I seem to be on some sort of roll today, maybe because of that wonderful ice dance last night won by "Canada," a concept momentarily inhabited by the wonderful young ice dance couple, Moir and Virtue, who in their unbelievably fabulous performance managed to successfully downregulate any negative nervousness and upregulate every particle of their well-honed strength and grace to take the gold in a most transcendent manner. I think they managed to navigate "even keel" through several different potential realities, toward victory. I think their sturdy sea-going vessel was "apprehensiveness." Let me explain:
If there was ever a word to describe human primates in general (perhaps me in particular), I think it would be the adjective "apprehensive." It ordinarily conjures up a sense of suspicion, nervousness, or anxiety, which I think is a negative social meaning that has accrued to it because of how extroverted people like to downplay sensible precaution; in fact, there is way deeper meaning to it than that.
"Apprehensive" means many different things: let's take a look:
1. quick to understand
2. mentally upset over possible misfortune or danger or consequences
3. in fear or dread of possible evil or harm
4. anticipating something with anxiety or fear
5. quick to learn, intelligent, capable of grasping with mind or intellect
6. the cognitive condition of one who understands
7. from Lat. (ad, "to"; prehendere, "to seize"), a term applied to a model of consciousness in which nothing is affirmed or denied of the object in question, but the mind is merely aware of ("seizes") it
8. (as verb) to legally seize or arrest
It was wonderful to hear Tessa Virtue thank her physiotherapist during a post-win interview. She's had injuries, for sure.
Well done, you two. You have made us (Canadians) proud and have entertained us all (wherever we are on the planet) absolutely beautifully and dazzlingly. So pleased you were able to "apprehend" the possibility, "apprehend" each other sufficiently to get the job done, let your combined brains "apprehend" gravity and other physical forces, "apprehend" correct responsiveness in each nanosecond in perfect poise, then "apprehend" the opportunity, and that medal, with all weight of its attached symbolism, graciously smile the whole time, and allow a sense of relief, joy, pride and connectedness to race throughout Canada and likely all round the world. Well done. Well apprehended.
Thank you (as a Canadian) also to the coaches (one from Russia) and the host rink (in the US, I think). It was a great moment to "apprehend" while putting in time in this Big Waiting Room called "life."
Showing posts with label physiotherapy. Show all posts
Showing posts with label physiotherapy. Show all posts
Tuesday, February 23, 2010
Friday, January 29, 2010
Exactly backwards
I had a chance last weekend to travel to Saskatoon and visit the PT school there for a few days, talk with a few of the profs, plan a tentative future. My (not very) lofty goal is to somehow gain permission to dissect, photograph and map out, in broad visual terms, the extensive forest of rami that project out to skin from the numerous cutaneous nerves that run along parallel to and beneath skin - even if I have to suck it up and do a Master's. My friend Angela, who characterizes herself as an obstacle remover, has been extraordinarily kind and generous with her time and hospitality toward me. She and I have completed a research project together, yet to be written up.
Everyone was kind, lent me their ear, but the impression I have come away with is that there is an invisible wall I could sense, that I may never be able to unlock, between what my profession has turned itself into, and what I think it could be.
Take, for example, the nervous system.
I had an opportunity to sit in on a two-hour neuroanatomy lecture, with permission; it occurred to me that these first-year students are getting more information handed to them in one day than I ever did in a year. In the space of two hours, the lecturer covered the embryological origin of the brainstem, its organization, an intro to each of the nuclei within it, all the spinal cord tracts that move rostrally through it and descend through it, the medulla, the cranial nerves and what each does and how each can be affected by traumatic head bangs, the branchial arches and neural crest, and which muscles were formed from which arch, and which cranial nerve was associated with each arch. It's a lot for first-year students, probably.
My question is, Why should they care? How hard would it have been to put an overall frame around that headfacethroatbrain zone, as neurological core sensor, effector, consciousness producer, and (according to some, like Jaak Panksepp, emotion initiator), plus metabolic engine for the entire organism, breathing and swallowing, able to operate bi-directionally?
The prof was kind enough to meet with me for an hour or so following. My impression was that the only real teaching he does regarding the peripheral nervous system is that it is segmented, each spinal nerve innervates all the stuff coming from a particular segment, and that the main important thing about its role in the body is that there are muscle spindles and sympathetics. Other than C fibers and A deltas, the sensory aspect was irrelevant to him, it seemed.
While all that is true, there is so much more to it than that!
But I was reminded yet again, about how physiotherapy, in order to gain permission to evolve as a profession, pretty much focused its awareness of neural matters entirely around motor output, and has been stuck there ever since, child as it is of the greater touch-phobic society into which it is embedded. We are licensed to touch people, but we are not permitted, it would seem, to examine, comprehend, conceptualize or even be taught anything about how our touching might be an interactive source of brain food for the recipient brain. Too .... sexy or something, maybe. Thar be monsters, or something. This potential pitfall could easily be bridged by a single class in transference/counter-transference, a standard issue that must be dealt with up front by the psychoanalytic community. Why let it remain in the subconscious of my whole profession? Why not deal with it up front? A preemptive strike? Forewarned is forearmed.
The profession has structured itself entirely around motor output, and a gaping void exists where understanding of how the brain and PNS reads and responds to kinesthetic input should be. To be fair, it was probably easier in the beginning to follow Cartesian divisions - you bunch of therapists go deal with the mind, and us, we'll stick with the body. Neuroscience has put this idea into total eclipse: there is no separation whatsoever.
Yet, emphasis on the INput side of the nervous system, and learning to understand it, is precisely, according to me, where becoming not just a good therapist, but a great therapist, lies. These are totally uncharted waters for our profession. We could be great therapists if we hadn't got our conceptual trajectory exactly backwards. We have been looking in through the wrong end of the telescope, all along. But we no longer have any excuse for continuing to do that. Not if we look at what neuroscience can tell us about ourselves in a body, and about ourselves treating other embodied people. Other humanantigravitysuits. (We DO have that word "therapist" in our name, not just the word "physical"...)
I'm doing my very best, but may never succeed in making a big enough noise about it to be able to make any difference in the status quo whatsoever. I have to realize this yet not allow it to defeat me.
Oh yeah, he's also an OMPT. Forgot to mention that.
Wednesday, November 18, 2009
Canadian Pain Physio Directory
I'm pleased to announce the launch of the Canadian Pain Physio Directory, an initiative of the Pain Science Division of the Canadian Physiotherapy Association. A permanent link has been added to this blog, at the top.
Wednesday, June 25, 2008
New blog - Eric Matheson PT: Feel Better, Move Well
The PT blogosphere is growing all the time. Eric Matheson has just launched a new blog called Live Better, Move well (and a new website, Matheson Physiotherapy. If you live in Nanaimo and need some help, Eric is your guy.)
Eric's latest blogpost is entitled Itch, and I must confess I read his post on SomaSimple and got the idea for my own blogpost, Itchy and Scratchy from it.
I like the line he drew out:
So true - for pain also.
Eric, I like your post better than mine.
Eric's latest blogpost is entitled Itch, and I must confess I read his post on SomaSimple and got the idea for my own blogpost, Itchy and Scratchy from it.
I like the line he drew out:
"This understanding of sensation points to an entire new array of potential treatments - based not on drugs or surgery but, instead, on the careful manipulation of our perceptions."
So true - for pain also.
Eric, I like your post better than mine.
Thursday, April 17, 2008
What the ....?
Somehow humanantigravitysuit has ended up on a list of chiro blogs.
I would like to state for the record, that I an NOT a chiro, and this is NOT a chiro blog.
I am now, always have been, and always will be, a physiotherapist, and this is a physiotherapy blog. Remove me from the chiro blog list. Whoever you are. Thank you.
I would like to state for the record, that I an NOT a chiro, and this is NOT a chiro blog.
I am now, always have been, and always will be, a physiotherapist, and this is a physiotherapy blog. Remove me from the chiro blog list. Whoever you are. Thank you.
Friday, November 16, 2007
Now back to function... Part II
2. UN-clear metaphor
In Part I, I introduced scenarios related to clear metaphors people use to describe pain. I used "icepick" and "fish hook" examples. When someone says they feel like they have a foreign object lodged somewhere, and it's perfectly obvious they don't, the comparison is at least acceptably clear as metaphor, even if the solution to the pain isn't yet clear.
What about if the metaphor used is not about a foreign object, but a body part that truly does exist inside the body? Suddenly comparisons are much less clear. Suddenly structures are blamed for misbehavior that is actually functional. Suddenly something that feels LIKE a "locked joint", becomes in a patient's mind, or in a therapist's mind, or a doctor's mind, a possibly 'real' locked joint. There are a million of these. Examples are, "I must have a bone out of place." "A muscle is cramped in my foot." "This tendon is too short - look". "I was fine until I lifted that couch, then my (whatever) seized up on me."
These are still metaphors, but now the issues the patient feels in the tissues are not clearly metaphoric at all. In fact, there has been nearly perfect reflection of metaphors like these, a verbal and investigative ping pong match of pain memes and memeplexes going on ever since humans have had pain and human primate social groomers have tried to help.
But.
Slowly it has begun to dawn on some of us who are fascinated by all the little tricks of the brain and the habits it has of setting up simulations of reality, that pain is something of a perception itself. A great example is phantom limb pain. This is pain that an amputee feels vividly and to his or her consternation, in the missing limb. It can't be the limb hurting, because the limb no longer exists.
But.
A representation of the limb does exist, in the brain. A brilliant neuroscientist/brain researcher named V.S. Ramachandran figured out that using a mirror box could help. The patient places the remaining limb in the box in a way that creates an illusion of a missing limb being present, and able to move freely. Even though the patient knows full well it's just a mirror image, moving freely and painlessly, some important part of the visual cortex actually will record this information and send it around the brain in such a way that pain is relieved in the "missing limb", the phantom of the missing limb, the virtual body part, the representational map of the part located in the brain. It's as if the brain thinks to itself, hmm, I must have made a mistake. It looks like that part can move ok.. Alrighty then, I'll take out the pain signal.
It gets even more strange - it turns out we all have these maps - everyone has them. And we all can feel pain in them, just as amputees do. Ready for more strangeness? Pain is usually in the brain map part instead of in the actual part. I know - this is where "what everyone knows" bumps into new science. Such apparent heresy! But not so strange if you accept the idea that the brain is a great big simulation producer. It can make you have a pain in a part that is not at all "damaged", just because it senses a threat to that part. Yes, you read that right. Nothing has to have happened to the part for the brain to make a pain in it. From my blogpost of September 4th, "Rhythms of the Brain" by György Buzsáki:
I really want you to know I did not make this up - György Buzsáki wrote an entire book about how this is not just possible but likely.
What can decrease pain? Helping the brain sort, refine, redraw its maps. How? Create an illusion for the brain in regular 4-limbed people in pain that is as powerful as the mirror box is for phantom limb pain. How? Well, movement is the key here. The brain needs to perceive some kind of movement before it can get off the square it is stuck on, pain-wise.
One can create a kinesthetic illusion of movement, through skin stretch. Simon Gandevia is the researcher who came up with this while studying cutaneous receptors. He is a lot less famous than Ramachandran is, but no less important to those of us who work with new ideas on how to pare back erroneous metaphor in our own thinking about pain. True, Simon Gandevia hasn't linked his own research yet to pain relief itself, specifically, but he has provided a huge clue. Putting this clue together with Patrick Wall's idea that pain is a "need state", and that pain relief follows a "consummatory movement", and bearing in mind the success of mirror therapy for pain in limb representations, is it really that hard to draw a line connecting the dots? Treating people who still have all their parts is much easier because you don't need a mirror, you just need to get on their skin and give their brain a movement illusion.
To me, this cuts through all the confusing metaphoric mesodermal tissue based wild goose chases that practitioners go on, led originally by convincing descriptions of pain given to them by patients, which they then go on and foist on other patients, and all of which becomes some version of gravely mistaken treatment orthodoxy. I am fond of saying three things to patients on their first visit:
(Truth is, I'm haunted a bit by all the years I worked as a PT, diligently and inadvertently contributing to peoples' pain experience by choosing wrong words, like, "looks like a disc problem", "Sudek's Atrophy? You'll need to wear this brace to keep your fingers from curling into your palm", "This looks like a tendon rupture", etc etc... I'm haunted by a past filled with thousands of faces of patients who intersected with my life, in pain, with ordinary nervous systems and intact tissue, looking at me as some sort of keyholder of relief for them, me having official human primate social grooming status and license but no key, no clue!- to how to really help them at all, other than temporary accompaniment and a set of protocols on how to get them to move anyway, even if it hurt, social manipulation/motivation. Cheer leader stuff. It makes me cringe nowadays - if I were in a patient's shoes I would want to shoot some kid fresh out of school who had the audacity to think she knew the first thing about what my brain and body were going through. But apparent sincerity and earnestness kept me alive, I suppose... Plus, to be fair to my former self, there was not all this nice research available back then, in the 70's. There is no excuse for continuation of perpetuation of inappropriate metaphor in my profession (or the medical profession) anymore, other than pure ignorance/being too busy to read/relying on the schools to have taught what is necessary to know to do the job. The schools are only just learning about this stuff themselves! It'll be awhile more before they figure out how to do the requisite "knowledge translation".)
Certainly there will be some hips that still need replacing and some knees, and so on, but the pain felt in those parts which have been sacrificed might not be relieved by the sacrifice, might not have been from those 'parts' in the first place!
Does it not make more sense to deal with pain first, provide the simulating brain with a movement illusion, see if it really is cranking out pain for no particularly good reason? If the pain goes away, great! Show the patient a few exercises to keep pain at bay. Another knee or hip or (insert name of structure) saved from sacrifice. If pain doesn't go away/stay away, then think about replacing the part.
In Part I, I introduced scenarios related to clear metaphors people use to describe pain. I used "icepick" and "fish hook" examples. When someone says they feel like they have a foreign object lodged somewhere, and it's perfectly obvious they don't, the comparison is at least acceptably clear as metaphor, even if the solution to the pain isn't yet clear.
What about if the metaphor used is not about a foreign object, but a body part that truly does exist inside the body? Suddenly comparisons are much less clear. Suddenly structures are blamed for misbehavior that is actually functional. Suddenly something that feels LIKE a "locked joint", becomes in a patient's mind, or in a therapist's mind, or a doctor's mind, a possibly 'real' locked joint. There are a million of these. Examples are, "I must have a bone out of place." "A muscle is cramped in my foot." "This tendon is too short - look". "I was fine until I lifted that couch, then my (whatever) seized up on me."
These are still metaphors, but now the issues the patient feels in the tissues are not clearly metaphoric at all. In fact, there has been nearly perfect reflection of metaphors like these, a verbal and investigative ping pong match of pain memes and memeplexes going on ever since humans have had pain and human primate social groomers have tried to help.
But.
Slowly it has begun to dawn on some of us who are fascinated by all the little tricks of the brain and the habits it has of setting up simulations of reality, that pain is something of a perception itself. A great example is phantom limb pain. This is pain that an amputee feels vividly and to his or her consternation, in the missing limb. It can't be the limb hurting, because the limb no longer exists.
But.
A representation of the limb does exist, in the brain. A brilliant neuroscientist/brain researcher named V.S. Ramachandran figured out that using a mirror box could help. The patient places the remaining limb in the box in a way that creates an illusion of a missing limb being present, and able to move freely. Even though the patient knows full well it's just a mirror image, moving freely and painlessly, some important part of the visual cortex actually will record this information and send it around the brain in such a way that pain is relieved in the "missing limb", the phantom of the missing limb, the virtual body part, the representational map of the part located in the brain. It's as if the brain thinks to itself, hmm, I must have made a mistake. It looks like that part can move ok.. Alrighty then, I'll take out the pain signal.
It gets even more strange - it turns out we all have these maps - everyone has them. And we all can feel pain in them, just as amputees do. Ready for more strangeness? Pain is usually in the brain map part instead of in the actual part. I know - this is where "what everyone knows" bumps into new science. Such apparent heresy! But not so strange if you accept the idea that the brain is a great big simulation producer. It can make you have a pain in a part that is not at all "damaged", just because it senses a threat to that part. Yes, you read that right. Nothing has to have happened to the part for the brain to make a pain in it. From my blogpost of September 4th, "Rhythms of the Brain" by György Buzsáki:
The short punch line of this book is that brains are foretelling devices and their predictive powers emerge from the various rhythms they perpetually generate. At the same time, brain activity can be tuned to become an ideal observer of the environment, due to an organized system of rhythms.
I really want you to know I did not make this up - György Buzsáki wrote an entire book about how this is not just possible but likely.
What can decrease pain? Helping the brain sort, refine, redraw its maps. How? Create an illusion for the brain in regular 4-limbed people in pain that is as powerful as the mirror box is for phantom limb pain. How? Well, movement is the key here. The brain needs to perceive some kind of movement before it can get off the square it is stuck on, pain-wise.
One can create a kinesthetic illusion of movement, through skin stretch. Simon Gandevia is the researcher who came up with this while studying cutaneous receptors. He is a lot less famous than Ramachandran is, but no less important to those of us who work with new ideas on how to pare back erroneous metaphor in our own thinking about pain. True, Simon Gandevia hasn't linked his own research yet to pain relief itself, specifically, but he has provided a huge clue. Putting this clue together with Patrick Wall's idea that pain is a "need state", and that pain relief follows a "consummatory movement", and bearing in mind the success of mirror therapy for pain in limb representations, is it really that hard to draw a line connecting the dots? Treating people who still have all their parts is much easier because you don't need a mirror, you just need to get on their skin and give their brain a movement illusion.
To me, this cuts through all the confusing metaphoric mesodermal tissue based wild goose chases that practitioners go on, led originally by convincing descriptions of pain given to them by patients, which they then go on and foist on other patients, and all of which becomes some version of gravely mistaken treatment orthodoxy. I am fond of saying three things to patients on their first visit:
1. There are people who have things on x-rays like degeneration (etc.) who don't have any pain
2. There are people who have pain, and have no x-ray changes
3. Pain and x-rays (or, pain and body weight, pain and posture, pain and... [etc.]) don't necessarily have anything to do with each other
(Truth is, I'm haunted a bit by all the years I worked as a PT, diligently and inadvertently contributing to peoples' pain experience by choosing wrong words, like, "looks like a disc problem", "Sudek's Atrophy? You'll need to wear this brace to keep your fingers from curling into your palm", "This looks like a tendon rupture", etc etc... I'm haunted by a past filled with thousands of faces of patients who intersected with my life, in pain, with ordinary nervous systems and intact tissue, looking at me as some sort of keyholder of relief for them, me having official human primate social grooming status and license but no key, no clue!- to how to really help them at all, other than temporary accompaniment and a set of protocols on how to get them to move anyway, even if it hurt, social manipulation/motivation. Cheer leader stuff. It makes me cringe nowadays - if I were in a patient's shoes I would want to shoot some kid fresh out of school who had the audacity to think she knew the first thing about what my brain and body were going through. But apparent sincerity and earnestness kept me alive, I suppose... Plus, to be fair to my former self, there was not all this nice research available back then, in the 70's. There is no excuse for continuation of perpetuation of inappropriate metaphor in my profession (or the medical profession) anymore, other than pure ignorance/being too busy to read/relying on the schools to have taught what is necessary to know to do the job. The schools are only just learning about this stuff themselves! It'll be awhile more before they figure out how to do the requisite "knowledge translation".)
Certainly there will be some hips that still need replacing and some knees, and so on, but the pain felt in those parts which have been sacrificed might not be relieved by the sacrifice, might not have been from those 'parts' in the first place!
Does it not make more sense to deal with pain first, provide the simulating brain with a movement illusion, see if it really is cranking out pain for no particularly good reason? If the pain goes away, great! Show the patient a few exercises to keep pain at bay. Another knee or hip or (insert name of structure) saved from sacrifice. If pain doesn't go away/stay away, then think about replacing the part.
Now back to function.. Part I
In the Butler blog is a post about painful words, how they conjure up horrible imaginings in peoples' minds, create needless stress and worsen pain. A comment from a reader of this blog about his knee pain, knee replacement, his surgeon's words reflecting insecurities about not being able to "fix" his patient's pain, and the reader's battle to withdraw from heavy pain meds came to mind immediately.
...I realized after months of difficult recovery from my joint replacement that one of the key things my surgeon said to me was "I am worried about our ability to control your pain". He is a great surgeon, and meant well. But he played directly into strong fears that I had about the surgery already. I obsessed on the idea that my pain might be uncontrollable. I believe that contributed a lot to me winding up on 350 mg per day of oxycodone.
I'm doing much better now and have been off the oxycodone for 5 weeks.
A battle is being fought by a tiny group of people in lots of ways, including through blogs (like this one), comprised of practitioners (myself among them) whose main agenda is to deconstruct pain for the sake of having less of it around perpetuating useless suffering. We are fighting an abstract battle, one of memes: the mindless and needless enticement of persistent pain into permanent suffering, through simple correctable things like word choice. We are trying to change this by presenting, studying, arguing, pointing out current pain science, science which refutes an entire historical mind set not only guilty of permitting needless suffering, but also of giving rise to a professionally reinforced sense of helplessness and avoidable drug use in patients.
There are at least two layers to this:
1. Clear metaphor
Some of the metaphors patients use are easy enough to understand as such: when someone says something like, "It feels as though I have an icepick through my shoulder here and a fish hook stuck in it back here", it's obvious both to them and to the practitioner that they have no such thing really - instead they are explaining how their pain "feels" to them. The practitioner response is often a little smile at the colorful language; if the patient is insistent after a few treatment attempts (based on having diligently tried to find and treat the offending tissue) the practitioner rapidly begins to feel helpless and either refers on or else decides the patient must be crazy with all that icepick talk.
At least three scenarios can ensue from here:
Stay tuned for Part II, Unclear metaphor.
...I realized after months of difficult recovery from my joint replacement that one of the key things my surgeon said to me was "I am worried about our ability to control your pain". He is a great surgeon, and meant well. But he played directly into strong fears that I had about the surgery already. I obsessed on the idea that my pain might be uncontrollable. I believe that contributed a lot to me winding up on 350 mg per day of oxycodone.
I'm doing much better now and have been off the oxycodone for 5 weeks.
A battle is being fought by a tiny group of people in lots of ways, including through blogs (like this one), comprised of practitioners (myself among them) whose main agenda is to deconstruct pain for the sake of having less of it around perpetuating useless suffering. We are fighting an abstract battle, one of memes: the mindless and needless enticement of persistent pain into permanent suffering, through simple correctable things like word choice. We are trying to change this by presenting, studying, arguing, pointing out current pain science, science which refutes an entire historical mind set not only guilty of permitting needless suffering, but also of giving rise to a professionally reinforced sense of helplessness and avoidable drug use in patients.
There are at least two layers to this:
1. Clear metaphor
Some of the metaphors patients use are easy enough to understand as such: when someone says something like, "It feels as though I have an icepick through my shoulder here and a fish hook stuck in it back here", it's obvious both to them and to the practitioner that they have no such thing really - instead they are explaining how their pain "feels" to them. The practitioner response is often a little smile at the colorful language; if the patient is insistent after a few treatment attempts (based on having diligently tried to find and treat the offending tissue) the practitioner rapidly begins to feel helpless and either refers on or else decides the patient must be crazy with all that icepick talk.
At least three scenarios can ensue from here:
a). With any luck the patient will be referred to a PT who understands pain, and can reassure the patient that perhaps that's really all it amounts to. A few little manual therapy maneuvers, voilá, some cranky neural tissue somewhere in the vicinity has more oxygen, the brain maps all overlap perfectly again, the protective motor reflexes dissolve, needless ion channels vanish, stress is gone, all is well, patient can move the shoulder just fine again. Metaphoric icepick and fishhook are gone as if they had never been there, even as "just" a feeling or sensation that was turned into an image in the patient's mind to help him or her communicate verbally something ineffable like pain that has no words of its own.
b). In scenario two, the patient may be referred for further imaging and possibly surgery. Diligent medical practitioners will diligently look for and usually find some aspect of the patient's body that they decide must be responsible for the pain, and will schedule a surgical intervention. They may be referred before or after to a PT who closely follows the medical tissue-based model for pain. The PT will do all sorts of things to try to help, but if their word choice is not careful, they will merely reinforce pain while trying to get the patient to do all sorts of activities in spite of the pain.
c). In scenario three, the patient is referred to a psychiatrist.
Stay tuned for Part II, Unclear metaphor.
Thursday, November 08, 2007
Boiling the flimflam off human primate social grooming
Every so often something crosses my path which cheers me up. Recently I found this blog by an ex-chiropractor who no longer tolerates wool pulled down over his eyes or his mind. Good for him. Here's another.
The sooner hucksterism leaves my field of endeavor the sooner I'll be way more happy. To get hucksterism out of this field requires that individuals like this begin to save themselves from replicating it, and then talk about it.
Really, it comes down to just this: Someone in pain, Person A, goes to see someone, Person B, about it. Hopefully Person B has been trained to be ethical and scientifically respectful. Hopefully Person B does not take on a hero's role. Hopefully Person B has been around long enough to have discarded uselessness in favor of honesty. Hopefully Person B is current with pain science.
Person B will do what he or she can to provide a favorable no nonsense context for the patient to conduct his or her own exploration. There will be usually some provision of exteroceptive input of some kind. There will be no funny business - Person A will be told what is expected of them, taught what to look for, asked to proceed at their own rate. It will have been made clear, one way or another, in some way Person A can understand, that it's their job to get themselves better, and that Person B is a helper.
Person B will realize all along that he or she is nothing but a catalyst. Person A will be doing all the hard work of sensing and learning, changing their own nervous system (or rather, allowing their own nervous system to change itself) to something more optimal. The desired reaction occurs entirely within the patient, and the only reagent is the patient and all their inTRA-relationships. None of this is a simple thing to understand at a scientific level, but progress is being made and the science base is growing; maybe one day the physical contact aspect of human primate social grooming will be not only stripped of flimflam but will have vindicated itself.
Changes occur, usually in the direction of improved function and decreased pain. But not always, and not in any sort of predictable way or speed. All this depends on the patient, the context, and on the quality of therapeutic contact within a treatment room.
Let's discuss "crucible". On the surface it means a container such as the ones used in chemical labs, able to stand high heat etc. A deeper level of meaning (without being religious in any way) is "cross", an intersection or crossroads, a place where a change of direction can take place. Other words contain the same root, words such as "crucial", or something that is the "crux" of a matter.
A treatment room is, then, a metaphoric crucible. As such it should be able to stand the metaphoric equivalent of "high heat" - the patient should sense that the room they are in is safe for them to be who they are, express whatever they want. And they may well need to.
Not only should the room be designed to take the "heat", the therapist should be "fireproof" as well, able to tolerate whatever sorts of pain offerings a patient might bring, emotional or physical, without flinching. Flinching is a non-conscious, mirror-neuron, socially connective, social behavior. To NOT flinch and still retain good therapeutic contact is definitely a learned behavior. Here, I must confess, I am still working on getting the right proportions of non-flinch combined with solid connection during the interview. I'll never be perfect - no therapist will ever be perfect. It keeps one humble and honest. I would like to add, however, that not very many people are "high heat" people - most cases of persistent pain are very straightforward.
The therapist will have tried to eliminate as many distractions and noceboic elements as possible from the crucible. He or she will have made it as clear as possible that the pain issue is something the patient must permit themselves to work through. This needn't mean having to experience more pain. In fact, the less the process "hurts" the better. No point in reinforcing the pathways associated with the very thing the patient has come in to try to learn how to deal with, get rid of.
Eventually the time will come for the reaction. I usually spend a half hour or so, interviewing, examining, explaining, which leaves a half hour for the patient to experience a sample of what happens on the table. Subsequent visits are much more tabletime. Usually at least two visits, sometimes as many as 4, are required to complete the process. (A few of my patients come in long term for various reasons, but very few indeed. It is not encouraged.)
Hands-on is definitely involved - for most people who come. Anything that sounds like wind-up pain, I like to leave alone, at least in visit one. I've had people leave disappointed, people who just didn't get that they would require more prep time, and who didn't return. C'est la vie. Better they leave in the same shape they came in, than feeling worse. I'm happy to say this is so rare it's only happened twice. I learned my lesson with a patient one time whose pain flared suspiciously with the sort of hands-on I do, so I learned to spot the signs, and do not use manual therapy in the first visit with a patient who says something like, "I've always noticed, whenever I get an injury and it heals, even just a scratch, it always feels painful after that - the pain never goes away." Fortunately these sorts of patients (highly sensitized ones with abnormal pain processing) are pretty rare. Most people just have regular persistent pain, good processing, but need some assistance so they can connect dots within their own nervous systems.
Finally, the hands-on part is nothing more than contact with skin, at varying pressures and angles, but mostly lateral stretch. This does nothing TO a person's "body", or TO any of the mesodermal derivatives that lie within it, rather it sets up volleys of firing sequences that have been mapped and studied by neurophysiologists and other curious people, and documented scientifically (by Simon Gandevia and others). One can predict that if one has chosen one's patients wisely, and guided the therapeutic relationship appropriately, Person A will let their own non-conscious system take over all the heavy lifting, let it will change itself/its output into something easier to live with, something less mechanosensitive, less painful, with easier movement to follow.
Like any catalyst, the therapist will have added nothing to this reaction, will have only functioned to help speed it up, and will leave nothing of themselves in the final product.
The sooner hucksterism leaves my field of endeavor the sooner I'll be way more happy. To get hucksterism out of this field requires that individuals like this begin to save themselves from replicating it, and then talk about it.
Really, it comes down to just this: Someone in pain, Person A, goes to see someone, Person B, about it. Hopefully Person B has been trained to be ethical and scientifically respectful. Hopefully Person B does not take on a hero's role. Hopefully Person B has been around long enough to have discarded uselessness in favor of honesty. Hopefully Person B is current with pain science.
Person B will do what he or she can to provide a favorable no nonsense context for the patient to conduct his or her own exploration. There will be usually some provision of exteroceptive input of some kind. There will be no funny business - Person A will be told what is expected of them, taught what to look for, asked to proceed at their own rate. It will have been made clear, one way or another, in some way Person A can understand, that it's their job to get themselves better, and that Person B is a helper.
Person B will realize all along that he or she is nothing but a catalyst. Person A will be doing all the hard work of sensing and learning, changing their own nervous system (or rather, allowing their own nervous system to change itself) to something more optimal. The desired reaction occurs entirely within the patient, and the only reagent is the patient and all their inTRA-relationships. None of this is a simple thing to understand at a scientific level, but progress is being made and the science base is growing; maybe one day the physical contact aspect of human primate social grooming will be not only stripped of flimflam but will have vindicated itself.
Changes occur, usually in the direction of improved function and decreased pain. But not always, and not in any sort of predictable way or speed. All this depends on the patient, the context, and on the quality of therapeutic contact within a treatment room.
Let's discuss "crucible". On the surface it means a container such as the ones used in chemical labs, able to stand high heat etc. A deeper level of meaning (without being religious in any way) is "cross", an intersection or crossroads, a place where a change of direction can take place. Other words contain the same root, words such as "crucial", or something that is the "crux" of a matter.
A treatment room is, then, a metaphoric crucible. As such it should be able to stand the metaphoric equivalent of "high heat" - the patient should sense that the room they are in is safe for them to be who they are, express whatever they want. And they may well need to.
Not only should the room be designed to take the "heat", the therapist should be "fireproof" as well, able to tolerate whatever sorts of pain offerings a patient might bring, emotional or physical, without flinching. Flinching is a non-conscious, mirror-neuron, socially connective, social behavior. To NOT flinch and still retain good therapeutic contact is definitely a learned behavior. Here, I must confess, I am still working on getting the right proportions of non-flinch combined with solid connection during the interview. I'll never be perfect - no therapist will ever be perfect. It keeps one humble and honest. I would like to add, however, that not very many people are "high heat" people - most cases of persistent pain are very straightforward.
The therapist will have tried to eliminate as many distractions and noceboic elements as possible from the crucible. He or she will have made it as clear as possible that the pain issue is something the patient must permit themselves to work through. This needn't mean having to experience more pain. In fact, the less the process "hurts" the better. No point in reinforcing the pathways associated with the very thing the patient has come in to try to learn how to deal with, get rid of.
Eventually the time will come for the reaction. I usually spend a half hour or so, interviewing, examining, explaining, which leaves a half hour for the patient to experience a sample of what happens on the table. Subsequent visits are much more tabletime. Usually at least two visits, sometimes as many as 4, are required to complete the process. (A few of my patients come in long term for various reasons, but very few indeed. It is not encouraged.)
Hands-on is definitely involved - for most people who come. Anything that sounds like wind-up pain, I like to leave alone, at least in visit one. I've had people leave disappointed, people who just didn't get that they would require more prep time, and who didn't return. C'est la vie. Better they leave in the same shape they came in, than feeling worse. I'm happy to say this is so rare it's only happened twice. I learned my lesson with a patient one time whose pain flared suspiciously with the sort of hands-on I do, so I learned to spot the signs, and do not use manual therapy in the first visit with a patient who says something like, "I've always noticed, whenever I get an injury and it heals, even just a scratch, it always feels painful after that - the pain never goes away." Fortunately these sorts of patients (highly sensitized ones with abnormal pain processing) are pretty rare. Most people just have regular persistent pain, good processing, but need some assistance so they can connect dots within their own nervous systems.
Finally, the hands-on part is nothing more than contact with skin, at varying pressures and angles, but mostly lateral stretch. This does nothing TO a person's "body", or TO any of the mesodermal derivatives that lie within it, rather it sets up volleys of firing sequences that have been mapped and studied by neurophysiologists and other curious people, and documented scientifically (by Simon Gandevia and others). One can predict that if one has chosen one's patients wisely, and guided the therapeutic relationship appropriately, Person A will let their own non-conscious system take over all the heavy lifting, let it will change itself/its output into something easier to live with, something less mechanosensitive, less painful, with easier movement to follow.
Like any catalyst, the therapist will have added nothing to this reaction, will have only functioned to help speed it up, and will leave nothing of themselves in the final product.
Friday, March 30, 2007
Clinical science and Occam's "chainsaw"
PT is a bit like a cowboy movie complete with saloon etiquette, that can include the the virtual sounds of glass breaking. I became entangled lately in a thread on an orthopaedic forum, the name of which shall remain anonymous in order to spare it embarrassment, because I think it tries, it really tries to be science-based....
I have a few points to make about issues raised during the course of this thread, that directly relate to science and the PT version thereof, that speak to the role of being or at least striving to be a "clinical scientist".
First of all, PT "science" should align itself with and adhere to basic science 101 tenets. It shouldn't make up things for the sake of convenience, such as correlation in any way equaling causal relation. Yet in a PT textbook, apparently, there is being taught some mechanism for doing this very thing. Very pseudo-scientific IMHO.
Second, it should assume nothing, and operate according to the essential scientific principle that all hypotheses are there to be knocked over. (I.e., no one should take issue with others if their much beloved "hypothesis" and treatment construct curves around and smacks them in the back of their own head one day.)
Third, in the clinic we can literally BE scientific. E.g, an hypothesis exists that "pain comes from joints". No one seems to have tried to take that one down yet. Well, except for me and a handful of others perhaps. An easy way to take that one down, to disprove it, to thereby either improve or even disprove the "construct validity" of the "hypothesis", and by extension all treatments based on that hypothesis, would be to design a system that does not involve treating joints in any way. (One like mine, just as an example.)
Such a system must have construct validity based on something, of course, so let's pick updated pain theory. None of the variables in treatment should exist unaccounted for. As best I can, I have tried to account for all variables. I trust that pain science as developed by Patrick Wall and Ronald Melzack, and theorized as the neuromatrix model, have already weeded out confounding variables better than my own profession ever has, with all its vested interests, youth and lack of perspective. I am encouraged by the fact that prominent physiotherapists, such as David Butler, Lorimer Moseley, Louis Gifford and Michael Shacklock, have themselves taken on the task of examining neuromatrix theory, thinking through the ramifications, and have pioneered physiotherapy research pertaining to pain and our professional interface with it. They have designed methods to deal with pain that include constructs other than the ones based on "pain comes from joints", and their constructs may or may not exclude that particular hypothesis. (My own treatment construct deliberately DOES try to exclude it, because I believe it is a false hypothesis to begin with.)
One can't "prove" an hypothesis, one can only disprove one. I aim to disprove the "pain comes from joints" hypothesis, or in the attempt, at least refine it more.
So, with a treatment system geared at ONLY the surface of the body, and the nervous system, devoid of provocation testing of joints (because why include that if you are aiming to reduce pain instead of amplify it), or even of thinking about joints in any way at all, other than to test for range, I somehow managed to help someone (a young female figure skater) completely eliminate pain and dysfunction in her hip area in two visits; pain that was disabling (i.e., she was limping), that had been present for a month and had had other (unsuccessful and joint focused) practitioner involvement already. Furthermore, the girl in question went straight back to figure skate training full tilt again, with no problem, after visit number one.
To me, as a clinical scientist, this suggests that I managed, and am still managing, to disprove the hypothesis that "pain comes from joints", n=1, one at a time, one after another on through time.
Not only that, but when pain truly does come from a joint, as in the case of a woman I treated who had a stress fracture of the hip, it is easy to know that in fact the hip joint is involved when the parameters of the method are followed, and the patient responds outside the normal cluster of responses, i.e., does not respond, period, i.e., still can't weight bear without crutches.
After three attempts, time to send her back to the MD, even though the first x-ray prior to her ever seeing me was negative (i.e., they missed the fracture first time round). She in fact needed a pin. She came once more post op to mop up more pain she had from the whole traumatic process of the hip pinning. Once. Fine after that.
I think this process is what is involved in being a good responsible clinician with a grasp of basic science principles and a desire to get past all the clutter our profession saddles us with. Occam's chainsaw. Everyone can learn to use it.
I have a few points to make about issues raised during the course of this thread, that directly relate to science and the PT version thereof, that speak to the role of being or at least striving to be a "clinical scientist".
First of all, PT "science" should align itself with and adhere to basic science 101 tenets. It shouldn't make up things for the sake of convenience, such as correlation in any way equaling causal relation. Yet in a PT textbook, apparently, there is being taught some mechanism for doing this very thing. Very pseudo-scientific IMHO.
Second, it should assume nothing, and operate according to the essential scientific principle that all hypotheses are there to be knocked over. (I.e., no one should take issue with others if their much beloved "hypothesis" and treatment construct curves around and smacks them in the back of their own head one day.)
Third, in the clinic we can literally BE scientific. E.g, an hypothesis exists that "pain comes from joints". No one seems to have tried to take that one down yet. Well, except for me and a handful of others perhaps. An easy way to take that one down, to disprove it, to thereby either improve or even disprove the "construct validity" of the "hypothesis", and by extension all treatments based on that hypothesis, would be to design a system that does not involve treating joints in any way. (One like mine, just as an example.)
Such a system must have construct validity based on something, of course, so let's pick updated pain theory. None of the variables in treatment should exist unaccounted for. As best I can, I have tried to account for all variables. I trust that pain science as developed by Patrick Wall and Ronald Melzack, and theorized as the neuromatrix model, have already weeded out confounding variables better than my own profession ever has, with all its vested interests, youth and lack of perspective. I am encouraged by the fact that prominent physiotherapists, such as David Butler, Lorimer Moseley, Louis Gifford and Michael Shacklock, have themselves taken on the task of examining neuromatrix theory, thinking through the ramifications, and have pioneered physiotherapy research pertaining to pain and our professional interface with it. They have designed methods to deal with pain that include constructs other than the ones based on "pain comes from joints", and their constructs may or may not exclude that particular hypothesis. (My own treatment construct deliberately DOES try to exclude it, because I believe it is a false hypothesis to begin with.)
One can't "prove" an hypothesis, one can only disprove one. I aim to disprove the "pain comes from joints" hypothesis, or in the attempt, at least refine it more.
So, with a treatment system geared at ONLY the surface of the body, and the nervous system, devoid of provocation testing of joints (because why include that if you are aiming to reduce pain instead of amplify it), or even of thinking about joints in any way at all, other than to test for range, I somehow managed to help someone (a young female figure skater) completely eliminate pain and dysfunction in her hip area in two visits; pain that was disabling (i.e., she was limping), that had been present for a month and had had other (unsuccessful and joint focused) practitioner involvement already. Furthermore, the girl in question went straight back to figure skate training full tilt again, with no problem, after visit number one.
To me, as a clinical scientist, this suggests that I managed, and am still managing, to disprove the hypothesis that "pain comes from joints", n=1, one at a time, one after another on through time.
Not only that, but when pain truly does come from a joint, as in the case of a woman I treated who had a stress fracture of the hip, it is easy to know that in fact the hip joint is involved when the parameters of the method are followed, and the patient responds outside the normal cluster of responses, i.e., does not respond, period, i.e., still can't weight bear without crutches.
After three attempts, time to send her back to the MD, even though the first x-ray prior to her ever seeing me was negative (i.e., they missed the fracture first time round). She in fact needed a pin. She came once more post op to mop up more pain she had from the whole traumatic process of the hip pinning. Once. Fine after that.
I think this process is what is involved in being a good responsible clinician with a grasp of basic science principles and a desire to get past all the clutter our profession saddles us with. Occam's chainsaw. Everyone can learn to use it.
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