Wednesday, July 20, 2016

Correlating nociception and pain

I have accepted, over time, that pain and nociception are two distinctly different animals.
Just because my cat eats grass once in awhile, that does not mean that it is a cow.
Yes, nociception can "hurt," but that does not make it pain.

Nociception can be directly measured and pain only indirectly.
And there is enough literature around, drawing the distinction, and slowly dragging us all up out of the muck of biomedical dogma that had the two conflated for so very long, that I seriously doubt there is much in the way of any dependable correlation between the two. OK, I doubt there is any that is relevant to the patient who stands before me. Especially three months in. Three months is the arbitrary length of time, decided by powers that be, when acute pain turns into chronic pain. That's how long it takes soft tissue to heal. (We're talking mesodermally derived soft tissue.) Most of the people I see have had a pain, or pains, for years. Pain is NOT about tissue damage. Pain is about pain. It's an emergent property of the nervous system itself. Nociception might be about tissue damage. Or not. It might only be about tissue danger. Nociception is a signal. Pain is perception, the personal meaning of something perceived as sensation.

Science geeks love correlating things to each other. I'm not much of a science geek. I am not involved in creating any of it.
I love science, but as a consumer, as an appreciator, not a producer.

Correlation has come up as a topic on facebook, specifically correlation between nociception and pain. Some who would proclaim themselves producers, have their hard-won academic black belt, argue with me when I say there isn't any. They think it's laughable, because of course, anything can be forced to correlate to anything else... that's part of the geeky business of it all.
See the Wikipedia entry for spurious correlation.
For some actual spurious correlations, see this link.

As Neil O'Connell PT repeated recently, "If you torture the data long enough it will confess to anything."
Furthermore, about hammering of hands, that demonstrates nothing about how brains respond to nociception, because even hitting a rubber hand that the brain has accepted into its body schema will elicit a protective response, no actual nociceptive input required! Pain (and in this case, protective response) is entirely context dependent!

I get that there is a whole world of measuring and correcting for and determining the Most Precise Measuring and Comparing of Variables that Could Possibly Exist, just as there is for fixing cars. I couldn't be more happy for people who love math and all the patterns they can find in the world, including lovely mathematical patterns in the abstract examination of something as measurable as nociception against something as nebulous as pain.
Nociception is probably causal for pain more than it is correlative. One thing I do distinctly remember from reading science appreciation, is that correlation and causation are also not the same thing, and should not be conflated.

To me, the effort to find a correlation between nociception and pain makes about as much sense as trying to measure the relationship between size of the matchstick, amount of flammable chemical on the end of it, etc. (i.e., nociception) and size of forest fire (pain). Especially when the fire could have been started by an unmeasurable lightning bolt instead. And the size of fire, ultimately, might have been way more about a lack of rain than any other factor or variable, including the match or the lightning. And in terms of pain, sensitization continually adds more fuel. In the end, maybe the creation of a backfire can help stop the spread of the forest fire.

So many variables, that measuring the size of the original match and trying to correlate it to the size of the fire, and seeing that as having any sort of relevance, scientific or clinical, is kinda ridiculous, on the face of it... to me at least.

Furthermore, nociception is not always unpleasant, whereas pain always is.
Here is something I wrote long ago, buried in Facebook somewhere I think, retrieved by Lars Avemarie:
“Nociception is sensation. Pain is a perception. Consider seeing: A sudden flash of light = sensory input. If it gets your attention it might be “sensation”.  But sensory input or even sensation ≠ vision. It does not yet have any assigned meaning. Only context (both inner and outer), considered and added, can provide meaning. A sudden flash of light might be a bomb. Uh-oh, duck and run. A sudden flash of light might be fireworks. Ooh.. pretty. Nociception is not always unpleasant: e.g., rolling around naked in snow, after a 4hr sweat lodge experience. Kinky things SM people do for fun. Nociception ≠ pain. Pain is always UNpleasant.” 


Saturday, July 09, 2016

First ever visit to Norway

In June I travelled to Norway to teach a couple workshops. Of any country I have been to, so far, Norway impressed me most.

I now have more confirmation bias on society vs: culture, fueled by having been to Norway.
My first impression was driving into town in a taxi. Lovely houses, open windows with no bars on them, really, open doorways, even, not even fences, flowers in pots, obviously closely tended, every thing painted fresh. Everything cared for.

After arriving at the hotel, and walking around outside: no litter anywhere. A big glass statue, entirely unmolested, in an intersection, no visible graffiti. Not many people, and no sense of danger. No one lurking. No eyes on the out-of-towner. Safe alleys. No trash. No homeless people. No disrepair anywhere. No signs of vandalism.

What on earth is this place? Did I die and go to heaven?

In Norway, culture and society do not appear to be in opposition. They seem to dance smoothly, together, to the same music. It appears that society grew out of basic culture, naturally.


How babies are treated

Imagine a country with a culture and a society that revolves around its babies. Instead of leaving each family to raise its babies as best it can, there is something different going on in Norway, and maybe other Scandinavian countries as well, as I have no idea how widespread this custom is - what custom am I talking about?
I'm talking about the custom of putting the baby into a buggy, outside the house, for a mid day nap.
That can only be done in a place where there is no fear. And where pitbulls have been outlawed.

One of my hosts who has a young child, 18 months, brought me to his home after I had checked out of the hotel, and before it was time to fly to the next city, to kill some time. I worked on my next presentation while he hung out with his son. In Norway, fathers get government-mandated parental leave. His leave was about to end soon. He and his wife had split up their workdays and time away from work so that each would have time to care for and bond with their child. He was every bit a devoted father, down on the floor in the play area, playing with toy animals with his baby.
This was a very relaxed baby. He mostly ignored me once he had given me a once-over, and had brought me a toy to examine and comment on. During the time I was there, he was played with, talked to, interacted with, and fed lunch, all very calmly. We ate ice cream cones together. I watched this dad nimbly put his infant's entire ice cream covered hand inside his own mouth to clean it off so that ice cream would not end up on the rug, all the while taking a phone call on his smart phone. Fast-thinking, responsive dad. No fuss from this baby. Over anything.
The house became very quiet for a long period of time. I asked where the baby was, and my host said, oh, he's having his nap. Oh, I said.
Would you like to see the rest of the house? my host asked. Sure I said. We went upstairs, me being quiet so as not to wake the baby. He showed me his child's room. I peered in, and didn't see any baby sleeping. Where is the baby? I asked. He's having his nap. But where? I was still puzzled.
Outside, he replied.
Yes, in his buggy... I was thinking, rather than bring him back in here, it will be better to put him straight into the car after his nap, so that he doesn't become stressed by bringing him in, letting him get interested in something, then taking him away from it in order to take you to the airport.
He's outside? (I was still trying to wrap my head around this.)
Wow, it's so safe in Norway that you can leave your baby outside?
Yes, we all do that. It's normal.
Normal? I was trying to grok how a country could be so safe that it was normal to leave a baby outside in a buggy. I must have looked a bit gobsmacked. I asked if he had been left outside in a buggy for naps when he was a baby.
He said, yes, of course. Everyone does that.


After I arrived at my second destination I asked my next host, in a different city, about the baby napping thing, and he said, yes, of course, totally normal.
He added, the only restriction on it is that you are not allowed to put the baby out if the temperature is below -15°C  (five degrees F).


I do not know how this practice evolved, or where it came from.
In my fond imaginings, I like to think it has been around since at least Viking times.
Baby Vikings, left in Nature's loving arms, by themselves, so they can grow up solid, calm, independent, tuned into and bonded with their environment.

I love the idea that Norwegian society organized itself around culture and cultural practices, not in opposition to them. I love the idea that Norwegian society looks after its people, and its people look after it, and that there is mutual respect.


Other little things about Norway that impressed me

1. There seems to be good health care, social programming, and housing for all. I did not see any dumpy or dodgy areas, even though I was touring around by car quite a lot.

2. No pitbull dogs allowed in the country. In fact I did not see any animals of any kind roaming around loose. There were peaceful sheep inside charming low rock fences along the highways, though.

3. Apparently pedestrians are sacred. When out walking, I was struck by the fact that cars stopped, even when the light was green, for pedestrians. In every other country I've ever visited or lived in, pedestrians are considered by society to be on their own and you take your chances. Even when you have a walk light or are in a designated crosswalk, you have to keep your eyes open, because as a pedestrian you are merely potential roadkill - cars don't care and drivers are inattentive. In Norway, there are massive fines for drivers who injure a pedestrian.

4. In Oslo, major highways are underground. So is all the traffic noise. Drivers all have a transmitter attached to their windshield and are monitored. Slowly but surely, the country is moving toward 'no gas vehicles'. Drivers of electric cars have perks - they can park closer to exits in underground parking areas. They have more choice of driving hours and underground streets and highways. Gas drivers can use the freeways, etc., outside their designated hours, but have to pay a toll for it.

5. Norway is not part of the Economic Union. I did not know this, and was caught out at the airport with nothing but Euros to pay the cabbie. Fortunately I had a credit card, and my host loaned me kroners just in case, but I didn't need to use them. Each krone is about 15 cents Canadian.

6. Not part of society, but impressive nevertheless: Norway is pretty far north. I was in the south end, but even so, the latitude was about 60 degrees north, or level with the top of Saskatchewan. It was summer solstice. There were only about two hours of darkness, long long hours in evening and a whole lot of daylight.

7. The official church of Norway is Lutheran, but religion is in rapid decline in general.

8. There is a king, but he doesn't do much. He has a farm, but he doesn't farm it. He has a palace, but he doesn't live there. He was once an Olympian competitor, but doesn't do much of anything anymore, it seems.

9. I saw a Viking ship museum, and a "folk" museum, (which looks after the king's farm), which contained a glimpse into the Sami indigenous culture. The first interactions of these cultures seems to have been about metal spoons, trading for those, as they seemed easier to come by than spoons made from reindeer bone. The Sami people were tromped on by the Nazis, who invaded Norway and the country side, burned the homes and villages, displaced everyone, all so that if the Russians decided to come down through Norway they would have a harder time of it.

10. We climbed the roof of the Oslo opera house. Such a touristy thing to do. But so beautiful. Made entirely of white Italian marble, designed to resemble a glacier.

Oslo Opera House, from