Tuesday, July 26, 2011

Deep south of Sask. stories continued

Older stories here.

Maybe I have adult ADHD or something. I got up from the waiting room chair this morning and read all about it, all the symptoms. Yup, that must be it.

Or maybe it was being expected to wait endlessly for my (second, booked) appointment at the Dr.'s office.

I called to find out what happened when the door to the Dr's office was locked at my appointed time, Friday afternoon. Lots of apologies, a new appointment, a confirmation that a sign on the door, letting people know the Dr. had had an emergency to attend, or else a phone call to cancel, would have been welcome. "Oh, yes yes, we will do that next time. Good idea."

So, I gave this guy another shot.
Got there today, 5 minutes prior to appointment time. Not so long before that people suspect me of OCD, but enough ahead of time to ensure that any untimeliness won't be on my account. Simple courtesy.

Forty minutes later, I walked out.

I'd seen him come into the reception area several times, once to help his staff look for some missing file. Another time was a kibbutz with a patient who was just leaving.

I still don't have the Weyburn groove, yet, obviously. Still get mad and fume and steam when someone besides me wastes my time.

Next week the walk-in clinic, just next door, will be open again. I'll try there, see if I have better luck getting my stupid form filled out that has to be signed by a doctor and lets the health bureaucracy feel assured that I'm not some sort of infectious threat to their charges and to other staff.  All so that they can turn me loose one day a week on their persistent pain patients, and make that wait list go down.

Sunday, July 24, 2011

Idle thoughts.

I can't find any pattern here, it's just what's going through my head today. Maybe it will turn into something, more likely it won't.

From recently:

Yet more mesodermalism: The fun never stops
This is from a conversation I had on Facebook last week with a mesodermalist devotee. It went exactly nowhere. You'd think I'd learn. But I never seem to.

The Chestnut Challenge
Byron, a member of Somasimple, wanted to get to the essential bits, in under 400 words.

From today:

Dissecting the empathic brain: an interview with Christian Keysers
I'm always interested in how to develop a more empathic brain and simultaneously retain firm interpersonal boundaries. It ain't easy, that's for sure. I think I might have a brain whose somatosensory apparatus can literally feel what's going on in other peoples' somatosensory cortex, and have to try to do something about it using physical contact. Insert myself into their brain loop. Excerpt:  
"seeing activity in somatosensory regions while viewing others being touched is primarily information about ‘where’ the process occurs. But it also shows that you transform what others feel into representations of what you would feel in their stead; ‘where’ becomes ‘how’ you understand others."
Using manual therapy to treat pain

Yes! It's all in there (beautifully laid-out):

"Laboratory and clinical studies have started to identify the physiological changes that occur in individuals undergoing manual therapy. Manual therapy results in a rapid-onset, localised analgesia, increases limb mobility and effects autonomic changes. Animal models have been developed to inform on neuronal mechanisms, and suggest a local action on nociceptors and modulation of central pain-inhibition mechanisms.

Manual therapy is a commonly used treatment modality for managing musculoskeletal pain that has been shown to promote rapid recovery. Localised, manipulation-induced analgesia is routinely seen following manual therapy and is proposed to occur via a number of mechanisms:

·  A local action on nociceptors.
·  Modulating the activity of both descending and segmental pain inhibitory systems.
·  Exerting psychological effects, probably as a result of treatment expectations.

The mechanical hypoalgesic effect occurs within minutes of manipulation, and meta-analysis of clinical studies has confirmed that it is associated with an increase in pressure-pain threshold and limb mobility. In contrast manual therapy does not modulate sensitivity to thermal pain.

In addition to the demonstrable analgesic effects, manual therapy also induces a number of autonomic changes such as increased skin conductance and cutaneous blood flow, increased pulse and respiration rate, and changes in skin temperature. This indicates that, in addition to changes in pain perception, manual therapy modulates central nervous system function in a sympathoexcitatory manner (promoting mobility).

The local analgesia and systemic autonomic changes in response to manipulation have been demonstrated in healthy individuals and those with pain. Manual therapy also achieves motor function benefits; cervical mobilisation in individuals with insidious-onset cervical pain has been shown to promote increased deep neck flexor muscle activity and improve pain-free grip. However, motor function benefit tends to be restricted to individuals with a clinical condition.

These patterns of effect are suggestive of activation of the descending supra-spinal pain systems. Further evidence of a role for descending pain modulation pathways has been generated using animal models. A rat model has been developed in which capsaicin injection induces hyperalgesia in the hind-paw; ipsi-lateral knee joint manipulation subsequently exerts an anti-algesic effect in the entire limb. The model has shown that the analgesic effect of joint mobilisation is inhibited by the intrathecal administration of serotonin antagonists and is partially modulated by a22-noradrenergic receptor inhibitors; in contrast opioid antagonists and gamma-aminobutyric acid inhibitors have no effect. This suggests that manual therapy affects the activity of the supra-spinal, descending pain-inhibitory systems that involve seratogenergic and noradrenergic pathways."

(Thank you, Dr. Julie Eastgate, from the U.K. )
Insight and creativity, by Janet Kwasniak.
I agree. They are quite different.
"creative thinking does not appear to critically depend on any single mental process or brain region, and it is not especially associated with right brains, defocused attention, low arousal, or alpha synchronization, as sometimes hypothesized."
 "insight is represented by distinct spectral, spatial, and temporal patterns of neural activity related to presolution cognitive processes that are intrinsic to the problem itself but not exclusively to one’s subjective assessment of insight."

" [JK]This implies that we can unconsciously notice that we are thinking about a problem in an unsuccessful way, search for an more successful framing, and evaluating the new way of thinking about the problem. To me, this hints at working memory not being required in this search for a transformation. Another interesting result is the gamma increase was in the right hemisphere (rather than left or both). This implies that the usually less dominant hemisphere was carrying the load in finding a transformation.... Insight may or may not be part of any thinking process – creative or not. Creativity is probably so varied and so complex a process that it cannot be correlated with any particular neural picture. "


Friday, July 22, 2011

Stories from the deep south of Sask.

There are aspects of living in Weyburn that I do not like. There is a certain structural (I think) lack of accountability, lack of business etiquette.

Story #1:

A couple months ago I looked for office space, found a real estate agent, who showed me a small streetfront space, part of a building housing independently living seniors, right downtown. I decided to take it. I contacted the real estate agent, who said "I think the owners might be wanting more for it than I quoted you." What the..??
I asked him to double-check the cost and let me know ASAP what the new "cost" was going to be. He said, the owners are out of town. I waited patiently, for three weeks. Well, patiently for me, at least. One visit in person (he wasn't in), a couple voice mails and three emails. He never, ever got back.


It was as if he had died and fallen off the face of the earth. No reply. A  couple weeks after I gave up trying, I found out through a completely different source, my mother (who had noticed activity in the space), and directly asking the guy who is the caretaker there, that the owners had rented the space to a different party, people who were were busy jackhammering up the floor, gutting the space, renovating it to turn it into a boutique hair salon.

I could have been notified. Surely a real estate agent's job is to keep all interested parties informed about what is transpiring with a space that's up for rent. Surely.

But, in this town, I'm chopped liver apparently.

It has all turned out OK. I never found the right space, but I do have a working gig with the "big" private PT place in town, two days a week, nice room to work in, private, has a door, a window, space for my small amount of stuff, fresh laundry, someone working there who does laundry.. A bunch of tough cases to treat, no time pressure. I'm working on an application to the other big PT place in town, in the public realm this time, outpatients in a government run facility, right within/part of an assisted living facility for patients who are much higher maintenance, needing skilled nursing care. Which leads me to my second story.

Story #2:
To fulfil application requirements at place #2, I was asked to provide a police check, an immunization list, a medical certificate of health.

OK. Here we go. It's been 7 years since I last visited a medical doctor. The last time I visited a doctor, she freaked out and had checked me out for breast cancer, which involved two (not one but two!) painful mammograms, one of which was exceedingly painful and made me swear out loud. Also an ultrasound and a clinical exam. None of which turned up anything. So I stopped the relationship. I never picked up another. Until now. Because of this application requirement.

So, here I am, in a new place, no medical relationship. I picked out a Dr., which in itself isn't easy here, because they aren't listed under "physicians", here, just medical clinics are listed. Anyway, I walked down the street, found the name I was looking for, took down the phone number because the clinic was closed the day I went looking, called, made an appointment, was ecstatic to find out I could get in today.

Went to the appointment. Was 5 minutes early. Light was on inside, but no one visible, and the door was locked.

I waited until my time. I knocked on the door. Nothing. I waited some more. Ten minutes past my appointed time, I left. I went and picked up some groceries.

On my way back, 20 minutes later, I looked in the window. Now the light was off.

I was stood up again. Chopped liver yet again. I realize, being a manual therapist, that the pattern-seeking and finding part of my brain is extremely well-neuroplasticized. So I'm apt to see patterns where they don't really exist, and make erroneous conclusions from that. I'm way better at NOT doing that than I used to be. Still... I can't help seeing a pattern here: it seems to be a pattern of "Don't-have-to-give-a-sh*t, unless I know this person and my parents knew that person's parents and they all voted the same way and/or went to the same church, and/or they are the sister-in-law of my brother-in-law's cousin, and/or I owe him/her a favour."

Now I remember one of the (many!) reasons I was so eager to escape small town BS 30 years ago, where systems are inefficient and all transactions occur based on who you know, not what you know, or need, or expect, where there are no objective standards of interaction, where business ethics seem to be ... well, the most charitable word I can think of, is wobbly. This aspect, I definitely do not like.

Sunday, July 17, 2011

CPACongress11 - Part II

I have been really busy! It's noon on Sunday; I skipped out of sessions today, following breakfast and AGM, to feed my inner blogger with some posting. I can't do it on the fly because unfortunately the conference center down the street doesn't support internetters. They have wifi but no provisions were made to give conferencers the password. Not wanting to lug around a computer for nothing, it has sat in my hotel room idle, most of the time, instead, while I've been out socializing for a change.

Anyway, catch-up time.
Lara Boyd spoke early on Friday morning. She is a PT/neuroscience researcher with the BrainBehaviourLab at UBC. The talk was fascinating (she should have been the keynote speaker); I don't recall much anymore, but what I gathered is that she looks at transcranial motor stimulation of the cortex of people with stroke. She talked about how the hemispheres inhibit each other all the time, and how in stroke, one hemisphere often shuts down completely and the other gets wildly excited. What I got excited about, was that she said cotico-spinal pyramidal cells don't just originate in the motor cortex, but rather, that they also originate from the sensory, and premotor cortices as well; that the motor, pre-motor and sensory cortices were really not discrete in their function as much as everyone used to imagine they were. She talked a bit about pain, but I forget what she said. I do remember Deb Patterson leaning over and whispering, "That must be why mirror therapy works!" And I remember the two of us, at the back of the room of 500 or so people, breaking out into spontaneous applause. A guy turned around and asked, "Neuro section?" and I replied, "Pain section."

I plan to read every scrap this woman has ever written.

Progressive Goal Attainment Program
One of the big surprises this year was that Michael Sullivan from McGill was invited to present. This is a HUGE step away from the pure mesodermalism I've learned to expect and dislike. He talked about predicting what patients would be less likely to do well with "regular" treatment, and helping patients keep moving along by avoiding therapeutic relational pitfalls common to our profession, common in that no PT school has ever bothered teaching us to be more "therapist" and less "physical." He extends the opportunity for interdisciplinary adventures with his by-now-famous Progressive Goal Attainment Program (PGAP). Which I plan to take one of these days. I think the ortho division brought him in, which is a huge departure from Jay Shah and his muscle needling, from Congress last year.

Pain Science and our (Pain Science Division) chair, Dave Walton
Several workshops this year focused on the pain system, stress, goal attainment, therapeutic relationship, goal attainment, motivational interviewing, and classifications of patient subgroups; Dave was involved in many of them. It was SO good to see. SUCH an evolution away from mind-numbing presentations about elbows and knees and necks. Well, we haven't managed to get away from the necks, quite yet - a lot of stuff was about whiplash; however, much was about yellow flags applicable to any kind of pain, but unfortunately (IMO) because of the nature of science, this body-part issue has to do with the way research is organized and research questions have to be addressed. It's necessary to focus on one bit at a time - no one can ever ask a broad question that would apply to the human organism in general. Apparently PhDs are gained particle by particle.

Dave Walton, new chair of PSD as of Thursday July 14/11, second from right, beside Ronald Melzack
Also in picture: Lesley Singer far left, green dress; me far right

Neil Pearson stepped down as chair (because it's a timed term, not because he wasn't great, because he was), and Dave is our new chair. He is a PT, a PhD, a martial artist, and has been known to do breakdancing at Local Flavour Nights during Congress; it is rumoured he can do full splits. Pretty cool. Go Dave!

Friday, July 15, 2011

Weather report

View from hotel room, Whistler BC, July 15/11
Chair lift in the background. 
Horrible cloud; cold, windy, November weather in mid July

So, here I am at CPA Congress. So far Congress has been brilliant, with great food and fabulous presentations. Can't say the same about Whistler weather. It's like going back into the cave, coming here. Hard to get here, very long trip. Next year I hear Congress will be in Saskatoon. That will be much better. 

So, what am I learning? 

Day I
All day Thursday, Pain Science Division presented "Clinical Chronic Pain Management: Practical Strategies for Everyday Physiotherapy" which was fabulous; Neil Pearson talked about neuroplasticity, how it required 90 minutes a day for a month to change anything in the brain, but that change was indeed possible. He showed a list of pain mechanisms; nociceptive, peripheral neurogenic, central neurogenic, autonomic/motor, and affective; he said that the MDs learn that list, and then they learn from pharmaceutical companies that there is a drug or class of drugs for each (and that that's ... about it). He discussed chronic pain in general, what it meant, etc. There was much more from Neil, but my notes are sketchy and handouts will be emailed out later, so, don't have those to refer to.

Deb Patterson talked about how everything that hinged on change in pain hinged first on developing a good therapeutic relationship and projective goal setting. She explained the SMART (specific, measurable, attainable, relevant, and time-bound) goal-setting model. She had a few videos of patients she had treated, including with DermoNeuroModulation (my thing), and how the therapeutic relationship had turned out. One was a woman whose ends of fingers had been amputated, traumatically, and the woman had developed horrible phantom finger pain. Previous (failed) treatment had been "desensitization" but it had backfired - tapping and stimulating the ends of the finger stumps had revved up pain instead of reducing it.  After Deb had treated her face the phantom finger pain had disappeared, briefly, giving the woman an opportunity to realize she was capable of "no pain." Deb used mirror therapy with her too.  In the video we could see how Deb had moved the woman carefully through just looking at an intact right hand in the mirror box (stimulating visual cortex), to stroking it lightly and VERY gently with a cosmetic brush (stimulating affective somatosensory cortex), to asking the patient to thoughtfully and sensitively move her fingers, watching them move in the mirror (somatosensory and premotor and motor cortex). The swelling and pain went away. Now she could now tolerate wearing her finger prostheses, and as a result was going out, was being a lot more social. Absolutely brilliant clinical intervention.

Lesley Singer talked about having chronic facial pain herself, stemming from surgery to remove a brainstem tumor; what having chronic (centrally generated) pain was like, from a patient's perspective as well as from a clinician perspective, treating other people with chronic pain. 

Dave Walton discussed measuring pain with pain scales, and scales for all things related, such as depression, catastrophizing, anxiety, locus of control, readiness to change, fear, kinesiophobia, coping behaviours and strategies. 

This day long workshop is going to form the backbone of an entire Level II of the Virtual Pain Symposium we put together a few years ago.

Day II
The plenary session this morning was by Lara Boyd of Brain Behaviour Lab at UBC. No time to discuss it right now, must run off to the next event. More to follow.

Saturday, July 09, 2011

Letter to a biomechanically - minded therapist

A new member at SomaSimple wrote:
I am still trying to get a grasp on everything I have been reading on this site. I would like to hear the rationale from an Ectodermalist of why I had success this patient.

Patient: 39 y/o female presenting with c/o left lateral knee pain while jogging. No reproduction of symptoms with AROM, joint mobility, palpation, special tests. Onset of symptoms after approx 3 minutes of jogging on treadmill. Patient described symptoms as "deep in the joint" and "sharp". Other objective findings: weak L hip ERs, L midfoot pronation.
Video analysis of running mechanics: excessive L DF and close to full L knee extension at heel strike.
Treatment: decreased patient's stride length by increasing number of steps per minute with use of a metronome; exercise for L hip ERs
Results: patient ran 10 minutes pain free with decreased step length at same visit
Rationale: decreased stride length will decrease ankle DF and increase L knee flexion at heel strike in order to decrease ground reaction force at L knee joint

Name deleted
I wrote back.
Inevitably I missed saying a few things that are probably important for clarity, so this blog post will be an elaboration of that response.

First of all, congratulations on having interacted with, and helped abate, a problem a patient was having with movement and pain. The question you seem to silently be asking sounds like, "because I used biomechanics and biomechanical analysis to help solve the problem, why should I bother trying to learn how to see things ectodermally?" 
This always seems to be the first question people ask. The second one is, how is what you do different from myofascial release? Which used to drive me batty, but doesn't anymore, because it's been so long since I extracted my own brain from entanglement with all the flawed ideas inherent in myofascial release as a treatment concept, But now, back to the letter:

I think that is a fair question. I really do.

I wrote a bit about the focal length of treatment a little while ago. Here is a link; Operator/Interactor.
So, it boils down to biomechanics and biomechanical analysis being a good example of "patternicity", fraught with Type I and Type II error, or pareidolia (seeing the virgin Mary in a piece of toast) or apophenia ("experience of seeing meaningful patterns or connections in random or meaningless data").
Manual therapy is full of pattern seeking and finding, and so is any sort of therapy, really. Psychotherapy is full of this too. A practitioner sees a certain kind of pattern, or sees a pattern a certain way, and starts to explain how he or she sees it, then other people (suggestible as we all are) start to see what he or she means, it all makes sense, and voila, a new institute is born!
 So was medicine for a very long time, and still is to a great extent, burdened by patternicity-seeking.

One of the biggest irritations I still have, actually, is the enormous influence still wielded by the Biggest Mesodermalists of Them All, Orthopods and Physiatrists, over the thinking processes of therapists of the physical persuasion. Why do they persist in knowing nothing about neuroscience? Because they are making a fine living from injecting joints and needling imaginary things called trigger points that they decided arbitrarily are located in muscle somewhere/somehow, and teaching new generations of keeners to think the same way they do about pain problems.

Last summer I sat and fumed for an hour, listening to Jay Shah talk about trigger points and needling them. He admitted upon questioning by Neil Pearson (then chair of CPA's Pain Science Division) in the audience that day, that no one has ever actually found trigger points to exist, but he had gone on for an hour before that, showing zippy video-embeds of naked muscles (skin removed) and needles put into them this way and that, leaving every brain in the room with the overwhelming impression that he was showing us real, anatomical, mesodermal entities that were "pain" generators. Way to mess with peoples' minds, Jay Shah. Way to not help anyone understand pain or the nervous system better. Way to reinforce Cartesian ideas about "pain" (not just nociception) being carried on pain strings inside the body up to the brain. That model is really not that clinically useful anymore. For any of us who don't like needling, for sure. Way to keep allied health professionals separated from a longer conceptual focal length and perhaps wider angle conceptual view of pain and its common persistence. Way to keep us in the dark. Way to reinforce mesodermalism.

But now, back to the letter:
Now, about your patient: You used a very well-established patternicity model to help your patient. There is nothing wrong with helping patients any way you can. However, there is a great deal of information in the last 30 years or so about the brain, about how the body and brain interact, about pain, about how the brain both creates and responds to a pain experience.

This forum, if it is about anything, is about exploring how to connect all that to what we all, in one way or another, do for a living, which in my opinion is human primate social grooming. Human primate social grooming (HPSG), to me, boils down to a wordless kind of interactive, kinesthetic support, fully accessing every affective and afferent channel in that patient that is therapeutically available to us, to help them. Them. Them. 
This is uppermost on my mind this weekend, because of a recurring fight I always end up in with chiropractors. The latest battle was on Facebook last week. This could be a whole separate blogpost, but briefly, I posted a video of Alannah Myles and immediately had my throat jumped down by a chiropractor who accused her of lying. Yes, lying. About her own experience of being in a body, taking it to see someone she thought would be able to help her, but hurt her instead. I documented the exchange here. To my mind, any profession that doesn't put the patient and his or her well-being, front and center, but instead reinforces victimhood by placing itself first and foremost in the mind of the practitioners it trains, is the exact opposite of what a healthcare profession or professional should be. I consider that to be an unconscionable juxtaposition, completely indefensible, although chiros really really try, reflexively, to defend themselves before any other thought crosses their minds, and end up weeing all over themselves and their (so-called) profession in the process. And they never, ever seem to get how ludicrous they are/it is when they do that.

But I digress. Back to the letter:
What the problem is, with patternicity, is that conceptualizations can interfere with our own brains. Several problems can emerge if we aren't really careful to always keep the patient first and foremost. A few examples, randomly, in no particular order:

1. We can become way too reliant on the tool, instead of what it is we are supposed to be doing with it. There will always be a patient who comes along who doesn't fit your tool/concept. Then what?
2. We can end up being tool collectors which can lead to a lot of confusion.
3. It's really, really hard to study therapy from a patternicity standpoint, because of there being nothing objective to measure, just a pattern in a head that feels real but isn't, because it isn't an object, it's an objectification.
Treating a set of ideas we cart around in our heads in a basket might overlap a good deal of the time with actually managing to help patients, but it can't always, and if we rely on conceptual baskets of ideas only, we will lose the paddle far up the creek on a regular basis.

Back to the letter:
Instead, what some of us old fogies have come to realize, is that we might have saved ourselves a lot of $ and frustration if we hadn't combed carefully through all those patterns, gurus, and institutes out there that are patternicities based on mesodermally-derived tissue. What is mesodermally derived tissue? It's the 98% of the body that is not nervous system (i.e., bones, joints, muscles, fascia, tendons, ligaments, etc.) Instead, we wish we had stuck with key principles.

In this post, Ian Stevens nails the essence of the problem we all face whether we are currently practitioners of one kind or another, or are people in pain (and I can pretty much guarantee that we all will be one day like it or not); ian s, paraphrased:
"..illness Pain is not (only and always) a mechanical process. Illness Pain is always multifactorial. That’s part of the nature of complex systems – they aren’t simple! The thrust of the argument is that it’s whole people who get ill pain, body and mind, inextricably interfunctioning, and not only that, but it’s whole people, embedded within the environments of their lives who get ill pain. I use the plural there deliberately. We are embedded in multiple environments, not just physical ones, but also social, cultural and narrative ones. We are meaning-seeking creatures."
I just loved Ian's depiction of nested problems, nested in contexts, several simultaneous human contexts, inextricable from them, rather like the way manual therapists find themselves inextricably bound inside the conceptual worlds they build and pay to have built around their/our own brains. Man oh man, we had better start building in some cognitive nimbleness to avoid being screwed in the left ear by hucksters from our own human primate social grooming troops, and/or in the right ear by 'submission to authority' in the form of actual medical doctors, like Shah (see above), who should be helping HPSGs find a way out of the mesodermal concept quicksand instead of deeper into it. 

Back to the letter:

To sum up, as long as we are putting the patient first, ahead of ourselves, ahead of our professional pride, ahead of being attached to results, ahead of being attached to our favorite patterns, or methods, or anything else, we'll probably do just fine in the long run and work our way out of the conceptual maze and realize that all we can ever know is just how to be just and ever and only one step ahead of our patient. Which is fine, because as their therapist you don't ever want to be any farther ahead than that, or they might lose track of you and you of them. It's only one step, but as long as it's the right step, you'll always go places, and be able to help them, and never hurt them. 

The Expert Mind.
The Patient's Brain: The neuroscience behind the doctor-patient relationship

All the best.

Monday, July 04, 2011

Why I don't buy the idea that "trigger points" are in muscle

This is what happens when vessels to nerves are under tension

We've all heard of trigger points, right? Those things that hurt when you press on them or when someone else presses on them. Right? So far, so good. They are spots, or points, fair enough; and they hurt when provoked, i.e., they "trigger" discomfort. I can accept all this so far. We have something physical, a sore spot, and we have some action, provocation that makes said spot hurt.

It all gets rather smushed together, this (ectodermal) phenomenon called "pain" being generated somehow, then "felt" or perceived as being associated with some (mesodermal) part of the body, with a motor deficit or malfunction of some sort, such that when a certain movement is attempted it is thwarted by a pain signal. I suspect it was the interference with motor output that made it somehow acceptable to leap to the conclusion that muscle was somehow to blame. But it isn't, not necessarily. Correlation is not causation. After all, muscle is just doing whatever the CNS tells it to do. Really. Muscle is just a puppet of the nervous system. It has no "behaviour" other than doing whatever the nervous system decides it needs (non-conscious) or wants (conscious) to do.

Now, why in the first place trigger points were ever blamed on muscle is probably, in retrospect, just sloppy, convenient, heuristic thinking. I can accept that stuff like that goes on all the time. Why such sloppy, convenient and heuristic thinking is allowed to continue when better explanations have come to exist, I don't understand, and sort of resent actually..

First of all, supposed "trigger points" are found/discerned/their existence implied from outside a patient by another person poking at them. Let's bear in mind that there is a thick layer of blubber, even on skinny people, between a patient's "muscle" and a practitioner's finger poke. Let us not automatically mentally subtract the outer layer as inconsequential, the way trigger point diagrams would have us do.

That layer, known as cutis/subcutis, usually a good half inch thick, contains:

1. a huge amount of neural structure, i.e.
  • Cutaneous nerves with all their rami to the surface
  • All the neural receptors needed to signal the state of the environment to the brain
  • All the neural structure required to regulate blood flow in the skin organ which according to Gray's Anatomy, is ten times that required to maintain the skin organ itself.
2. a huge amount of vascular structure, for thermodynamic radiation of heat away from person-as-organism

3. Plenty of smooth muscle tissue, responding not to the will of a person but rather to brainstem exigencies/dictates, e.g. shivering/goosebumps, vascular lumen contraction via sympathetics, vascular lumen enlargement via efferent neuropeptide leakage by afferent sensory neurons, plenty of opportunity for nociceptive afferents to be bothered by sympathetic efferents and vice versa.

Could it be, therefore, that "trigger points" are no more than areas of secondary hyperalgesia? Tell me how it is possible to diagnose "trigger points" in striated muscle, through a half inch of protective cutis subcutis full of all sorts of autonomic behaviour and potential afferent crankiness, plus a dense layer or two of fascial containment around said muscle? I just don't buy it. And I can't buy any diagram that shows red striped muscle with a red "x" on it, indicating a sore spot, with no skin over it or neural structure depicted in the area. I.e., Travell and Simons. To me, all this blaming a muscle for pain is a good example of looking backward through a telescope. It can be done, I suppose, but it doesn't help anyone see or conceptualize anything better. (I realize this all sounds like heresy. So shoot me. But please read on.)

Several years ago, Quintner and Cohen pointed out some of the logical problems inherent in the 'myofascial' idea surrounding the phenomena of "trigger points", making what I still think is a really good stab at deconstructing the nonsense in which they (still) remain embedded. See their article, "Referred Pain of Peripheral Nerve Origin: an Alternative to the "Myofascial Pain" Construct." I think it's a great article, one of a kind, but still, I wish they had gone further and pointed out or at least mentioned that no tissue other than neural tissue (i.e., neurons, direct ectodermal derivatives) can directly signal the brain (also direct ectodermal derivative) to provoke it into mounting a pain output/perception for our conscious awareness to,.. um, be aware of, consider. In other words, quite apart from the "trigger point" issue, is there really any such thing as "myofascial pain"? I would argue that no, there isn't. Only neural tissue can send sensory-discriminative information to the brain, and only the brain can mount that sort of cognitive-evaluative-motivational-affective-sensory-discriminative display known as "pain". Other kinds of tissue in the body are usually innocent victims, not guilty culprits. (I can hear people thinking, "But what about inflammation? The immune system?" Yes, the immune system can bother the nervous system, terribly, but ultimately, the internal regulation system controls the immune system, so there you go. The only exception I can think of is a channelopathy or other genetic or epigenetic pathology. For regular garden-variety mechanical pain? Not so much. Please read on.)

A few years ago I started reading about tunnel syndromes. There are more than enough of these described in this book (see below) that I think I'll go with the idea that most of the "pain" (in the mechanical sense) experienced as being located in the body, is likely due to one or more neural entrapments, not misbehaving mesoderm being some sort of causal factor.

In the book, Tunnel Syndromes, (Marko M. Pecina , Andrew D. Markiewitz , Jelena Krmpotic-Nemanic, 2001) over 50 different neural tunnel syndromes are described and illustrated. The non-invasive treatment recommended in this book is kinda pathetic, really, but they probably don't realize what manual therapy can do with mechanical pain, and each tunnel syndrome is fully described and its diagnosis differentiated. Here is what the authors say:

1. Tunnel syndromes can occur with no apparent “cause” (e.g., a tumor pressing into a nerve, etc.) - many are “idiopathic”
2. Function of a nerve can be dramatically altered without needing to be compromised in terms of space: diverse factors can adversely affect nerves function, such as: 
  • inflammatory changes that thicken a neural wall/reduce blood supply, 
  • edema 2° to hormonal changes from pregnancy, menopause, birth control pills, myxedema from hypothyroidism, 
  • anatomical variation (anastomoses, other soft tissue variations not visible on x-ray), or 
  • repetitive movement.    
3. A nerve that abruptly enters a new tissue produces a fulcrum on which external forces can act.
4. Ischemic changes will first affect sensory fibers; if they continue motor fibers will be affected.
5. Pain (i.e., nociceptive input, nociception) is the most common symptom.

(I would add, pain on provocation, or secondary hyperalgesia, fits in here too, since nerves themselves
a) can "hurt" because of being innervated by nervi nervorum, and
b) come all the way out to skin by way of cutaneous rami sheathed in skin ligaments.)

So, in addition to repetitive movement, how about not enough movement, or variety of movement? 
I would urge everyone to get a copy of Rempel D, Lundborg G,  Dahlin L;  
J Bone Joint Surg Am. 1999;81:1600-10. 

Check out the wonderful diagram of the microanatomy of peripheral nerve it contains (posted above).

Lundborg, back in the 80's, worked out the microanatomy, how the vascular supply inside a nerve worked,  what assisted it to function (um, movement), what happened to it if it became impaired, the sorts of mini-compartment syndrome effect this could have; he measured all sorts of finicky pressure gradients within a given nerve, and so on. Without lymphatics (although this idea of no lymphatics inside nerves is itself disputed by some), sometimes venous drainage alone can't take care of all the neural needs by itself, in there. Inside a tunnel. Who needs to worry about external compression on a nerve if it can develop problems all on its own inside its own tunnel? From blood flow backed up? I.e., increased volume? Lately Coderre has hypothesized a link between mini-compartment syndrome of blood flow in nerves and CRPS.

Why did Lundborg bother studying all this nerve stuff? Because he was learning how to do nerve grafts, and was trying to figure out what he had to do to keep his grafts from failing. What must have been blatantly obvious to him was that nerves have/are special kind of tissue(s) and require just the right conditions to grow together again.

Why should we as manual therapists care about any of this? Because by knowing about it, by knowing about nerves and the kinds of trouble they can get themselves into, how they can become nociceptive "drivers" themselves, we can drop off a lot of cumbersome and useless hypothetical baggage that forces us to consider and develop extraneous ideas about what tissue we think we are treating when we treat "trigger point" "pain" in people.

If we can get onto the correct tissue conceptually, then we stand a better chance of getting on the right tissue perceptually, too.

As always, it doesn't hurt to remember that the nervous system is only 2% of the body but uses up 20% of available energy, signals itself constantly at an average speed of 120 meters per second, constitutes 72 kilometers of nerve in a single human, and if every neuron were laid end to end, it would be more like 100,000 km.; that if a neuron's soma were the size of a tennis ball, its axon would be a half mile long and the size of a garden hose. The other 98% of the tissue comprising the human body doesn't know, doesn't much care, lives fast, dies young, replaces itself without much fuss. In other words, don't blame mesodermal derivatives for things over which they have absolutely no control. They're just passing through something called a human life, controlled for the length of a life span by something called a nervous system. Treat that instead - it can respond to what you do. From skin cell to sense of self. Continuous and indivisible from a signalling point of view. The other stuff can't.

Two different sources on tunnel syndromes, same information re: mechanism
Note the second source, re: "Ischaemic changes will first affect sensory fibres" 

Friday, July 01, 2011

Conversation with a patient

I've started working again lately. I'm treating people who have persisting pain.
A woman I'm treating told me she has a lot of stress, has anxiety. For sure she does. For sure she does.

I told her we all have to learn to control anxiety. I said it was tied in with stress, and that stress made the hypothalamus send out a hormone that made the adrenals send out juice to make the brain learn. Taking a tip from Deric Bownds (and many others), I said that metaphorically the hypothalamus was a bit like a loyal alpha dog, lead sled dog, very big, very muscular, constantly and consistently protective. We want it to do its job but we have to learn how to not scare it with all our imaginings. That we should always check, then affirm, that "there is no bear in the vicinity".

I told her that the hypothalamus was part of a threat detector system older than humans. That it was an evolved system older than the human part of the brain. That our job as humans was to learn to tame it. That we could do that by:

  • being kind to it
  • giving it attention
  • giving it treats (the way we would with any critter we needed to tame)
Like training any wild, abused, or neglected critter, taming the self's own instinctive protective parts is similar. It requires patience and positive reinforcement. If we don't gain control of the lead dog, it will pull our sled in all sorts of unwanted directions.

It requires treats for good behaviour.

What is the most important thing in the whole world to the internal regulation system? That part of the brain that is responsible for absolutely everything? life itself? Pretty simple actually. Oxygen. Deliberate deep breathing.

That's when we were interrupted by my patient's cell phone, and the conversation ended.

Further reading:
1. Deric Bownds Mindblog Biology of Mind

One of nature's little conversations

Squirrel: (Approaches, shakes tail vigorously and pointedly) "Get away from there get away from there....!"
 Crow: "What the... huh?...?"

Squirrel: (Inspects its spouse's/child's/friend's body) "(Ohno,ohno,ohno...) Hey, you! Back off or I'll point my tail right at you - like a gun!!"
Crow: "Back off? Hey buddy, you're inserting yourself between me and my lunch. That's not nice.. OK, not sure if that's a tail or a pellet gun... But I can tell you're upset...

Squirrel: (Stands up to make itself look more dangerous) "Damn right I'm upset! I'm warning you! Back the ef up!"

Crow: "Ya.. sure, whatever..." (Crow moves out sight range, and squirrel bends down to attend to dear friend, see if it can possibly do anything to help; offers recumbent and unconscious, possibly dead friend a Whiff of Behind, to see if that can revive him or her. It doesn't. Meanwhile, crow circles round to see if it can get closer..)

Squirrel: (Suddenly charges at crow) "I told you to back off!"

(Squirrel hastens back to side of its beloved. It knows there are other crows nearby just waiting for a chance to dine. Squirrel figures out how to apply Whiff of Behind first aid, plus keep an eye on the crow, at the same time. Crows stroll around patiently, looking for an opening.)

Squirrel: (Spits on its hands, charges at crows again) "You guys, back up more! Give me space! I've got a life here I'm trying to save!"

Crow #2: (Hops into frame) "Life? That's not life, that's food! And I'm peckish. And you, my furry friend, are standing directly between me and lunch!"

Squirrel: "Not true not true not true!!! Get away!"
(Crows look at each other.  Squirrel is suddenly overcome, flops prone beside friend; grief surges as it begins to suspect the crows could be right; the accompanying physiological, mammalian bone-chill feeling brings on weakness and sudden exhaustion. Squirrel stands up again) "Well, at least give me a moment to say a decent goodbye then, before you start pecking out eyeballs!!"