Not for sissies

It struck me today that being a human awareness inside a humanantigravitysuit or any sort of awareness inside any biological kind of antigravity suit is not for sissies. Which is why, I suppose, that defensive mechanisms evolved in the first place.

The nervous system is not monolithic.
I say this every day to patients, as I try to help them understand what the inside of themselves, the inside of their own operating system, is like.
I tell them a story about how it's like a farmhouse that might have started out as a simple cottage in the days before electricity, but that over the decades new bits were added, a second story, a garage here, a new wing there. Before long the original cottage was completely buried by additions. Had it been an actual farmhouse, the sensible thing would be tear it down and start completely over with new wiring and plumbing. However, as a nervous system, it didn't turn out that way: nature never got rid of anything neurological, it just added more layers over top.
So, now we have the original, probably the enteric system, autonomic system, and a bit of somatomotor, covered over by faster, bigger, more complex inhibition systems.

Skin is weird, because it comes from ectoderm, as do all the nerves. Neural crest cells make up all the nerves that go to and from skin, as well as - get this - they make teeth. Teeth. I read earlier today that teeth evolved from skin. Or at least, from neural crest cells in skin. Or, at least, outside the mouth, which makes good sense, if the whole point of life and its evolution is to transform energy from one form/state to another to reduce energy gradients. I mean, to transform other organisms into sources of energy, it's necessary to rip them into tiny bits to be digested.. teeth come in handy, whether inside or outside the "mouth"..

Exaptation accounts for a lot of the preservation one sees in nervous system function.

Seth Grant in Australia has built an entire career on studying synaptic proteins, some of which have been conserved from original yeast-like single-cell ancestors.

Take-home point: Nature does not toss out anything that has proven useful, especially when it has to do with the operating system, i.e., the nervous system.

So, we ended up keeping everything that was there from the beginning, and added on. Now we have brains five times bigger than they need to be to run a creature/humanantigravitysuit our size. They suck away 20% of all our metabolic energy. Even though they comprise only 2% of our physicality. A measly 2%. Sucks up 20% of the energy. Think about it. It's no wonder we get distracted.

So, I was thinking, to actually turn it around enough to pay inward attention to our bodies, themselves, the physical creatures we inhabit, with attention and awareness, is so different from normal life, so ... non-social, kind of, so... outside a culture that pays the body almost no mind except to dress it up, or have it relate socially. To go in there just to find out how it's feeling, just out of interest, is not really supported by this culture. This generic North American culture. This culture is anything but introspective. Anything but intero-spective.

So, I'm thinking it takes courage.
It takes courage to go in and check interoceptive systems.
No wonder, then, that cultural systems that appear to have successfully navigated these strange waters are adopted holus-bolus, for the most part - things like yoga, meditation, acupuncture - with no translation. They are interoceptive practices, and mostly non-verbal therefore, anyway, except for the packaging, which is usually spiritual veneer of one sort or another.

What happens when a nervous system is probed, even by the awareness it gave rise to? Well, it might be important to remember that in any given individual parts of the nervous system may not get along with each other perfectly. If you are an "I" illusion inhabiting a particular brain, and you decide one day that you want to probe your own interoception, and your culture has never supported such a notion or behaviour, you find yourself swimming against a tide. You either graft a system onto yourself or you go it alone. You may find yourself outfitting yourself in yoga pants and learning a lot of polysyllabic words in a foreign language, or learning mantras and about mandalas, or learning strange non-existent non-anatomical body systems. To go it alone is preferable in my opinion, but may still require some outside support from a patient observer/coach from time to time. Most people won't bother doing any of this stuff until such time as they are unfortunate enough to sustain a pain episode, at which time it will suddenly be the only way out of the cage.

No matter what, anxiety will be a feature. If you are exploring by yourself, you will learn that deep breathing will take care of a lot of the anxiety, and will smooth out the process. You have to make yourself keep going back, though, until the behaviour becomes pleasurable enough to motivate you by itself. You could think of it as getting to know your inner zoo, all the creatures your antigravitysuit evolved through on its way to becoming human. You have to be careful not to spook any of them. Or yourself.
If you use one of the cultural adaptations, you have to adapt yourself to them. Which is fine, I suppose, until/unless cognitive dissonance interferes. Which it may well do, sooner or later, Which is why I personally choose/recommend the go-it-alone method.

If pain has driven you into the corner of your own existence and has forced you to become interoceptive just to get through the day, I feel for you - I really do. Deep breathing will still help, plus it will be of use to find yourself a caring human primate social groomer who vows not to create more suffering for you to have to endure, but will stand by you as you find your way out of the gloomy forest of being lost inside your own physicality with a suddenly heavy humanantigravitysuit that doesn't work right, and a nervous system that no longer feels like "you", but instead feels like a bunch of alien creatures biting at you.

IASP in Montreal - post event snippets

This is a series of little personal and professional snippets, vignettes, from the IASP Congress, held in Montreal Aug. 29-Sept 2 2010.

Lost luggage (again..)
I got back Friday afternoon (Sept 3), minus my luggage, lost somewhere in the bowels of Toronto airport by Air Canada in connector flight limbo, for the second time in 4 months. It has yet to arrive - the first time it was lost by Air Canada as I came home from Brazil, it arrived the next day. This time the wrong bag appeared at the bus station. Someone else must be in Air Canada luggage hell with me, our suitcases delivered to each other. This is getting very stressful. No more Air Canada for me I'm afraid. I'm already going through a mourning process more severe than should be necessary - especially once I realized I had packed my notebook FULL of scrawled notes taken at all the presentations. That really sux. The clothes? Meh. The shoes? Meh. Replaceable. But the two hard cover books, a dental pick, favorite scratchy Japanese bathing towel, MUCH harder to replace; the bamboo back scratcher that was my dad's before he died, and the note book (!) - irreplaceable!

The Melzack reception
It was the first time I'd ever been to an IASP Congress, ever. I knew they occurred but this time I wanted to go specifically to attend the reception for Ron Melzack. I not only was in the same room as he was, but I got to meet him, shake hands, and have a picture taken with him and the other members of the CPA Pain Science Division who attended. The photographer is a retired neuropathologist married to a Canadian pain physio we know, who said he'd email the photos but hasn't so far. When he does I'll post one. This event is the highlight of my life so far.

John Loeser presented a slideshow of Melzack's life and work, lots of photos of his childhood, family, vacations he was on, people he met and worked with, with lots of hair and without, all the way from age 10 to now. I was previously unaware Melzack had written books of stories of the indigenous peoples of the far north. He was there with his wife in her wheelchair, gracious and charming, shorter than I had expected. There were probably close to a hundred people gathered, beautiful food, plenty of wine, lots of huddle around the guest of honour.

I really wanted to say hello to him, saw that there was sort of de-reception line had formed as he tried to make his way out the door into a larger foyer for a planned photo with his "family" of grad students. I walked over and waited a turn. When he got to me it was clear on his face he had never met me before. He extended his hand anyway. I rapidly introduced myself and reassured him we had never met previously but that I was very pleased to meet him, that I was with the physiotherapy Pain Science Division, that I wanted to thank him for his life's work, that it was already having a large impact on my profession and that if I possibly could I would want all PTs in the world to become conscious neuromatricians. I asked him if he would be willing to have his photo taken with those of us from PSD who were there, and he graciously nodded. And then it happened, out in the lobby, after the more official photos were taken.

SomaSimple thread
A SomaSimple thread was started while IASP Congress was happening, to which we posted highlights (and some photos) when we had time.

More to come. Much more.

Accepted

I found out that I've been accepted into a pain management certification program at U. Alberta in Edmonton. This online post grad program would count a bit toward a masters degree at U. of S. (if I decided to pursue one).

Also, plans are afoot for an RCT for me to be involved in. It's still tentative, but if it becomes reality, I'll be making a lot of bus trips back and forth to Saskatoon, 4 hours each way. Fortunately, buses have wifi these days. :)

Still no big urge to "work" (as in, for money), but I've been dreaming about working lately, treating people, so maybe my brain is working up an appetite for doing that once again.

Meanwhile, I look forward to seeing Ron Melzack and meeting some people I know but only from online.

Anniversary reactions

So, I thought back to where my life was at a year ago, which in some ways feels like just yesterday; I reminded myself that only a year ago I was dismantling a lifetime, not just a practice from which I have been detached - still responsible for but emotionally detached from - for about 9 months.

I was faced with jettisoning a lot of belongings, books, purging and cleaning and scraping and painting and scouring and selling and usually fell into bed at night exhausted.

I realize that some part of my brain still feels open raw places from having undergone that experience, even while other bits are ecstatic to be back under big bright empty sky. When another stressor comes along, I realize that the reverberation of a year ago is like an echo chamber. I realize that as a brain ripens and ages through a life span the echo chamber doesn't go away, in fact it just gets bigger and bigger as years and anniversary reactions accumulate. If would be lovely if there were a delete key on stress, something easy to simply click and make the anxious stuff disappear. That isn't the case. So I go for long walks instead. It helps.

As I walk I think about how I'm helping my brain produce the millions of different kinds of neurotransmitters it needs to remain healthy and help me, its "I" illusion, to remain calm and content. I think about how lucky I am that I'm on the eve of 60 years old and am in a body, with a brain, and feet, that don't hurt me, that let me walk pretty far (3 or 4 km) without getting the least bit tired or sore. Bored a little, maybe, sometimes, but not in any pain. I think about how nice my nerves feel, sliding around in my body, first one side, then the other, how my spinal cord is slightly rotating within its canal, how blood flow is being engaged to feed it generously through mechanical stimulation. Yeah, mechanical stimulation is a stressor, but it's the right kind of stressor, and I remember that all this slidey motion will spur it to stay juicy and healthy and functional.

As I relax into the rhythm of walking I try out different things to challenge my brain, just a little, try a bit more novelty, explore my body adapting to it. I see how tall I can be as I walk along. I feel the difference between using abs and not using abs while walking. I notice what happens to my breathing. I work with breathing. I place my feet on a narrower trail with out breaking stride. I play with stride length without breaking stride. I experiment with which edge of my feet I'm walking on. I run a little. I play. I stride. On the outside, I am just a woman walking, but on the inside, I'm engaged in a process of discovery and comparison and full body sensing.

I think about how lucky I am to not have to carry a little roof all the time, called an umbrella, shutting out the sky, bumping other umbrellas, being bumped by other umbrellas, or, the alternative, rain on the top of the head - ceaseless remorseless rain. Seventy-five different kinds and sizes of rain.

I note the lack of other people and feel grateful to be in a place where there are no drug dealers being obvious or their customers reeling around or shouting at each other or at nothing at all or thick knots of tourists standing and gawking everywhere or beggars asking me for money or trying to sell me something - people crowding me, people who represent huge obstacles, both physical and psychological, to navigate through and around. I am alone with my own thoughts, and all around is just empty space I can relax into, nobody nearby I have to worry may knock me down and steal my wallet, or knock me down because it's a gang initiation ritual, or knock me down because they are bigger and taller and didn't even know I was there.

I always see a little something I never noticed before, even on familiar routes. I am free to gaze around at sharp contrast of light bouncing off surfaces, at the brightness of snow (well, not lately - it has developed that cavitated, dulldarkgrey look as spring arrives..) at the brightness and blueness of the sky, and think, this is all very good for my brain. I tell myself, it will synchronize and neuroplasticize itself in a positive direction. I tell myself that its emotional buffers will continue to improve every day in direct proportion to increasing clarity of thought and access to cognition and sharpness of logic. I realize these are beliefs, but I also know they are beliefs based on science. Science is my comfort and strength. It always changes but its changes are always for the better, provide ever more solidity.

I go home, look at the pedometer and how many steps I took. I think, OK, I can do better than that. Tomorrow I'll go again. Life is a series of small steps, physical and metaphorical, that accumulate over time, will add up to something, positive or not. Every step should be consciously chosen or result from a habit consciously chosen and feel like the right step to have made, no matter how tiny it may have been. With each step I take, I'm putting distance between myself and what I've left behind; with each step I'm coming closer to whatever it is I want out of life, whoever it is that I am becoming.

Every walk I take is a victory, my pitting of my own life against everything that would do my life harm. I have synchronized myself with me, as best I can, and after, I feel ready to read a paper and make a few slides and write a few thoughts down on a file card. My new life.

I'll deal with that recent workquake in Vancouver as I can, when I can. It's not my life. Not really. Not anymore. I'm not there, not anymore. I'm Here. And this is Now. Things could be much worse.

The "verbiness" of terms for describing pain

From a discussion thread on Somasimple, the difference between kinds of pain:

"I tend to think in terms of "persisting" and "resolving". - Sebastian Asselbergs PT

"Aha. I'm starting to get it. Conceiving of pain as a condition like alcoholism where the diagnosis of it being a "problem" can only come from the person experiencing it makes sense.

This is helpful to me. Assisting a patient towards resolution will be more effective if I have an appreciation of how their pain may be working for them. Only when they admit that the pain's not working, and become willing to change whatever behaviors are contributing to its persistence can they start towards resolution. This sounds like the movement from a pre-contemplative to contemplative stage of behavioral change.

Cognitive behavioral therapy principles come in to play here because patients may think their pain is working, but they are often mistaken. They don't see the whole picture, or are not reasoning effectively...because of the pain. Obviously, pain clouds jugdment(sic) and reasoning abilities. It also robs one of options- and the ability to imagine other possibilities.

I like the "verbiness" of "persisting" and "resolving." Conceptually, this supports a more interactional as opposed to operational mode of providing therapy.

I don't want to be a hero for my patients." - John Ware PT

Perfect. Pain as verb, not noun. Pain as a natural process (i.e., something that moves along) for which adverbs might be helpful, not as some static something requiring scads of ever more clashing and diametrically opposed, mutually exclusive adjectives, like "normal" and "abnormal."

Thank you John.

Adverb:
1. a word that modifies something other than a noun
2. the word class that qualifies verbs or clauses

Adverbial: a word or group of words function as an adverb

"The pain is gone"

To me, an old-fashioned human primate social groomer who has always leaned harder toward the "therapist" side of treatment rather than the "physical", but who uses manual therapy as my main intervention, the advantage of deep science-based pain models like my favorite, the pain neuromatrix model, is that one can remain connected to one's patient (i.e., in good therapeutic contact) while explaining to them what their experience of pain, or in this case radical pain relief, might mean, regardless of how strange it may seem to me or may have seemed to them.

Here is a diagram, famous by now I'm sure, of Melzack's neuromatrix model. Click on it to make it bigger, so you can read the detail.

I often haul out this little diagram and sit down with a patient, because a lot of times, simple handling isn't quite enough - they need answers.

Case in point: last week I saw a young woman for the first time. She had been sent to me by her massage therapist (who I've known for years) who had worked with her for many months. Let's called the patient Rosie (not her real name).

Rosie had had a prior history of low back pain for ten years, for which she had gone to a chiropractor semi-regularly. She had worked as a fund raiser for some outfit, until about two years ago; while nursing a sprained ankle (and on crutches) she was in a car accident. Now she had back pain, sprained ankle, and neck and shoulder pain. She was unable to do her fundraising job anymore and had had to quit.

She had endured persistent neck and shoulder pain for two years in spite of seeing 36 of the finest manual therapists, both conventional and alternative, that Canada has to offer, in two different provinces, and having attended a modern pain clinic.

Then, to her surprise, during a meditation retreat in December last year, her pain vanished. All of it. Gone.

Emboldened, she began a vigorous yoga program, and inadvertently overstretched something. Bam. She had felt instant leg pain and a lot of weakness in the quads. This had persisted beyond the massage therapist's expertise, and was why she had been sent to see me.

I learned that after she had given up fundraising after the MVA, she had become involved in an experiential psych counselling training program, where they let her learn from a physical position of comfort, i.e., horizontal.

At visit #1 I had taken her history and provided some manual treatment, some very rudimentary pain education, and showed her a neural glide to do for the leg. She'd been happy for something to do - anything.

Yesterday at visit #2, I was ready with a neuromatrix diagram and was planning more in depth pain ed.

She arrived.
I asked how she was doing, and she said, "Fine, I'm all better."

(I was thinking,... huh? Did she go on another retreat?)

I asked how she had managed it this time, and she replied that the evening prior she had invited two shamans in to work on her, and they had, with burning herbs and drumming, and lots of touching. Before they left, they had pronounced her cured.

And sure enough, she felt that way. No pain.

She really did seem better, could walk better, move better, sit comfortably, breathe better.. Wow, I thought. "Good for you," I said.

"Well," she said, "I still feel some stuff..."
"..It looks like the stuff you might still feel doesn't bother you anymore - is that how it feels?" I asked.
"Yes," she replied, "I still feel some stuff but it doesn't bother me at all. I didn't need to come today, but it was too late to cancel my appointment."

We had an hour to spend, so I decided to stick with the plan; I asked her if she was interested in learning some things about pain. She said yes, so I invited her to go through the neuromatrix diagram with me. We sat down and I began explaining how the center circle with circular arrows represented the entire nervous system, how it was always processing even at night during sleep, how it was more of a verb, therefore, than it was a noun, how the diagram depicted the movement of this neuromatrix through time... how it had three main inputs on a spectrum that ranged from mental (cognitive evaluative) to physical (sensory-discriminative) to physiological (motivational-affective) and three main outputs, one of which just so happened to be pain, which could be influenced by any of the three inputs and which in turn influenced the three main inputs plus the other two outputs...

As we wandered through the diagram, I plugged in pieces of info she'd given me, she asked questions, we talked about treatment crucibles, safe containers and catalysts, symbolism and shamanism, meditation and movement forward. During her shamanic experience she had had a great deal of novel sensory-discriminative input, through all her senses, not just kinesthetically. I told her it sounded like it had been enough to get her neuromatrix off the square it had been stuck on. I pointed out, based on the prior meditation/pain relief experience, how much more her particular pain matrix seemed to respond to shift of cognitive input than it did to sensory-discriminative input. I mentioned that for most people, sensory-discriminative input of the physical kind was often sufficient, but that she'd burned through 37 manual practitioners of various kinds, including me, without much help, and she nodded..

She told me this was all making more sense to her now.. that she was someone who just didn't "get" things through only her body, the way most people can if some reasonable sensory-discriminative input of a novel sort is provided... Instead things had to make sense to her through her emotions/mind.

Apparently long ago some other PT had loaned her the book "Explain Pain", for a few months, and she had diligently made notes and some photocopies, but it had never quite sunk in or gelled. Now it was finally starting to make sense. She said, "I wish I could read that book again. It was really good, as I recall." I replied that she could buy her own copy if she wanted.

We discussed rehab, and I told her about some options, but that wherever she went, to stay in complete control, not let anyone rush her, and to use "graded exposure" and "pacing", concepts she already knew about.

I showed her two chapters from Pain: A Textbook for Therapists and she took copies. She said this would help her learn the neurobiology for when she herself would be a therapist, counselling pain patients. I mentioned she would be able to buy this book online as well - that buying these two books for herself would be much cheaper in the long run than seeing a bunch of expensive therapists for sensory-discriminative input that her particular brain seemed to not be wired to be able to easily accept. She agreed.

I worked with her leg for a little while, and unlike the first time, this time she remarked on feeling heat and movement in the thigh, and non-painful sensation connected to the leg in other parts of her body. I asked her if she could do an active straight leg raise after, and to her surprise, she could.

She left very pleased with all the progress she had made in one week, by her own efforts. I didn't need to see her again in my opinion; her downregulation was well and truly hooked back up. She's away to her next adventure, all in one piece again finally.

Way to go, Rosie. Way to go.

"Mindfulness Based Stress Reduction" - Jon Kabat-Zinn

I finally checked out Jon Kabat-Zinn more closely, after having heard about him and his work several years ago. He has written several books, some or all of which entered the world of persistent pain via pain clinics, probably because of the obvious overlap of stress reduction. I heard him interviewed on a radio program a few years back, and very much liked his blend of common sense coupled with description of the kinds of ordinary stressors meditation can help with. His book, Full Catastrophe Living (one of many) has been around since 1990, and I'm embarrassed to admit I've never read it.

Here are some links:

1. Mindfulness Meditation, 72-minute you-tube presentation to google employees (recommended)

2. "Coming to Our Senses" a short (9.15 minute) you-tube video

3. Coming to Our Senses, a 57 minute google video (long intro by someone at UCSD Medical Center)

4. A simple bio. Excerpt:

Dr. Kabat-Zinn received his Ph.D. in molecular biology from MIT in 1971 with the Nobel Laureate in Medicine, Salvador Luria. Dr. Kabat-Zinn’s research between 1979 and 2002 focused on mind/body interactions for healing, on various clinical applications of mindfulness meditation training for people with chronic pain and/or stress-related disorders, on the effects of mindfulness-based stress reduction (MBSR) on the brain and how it processes emotions, particularly under stress, and on the immune system; on the use and effects of MBSR with women with breast cancer and men with prostate cancer; on patients undergoing bone marrow transplant; with prison inmates and staff; in multicultural settings; and on stress in various corporate settings and work environments.

5. Wikipedia entry on JKZ.

6. An interview, "Mindful Medicine". Excerpt I:

Jon Kabat-Zinn was one of the earliest students of Zen Master Seung Sahn and was a founding member of Cambridge Zen Center. Over the years he has studied with a number of Buddhist teachers and incorporated their teachings, especially the practice of mindfulness, into his practice of medicine. His book Full Catastrophe Living (New York: Delacorte Press, 1990) was on the New York Times bestseller list.

Excerpt II:

"The two fundamental things that most people get out of the program, independent of symptom reduction, are these. First, the breath is an ally and can be used to calm down and see more clearly. The other, related discovery, is that you are not the content of your thoughts. You don't have to believe them or react to them. That's incredibly liberating."- JKZ

After seeing him, especially in the 72 minute video linked higher up, I might actually acquire and read that book. What he says is simple and it makes total sense.

Virtual Back Pain Study Idea

In the Neurotonics blog I wrote up a post about virtual body experiments, and while doing so had a thought on how one might develop a study about back pain using the strategy of virtual movement illusion.

In that the back, unlike other areas of the body,
a) can't be "seen" as easily in a mirror or any other way
b) does not occupy much "cortical real estate" kinesthetically

...it would definitely need kinesthetic input.

1. First the virtual body illusion would need to be firmly established. The researchers, Henrik Ehrsson in Sweden and Lenggenhager/Blanke in Switzerland have already figured out how to do that with their cameras and kinesthetic input (stroking the back with a pen, etc.). Apparently the brain finds this ridiculously easy to "believe".

2. It shouldn't require mirrors or camera projections of the "real" back, just a projected image as per Moseley with his paraplegics (see Matthias' blog post about that). Probably any "back" would do. Maybe fitted to the patient's size and shape and color of clothing. Just a film of a generic look-alike back might do, projected ahead of the patient's eyes.

3. Then the back in the movie (the "virtual" back that the patient's brain now feels it belongs to) would bend, lift its legs up alternately, rotate, extend, sidebend, whatever.. move easily.

4. The brain should be able to overcome its pain output to the physical back, because it can "see" the back it "thinks" it is embodied into (i.e., the back in the film), moving easily.

I think this might be a really really interesting study. Moseley, please consider doing something like this. Or Ehrsson. Or Lenggenhager/Blanke.