Rest in peace, Ronald Melzack

Last night I heard about this. Details are scant so far but Ronald Melzack has died, just a few days ago. Lars Avemarie, a very prolific writer, archiver. and Scandinavian physiotherapist wrote a comprehensive tribute immediately after. Here is his wonderful factual blogpost. 
These are sad sad days.
I first encountered his thinking sometime around 2000, when I started reading Topical Issues in Pain by Louis Gifford, 5 books in the series. Melzack had written an introduction in one of them that quickly entranced me, so much so that I have been a firm fan ever since.

In the early 2000's I agitated a few other physios I knew to band together and get a pain science special interest group together within the profession. Eventually, we succeeded. In 2010 I traveled to Montreal to the IASP congress there, mostly to attend a reception in Melzack's honour, fangirl that I was and still am. It was and still is the highlight of my life to have been in a photo with him. 

In 2013 I went a bit nutty; in an uncharacteristically ambitious state fueled by passion for his thinking I wrote a very long blog series based on a paper he wrote with Joel Katz, titled simply "Pain." 

Here is a link to a blogpost that contains all the links to all the various parts of my dogged intense study of this paper, sentence by sentence, if anyone cares to wade through them. I went through every single reference in the reference list too.  It took a number of months and I faithfully blogged almost every single day. It was quite the journey. (Alas, several of the images I posted were clawed back by google bots, but many remain.) 

Now that he is gone the world of pain science has a great big hole in it. I shall miss him as long as I remain alive.

Edit Jan 7, 2020:
Tributes pour in. 

End of the year stuff

I have neglected this blog for a long time. 
It's the end of the year already. 
End of the decade. The decade!
My birthday yet again, sigh.

Having a birthday at the end of the year sucks because it makes you think about how old you are squished in along with the end of the year, and this year the end of a decade. Often I think about it as if I were strapped spread-eagled on a wheel of fortune, the wheel takes a whole year to revolve, every December that brake hits me on the head and gives me another concussion. I don't think life feels like that to everybody (lucky everybody else!), but it does to me. 

I've been busy off-blog, mostly watching John Vervaek's videos, discussing important matters with people on facebook (mostly important for the next five minutes at least), taking time off clinical work (like, the entire month of December plus an extra week before and after), getting ready for the coming year, which will be exhausting for the first 6 months but after that not quite as much. Then in 2021, I'll taper off, and in 2022, I'll take the whole year off. I'll be 71 that year. 

Will I return to working after 2022? Clinically? Traveling and teaching? Not sure. Maybe I won't need to financially but I might want to, or maybe I'll still want to be involved somehow but don't know yet what that will look like. Maybe I'll move out of this remote location to somewhere closer to the airport and set up a school people can get to easier, and where I can teach when I feel like it but won't have to travel. 
Maybe (also, or instead) I'll take up painting or something else visual and non-verbal to exercise rusty cognitive pathways. 

All I know about all this is that it feels really weird to me, to be getting "old."
Everyone else I graduated with retired ages ago, and two people from that class including my closest friend have died from cancer. Weirdly, on the inside, I still feel exactly the same as I did then, or even more like that, now that the pressure is much less intense than it was when I was a baby adult starting out with only hope and stress and foibles foisted in childhood and a license to touch people that I managed to acquire somehow, thanks to people around me who would lift me up whenever I would fall down. 

John Vervaeke's videos have fed my brain for months now, in spite of the fact that I didn't even realize it was hungry for this stuff:

1. Awakening from the meaning crisis
2. Buddhism and cognitive science
3. Cognitive science
4. John Vervaeke's talks with other people on youtube, long conversations where he puts into practice everything he actually stands for.

Suffice to say, the guy seems to be really onto something. And I trust him (no small thing, because my trust level for youtubers is pretty low, generally), where he's going, where he wants to go, and how he's getting there. 

Some DNM studies have appeared

1. Mathankumar, K (2019) Effectiveness of Dermoneuromodulation on Pain Reduction and Shoulder Internal Rotation Improvement in Post Operative Slap Tear among Athletes: An Experimental study. Masters thesis, RVS College of Physiotherapy, Coimbatore.
2. Nishar Basha, K A (2019) A Study on the Effectiveness of Dermoneuromodulation on Neck Pain and Disability among Patients with Cervical Spondylosis. Masters thesis, RVS College of Physiotherapy, Coimbatore.

These researchers are physio students in India. In 2018, Louise Tremblay went there to teach DNM.

Her efforts clearly have borne some fruit! It is exciting to see these masters-level studies starting to appear.

Treating cutaneous nerves and reducing muscle hypertonicity: What's the connection?

This question was posed to me in the DNM group on Facebook a few days ago. It's worth a blog post, I'm sure, because way too many practitioners out there in the big wide world still think they must have magic hands or something, and their instructors never explained to them that they don't.

Here was the question: 

I will reproduce my answer and alter it slightly so that it contains (I hope..) more clarity and expand it with links.

The whole physical basis of DNM is neurodynamics, as treatment described by Butler and Shacklock (although they only discussed long deep nerves), plus neurodynamics, as normal nerve movement as described by Lundborg in his nook, Nerve Injury and Repair, 1988. 

TWO DEFINITIONS FOR NEURODYNAMICS
It's important to realize there are two definitions for "neurodynamics":
1. the "normal" "physiological" movement of nerves through neural tunnels, with ordinary active movement as so well-described by Lundborg in his book, Nerve Injury and Repair, from 1988, with all its gorgeous, rich illustrations
2. the "applied" "treatment" kind, defined by Michael Shacklock in his pivotal 1995 paper, "Neurodynamics" (Type the word into the box and click on the teeny box beneath to read the full paper, or download here instead.)  


PERIPHERAL NERVES ARE NAMED IN FAVOUR OF THEIR MOTOR FUNCTION

(cont.)
... I like to think of nerves as information highways inside tubes throughout the body - 72 kilometers of them. The cutaneous nerves are fascicles branching away from the deeper named nerves, as are the motor branches, even though the motor branches are not usually given their own names the way cutaneous branches are. If you think of a highway in normal driving life, let's call it Highway 315, it would be like exit 42 goes to a muscle; the branch to the muscle contains motor neurons, but the name of that branch isn't separate from the name of the nerve itself (which is odd in my view, but oh well..). So we say, Highway 315 innervates the blahblah muscle, or even several muscles.

The nomenclature of peripheral nerves has always been biased in favour of the motor function of the nervous system. Even though ALL the main peripheral nerves are "mixed" (both sensory and motor), only cutaneous nerve branches are selected out for being "different" enough to get specific names. Motor branches of peripheral nerves do not.
From one perspective, this makes cutaneous nerves easier to learn from an anatomy text.
From another perspective, it can present a cognitive chasm - how does handling affect motor output? Pain output?
For manual therapists, it means that to understand how our handling affects nerves/nervous system we have to delve a lot deeper into the body of knowledge and are forced to be more rational. 

From this wonderful youtube video with Rafe Kelley and John Vervaeke, about minute 51

Back to the answer to the question:

But then we have exit 73. As soon as you take that exit, you find yourself on a "new" highway with a "new" name, maybe "Lake Road" or something. It's a different branch of the same big nerve, but it goes away from muscle instead of into it, doesn't contain any motor neurons, only autonomic motor neurons and sensory neurons, and it goes to skin. 

I want to rename this highway branch, "Vista View Road."
It doesn't go to a lake, it goes out to skin, and skin is open to the world.
To the environment.
These nerves pick up on everything out there.
Ambient temperature, breezes, contact with the planet through the soles of the feet.
Furthermore one can argue that special senses also have "skin" or at least, specialized membrane containing receptive neurons for picking up on light levels, different noises, different scents in the air depending on what season we are in, humidity levels, all sorts of inputs that are mainly subliminal and are handled efficiently by very old predictive processing systems in our central nervous system.
But I digress.
And I got carried away with the sensory function in cutaneous nerves. Lest we forget, they also contain numerous autonomic neurons, which are sympathetic, which are motor, and which regulate all the enormous vascular function of the skin organ, which contains 10 times more blood supply than needed for its own metabolic function, acting as a reservoir for emergencies and a thermodynamic regulatory organ for keeping body temperature within the narrow optimal homeostatic range necessary for life processes in mammals (of which we are a kind). I learned all this from reading Gray's Anatomy.
And I digressed again.
Back to the original answer: 

With me so far? 
Now, imagine that you can put your hand on "Lake Road", and physically move it, because it's embedded right into the underneath side of the skin! It's got its own fascicle inside the tubular Highway 315! When you move the skin, you move that fascicle (physically) all the way up Highway 315 (or at least a long way up it), and even, in fact (sensorially), all the way up to the brain. 

This is an important manual therapy concept to get: imagine pulling a string through a tube.
Imagine the tube (which is the peripheral nerve itself, containing lots of strings) goes all the way to the spinal cord.
Imagine the string you pull is easy enough to pull because it embeds right into the skin (organ), which you can "KNOW" (for a fact!) that you can get your hand directly on and move.
Plus, you are activating all kinds of computational low-threshold mechanoreceptors right at the skin organ surface. Of course the brain will know that someone is touching its organism, and how. 



ASCENDING PATHWAYS

This might be where Descartes got off track thinking there were specific "pain" neurons going to the brain. The thick heavily myelinated low-threshold A-beta mechanoreceptive neurons in skin certainly do - they go up the dorsal columns of the spinal cord to dorsal column nuclei in the medulla, synapse there, cross over, synapse again in the thalamus, and end up in the primary somatosensory cortex with high fidelity.
Nociceptive-capable, high-threshold neurons end in the dorsal horn of the spinal cord.
Well, unless they are A-delta nociceptive neurons, which are a bit thicker and faster with a bit more myelination, seem to have a lot more sensory-discriminative capacity, and are usually well and quickly inhibited.
See link.
And I digressed yet again.

(Furthermore, "Lake Road" has multiple turnoffs that go straight to the skin organ's surface, called rami, each inside its own little tube called a skin ligament!)

Yes. I took pictures of them.
With special permission.
Specifically, these are cutaneous rami of the lateral cutaneous nerve of the forearm (highlighted with a black felt marker).
I did this dissection in 2007 at UBC.
See Nash 2004 for a description of skin ligaments. 

ANASTOMOSING

Anatomically things are a lot more complex of course, fascicles anatomose and diverge right inside the nerve, and nerves themselves diverge and anastomose inside the plexuses from which they differentiate, etc.. PLUS all these fascicles have blood vessels going into them from accompanying arteries and out of them into accompanying veins and all this attached vasculature will ALSO be moved a little.

To see images of all this anastomosing business, plus neurodynamic elongation of nerve fascicles, go here. 

AND (we hope) moving said vasculature can mechanically affect, for the better (we hope!), said vascular function within the nerve (intraneural blood flow). Particularly if there is local pain, which MAY be a tunnel issue secondary to insufficient drainage/consequent intraneural engorgement/entrapment. 
But be all that as it may, Lundborg showed that fascicles can slide a bit to afford nerve elongation (sort of like a telescope can elongate by its inner parts sliding outward). 
And Butler and Shacklock (and whoever came along before they did) took these ideas and pain science at the time (late 80's, early 90's) and developed nerve sliding etc. as a treatment approach. Neither one of them worried much about cutaneous nerves, however, which is where I picked up the ideas and have included neurodynamics in treatment approaches to skin, i.e., moving of cutaneous nerves and their multiple rami, 1.) not just trying to have a sensory influence on the brain via skin receptors (although that is responsible for a lot of treatment effect), 2.) completely eliminating all irrelevant operative erroneous superfluous assumptions (still floating around like stinking bloated corpses in the river of ideas... 🙄👎 ) imagining we could possibly in a billion years affect mesodermally derived tissue (e.g., the myo, or the fascia..) directly

Then after some time had elapsed, I realized I still had not addressed the actual question:

TOP-DOWN, BOTTOM-UP

Gad, I wrote all that stuff but didn't get around to answering the question did I? >>> "I have not found a concrete explanation as to how affecting the cutaneous nerves reduces hypertension in a muscle. So, what is the mechanism?"The only mechanism that has a ton of research to back it up is "non-specific effects", more specifically, top-down "descending modulation" by the brain, of the spinal cord. The brain's usual order of business is to inhibit gross spinal cord reflexive behavior. It's like the spinal cord thinks its job is to make everything BIG and the brain's job is to say, now now, not so big, and not right now. Remember the spinal cord can elicit withdrawal reflex in response to nociceptive input BEFORE the brain even registers a problem (i.e., be VERY protective. Maybe even over-protective.) (Plus the spinal cord came along earlier than the rest of the CNS so it tries to play the seniority card I suspect.)
Anyway, 50 years after Melzack and Wall's paper on gate control theory, a paper came out in 2015 that afforded it some direct evidence. (Foster et al 2015, see link) so there is now a shred of support for a bit of bottom-up inhibition of nociception as well. 
Yay. 

The Foster et al. paper is here. 

SPINAL CORD WITHDRAWAL REFLEX

I added a bit later on in the thread that is my hunch (can't find any definitive reference for it yet) about why muscle hypertonicity occurs, even though it irritates the heck out of peripheral nerves that may be getting squeezed on in the process. 

From this thread

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I hope this rounds out the discussion a bit more.

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1. Shacklock, M. (1995). Neurodynamics. Physiotherapy, 81(1), 9–16. doi:10.1016/s0031-9406(05)67024-1
2. Neurodynamic Solutions 20th Anniversary Newsletter, "Nerve movement in 2015 - 20th Anniversary of neurodynamics in physical and manual therapy." Contains nerve movement video showing proof of concept and download link to full Neurodynamics paper cited above.
3. https://thebrain.mcgill.ca/flash/d/d_03/d_03_cl/d_03_cl_dou/d_03_cl_dou.html
4. Nash, L. G., Phillips, M. N., Nicholson, H., Barnett, R., & Zhang, M. (2004). Skin ligaments: Clinical Anatomy, 17(4), 287–293.doi:10.1002/ca.10203 
5. Foster, E., Wildner, H., Tudeau, L., Haueter, S., Ralvenius, W. T., Jegen, M., … Zeilhofer, H. U. (2015). Targeted Ablation, Silencing, and Activation Establish Glycinergic Dorsal Horn Neurons as Key Components of a Spinal Gate for Pain and Itch. Neuron, 85(6), 1289–1304.doi:10.1016/j.neuron.2015.02.028

Scroll of Truth

I don't know who made this cartoon but whoever it is, THANK YOU!

So true. So very true.
Haha at all the spinal HVLA manipulators out there. 

The majority of patients having manual therapy for back or neck pain report adverse events. 

Meanwhile, this might be what manual therapy is REALLY all about..
The interoceptive turn. "The science of how we sense ourselves from within, including our bodily states, is creating a radical picture of selfhood."

Is it ever.

This new paper, just out, proposes that the effects of massage on depression may be all about helping this inner sense of self to change. I would argue this is not limited to only massage but pertains to all slow, kind, interactive, intelligent manual therapy. 

Michael Eggart, Silvia Queri,  Bruno Müller-Oerlinghausen, 2019, Are the antidepressive effects of massage therapy mediated by restoration of impaired interoceptive functioning? A novel hypothetical mechanism. Medical Hypotheses Volume 128, July 2019, Pages 28-32

I wrote this a few days ago: Attention, people with pain: Check out PainChats, by Lissanthea Taylor
Furthermore, "People need to feel HEARD, not HURT" (Lissanthea Taylor).

And, What lurks at the bottom of the chasm?
And, finally,  Testa M and Rossettini G, 2016, Enhance placebo, avoid nocebo: How contextual factors affect physiotherapy outcomes. Manual Therapy 24 (2016) 65-74

What lurks at the bottom of the chasm?

When Dave Nicholl's published this particular blog post, I rejoiced.
Excerpt:

The model does not explain the real world. If it did, it would reside in the real world and one wouldn’t have to study to become a trained health professional to understand and apply it. Biomedicine then, at its worst, sits at odds with the people it is meant to serve; looking, again, rather like a spoilt (white, male), only child of very rich parents, in a room full of people whose lives are very different indeed.

But, then this piece caught my eye, and I rejoiced even more. Philosophical bias is unavoidable by science.
Excerpt: 

One school of thought viewed the new plant as a conventional hybrid and argued that, in most cases, one can deduce the safety of the new plant from knowledge of the safety of its parental GM plants. This means thinking about complexity as being various combinations of unchanging parts. The other school, however, argued that one cannot deduce the safety of the new plant from the safety of the parental GM plants. Here, complexity is thought of as an emergent matter where parts lose their properties and identity in the process of interaction.

Imagine: one idea of complexity is all about nouns (like plant parts) moving around as though they had autonomy or something, and another idea of complexity is that of emergence, that the plant parts are moved by their environment and relationships, interactively, and it's all contextual. 

Then I really rejoiced when I noticed this, today: The Burning Question. 

Trying to find anything specific in therapy of various kinds performed on alive awake cognizant individuals with pain reminds me of Tim Conway skits on the Carol Burnett show, ones in which he would play an old guy trying to open a door but banging it shut with his head, over and over.  


Why did I rejoice?
Because the mystery is becoming more clear. Not what can clear up the mystery.
So is the chasm.
And what is at the bottom of it. 

1.  https://criticalphysio.net/2019/06/05/critique-of-the-biomedical-model-2/
2. Philosophy of biology: Philosophical bias is the one bias that science cannot avoid.
3. https://www.facebook.com/photo.php?fbid=10161759445590183&set=gm.2231921840431689&type=3&theater

Teacher upgrade

When I got back from teaching DNM in Montreal I was exhausted as usual, but I feel like I can see a new vista in my internal landscape. I feel like I was enclosed in my own tunnel of ignorance about teaching for all this time, and didn't even realize I was in one, was dimly aware though how I was out there in the world teaching away with absolutely no teaching skills or tricks, just blurting out foundational stuff and showing a lot of powerpoint slides.
Yannick Wenger from France showed me a few new tricks - like how to draw more out of the minds of the people in the class by asking them what they remembered from the previous day, and making sure their purpose for being there was being fulfilled adequately. The French have been onto all this stuff ever since their revolution, it seems.
Thank you, Yannick.

Theory U
Social constructivism
Universal method of education (Jacotot)

What the class remembered. 

"People need to feel HEARD, not HURT" (Lissanthea Taylor)

Is it really April? Already? 

("Time keeps on slipping, slipping, slipping, into the future..")

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So far this year has been technically prolific.
Technology is all around, and people who know how to use it, and want to use it.


1. An interview Lissanthea Taylor did with me at the San Diego Pain Summit in February. She came up with the great tagline, "People need/want to feel HEARD, not HURT".  PainChats is her brainchild, her attempt to get accurate information about pain out into the world and into the lives of as much of the public as possible, to change attitudes toward pain and the culture itself. She is part of Pain Revolution, an annual outreach bike tour in Australia that brings updated pain information to rural communities.

Know Your Nervous System And How It Causes Pain

2. A trip to Australia, and two more workshops done. Antony Lo filmed the first one in Noosa. All his filming will make it to Embodia, an online education resource for physios, affiliated with CPA, and the brainchild of Maggie Bergeron. It will be whittled down (a lot!) and (we hope) produced into an educational video.
He also interviewed me for his podcast, for PhysioDetective.

Antony Lo and his PhysioDetectivePodcast interview, March 2019

3. Nick Efthimiou hosted my workshop in Melbourne, and wrote up an overview of the time we spent together for his blog at Integrated Osteopathy.

10 Things I Learnt From 10 Days With Diane Jacobs

Previous to the workshop, he arranged for Stephen King of 21st Century Physio Podcast to interview me - Episode 017 - Diane Jacobs Brings You Into the 21st Century.

Stephen King interviewing me at home, from Australia

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Now it's time to go to Paris and teach the workshop prepared and hosted by Louise Tremblay. It will be fun to hang out with Louise there - she is Francophone,  knows the city well.
The rest of 2019 workshops are all on this continent - relief from jet lag until 2020.

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