Wednesday, April 30, 2014

The ants go marching one by one..


Recently I read an article in Nautilus that captured my attention - here it is:



Wow. Great article. I'm still thinking about it days later. 

Some excerpts:


"The behavior of each individual in the group is set by the rate at which it meets other ants and a set of basic rules. Its behavior alters that of its neighbors, which in turn affects the original ant, in a classic example of feedback. The result is astonishing, complex behavior. “Individually, an ant is dumb,” Gordon says. She gazes off into the distance and inhales sharply. “But the colony? That’s where the intelligence is.”... 

Both of these systems (ants and neurons) accumulate evidence about their inputs—returning ants or incoming voltage pulses—to make their decisions about whether to generate an output—an outgoing forager or a packet of neurotransmitter."


"Each of the brain’s 86 billion neurons can be connected to many thousands of others. When a neuron fires, it sends a signal to nearby neurons that changes the probability that they will also fire. Some neurons are excitatory, and increase the chances that other neurons will fire. Others are inhibitory, and reduce this chance. A combination of inputs from a given neuron’s neighbors will determine if it fires. If two neurons make each other fire often, the synapse between them (a small gap across which chemical or electrical signals are passed) will strengthen, so that they can more readily provide feedback to each other."

“This is where you get the saying that ‘Neurons that fire together, wire together,’ ” says Dmitri Chklovskii, a neuroscientist at the Howard Hughes Medical Institute. But what is often not appreciated about this adage is that wiring also requires the second neuron to send a message to the first that it, too, has fired."

“The only way the upstream neuron knows that the second neuron fired is that it produces a feedback spike. This helps the synapse make the decision to get stronger,” ..

"Feedback is where the similarity with ants begins. “Feedback loops are everywhere on every level. They allow the system to realize that what it used to be doing isn’t working any more, and to try something new.”


"Both ants and brains actually rely on two types of feedback, held in a delicate balance: negative (or inhibitory) feedback, and positive (or excitatory) feedback. “Negative feedback tends to cause stability. Positive feedback tends to cause runaway behavior,”... “These two simple rules make something very powerful.”  

"Czaczkes mentions a tale involving the South American army ant, which unlike the harvester ant, relies on pheromones for navigation. In 1936, ant biologist T.C. Schneirla watched a group of army ants fall into an “ant death spiralas they created a pheromone trail completely around a large tree. The lead ants, Schneirla noted in a 1944 paper, discovered and followed their own pheromone trail. More and more ants joined in, following an endless positive feedback loop around the same tree, continuing for days through pouring rain until the ants began to die from exhaustion."

“Relying only on positive feedback can get you stuck like this,” said Czaczkes. He would later show that positive feedback was balanced by negative feedback in the black garden ant, and that negative feedback allowed for rapid adaptation to the environment."

"Similar feedback networks are found in the brain, both at the level of individual neurons and of the whole brain. Just as the discovery of a cache of seeds by one or two harvester ants can trigger a massive exodus from the nest, the entry of a few sodium ions into a neuron can trigger a massive influx."

"This positive feedback raises the voltage of the neuron past a certain threshold, causing it to fire and temporarily stop the influx of sodium ions, while simultaneously letting potassium ions flood out... activity of individual neurons induces electromagnetic fields around the brain that can be recorded with electroencephalograms (EEGs). The EEG signal, too, is a form a positive feedback."

My bolds.

I must interject here to remind readers that "positive feedback" used here is not the same meaning as the conventional social meaning, which is "always say nice things to people". The scientific meaning is "
process in which the effects of a small disturbance on a system include an increase in the magnitude of the perturbation."  Snowball effect. Avalanches. That kind of thing.


Researchers can study ants a lot easier than brains; behavioural emergence and positive and negative feedback loop observations can eventually be extrapolated to and tested in some yet to be determined way in brains themselves, once the parameters have been figured out and they know what they are looking for. Pretty cool.

Anyway, the thing that jumped out at me was the part about the ants circling the tree until they died in the rain, the positive feedback loop scenario. Poor ants.


Like microphone squeal. 

Like pain? I think so. Maybe. 

I'll never be able to think about pain neurotags again without thinking about positive feedback loops, and that unfortunate bunch of ants endlessly looping around the base of a big tree, doomed by the pheromonal situation they never asked for but got anyway, unable to exit their colony's death spiral. Natural selection is so completely, blindly, unfeelingly mechanical...

May 1/ 2014
Back in to link to Erik Meira's excellent blogpost, Getting rid of something positive. All about positive feedback and getting rid of microphone squeal, in our work as therapists. Great post.  

Tuesday, April 29, 2014

"Shifting away from nociception and mesodermalism.." by Alice Sanvito

Seriously good guide, Alice, seriously good. Alice has a real knack for writing nice, well-constructed guides to things. 
Here is her guide to learning pain science for massage and other kinds of manual therapists. 


Shifting away from nociception and mesodermalism and towards "yesciception," neurocentrism, and pain science.

Wednesday, April 16, 2014

"We are nature" and nature is fractal, so let's work with that idea



Yes, we are nature.
We are a connection of cells, in relationship with each other. Cells that have decided to live together in a coordinated fashion to enhance their own lives. The ultimate coordinator, supporter, manager, protector and initiator of all this multicellular existence and function is the nervous system, and, before it, ectoderm. 

The river running through us, and through each nerve, through our whole nervous system, is our blood supply. 

At every level of function, a more complex version of this nervous system can interrupt and substitute another pattern upon a function - provided all the cells can make the right kind of proteins, and provided the immune system remains obedient to the nervous system, and doesn't try to stage some kind of coup d'├ętat.

.......

Out in the social world, things often seem organized along similar principles. In fact, society (any society, based on any idea, in any era) seems to make every effort to convince us there is a vast social order with us residing at the bottom.
Mostly, schooling reinforces this. Please see Seth Godin's remarkable little free e-book all about this; Stop Stealing Dreams. It's great. He would like to see schooling change, a lot. So would I.

Here are a few excerpts, and some thoughts I have about the profession I inhabit. And am trying to not just redecorate, but renovate, from the studs out. From:
Stop Stealing Dreams - - Seth Godin



EXCERPTS:

1. "Be ashamed to die until you have won some victory for
humanity." Horace Mann, Civil War era, who installed public schooling.

2. " To efficiently run a school, amplify fear and reduce passion....fear must be used to keep the masses in line... the flip side.. is that passion will be destroyed. There's no room for someone who wants to go faster, ..do something else, or someone who cares about a particular issue."

3. "There really are only two tools available to the educator.
"The easy one is fear.”
"Fear is easy to awake, easy to maintain, but ultimately toxic."
"The other tool is passion. A kid in love with dinosaurs or baseball or earth science is going to learn it on her own. She’s going to push hard for ever more information, and better still, master the thinking behind it."

4. "The industrial structure of school demands that we teach things for certain. Testable things. Things beyond question. After all, if topics are open to challenge, who will challenge them? Our students. But students aren’t there to challenge—they are there to be indoctrinated, to accept and obey... The obligation of the new school is to teach reasonable doubt. Not the unreasonable doubt of the wild-eyed heckler, but the evidence-based doubt of the questioning scientist and the reason-based doubt of the skilled debater."

My "profession" (physiotherapy) is WAY tilted toward factory style learning and delivery. When I think about it, I'm rare in that my passion managed to stay alive somehow... I carefully nurtured it, like some subversive. I have a LOT of gripes about my profession, and now I see that most of them revolve around style, same style as Seth Godin is saying is obsolete, not because my interior human primate social grooming instincts were wrong. (These instincts were right all along. The style of "training" almost killed them! Good example - the deliberate imposition of biomechanical thinking upon otherwise [already perfect] human primate social grooming in manual therapy. Teaching groomers to groom too hard, too fast, too deep, too operatively. Not letting the brains of the patient, their critter brain and human brain, the opportunity to make new sense from new input, together, and mutually pleasantly. )

5. "One of the things that school is for is to teach our children to understand and relish the idea of intellectualism, to develop into something more than a purpose-driven tool for the industrial state."

The zombie model.
Is it any wonder zombie movies are so popular?
I caught up on movies while flying to and from Brazil. One of them was WorldWar Z with Brad Pitt.
Maybe zombie movies are a clue that pushback is happening against the outer social world having tried to turn us *into* zombies. Or at least intellectually suppressed, domesticated humans.

6. "An artist is someone who brings new thinking and generosity to his work, who does human work that changes another for the better. An artist invents a new kind of insurance policy, diagnoses a disease that someone else might have missed, or envisions a future that’s not here yet. And a linchpin is the worker we can’t live without, the one we’d miss if she was gone. The linchpin brings enough gravity, energy, and forward motion to work that she makes things happen."


Can any physiotherapist be either, given our (ahem) "training"?
Remember, our training teaches us:
1. Outdated concepts
2. In order to pass exams
3. To prepare us for an industrial version of health care
4. That has little or nothing to do with actual individuals or their needs to have their main positive feedback loop interrupted.
... See Erik Meira's blogpost about positive feedback loops, http://ptpodcast.com/getting-rid-of-something-positive/ , fear being the main one, and how we must break these loops to help people return to "thoughtless, fearless movement" as per Louis Gifford (2005).

Passion and drive and some intelligent reworking of concepts, plus some decent information about how the nervous system works, how pain works, could reverse a lot of zombie-like behaviour in my profession and restart its engine, rekindle peoples' intelligence/critical thinking, ability to entertain doubt, embrace uncertainty, reboot PT's effectiveness out there in the world. Support its capacity to become way more than it is right at the moment..

7. "What we *do* need is someone to persuade us that we *want* to learn those things, and someone to push us or encourage us or create a space where we want to learn to do them better."

Exactly what the PT profession needs... more teachers willing to be honest about how zombified our profession made us/we let ourselves become, how we each have to take steps that point away from this.

8. "In a post-industrial school, there is no us and them. Just us."

And in an ideal post-graduate manual therapy class, there is no "patient" vs. "professional"; there is only the nervous system, and how to learn to help it work smoother so it doesn't bother the person living inside it so much.

What a lot of work it would save everyone if this were just taught matter-of-factly at the
undergraduate level!

9. "Every great teacher you have ever had the good luck of learning from is doing the irreplaceable labor of real teaching. They are communicating emotion, engaging, and learning from the student in return. Emotional labor is difficult and exhausting, and it cannot be tweaked or commanded by management."
"As our society industrialized, it has relentlessly worked to drive labor away and replace it with work. Mere work. Busywork and repetitive work and the work of Taylor’s scientific management. Stand just here. Say just that. Check this box."
(Evaluation forms, anyone?)
"I'm arguing that the connection revolution sets the table for a return of emotional labor. For the first time in a century, we have the opportunity to let digital systems do work while our teachers do labor."
"But that can only happen if we let teachers be teachers again." - Seth Godin

As PTs, we are educators crossed with animal trainers. I say that because mostly we deal with critter brains in people. Just because they are in people doesn't mean they aren't critter brains. We want them to stop biting the person trapped in there with them.
We have to educate nervous systems out of doing whatever they are doing that doesn't work, and help them learn how to do something else. That "something else" is not under our direct control. It will always be under the control of that particular nervous system, unique and individual. All we can do is our best, and hope for the best. Nothing is for certain.
Still, we have to do our best.

At the profession level, we have to stop seeing ourselves as trained monkeys, eager to perform for mere cucumber slices or grapes dished out only if the “health care” system approves of our behaviour, and develop our reasoning and critical thinking capacities. How else will this profession truly grow up and become a real profession?

10. "Leadership isn’t something that people hand to you. You don’t do followership for years and then someone anoints you and says, “here.” In fact, it’s a gradual process, one where you take responsibility years before you are given authority. And that’s something we can teach."

11. "The librarian isn’t a clerk who happens to work at a library. A librarian is a data hound, a guide, a sherpa, and a teacher. The librarian is the interface between reams of data and the untrained but motivated user."

My sister is a librarian.

12. "Five years from now, electronic readers will be as expensive as Gillette razors, and e-books will cost less than the blades...Librarians who are arguing and lobbying for clever e-book lending solutions are completely missing the point. They are defending the library-as-warehouse concept, as opposed to fighting for the future, which is librarian as producer, concierge, connector, teacher, and impresario... "We need librarians more than we ever did. What we don’t need are mere clerks who guard dead paper. Librarians are too important to be a dwindling voice in our culture. For the right librarian, this is the chance of a lifetime."


We need PTs too. What we don't need are zombie PTs who fill out paper reports and forms and micro-manage. We need PTs who are willing to stick their necks out and teach more people how to be caring human primate social groomers, and to he11 with any negative opinions on my choice of language for *this* valuable service we can easily provide, once we know what is actually entailed..

"I don’t know what your destiny will be, but one thing I know: The only ones among you who will be really happy are those who sought and found out how to serve."– Albert Schweitzer, via Seth Godin
.............

Sunday, April 06, 2014

Reflection on meeting Jan Dommerholt: Trigger points II

The computer appeared to be working much better this week. I'm all set to go to Brazil tomorrow, stick loaded. Last minute fussing over this and that. Had a moment of panic when I couldn't find my ziplock bag with the adaptors and phone charger in it. Looked all over. Finally found it in the new computer bag I bought on my way home from the Vancouver MTABC Pain Conference last weekend, while I was killing some time waiting for the finishing touches on my dead computer. Turned out it wasn't dead after all.. just comatose again. It smartened up with a new library rebuilt by the technician. So, yay.. staved off having to buy a new one, yet again.

Anyway, the weekend went well, I think.. Doug Alexander from TouchU.ca is going to put all the presentations online, accessible by the conference attendees for a year, and available as online courses to anyone.

A highlight was that I got to meet and have a nice long conversation with Jan Dommerholt, who up until now had had email exchanges with years ago, but had never met in person. He was very nice to me.

I still don't buy the idea that "trigger points" of the sort that are palpable are actually in muscle, despite his protestations that a) he can palpate them there, and b) he can prove they are in muscle through modern day imaging. The only picture of one (supposedly one), is from the 1950's.. he had it in his presentation.  



Here is a pic someone took of us after lunch. He is in a wheelchair these days because he is recovering from a hip fracture sustained in a freak car accident five weeks prior.
From Jan's presentation I learned several things -
1. he does not discount any sort of input into the left side of the neuromatrix, including cutaneous input 
2. he does include nervous system considerations, including the neuromatrix model itself 
3. he admits there are "trigger points" that are too deep for him to get a fix on/palpate 
4. the work done so far has shown that contracture in striate muscle is *not* because of acetylcholine leakage at motor end plates (i.e., at least one hypothesis is disproved) 
5. the "bibles" by Travell and Simons need a massive update, which is unlikely to happen, as long as they keep selling the way they still are/do. Lots of $ for the estate.  
(I forgot to ask him, but this may be the source of all that money the trigger point people use to fund all the research they do on trigger points.)
He took us through the history of his meeting with Travell and Simons and becoming hooked up to their enthusiasm. They found an inexhaustible promoter-scholar-researcher in Jan, that's for sure.

ON THE CURRENT STATE OF "NEEDLING"
He teaches courses in dry needling. From our conversation I learned he feels despair (as we all do) about all the needling going on out there that is not accompanied by any neuroscience or pain science (he makes people pass a test on all of that before they can be certified by him.)  He deplored the state of affairs, with way too much needling going on based in poor training. I gathered he didn't approve of the Chan Gunn model (the one that took over Canada like a strangler fig tree).


WHAT EXACTLY IS A TRIGGER POINT, DEFINED?
He answered my question re: what exactly is being "triggered", & why are these points (so far inside the body, so supposedly responsive to a needle) called "trigger" points, with this: If they trigger a "muscle" twitch, then they are trigger points.
He doesn't differentiate between teeny muscle contracture "trigger" points and other "sore" spots, as near as I could determine: if there is a twitch to palpation, that defines it as a "trigger" point in his mind - nothing else, like for example, a crabby nerve with secondary hyperalgesia creating protective reflexive motor output from the cord (which would be palpable much more superficially). 
To me this represents a confound that has not been satisfactorily answered or eliminated. Simon Gandevia tried hard to eliminate cutaneous confound from ordinary "muscle" reflex testing and as far as I know, couldn't.

ARE THEY CAUSATION OR JUST CORRELATION?
He didn't say much when I asked him, "what if the teeny muscle contractures you study are just secondary to altered physiology that is secondary to nervous system dysfunction, and not a "cause" of anything"?
He slid past the idea that perhaps other things buried in the skin organ, contracted up by smooth muscle, secondary to physiological disturbance, might be a confound to the notion of being able to reliably palpate trigger points in striate muscle. He insisted his hands could find them except where "they are too deep" - one was left wondering if he meant the muscle was too thick, or if the cutis/subcutis was four inches thick and hard to feel through. This was unclear.
HE DISAPPROVES OF SOMASIMPLE
He thinks SomaSimple is mean to people. He has the right to entertain that opinion. Certainly SomaSimple isn't any friend to trigger point hypothesis, or ideas about treatment that are based on fascia. It's there to critique ideas, not people, but if people are too wedded to their ideas they may feel it's an inhospitable place.. that isn't SomaSimple's fault though.
I countered with this: people who are trying to think for themselves and who have become burdened by popular (but wrong, from a nervous system standpoint) opinion need a place to get gripes off their chest, and argue with (not from) "authority."

MY TAKE ON JAN DOMMERHOLT (FWIW)
Even if I still think trigger points don't exist except (*maybe*) as fleeting physiological phenomena that need no intervention of the stabbing or skewering sort, I appreciate that he has enough energy to continue researching. (He finds it effortless, apparently, whereas I found my one lone foray into it exhausting and a complete waste of my precious life that I'll never get back again.)
Maybe one day he'll manage to disprove "trigger points" as any sort of clinically important entity to his own satisfaction and to all, but meanwhile he is still invested in the hypothesis, and has funding to continue. He was clear about the model not being a scientific model yet, but only an hypothesis. Which he loves to test endlessly. And is paid to test endlessly, I gather, or else maybe gathers enough credibility equity from to make it worth his while.
Anyone who can fluently speak and write in four languages has a cortex at least four times thicker than mine and earns my respect. English as one's lone language is so limiting.  
On the other hand, there is surely something to be said for weeding out ideas that are mutually exclusive. I imagine that decluttering concepts from one's brain is at least four times harder to do when one thinks fluently in four languages.
A HUMOROUS MOMENT During the panel session he recounted a woman he treated with ultrasound, three visits to her home, with the machine not plugged in. He said, "I don't know how she got better because I didn't do ANYthing." 
I pointed out he had touched her skin.
At which point the crowd laughed. To which he replied, "Touche." About which I was pleased. (But I hope not too smug.) ........... ADDITIONAL THOUGHTS The fascia people are excited about finding "nociceptors" in fascia. One of the questions that came up during the panel discussion was an open-ended query into the significance of that. I replied that since C-fibres are everywhere (most of those polymodal) and that their main job was to assist tissue health by providing trophic factors (e.g., Substance P, CGRP, etc) to tissue to help it stay healthy, I wondered aloud if researchers were conflating "C-fibre" with "nociceptor" as if the two terms were completely interchangeable. The panel discussion closed on that note.
But back to trigger points for a moment: apparently there is a needle in existance that can suck up fluids in tissue very precisely. The procedure is a) find a trigger point b) stick it and suck up the fluids. Then, I guess, dry needle, then test again. Write up another paper noting that after dry needling, trigger points are usually gone. Interestingly the substances picked up by the needle are the usual - Substance P, CGRP, etc. However, those are just regular C-fibre products - and trophic factors! - the cell gets rid of through exocytosis, as far as I know. Everyone gets excited and thinks it automatically means they've found a "nociceptor" which usually becomes conflated with pain generator, or something. Seriously, that stuff is going to be in tissue everywhere you look, probably. Including in the skin organ. Anyway, my point is that you'll often find sand on a beach. Maybe these substances aren't anything too special - strictly correlative, not causative.
FURTHER READING (OLD BLOG POSTS)

1. Melzack & Katz, Pain. Part 19c: Implications of the Neuromatrix concept - fibromyalgia. (Aug 2013: Discussion of Fred Wolfe's current thinking while studying Melzack's latest paper.)

2. Digesting the Moose Jaw adventure: Part I (October 2012: reflections on how the medical people relate to the (ahem) hypothesis of "trigger points" from their terminally operative perspective)
3. To sum up.. (Feb 2012: A synthesis of blog posts to do with operator mentality and treatment models)
4. Letter to a biomechanically-minded therapist (July 2011: About pattern-seeking behaviour and how we have to remain vigilant about it)
5. Why I don't buy the idea that "trigger points" are in muscle (July 2011: could be all sorts of things besides muscles misbehaving)
6. Yet another "trigger point" discussion (January 2012: Lots of quotes, discussion re: pain as a brain output not a muscle input)
7. 
Trigger point model deconstruction, models in general (January 2012: A Spanish blogger retweets a paper debating the existence of trigger points (I'm an atheist myself, in case no one noticed...)
8. Fred Wolfe, trigger points, fibro (Feb 2013: a welcome surprise, a voluntary withdrawal by the guy who married tender points to a diagnosis of fibromyalgia, of this same diagnostic criteria.)

Inside these blog posts are links to papers, etc. that further discuss the issues at hand.