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?

Clinical science and Occam's "chainsaw"

PT is a bit like a cowboy movie complete with saloon etiquette, that can include the the virtual sounds of glass breaking. I became entangled lately in a thread on an orthopaedic forum, the name of which shall remain anonymous in order to spare it embarrassment, because I think it tries, it really tries to be science-based....

I have a few points to make about issues raised during the course of this thread, that directly relate to science and the PT version thereof, that speak to the role of being or at least striving to be a "clinical scientist".

First of all, PT "science" should align itself with and adhere to basic science 101 tenets. It shouldn't make up things for the sake of convenience, such as correlation in any way equaling causal relation. Yet in a PT textbook, apparently, there is being taught some mechanism for doing this very thing. Very pseudo-scientific IMHO.

Second, it should assume nothing, and operate according to the essential scientific principle that all hypotheses are there to be knocked over. (I.e., no one should take issue with others if their much beloved "hypothesis" and treatment construct curves around and smacks them in the back of their own head one day.)

Third, in the clinic we can literally BE scientific. E.g, an hypothesis exists that "pain comes from joints". No one seems to have tried to take that one down yet. Well, except for me and a handful of others perhaps. An easy way to take that one down, to disprove it, to thereby either improve or even disprove the "construct validity" of the "hypothesis", and by extension all treatments based on that hypothesis, would be to design a system that does not involve treating joints in any way. (One like mine, just as an example.)

Such a system must have construct validity based on something, of course, so let's pick updated pain theory. None of the variables in treatment should exist unaccounted for. As best I can, I have tried to account for all variables. I trust that pain science as developed by Patrick Wall and Ronald Melzack, and theorized as the neuromatrix model, have already weeded out confounding variables better than my own profession ever has, with all its vested interests, youth and lack of perspective. I am encouraged by the fact that prominent physiotherapists, such as David Butler, Lorimer Moseley, Louis Gifford and Michael Shacklock, have themselves taken on the task of examining neuromatrix theory, thinking through the ramifications, and have pioneered physiotherapy research pertaining to pain and our professional interface with it. They have designed methods to deal with pain that include constructs other than the ones based on "pain comes from joints", and their constructs may or may not exclude that particular hypothesis. (My own treatment construct deliberately DOES try to exclude it, because I believe it is a false hypothesis to begin with.)

One can't "prove" an hypothesis, one can only disprove one. I aim to disprove the "pain comes from joints" hypothesis, or in the attempt, at least refine it more.

So, with a treatment system geared at ONLY the surface of the body, and the nervous system, devoid of provocation testing of joints (because why include that if you are aiming to reduce pain instead of amplify it), or even of thinking about joints in any way at all, other than to test for range, I somehow managed to help someone (a young female figure skater) completely eliminate pain and dysfunction in her hip area in two visits; pain that was disabling (i.e., she was limping), that had been present for a month and had had other (unsuccessful and joint focused) practitioner involvement already. Furthermore, the girl in question went straight back to figure skate training full tilt again, with no problem, after visit number one.

To me, as a clinical scientist, this suggests that I managed, and am still managing, to disprove the hypothesis that "pain comes from joints", n=1, one at a time, one after another on through time.

Not only that, but when pain truly does come from a joint, as in the case of a woman I treated who had a stress fracture of the hip, it is easy to know that in fact the hip joint is involved when the parameters of the method are followed, and the patient responds outside the normal cluster of responses, i.e., does not respond, period, i.e., still can't weight bear without crutches.

After three attempts, time to send her back to the MD, even though the first x-ray prior to her ever seeing me was negative (i.e., they missed the fracture first time round). She in fact needed a pin. She came once more post op to mop up more pain she had from the whole traumatic process of the hip pinning. Once. Fine after that.

I think this process is what is involved in being a good responsible clinician with a grasp of basic science principles and a desire to get past all the clutter our profession saddles us with. Occam's chainsaw. Everyone can learn to use it.

Manipulation and the Brain

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

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

I answered with a prior version of this:

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

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

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

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

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

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

Graded Exposure

In this Feb. 4th entry, painonline blogger Kevin McHenry discusses Mt. Everest.

Climbers..

...can SEE the top of Everest and the fact they can SEE it makes them think they can climb it. Everest is only the equivalent of 2229 stairs. Surely we can do it. Yet, fairly frequently, we may die trying. It is not just mountains which give this illusion. A windsurfer on Maui who could see Molokai clearly from Kannapali Beach disappeared on a day of rough weather, attempting to make the crossing.

The Everest principle then is letting the eye overcome reason. Being able to SEE the top of Everest is no assurance at all that one can climb it. A slight worsening in the weather can spell the end of life. Mallory's story is one such example. In other words, unexpected troubles change everything and we should not take chances with survival. Ed Viesters, a survivor of the 1996 disaster, went up Everest, slowly, without oxygen. He claimed the reason so many die is that they go up too fast, misled as to their abilities by carried oxygen. When the climbing is tough, as in bad weather, they use too much oxygen, and when they run out, they are dead. He felt that slow acclimation was a better protection for him and has managed to prove it. Viesters has climbed most or all of the world's most dangerous peaks without oxygen. His idea, don't risk taking on more than you are really ready for.

This is a very apt comparison for what it takes to slog along through life when in pain, the sense of physiological demand embedded within. In a pain state, it's just as if someone took ordinary life and turned it upward at a steep angle, with less oxygen available. Thank you for the great analogy Kevin McHenry - good example of something called "graded exposure" - going along toward a goal, but in slow enough and small enough stages that there is no overshoot, no physiological payback, no fall into defeat.

By climbing that mountain slowly, Viesters' physiology was able to adapt. He was able to build hemoglobin levels that could cope with the altitude and decreased air pressure. His heart had time to "try out" and "learn" new strategies to maintain his blood pressure within normal range. In short, he gave himself time to adapt. He gave his physiology time to learn how to maintain homeostasis in the face of increased allostatic load from the environment.

Graded exposure is a cognitive behavioral therapy tool used by psychologists to help people overcome phobias. For example, let's consider people afraid of spiders, to the point where ordinary life becomes absolutely narrowed and imprisoned by fear. A patient wants to overcome the fear, which is step one. It has to be, obviously. The patient is so uncomfortable and trapped by this fear that they don't have much of a life.

A psychologist teaches the patient to recognize the earliest symptom of fear, a speeding up of heart rate perhaps, cold clammy hands, what have you.. Gradually and gently, the patient is taught how to experience tiny bits of this overwhelming fear, before it gets to the point of overwhelming them. By learning to approach and retreat from something they "know" can't hurt them, like a picture of a spider, they are taught to modulate their own fear. Eventually this modulation will become "downregulation" - their own nonconscious brain, through consistent, steady, successful cognitive self-input, guided by another factor in the environment, i.e., the psychologist, takes over the job of inhibiting the fear that was formerly all encompassing.

Graded exposure has been successfully used to teach people, and peoples' brains, how to downregulate pain, as well. Lorimer Moseley has done several studies showing long term pain relief measurably improves with education about pain, about the physiology of it and by practicing graded exposure. In cases of central pain, in fact, there simply is no better way to deal with it than for patients to learn to regulate their own physiology, much in the way Viesters did on the mountain. He went up and came back down without oxygen and with his life intact according to McHenry, and that certainly suggests something done right.

See my list of links to the right for the painonline main blog link.

Adrenal Cells and Pain

Kevin McHenry's latest blog is on chomaffin cells and the relationship they may have to reducing pain. In there he mentions their "strange affinity" with neurons. He marvels that with the addition of "a little acid", chromaffin cells can be made to turn into neurons.

Perhaps this is not so strange when we remember that they are close relatives, coming as they do, embryologically, from neural crest. Anything made after mesenchyme splits off (to make mesodermal derivatives like bone, muscle, joints, connective tissue, which create structural support for an organism and use way less oxygen) ... anything made after the mesenchymal layer splits off is likely to have a higher "access code" to the nervous system proper than anything mesodermal, and enjoy a closer relationship.

Neural crest makes the entire peripheral nervous system - not motor axons, but all the sensory neurons including dorsal root ganglia, and all sympathetic nervous system related structures like chromaffin cells.

Hands on Heads

I have submitted this piece to the CPPSG (Canadian Physiotherapy Pain Sciences Group) for inclusion into the next newsletter:

What is truly happening when we put our hands on heads, and slide scalp over bone?

DOI: 10.2519/jospt.2006.2278
November 2006 Vol.36 No.11
Craniosacral Therapy: The Effects of Cranial Manipulation on Intracranial Pressure and Cranial Bone Movement
• Patricia A. Downey, PT, PhD, OCS, Associate Professor, Physical Therapy Program, Chatham College, Pittsburgh, PA
• Timothy Barbano, BDS, MS, DMD, Research Specialist II, Department of Anthropology, University of Pittsburgh, Pittsburgh, PA
• Rupali Kapur-Wadhwa, BDS, MS, DMD, Assistant Professor, Department of Orthodontics and Dentofacial Orthopedics, University of Pittsburgh, Pittsburgh, PA
• James J. Sciote, DDS, MS, PhD, Associate Professor and Chair, Department of Orthodontics and Dentofacial Orthopedics, University of Pittsburgh, Pittsburgh, PA
• Michael I. Siegel, PhD, Professor, Departments of Anthropology and Orthodontics, University of Pittsburgh, Pittsburgh, PA
• Mark P. Mooney, PhD, Professor, Departments of Oral Medicine and Pathology, Anthropology, Surgery Division of Plastic and Reconstructive Surgery, and Orthodontics, University of Pittsburgh, Pittsburgh, PA

Study Design: Quasi-experimental design.

Objectives: To determine if physical manipulation of the cranial vault sutures will result in changes of the intracranial pressure (ICP) along with movement at the coronal suture.

Background: Craniosacral therapy is used to treat conditions ranging from headache pain to developmental disabilities. However, the biological premise for this technique has been theorized but not substantiated in the literature.

Methods: Thirteen adult New Zealand white rabbits (oryctolagus cuniculus) were anesthetized and microplates were attached on either side of the coronal suture. Epidural ICP measurements were made using a NeuroMonitor transducer. Distractive loads of 5, 10, 15, and 20 g (simulating a craniosacral frontal lift technique) were applied sequentially across the coronal suture. Baseline and distraction radiographs and ICP were obtained. One animal underwent additional distractive loads between 100 and 10 000 g. Plate separation was measured using a digital caliper from the radiographs. Two-way analysis of variance was used to assess significant differences in ICP and suture movement.

Results: No significant differences were noted between baseline and distraction suture separation (F = 0.045; P>.05) and between baseline and distraction ICP (F = 0.279; P>.05) at any load. In the single animal that underwent additional distractive forces, movement across the coronal suture was not seen until the 500-g force, which produced 0.30 mm of separation but no corresponding ICP changes.

Conclusion: Low loads of force, similar to those used clinically when performing a Craniosacral frontal lift technique, resulted in no significant changes in coronal suture movement or ICP in rabbits. These results suggest that a different biological basis for craniosacral therapy should be explored. J Orthop Sports Phys Ther. 2006; 36(11):845-853. doi:10.2519/jospt.2006.2278

Key Words: cranial bone movement, cranial sutures, manual therapy

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The abstract provided above is from a paper recently published in The Journal Of Orthopaedic and Sports Physical Therapy.(3) An accompanying editorial(5) by orthopaedic PT researchers suggested that:

"We need to abandon CST as a viable rehabilitative theory (i.e., that cranial sutures move) and instead focus on whether any of these procedures as manual techniques can be proven effective for specific musculoskeletal conditions."

(Italics mine.)

While I agree completely with the need to scientifically study and reject the implausible hypotheses associated with the equally implausible underlying theory of craniosacral therapy (even if it requires the sacrifice of rabbits to do so) I do not entirely support the editorial statement quoted above. I think it doesn't quite hit the mark - it completely leaves out the phenomenon of persistent pain, a condition in its own right, which can occur completely divorced from any "specific musculoskeletal condition." In fact, it usually does. Why? Because persistent pain problems are nervous system based, perhaps connected to movement dysfunction but not “musculoskeletal” (orthopaedic) “conditions”. I do NOT agree therefore, that everything in PT or in manual therapy provided by PT must be elucidated or defined according to "musculoskeletal" dictates, by being “proven effective for specific musculoskeletal conditions.” I think the orthopaedic PTs have made a category error in their editorial, understandable given their focus on mesodermal derivatives (i.e., bones, joints, muscles), and I am writing this to challenge their assumptions, as well as to support the Downey report in its challenge of craniosacral theory as being an invalid construct.(3)

Regarding theory, there are perfectly acceptable neurological mechanisms to account for the rumored efficacy and clinical usefulness (pain relief, increased sense of well-being) of the procedures associated with craniosacral therapy (CST). Perhaps it's time we rationally deconstruct this infamous form of manual treatment and take a slow look at what might be happening in the nervous system that is on the receiving end of the application.

These are some thoughts I have on the topic (I’m sure others can add more):

1. According to Neuromatrix theory(6) (Ron Melzack), the "body-self neuromatrix" "comprises sensory, affective, and cognitive neuromodules." Continuously through time, inputs into the system will be processed by this neuromatrix, and output such as stress regulation, action programs (including reflexive motor activity), and pain perception, will ensue. There are three "motor" systems involved: voluntary, autonomic, and neuroendocrine (Brain Architecture(7), Larry Swanson) working independently/interdependently/continuously (with one exception: the voluntary system during sleep). The application of a set of therapeutic hands on the head will be interpreted by the neuromatrix as helpful or harmful, depending on multiple historical factors such as the patient's beliefs and experience. At the very least, because manual treatment to the head (or anywhere else) is primarily a sensory-discriminative input into a nervous system, frequently a sensitized one, it is imperative that it be non-nociceptive, devoid of threat - five grams is indeed sufficient to facilitate change if we base our intervention on neuromatrix theory. In short, the nervous system is more of a verb than a noun.

2. Contact on the back of the head stimulates mechanoreceptors – mechanically stimulated sensory information travels in through cutaneous nerves (the occipital nerves, cutaneous branches from upper cervical spinal nerve roots) to dorsal root ganglia. From there, benign exteroceptive (arising from outside the body) input is handled by the CNS, both at a spinal cord level and at a sensory cortex level(7). Part of this input is processed non-consciously, resulting in motor output that is reflexive (e.g., increase in blood flow to scalp and associated cutaneous neural tunnels, outward to the rest of the body), and the rest of the input is evaluated by the sensory cortex/conscious awareness of the patient, where it filters through all parts of the brain, reaching into the cognitive-evaluative and motivational-affective aspects of an awake individual's central nervous system, as well as to all the motor output parts yet again.

The trigeminal ganglion receives and processes any exteroceptive input from the skin on the front of the head/face. The trigeminal ganglion is like a dorsal root ganglion, except that it is also a central nervous system structure, and is intimately connected to other CNS processors and effectors.

Exteroceptive sensation will quickly get the attention of the nervous system, and be scrutinized by it, as will any novel stimuli(2), for any potential threat before it will be accepted as neutral, comforting, pleasure inducing, educative in a kinesthetic sense, as naturally as interoceptive (arising from within the body) sensation.

3. Any sort of therapeutically contexted physical contact can catalyze change in a nervous system. The practitioner's job is to have an idea what a good result might consist of, seek out and enhance and teach patients the characteristics of "correction" - i.e., warmth, softening, a sense of surprise and effortless movement(4) (Barrett Dorko) during and directly after a session. The patient's job is to be willing to seek out and accommodate lasting change. An ethical practitioner must be willing to remain a mere catalyst, encouraging development of self-efficacy, not "maintenance" dependence.

4. Patrick Wall said, "A placebo is not something that is administered TO a patient, it is something that is elicited FROM a patient."(8)

5. The therapeutic container or relationship is the responsibility of the practitioner. It will serve to establish a physical and psychological safe "crucible" in which a lasting "reaction" can occur, after which time it should dissolve, never to be perpetuated as a “maintenance” scheme fostering dependency. Part of the attached responsibility of a practitioner is to strive for truth and clarity, be accurate as possible in setting out facts of treatment and pain education. Perpetuating implausible hypotheses/ memeplexes(1) when science suggests otherwise is not ethical in a therapeutic relationship and not acceptable from a professional standpoint. Using metaphor to illustrate an idea or a kinesthetic perception is perfectly acceptable - the practitioner must self-educate to know the difference, draw a line, and then toe it.

6. Neuroscience and pain science can be drawn on to defend the use of any procedure used in physio/physical/manual therapy. There is no need to resort to anti-scientific or pseudo-scientific constructs to explain soft tissue treatment techniques to patients (or hard-tissue treatment techniques either); eventually the faulty memes that accompany useful procedures must all be eliminated, discarded, replaced by better ones.

We can support professional and science-based use of gentle forms of manual therapy by doing valid and reproducible outcome studies; we will thereby continually improve this profession, help one another treat our patients meaningfully and respectfully, teach them to battle pain through understanding it, and enjoy increased amounts of our already widespread credibility.

7. I leave you with this thought on the subject of complexity:

"Was it really true, that all this business of chaos and complexity is based on two simple ideas - the sensitivity of a system to its starting conditions, and feedback? Yes, he replied, that's all there is to it."

-John Gribbin, author of Deep Simplicity, speaking of his conversation with James Lovelock.

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References:
1. Blackmore, S.; The Meme Machine; Oxford University Press 1999

2. Butler, David; Moseley, Lorimer; Explain Pain: NOIGROUP publications

3. Downey, P.A.; Barbano, T.; Kapur-Wadhwa, R.; Sciote, J.J.; Siegel, M.I.; Mooney, M.P.; Craniosacral Therapy: The Effects of Cranial Manipulation on Intracranial Pressure and Cranial Bone Movement; JOSPT 2006; 36(11):834-836. doi: 10.2519/jospt.2006.2278

4. Dorko, B.; Characteristics of Correction

5. Flynn, T.W.; Cleland, J.A.; Schaible, P; Craniosacral Therapy and Professional Responsibility; JOSPT 2006; 36(11):834-836. doi: 10.2519/jospt.2006.0112

6. 2003Melzack, Ron; Pain and the neuromatrix in the brain: J Dent Educ. 65(12): 1378-1382 2001 © 2001 American Dental Education Association

7. Swanson, Larry; Brain Architecture: Understanding the Basic Plan: Oxford University Press 2003

8. Wall, P.; Pain: The Science of Suffering; Columbia University Press 2000

Brain Architecture

This book (published 2003) is a great refresher for anyone interested in learning more about the nervous system. The author, Larry Swanson, picks up from where a zoologist, G.H. Parker, left off in his book from 1919, The Elementary Nervous System. The first three chapters alone are worth the price of the book, discussing behaviors of creatures without nervous systems, like protozoa and sponges, then the very basic building blocks of the nervous system as they manifest in simple creatures like Cnidaria (jellyfish, hydra).

Stepwise and logically, without missing any small but crucial points, we are taken through the historical milestones of Cajal and others over several centuries of research and conclusions, plus recent findings - and that's all in the first 40 pages. The next 40 pages reviews the basic vertebrate plan, and the rest of the book (a mere 241 pages in all) discusses brain function.

The prose is clear, concise, interesting. Highly recommended as a basic overview/review.

Canadian Physiotherapy Pain Sciences Group

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

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

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

It's a compromise.

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

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

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

November Workshop

I have to say, it went better than anticipated. At the last minute two more people let me know they wanted to come, which meant printing out more handouts and scrounging more chairs, and increasing the size of this class over the size of the last class by 150%, up to 5... plus the photographer made 6. Somehow they all squeezed into my treatment room.

And the best part, I was less stressed and less nervous and less exhausted afterward.

I think I might be getting the hang of this teaching thing. This time I had a white board ready, and some flip charts on which I'd prepared diagrams, a bit smoother flow. I still felt like I rambled around quite a bit, but no one was yawning that I could see.

The next day a few of us including the researcher friend went off to visit BodyWorlds, my second trip there. I lingered over the nerves pointing out each one by name to my participants. It was so much easier to grasp how they flow and penetrate layers when the layers are separated slightly, the way these exhibits are, how muscle structures spiral their way around bones like flower petals, and how the nerves slide through them like corset laces.

To top it off, the researcher friend tutored me in how to make power point slides for the next teaching adventure.

More teaching

I guess I must be fully recovered from the teaching episode in June, because I am about to do this once more, on Saturday next. The class size has increased by 50%, to three, and Eric, an ex-student from the first class, will be on hand to take pictures for an upcoming treament manual I'm writing. This time there is a name for the technique, discussed in a previous entry, Dermoneuromodulation. So things are looking up.

It's still a free class though. I can't bring myself to charge any money for this work. It's still in such a rough state.

Attending this round will be an old classmate, well, two in fact, who have taken an interest in this work that has defined itself through my two hands and mind and all the various beast brains that have stored themselves in my skull in this particular physical configuration, this particular intersection of life with space-time around it which I call me..

One of them became an academic, who is responsible for an entire PT program in a major university, and whose forte and personal interests happen to lie in research design. She and I have plans to begin a study in the new year.

I know it will be a few more years before anything comes about, but I have high hopes it will be published one day, that it will be a small seed that can grow into something substantial, something that can move PT from the doomed track it is currently on, or that I perceive it to be on, toward something more hopeful, not just for PT itself but for all the nervous systems of all the patients we treat.

It will be a single subject research design. My colleague will handle all the paperwork and analysis. All I have to do is treat the patients, who won't really be patients - they will be "subjects." She will measure their pain before and after, and again several months down the road.

This is all a dream come true. Despite that November and seasonal affective disorder is upon me once again, I still couldn't be more happy with the way life is turning out.

Body as "environment"

I happened to see this Go Animal newsletter entry this morning, beautifully written, a plea to adjust the viewing goggles on existance to include the human body in context instead of as object.

I agree, and would go a step farther.. the human body can be viewed as an "environment" built by the nervous system, nervous system "clothing," an organic little "antigravity space suit" it builds through which to negotiate its way through life on the earth planet. Some antigravity suits need more help (maintenance from without, from other people) than others..

How can I say this? Because epiblast gives rise to ectoderm. Ectoderm makes mesoderm, which turns into many many things in the body. Various stages of ectoderm make various levels and types of mesoderm, even the body's endoderm (the original hypoblast or endodermic layer is used to build amniotic structures)in addition to its own infrastructure, i.e., germ cells, brain, spinal cord, nerves and skin. It's all in Gray's if anyone cares to check. Each human nervous system is a community builder with an eye on its own future.

Missing? Or just cognitive "hemi-neglect"?

It seems most everyone in the orthopaedic branch of my profession is overly focused on mesoderm of one kind or another as if it had control of its own behavior, ignoring the nervous system as simple background noise. I thought this attitude was chiro driven, a memeplex to which PT had fallen prey, but I don't think so anymore - I think it's just naivité/simplistic thinking all round, like drawings of five year old children conforming to a predictable style. Ortho PT bases itself on what it has learned from its roots, the century-ago thinking of army gym trainers, masseuses, and orthopaedic doctors. (Who knows where chiro got its memes from?)

When the nervous system is considered at all in orthopaedic thinking, it seems to me it's only ever in terms of its output, and then only into muscles, that which can be "controlled" through acts of strengthening or will, i.e., "neuromuscular." There is rarely any work done or books written about the other side of the coin, sensory input, or what can happen to actual sensory fibres of nerves, physically, except for Shacklock and Butler. No one ever considers skin, how innervated it is, how sympathetically driven it is, how kinesthetically sensitive all the various levels of brain function are, how completely obedient the various levels of output (including pain output, motor output) are to miniscule amounts of sensory input, how the brain immediately engages with it, interprets it, expresses new output as a result. An understanding of sensory input into an intact NS from another nervous system could make our lives as PTs/professional human primate social groomers way easier and less cumbersome, and abolish a whole lot of excessive trappings/techniques/treatments. Something huge is missing!

My concern is about a significant perspective which is simply lacking in this whole mesodermally mad cognitive world we work in. The ortho part of the profession seems to only recognize half a picture, like the world certain stroke patients live in, those who ignore half the food on their plate because they can't perceive it, just aren't aware it exists. Most PTs have either wittingly or unwittingly decided to accept this state of affairs as normal! Sometimes I despair. That's all.

The Human Organism is a Verb, Not a Noun

The title for this entry is based on Michael Shermer's comment in this Salon.com piece that "science is a verb, not a noun." Thank you for that idea, Michael Shermer. I am going to borrow it for other applications - I hope that's all right with you.

I went to see the BodyWorlds exhibit Sunday morning and was, as I expected, blown away. Certainly there were throngs of people, more than I've seen all in one place at Scienceworld in a long time, more than one would ever see at a science exhibit probably, in Vancouver at least.. the crowds tend to gather for music festivals instead. But here were people, hundreds of human primates all patiently lined up, thoughtfully gazing, murmering to each other in hushed tones, closely examining the most spectacular array of carefully prepared, formerly live human bodies the public has ever seen.

I went to see nerves.

There they were, well preserved and displayed on most of the specimens, flowing downward and inwardly spiralled around the limbs, around and through equally spiralled muscular parts.

The Gunther von Hagen preparations were dynamically displayed. Through the audio device I listened to how von Hagan had decided to place the specimens into lifelike poses after an exhibition in Japan, where people had complained that the standard anatomical positions used made the plastinates look too stiff, "like ghosts."

Regardless of how they came to be in these athletic looking poses, the bodies look amazing. The nerves are clearly visible, especially their relationships at knee and elbow in flexed poses, and through windows strategically cut out of the body wall to permit a view in to the plexuses.

On the body wall the nerves are surprisingly large. I've always thought I could palpate them, but wasn't quite sure until I saw how thick they are, and how they angle downward and obliquely out over the wall, under the skin, in 90º angles to the fibres of the latissimus muscle over which many of them pass.

According to the audio program, there are 45 miles of nerves in the human body, running everything. As the peripheral nervous system reaches the lower parts of the extremities the nerves become more numerous, carefully tucked up into hands and feet.

This is an opportunity to see how our human physicality is constructed, while simultaneously beginning or continuing the process of meditating upon the end of personal existance. This exhibit facilitates both. I'm so glad I live in a time when it exists, and under circumstances in which it's possible to see it, contemplate it. Take full advantage of this opportunity. It's a beautiful thing, to be in a human body, being. Doing.

Expert mind

I am currently reading/absorbing this article from Deric Bownd's blog, originally published in Scientific American, Expert mind, which discusses what is involved in a mature mastery of a given skill set of any kind. A chess master named Capablanca, who won 168 matches in a row while on tour in 1909, said, ""I see only one move ahead,.. but it is always the correct one."

When treating a nervous system, when treating "pain", this is all that is necessary. The nervous system is smart enough to unlearn the pain is has been outputting, providing the pain isn't pathological, merely persistent. One can be an "expert" at anything, including human primate social grooming.

Mindblog: Deric Bownds

I was recently sent a link to this fine site whose author is Deric Bownds.

I'm luxuriously lapping up all his archives these days, which is enough to keep a thinking person busy for weeks. He seems to be interested in providing thoughtful high quality information about the brain, mind, and consciousness from many sources, plus creating a continuous and seamless stream of his own writing and essays. One of my favorites so far is The Beast Within, an overview complete with images of all the layers of brain we have accumulated throughout our evolutionary development, how they function in all of us.

Also linked in his blog is a google video (about an hour long) featuring Alan Wallace, discussing how science might want to get around soon to concerning itself with first person phenomena such as introspection and contemplation.

There is an online book available, called Biology of Mind, for all who deal with people and/or with peoples' nervous systems for a living. I've linked him into the index as well. Enjoy.