists are the worst for this! smile emoticon

And so on. 
You can still use your well trained biomechanically nit-picky eyeballs. But you can convert them over from spotting "biomechanical defects" into spotting motor output stasis habits that put diagonal shears into the peripheral neurovascular tree (metacognition?). 
Habits. Default resting positions. They are detrimental. A small force over a lifetime can be just as annoying to a nervous system as a big force over a short period of time. 
You can help people become aware of their habits. Then you can invite them to change them. 
Homework is simple - ask them to consider watching themselves (metacognition?) and intervening every time, to practice the exact same behaviour on the other side of themselves (just a few minutes at a time) (graded exposure), until it feels just as easy and natural to them as the habit does. They can symmetricalize themselves with way fewer visits, way less expenditure, and stop or at least cut way back on irritating their own peripheral nervous systems. 
How long does it take to feel comfy doing an unfamiliar yet easy motor output task? Surprisingly, not very long, maybe 3 or 4 days, same length of time it takes for receptor turnover. Like any kind of learning slope, it should be as low-angle as possible.
I call that a kind of cognitive behavioural therapy. I don't know that it would count as such, academically, but it's the kind I've cobbled up over a lifespan.
She replied,
That is exactly CBT to me. And some people think PTs are working out of scope if they "do CBT"?!!
I replied,

Bronnie, those people must not have a very broad understanding of what PT is really about! To me, that is what it's supposed to be about - helping people learn how not to be patients, and avoid useless surgery by learning how to be in a body better. Of course it will involve teaching and learning. Doesn't everything involve teaching and learning? I was so ecstatic when pain science came along, because it helped me make sense of my entire profession. Not everyone in my profession agrees this is what it's about though! They think it's an industry in which they can pop stuff or poke holes in people and hand them "pain education" in a pamphlet! OK, rant over.

Tuesday, February 02, 2016

One of those patient encounters you never forget

The time: afternoon, typical work day, 1994. I had opened my first ever solo practice a few months earlier. It was autumn. My practice was still slow, still building. Even when it was busy, I had it organized so that I only ever saw one person at a time. This was completely against all ordinary practice in PT at the time, in that province.
The place: my work space, a quiet large airy office, upstairs in a busy funky artsy retail neighbourhood in Vancouver. It was a large room with a desk at one end and a screened off treatment bed closer to the windows, which faced west.
Dappled afternoon light beamed in.
For a change.
I mean, it was Vancouver. The only time the sun ever comes out there, usually, is just for a few hours before it slides into the ocean for the night.
The guy: He was a Middle Eastern refugee, sent by a doctor. I actually can remember his name, which is unusual for me and an indication of how our encounter left a groove deep in my brain, but to protect his identity I won't reveal it. He was in his thirties. I can't imagine what he'd been through in his life. We never got into it.
His situation: He could speak English very well. He had been in the country for only a few months. He told me he had arm pain, so bad he couldn't move it. He was visibly anxious and cradled his left arm carefully with his right. He said that a couple weeks earlier he was getting off a bus through the rear door. The bus driver had closed the door on his arm, and then started to drive off. He was dragged a few feet. Ever since then, he had not been able to move his arm, or sleep very well, because, pain. The doctor had told him nothing was broken inside his arm. The doctor had told him to come to see me. Earlier that year I had visited doctors and told them I was a manual physiotherapist who treated pain. The doctor who had sent him had taken a chance. A welcome chance, because I needed referrals.
The treatment: I did not have the faintest clue what to do. I told him I wouldn't hurt him, that I wanted to feel his arm. Assessing it was impossible, as he could not move it voluntarily. He was apprehensive, but agreed. I invited him to lie down on his back on the table. I carefully slid my hands under and around his arm. I don't even know what I thought I would accomplish. I guess I must have been thinking I would assess to see if he had passive range available. But before I could even start, the guy started sobbing. Out loud. Hard. Body shaking. Head lifting. Abs contracting. I froze, his arm still suspended by my hands, not even off the table yet. Everything in his body shook violently with his sobs, yet his arm stayed perfectly still, and I stood perfectly still, holding it gently, trying to figure out if I was hurting him somehow, and deciding no, I was not, best to wait until the storm cleared.
He went on with this for what seemed like an hour, but was probably just a couple minutes.
He stopped sobbing just as abruptly as he had begun. He looked surprised, and said, it feels better.
Really? I asked? Really, he said. He sat up, and, remarkably to me, moved his arm all around as though he had never had any pain at all. He smiled. Thank you, he said. For what? I wondered to myself, as I smiled back.
That was it.
Aftermath: I saw him about a year later as we crossed the same street in different directions. He recognized me, smiled and moved his arm all around at me. I smiled back.
It was the easiest treatment I ever gave but has been the absolute hardest to figure out. And it's been 22 years. Clearly all the drama, pain, angst and all its resolution was inside his own nervous system. My role was so vanishingly small it amounted to nothing.
Probably all we ever are is catalyst no matter how we like to imagine we possess technical prowess and skill. When kindling is ready to burn it practically self-ignites. When it's wet, it needs to be blown on for awhile. And lots of manual therapy is nothing but a lot of hot air.