Neurotopian's "Pain for Dummies" series

Neurotopian is a German PT I met online long ago, named Matthias. He is and was brilliant - I am so glad he is writing his blog in English for those of us who don't speak, write, or communicate in any way in German.

Recently I came to realize that people actually do read this blog, that it comes up when they search for certain words, like "pain", etc.. If that's the case, I really want to give Matthias and his Neurotopian blog some press.

Check out his latest post, Pain for Dummies VI. Read through his older posts in the series as well. This is a guy who never stops thinking. Thumbs up Matthias. :)

Thoughts on zombie states

Deric Bownds always has interesting bits blogged at his site, Mindblog (see link to the right). Today, he offered up this: Some Rambling on Selves and Purposes.

I won't recreate the links in his post. Just go to his post and click on them yourself. Especially, read the quote from the Blakeslees' book.

Ginger Campbell recently interviewed Christof Koch (neuroscientist) (see her show notes page for podcast #22) who has many insights into what he calls "zombie" behavior. Zombie behaviors are those which have grown so automatic that no one really has to really be "home" for them to be enacted. Much ordinary social exchange could go into this category - conventional behavior, smiling, etc. I think much PT practice can easily become zombie-like as well. This is a little-recognized and glossed-over possibility. If I am in pain, and am taking my body in to see if I can get some help for it, I don't want a zombie PT treating me. I want someone who will come alive to the pain output my nervous system is broadcasting throughout my body, and I want that individual to care about it and for it. I want her or him, to demonstrate this care, by handling me gently.

I will need this consideration from them, for no matter how together I may seem on the outside, inside I will feel thoroughly discombobulated. My nervous system will be completely sensitized to any hint of any lack of attentive care, especially while being touched - my nervous system will be reading theirs like mad. It will be like I have no boundaries, and I will rely on my caretaker to have ones that are adequate, both with respect to my physicality AND inside themselves, a simple ability to attend, to stay focused, to not permit interruption from outside the treatment room during this process, and to set up the treatment crucible with an optimum length of time in which our two nervous systems can be connected through manual contact.

I will most definitely need to be reassured in the midst of my decompensation, wittingly or unwittingly, and will need a helper who is NOT enacting behaviours from some disconnected state of awareness or attention. I want nothing less from a care giver of mine than I offer to others as their chosen Human Primate Social Groomer.

The only way to not become a zombie, insofar as I can gather, is to practice attending to things (with whatever illusion we can scrape together as an "I" construct), simple, physiological things like breath, like one's own movement/motor output, finding something fresh and new in it every single day, until the day comes when finally we no longer need to think about constructing any more "days" - our personal arrow of time will have hit its mark.

Sorting out manual therapy

As far as I know, no one has really taken this on in any sort of serious way. So what the heck, I'll give it a bit of a go.

First there are a few self-explanatory truths to base this project on, that are beyond dispute in my opinion:
1. Energy concepts do not belong in manual therapy.
2. The nervous system is the part keeping a human organism "alive", and it is the part responsible for the phenomenon of felt and experienced pain. Nothing about the pain experience will change until this system is ready to change it, or to let it change.
3. Neuro-modulation in the broadest sense means, supplying a novel input in order to facilitate a new output.


If we are faithful to these three basic concepts, and use Occam's razor, ever so carefully, ever so precisely, we will end up with the following idea: All manual therapy involves touching the body somehow, so therefore all of it is neuromodulatory. The receptors that are affected are mostly mechanoreceptors and exteroceptors, all afferents. We could call ALL manual therapy, "Extero-Mechanorecepto-neuromodulation."

Some forms of manual therapy, or mechanorecepto-neuromodulation, focus on the surface more, while other forms focus on what lies below the surface. For example, acupuncture and needling in general supposedly treat something underneath the skin, but given the depth of cutis/subcutis, and the ubiquity of cutaneous neural twigs, it is more likely that needling stimulates mostly exteroceptors, maybe a few mechanoreceptors. Which is fine. Let's move on.

Manipulative therapy purports to treat joints, including those mechanoreceptors known as proprioceptors. To get to those, it is necessary to get past mechanoreceptors in skin and other tissue; however, manipulative therapy ignores more superficial mechanoreception as if it were not even there.

Soft tissue sorts of therapies, of which there are too many to call out by name, stimulate mechanoreceptors in skin mostly, and in layers just deep to it. So we could classify all these as neuromodulation of the exteroceptor/mechanoreceptor classes of afferents.

So, we could end up with a very small flow chart that depicts all of the manual therapies, with "Manually Applied Neuromodulation" at the top. There would be two branches off this item. One would read, "Extero-mechano-proprio- neuromodulation" (for manipulation of joints) and the other would read "Extero-mechano-neuromodulation" - exactly the same but for proprio (everything else).

Now, the razor can be pulled away for a time, until it is shown that Extero and Mechano only are more than enough effective to permit the dissolution and gradual fading entirely away of that whole first branch of the tree, which basically includes only joint manipulation.

I contend that any "proprio" stimulation necessary can be done without the audible pop noise. Studies support this. I contend also that joint manipulation by whatever name, as a manual therapy, has been kept on life support for a hundred years, and it is time to pull the plug on it. If it can stay alive under its own steam, fine, but no extreme efforts should be made to maintain its existence as a set of "special" knowledge to be handed along in a cult-like manner.

Body Maps

Since my new book, The Body Has a Mind of its Own: How Body Maps in Your Brain Help You Do (Almost) Everything Better arrived I've been buried in it. The Blakeslees have written a very good book, (even if they didn't include a reference list).

Ginger Campbell MD has an excellent podcast about this book. Visit her show notes here.

This book, and for those in a hurry, the podcast, affords us a long leisurely look into the brain and its workings (especially after having just read Rhythms of the Brain!) The brain creates several maps, mostly in the parietal lobes, mostly of the body itself (the human antigravity suit itself, inside and out) but also of the space around the body - it will change the maps to include any tool that is being used, for example, a cane used by a blind person to navigate along a street. The kinesthetic/motor map stretches out to include the cane, spreads over the visual cortex, and enables the person to "see" the sidewalk through their body.

The brain turns on as soon as it forms embryologically, starts to function even as it still grows (the frontal lobes are not fully grown for a couple decades), and does not ever turn off until the moment we die. Even while we are sound asleep, it is still working away, keeping our lungs breathing and our heart beating. Amazing. First there is movement, then through feedback from the movement and subsequent encounter with the environment, the brain refines its maps of space and how the body fits into them. Strokes and other neurological twists of fate can lead to some very strange mapping problems, like the feeling of having three arms, or only one, or that a limb does not belong to one and must be amputated.

Of interest to me as a manual therapist is a careful and lengthy explanation of various dystonias and what is thought to happen to the mapping in association. Stress-free practicing of any honed motor skill is advised; just practicing mentally (e.g., golfing) will preserve mapping with good fidelity - the brain will use premotor maps, so no need to burn out your actual motor maps. Musicians will find this an important book to read, sports enthusiasts, anyone who uses their body for skilled performance of any sort.

When I think about how I use my own body, I realize I'm not apt to incur dystonia over time. For one thing, I don't rush, and for another, I never do the same thing twice, the same way, ever.

"Rhythms of the Brain" by György Buzsáki

I've been engrossed in this book ever since it arrived into my hot hands last week. The first sentence reads:

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.

He writes in the introduction;

My connection with brain rhythms began in April 1970, during a physiology lecture given by Endre Grastyán in the beautiful town of Pécs, on the sunny slopes of the Mecsek mountains in Hungary. The University of Pécs, or Universitas Quinque Ecclesiensis, as it was called when founded in 1367, has produced a remarkable set of neuroscientists, including János Szentágothai, the legendary neuroanatomist; Béla Flerkó and Béla Halász, pioneers of neuroendocrinology; György Székely, the renowned spinal cord physiologist; and Ferenc Gallyas, the creator of the silver impregnation methods widely used for neuronal labelling.

He goes on to talk about Grastyán's path to neuroscience, then comes back to the intersection of his own life with that of his mentor and inspiration, i.e. Grastyán himself:

In that particular lecture of April 1970, he talked about how the brain outputs, such as movement and cognition, control its inputs, rather than the other way around. His key idea was that control in living systems begins with the output. This is the seed for further evolution of the brain. Even in the most complex animals, the goal of cognition is the guidance of action. Indeed, the first simple biological systems did not have any inputs; they did not need them. They simply used an economical motor output, a rhythmic contraction of muscles. This is, of course, sufficient only when food is abundant in the sea environment. More complex forms of life evolved from this simple solution by modifying the simple rhythmic output. Sensation of direction and distance developed only after the "invention" of movement through space. The idea of output control and feedback is a profound thought even today. Back then, when Pavlovian sensory-sensory association was the dominant ideology in the East and the stimulus-decision-response paradigm dominated Western thinking, Grastyán's teachings were unusual, to say the least... in his physiology lecture, Grastyán was talking about some truly intriguing questions that sparked my interest. I applied to become his apprentice and spent most of my student life in his lab.

A note - Buzsáki was in med school at the time.

His book is a treasure, deliberately written for general readership but minus any dumbing down or tedious linearity/tunnel vision. He reminisces about lunchtime conversations fondly;

The best training in Grastyán's laboratory occurred through my participation in the regular lunch discussions that could go on for several hours, where topics meandered chaotically from homeostatic regulations of the brain to complex philosophical topics. It was during those lunch lessons where I first leaned about the hippocampal "theta" rhythm, the oscillation that has become my obsession ever since... As I have repeatedly discovered in my career, the informal lunch-seminar approach to science is hard to substitute with formal lectures or the reading of dense scientific papers. Seminars are tailored for an average group of people with the naive assumption that the audience retains all the details and follows and accepts the fundamental logic of the lecturer. In contrast, the essence of lunch conversation is to question the fundamental logic, a quest for clarification and simplification, a search for explanations and answers without a rigid agenda, where the focus is not on covering large chunks of material but on fully understanding even the smallest details. Of course, one can follow up a lecture by finding and reading the relevant published papers on the topic. However, most of the exciting findings in neuroscience are hidden in the small print of specialty journals, often written in a specialized and arcane language comprehensible to, at most, a handful of specialists. Overwhelmed with new and important discoveries in the various sub-subspecialties, the practicing neuroscientist, such as myself, tends to forget that neuroscience is of startling relevance to a contemporary society wrestling with complex issues such as social behavior, depression, and brain aging. It is hard to predict which of the numerous fundamental discoveries could alter the face of such large issues, and unless they are conveyed to others, they might be overlooked without making an impact. This is mainly so because the explanations we provide in papers to the superspecialists may be impenetrable to the uninitiated. Without attempting to place our work into a larger context from time to time, we deprive ourselves of the chance to be able to connect to the more macroscopic and microscopic levels of research. Yet, discoveries and insights realize their power only when understood by others. Understanding this important connection is what mostly motivated me to write this volume.

The entire book is written in this conversational style, but be aware that footnotes are to be found on nearly every page, dense with bibliographical/ historical/ explanatory detail. He explains the impact on neuroscience of several fields of science, including but not confined to complexity theory, consideration of temporal domain, why fundamental mathematical understandings are important. He takes care of both "why", and "how". His book does not contain chapters, instead he has broken his book into "Cycles", that unfold outward sequentially but also radially from a core, like a good orchestral symphony. If anyone has ever succeeded in giving a readership a sense of kaleidoscopic expansion of concept, a feeling of putting new ideas into order, it is this writer. A sense of movement is part of the reading of this book - he carries the reader along swiftly, effortlessly, gently and surely, providing long, sustained, spherical vistas into the knowledge base from lofty heights, as surely as any experienced and people-skilled mountaineering guide would do for a novice hiking group (minus sweat and exhaustion!), providing opportunities to examine the view from various pinnacles, ensuring not only that the experience provides memories to last a lifetime, but taking great personal pains to provide the possibility that the reading experience itself will be life-changing/enhancing/motivating. No one will come away from this book still ignorant of neuroscience, with no clue of how the brain works, of how the organism is integrated into it, of how it is integrated into the organism, or not able to "feel" the material on some level of being.

No one would regret reading this book. Highly recommended.

I will be bringing more of his book here over the next little while.

Trailblazing; No Time Left for Making Nice

Yet another discussion cropped up on SomaSimple, necessary though not without misunderstandings. It had to do with a "health performance solution" system dreamed up by a chiro and sold for major bucks to athletic trainers (among others), a rehash of everything that's already known and recycled endlessly in what I like to think of as "Mesodermolandia", a mythical "rain forest primeval" that gave rise to the world of human primate social grooming. Here is where reliance on "what works" feeds and fosters a conceptual anything goes attitude. Here, safe from challenge to status quo, a predatory spirit of postmodern what-the-bleep-do-we-know-anyway retreat into confused troop mentality flourishes, and a dense fast-growing tangle of argument based on next to nothing at all, combined with the blistering humidity of interpersonal opinion, chokes any real effort to think scientifically or even logically; all ideas underpinning this little subculture remain unexamined yet vigorously exchanged for coin.

After a reasonably successful deconstruction, the thread postmortem included the usual comments re: we weren't "nice" to the bringers - we pressed them for detail on their treatment construct (something seen as a bit rude in this world, believe it or not..), our interchange was seen to be "sarcastic", we seemed "hostile". I wrote the following post in response to these criticisms of our seemingly poor demeanor.

I'd like to point out that therapeutic niceness and politeness is likely what got us the deepest into this boggy morass in the first place, the swamp of erroneous belief, unsupportable treatment construct, and mesodermal bias, out of which grow giant trees of nonsense, treatment systems with deep roots down into the economy, choking out rational thought and real scientific advance of our human primate social grooming professions.

We each wake up one day and realize we have a choice to make - continue playing nice and do nothing, the mental equivalent of living wild and swinging from vine to vine like our primate siblings, OR.... learn to exercise our minds and their capacity to think, sort, discriminate, categorize, make sense, link, develop and strategize a way out of the mental jungle we have found ourselves in. Occam's razor isn't nearly big enough to do the job required in this profession. We need Occam's chainsaw. And when wielding Occam's chainsaw, inevitably some sawdust will get in someone's eye from time to time, or a wood chip hit them on the head, or the roar of the machine itself may sound uncomfortable.

But it's necessary. We mean no one any personal harm. Wear a hard hat and stay out of the way when the big trees topple. We're going to do this, blaze a trail of deconstruction, because we have to find a way for this profession to get itself out to the main road. Don't worry, it's far from being a clearcut.

Personally I'm determined to cut down whatever I need to, and in my tiny backpack I'm salvaging and carrying the essentials of soft kind gentle manual therapy. I get ever more invigorated to the task when more mesodermal bias looms in front of me, blocking my way.

The Brain's Kindness Detector? Right Anterior Insula

There is a long thread on SomaSimple to do with the insular cortex, a part of the brain that was researched heavily last winter. Well, the fun never stops, and now there's a book by Sandra and Matthew Blakeslee called The Body Has a Mind of its Own: How Body Maps in Your Brain Help You Do (Almost) Everything Better, not quite published yet. I will be reading the book not only as the owner-operator of an insula, but as a therapist who treats patients with persistent pain, who therefore deals with other peoples' insulae on a daily basis.

The September edition of Scientific American Mind features an excerpted chapter that has definitely sharpened my appetite for the book. The Blakeslees discuss the point that this region is found only in primates and by extension, us. Frogs, even other mammals like dogs etc, even though they can act sometimes as if they can feel everything the way we do, can't/don't. But first they explain the system. Here is a small part of it:

Quote:
Just as a road atlas is full of maps that represent real-world locations, your brain is full of body maps that represent aspects of yourself, inside and out. In contrast, the main goal of exteroception, externally oriented perception, is to create maps and models of your body, the world around your body, and your body's relation to the world. Your brain creates and maintains maps of your skin surface, limb position, joint movement and musculoskeletal system so that you can move about and interact with objects and people. You have distinct fibres in your spinal cord that carry such information in both directions: up from your body to your sensory maps and back down from your motor maps to your muscles.

Interoception is a separate realm of somatic sensation that is oriented inward. It has two sources. The first is the internally mapped state of your body. Bring your attention to the sensation these maps are generating in you right at the moment. Think about your heart, lungs, stomach, intestines, rectum, larynx, throat. Try to feel their activity if you can. All your innards have receptors that send information up to your brain for mapping your "gut" feelings of hunger, thirst, air hunger and other visceral sensations.

The second source of your interoceptive maps consists of a different class of receptors found on your body's surface, including your teeth, gums and tongue. Unlike the touch receptors that deal in pressure and vibration and are tied mainly to deliberate touch and action, these other receptors carry information about the "homeostatic" condition of your body - temperature, pain, itch, muscle ache, sexual arousal, crude touch and sensual touch. Homeostasis refers to your body's ability to maintain internal balance. Your spinal cord contains an evolutionary older set of fibres that carries this information to and from your brain.

This may seem strange at first, because many of your body parts end up being mapped by both systems. If someone pinches your arm, the pressure and pain will be represented in your primary touch map. But the pain will be rerepresented in your insula. Why is pain from one pinch mapped in two places? Because your insular maps serve a different function from your primary touch and motor maps. They are the command center for homeostatic self-regulation. For example, to run your body's thermostat properly - to keep your body temperature constant - your brain needs to know not just about your core temperature, but also about air touching your skin. Pain in your muscles, lungs and joints is important for marshaling your body's resources during exertion, but so are sensations of strain and movement and resistance in your joints and skin. So the primary brain maps for homeostatic signals from your body surface - about itch, sharp pain, dull pain, burning pain, tickle, sensual touch, heat and cold - as well as the sensations arising from your body's interior, are mapped in your insula, not in your primary touch cortex. You use those feelings less to deal with the outside world than to seek balance within your body and put your internal sensations in context. And as Critchley's results imply, interoception does far more for you than just letting you know your are hungry or exhausted or sexually sated. It is also a crucial ingredient in some of the most important aspects of human beingness: sentiment, sentience and emotional awareness.

The take home point here, is, keep your handling of patients, above all, kind.

Let kindness and slowness and non-invasiveness and invitation to move be the first and the main kinesthetic food you feed your patients' insulae, and all will be well.

This is the part of the brain you really need to impress with what a wonderful manual therapist you are, by being kinesthetically non-noceboic. Because it picks up emotional content so easily, make darn sure you are operating from your own best/highest emotional ground - THIS is the part of your patient's brain that can read your intention, emotionally. Give it NO reason to be suspicious of you in any way whatsoever. Make sure you get to know your own insula intimately, and inspect and repair the fence you put up around it, daily. These are your personal boundaries. In no way should your patient ever come to know what its contents are. What's in your own insula is absolutely none of their business.

"A memory is a moment when the past meets the future in the present" - Joseph LeDoux

Narrow Trail Walking

In this age of reduced car use I've developed a personal practice/ treatment strategy/ homework piece that I call "Narrow Trail Walking". It involves walking at a normal pace, with a normal length stride, but with one foot directly in front of the other as if one were walking on a narrow trail. Feet are to be kept pointing forward.

We become awfully lazy walkers on our smooth, sprawling sidewalks. Most people walk as if they were on a trail about a foot wide; I ask them to practice walking on one that is just one foot-width wide. At first people walk as if they were walking a plank (all tentative, slow, eyes to the ground, arms out to the side for balance) and need to be reminded that they're still on the flat ground, won't fall, to just stride along.

To stride requires elongation of forward leg and telescoping or shortening up into the body of the back leg. Of course, all this is handled by the pelvis and low back, not the legs themselves, but it's a useful sensory cue to give a patient at first. Once they've got the rhythm, then one can tell them to become aware of how the pelvis has to rock and roll to get the legs smoothly organized, how the back has to sidebend/shorten on one side, while elongating on the other. Both lumbosacral plexuses get flossed alternately.

Next, I ask them to become aware of how their trunk must be capable of twisting and "wringing" to remain facing forward. This is a bit of a "stretch" for most people accustomed to walking like robots, with no trunk motion whatsoever.

The next piece is the arm swing. Invariably people try to swing the same side arm and leg at first, but they correct it easily once they know to, alternate to the legs which are going along fine by now. Voilá, all the peripheral nerves are now flossing through the body from the neck down. The spinal cord is rotating/wringing like a non-rigid bidirectional washing machine agitator, flexing and elongating, feeding itself inside its columnar support with every step.

The last piece is to ask them to keep their eyes level on the horizon, looking for food/predators, like any proper biped. It's interesting how fast heads stop bobbing. The neck automatically starts to do what it's supposed to do, i.e., adapt to movement from below, and balance a still head effortlessly over a moving body.

This N. American culture does not model simple walking very well to its children. I started imitating runway models, but they prance too much. So I kept the crossover portion but toned down the prance, then realized I was walking the way we bipeds likely evolved, on little trails through long grass, every cubic inch of body generating or receiving some sort of motion in the process. My kinesthetic input conjured up visual images of every example of truly graceful walking I'd ever seen. After awhile it does feel effortless and natural, and one needn't be a woman to walk gracefully. Narrow trail walking can take care of lower limb pain to a large extent, and keeps the outside of the legs stretchy and extensible.

"Go Animal"

I've placed a link to this site in the link menu to the right. I found this site quite by chance one day while googling info on long term potentiation.

Frank Forencich is a combination physical educator, neuro science lover and author. His newsletters are a delight to read, although sadly he seems to write them quite rarely. I guess he's out doing what he loves, which is moving.

"Sicko"

I went and saw this movie last night. It had some shocking, several touching, and many hilarious moments, all the better to convey the main point, i.e., the absurdity of the U.S. healthcare system's provision of health care BY bottom line profiteers.

In one scene, Michael Moore is sitting at a table of American ex-pats in France, sipping wine with them while they tell of the ease with which they raise their families in a family centered place like France. The government supports child-rearing by providing heavily-subsidized, universal daycare and even nanny-support. When the spectre of high taxes for such exquisite provision is raised for discussion, we see into a typical middle class French home complete with children, decorated with original art and souvenirs of trips abroad, taken with the 5 weeks of (paid) holidays commonly enjoyed for family bonding time. The homeowners state that holidays are probably their biggest household "expense".

At the table of ex-pats, Michael Moore can't take it anymore, sticks his fingers in his ears and sings "La-la-la-la...."

A touching moment (for me) was his interview with a Canadian on a golf course, who although he identified himself as a Conservative, wouldn't dream of trying to change the Canadian health care system as was envisioned by T.C. Douglas.

The movie captures all the blank looks of disbelief and smiles on the faces of citizens of non-US countries as Moore probes them for the political dirt - surely there must be a catch, right? After all, the powers-that-be in the US talk about all the terrible conditions that exist in socialized medicine countries, so they must be hiding the real truth, right? What is the true "cost" of all this "free" care? Try as he might, he just can't seem to find any smut to highlight. People seem happy, secure, peaceful, and in control of their lives. Governments in charge of operating egalitarian health care systems exist to carry out the "will" of the "people" to have the right to ...normal existence; happy, peaceful, secure and in control of their personal lives. Not the other way round.

By contrast, in the U.S., people, even those who can afford the $600 or so per month insurance premiums, have no guarantee they will be covered. A man who used to work for a health insurance company is interviewed - his job once was to screen out people as ineligible AFTER they received a medical diagnosis or treatment. They are rewarded for saving the company money by denying claims.

What if a patient has no insurance? They can end up dumped by a cab in front of a homeless shelter in the middle of the night, still wearing a hospital gown.

TakeHome Points about Autonomics to Skin

Here is a section of the concluding remarks Gibbins makes towards the end of his chapter, my bolds.

Quote:

GENERAL FEATURES OF AUTONOMIC PATHWAYS TO CUTANEOUS EFFECTORS

From the preceding account, it is obvious that the skin is a major target of the autonomic nervous system in most vertebrate groups. In mammals with hairy skin, up to 25% of neurons in the paravertebral sympathetic ganglia lie in pilomotor pathways in addition to various populations of vasomotor neurons. Although few details are known, there is likely to be at least as large a pool of neurons supplying the dense innervation to the sophisticated pennamotor system of birds. Mammals with extensively innervated and widely distributed sweat glands, such as humans, have up to another 15-25% of their paravertebral sympathetic neurons in sudomotor pathways. Similarly, 25-50% of neurons in the sympathetic ganglia of anuran amphibians lie in cutaneous secretomotor pathways. Overall the skin represents a substantial target of the autonomic outflows, rivaled in size and number of neurons only by the sympathetic vasoconstrictor pathways that supply virtually all of the vasculature in most vertebrate species.

Despite significant and marked differences in the details of the cutaneous autonomic pathways, some common features are apparent. Most obvious of these is that the final motor neurons in the cutaneous pathways tend to run out to the skin in a segmental fashion, travelling with the sensory fibres in cutaneous branches of the spinal nerves to the dermatomes. The autonomic dermatomes usually are not as well defined as the sensory ones, but they have the potential to allow a unique insight into the organization of peripheral autonomic function. This characteristic has been utilized well in studies of the control of colour change in teleost fish and in abnormalities of sweating function in humans.

The final motor neurons in cutaneous pathways show surprisingly constant differences in the pathway-specific expression of their morphology and neurochemistry (Figure 1.11). In all species examined to date, neurons in vasoconstrictor pathways have the smallest cell bodies. Moreover the smallest of the vasoconstrictor neurons are those projecting to cutaneous vascular beds. As in the case elsewhere in the nervous system, it is generally accepted that the size of a sympathetic motor neuron and the complexity of its dendritic arborisation is related to the number of synaptic inputs it receives. It is likely therefore, that cutaneous vasoconstrictor neurons receive less synaptic input than do pilomotor neurons in mammals or cutaneous secretomotor neurons in frogs. The size of neurons cutaneous vasoconstrictor neurons generally have slower conduction speeds than autonomic motor neurons in other cutaneous pathways. Why this should be so is not clear. However, one potentially important factor is that the vasoconstrictor pathways tend to be tonically active, whereas the pilomotor and secretomotor pathways tend to be activated only in specific circumstances. Synaptic transmission in vasoconstrictor pathways tends to be very reliable, often requiring only one suprathreshold preganglionic input. In contrast, it might be predicted that the larger pilomotor and secretomotor neurons are only activated after summation of several preganglionic inputs. This prediction remains to be tested.

The neurochemical differences between different functional classes of neurons in cutaneous autonomic pathways provides unambiguous evidence for the presence of highly specific pools of neurons projecting to well defined effectors. Within the cutaneous vasculature it is clear that there are separate populations of neurons projecting to the proximal vessels, small distal vessels and AVAs and veins. It is also clear that pilomotor neurons form a well-defined population distinct from any of the vasomotor neurons. Furthermore, it is likely that cutaneous vasodilator neurons, when present, are distinct from sudomotor neurons. These results are consistent with more recent studies on the central pathways responsible for autonomic activity which indicate that there is a series of distinct areas in the periaquaductal grey, hypothalamus, and medulla that activate specific autonomic pathways in response to well defined changes in the external or internal environment. Furthermore, it is clear from physiological and anatomical studies that there are separate pools of preganglionic neurons projecting to different functional population of cutaneous motor neurons. Although we still do not know how the central areas are connected to the final autonomic motor and premotor neurons responsible for generating the appropriate effector activity, it is absolutely clear that there is no such thing as a generalized autonomic outflow, and that the widespread activation of different cutaneous effectors must require the coordinated recruitment of multiple independent autonomic motor pathways.

Piloerection

From Ian Gibbins' excellent book chapter (Ch. 1 in Autonomic Innervation of the Skin, 1997) on autonomics, p. 29:

Pilomotor neurons also can be distinguished from most vasoconstrictor neurons by the size of their cell bodies and dendritic arborizations. Thus the pilomotor neurons, on average, are larger than vasoconstrictor neurons in mice and guinea-pigs (Figure 1.6; Gibbins 1991; Gibbins and Matthew 1996). This result is consistent with physiological observations in cats showing that pilomotor neurons generally have faster axon potential conduction velocities than do cutaneous vasoconstrictor neurons (Jänig 1985). The reasons for these differences are not clear, but two points are worth considering in this context:

1. Sympathetic final motor neurons with larger dendritic arborizations tend to have more convergent preganglionic inputs than neurons with smaller arborizations (Purves 1988). Thus, in general, we would expect pilomotor neurons to receive more preganglionic inputs than vasoconstrictor neurons.

2. Sympathetic final motor neurons within pathways that are used only intermittently tend to be larger and have faster action potential conduction velocities than those that are tonically active. Thus within the superior cervical ganglion, for example, cutaneous vasoconstrictor neurons, which are active most of the time, are smaller than pilomotor neurons, which are themselves smaller than salivary secretomotor neurons which probably are activated only rarely.

Most of the information on the organization of pilomotor pathways comes from studies in cats (Langley and Sherrington 1891; Langley 1894; van Rijnberk 1907; Jänig 1985; see also Lichtman et al. 1979 for a study on guinea-pigs). Mostly the pathways that have been studied are those activated during the fear/aggression response. In cats under these conditions, piloerector activity occurs in the facial skin between the eye and ear, a strip about 10 to 12 cm wide extending from the back of the head along the dorsal midline to the base of the tail, and most of the dorsal and lateral part of the tail (Langley and Sherrington 1891; van Rijnberk 1907; Jänig 1985). Although pilomotor muscles themselves are more widely spread than this within cat skin and seem to be innervated, the conditions under which they are normally activated are not really know: presumably they have a role in thermoregulation, but surprisingly, this has not been show explicitly. Certainly, in other species such as rodents (guinea-pigs, rats, mice) and primates (rhesus monkey, human), cold-induced activation of piloerection is widespread over much of the skin.

I have to stop for a moment and consider that strip of skin down the back of the cat that stands the hair up in a fear/aggression display. Just because it is so visible in cats, does this not happen with many animals? I recall a Siamese fighting fish I once kept, who did this upon seeing his own reflection in a glass, every time.

Does this not happen with humans? Is not "get your back up" a common expression? I can often feel a "shudder" and other weird sensations shoot down my back, and wonder if these are related in any way. Pure speculation, I realize..

Dorsal cutaneous nerves innervate that particular strip of skin. I see an implication: could it possibly be, that the sympathetic neurons ... that innervate piloerector muscles in skin... skin which is supplied by dorsal cutaneous nerves... have a closer relationship with the bits of brain that have old mammalian (pre-mammalian even) sympathetic fight/flight reactions?

It makes me wonder about any possible relationship there might be among circulating stress hormones, need to suppress aggression/display submission within our human primate troop (i.e., get along),.. to chronic back pain. However tenuous.

I visualize the cutis/subcutis smooth muscle cells along the spine, a spinal "Mohawk" of smooth muscle lifting with all its might, but alas, barely any hair to lift and struggling all the while against clothing and chair backs, piloerecting like crazy but nothing visible to show for it. Us, barely aware of their efforts to express themselves/our non-conscious responses. Us, completely involved in our conscious, inhibiting, troop-appeasing, socially appropriate descending control of muscular effort to provide deceptive "cover".

Could it be that a "war" between brain modules is constantly raging? Expressed by smooth muscle cells (tiny), against somatic muscles, much bigger and more under conscious control. Dorsal cutaneous nerve rootlets pulled this way and that, and secreting like crazy, all the stress stuff that gives them the neural equivalent of diaper rash (abnormal impulse generating sites) inside their little neural cages - I mean tunnels. Especially in those human primates who are lower ranking in the human primate troop. Having to put up with horrible bossy bosses or just life as a worker in general. Having to fake being cheery even if they don't feel it. Low back pain for no "good" reason, such as a definitive injury, an all too common human fact of human life.

Anyway, just some idle speculation on my part. What else is a blog good for?

The pilomotor pathways have an overall segmental distribution, that loosely follows the sensory dermatomes, especially on the trunk (Langley 12894; van Rijnberk 1907; Jänig 1985). For much of the body, the preganglionic fibres in pilomotor pathways project directly from each spinal segment to the corresponding ganglion; i.e., they do not project up or down the sympathetic chain to a significant degree before connecting with the pilomotor neurons themselves. Similarly the pilomotor neurons project directly from their ganglion into the corresponding spinal nerve. Overall the preganglionic neurons in pilomotor pathways of cats extend from spinal segments T4 to L3 or L4 (Langley 1894). The pilomotor neurons innervating the skin of the head arise from cell bodies in the superior cervical ganglion and receive inputs from preganglionic neurons in upper to mid thoracic level spinal segments (T4 to T6 or rarely T7 in cats, T4 to T6 in dogs, Langley 1894; T1 (rarely) or T2 to T5 in guinea-pigs, Lichtman et al. 1979). In guinea-pigs there is a clear correlation between the level of spinal origin of the preganglionic neurons and the region of skin innervated by pilomotor neurons. Thus, neurons with preganglionic inputs from more rostral spinal levels tend to innervate piloerector muscles on the more rostral and ventral areas of the face whereas neurons with preganglionic inputs from more caudal segments of the spinal cord tend to innervate piloerector muscles on the more caudal and dorsal regions of the head (Lichtman et al 1979).

The central pathways generating piloerector responses clearly must include areas of the hypothalamus associated with thermal regulation, such as the preoptic/anterior hypothalamus, and areas such as the amygdala and the periaquaductal grey involved in generating aggressive or defensive behavioral displays (Schönung et al. 1971; Swanson and Sawchenko 1983; Smith and DeVito 1984; Hilton and Redfern 1986; Holstege 1990; Jordan 1990; Gordon 1993). In particular stimulation of the lateral areas of the periaquaductal grey can cause piloerection as a component of a induced threat display in cats (Bandler, Carrive and Zhang 1991). Although all these areas are known to project directly or indirectly to the spinal cord (see Holstege 1990; Swanson 1991), nothing is known of the specific pathways linking these central areas to preganglionic pilomotor neurons in the spinal cord.

Periaquaductal grey areas are part of the fish brain (basal ganglia) as I recall.. I can hardly wait until people like Gibbins get the pathways more sorted out. I think the implications are quite big, actually.

Steven Rose, Future of the Brain, excerpts

I love his action verbs - he uses them in such a way that it creates a clear mental movie to watch. From p. 72:
Quote:

Young neurons must recognize their migratory path and move along it; finally they must at some point recognize when to stop migrating and instead begin to aggregate with other neurons of the same kind, put out axons and dendrites, and make the right synaptic connections... As the glia migrate they spin out long tails up which the neurons can in due course climb. The cell membranes of both neurons and glia contain a particular class of proteins called CAMs (cell adhesion molecules). In the developing tissue the CAM work a bit like crampons; they stick out from the surface of the membrane and cling to the matching CAM on a nearby cell; thus the neurons can clutch the glia and ratchet themselves along. As a further trick the migrating cells also lay down a sort of slime trail of molecules related to the CAMs - substrate adhesion molecules or SAMs - which provide additional guidance for the cells following. The neurons can move along the SAM trail rather like amoeba - that is, they ooze.

This part is reminiscent of Into the Cool, "Nature abhors a gradient" :
Quote:

What provides such map-references for the cellular route-marches? Even if neurons follow glia, the glia themselves must have a sense of direction. Both distant and local signals must be involved. One way of signalling direction is to have already in place some target cell or tissue towards which the migration must be directed. Suppose the target is constantly secreting a signaling molecule, which then diffuses away from it. This will create a concentration gradient, highest at the target and progressively weaker at increasing distances from it, just as in the case of the unicells discussed in the last chapter... early born neurons secret a protein called reelin which sticks to the molecular matrix surrounding them, acting as a stop signal for each wave of arriving cortical neurons, telling them to get off the glial fibre and develop into a layer of mature neurons.

He uses principles established from other orders of magnitude to illustrate more about brain development, e.g., survival of, if not the fittest in a reproductive sense, survival of the fittest in terms of those most adept at connecting:
Quote:

..there is a further process operating here. During embryonic development there is a vast overproduction of cells. Many more neurons are born than subsequently survive. More axons arrive at their destination than there are target cells to receive them. They must therefore compete for targets. Those that do not find them wither away and die. There is this in this model of development, competition for scarce resource - trophic factor, target cell, synaptic space.

He goes on to be more explicit:
Quote:

This overproduction of neurons and synapses might seem wasteful. It has led to the argument that just as during evolution 'natural selection' will eliminate less-fit organisms, so some similar process of selection occurs within the developing brain - a process that the immunologist and theorist of human consciousness Gerald Edelman has called 'neural Darwinism'. However, this transference of the 'survival of the fittest' metaphor from organisms to cells is only partially correct. It seems probable that the whole process of cellular migration over large distances, the creation of long-range order, requires the working out of some internal programs of both individual cells and the collectivity of cells acting in concert. Even though synapses from only a particular neuron may end up making successful connections with its target cell, if the others had not been present during the long period of growth and migration it is doubtful whether a single nerve axon would have been able to reach the target. Survival of one depends on the presence of the many. Overproduction and subsequent pruning of neurons and synapses may at one level look like competition and selection; viewed on the larger scale, they appear as co-operative processes. It seems to be necessary, to ensure that enough cells arrive at their destination and make the relevant connections, that others must assist them, only themselves to die en route - a process called programmed cell death or apoptosis. Indeed, in a creature like C. elegans, ... those neurons destined to be born and to die en route to their seemingly final destination can be identified from the start. The process is orderly rather than random.

Here is something that is dear to me, because I thought of it independently - the idea of environments within and not just without. This makes total sense to me who sees the body as an ecosystem, kaleidoscopically, from multiple viewpoints, from the viewpoint of every cell (p. 59):
Quote:

'The environment' is as much a myth as is 'the gene'. Environments exist at multiple levels. Thus for an individual piece of DNA 'the environment' is all the rest of the DNA in the genome, plus the cellular metabolic system that surrounds it, proteins, enzymes, ions, water ... For a cell in a multicellular organism... the environment, constant or not, is the internal milieu in which it is embedded or adjacent cells, signalling molecules, bloodstream and extracellular fluids. For organisms, the environment is constituted by the biological and physical world in which they move...

This supports the idea that the environment of nerves is just as important to them as the environment around anyone is to anyone.

There are more delicious bits in this book, but what I most appreciate so far about Rose is how he sees the human organism and all subparts of it and all functions of them as verbs, not nouns.

Podcasts About the Brain

These are great. Check them out. I've linked to a list of all of them, and to Dr. Ginger Campbell's discussion forum. (There is also a link to the discussion forum on the right, in the link menu.)

The Future of the Brain, by Steven Rose

I'm departing briefly from the topic of autonomics to mention that this book is great. The first couple dozen pages on evolution (in the beginning of Chapter 2) are alone worth the price of the book - everything from how single cells do things, to a brief discussion of symbiogenesis, to limitations on size, an evolutionary process called exaptation, and "homeodynamics" (which he suggests is an improvement on the term "homeostasis") then he starts to discuss the evolution of the brain itself.

Are we "sympathetic" enough?

From p. 10 of Autonomic Innervation of Skin (1997), Chapter 1, Cutaneous Autonomic Pathways, written by Ian L. Gibbins:

"..most of the autonomic vasodilator innervation of the face of normal humans is of sympathetic origin with nerve cell bodies probably located in the superior cervical and stellate ganglia. However, there is also likely to be a parasympathetic vasodilator innervation to specific regions of the facial musculature, particularly that of the lips and forehead. This pathway can be activated by noxious stimulation of the eye or oro-nasal cavity (Drummond 1993, 1994; Kemppainen et al 1994). In some cases, it accompanies eating. This vasodilator response usually is accompanied by sweating, hence the term "gustatory sweating" that sometimes is used to describe this phenomenon (see below). These responses survive sympathetic blockade, and even may be enhanced after chronic loss of sympathetic activity. They probably are due to activation of facial nerve and glossopharyngeal nerve pathways (Drummond 1994), presumably homologous to those described above in rats and cats, via sensory pathways running in the trigeminal nerve."

I was surprised to learn, a number of years ago, that there was no parasympathetic innervation to skin in humans. One of those myths I swallowed pretty much whole way back when, a blithe assumption adopted by soft tissue manual therapy types like myself, was that there was some sort of global parasympathetic response by the human organism to hands-on work, in other words, via skin input. I mean, there had to be, right? People relaxed, and their tummies gurgled; that meant a parasympathetic response, so there must be parasympathetic nerves in the periphery, in the skin, right? Didn't blood vessels dilate? Wasn't dilation "caused" by parasympathetics?

Wrong.

This idea was actively fed as a treatment hypothesis, and/or never properly countered by purveyors of the courses that taught the hands-on work. The same individuals seemed to never carefully check and/or even list their sources. They continued to thereby allow ignorance to slow down the speed of understanding this form of human primate social grooming from a scientific perspective. Only much later did I come to understand, as an individual practitioner, that some kind of global parasympathetic response to direct touch or handling was frankly impossible, that everything out in the body that can be touched, including skin over those forehead and lip muscle bits, is sympathetically innervated, and will react sympathetically.

This only makes sense, given that parasympathetics are mostly about digesting (we don't digest on the outside.. we don't take food in through a surrounding membrane anymore as single cell creatures do). Given our skin is the first layer of sensory protection against exteroception and primarily a radiator for cooling the brain, it especially makes sense given that sympathetics do everything, vasoconstriction or dilation, depending on how they hook up, what transmitters they respond to, and what sort of size they are.

But what about that gurgling? In view of the fact that the brain is not monolithic, that in fact we could even say it's still full of all the creatures we once evolved away from (see "The Beast Within") and knowing that there is no parasympathetic innervation to skin, we could instead conceptualize that some sort of inner highlighting of non-conscious threat tension ensues, and is successfully resolved, right inside the system with which we are engaged. Butler is fond of saying, "Remember, just as you are reading a patient's nervous system, theirs is reading yours." The skin and sensory motor part of the system will see exteroception as a "threat", no matter how kindly it is provided. The human/primate/mammal level probably will not. There will be a battle of sorts within that system, completely invisible from the outside but palpable. The "higher" centers will prevail by regaining the ability to do what they do best, which is inhibit, and peace will be restored to both the body and to the individual who can now more comfortably inhabit that body. If we as practitioners think that we have anything more to do with this process other than catalyze it with handling, we are full of it. The patient's brain does it all, and then gives us some credit (probably ill-deserved much or even most of the time).

Back to the point, about good info on sympathetic/parasympathetic innervation or lack thereof, looking back, I have had more than a few moments of irritation, realizing that it's actually a very deep insult to be treated as if one were nothing but a pair of hands to be trained, no real care taken about what goes into the cognitive "compost bin" attached. Furthermore, I have a lot of irritation that I let my own personal cognitive compost bin be filled with meme garbage of varying kinds, some good and a lot bad. I've done a lot of subsequent composting, finding and tossing out incongruent bits of info; like small toy trucks, they don't break down or blend in, so they are easy to spot and remove. I've turned and aerated the contents on a regular basis, but mental composting is never really finished. It's always a work in progress; eventually however, you can extract something that looks like fertile soil, something that looks like it could sustain mental growth.

More important even than what goes in the bin is how the bin is constructed in the first place - one wants a bin that is rat proof. Instructors who name reliable external sources give one the means with which to reinforce the bin anywhere/everywhere, anytime. I can say without hesitation, don't ever waste your money going to courses where no one names sources, or where the sources are only vague or self-referent. The maintenance of a solid bin is too important in the long run, and developing gentle means by which to handle people in pain is too strategic a goal to permit its continued erosion by poor scholarship.

How does one correct the direction soft tissue work took way back when? One can't - one can only save oneself, share the story, warn others, and demand higher standards in general.

Autonomics, Skin, and Sensory Input (Exteroception)

The title of this entry is linked to a thread I've been working on at SomaSimple lately, on this particular topic to which I think the entire world of human primate social grooming should expose its group mind.

Of particular interest to me this morning is this little tidbit, from the preface of Autonomic Innervation of Skin and to all (I think) 14 volumes of the Burnstock series:

...the concept of antidromic impulses in sensory nerve collaterals forming part of 'axon reflex' vasodilation of skin vessels was described many years ago (Lewis, 1927).

What? 1927? TWENTY-SEVEN ??

Most of our professional existence has been after that particular date. Why wasn't this little factoid hammered into our receptive PT brains from day one, I'd like to know? We who are charged with handling people all day/every day?

Autonomics in skin

I have been thinking a lot about that last post, about sensory fibres behaving like two way streets, able to operate as autonomic motor (E-ffector, output) fibres as well as sensory (A-ffector, exteroceptive input) fibres.

I really, truly think this is a key piece for us as PT manual therapists.
I really, truly think this is a key piece of info that has been until now (pick one or more from following list):

1. never learned properly or explicitly
2. never understood within a frame of how touch can lead to physiological changes
3. bypassed as "too hard" or insignificant
4. not taught
5. taught but not emphasized
6. never linked to anything manual, never linked to any manual technique class
7. never taken seriously by our profession, or else our "as-if" capacity was never permitted awareness of even the slightest possibility that something like this could be remotely true
8. unavailable to a profession that prides itself on being science-based because it has only recently been verified/verifiable.
9. not allowed to inform our treatment constructs

There are probably more ramifications/ extrapolations I haven't thought of yet to put on this list. But for now, I'm just living with this info as if it were a new lens through which to view the entire world of manual therapy.
Mind-boggling to me, the infinity of how this little piece of basic info could change everything about everything... provided we were to let it sink all the way in.

Skin and Autonomics

In PT manual therapy there seems to be some sort of horrified embarrassed mental block about the info I'm going to place here in this blog, as if wanting to understand these kinds of mechanisms was equivalent to wanting to wander into church completely naked. In the interests of deconstructing attitudes that make absolutely no sense to me, I've decided to share this info here.

Earlier in the spring someone said that I couldn't state anything about handling skin being able to affect autonomics in the skin in the newsletter piece I submitted. Six weeks after, I had a bit of time, dug for this basic info and sent it to him post publication. So here is what I found out, a bit more support for treatment of cutis/subcutis having something to do with autonomic function/change. I hope no one thinks any of this info is "crazy". It's basic research out of Australia, done over the last 20 years or so.

1. From p. 133 of the Autonomics of Skin, a book in the Geoffrey Burnstock series, Chapter 5, "Autonomic Control of Cutaneous Veins", by Loring B. Rowell:
Quote:
"Veins of the skin in many mammals form a capacious network - even in those not experiencing the great increases in cutaneous blood flow seen in humans. We are unique among mammals, especially those who bear fur and must pant to exchange heat. Some mammals have powerful vasodilator and heat exchange mechanisms in the dense vascular network of the tongue where blood is evaporatively cooled. Others have specialized vascular networks such as the carotid rete that provide counter-current exchange of heat between arteries supplying the brain and veins draining cooler tissues. These structures permit separate cooling of the brain without at the same time requiring decrements in temperatures over the rest of the body. Unlike these mammals, humans have no significant heat-exchange mechanisms in the head that can minimize the rise in brain temperature when body temperature rises. Therefore we must cool the brain by cooling the rest of the body."

Right here, we see that human skin is special. It needs to breathe, and be cool. Add to this the fact that our brain is 5 times larger than needed to operate a mammal our size, and you've got to think, is it any wonder we lost our fur? We had to or our brains would have probably overheated. We are the sweating mammal.

2. "In humans the entire burden of cooling the central nervous system during heat stress falls on sweating and the cutaneous circulation (Rowell 1986). This means that brain and body temperatures are controlled together as a single unit. Most of our heat exchange occurs within a dense system of capillary loops and the capacious subpapillary venous plexus into which they drain. Human skin is unique in its vascular anatomy, the density of its vascular supply, and the innervation of its arterioles, which contain a powerful active vasodilator system. These features fit with its uniquely important role in temperature regulation (Rowell 1974a). Innervation and control of the cutaneous veins appear to be similar among species, but only in humans does the cutaneous venous system receive such high blood flows or contain so much blood volume during hyperthermia. The rich sympathetic innervation of cutaneous veins permits them to actively constrict, thereby conserving body heat during cold exposure. Their constriction diverts venous return away from the body surface to deep veins that are not constricted, establishing what is in effect a "thermal short circuit"."

The sympathetics have to do everything - i.e., there are no parasympathetic outflows to skin. Sympathetics control both the ebb and the flow out there in the skin layer, an ebb and flow unique to humans apparently.

3. Chapter 6 , "Cutaneous Effectors as Indicators of Abnormal Sympathetic Function" by Phillip A. Low (who went to school in Aus) and William R Kennedy, both of whom work in the U.S. From p 166:
Quote:
"Skin sensation for touch, temperature, and pain exerts a strong influence upon sympathetic nerve activity."

There it is in black and white. Touch affects autonomics.

4. "The location of the nerve endings that convey these modalities has recently been put into question with redescription of the innervation of epidermis by a complex of unmyelinated nerve fibres (Wang et al. 1990; Kennedy and Wendelschafer Crabb, 1993) that are not included in sensation theory (Light an Perl 1984). Although epidermal nerve fibres are almost certainly sensory, they may have motor-like influence on their environment through secretion of neuropeptides (Eedy 1993; see Holzer, Ch. 7 this volume)."

So, sensory fibres (which are actually long dendrites according to Larry Swanson who wrote "Brain Architecture") can operate as axons too, autonomic axons.

5. "There is an intimate relationship between skin blood flow and pain in several disorders. Skin blood flow reflects vasomotor tone which is determined by the level of sympathetic activity. The relationship between sympathetic activity and pain has recently been reviewed (Jänig and Koltzenburg 1991)."

Apart from the fact that the author uses the word "pain" (a neural output) instead of the word "nociception" (a neural input), a common error still committed by way too many writers, this makes complete sense.

6. In chapter 7, by Peter Holzer, page 214:
Quote:
"Under appropriate circumstances...primary afferent nerve fibres can behave AS IF they were axons of autonomic neurons. We now know that afferent nerve-mediated control of vascular functions is due to the release of vasoactive peptide transmitters from the peripheral fibres of fine afferent neurons."

More about sensory fibres being two-way streets.

My bolds. I suspect this is at least part of the mechanism by which physiological changes can occur in a patient with little or no physical effort on the part of the therapist, no biomechanical obsession, no need for strenuous evaluation, no need for painful provocation testing, maybe little or no need for the entire orthopaedic slant of Manual Physical Therapy (said with hope that OMPTs can find some way to forgive me some day). Self-correcting mechanisms within the nervous system itself, elicited with only a modest amount of the right sort of mostly non-nociceptive input. A prerequisite is rapport with the patient, but only enough for them to be able to accept handling from the therapist. No need to ever go into deep emotional baggage or bonding or spiritual realms. Bio-logical. (Physical) Therapist as catalyst, nothing more. Facilitate some change in the chemistry a little in the periphery, combined with S1 neuroplastic changes, assume the brain is reading it all like crazy, that a small amount of sustained input over a longer period of time will make its way quickly around the system, hang out long enough to perceive a change in the system's output, then move on.

The Problem with OMPT: Part II

The following is something I wrote this morning in the MyPTSpace pain forum in an attempt (which may be in vain) to clarify what I'm wanting to show by doing a study on DNM:

I'm not sure why you think pain patients are a different group than regular patients. Do not all patients who arrive for PT treatment have pain, or at least discomfort when they move parts of their body? Is that not why they come in the first place? Seems to me that all PT outpatients have at least three things:
1. Intact functioning nervous systems, i.e., no major neuro deficit
2. Skin, usually intact and also functional
3. Pain of some kind.

They may or may not have some kind of mesodermal joint/bone/muscle problem. We just don't know. Even if they do it may or may not have anything to do with the discomfort they feel. These are correlations, and we may not assume cause if we are serious about being clinical scientists. Yes we've been "trained" to treat as if cause were to be assumed, but in fact, "education" tells us we can't get away with that if we are going to start sorting our profession out a bit more logically.

So, what do we do with all these people coming in to see us that may or may not have a mesoderm issue but who almost 100% of the time have a pain complaint? Well, why not devise a way to lower the pain factor *first*? Then, all the patients for whom the pain was causing the "impaired" function, will separate themselves out into a beautiful and identifiable "subgroup", leaving those whose pain may be lessened but who still have a *mesodermal* impairment of some sort, in another beautiful and identifiable subgroup, who then can go on to be treated in the myriad of ways that will benefit *them*. And less painfully to boot.

See, really I'm trying to make our professional lives easier, not harder. I really would like to see how well the horse could pull the cart instead of forever plodding along behind it. My study will be a test of how well horses can pull carts. I'd like to see DNM and by extension all "ectodermal" therapies, become a simple and effective sorting tool for the profession to use.

Don't worry, the profession will always need the mesodermal people too. Cows are animals but surely not all animals have to be cows.

Bear in mind I am not diagnosing and treating impairments. I am not stretching an area of skin because it is tight and then saying treatment will probably be successful because the skin there isn't tight anymore (this is essentially what the MFRers are saying about fascia for example). If I were, then arguments about the reliablilty and validity of diagnostic testing and outcome would be appropriate.

But all I'm saying is that novel, skin-based input at and surrounding the symptomatic region may modulate ongoing nociceptive processing. While this certainly requires construct and face validity (which, while not yet 100% proven, I think I am in the process of addressing satisfactorily), it does not require reliable methods of finding impairments that I'm not treating anyway.

So the only real question is what essential diagnoses is this method appropriate and effective for. And since we really have no reliable clinical methods of determining essential diagnoses for most pain conditions I say we need some basic research here, which I will do, to see if DNM is as good or better than other methods that are really no more certain, as a sorting tool to see which patients or what percentage or kind may *need* a stronger form of manual treatment and which ones most definitely do not.

In retrospect, I'm sure they'll jump all over me for having used the no-no word "all" in the first paragraph. I should have painstakingly qualified that by using the word "most" or "virtually" as in "virtually all".

"The Problem with OMPT"

I just love this post that appeared this morning, simultaneously in two places; one place was SomaSimple (where the link goes), and the other is Evidence in Motion, a PT site where a few "defenders of the faith" soldier on to try to maintain the argument that orthopaedic manual therapy is the best PT has to offer the nation (U.S.) and therefore the world.. It was written by a DPT who is also an U.S. army captain stationed in Germany. He happens to be a very clear-thinking individual who is not still involved in some protracted honeymoon bliss with manipulation.

All this sits on the top of an intense debate that has raged for months on EIM, deep in its bowels, deep in the MyPTSpace community forum that supposedly has to do with discussions of pain. Almost as soon as the community formed, and some PTs (including me) went on there to discuss.. um, pain, we were subject to all sorts of barking and yipping at our virtual heels by a couple members who see our presence there as a threat to themselves somehow. One of them even said just yesterday he wished he could reach through the computer to "wring my neck". It's the first time I've been actively threatened, in my life, by someone who is a complete stranger (other than knowing him through volleys of posts), and who calls himself a PT. I've either led a charmed life until now or he was just kidding, and hit "reply" before editing. Once you post there, no editing is possible. So I will give him the benefit of the doubt. Furthermore, I see no point in reacting particularly to a mere virtual threat - he's a long way from me geographically. Besides, the feeling's somewhat mutual... and I know (using my mirror neurons) I'd never act on such a feeling. It seems to me that's what science is for, to settle disputes, especially ones that lend themselves to scientific solutions.

Speaking of science, what made him so mad was that I began to discuss a new project that Angela and I might just take on in the future (dreaming is still free, right?), that would set up an RCT with three arms, one arm that is a control group, one that treats according to the usual ortho standards, and the third arm me.

Now you might read this and think ok, that sounds interesting, or ok, that sounds boring, but to this individual and to a few others, it sounds threatening. They are not scientifically mature enough to welcome challenges to the world as they know it, especially to their mesodermal treatment constructs.

Enter Jason's post. It has dampened down the forum a bit. For awhile. It would seem. Which is good. Very good.

A single year

Exactly a year ago I was at the brink of something new - teaching for the first time in my 55 years. This represented a long and not altogether confident step into new territory. I survived to teach again several months later, an event made much less worrisome by virtue of the fact I now had "experience". In a few short weeks I'll be teaching again, this time for real, with paying students and an actual manual in an actual binder, complete with pictures and diagrams, not just a sheaf of typed papers stapled together. There will be a power point presentation involved, and cont.ed. credits, certificates, and snacks. The workshop will be spread over two days instead of crammed into one.

There is more that has happened in the span of a year, much more.

A few years ago while attending a large Sahrmann workshop I recognized and reconnected with an old classmate, Angie, from first year PT school, someone I hadn't seen since first year, because she dropped out for a year and went back in later. There she was, looking exactly like the Angie from first year 40 years ago. We went for lunch, and to make a long story short, I made sure she was on the invite list for the class reunion in the fall of this past year. There have been several of these, but it would be her first, and my second.

This reunion was held in Whistler B.C, a three-day weekend. Not all of the class of twenty originals made it; we've lost one member to pancreatic cancer, and a few others couldn't arrange their schedules to suit our time frame. But a great time was had by the dozen or so who did make it - the condo was a comfortable, spacious 5-bedroom, 2-hot tub, 500 thread-count-sheet excellent deal, food was great, the wine flowed, we sang old songs, the conversation bubbled continuously. We were all ten years older than we'd been at our last reunion; there were deeper lines in faces, greyer hair, a softer edge somehow. Both tears and laughter came from deeper places, and more easily it seemed. Somehow everyone seems to be getting more real. Conversations were more about husbands, hip replacements, having fought breast cancer, less about children and who was living where and who was doing what - in fact many have since retired to enjoy grandchildren.

Angie hasn't though. She went on to get a PhD in research design, and is now the busy director of an entire PT program at U. of S. We found ourselves discussing the state of physiotherapy many times during the course of the weekend, and in the end, she invited me to do a research project together with her. I won't go into all the details about this, but will just say that it has been carefully set up, will be scientifically acceptable, has been approved by an ethics committee and all the rest of the hoops something like this must pass, and will test the effectiveness of a completely nervous system based approach to manual therapy.

As if that weren't enough excitement for one year, in April I was able to complete the anatomy study described in an earlier blog. Angie is helping me prepare a good-length article on this for publication. She makes me write in a scholarly and neutral style, the way it must present for a journal contribution, not excitedly and opinionated, how I really feel.

Angie and I made plans at the reunion to get together again, this spring, to "think tank" together. The idea of retreating to a remote cabin for ten days armed with laptops and several bags of groceries was scaled down to her arriving a few days before the World Congress of Physiotherapy is due to begin, and stay at my place to continue the ongoing conversation about how best to improve our already pretty good profession, but which we have noticed has had some serious drift over the last few decades. I think we'll just go to the Drive and eat out.

Anatomy of skin

I am currently involved in an anatomy project at UBC, a piece that will help me fulfill a dream I have to help the relatively small and far from earth-shaking world of manual therapy finally make sense. My only ambition in life at this point is to be part of the solution instead of part of the problem. (I'm copying and pasting most of this blog from comments I made on a discussion forum thread, which is why it reads a bit choppy.)

This is from day 1, on April 3:

What a day. I finally got to set foot in an anatomy lab today, after a few frustrating years trying, finally getting an appointment set up, only to have the plan delayed in February because of a building problem. But today was the day.

The room was enormous and brightly lit, new white walls and gleaming tiles, 44 gurneys, 4 across and 11 down, each with enough space around it for a cluster of ten or so people, one long wall filled with blackboard. Cadavers lying horizontal, each dressed in a bright blue body bag. Not much smell at all.

At 9:30 AM I was given a bright green coat, gloves, a tray, some tools, shown how to use them, then left on my own to look at skin from the inside out. The hours flew by - suddenly it was 1 PM and I had to stop for the day. I realized I'd been standing on concrete and working the entire time with no rests or bathroom breaks and it never even registered, although maybe it will tomorrow... What an unbelievable opportunity to see layers and layers and layers.. all that slightly stretchy filamentous stuff in there holding everything together, wafting this way and that way, to sink through them with my own fingers. I really can say I've done "myofascial release".

My guy (I started referring to him in my head as "my guy") was old, had had an IV, had had a pacemaker at some point, had been dissected quite a bit already, but there was still one arm on him that had not been examined yet. An arm for me, My Guy's arm, still full of nerves.

The Dr. in charge unveiled My Guy's arm, pulled it out of the bag, leaned on it several times to externally rotate it, and supinate it, then showed me how to use the scalpel and change the blade, use probe, scissors, forceps, etc, told me where she would be if I needed anything, and said go for it. I asked her if there was anything wrong I could possibly do, i.e., wreck, and she said no. She gave me a whole arm to work on. Make mistakes on without worrying about how precious My Guy was. Unbelievable opportunity. So I went ahead. I'm sure it's not surgical quality dissecting I did this very first time, but I sure learned a pile of stuff.

I followed the musculocutaneous nerve (very big, unmistakable) from behind the bicep to the lateral side of the forearm, inspecting the big bruise and clotted blood that had been left by some long ago IV needle along the way. The way nerve wrapped under and over vessel was interesting. Where they connected (to feed each other, I guess) was interesting. I found several small cutaneous branches that headed up into skin - they looked like they come up to skin in bunches every couple inches.

I really had no clue until today just how thick skin is. This was an old guy, not obese at all but a good size male, with a regular size male arm. The skin was a good half inch thick in places, I kid you not. Lots of fat right in it. It slid around on the deep fascia layer, well, not as much as it does on a live person, of course, but there was still motion between layers. I prodded and squeezed the fat away from the network of neural tissue I was studying, managing to get a good sense of how three dimensional it is, how tough the outermost layer is, how tight the nerves are attached to the underside, how little they are by the time they get out that far, managing to break a few in the process alas...

I was down by the wrist by now, so I cut a square of (much thinner) skin about 2.5 by 2.5 inches on the back of the hand, and blunt probed it loose, in order to look under it to see the skin ligaments. There were several under there, permitting movement in all directions.

Going back up, I managed to get the biceps free from all sides. I could hardly believe how small it looked in this big arm, only about an inch and a half in diameter. Skin with all its fat takes up an huge amount of space, more than I ever expected.

I found the ulnar(?) nerve from axilla to part way down the arm, but couldn't really get at the medial side of the elbow. Maybe next time - I get to go again. The skin over the deltoid zone was very interesting, very thick, full of physiological webbing/tubing/neural structure, but I haven't found the axillary nerve yet.

At 1 PM, the Dr. in charge came back in and showed me how to wrap up My Guy's arm, put it into a plastic bag, spray it with solution right into the bag to keep it fresh, put a sign on it saying "don't touch", then put it all back in the big blue bag and zip him up 'til next time, scheduled for April 12. Can't wait for the next episode.

Part of the reason that it took me so long to get into an anatomy lab was the difficulty convincing anyone that a PT could actually be interested in something other than muscles&joints. There are workshops/refreshers from time to time here, but it's always the "knee", etc. Luckily, the Dr. in charge (who used to be a PT once upon a time) gave me an hour long interview, and listened. She really listened. It also didn't hurt that I sent her the skin ligaments article, which impressed her no end. I finally convinced her that what I wanted to look at was OK, and that I wasn't a nut case. What does skin have to do with anything? Oh.. just about everything..

Nerves are white and round and tough. Quite big. The musculocutaneous nerve is about the width of a printer cable. The vascular structures are darker and more flattened. The cutaneous branches are numerous and quite wispy, but tougher than the fascial wisps that they are embedded within. I got fairly adept at seeing the difference, checked with the instructor who came in to check on how things were going once, who said good, assured me that everything I was finding was nerve. When one inserts a probe under some fascia and lifts it up from behind, it becomes clear, like thick wet saran wrap. There's a certain resistance to it. When neural filaments are embedded within, they provide a bit more resistance, and if you look close they look like white threads inside the rest, more visibility. I spent a whole lot of time carefully breaking everything that was not nerve. Then when I lifted the big skin flap, it was still attached by the cutaneous nerves, obliquely running from the nerve to skin. They were lifted clear of the arm and I could see their pattern. So very cool.

There was never any focus on any of this cutaneous innervation when I was in first year, the only year we studied anatomy. All we had were dried up shreds from whatever was left after the med students had done all the dissecting. A big bone and some sliced up muscle attached that we were supposed to try and figure out how it went together, how it would look if it hadn't been cut up. No skin, and certainly no cutaneous nerves on anything, all useful bits burned off by chemicals. And certainly the smell used to be much much worse.

From April 12:

Today I was able to get back into the lab to visit My Guy's Arm. I went armed this time with a bunch of drawing supplies, and drawings I've already done to show the Lab Director. She liked the way the artwork was coming along.

Into the lab we went, and she took a look at the work I'd done last week. It was good, she said. As we peeled the cutaneous layer away from the lateral arm, the lateral cutaneous nerve of the forearm was pulled taut by all the cutaneous twigs and skin ligaments through which they convey, outward and obliquely. Isn't that interesting, she remarked. Usually we just plow through all those. I know, I said. There is only that one paper I know of that I sent to you to read. That really looks good, she said. You did a good job. I basked in the moment.

She had a whole morning to kill, so we worked on My Guy's arm together. She showed me how to shove a board under his abducted arm/shoulder and tie his wrist back to the board so we could get his skin detached up both sides right up to the axilla, all but for the little neural tunnels.

We worked for several hours, chatting away as she worked on the cephalic side of the arm and I worked on the basilar side, named for the veins, (which mean "top side" and "bottomside"). I unearthed several more layers of skin, subcutaneous fascia, a large plexus of neural tunnels on the medial side of the arm. She worked on the outside, carefully peeling away the skin/subcutaneous fascia laterally and over the deltoid. She also dissected the axilla, removing all soft tissue but for neural structures and their disseminating branches.

It was quite a sight when we were done; From the perspective of the hand end, looking medially up the anterior surface of the arm into the axilla, the deep fascia is still intact over the forearm. We have biceps loosened but not cut at its tendon, and access to musculocutaneous nerve from either side. With the big heavy thick cutaneous layers folded back, there are two huge veins visible, within those flaps, one on each side, The neural tunnels are still attached to the skin, and from the inside they run obliquely, holding the skin up like the oblique rigging on sails.

All the main zones of the arm have different thicknesses of "skin". The inner arm is thickest of all, suprisingly (to me at least); there are at least three main layers or compartments, each with their own cutaneous neural tunnels. These tunnels all sort of converge in something that looks a bit like a freeway - the nerves change from one layer to another, and continue on down, send a few branches out to the skin all the way along.

We found intercostobrachialis, the posterior cutaneous of the arm, the upper cutaneous of the arm, lower lateral cutaneous of the arm, the medial cutaneous of the arm and the medial cutaneous of the forearm. I saw what lymph nodes look like, in the axilla. She told me about her own episode of frozen shoulder. We discussed all that PT could be and wasn't.

There are more cutaneous nerves in there, completely unrelated to the ulnar and median, (many off the radial), buried right inside the skin layer(s) than I ever suspected when I started this whole project, and they come off a whole lot higher than I ever suspected- who'd have thunk? ... I've had to alter my my own understanding to concur with reality since getting the Gray's CD, and since seeing My Guy's Arm on the inside. However, reality is brilliant, and supports DNM better than my previous lack of good information/understanding.

There are many places in the pathways of the nerves where they are attached to vessels. There are many branches of nerves that go to vessels and vice versa. They never travel very far apart from each other, not in the upper arm.

The forearm is built quite differently from the upper arm. In the upper arm, there is more crossover between deep structures and the more superficial ones, the layers are less well defined even though there are more of them, and the deep fascia is less tight and thick and tough. The vessels and the nerves are in a more defined "neurovascular" bundle.

In the forearm, the deep fascia is much more defined. The median and ulnar nerves are so buried, I don't see any way to deal with them manually except through the hand. The two arm bones, interosseous membrane and musculature is very packaged, very contained. The vasculature and nerves I have looked at so far in the forearm travel subcutaneously and outside this deep stuff, although it would appear they wander away from each other a bit more than they do in the upper arm, they still plug back into each other at regular intervals.

I was told that people wanting to get into the anatomy lab are heavily screened. They admit ortho PTs fairly regularly for advanced study, but expect them to teach a class in return. My admittance probably had most to do with being the right combination of persistent and hopeful and non-expectant all at once. After all, I had a unique request. And wasn't interested in teaching, wasn't even asked. Who knows, maybe some day. But first, I'll have to get others interested. Unimaginably to me, these nice and well meaning anatomist people (I met another one there who was also an ex-physio) have never heard of Butler. It will take awhile to get this mountain moved. Meanwhile I count my blessings that they are willing to entertain a theoretical concept that is radically new to them, for which hardly any anatomy studies have been done, for which almost no actual anatomy exists, period. There's just so much mesoderm that it takes all their attention; they ordinarily just rip through all the little neural tunnels on their way to diving into and around the mesodermal stuff, preserving only the large nerves but not bothering to preserve their paths to skin. Mesodermal bias at every step of the process. Small wonder no one out in the world hardly can conceive of this neural net between layers- usually it's destroyed, not preserved/studied.

The ambition I feel toward this project knows no bounds - all I want to do with the remainder of my life now is dissect and map and document this system throughout the entire body. However, this is not likely to happen.. so my next fondest wish would be that anatomists everywhere fire up with the possibilities inherent in the exploration of this diffuse neural net, the last PNS frontier in the body, study the overall pattern of it, photograph it, draw everyone's attention toward it, toward these end organs of the kinesthetically sensing part of the brain, the organism, some of our best and phylogenetically oldest bits of nervous system.

Spinal Manipulation

This is why I don't like manipulation: It is a treatment system for people who don't know (yet, or ever) what else to do with their hands and with patients. It's a "put your hands here and do this" formulaic bunch of maneuvers designed to help unskilled hands/minds earn a living as human primate social groomers while simultaneously looking somehow like they deserve to. It's like learning to ride a bike using training wheels but never learning to not need them. It's a system by which the blind can lead those who can't see to go on to lead those who were born with no eyes.

And the "science" that is done in PT on manipulative therapy and overwhelmingly in chiropractic? Much of it is "training wheel-ology", studies done specifically to support the perseveration of said training wheels, science that never explores ways to move beyond. Those who would forever rely on such a crutch have quite a nerve suggesting that all manual therapists should do the same or else they are treating "suboptimally". They even have the nerve to go on to suggest that manual therapists who refuse to use manipulative techniques are being anti-scientific.

That is simply hubris, based on a huge pile of willful kinesthetic ignorance. We are primates! There were sensitive fingers used to feel for nits too small to be seen through fur on the bodies and heads of troopmates, hundreds of thousands of years before we humans came along with the big cerebral hemispheres! We have fingers and hands with kinesthesis which can be harnessed to feel physiology. Our minds have enough hard drive that we can "learn" to practically "see" these sensations. If we can learn to make sense out of Braille, we can learn to make sense out of tissue tensions and bumps we feel through skin; furthermore, these small issues in tissues change as we explore them. So exploring them becomes seamlessly blended into the treatment of them.

The only "danger", easily avoided, is in letting one's own mind drift off into perceptual fantasy to construct treatment hypotheses that completely exclude reality. (Don't go there. Stay boundaried, and stay with what is known. Stay with pain science and neuroscience.) There are no actual dangers to the patient's physicality the way there are with manipulation - anatomy is notoriously variable, especially the anatomy of physiological structures; there is NO WAY a manipulator can know in advance which patient has a A-V malformation in the vessels feeding the spinal cord, for example. Break one of those with a forceful "manipulation" and voilá! - you've just injured someone unnecessarily and perhaps permanently. Strokes are not unheard of.

The art of really riding a bicycle is gained through pitting one's own cerebellum against complex problems of momentum and balance and gravity, finally achieving effortlessness - not on remaining dependent on training wheels! Manual magic is achieved by learning as much as one can about the materials with which one has decided to work, letting go of metaphoric treatment training wheels, pitting oneself against the complex problems of placing one's own nervous system juxtaposed to another person's, observing the inevitable interaction, and allowing systems of treatment to evolve based on reason and critical thinking. No one in the human primate social grooming business should ever succumb to using training wheels forever, or developing an entire treatment culture based on their usage, or becoming enveloped forever by such a treatment subculture. Manipulation cults are a cop-out. Where would Lance Armstrong be if he had never learned to really, really ride that bike?