Thursday, April 26, 2018

Ann massaged me

Yesterday I arrived in Taiwan for the first time. First time ever in Asia, in fact.

I found my way through all the corridors and immigration lines to the exit, where I saw a long line of signs with names on them, arriving people being met by locals.
Two smiling young women held a large blue sign with my name on it.
We greeted each other, posed for smiling pictures under a large sign that said Welcome to Taiwan.
Someone's phone rang before we got a taxi - it was another host who informed me she would be waiting for me at the hotel and that they had booked me for a massage at a nearby spa. 

By now I had been up longer than 24 hours without being horizontal, one of the least good things about traveling. I also felt like I needed a shower. Taipei is hot. They reassured me that it didn't matter, I could go get the massage without needing to take a shower first.

We got to the hotel. My hosts, by now numbering 4 young women, escorted me up to my room, made sure I was connected to the internet, made sure everything was OK.
I'm not used to having so many people taking care of things for me. Very luxurious.
The room itself is very luxurious, a giant kingsize bed, a large bathroom with heated toilet seat, a washlet that can spray at least four different ways, a large walk-in shower and and deep soaker tub, both, gold faucets...

Anyway, I had no time to enjoy any of that because there was a massage therapist waiting for me, and they seemed very determined that I go meet her and let her do her thing. My impression was that they could not imagine anyone who might not be attracted to the idea.
I had not received a massage since... about 1994 I think.
I've never been that crazy about massage, getting it from a stranger, even though I learned to do it in physio school, and remember that I liked it a lot at that time.

In any case, I complied, caved to peer pressure, and off we went.


We walked halfway around the block to the spa.
I was given slippers to put on. Shoes and socks sat in neat rows in the front lobby. The place was quiet, smelled good, was full of quiet smiling people serving ginger tea.
My massage therapist, Ann, ushered me into a room at the back; a raised bleacher-style bench was punctuated at intervals by large round crocks. She asked me to sit in front of one of them. She sat at a low stool on the other side. Slippers came off. Feet went into the crock. It was filled with lovely hot water. She proceeded to massage my feet and lower legs up to the knees with some oil and some gritty stuff that felt good. She even filed away at my calloused heels. I was glad I had been doing that for myself, so that someone else handling my 67 year old feet would not find them as cracked and rough and thickened as I had, a couple years ago... Amazing how time takes a toll on foot epidermis. I use foot cream on a regular basis, which helps a lot.

As she worked on my feet I noticed that the floor behind her had a long strip of large glass panels, under which swam live goldfish.

When the foot treatment was finished, slippers went back on and she escorted me to the toilet, indicated that I should use it. So I did.
When I emerged she took me to the massage room, a lovely room with a sliding door. We went in. She opened up a small package, and pulled out the smallest pair of panties I've ever seen in my life, a g-string really, made of the same stretchy material as panty hose are made of. There did not seem to be any point in putting them on, but she wanted me to, so I did, to help her maintain her own professional boundaries. She gave me lots of time to get my clothes off and get comfortable face down under the blanket with my face in the hole. Lovely quiet spa music was playing.

She came in and went to work. My awareness became completely kinesthetic. First, she made complete contact with my entire back and back of hips and legs through the blanket. Just some lovely pressure. She would make contact slowly, then accelerate. Like she knew what my brain needed, how it liked being contacted or something.

She put hot wet towels onto my back. Something inside me melted when she did that. A bunch of spinal tension I had had when I first lay down, and when she had first pressed through the blanket, went poof and just.. disappeared.

She uncovered the entire lower left limb. First she massaged it in its straight position, then she bent it up like a frog's leg and worked on it some more. She did not leave out the foot, even though she had already worked on it in the room with the fish and the big crock pot.
Then she did the right leg.
Then each arm.
Then the neck and back.
The table was very wide. Clearly, she was up on it, and working very symmetrically with both hands. Yet I never felt her touch me with any part of her body except her hands.
I thought to myself that she must be very strong and agile, and that this was hard work. That she must be pretty tired by the end of a day.
Then she said, lie here for a moment, and left the room. After awhile she came back in, and covered my back with hot wet towels. She used some sort of hot sandbags on it also.
When she was done she asked me to roll over onto my back. Which I did. As she held the blanket up in front of herself like a curtain, to preserve my modesty.
The blanket came down over me.
She moved behind me and worked on my neck some more. She rolled my head to one side, massaged my head and ear. Then the other way. I was pretty limp by then. I can't even remember the last time someone was able to turn me into a cooked noodle like that.
She asked me to sit up, worked on my shoulders some more, then let me know we were done.
I turned to look at her, and saw she was wearing a face mask!

This is something I have seen a lot of people wearing here.
The woman who processed me at immigration was wearing one.
I don't think they are sick. I think they are protecting themselves from inhaling other people's germs probably. 

The entire massage encounter had lasted about two and a half hours. But it all had gone by in a flash. So nice to feel a different sense of time, to experience each moment as a Now, not be sucked into either the past or the future.
I got dressed and exited the room. She was there to guide me up the hall. She gave me her arm, in case I stumbled. The hall was basically a set of railway ties, painted black and heavily varnished and impeccably clean, quite close together with white rocks in between. But you do have to walk on the ties, not the rocks. I guess that was a way to make people's brain come back into focus - give them a small predictive motor task.
I was taken back to the tea room. It had floor seating all round the wall, flat foam cushions with wall cushions for leaning back. I was given a plate with ginger tea and some sesame cookies. When I was done with the tea, I went back to the front lobby and put my shoes and socks back on. 

My hosts had vanished, and it was now about 6 pm. I didn't wait long though - they arrived en masse to walk me back to the hotel - Joanna, Rainbow, Livia and Tina. 

After a quick shower I joined them downstairs - another host had joined us - Poppy. We went out for a lovely dinner at a restaurant just across the street, and I had the opportunity to remember how to use chopsticks. 

Tuesday, April 24, 2018

Yeah... about burnout. Been there, done that.

Rajam, my San Diego friend and CEO of the San Diego Pain Summit, posted a thread to Facebook and linked a blog post by a recent physio grad who was fed up and had decided to quit physio. She is planning to include a workshop in the coming 2019 SDPS that will explore this topic.

It reminded me of my own episodes of burnout, how they felt, how I navigated them. I posted the following:

"I graduated very young (age 20) and flamed out completely several times right away (mostly because of being so immature). Most of the time I left PT behind completely and did something else for awhile, always knowing: 
1. That I could go back to it if I wanted; 
2. That I really didn't want to right then. 
I would throw myself 100% into something else. Nothing else I did ever worked out, not the way I wanted it to anyway. And always (bizarrely!), I would start to miss physio after a year, or two, and I would go find a job somewhere and start over. I started over So Many Times. Mostly because while I liked the work I hated the jobs and the work environment (hospital). 
Things I escaped to:
1. University (several times)
2. Tried to be a real estate agent for awhile. Which was way worse. 
Things I assiduously avoided:
1. Marriage
2. Children 
After about 13 years of going back then quitting again then going back, I left the province I had grown up and worked in (Sask) for an entirely new life (B.C.). I managed to adapt and reconciled burnout as being not about the physio but about the physio JOBS, and did a lot of locum work to get by. Locum work suited me perfectly. I had no responsibility, didn't have to "fit in" anywhere, didn't feel obliged to participate in longterm work relationships, just parachuted in, handled patients for somebody, then left a few weeks later when they came back. And I did some travelling, learned Spanish (sort of). 
I bumbled along through life for a couple decades that way, until I finally felt ready to have my own practice. After that I settled down quite easily, and it was about 15 years later I got itchy feet again, moved back to Sask. almost a decade ago. Took a two-year sabbatical. Opened a new practice. Have bumped that one around three times before finding it a forever home.
It's been a crazy pothole filled road full of sharp bends and several times in the ditch, but no serious accidents. I managed to do it my way, which happened to not have been the usual way, that's all. Me and physio, we've been married for 47 years but not monogamous (at least I wasn't), and eventually I think we simply got used to each other. It has always taken me back, so that's something good right there. I've seen other careers not last nearly that long. 
And I've moved personal (home) location about 30 times in that 47 years. I can't even begin to remember how many different places I've worked. Lots and lots, enough to see the grim underbelly of both private and public practice. I only really "loved" physio after I got my own practice together, which looks way more like a massage practice, really. But I like it. Nowadays I call it my retirement practice. About a half-hour away, there is an old osteopath, in her 90's, who still works, still sees patients out of a trailer. I often think to myself, that will probably be me, working with people in pain until I drop dead, because why not? Life blows by and then you die. So why not do whatever you most desire at the time, whatever turns your crank for awhile, all the way through it?"

Looking back, I realize that burnout is mostly just a brain's way of signaling that it needs novel stimuli, a change, a rest, a chance to spread different wings, try new tricks, to take a break. By caving into my own brain every time I got that signal, I hope I managed to preserve most of it for my old age. Or maybe I simply had social attention deficit disorder. Not biological, because I can focus like a fiend on anything if, and as long as, I want to.
Wanting to. That's where the rub lies.
Other people's expectations may not be, may never have been, congruent with my own.

Life is not for sissies. I have come to appreciate (especially after reading Damasio's book!) that most of my own personal conscious awareness became locked up in navigating boundaries between 'self as authentic individual' and 'self as member of the human primate troop', locked down into the delicate psychosocial navigation needed to live life (on the one hand) according to my own psychobiological drives and demands, and (on the other) the human intricacies needed to dance with the rest of the people I had to work with and deal with, neverendingly. Which is always hard, but especially for an introvert.

In the video called The Quest to Understand Consciousness, Damasio briefly described various sorts of self, and a quick superficial tour through the brain.

I built a few slides of screenshots I took. These slides will be in the presentation I am scheduled to make in Taiwan. Thanks, Damasio. I cannot wait to see you live in person, Feb 2019 at Rajam's conference.

1. All the major action in our nervous system has to funnel back and forth through the brain stem. When I refer to "nervous system" I include the peripheral nervous system; enteric, sensory, autonomic. So does Damasio. 

2. A close-up of the brainstem reveals that it has a dorsal part and a ventral part. The dorsal part (red) contains many closely and heavily interconnected nuclei that regulate survival and homeostasis, including the periaqueductal grey (PAG), which as we know, is crucial in pain regulation. 

Note that it is also connected to the cerebral cortex.
Ah-ha! Thoughts and perceptions can influence our physiology. See?
AP = Area Postrema (controls vomiting)
NTS = Solitary nucleus (regulates gustatory things among many others)
PBN = parabrachial nuclei (more about food intake, also breathing and cardiovascular regulation)
SC = ? not sure. Maybe superior colliculus, to do with vision
hypothalamus = regulates everything to do with everything. 

3. If the dorsal part is damaged, say by stroke, you lose your mind. Your body will carry on for awhile all by itself, and later with a lot of help from caregivers, but you won't have awareness, be able to form thoughts, nothing. No volition. Total oblivion.
If the ventral part is damaged, say by stroke, you can get locked-in syndrome, where you have plenty of volition but no access to your body. None. Unable to moooooooove. Unable to communicate. (Seriously, can you imagine anything worse? Which is why I will go to my grave denouncing high neck manipulation. But that's for a different blogpost.)

The colliculi are for vision and hearing. The brain itself will take in visual and auditory stimuli and make sense out of them, concoct a story long before "we" (the "I"-illusions riding around in the same nervous system that is the boss of us, not the other way around) can possibly become aware of said story. 

4. Then I made a slide of the remainder of his talk, about all the different "selves" we have thanks to evolution. (This is what his entire new book is all about.)
Every animal (including smart invertebrates, probably) have proto and core selves. In fact, in the book he talks a lot about bacteria and how they get along with no nervous system at all. How they operate as individuals (un-divide-ables) and also when in a group.

Autobiographical selves are a lot fancier. I think he should have included elephants, but that's just my opinion. He jokingly included dogs, which I left out.
Their main claim to fame is they have access to past events, and future possibilities, the ability to imagine different scenarios, and the capacity to make meaning out of all of it.
At once.

The human species is off by itself in a text box, because of the way we have become so utterly dependent on culture to regulate us.

This is what I was referring to earlier, re: burnout. So much psycho-social hard drive seems to get burned through simply adapting to each other, other people and their ways, starting with family and the culture itself and its history, our society and what "it" (whatever it is) expects in terms of behavioural homogeneity from its citizens. We all have that hypothetical cross to bear.
For introverts the cross seems extra large and heavy.

Thursday, April 12, 2018

Damasio's "The Strange Order of Things"

I just finished my first read-through of this new book.

It's so good.

Rarely does a single book include the evolution of nervous systems all the way from single cell organisms forward to humans. But Damasio doesn't leave out a single thing. He includes all the functions of nervous systems as well as all their bits, in order of their appearance, and manages to line them up appropriately with different stages of nervous systems in evolutionary time. I appreciate this because it's what I try to do in my own lectures; I figure that if you can understand the nervous system as a movie through evolutionary time, you can understand its function better.

His organizing theme is that homeostasis is the driving force and anchor point for everything that living organisms, with or without nervous systems, can do.

It's such a great book that I want to go through it carefully, blogging all the way. I want to sift through each idea (and there are a LOT of them, including ideas about pain that are brand new to me), and ponder how they relate to our profession.

I guess we shall find out if I have the time and the energy both in sufficient quantity to fulfill such an ambition or if the ambition is just a fleeting dream. Right now I still have jet lag, and I can't make a firm committment in such a state.

While I consider the pros and cons, here is a recent (2017) video of Damasio speaking about the same subjects he discusses in his book.

Here is a recent review of his book. LINK 


Tuesday, April 10, 2018

Into everyone's life a bit of knee pain may fall

I have just returned from teaching a class in Barcelona.
Lovely city.
Glad I finally had an opportunity to see a bit of it, namely the Gaudi architecture.

In Europe, the bathroom stalls are like small rooms. They are floor to ceiling, with doors that close completely - no gaps.
They also often have a small step up.

So, the first day at the teaching venue I went to visit the ladies' room.
I blame jet lag. I blame the fact it was the first teaching event of the season and I was adrenalinized.
I blame myself for forgetting there was that small step.

On the way out of the stall my brain made a stupid motor prediction error.  The floor was about 3 or 4 inches lower than I expected. My brain did not account for the step. The floor wasn't where it was supposed to be. My foot hit the actual floor and jarred my whole body. 

From then on the knee was very crabby with me. 

It's getting better now, 5 days later, and it felt fine the day of the incident, but the next day, it refused to climb or descend stairs smoothly, and after I had sat awhile, getting up and asking it to move felt quite painful. Medial knee, saphenous nerve, of course... 
I taped it, which helped me feel it much less so I could focus on the people and not on myself.

In younger years there would not have been pain associated with a dumb move like that; I know because I've made dumb moves like that in the past, and they didn't used to bother me. I wonder if, when we get past 60, 65, if the immune system doesn't get grumpier and stronger? Quicker to throw mast cells at anything? For any excuse?

Or the whole spinal cord? Maybe as the brain starts to falter, the spinal cord seizes the opportunity to do what it tries so hard to do against all that built-in descending inhibition, which is to be an amplification system for nociceptive input. 

I have this fantasy that the spinal cord sits in there, resentful and fuming that the brain grew big out of one end of the brainstem while it, the spinal cord, stayed the same. 

That it struggles all its life to take precedence again, as it still does in fish, and be The Main Event, the star of the central nervous system.

I fantasize that it plots a takeover, or more accurately a takeback, gradually erodes the system, makes small gains, and eventually (in aging mammals, primates, humans) succeeds to a certain extent. That it does this by making nociception much bigger and more dramatic than need be and the spinal cord glia stronger/more facilitated, which go on to sensitize the sensory branches of a peripheral nerve, whichever one received the most mechanical force during some predictive coding mishap.
Positive feedback loop.
Spinal cords, doing their protective thing but at the same time hastening physical entropy! 

Maybe the reason for doing deliberate daily exercise/movement/strengthening is simply to activate all large fibre sensory input from muscle, in order to keep spinal cord function locked safely in its cage. (See Foster et al 2015, my favourite paper so far about stimulating glycinergic interneurons in the spinal cord that inhibit nociceptive input at the first synapse in the dorsal horn.)

This is me, age 67, pondering and probably trying to talk myself into exercising more regularly again.
I have always said aging is not for sissies.