Saturday, February 18, 2017

Peter O'Sullivan, Cognitive Functional Therapy. San Diego Pain Summit 2017 blog series #1



This 2017 pain summit was the the third and best so far. If there was an overall theme, it was that to help people in pain, we as caretakers have to dismantle a lot of our own wrong fears and ideas about pain itself. 

Attendees have been asked to write blogposts reviewing the summit, and I plan to do just that. This is the first of several I plan to write. 


You can obtain videos from the summit, here



COGNITIVE FUNCTIONAL THERAPY

DISCONFIRM

I had marvelled at videos online of Peter convincing patients with chronic low back pain that it was perfectly safe for them to bend over and do things they had not done in a long time. Here is a youtube video of Peter explaining what's what, about back pain, to someone who has back pain. 







I attended Peter O'Sullivan's two-day pre-conference workshop and marvelled anew. Not only at the vision he presented, but also his skill at handling two actual people very different from each other who both had chronic low back pain. I learned a new word: "disconfirm."





Such a polite word.
So much more neutral than "challenge" or "refute" or "demolish."
"Deconstruct" has been my favourite word up to now. Now I like "disconfirm" better.


DISCONFIRMING FEARS AND BELIEFS OF THERAPISTS


Peter started out by admitting he had had to disconfirm his own beliefs first: he participated in a bunch of research that showed the opposite of what he originally believed; core strength was NOT important for pain, back pain was NOT biomechanical, etc., etc. 


His research has disconfirmed the deep-seated biomedical belief that has propelled the entire profession for a long time that tissue damage -> pain, that nociception -> pain. He showed the usual graphs, references, etc. for geeky people. There are a lot of geeky people in my profession.

Here is a short video (11 minutes) about disconfirming the idea of "core stability."





He is brave enough to rest on this disconfirmation completely, let it be the life raft on which he rides in every oceanic encounter with a new patient. Just by interacting with them, he rules out potential red flags. No type one errors for him. 

He also believes that you must not rush that first encounter. He schedules open-ended sessions that leave him relaxed and free to focus entirely on the patient and their story. He says, sometimes his sessions take a good two hours. 

After presenting his research, he went on to demonstrate how he then disconfirms patients' beliefs about their own back pain. 

First he invites them to tell him their story. He listens very hard to their story. 
Then he starts asking questions and they reveal their fears and beliefs about their pain. (See the first video.)

He gives them lots of positive messages about how strong they are and safe their backs are, about how plenty of studies show that a lot of people with no pain have lots of changes on imaging, so imaging by itself is not a very reliable method of determining pain issues.


He finds out what they would like to do, how they would like to move if they had no pain. What activities they would like to pursue in life or get back to if they weren't afraid of injuring themselves. He talks about the difference between a pain event and an injury,  how pain is protective but how sometimes one's own behaviour can prolong a pain event.

He uses short phone videos to show people how they move their backs. He asks them to bend over, in sitting and standing, takes videos of them moving, does a bit of therapy, communicating to them the entire time, asking them questions, explains how if they contract their abs they actually load their spines more, make their back harder to move, create more anxiety in themselves. He uses the analogy of a tire with too much air in it, which makes it too bouncy. Let a bit of the air out. Soften it a little so that the ride is smoother. He points out that gravity is their friend when they bend over, that they can relax into it, that they don't have to have their abs turned on because gravity can pull them over just fine all by itself. He throws a small object on the floor and asks them to bend over and pick it up. Repeatedly. They do. He asks them how they felt doing it the second time with relaxed abs. They say, better. He takes another video of them doing so, easily. Then he shows them the before and after videos to show them they don't need to protect their backs so much.


DISCONFIRMING FEARS AND BELIEFS OF PATIENTS: JOLETTA


In Peter's workshop he worked with two actual back pain patients. 


The first was our internet friend Joletta Belton, @MyCuppaJo, blogger about pain at My Cuppa Jo. She is in her thirties (I think), wonderfully open and gracious, frank and honest about the suffering she endured as her life fell apart after onset of acute low back pain that came on after she stepped off a fire truck. 


Yes, that's all she did. Stepped down from a truck, ended up in rehab. She was fit and healthy and strong, lean, trim (still is). She taught fitness to firefighters and paramedics. She was a strength and conditioning professional. She prided herself on being a warrior. 

Then she was consumed by a pain nightmare, including hip surgery, that changed her whole life, and which she continues to emerge from. She loves being outside, snowboarding, hiking, trekking around, taking photos of natural wonders. Recently she had started organizing groundwork for hosting retreats for people with chronic pain. Also recently she had started feeling pain over her non-operated hip. 

In her interaction with Peter she revealed that her biggest fear was that the other hip had started bothering her and that she feared more surgery. Peter pointed out that it was common for pain to start up in times of increased stress, and asked her if she thought she might have been stressing a bit over getting the new organization up and running. She concurred. 


Peter asked her to do single leg squats. Many many many squats. He emphasized repeatedly how strong she was, how competent her body was, how if she had any labrum issues she would never be able to do what she did in front of the class. He disconfirmed her beliefs and fears about her hip in the nicest way I've ever seen anyone disconfirm anything. He praised her for her strength (she snow-boarded!) and bravery. 


He noticed she was in the habit of "checking" her back frequently to see if the pain was still there, by drawing herself erect. He called these pain behaviours "rules" that people employ. He emphasized that behavioural "rules," whether self-imposed or suggested once upon a time by some well-meaning care-giver, generally limited movement variability, and limiting movement variability was counter-productive because that maintained a fear/anxiety/pain cycle. A big one is to bend from the knees, not the back. Every ergonomic class has that idea embedded in it. It is so wrong. 


(I used to teach that myself, doing inservice for hospital employees. I didn't know any better back in those days, in the 70's. Nobody did. Yet apparently that idea still persists.) 


He asked her to let go of her abs long enough to sit in a slumped position. When she did, and he asked her how it felt, she reported feeling less pain. So he gave her that for homework - to slouch instead of check. So simple.


DISCONFIRMING FEARS AND BELIEFS OF PATIENTS: "DAVE" (NOT HIS REAL NAME)


The second patient was a 60-year old man, large, imposing. He had previously had two knee replacements. 

He had gone in for surgery for low back pain a few years ago (I don't remember how many). The aftermath was harrowing: two bouts of MRSA infection that required opening up his entire back and being on IV drip, for months. His low back auto-fused. 


He pulled through. 

He had been an executive, had financial means. He had liked skiing and motorcycling before all this. He couldn't do either activity anymore because of the unpredictability of bounces and bumps and fear of pain or of losing control. He had been on 14 different meds at one point, now he was down to two. He was doing very well, was out and about, engaging in life, but there was a problem. He would get sudden onset pain across his upper back which would stop him in his tracks, and he would have to sit and rest until it passed, about a half-hour to an hour later. 


He wore a back brace when he was out doing things. Peter asked him if he did that because he was worried that perhaps his back was still fragile. Dave answered, yes. Then Peter disconfirmed that his back was fragile by pointing out that his low back was fused, in fact it had auto-fused! So it was protecting itself just fine - he didn't really need the brace, or the belief that his back was fragile.. could it be that the protective behaviour of wearing a brace stemmed from the original issue he had had with his back, more so than any current issue? Dave said that made sense. Peter let that idea hang in the air for awhile. 


Peter asked him about sleeping. It turned out he had to wake up to roll over, about every two hours. And he slept with a pillow between his two replaced knees. 


Peter asked Dave if he would be OK taking off his shirt. He had wide shoulders and a big burley back with a big scar right down the centre, neck to his upper lumbars. I sat there thinking about all those poor severed dorsal cutaneous rami. It turned out his upper back was quite numb, except for when he developed that excruciating pain that would stop him cold. 


Peter examined him for pain behaviour by having him lean forward in sitting, in standing, pick up the water bottle from the floor, etc., made a little video on his phone, then taught him how to let go of his abs to relax his back so he could bend it better, etc., had him pick up several more items using the new strategy, filmed him again, showed him both videos. 


He had him adopt the relaxed slouch posture he would be in if he were on a motorcycle. He asked Dave to go sit on his motorcycle at home, get a picture of it, and send him the picture. 


He had him lie on the plinth at the front of the room and demonstrate how he rolled. He basically log-rolled, protecting his back from any rotation. Peter taught him how to fold his top leg up higher, let it drop so that his pelvis could rotate forward. He taught him how to roll his upper body the other way, leading with his head, let it roll back, follow with the shoulders/ribcage. He had him practice abdominal breathing and relaxing his abs, then perform spinal rotation again. The difference between the first time and the second was astonishing in terms of amount of range he had gained. I could see how it was similar to Feldenkrais' "Spine like a chain" exercise/movement strategy. So effortless. So easy. 


He said he wanted to go skiing with Dave next time he was back in the US.


SUMMARIZING THE HOMEWORK

For both the patients, Peter had not reacted aversely to anything they said. He had stayed in neutral eye contact and had responded empathically, by saying things like, "that must have been hard for you." 


After the session he recapped for them all the ideas, beliefs, fears, anxieties and protective behaviours he had noticed, showed how they were all linked to each other in a positive feedback loop that did nothing but maintain pain. He drew little stick people doing the movements he had suggested, for their homework. He ended each session by reassuring them that they were strong and didn't need to protect their body part anymore, as it was healed completely and doing just fine on its own. 



Peter's summary for one of the workshop patients

MY TAKEAWAY
I had an opportunity to self-measure. I've been at this work longer than most who were there, 46 years now. I remember way back when we were taught professional assumptions instead of facts that had been elucidated by science from within our own profession. I remember how wrong many of them were. Yet, clinically, I also remember how we had to make do with the simple things, like empathy, reassurance, encouragement. I remember the whole job was about getting people in pain up from bed and persuading them to do exercises after all sorts of surgery that left them with long rows of very uncomfortable stitches up their abdomens, along their knees, over their backs, or hips, or ribs, teaching them to walk on crutches or to deep breathe and cough to prevent post anesthesia pneumonia (now surgery is much kinder, leaving only small puncture wounds and tiny scars).
In a way, it was revisiting an old skill set I already have, this time with a bunch of deorthopaedicalized science to back it (see Peter's references below).

It had to happen. The science I mean. To disconfirm the old beliefs. 


It's not over yet, though, not by a looooooooooong shot. The orthopaedic mindset in my profession was (and still is) very concrete, biomedical, and overwhelming when it comes to pain - pain must have a cause, and the cause must lie in tissue.

This is still current thinking with orthopaedic surgery. Problems in tissue cause pain, can be visualized on MRI, and must be cut out, or fixed so it can't move, because moving creates more pain.


Sometimes surgery helps people, but much of it is completely unnecessary and it can be a true horror show as well. Here is a sad tale about a young woman who died post-op after spinal fusion. The assumption was that her pains and discomforts stemmed from too loose a spine. I wonder what might have happened if instead, first, she had been lucky enough to have a consult with Peter or someone else with his ease and grace, experience and knowledge, to disconfirm ideas that the biomedical approach and mindset had implanted in her?

I stumbled upon a nice paper describing the various pathways in the brain associated with pain that are hooked up to amygdalar function. I want to study it closely as this is my way of being geeky. 


Here is the link:  Jiang Y, Oathes D, Hush J, Darnall B, Charvat M, Mackey S, Etkin A.; Perturbed connectivity of the amygdala and its subregions with the central executive and default mode networks in chronic pain. Pain. 2016 Sep;157(9):1970-8 (FULL TEXT) All in all, I would sit through a class Peter was teaching any number of times. It's like water to a thirsty camel. A huge bouquet to Rajam for reaching out to him and inviting him to speak and teach at the summit, and to Peter for accepting!
......................


REFERENCES:

Here is a list of linked references Peter used in his talk. 

  1. O’Sullivan P (2012) It’s time for change in the management of non-specific chronic low back pain, British Journal of Sports Medicine, 46:224-227.
  2. Fersum K, O'Sullivan P, Skouen JS, Smith A, Kv√•le A. (2012), Efficacy of classification based 'cognitive functional therapy' in patients with Non Specific Chronic Low Back Pain -  A randomized controlled trial, European Pain Journal. 17 (6) 916-928. (FULL TEXT)
  3.  O’Keefe, M, Cullinane P, O’Sullivan K, Hurley J, O’Sullivan P, Bunzli S, (2015) What Influences Patient-Therapist Interactions in Musculoskeletal Physiotherapy? A Qualitative Systematic Review and Meta-Synthesis, Physical Therapy Journal, Oct 1. [Epub ahead of print] PMID:26427530
  4.  Paananen M, O'Sullivan P, Straker L, Beales D, Karpinnen J, Pennell C, Smith A, (2015) A low cortisol response to stress is associated with musculoskeletal pain combined with increased pain sensitivity in young adults: a longitudinal cohort study, Arthritis Res Ther. 17: 355. (FULL TEXT)
  5.  Bunzli S, Smith A, Shutze R, O’Sullivan P. (2015) Beliefs underlying pain-related fear and how they evolve: a qualitative investigation in people with chronic back pain and high pain-related fear, BMJ open, 5:e008847. (FULL TEXT)
  6.  O’Sullivan P, Dankaerts W, O’Sullivan K, Fersum K (2015) Multidimensional approach for targeted management of low back pain. Modern Manual Therapy, Elsevier. (NOT FOUND)
  7.  Rabey M, Smith A Slater, S; Beales, D, O'Sullivan, P (2016)  Differing psychologically-derived clusters in people with chronic low back pain are associated with different multidimensional profiles, Clin J Pain, accepted 22.1.16.
  8.  Bunzli S, McEvoy S, Dankaerts W, O’Sullivan P, O’Sullivan K, Patient perspectives on participation in Cognitive Functional Therapy for Chronic Low Back Pain: A qualitative study, Physical Therapy Journal, in press 3.2016
  9. Coenen, P; Smith, A; Paananen, M; O'Sullivan, P; Beales, D; Straker, L. (2016) Trajectories of low-back pain from adolescence to young adulthood, Arthritis Care & Research in press 1.6.16.
  10.  O’Sullivan P, Caniero JP, O’Keefe M, O’Sullivan K, (2016) Unravelling the complexity of low back pain, JOSPT, in press


PETER O'SULLIVAN VIDEOS ON YOUTUBE

Back pain - separating fact from fiction - Prof Peter O'Sullivan 15:21


Making Sense of Low Back Pain 1:24:45


Prof Peter O'Sullivan and Core Stability - April 2012







......... 

Thursday, January 05, 2017

Remembering Gayle

She passed away just a few days ago. I've been awash the past few days remembering so many times we were together. The very first time I met her in PT school, that astonishing empathy that radiated, palpably. Her tinkly laugh. Her graciousness. All the singing of course. She invited me over for her 21st birthday, and I remember drinking chrysanthemum tea with a little flower floating in it. So exotic. I remember the way she held her long Benson and Hedges cigarette. So elegant. She had been to university in Montreal and had a degree in English lit, which I admired - she seemed so wise. The way she never walked past a flower patch without pulling one toward her, and inhaling deeply, with a smile. So blithe. Her beautiful handwriting. The way her voice sounded like music. The bits and dabs of Chinese she had picked up from her even more exotic boyfriend. The way she rocked that huge tattered second-hand fur coat that first bitterly cold winter in Saskatoon. Practicality before style.


She helped me get through PT school. We studied together. All those wiring diagrams made no sense to me, but she understood them, being so much older and wiser, and I managed to squeak through electrotherapy exams.


We had many adventures together.


1. I interned in Winnipeg right after her. She had an apartment there that I moved straight into. Judy (another classmate) moved in there too. Gayle and I overlapped by a few days. I remember marvelling at how effortlessly she inhabited her body, watching her do cartwheels in a big park there, by the Red River. She loved her physicality, her kinesthesis, just being in a body, feeling it. She seemed full of joy back in those days, doing tricks like that. I, on the other hand, liked my body best when it sat still because then I could think straight.


2. She moved to Ottawa with Lordson, her boyfriend. I visited her in 1972 and we went camping together in Quebec. On the way to the Laurentian hills, we stopped in a little town to buy milk, and she asked, Avez-vous lait? I was impressed. We did about 3 days of canoeing and tenting. It was September and getting cold. It was windy and choppy. I had no experience canoeing. We had no life jackets, if you can imagine, not even warm clothing, so we wore garbage bags under jean jackets. I was terrified but she loved every second. I remember thinking, woman, you are brave, and I am so not. The first night, we camped on shore of some island covered in raw old forest. I found the stillness and silence disconcerting. Forest primeval, Gayle called it, as she drank it all in, checking out all the different bits of moss bursting from trunk and twig. We found a flat spot to put up the tent. Sometime during the night a loud thudding woke us up. I was, as usual, terrified. In my mind it was either a bear or an ax murderer. She turned on the flashlight to peer out, see what was out there, and the whole tent glowed orange, which I thought made us even more a target. Turned out it was just a rabbit. We laughed hysterically. Both the trip and my canoeing improved after that.


3. She parted ways with Lordson and travelled in Europe, working here and there to support the trip. Back in those days, PTs could work wherever we wanted, it seemed. I was supposed to meet her in Greece, but in the end, I didn't go. I ended up back in university instead.


4. She came back from Europe, and moved in with me in Regina, worked at Wascana. I think it was less than a year. She moved to Prince George BC. Her fantasy was to build a log cabin and live in it, in the woods. I continued to work, live, and attend art school in Regina.


5. I visited her in Prince George, Thanksgiving long weekend in 1975. She didn't have a cabin built yet. She was working at the hospital, making lots of friends, enjoying the rugged countryside. It was a lovely sunny weekend. We were outside a lot.


6. Somewhere in there I visited her in Calgary where she was attending her cousin's wedding, to which she invited me along. I remember the bride cried. I remember thinking, that will never be me. Barry, her brother, was there. We had a good singalong after, outside on somebody's lawn.


7. In the summer of 1976 (I think it was) I got a scholarship to attend Banff School of Fine Art for a 6-week painting intensive. It wasn't super far from Prince George, so we thought it would be a good chance to meet up. She phoned to let me know she had arrived, and we planned to meet for dinner that evening. She said she wanted to go hiking on Tunnel Mountain, check out the trails. I told her to be careful of bears. She laughed. I was always paranoid about bears, she was never paranoid about anything. She never called, and I panicked. About 10pm that night I called the police, anybody I could think of. I said, I think my friend might be in trouble, because she hasn't called. The police said, oh, she probably went to the Calgary Stampede. I said, no... that's not her thing, besides she's utterly reliable and she would have let me know. She went hiking, Tunnel Mountain I think she said, and she might still be out there, and I'm worried. They weren't worried. They said, well, let's wait until tomorrow and meanwhile she'll likely show up. I worried all night, and the next morning got a call - she had been admitted to the Banff hospital. I raced over, and found her in emergency, where I watched her transfer herself from one stretcher to another. I was a sobbing mess, she was calm. She had climbed some godawful rock face with no lines or picks or any of that stuff that you should have if you go rock climbing. She got up OK, about thirty feet she said, but on the way down, slipped and fell backward off the rock face, got dinged pretty hard in the process. She passed in and out of consciousness, tried to light a fire but it got away, crawled around trying to put out the fire (succeeded I guess, because Banff didn't burn down that night), and passed out on a trail. The next morning some army cadets out for a drill found her and radioed in that they had found a "casualty." I remember her take fleeting but distinct note of that word. She was rescued by helicopter on one of those dangling stretchers. That must have been quite the ride. She was about to be transferred to Foothills.
It turned out her injuries were pretty bad. She needed spinal fusion at four levels, and a fusion of her left foot because the talus had shattered. The other heel was broken, but it healed OK. She was on a Striker frame for a couple months. I came to Calgary from Banff to see her on the weekends. We went crutch-walking outside. It was a lovely sunny summer.


8. She went back to PG. She sent a picture of herself, astride a big log, peeling it, crutches parked alongside. We wrote lots of letters back and forth. I remember her asking specifically if I thought there was really such a thing as a death wish. I remember having no idea at all about such a thing.


9. Sometime in the early 80's, (maybe it was 1982) she visited in the month of May - she wanted me to go to CPA Congress with her, in Winnipeg. I had moved into a rented house and wanted to plant a garden. We spent a whole day putting in the garden, then raced to Winnipeg, in my '72 Chevy Nova, me driving 5 hours straight with a seat that wouldn't pull forward, so, leaning the whole way. I had the worst backache from that. We stayed in a YWCA hostel. She worked on my back for about an hour. I remember crazy interoceptive experiences, maybe from all the opioids my brain manufactured in response to her excellent intuitive handling. I think I passed out. The next day I was fine, pain gone. Congress was boring. We drove back to Regina and she went home to PG. 10. I remember her altered gait from the injuries. She moved with a distinct limp that she couldn't hide. I remember falling behind her as we crossed Burrard Street bridge in Vancouver, going fast, watching her as she strode, turning that limp into propulsion. I think it was around that time she took up Tai Chi in a big way.

11. She gave up on the log cabin idea, I guess, and moved to Vancouver. She invited me to visit her there and I can't remember now whose idea it was, probably hers, that we do a road trip to California. She had a beat-up truck to take us there. It seemed like a fine idea, even though I was paranoid about traveling in the US. I thought everyone was out to shoot each other there. She laughed. She had already scoped out the US and had found it utterly wonderful. We took our trip. We stopped on Orcas Island and she introduced me to what she was really into just then, in a big way, therapeutic touch. It was her gateway into years of spiritual investigation, a lot of which I ended up not being nearly as fascinated by as she was. Whatever. Anyway, we drove to San Francisco, visited some art galleries, saw a Flamenco dance production, drove back, camped along the way. On that trip I remember her driving, telling me about her mom dying of bowel cancer when she was 13, and her dad dying in a car crash a year or two later, and suddenly bursting into tears. It was the first time I had ever seen her cry. Ever. She retained perfect control of the truck even as she sobbed out loud for a few minutes.


12. I moved to Kamloops in 1983. I was determined to learn manual therapy, BC seemed to be the place to be in those days, and I got a sweet job in Kamloops running a private practice for a manual PT who taught me everything she knew inside a two-week space before she left town to go study vet. med. That lasted about 18 months. Meanwhile, Gayle had found a man (Frank), and they planned a wedding, and I was a bridesmaid. That happened the summer of 1984, a lovely outdoor wedding at Jericho Beach. Her brother, his wife, their two children, and her aunt, went with them on the honeymoon.


13. On the way home from the honeymoon, everyone died in a car crash except for the two children, who had been asleep in the back seat. She was no sooner a bride than she had to go back to Sask to pick up these children, aged 10 and 6 at the time, the youngest with two fractured femurs. On the way back to BC they stopped in Kamloops and we had Thanksgiving dinner together. Even though there didn't seem to be a whole lot to be thankful for at that moment. She cried frequently after that. I remember Frank asking me that evening, out of earshot, if I thought Gayle was going to be OK. I remember telling him I was sure she would be, that she was the strongest person I knew.


14. A bit more time went by. Gayle was now 37 and wanted to get busy building a new family. I moved to North Vancouver in 1985, lived in her basement for a year, ran her practice for her while she was on mat leave. She was horribly disappointed with her experience because they made her have a C-section. The next time she had a baby, in 1987, it was a V-bac at home. She had been determined to have a natural birth in spite of restricted mobility in her lower trunk. Alas, the baby sustained a head injury during birth. I think that was pretty stressful. She cried even more after that.


15. Over the next few decades we were less in each others' lives, because of very different personal interests, but remained in touch and saw each other several times a year. We attended lots of educational workshops together, the last one 2005 in Nanaimo. She continued to grieve. She had developed chronic pain, especially in the leg and foot that had been fused. I treated her once in awhile. I continued to marvel at how strong she was in spite of everything that had happened to her and her family.

16. Eventually I couldn't stand the dreary wet-coast weather anymore, and moved back to Sask in 2009. The last time I saw Gayle was 2010 at our class reunion at Waskesiu. My very last memory of her is seeing her crying. Publicly or privately, no difference. She would brighten up for brief periods, but it was as though crying was the only thing could keep her going.

I absolutely loved Gayle, who didn't seem to mind being the big sister I never had. I learned so much from her. I am kind of a mess, missing her big time at the moment, as our whole class is, I imagine. I really hope she's in a happier state. Life was not nearly as kind to her as she was to it, and to others.




In black text frames, Deb (the first one in the class to die) and Gayle. Both died from cancer. 



White Owl Flies Into and Out of the Field

by Mary Oliver
"Coming down out of the freezing sky 
with its depths of light, 
like an angel, or a Buddha with wings, 
it was beautiful, and accurate, 
striking the snow and whatever was there 
with a force that left the imprint of the tips of its wings — five feet apart — 
and the grabbing thrust of its feet, 
and the indentation of what had been running 
through the white valleys of the snow — 
and then it rose, gracefully, 
and flew back to the frozen marshes 
to lurk there, like a little lighthouse, 
in the blue shadows — 
so I thought: maybe death isn't darkness, after all, 
but so much light wrapping itself around us —


as soft as feathers —
 
that we are instantly weary of looking, and looking, 
and shut our eyes, not without amazement, 
and let ourselves be carried, 
as through the translucence of mica, 
to the river that is without the least dapple or shadow, 
that is nothing but light — scalding, aortal light — 
in which we are washed and washed 
out of our bones."

Added January 14:
Today is the memorial for Gayle. Here is a link to a lovely tribute from the North Shore Special Olympics organization.

It is with great sorrow that SOBC - North Shore says goodbye to beloved coach, manager, volunteer and athlete council coordinator, Gayle Robinson. Gayle passed away yesterday after a long battle with cancer and leaves (husband/coach) Frank and (daughter/athlete) Kara Williams for us to care for as well as many others. If anyone is interested in supporting the family (i.e. prepared meals), pleasecontact Kelly Klein at LocalCoordinator@sobcnorthshore.ca. Kelly can also be contacted on her home (604) 904-1020 or cellular (604) 992-1020.

A LIMB HAS FALLEN
A limb has fallen from the family tree,
I keep hearing a voice that says "Grieve not for me."
Remember the best times, the laughter, the song,
The good life lived while I was strong.
Continue my heritage, I'm counting on you,
Keep smiling and surely the sun will shine through.
My mind is at ease, my soul is at rest,
Remembering all, now I truly was blessed.
Continue traditions, no matter how small,
Go on with your life, don't just stare at the wall.
I miss you all dearly, so keep up your chin,
Until the day comes we're together again.
~ Author Unknown

Gayle Winnifred Robinson
Jan 18 1948 – Jan 3 2017

It is with heavy hearts that we announce the passing of our beloved Gayle: Wife, Mother, Sister, Aunt and Friend to all. After a lifetime of caring so deeply for others, Gayle passed away peacefully at midday on Tuesday, January 3, a bright cold winter’s day, at the North Shore Hospice surrounded by family and friends.
Born and raised in the small farming community of Lone Rock, Saskatchewan, Gayle grew up with strong family values, a sense for community and a deep love for nature.
A graduate of the University of Saskatchewan (BA; Diploma of Physiotherapy) and the University of Alberta (BSC Physical Therapy), Gayle was resolute in her commitment to health and healing. In her work as a Physiotherapist, she continually sought innovative approaches to enhance her patients’ well-being.
Gayle lived on the North Shore for the past 32 years, raising a family with her husband Frank, gardening, and welcoming friends for singalongs which she accompanied on piano or guitar.
When daughter Kara became a Special Olympics athlete, Gayle stepped into volunteer coaching, team managing, driving to games, and doing whatever was needed. She was deeply moved to receive a special award by North Shore Special Olympics in June 2016, for initiating the Athlete’s Council.
With her great interest in the arts, Gayle fostered her son Jesse’s creativity. She was an ardent supporter as he developed into a talented professional painter/illustrator.
More than being merely ‘survived by’, Gayle is clearly celebrated by her loving husband Frank Williams and their children Kara and Jesse (Jen); her brother Morris; her niece Colleen, and nephew Christopher (Rochelle) and baby Ruth.
Countless friends, colleagues and patients have benefitted from her soul’s warmth and healing hands.
The family wishes to thank Dr Paul Sugar and the nurses at Lion’s Gate Hospital and North Shore Hospice for their caring.
A Celebration of Life for Gayle will be held at the North Shore Unitarian Church at 370 Mathers Ave, West Vancouver, BC on Saturday, January 14, 2017 at 11:00 AM. All are welcome.
In lieu of flowers, kindly consider a donation in Gayle’s name to the Paul Sugar Foundation, Inspire Health or North Shore Special Olympics.

I thought of this song, by the Seekers, one of the many folk groups that walked the earth, being minstrels, getting the baby boom out there and into life. It used to be on the radio all the time. It pretty much covers the feelings I had for Gayle when I first met her and as we went through a lot of life together through our twenties and thirties.

Saturday, December 10, 2016

Out of gear

Just coasting these days.
One-third of the way through December. Sudden onslaught of winter - a foot of snow and minus 25C weather. A big change to adapt to after the creepy warm November we had, with rain and daytime temperatures that reached plus 20C..
........

Anyway.. it's a slow time of year, not much happening at work last week. The book has been out for a week and a bit. I have amused myself by looking up the stats on book sales. Definitely not a runaway best seller, but it seems to be steadily moving out into the world. I am pleased with the progress so far, a couple hundred ebooks and dozens of regular books. A guy who attended my class, Jaire, posted a picture of himself holding his new DNM book. So did another guy, William. A woman who blogs at My Cuppa Joe, Joletta Belton, wrote a lovely blogpost about her experience attending a DNM course taught by Rey Allen recently.

What pleases me even more is a sense of the ideas it contains taking root out there in the world, with or without the book. Not many of the ideas in it are original, but I like to think that juxtaposing them to each other my own way has maybe helped give them more pizzazz.

All this is great. The feeling is one of completion, contemplation, enjoyment. Maybe it's similar to that feeling women my age (who reproduced) have when they watch their baby grandchildren or great grandchildren doing adorable things.

Sunday, November 27, 2016

Sacral outflow is entirely sympathetic



The book, Dermo Neuro Modulating, is out on Amazon as ebook only just now.. seems to be selling well based on feedback from twitter and facebook, but really I have no idea of stats, or of when the hard copies will be available, and won't until the coming week when I can converse with the company that helped me self-publish.

For the time being, if anyone interested in taking a look or picking up an e-copy, here is a book link to Amazon.
.........



Time for a nerdy, nerdy interlude. 

In the past week it came to light that researchers got right down to the molecular level and found out that autonomic sacral outflow is entirely sympathetic, that there is no such thing as a parasympathetic cord supplying neurons to pelvic viscera or reproductive or sexual response function. This is huge news. Before I express any thoughts on that, here is Peggy Mason on the topic: 




Here is a blogpost she wrote on this topic! It examines a few of the implications from a science perspective, including the history of the concept and why textbooks will have to be updated.

Peggy Mason works at U. Chicago. I first encountered her brilliance at the IASP congress in Montreal in 2010. She discussed brainstem nuclei involved in micturition. I think that's her specific research area. But she does much much more besides. She teaches an online course for free, through Coursera, Understanding the Brain: The Neurobiology of Everyday Life. I signed up for it a few years ago but it was in May and I underestimated the daunting time factor. I had to run around teaching, myself, so had to drop out. But the amount I managed to assimilate was great, and I recommend it. She's a very engaging teacher.

She has also written a book, Medical Neurobiology. What I love about it is the non-hierarchical format - every single topic and even every little sidebar is connected to bits in other chapters, all the way through. Which means you have to turn a lot of pages frequently in a rather heavy book, but your brain is going to take in the information from lots of sides and angles and directions.

About the sacral outflow thing, clearly this is a big shift in the dogma surrounding neuroscience. I love that she's so excited about it! I know a lot of people whose world if rocked or their worldview pulled out from under them makes them anxious and upset. What does she say? She's excited, and says Whee!!!!

Anyway, here is what the new, more updated picture of sacral outflow looks like, from the Espinosa-Medina et al paper:




.........

OK, so what is the big deal? For manual therapists?
Well, the implications are kind of big, in my opinion.
First of all, there are still plenty of us roaming around imagining that there is some sort of magical elicitation of parasympathetic activity directly stemming from hands-on work. So much so that there is even a kind of guru-based modality empire out there called craniosacral therapy. That set of ideas needs to go. 

Second of all, and more importantly I think, we need to understand that when we do hands-on we are playing with the brain, and that EVERYthing we touch or do is going to excite, for better or worse, the sympathetic nervous system. The sympathetic nervous system has dual control of the entire body wall, and blood flow to each and every bit of it, including to that forest of highly sensitive neural tree comprised of 72 kilometers of passive noodle-y tubing throughout our body. THAT is what it is most protective of, and that extends to the surface of the body, everywhere. Really. Everywhere.
Think about it.
Think about how everything that was ever thought about how sex works (i.e., an orchestrated interchange of sympathetic and parasympathetic outflow), is wrong in light of this new information.
If this is how sex really works, then it must also be how any kind of manual therapy works, also. Because if there is no parasympathetic outflow to genitalia there certainly is none running out anywhere else in the body wall, either.
Which supports the idea that context is everything, and that descending modulation from brainstem nuclei is where it is truly at, for blocking ascending nociception, and (given everything else is level) for pain relief.

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

1. I. Espinosa-Medina, O. Saha, F. Boismoreau, Z. Chettouh, F. Rossi, W. D. Richardson, J.-F. Brunet; The sacral autonomic outflow is sympathetic. Science  18 Nov 2016:
Vol. 354, Issue 6314, pp. 893-897

2. Adameyko I, Neural circuitry gets rewired. Science 18 Nov  2016 • Vol. 354 Issue 6314, pp. 833-4
 

Friday, November 25, 2016

The year's not over quite yet.



But it's drawing to a close.

A lot has happened, most of it in the last few months.

1. I finally finished the book. 

It will be available in the coming week I'm told.
Here is a picture of the cover, back to front.



Whew, glad that's done.

2. I moved my clinic. 

Total unplanned surprise. In September I got a call from another physio in town who told me she was opening a new clinic in a renovated school, and would I like to join her?

The deal was,
a) I got to keep my own name and business and patient list and files
b) I got to have lower rent per month, secure for the next five years
c) I got to have a room with a window and could add a sign to it



d) I had to break my lease in the old dilapidated building where my practice was formerly housed

VERY fair terms.
So I did move - I took a big hit because there was still over a year left in said lease, but opportunities like this do NOT come easily in this town. There is almost no new construction apart from residential. So I jumped at the chance.

And I feel like I dodged a bullet, because the same day I moved out, October 3, a giant rainstorm happened, the roof leaked, and water poured down from beside one of the light fixtures in the building.

Lucky me, out of there.
Whew again.

3. The weird election that just happened down south 

It has to have been one of the most bizarre elections humans have ever held since we've been human and since elections became a thing.
I used to think the following, ever since the Free Trade Deal with the US and Mexico, NAFTA:
That Canada and Mexico were like nurses, walking a large demented patient named Uncle Sam up and down the hallway helping him to not fall, and that he was abusive, striking out at both of us even as we tried to support him and look out for his needs.
Now that demented patient has been elected president of the US. He's now going to represent the US in the entire world. Unless some equally bizarre miracle happens..
Nothing he ever said or did in the election run up convinced me that he would do anything but lurch about and break things and hurt people and be thoroughly abusive.

Gad, I'm going to miss Obama.
Whew that I don't live directly in the US.
Quaking because I live very close to the border.




Sunday, October 30, 2016

Dream drama

Bizarre dream this morning, made me wake up at about 5:30 am. Like all dreams, absurd in retrospect.
Still, one of those dreams that is stark, memorable. The kind that twist you a bit, emotionally. Clearly a message from one part of my brain to some other part.

The dream

I'm a teacher in a classroom in an institution. The reason I know this is because it's a home room with those university type desks and a front wall covered in green board, and outside a long hallway with other doors to other classrooms. Apparently I've taught in there forever. (Absurd.)

I arrive to class to see that two other people are in there teaching. Not only have they taken over and are teaching my class, they are teaching them biomechanics. They are not teachers that I know well, but I'm willing to let them complete the exercise.

They have a human skeleton, or rather a vertebral model, about twice human size, a real one I guess, lying on its side curled up on a table. One of them has a percussive implement of some sort. She is thumping each of the vertebrae in turn. Each thump results in a unique movement of the parts of the column.

This is supposed to mean something profound, I guess, because she looks around at each student as if to say, Truth. Case closed.
They all seem quite dazzled by this demo.

I ask, where does this biomechanical demo and tool come from? And she looks at her teaching partner, then says, Scandinavia. (Which might be absurd, but I'm not sure.)

Oh, I say.

She is a large woman, broad shoulders, about 40-ish. Looks like a lifter. Cropped blond hair. Glasses with dark frames.
Anyway, she leaves out a back door, and I turn my attention to the other one, whose looks I can't recall clearly.

I ask, from a pain standpoint, what does this biomechanical movement model have to do with treatment?
He can't answer.
He stares at me for a moment, dumbfounded, as though I'm the incomprehensible one, not him; then, still mute, with an irritated look on his face he strides out the front door and SLAMS it shut behind him.

I and everyone else still in the room startle. Such a passive aggressive thing to do. I hope that lesson is not lost on anyone.

I have my classroom back, and all the people that are supposed to be in it. I try to gauge how mesmerized they have been by the demo, start a conversation with them by asking questions about what relevance they think this has for a real patient with pain. One thing I want to drag out of them is, do they think this movement (which was presented as the only true movement) is true for every individual? Alive? With nervous systems? all sorts of tissue layers burying their vertebral column?
I don't remember how this part goes. It goes on for quite a while.

At the end of the dream, I'm taking the skeleton home in my car with it still dripping a little after having given it a careful shower. (Absurd.)






Tuesday, October 25, 2016

New rumblings in defining and philosophizing pain

Very low rumblings, like thunder far away, but who knows? They could turn into something, right?

1. This just in: Updating the definition of pain. (Full text, at least for a little while..) 



Current def:
>>> An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

Proposed def:
>>> Pain is a distressing experience associated with actual or potential tissue damage with sensory, emotional, cognitive, and social components.

Yes, I think I like the proposed def more.


It seems the world has moved past the general systems theory upon which the BPS model was constructed, into something much more integrated, less objectified, more phenomenological, (more post modern?), so therefore a better model is required.

Gee, and here I thought BPS was soooooooo much better than the odious biomedical/biomechanical/postural-structural models that so many are still working with, when it comes to pain experiences.


How interesting that these two rumblings both arrive in my facebook feed on the same morning and amplify each other.

REFERENCES

1. Williams, Amanda C. de C.; Craig, Kenneth D.; Updating the definition of painPain:
November 2016 - Volume 157 - Issue 11 - p 2420–2423

2. Dave Nicholls; Is the Biopsychosocial Model all it’s cracked up to be? Critical Physiotherapy Network 25th Oct 2016