Understanding Pain and what to do about it in less than 5 minutes.

GREAT little video on YouTube - Understanding Pain and What to do about it in less than 5 minutes. on Facebook posted by Sandy Hilton, PT and Noigroup.

"We now know that pain is 100% produced by the brain!"

Unfortunately I can't embed it, can't find the code anywhere. So click on the link to see it on YouTube - well worth the minor effort. ---> LINK

Killing Pain Part II

Yesterday I wrote a florid limbic account of my episode of "frozen shoulder", experiencing the crippling, spreading sort of pain for the first time in my life, how I coped with it, and managed to get my brain back on track, so it could defend properly and not give me a lot of pain noise I didn't need, that no one needs. 

Today, I thought I'd deconstruct it all.
Here is what I've got so far:

This is a slide I made a few months ago for a presentation on the Neuromatrix model of pain. The overall gist of the presentation was rostral mechanisms and how they are involved in pain production and reduction. The subtopic for which this slide (and the next) was used, was Sensory-Discriminative; Descending Modulation.

Here we see flight/fight reponse, whereby an animal, or any vertebrate for that matter, including human, can defend itself to the death by deliberately ignoring cuts/bites/scrapes, with resolve fueled by noradrenaline. I really don't know that it's completely analgesic, but it likely allows the animal to ignore all the nociception with which it is being flooded in the moment. If it's being attacked (e.g., for food), it will try to escape. It still needs its wits to do that.

This descending modulation is activated by the hypothalamus based on input from more rostral centers which are reporting to the animal's brain about the direct context, what's going on in the environment in the moment - the dorsolateral portion of the periaqueductal grey is activated. 

Here, we see a different kind of response, passing out completely.
This is activated when all hope is lost. Much more conserving of the organism's energy.

The ventrolateral part of the PAG is activated instead. The animal "escapes" by going unconscious. I guess enough possums have lived on to reproduce by doing this, that they've evolved this tactic as their primary defense.


Here are the thoughts about the encounter with pain that I've entertained today.

1. I needed a fight/flight response to kick in ("Kill" or "be killed"). My dorsolateral prefrontal cortex knew that I wasn't in any actual danger. It had to access this system however, even in the absence of any real danger.

2. I was in complete control of the process. I had complete locus of control of the event. I directed my therapist and she adapted herself to me.

3. I had a lot of pain education - i.e., I knew pain wouldn't actually kill me, regardless of how threatening it felt.

4. It was, actually, a novel experience to have this magnitude of pain. I'd never experienced anything like it in severity and pain restriction, especially this awful spreading quality. I think the spreading quality concerned/scared me the most.

5. I managed to take fear and change it to fighting fury (elicited a noradrenergic response). I asked the therapist to treat what I figured was the core of the physical bit of the whole problem (exerted locus of control). The pain spread like wildfire - I could feel it but I did not let it deter me (noradrenergic resolve). Then, but only then, I let the part of the threat detector/pain production system that is part of the frontal lobes (anterior cingulate cortex) take over and "run away" immediately following (permitted ideomotor movement), but only after "I" (my dorsolateral prefrontal cortex) showed it who was really boss, by controlling the timing.

6. Although I didn't collapse in an unconscious heap, some part of my brain might have, because the opioids finally kicked in. Perhaps the dorsolateral prefrontal cortex got mean enough (in a controlled environment) that both the dorsolateral part of periaqueductal grey AND the ventrolateral part of PAG were activated simultaneously: the DLPAG fought and snarled and ran, the VLPAG felt sufficiently attacked that it "fainted" and let go of a big gob of all the necessary opioids such that I got the much needed relief I wanted.

7. It all felt very life-and-death dramatic, but I entered the encounter knowing that these centers were the ones that respond to actual life and death stuff, so I didn't mind the heavy emotional powering up that occurred.

8. I was determined to come out the other end feeling better - so the dopamine was clearly flowing from the expectation, probably was a factor, may have helped via various pathways.

9. The therapist was great. No nocebo from her at all - no cholecystokinin was triggered, which would have interfered big time.

10. I was free, and felt free, to manage my PAG and stimulate it from rostral centers using

• emotions (HATING pain, determination, focus, no-nonsense, I WON'T put up with this, I WILL construct a boundary between me and this Pain) as fuel
• information (I won't die if I try this, pain is just my brain being freaked out about something, it's not likely any big deal, it's only pain, I didn't injure anything lately) as message containers
• social context/therapeutic contact (I'm appalled by so much of what I see in the world, and my own body is where I should have the right to feel safe (dammit)/ my therapist is here to help me, I have locus of control) as delivery chutes

11. Even though I'd never done such a thing before, it worked. So I guess it can be done. Sample of one. Now that I've done it once, next time (should there be a next time - there may not ever have to be a next time) it should be easier. (Optimistic thought)

 I've also learned that help is there when I need it.

 Other posts on the topic:

Killing Pain

Killing Pain Part III

Killing Pain Part IV

Killing Pain Part V 

Killing Pain Part VI

Somasimple discussion thread about this post series.  

Scientific American: Anger Gives You a Creative Boost
This article is about interpersonal confrontation, however, I see no difference, from the perspective of the "I"-illusion, whether the perceived "foe" is external or internal. 

"Touch is good" - HumanPrimateSocialGrooming manual

In a recent SBM post, Mark Crislip discussed reflexology among other things.

He said,

“Monkeys, and other animals, groom each other often with a marked reduction in stress. Touch is good, and one doesn’t need to wrap it up in pseudoscientific nonsense for it to be beneficial.”

To which I replied, in the comment section,

"Thank you for saying that Mark; I’ve been saying the same thing for years. I call it “human primate social grooming.” Most human primate social grooming professions/professionals dislike the term, for some weird reason. Oh well.

Diane, human primate social groomer and manual therapist with a PT license to touch people."

Another commenter suggested that it was more succinct to use the term "pedicurist", which I took as an opportunity to explain the difference between operator model of human primate social grooming and interactor model of social grooming. So, I replied,

"Well, strictly speaking, any profession that is licensed to touch human beings for whatever reason including hair dressers, dentists, pedicurists and medicine, could all be considered human primate social groomers, I think.

It’s the “WHY-we-touch” that shakes the idea into layers, I think.

Those who touch to get a specific job done, like get a tooth out, get a toenail clipped or a callous scraped off, or hair cut, or appendix out etc., i.e., have an obvious, clear, objective purpose for both patient and practitioner to focus on; these practitioners have the option of being ’something more than just’ human primate social groomers. We could call these people “operator model” human primate social groomers.

Those who groom humans specifically to help them with nebulous perceptions and experiences of stress/pain, are (fundamentally) practitioners of what I would call the “interactor model” of human primate social grooming.

Could a desire to be more “operator” than “interactor”, to have some externalized reason for treating no matter how imaginary, i.e., a treatment “concept”, be a big reason *why* human primate social groomers (and now I’m talking about only the ones like me, interactor-model ones who touch to relieve stress and reduce pain perception/experience) made up (and still make up!) crazy ideas like acupuncture meridians? Trigger points? Subluxations? Untestable and unprovable? then go on to develop complicated ways of treating them?

I’m content just treating human primates with pain problems nowadays, supported by pain science and neuroscience, rather than trying to learn to treat crazy concepts some other groomer(s) invented once-upon-a-time for fun and profit. I guess this makes me a full-on, out-of-the-closet, interactor-model human primate social groomer on the lowest possible rung of the human practitioner hierarchy; oddly, though, I find it the most comfortable place to be, the most science-based, with the least distance to fall.

Diane, human primate social groomer and manual therapist with a PT license to touch people/many opinions on the matter"

I would add, any idea about anything anyone thinks they can affect below the surface of the skin must be put carefully through Occam's Mental Meat Grinder before being adopted as verifiable fact.

* The truth is, we can't literally touch anything but skin.
* The truth is, skin (cutis/subcutis, the actual organ of "skin") is thick. (It's also rubbery and full of physiology, busy-ology)
* The truth is, we can bend things around a bit, things that are located inside, beneath skin, but we cannot "touch" them - only if they are exposed, as in an operation, can we literally touch them.
* The truth is, we are probably mobilizing neural structure a lot more than anything else with manual therapy


Which means, when we treat, we are using our imaginations a LOT.
It's ok to use imagination, but it's not OK for one group of PT or manual therapy imagination users to claim higher scientific turf than some other group of PT or manual therapy imagination users.
Get real.
What do you think you're testing/treating? What you imagine you are touching/affecting, instead of what someone else imagines they are touching/affecting?? How is your science based on whatever you think you can "operate on" under the skin ever going to be more than more tooth-fairy science, based on some hypothesis which is implausible because you can't get your hands literally on the thing that you are trying to affect with your hands, and you cannot rule out the fact that the patient's brain/neuromatrix is being very attentive to you and anything you try to do to it with those same hands? Give me a break.


Adoption of an interactor model would slice the matter in several novel directions.
a) we would be more science-based.
b) it would place neuromatrix and biopsychosocial models of human pain/function/dysfunction ahead of orthopaedic and biomechanical and other (also largely pseudoscience) operator models.
c) it's already pretty hard to design experiments that can test aspects of manual therapy.
d) adopting an interactor model would make things even harder.
e) we would, however, as clinicians, be on much firmer scientific ground.
f) why strive so hard to build an evidence base, based on operator models of treatment that contain such implausible tissue-based hypotheses (biomechanical, craniosacral, myofascial, triggerpoint, joint-based, reflex zone, acupuncture, you name it) in the first place?
g) adoption of an interactor model would make things harder but also easier. We could work toward improving what already works, i.e., the verb of therapeutic contact, as a new social element of that individual's biopsychosocial, pre-existing landscape, the entry of oneself as a therapist, with a social-grooming interactor role, into that person's neuromatrix. Not have to try to substantiate the noun (and therefore, myth(!)) of some system for
- supposedly pushing a joint sideways and thereby supposedly decreasing nociceptive afferent stimuli, or
- supposedly bending a suture somehow and thereby supposedly squishing cerebral spinal fluid around thereby supposedly decreasing nociceptive afferent stimuli, or
- supposedly physically stretching fascia (of all things!), a tissue whose job is to keep an organism and its layers from falling apart..
- etcetcetc.....
h) what is the element common to both the operator model (even though the operators won't admit it) AND the interactors? Skin.
i) Which takes us all the way back round to the question, "What are we really handling?"

Answer: The surface of someone's body. All the representational maps stored in the brain of the individual we are touching. All the feelings, thoughts, beliefs, impressions, perceptions that individual has stored up over a life time. The person has the pain problem. We don't. The person has to fix his or her own pain problem. We have to try to help them.

It's that simple.

It's a grooming encounter and they have a pain nit they can't reach by themselves. They need someone outside to verify it, so they can begin to downregulate it. Maybe it's a little, buried, default primate social need our human primate brains still have. I don't know. But I know we don't have to press very hard for that. We only have to apply a bit of judicious and NON-nociceptive stimulus to that person, at the right speed, for the individual. They need to become more aware of their body and simultaneously less aware of their pain.

It's that simple.

Handling skin properly is simple: Do anything to it you want, just avoid hurting the person through it, and the person's brain will take care of all the rest. Bear in mind what I will now call the...

First Law of Human Primate Social Grooming: Do No Nocicepting

Stick to that law even if the patient seems to have a high nociceptive threshold, even if they "think" they should pay for gain with more pain, even if they kid around and act tough, even if they've been told by countless other treaters that it's OK, just suck it up. Don't get sucked into that movie, people. Stick to the First Law and you will never have to hold yourself responsible for having created a new chronic pain patient.

They are out there, you know... Life is a verb, not a noun. The brain is a verb, not a noun. It interacts continuously with its environment, both inner and outer. Those whose nervous systems aren't organized quite normally, who perhaps lack the means by which their cells can produce that absolutely crucial opioid receptor in quite the right synapse, or whose systems go haywire and produce way too much Substance P or some other excitatory substance which can jimmy the ordinary downregulatory system... those people are out there. Yes, they are rare, and yes, they might instinctively already "know" they don't tolerate rough-house well, but some of them may find their way into your clinic regardless. They only want what any patient wants - some professional interactive human primate social grooming from someone who will take them as a person and all their possible baggage into account while being in therapeutic contact with them, and leave them explicitly with the locus of control over the treatment. If it happens to be you, and you didn't interview them enough to pick up they aren't appropriate for your kind of manual treatment (or manual handling, period), don't set the context correctly, or you wander off into your own operator mentations inappropriately or at the wrong moment, or you haven't told your patient to tell you when your handling feels uncomfortable... congratulations![not] - chances are pretty high you may have just initiated another person to the (already too high) chronic pain population. Oops. You (and your treatment idea) became their tipping point. Now you'll have to live with that, and (much) worse, so will they. No one starts out thinking they'll end up in chronic pathophysiological pain - they just do. Don't play any role in making worse problems for people than they already have.

If you're going to be a human primate social groomer, for goodness sake be an intelligent one - think about stress reduction - get that person's stress levels down before you ever begin - set the stage. Make it easy for yourself, and for them. Make it clear they are in ultimate veto charge of you and your handling. Make it a habit to give them cognitive material in the form of pain education to work with. Human primates need that as part of the human primate grooming process; those big frontal lobes need information to chew on throughout the process. With stress levels down, the individual will be more apt to incorporate you and your contact into his or her body schema, and good things will have a better chance to result. Go slow - the slower you go the more that person's brain will be able to take in what's going on and use it best to help itself.

Additional reading:

1. Bennedetti: The Placebo and Nocebo Effect: How the Therapist’s Words Act on the Patient’s Brain

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.

Selves and selves and selves

By happy fluke a friend, Jon Newman, posted a thread on SomaSimple about Sandeep Gautman's blog, The Mouse Trap, and links to several posts about the many selves we each carry around. I was delighted to learn that someone has bothered to study their existence, hypothesize their functions - I don't have to do it all by myself (haha, lame joke).

Listed below are the particular posts Jon found, and thought were compelling enough to bring onto a physical therapy board. They are compelling, because even when we are tootling along in a well-integrated, functioning state, working for a living providing services to health consumers, etc etc., we are dealing with psyches which might seem glued together on the outside but which might feel shattered to pieces on the inside. I've preferred to see this shatteredness as merely kaleidoscopic, interesting and even lovely, but I can appreciate that a sudden plunge into the depths of self/selves might feel shattering to people at first exposure to it. It was that way for me at first, too.

Anyway, for those interested:
1. Development of Infant Consciousness
2. Splitting of the self: "me" and "I"
3. Five kinds of self/self/knowledge

I had no idea there was a field called Philosophical Psychology, with its own journal, but there is. Someone named Ulric Neisser wrote a paper way back in 1988 and delineated Five kinds of Self-Knowledge. In his blog, Gautman has outlined them:

•The ecological self is the self as perceived with respect to the physical environment: I am the person here in this place, engaged in this particular activity.
•The interpersonal self, which appears from earliest infancy just as the ecological self does, is specified by species-specific signals of emotional rapport and communication: I am the person who is engaged, here, in this particular human interchange.
•The extended self is based primarily on our personal memories and anticipations: I am the person who had certain specific experiences, who regularly engages in certain specific and familiar routines.
• The private self appears when children first notice that some of their experiences are not directly shared with other people: I am, in principle, the only person who can feel this unique and particular pain.
• The conceptual self or ’self-concept’ draws its meaning from the network of assumptions and theories in which it is embedded, just as all other concepts do. Some of those theories concern social roles (husband, professor, American), some postulate more or less hypothetical internal entities (the soul, the unconscious mind, mental energy, the brain, the liver), and some establish socially significant dimensions of difference (intelligence, attractiveness, wealth). There is a remarkable variety in what people believe about themselves, and not all of it is true.

No mention in there of the over-extended self.. which women end up becoming a lot of the time.. I think (with my private self) the over-extended self may house a bunch of the subselves which can cause trouble. Perhaps it depends on the sort of "specific and familiar routines" in which one engages. I think it's the one our "role" is housed within. Of all of them, it's the one that changed itself right under my nose, and seems like is busy plotting a coup with my conceptual self these days.

Also, no mention that I can find of how each of the discretely labelled selves experiences time passing. I have a hunch that a key to re-integrating them is to get them all back on the same clock again somehow.

As an aside, recently neuroscientists found brain cells that keep track of time with extreme precision in macaque monkeys. Everything gets a time stamp. See MIT news story, A Head of Time.

If the brain is an oscillator, predictor and simulator, I can see how easily one's sense of self/selves can develop a few timing problems and need "tune-ups" on occasion.

Brain as Composter VIII

Re Brain as Composter VII:

What follows in this post will be a (long) series of points that summarize attributes of what Claxton calls "D-mode" intelligence:

1. D-mode is much more interested in finding answers and solutions than in examining the questions. (Is the 'primary instrument of technopoly', is primarily concerned with problem-solving, treats any unwanted or inconvenient condition in life as if it were a 'fault' in need of fixing.)

2. D-mode treats perception as unproblematic. (It assumes the way it sees the situation is the way it is.)

3. D-mode sees conscious articulate understanding as the essential basis for action, and thought as the essential problem-solving tool. (Tries to gain a mental grasp, figure it out with everything from impeccable rationality with equations and flow charts to just weighing up pros and cons, taking things through, making a list, jotting down thoughts, making a pitch, etc.)

4. D-mode values explanation over observation (Is more concerned about why than what. The need to have mental grasp, to be able to offer an acceptable account of things is integral. Assumption is that it is normal to be intentional and proper to offer explanations. "..when this purposeful, justificatory, 'always-show-your-reasoning' attitude becomes part of the dominant default mode of the mind, it then tends to suppress other ways of knowing, and makes one skeptical of any activity whose 'point' you cannot immediately consciously see." My italics.)

5. D-mode likes explanations and plans that are 'reasonable' and justifiable, rather than intuitive. (Doubt in the sense of lack of conscious comprehension, becomes stultifying, a trap rather than a springboard.)

6. D-mode seeks and prefers clarity, and neither likes nor values confusion. (Likes to move along 'a well-lit path' from problem to solution, preserving.. as much mental grasp as it can...while some learning may proceed in this point-by-point fashion, much does not.)

7. D-mode operates with a sense of urgency and impatience. (Yeah, that's got to be real relaxing for patients..)

8. D-mode is purposeful and effortful rather than playful. (Always a sense of being under time pressure, being intentional, purposeful, questing, needing to have an answer to a pre-existing question, misses the fruits of 'relaxed cognition'.

9. D-mode is precise.

10. D-mode relies on language that appears to be literal and explicit Claxton:

"..tends to be suspicious of what it sees as the slippery, evocative world of metaphor and imagery. If something can be understood, it can be understood clearly and unambiguously, says the intellect. An intimation of understanding that does not quite reveal itself, that remains shrouded or indistinct, is, to d-mode, only an impoverished kind of understanding; one that should either be forced to explain itself more fully, or treated with disdain. Poetry does not capture anything that cannot ultimately be better, more clearly rendered in prose, and rhetoric is a poor cousin of reasoned explanation."

11. D-mode works with concepts and generalizations (likes to apply rules and principles, favors abstraction over particularity, works with generics or prototypicals, even individuals are treated as generalizations.)

12. D-mode must operate at the rates at which language can be received, produced, and processed. (maintains a sense of thinking as being controlled and deliberate, not spontaneous or willful.)

13. D-mode works well when tackling problems which can be treated as an assemblage of nameable parts. Claxton:

"It is in the nature of language to segment and analyse. The world seen through language is one that is perforated, capable of being gently pulled apart into concepts that seem...self-evidently 'real' or 'natural', and which can be analysed in terms of the relationships between these concepts. Much of traditional science works so well precisely because the world of which it treats is this kind of world. But when the mind turns its attention to situations that are ecological or 'systemic', too intricate to be decomposed in this way without serious misrepresentation, the limitations of d-mode's linguistic, analytical approach are quickly reached. Any situation that is organic rather than mechanical is likely to be of this sort. The new 'sciences' of chaos and complexity are in part a response to the realisation that d-mode is in principle unequal to the task of explaining systems as complicated as the weather, or the behaviour of animals in the natural world. Along with the rise of these new sciences must come a re-evaluation of the slower ways of knowing; of intuition as an essential complement to reason.

I want to say that I think there are many excellent scientific minds out there these days who can conceptually synthesize as well as they can analyze, so I think this list and its attempt to compare scientific thinking with D-mode thinking sounds a bit dated. However, an awful lot of society and its institutions/structures still use this mode reflexively - I would agree with him there.

And I am a bit torn over point 4, because I do explaining all the time, but I like to think that in me, explanation does not overrule or suppress observation/contemplation/other ways of "knowing," that in me, they go hand in hand. This whole blog series is a case in point. However, I've no way to be "certain"... so I'm likely to be wrong on that at least half the time.

I've always chafed at my own profession, PT, which strives to be as classically D-mode as possible for a supposed hands-on helping profession to be... I'd have to say, though, chiropractic with its complexification and ornate verbal embroidering of what is actually a simple set of tricks, manipulation, and which does not require any sort of brilliance to learn or to apply, takes most of the cake for being D-mode, e.g., it fabricates elaborate explanation upon very little observation, and imagines itself to be precise. As Claxton points out in #13, any insistence on using D-mode for treating a natural system (like a live, conscious human being in pain) is misplaced, probably: "when the mind turns its attention to situations that are ecological or 'systemic', too intricate to be decomposed in this way without serious misrepresentation, the limitations of d-mode's linguistic, analytical approach are quickly reached."

Next up, what Claxton thinks is involved in wisdom.

Brain as Composter VII

Re: Brain as Composter VI:

Two more qualities of 'slow thinking' are poetic sensibility and mindfulness.

About poetic sensibility, Claxton says,

"poetic sensibility has the ability to reset or create our agenda; to uncover issues and reveal concerns, perhaps in unexpected quarters, or surprising ways. By allowing ourselves to become absorbed in some present experience without any sense of seeking or grasping at all, we can be reminded of aspects of life that may have been eclipsed by more urgent business, and of ways of knowing and seeing that are, perhaps, more intimate and less egocentric (...) There is a kind of knowing which is essentially indirect, sideways, allusive and symbolic; which hints and evokes, touches and moves, in ways that resist explication. And it is accessed not through earnest manipulation of abstraction, but through leisurely contemplation of the particular.(...) For a person whose apprehension is under the spell of this attitude, the immediate context commands his interest so completely that nothing else can exist beside and apart from it (...) One slips away from self-concern and preoccupation into the sheer presence of the thing, the scene, the sound itself."

He quotes Kafka:

"You do not need to leave your room. Remain sitting at your table and listen. Do not even listen, simply wait. Do not even wait, be quite still and solitary. The world will freely offer itself to you to be unmasked, it has no choice, it will roll in ecstasy at your feet."

He quotes Rilke:

"If you hold to Nature, to the simplicity that is in her, to the small detail that scarcely one man sees, which can so unexpectedly grow into something great and boundless; if you have this love for insignificant things and seek, simply as one who serves, to win the confidence of what seems to be poor: then everything will become easier for you, more coherent and somehow more conciliatory, not perhaps in the understanding, which lags wondering behind, but in your innermost conciousness, wakefulness and knowing."

It's hard to get through life without visiting this sensibility. It restores one to oneself, to one's own "nature." You can bask in it - you can roll around at your own feet if you want, interpreting it physically and sensorially and personally. From it you can write your own poems and paint your own pictures and sing your own songs and play your own music and create your own dramas. All these expressions will bring you closer to your own selfness. It's all good. But I would add, do not inhibit the development of your own capacity for critical thinking either.

Claxton's fourth quality is mindfulness:

"The fourth manner of paying attention which I want to describe in this chapter is a way of seeing through one's own perceptual assumptions. It is called mindfulness. The extent to which the world-as-perceived is a mirror of our preconceptions and our preoccupations (...) is easy to underestimate. It takes an effort to see what is happening, because our beliefs are dissolved in the very organs we use to sense."

He follows with an example of tasting saliva that is in your mouth, noting its pleasant quality, then spitting some into a glass and retasting it, noting how one's perception of it immediately changes into something less positive.

"The spit hasn't changed, only the interpretation."

He goes on to talk about aging and mindfulness:

"Being 'old' is not just a biological phenomenon; how one goes about 'being old' depends on one's (largely unconscious) image of what it is like, what it means, to be old, and this in turn reflects a whole raft of both cultural assumptions and individual experiences. Ellen Langer and colleagues at Harvard U. have examined the effect on elderly people of their own vicarious experiences, as children, of ways of being old. They reasoned that children may unconsciously pick up images of old age from their own grandparents - which they might then recapitulate as they themselves get older. Specifically, they surmised that the younger their grandparents were when children first got to know them, the more 'youthful' would be the image of old age that the children would unconsciously absorb, and the more positively they would therefore approach their own ageing. (...) it was found that those elderly people who had lived with a grandparent when they themselves were toddlers were rated as more alert, more active and more independent than those whose first experience of living with a grandparent had not occurred till they were teenagers (...) it looks as if the ways in which different people age depends quite directly on the assumptions and beliefs they have picked up in their own childhoods about what it is to be old."

He talks about pain and mindfulness:

"The unconscious assumptions that people stir into their experience are often hard to alter, but sometimes they can be changed just by a suggestion, especially if it comes from some kind of an authority figure. The experience of pain, for instance, can be dramatically altered, in normal conscious subjects, simply by telling them to think of it differently. When a group of people who had volunteered to suffer some mild electric shocks were told to think of the shocks as "new physiological sensations," they were less anxious, and had lower pulse rates, than those who were not so instructed. In another study, hospital patients who were about to undergo major surgery were encouraged to realise how much the experience of pain depends on the way people interpret it. They were reminded, for example, that a bruise sustained during a football match, or a finger cut while preparing dinner for a large group of friends, would not hurt as much as similar injuries in less intense situations. And they were shown analogous ways of reinterpreting the experience of being in hospital so that it was less threatening. Patients who were given this training took fewer pain relievers and sedatives after their operations, and tended to be discharge sooner, than an equivalent group that was untrained.
These experiments demonstrate how other people may be able to rescue us from what Langer refers to as 'premature cognitive committments' - help us become aware of the assumptions that we had dissolved in perception, and contemplate alternative ways of construing the situation."

My bolds.

"Mindfulness involves observing one's own experience carefully enough to be able to spot any misconceptions that may inadvertently have crept in. There are a number of ways in which this quality of mindfulness towards the activity of our own minds can be cultivated, though all involve slowing down the onrush of mental activity, and trying to focus conscious awareness on the world of sensations, rather than jumping on the first interpretation that comes along and hurtling off in the direction of decision and action. Mindfulness can be taught directly, as a form of secular meditation, for example. (...) "The essence of the state is to 'be' fully in the present moment, without judging or evaluating it, without reflecting backwards on past memories, without looking forward to anticipate the future, as in anxious worry, and without attempting to 'problem-solve' or otherwise avoid any unplesant aspects of the immediate situation. In this state one is highly aware and focused on the reality of the present moment, 'as it is', accepting and acknowledging it is its full 'reality' without immediately engaging in discursive thought about it, without trying to work out how to change it, and without drifting off into a state of diffuse thinking focused on somewhere else or some other time.. The mindful state is associated with a lack of elaborative processing involving thoughts that are essentially about the currently experienced, its implications, further meanings, or the need for related action. Rather mindfulness involves direct and immediate experience of the present situation."(Jon Kabat-Zinn)"

......................................................

So, in summary, from Hemenway's article on permaculture we have the basic design principles combined into four pairs:

I. ECONOMY AND ELEGANCE:
1. "Do only what is necessary. Conservation involves passive restraint from change or disruption of natural systems and active participation within them."
2. "Multiply purposes. Never do anything for only one reason. "Stack functions""

II. BALANCE
3. "Be redundant. There is always a variety of pathways by which an ecosystem can proceed about its business. A system's capacity for storage and resilience stems from its redundancy."
4. "Check your scale. Design and act within an appropriate size frame. The only cultural tools our society provides for evaluating scale are economic; these often lead to the selection of scales that are counterproductive, inefficient, and destructive."

III. RESILIENCE
5. "Work with edges. That is where the action is. Straight lines have far less edge than waves. You know this instinctively."
6. "Encourage diversity. Diversity here is intended to be diversity of relations between things, and not just a bunch of different structures assembled. Diversity of pathways is redundancy. Diversity allows both stacking and repeating of function."

IV. RECIPROCITY
7. "Look both ways before crossing. Everything works both ways."
8. "The gift must always move."

From Claxton's book we have the four slow ways of seeing:
1. Attentive Resonance
2. Focusing
3. Poetic Sensibility
4. Mindfulness

How they stacked up as being congruent with each other in my mind was as follows:

1. "Economy and Elegance" with poetic sensibility ("reset or create our agenda; to uncover issues and reveal concerns, perhaps in unexpected quarters, or surprising ways");

2. "Balance" with focusing ("awareness" (like that in "attentive resonance", see below).."is now directed inward, towards the subtle activities and promptings of one's own body" - this is a tough one to learn when everything in our culture has prompted/taught us to be externally directed);

3. "Resilience" with attentive resonance ("The habit of attending closely and patiently to the evidence, even - sometimes especially - to tiny, insignificant-looking shreds of evidence" - another hard one when all exhortations are to keep an eye on "the Big Picture.");

4. "Reciprocity" with mindfulness ("seeing through one's own perceptual assumptions", not fall prey to "premature cognitive commitments" - in our culture, no one seems to care about this at all, except those who prefer to consider all things from a scientific perspective before unleashing them outward, as Burton reminds us in On Being Certain).

Next I want to highlight more from Claxton, his comparison/contrast of what he calls "D-mode" thinking ("D" is for deliberate) with slow, "undermind" thinking, the kind that is ongoing and one can peer into using his 4 "qualities." (I would call them "mind gardening tools.")

"On Being Certain": Ginger Campbell interviews the author, Robert Burton MD

I help out Ginger Campbell sometimes by transcribing some of her podcasts for her, just the ones I decide are so interesting I want to spend time with the podcast and might as well be doing something useful at the same time that might help out other listeners, i.e., typing. The typing helps me too - makes me listen more slowly, makes me repeat parts to make sure I heard them right.

Here is a link to my transcription of her BrainSciencePodcast interview #43, an interview with author Robert Burton MD, about his book, On Being Certain: Believing you're Right Even When You're Not. (I wrote a post based on this book, and the previous BrainSciencePodcast #42, here.)

In the interview, toward the end, Burton compares perception of mind to perception of pain:

"I don't know if I can articulate this because it's still sort of seeping around in there is that most of us feel that we are what our conscious mind tells us we are. That question you asked about the free will and about someone said what your unconscious is doing is not part of 'you' - I think that we sense only what we sense. We sense ourselves as starting an idea, having a thought, making plans, etc etc. and we really don't see that that facility arises out of the same cognitive stew that causes all these perceptual illusions in general. And somehow, if you were to take a look at sort of western thought, it really is all about the mind-body thing. All the major questions arise out of the conception that the mind is somehow a separate entity. I mean there's a book by John Searle the philosopher - he has a whole book called The Mind, and he covers all the various kinds of theories, but none of them make any sense if you think about it. Because way down deep the mind is simply a higher level function that we can't conceptualize, just the same way as you said it's more than the sum of its parts I think you said.. this whole idea of emergence is really impossible to visually see - in other words you realize that if you take a chocolate chip and you take a piece of flour and take water, there is no embedded cake in there.. there's nothing - there's just chocolate and flour but we know you can make a cake. Well the cake is material. You can still see it. But in this case the problem is, the problem is what the brain generates is immaterial, that we can't see, yet does exist. I mean exists in the same way that pain exists. Pain isn't anywhere. The brain doesn't experience pain in the neurons I'm suffering. When you stub your toe there's no neuron that goes ouch. It occurs at a higher level. The problem I haven't figured out yet which I think might be the next project is, there needs to be a metaphor for understanding higher level function when seen from a lower level that will allow people to get rid of this distinction and argument about the mind and free will and causation. I think these are all problems of language that arise out of misconceptions what the mind is. Which is sort of what I think might be the next project."

Ginger says:

"You pointed out in your book that we don't think pain is something mystical or magical just because it can't be localized - it's emergent - yet somehow it seems natural to look at our mind and feel that it has to be somehow different."

His next comment is:

"Right. And I haven't been able to think of it because maybe I'm too dense, but there must be some analogy or metaphoric analogy where you can say, well just as pain exists but is undetectable, the mind exists, but it exists arising out of stuff that we cannot control so even though it feels like it's separate and also feels like it's in control in some sense it also feels like it's you, and feels like a self - these are all phenomena that are undetectable but necessary - I don't want to use the word illusion because illusion implies it doesn't exist - but on the other hand it is an illusion if you mean by illusion you can't see or taste or smell or touch it. It's an illusion without being an illusion."

I'm working on an analogy/metaphor for him - it has to do with brain as compost bin, thoughts generated by the unconscious or fed into the unconscious as compost itself. What occurs in the bin is unconscious thinking; conscious thinking or ruminating on something would be analogous to deliberately turning the compost, aerating it, waiting until it is aged to perfection.

Developing a systematic thought process, for example a scientific approach to thinking, or a scientific process to test an idea to make sure everyone can feel "certain" about it, would be analogous to using the compost to grow something with. But the thoughts that end up as conscious tested thoughts, although they may have sprung forth with the help and support and nutrition provided by the compost, are no longer compost - they become living and growing ideas that belong out in the culture, seeding new thoughts.

OK, it needs work, but I think it's a start.

Brain Science Podcast #42: "On Being Certain"

In reference to Alberta woman with chiropractic stroke sues bigtime:

Ginger Campbell's latest podcast is about the book, "On Being Certain: Believing You Are Right Even When You're Not ", by neurologist Robert A. Burton, MD.

About half way through it, she says;

"Earlier on I asked the question, "What would be the possible benefits of "a feeling of knowing" that is actually false?" This brings us to a consideration of our brain's reward systems, and how they interact and influence our thoughts.

We know that there are extensive connections between the pleasure rewards systems, emotions, and the opioid peptides in the brain. We have talked about in the past the mesolimbic-dopamine system, which is a key component of the brain reward circuitry that originates in the upper brainstem. It, not surprisingly, seems to use dopamine as its key neurotransmitter. This mesolimbic dopamine system connects to the parts of the brain that are involved in emotion and cognition, including parts of the frontal lobes, and the nucleus accumbens which is thought to be involved in addiction. It's been shown that brain mediated rewards cause behaviours to persist, including addictions.

So you have to wonder, how is this related to the feeling of knowing? Dr. Burton gives an example in the book, of a person faced with a charging lion, who climbs up in a tree and survives. After the person escapes he has the feeling that he has learned something. And if you make these sorts of decisions repeatedly, you will probably have a positive feeling of "correctness" that becomes linked to that behaviour.

Dr. Burton argues that the feeling of knowing and feelings of familiarity are integral to learning."

Fine, so why am I bringing this forward? Because my human primate social grooming brain thinks humans are learning machines who:
1. can learn all sorts of crazy things
2. learn all sorts of physical actions
3. make up all sorts of bizarre and sometimes dangerous rituals

.... that often fall into the category of "stupid human tricks."

Among these, I would definitely put neck manipulation of the high velocity sort.

I can't prove it, but have always suspected that both doing it and having it done to one's own person likely belong in the category of "addictive behaviours" as well as "stupid human tricks", but this is the first time I've heard a (potentially associated) brain pathway actually spelled out.

No one in the greater HPSG sub-troop acts more "certain" of themselves, on the whole, than those practitioners who favor this approach. Except possibly the patients who've been on the receiving end of it, convinced that it "helps" them, even when they still "need" it monthly for 10 years, etc. (See Keith's observations/comments in "Alberta woman" link.) I'd put that in the category of "false knowledge"; the feeling of being certain outweighs the obviousness that it doesn't really help much of anything at all, except a reward pathway (temporarily) and furthermore only reinforces a behaviour peculiar to humans, reinforces a pathway that goes nowhere and does nothing permanent, does not give the brain a chance to learn a new behaviour toward self-sufficiency.


Further reading:

1. Harriet Hall's review of the same book.
2. Is certainty a dopameme?


August 8/08

I'm back into this post to drop a link to Ginger Campbell's Podcast #43, an interview with the author. It really rips along - give it a listen! Thumbs-up.

Itchy and Scratchy

The New York Times has a great article by Atul Gawande about itch, and how sensors can go wrong. It's not the same as persistent pain, but it sounds awfully similar in behavior. Here is a link to The Itch. Here is a link to an audio interview about it.

Here is Jonah Lehrer's blogpost about it in his Frontal Cortex blog.

Here is a link to Atul Gawande's website.

"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.

Still Meditating on Meditation

In reference to Growing a steering wheel for one's brain, and "Mindfulness-Based Stress Reduction" - Jon Kabat-Zinn:
A recent article in the NY Times delves into the history of mindfulness meditation in therapy; check out Lotus therapy by Benedict Carey.

Thank you to Deric at Mindblog.

I just (a few days ago) obtained a copy of Kabat-Zinn's book, Full Catastrophe Living, and am reading random pages from it at bedtime. I usually do this with books ... expose my sleepy brain to them, see if something in there can grab my tired attention hard enough to make me want to read them cover to cover when I'm awake and can fairly engage. It's my own Sleepy Brain Interest Detection Screening Mechanism.

I'm grateful, actually, that at this stage of life I appear to be relatively catastrophe-free - there has been a very nice patch of smooth sailing for several years.

PS: I'm back in this post on May 29, to link to a just-released podcast from Ginger Campbell, in her books and ideas series, an interview with Delaney Dean on Mindfulness Meditation. Here are Campbell's show notes. Here is a link to the actual podcast. I am eager to listen to it.

Transcript For BrainScience Podcast #31

I have prepared a transcript of Dr. Ginger Campbell's Episode #31, Brain Rhythms with Györgi Buzsáki, with her permission.

You can read it here: Synchrony and Oscillation in the Brain.

The transcript was written to assist my own learning of the material in both the book and podcast. Here is a link to Brain Oscillations: Ten Part Series, on the same topic.

The ideas in the podcast are much easier to follow if one can read along as one listens; the intention of publishing this transcript is for it to be a listening/learning aid for anyone who wishes to dig deeper into understanding the presentation, and the book upon which it is based.

Manipulation and the Brain

This entry is a more edited version of a post I made on NOI in a discussion regarding manual therapies. I have included some references.

One of the participants asked, “If we discredit manipulation are we not at risk of undermining other manual type techniques for the same reason (myofascial, massage, mobilizations etc)???”

I answered with a prior version of this:

I don't think so. There is a layer of "brain" all around the outside of the body, a.k.a. skin, with fibres that go straight up to the insular cortex.1,2,3,4 We could consider manual therapies as altering the nervous system through THIS organ - I think all of the manual therapies you named do this anyway to a large extent, yet there is a conceptual void that needs filling; long ago manual therapies were named for the mesoderm (deep to the skin sensors) they were supposedly targeting (e.g. myofascial) or the sort of physical movement needed to perform them (e.g. massage, mobilization). These sorts of archaic designations deflect accurate therapeutic understanding from including the perspectives that patients' own unique nervous systems may have, keep our constructs off track, bias our self-image toward being PHYSICAL therapists instead of being physical THERAPISTS.

I doubt the actual therapy procedures, the physicality of them, are discreditable. These seem to be something humans evolved doing in order to help/comfort one another, cognitively consolidated action memeplexes that appear to stem from some deep ancestral well of primate social grooming. However, the constructs that attempt to explain and inform their use do nothing but describe such treatment as something we the treatment heroes "do" unto others. This perpetuates confusion, maintains invisibility/disregard of the highly variable nervous systems at the receiving end of the interactions as passive recipients, does nothing to consider or include the highly active role that nervous systems play in their own recovery by first accepting as non-threatening, then responding to, exteroceptive input.

Manual therapy ranging from skin touch only to active skin stretch to deeper pressure into underlying bones, muscles, neural tunnels, what have you, at varying speeds, should always be kept within our scope, but framed instead as varying kinds of exteroceptive input into a living perceiving system. Rather than being framed so strictly in biomechanical language, with its attendant and unavoidable misconceptions of cause and effect, the effects produced by manual therapies should be more carefully read as responses by the patient's living perceiving system. This necessitates seeing a patient's nervous system as more of a verb than a noun. This necessitates developing abilities to stay one step ahead of that nervous system, guiding it toward better behavior/output, not overtreating the mesodermal anatomy of it, or holding that foremost in our minds.

I'm all for retaining, but renaming, all forms of manual therapy interventions as a necessary part of their long overdue upgrade; new manual therapy names should include and reflect modern pain and nervous system concepts, and a sense of the interactivity of two nervous systems working together at every level to help one of them reduce pain and improve function/freedom. I would predict that as the perception of them shifted in us, the users of these therapies, the balance of usage of them would too; I think a trend more toward less intensive and slower forms would develop.

1. Unmyelinated tactile afferents signal touch and project to insular cortex; Nature Neuroscience (2003); H. Olausson, Y. Lamarre, H, Backlund, C. Morin, B.G. Wallin, G. Starck, S. Ekholm, I. Strigo, K. Worsley, Å.B. Vallbo, and M.C. Bushnell.
2. Pain Mechanisms: Labeled Lines Versus Convergence in Central Processing, Annu. Rev. Neurosci. 2003; A.D. (Bud) Craig.
3. Antero-posterior somatotopy of innocuous cooling activation focus in human dorsal posterior insular cortex, open access 2005; L.H. Hua, I.A. Strigo, L.C. Baxter, S.C. Johnson, A.D. (Bud) Craig.
4. The Integrative Action of the Autonomic Nervous System: Neurobiology of Homeostasis 2006; W. Jänig.

I see the understanding of how to treat live people as inversely proportional to the amount of force used and the speed of its delivery. I see the misunderstanding of how to treat live people as directly proportional to the amount of force used and the speed of its delivery. I guess nothing will ever be able to make me change my mind on this, ever.

Canadian Physiotherapy Pain Sciences Group

A PT friend of mine a long way away wrote to ask if I knew anyone in Victoria doing "soft, gentle" manual therapy. I knew he meant therapy that takes into account the patient, and the patient's pain perceptions, and is not just applied to their tissues as if said tissues were abstracted from the body and not connected to a nervous system, or as if the treatment of the tissues in abstracted isolation would in and of itself lead to a predictable and desireable outcome in terms of pain reduction for the patient.

Unfortunately, there is no category for such therapy. There is a category for "orthopaedic" manual therapy (pushing bones about), one for "acupuncture" (pushing needles into soft tissue, especially the sore spots, with the idea that tissue if aggravated will be stimulated to be less chronic, more acute, and finally "heal"), and various other categories for various definable conditions, age groups, or social classifications of behaviors, such as "sports"...

I settled, with a sigh, on two practitioners out of dozens listed, who had been brave enough to put themselves into a category listed as "complementary." I don't know them, or what sort of "complementary" PT they practice, but I took a chance because sometimes the unknown is less scary than the known. I also am listed as practicing in a "complementary" manner, along with "orthopaedic." To me, an "orthopaedic" listing is necessary, because it lets people know that you've studied the body in detail at least, and have acquired certain skill sets, even if you don't use them much. And "complementary" is my code-word for "willing and able to treat persistent pain problems in people."

It's a compromise.

My attempt to help my friend reminded me of why I was so interested a few years ago in helping set up a pain physiotherapy special interest group/CPA division in Canada. At the time I thought being able to present a new official category would gradually replace the one listed as "complementary", odious to many because it can mean non-orthopaedic hands-on techniques that include all sorts of anti- and pseudo-scientific hands-on theoretical constructs. Aha, I thought at the time. All these practitioners really need is access to updated pain science and neuroscience, and all will be well in PT land. The practitioners needn't necessarily change what they physically do with their hands, or how well they relate to their patients, but their thinking and understanding will take a big leap forward, and the sort of conversations they have and meanings they convey to their patients will become congruent with all that has been learned in the last decade or two. Eventually PT would be able to drop that compromising, dubious and embarrassing, even, "complementary" category in favor of the much preferable (to my mind, anyway..)"pain sciences" category.

Well, long story short, it seems the physiotherapy beaurocracy in Canada wasn't ready for such a move. Our application to become a division of CPA was rejected, tabled, postponed, moratorium-ed.

So, we decided to plow forth anyway and the Canadian Physiotherapy Pain Sciences Group was born instead. It is doing very well under the combined leadership of Neil (western Canada) and Dave (central Canada), both young with solid academic credentials and teaching experience; Deb, who is from my own era and who has revitalized her PT career by teaching pain seminars; myself, not doing much publically but always working behind the scenes, trying to help the profession get unstuck from the past.