Thursday, August 09, 2018

About CKS (crabby knee syndrome)

I have a story about my right knee.

Picture the following scenario: I am a 67 year-old, overweight, under-fit female, in a foreign city (Barcelona), in the ladies room of a teaching venue. The 3 stalls are little rooms, with complete privacy, ordinary doors, not the kind we are used to here which are just partitions. I quite like this foreign version of toilet privacy, but it's a bit off topic so I'll head back to the point: when you gotta go you gotta go.
I use one of the little rooms, and completely forget that the little room is up a step that is about 4 inches high. I presume the plumbing had to be accommodated or something, but before I wander off topic yet again, let me just say I didn't notice myself stepping up to go into the stall (jet-lagged probably), and my brain did not account for the height-of-floor-difference coming back out again.

Long story short, I made a predictive motor error. Or at least my brain did. I thought the floor was all one height, and when it suddenly wasn't, I landed pretty hard when finally the floor came up to meet my descending foot. My foot that descended surprisingly farther than anticipated. With all my considerable overweight jolting down an extra 4 inches to stop more abruptly with a lot more gravitational force than I had expected. Four inches in which apparently a lot of acceleration can occur, within mere nanoseconds.

I didn't fall over or anything.. I carried on.
The knee felt weird though. Not right. Like it wasn't quite me. Stiff and unnatural. Like there wasn't any room for "me" in it. Like a mechanical thing more than an alive thing. The interoception felt cloudy, and the proprioception seemed to be missing. My brain didn't trust it anymore.  It didn't really hurt at first, but I could feel machinery running in the background of my awareness as though my brain was trying to figure out where it had gone wrong. And the knee acted slow and stiff. But I hobbled around for the next 5 days, teaching, sightseeing on foot (slowly). The best thing to do with stuff like this is ignore symptoms and keep moving, right? Treat whatever it is as though it were normal, make normal demands on it, don't baby it, just keep going. And that is exactly what I did.

Pain set in during the long flight home, but I just kept going. I had to go to Taiwan, then Winnipeg. Then Minnesota, just last week. Four months have elapsed since the bathroom floor predictive error encounter.
It has been variable, with entire days pretty much nociception free, but it would wake me up at night, pain shooting through my knee. I would have to wake up fully to change position. I did not let this worry me. I would just go back to sleep, easily enough.
Some days it really hurt, so I would baby it with some stretchy tape and keep on going.
It was always worse after sitting for a long time.
Like on airplanes.
And a number of different people helped me by treating it, which always made it feel better, for a little while at least. 

It did not slow me down at all, really, except when descending stairs. Then I knew I still had a knee pain problem. I live on the fourth floor. Three flights of stairs. About 60 steps in total. Going up was easier than coming down. Yes, there is an elevator. Yes, I took it, but I tried to make myself do stairs as much as I usually do, which is about half the time going up, and all the time going down. So, I worked it under load.


The backstory: I had a terrible time getting paid for the work I did in Barcelona.
Finally, after a lot of back and forth and several attempts (according to the party that had hired me) to wire the payment through, I got paid through good old Paypal, at my suggestion.
I was in Minnesota when the money from Barcelona finally came through; I emptied the Paypal wallet into my account, mentally heaved a sigh of relief that that particular psychosocial worrisome bothersome irritation was over with, crossed off my list of things to be dealt with.


Here's the weird part, the gist of this whole story, the juice in the blogpost: Almost immediately with the experience of relief of this formerly noxious situation, I felt a reduction in pain, like someone flushed a toilet in there, and "me" gushing back into my own knee, able to "re-inhabit" it physically, much much better. Such a peculiar feeling.
Slept through the entire night that night, didn't wake up once.
The psychosocial aspect of pain perception.


I'm back home now, and 8 or 9 days later, I can feel my knee getting better with each day. (FINALLY!)(After 4 months!)
I can do stairs normally now, descending straight down without needing to have a hand on the handrail. I even noticed, today, I led with my left leg! Unconsciously! I could not do that for the entire 4 months the right knee was being a pain. There are still little twinges in it, but I can fully flex it now, just as far as the other knee, and the twinges feel a lot more superficial, medial knee, saphenous nerve, not throughout the entire joint as though it were made entirely of wood and discomfort. Now it's time to work on squatting.

So much more space inside it for "me."
I love endogenous opioids, so much. Especially when they hit at the precise representations in the various somatosensory cortices where they've been dried up for however long an accompanying situation has been grinding along, unresolved. Another neurotag bites the dust! 

Monday, August 06, 2018

DNM 2.0

Totally exhausted, but in a good way, after being in Minneapolis for a week attending a 6-day long seminar that Jason conceptualized and organized, such that all the people out there in the world who are explaining their manual approaches using the stretchy framework of dermoneuromodulating could have a chance to build a new community.

DNM has stretched from standing for dermo, neuro, modulating, to also include everything from "deconstructing/demolishing nonsensical methodologies," to "deep 'n meaningful."

Too many highlights to list everything from every topic or every person, but overall:

1.  I appreciated the inclusion and emphasis on cognition and psychosocial aspects, like Robert Rex's inclusion of narrative medicine, and Erik Ouellet's emphasis on cognitive biases and perceptual fantasies/illusions.

2. I absolutely loved the examination and treatment directed toward cranial nerves, by Julie Porter and Jeff Rockwell. This was a bio part I've been missing all my life, and I think, a missing part for most of us probably. We have plans to bring together a new book, written by Julie and Jeff, with some art provided by me. It will be a separate book for now. (Maybe later, as in someday in the far distant future, a new inclusive edition of the original DNM book will emerge in which EVERY nerve will be included, and the head and body will finally be reunited in manual therapy examination and deployment. But that will have to be a long way away. Meanwhile Julie and Jeff deserve the first round of royalties from all their hard work placing all these cranial and superficial nerves into DNM context, so a separate book will come first.)

3. Brian Rutledge, a Feldenkrais practitioner, spoke for about 10 minutes in a very metacognitive fashion about how he sees cognitive/bio integration.

4. Jason Erikson always thinks in a way that is social first, psycho next, and bio eventually. He spoke about how to integrate change in culture as manual therapists, the manual therapy culture that currently exists, promoted the idea of joining organizations that improve social acceptability of our work, make it more visible. Some of the participants were moved to speak about social inclusion/exclusion, their experiences of having personally felt the impact of discrimination, how they deal or have dealt with it. The feelings were big and traveled through the room, as they usually do when the topic is about the experience of personal injury or harm. I had several thoughts initiated by this, outlined further along in this blogpost.

5. One event stands out in particular: One of the participants had a longstanding inability to flex forward to touch her toes. In fact she couldn't reach much past her knees. Julie asked her to hum while flexing, and she did. Suddenly, while humming, she reached way past her knees all the way to the floor.
It was stunning.
Julie did a little victory dance, and the participant was astonished. Having successfully reached the floor while humming, she did it several more times to make sure it wasn't a one-off, that she would be able to repeat it from then on.
It was the most fabulous example of a distraction technique I have ever seen.
The participant "believed" she could not forward flex her trunk in a standing position. Her brain was kept busy by humming (novel input and output) while bending. Her predictive motor control was interfered with. Her belief that she couldn't flex her back was disconfirmed. Her next job was to integrate all the new information and realize she had successfully crossed a chasm of sorts, a chasm that had existed only inside her own competing neurotags.

6. Such wonderful partying. This is what my own social life consists of, mostly, as I am generally a hermit where I currently live, and because I'm a big-time introvert it suits me just fine these days. But I do love me a good round of being with other people, in a suitable context, where there is deeper meaning and purpose, enjoying rounds. :)

7. It really did feel as though Jason created a context within which DNM is about to go to the next level. I couldn't be more content about that.


I love that DNM is a stretchy enough conceptual container that just about every form of manual therapy (but only the interactive kinds, not the coercive kinds) can find a home in it. It is essentially about:
1. embracing human primate social grooming at its most fundamental, i.e., be kind, purposeful, slow, responsive, intelligent, with physical touch;
2. incorporating widespread biopsychosocial principles which boil down to listening first and talking after (minimally, without nocebo);
3. deliberately dis-including all conceptualizing about any tissue but skin and or nerve;
4. promoting nervous system awareness and handling.

I sit back and think, wow, here we are/here manual therapy is, at the bottom of society's ladder, really, without a lot of respect or acknowledgement for our efforts, which in the end doesn't really matter anyway, because human primate social grooming doesn't require much more nod to society other than a basic license to touch people and it sort of returns the favour. Yet, YET, here we are in all our multiple professional designations, called to them for whatever reason, trying to figure ourselves out and fit in somehow, the non-pharmaceutical, non-surgical alternatives to helping people with pain problems. We are in a similar clinical boat as the psychologists that way, except that we also have the advantage of being licensed to touch people.

All people.
Every person who asks.
This is a huge advantage.

We get to cherry-pick and be as evidence-informed as we could possibly want to be because we know how to read, think, and use scihub to look up all the latest information and scientific literature. We get to freely make up new conjecture, simultaneously weeding out anything ridiculous because now we know we can't just make shit up - we have to be from the start at least scientifically plausible and, if not completely bias-free, at least bias-reduced, because we know about fallacies and all the cognitive biases that exist and can appreciate how science itself is in a similar boat, and that science exists to prune back airy assumptions. We can trust it, and trust ourselves to be better off than we were before we were science-literate. We can deploy science-based consideration of every idea that pops into our head, and weed out all the mutually exclusive ones. We can be Occam's Razor all we want. We can place our work on a platform that is more solid, therefore.
We still get to be as jazzy as we like - but we aren't on crumbling ground conceptually or perceptually anymore.
And pain science and neuroscience are proving to be our best way forward into the future.

Just think: this might be the freest least-confining and simultaneously most challenging field of endeavor any human could possibly choose: we each have a human brain to use - the human brain, thought of as the most complex object in the known universe.
And what do we do with ourselves? We access and work with human brains all day long.
Is that not awesome? The most complex objects in the known universe taking on the most complex objects in the known universe as our daily work.

And here we are, asking those people inside those brains to change their pain perceptions by providing them with a bit of novel stimulus, getting them to disconfirm their beliefs about their pain by a little or a lot.

Picking back up on the thread of the inclusivity of DNM, as I sat back and observed a bit of acknowledged social pain ricocheting round the room for a little while, I reflected on how much stretchier I have become in my own life - in the past I might have squirmed and judged. Some thoughts that might have arisen may have been along the lines of, wait a minute, I'm not here for this - what does this have with learning how to use my hands - this is taking up too much oxygen and is not the focus we should be having - that guy does not know how to keep the room contained, etc.
I might have become impatient and annoyed and blamey.
I watched myself watching and listening and was pleased to note I felt or thought none of those things whatsoever, and instead just waited for the tension to conclude on its own, which of course it did.
I had some political thoughts too.
As a Canadian watching people interacting so close to the bone in an American context close-up, I marveled at how in Canada this would probably never happen. I extrapolated on that thought, comparing the US to all the other more hidebound countries - basically, all the other countries - where tradition dictates everything and freedom to invent new ways to be human don't really exist, although we love to pretend we're just as hip as US people who are constantly inventing new language and new things like internet and new music.
It occurred to me that after the US dumped the monarchy it built a pressure cooker for its citizens, politically, and although it is probably hard to live in it, it has innovated very cool stuff. Furthermore, without all the huge effort people in the US make in terms of social interaction, there would be no social progress anywhere else in the world, or there might be but it would be a lot slower to evolve. For example, as a queer woman (and I have my own definition of that, but totally identify with queerness in general and consider myself part of the queer community) I wouldn't likely have enjoyed my life as much as I have, so far, or come to know myself as well as I've managed to, and in Canada I would never have had access to anything social outside my white-bread rural upbringing and the rather conservative social conditions that accompany it (of which I am acutely aware, having gone back to live in it again, at least for now, but could never succumb to ever again).
So, thank you US people for all the discomfort you endure, having the courage to be vulnerable, speak your truth even though it takes a lot of nerve to do so, living in your social pressure cooker of a country, raising the boiling point so the cognitive and social interaction food can cook faster and be more delicious for everyone including all those who see it then duplicate it (social progress for all formerly dis-included people or groups) in our own respective, probably slower-moving, slow-cooking countries. 
And I sincerely hope that you will manage to deal with the orange menace appropriately when your time comes to vote.