Saturday, August 13, 2016

Mental models in manual therapy

Our mental models, (ESPECIALLY in manual therapy) need continuous examination, updating, renovating, because if we stay caught up with basic science, especially pain science, we'll notice that it's all quite turbulent, philosophically problematic, scientifically problematic, and therefore, we have to be nimble, like a kayaker in white water, paddle on one side then the other to avoid tipping over and still make our way down the river. (Forgive the analogy, I recently watched the kayaking event at the Rio olympics.)

Our mental models are subject to cocktail party effect, or cognitive conspicuity. We need to be aware of that.

What is the biggest clue we are responding only to cognitive conspicuity?
When we realize we are paying more attention to some movie going on in our own head, and not to the patient or any discomfort they may be experiencing as we impose our lovely mental models on them.

We still need mental models, because that's the human part of our own brain, the most complex object in the known universe, mostly still unknown, possibly unknowable in the ultimate sense.
"Acquiring knowledge can be a very daunting task. If you think of the mind as a toolbox, we’re only as good as the tools at our disposal. A carpenter doesn’t show up to work with an empty toolbox. Not only do they want as many tools in their toolbox as possible, but they want to know how to use them. Having more tools and the knowledge of how to use them means they can tackle more problems. Try as we might, we cannot build a house with only a hammer. 
"If you’re a knowledge worker, you’re a carpenter. But your tools aren’t bought at a store and they don’t come in a red box that you carry around. Mental tools are the big ideas from multiple disciplines, and we store them in our mind. And if we have a lot of tools and the knowledge required to wield them properly, we can start to synthesize how the world works and make better decisions when confronted with problems."

What if the mental models our professions chose to teach us were based on tissue-based, structural, patho-anatomical sidetracks? What if they were modeled after or taught by people steeped in orthopaedic medicine and surgery? What if they are all completely beside the point when it comes to pain? Like the pain being experienced by your next day full of patients? That 50 year old woman who still has neck pain from a car accident when she was twenty? That 16 year old who loves snowboarding but developed knee pain 5 months ago, has been told he "has a miniscus," has been receiving brutal massage therapy that helps for about a week but then the pain returns?

How do tissue-based etc. mental models help people like that?
Are they not swamped by nocebo and subject to the revolving door of treatment?
Have they not probably concluded they are doomed to forever be a patient of one treatment person after another?

Do we (the practitioners) have any shot at all of developing mental models that actually help people recover, get off the merry-go-round, feel normal again, feel themselves in their bodies the way they used to?

I think first of all we have to decide to entertain the possibility that the old models are wrong. Dead wrong. And be brave enough to operate from that assumption. As a test. Of faith? Maybe. Of reality? Maybe.. OK, probably.

As the Farnam Street piece points out,

“...two main factors contribute to our inability to make good initial decisions. First, we don’t have the time to think. And second, we don’t have a firm understanding of how the world really works...”
“We don’t often realize that our first thoughts are usually not even our thoughts. They usually belong to someone else. We understand the sound-byte but we haven’t done the hard work of real thinking. After we reach a first conclusion, our minds often shut down. We don’t seek evidence that would contradict our conclusion. We don’t ask ourselves what the likely result of this solution would be — we don’t ask ourselves “And then what?” We don’t ask what other solutions might be even more optimal.”
“Mental Models allow us to make better decisions, scramble out of bad situations, and think critically. If you want to understand reality you must look at a problem in multiple dimensions — how could it be otherwise?”
“Getting to this level of understanding requires having a lot of tools and knowing how to use them. You knew there was a hitch right?... Luckily there is another path.”
“If you understand the world as it really is, not as you’d wish it to be, you will begin to make better decisions.”
The tools in this case are NOT more courses or treatment systems or actual physical tools, such as expensive equipment, needles or cups or machines that go ping, ding, ring or ting, electronics that zap or zing.
The tool we need in this case is "knowledge that changes slowly over time," but not so slow that it ends up dogmasphere type knowledge that lets the world go by and won't evolve.

Higher-order thinking is recommended in the piece, an awareness and acceptance of the fact that with each action, even a mental action, second and third-order effects ripple out into the world. Each of us in a node of information/knowledge transference. Things we might want to consider: What is the range of possible outcomes? What’s the probability I’m right? What’s the follow-on? How could I be wrong? As a philosophic massage therapist friend pointed out long ago, what about taking care of the future of the neuromatrix of each person who comes to see someone like us?
Understanding how the world itself works is hard enough.
"Understanding how the world works isn’t easy and it shouldn’t be. It’s hard work. If it were easy, everyone would do it. And it’s not for everyone. Sometimes, if your goal is to maximize utility, you should focus on getting very, very good in a narrow area and becoming an expert, accepting that you will make many mistakes outside of that domain. But for most, it’s extremely helpful to understand the forces at play outside of their narrow area of expertise.
Because when you think about it, how could reality be anything other than a synthesis of multiple factors? How could it possibly be otherwise?"
If a human brain is the most complex object in the known universe, a human neuromatrix is its most complex verb.

So, what's the solution? I'd say, don't only learn about paddles or kayaks. Learn to understand the river. Interact with the river. The river.
Interact how?
Well, telling patients all about your great paddle or kayak probably will make you feel like a hot therapist, but won't help them.
Remember rivers get along just fine without you. Unless a river comes in dammed up somehow, and your job is to undam it...
It's not about you, the paddle or the kayak.
It's about interacting with the river, clearing it so it can flow better (now and in the future), and not becoming drowned in the process.

Sunday, August 07, 2016

Waves of thought

A lovely Sunday morning in August.
Idly sitting, watching TV at a time of day I'm not accustomed to.
Watching swimming, Rio Olympics.
Also doing a jigsaw puzzle on an iPad, and sipping coffee. The jigsaw is about water. Lots of wavy turquoise colours.

My thoughts disengage and go inside, which is quite common for me.
Mostly they are forgettable.
This time, though, they hook up in a way that is more interesting, a way that leads to a realization.
Here are the thoughts.

Alberta, swimming
The time: mid-seventies.
I was about 25 or 26 years old, very involved in art school, had won a scholarship to paint intensively in Banff for 6 weeks. While there, I hang out with a small group. One of the group, a woman who lives in Calgary, has logged actual exhibitions. Another woman and I are just students with nothing much to show for ourselves except active learning about perception, and big gobs of enthusiasm.

Woman #1, the accomplished artist, loves to swim. We all go swimming every evening, at the Banff Springs Hotel.
It's a big pool. When I first start, I can make it only about one length, along one side, with frequent rests along the way. By the end of the summer, I can swim 4 lengths with no stops.

Homeward bound
On the way home from this excursion we are invited to this woman's place in Calgary.
She and her husband, also an accomplished artist, prepare simple tacos for a group of 5 or 6.
We are sitting, eating, enjoying: She suddenly develops a severe headache. Out of nowhere. So bad that she starts to cry. She stays put, though, doesn't seclude herself in a bedroom or anything. She is in a lot of pain, and everyone tries to figure out some way to help, but nothing comes to mind.
I sit there.
Even though I'm supposedly a trained professional.
I commiserate, but have no clue what I could possibly offer. I am completely outside my therapy world. I can "be" a therapist, but only when I am in that therapy bubble (which in those days was a hospital setting) do I feel the least bit competent.
Like everyone else, in this situation, I feel helpless.
The other woman in the swim group gets up, stands behind her, and rests her hands lightly on the hostess' shoulders. She attempts some amateur massage, which is better than nothing..
I don't think it helped the headache, but at least she tried to help; I did not.

What I conclude from having this drift up into my mind is that it had an influence on me. A big one, mostly unconscious. Mostly being embarrassed that I was supposedly a trained hands-on professional and I somehow lacked empathy to the point where I felt too inhibited to even try to help somebody who was having a bad time with pain.
Whereas my art student friend instinctively reached out and did her best.
Makes me realize my early PT training actually stopped me instead of helping me to help somebody else, with a pain problem, in a common social situation.
I buried this aspect of this memory until now, but to have it drift up in this new way makes me realize that at least some part of my brain tried to sort it any way it could, by helping to motivate my interest in pain and in what I now like to call, human primate social grooming, that instinctive reaching out to help by touching, feeling, massaging, making some kind of physical contact with any individual who feels crappy. This isn't the ONLY reason, of course, but it definitely helped; I do not doubt that now.
Now I feel competent enough to be fully capable to take a role in any situation, and in many cases, I have.
The woman on the plane sitting beside me who told me why she was wearing a brace on her hand. A fresh ulnar nerve compression syndrome from about 7 hours of unaccustomed mountain biking and leaning too long on one handlebar.  After about a half hour of working with her, she regained use of her hand and could touch her little finger and thumb together again.
The young Swiss guy sitting beside me on the plane home from Europe who had neck pain.
Many other examples that don't involve planes.
Like the wedding I attended in a back yard, where one of the other guests developed sudden horrible back pain, and the bride sought me out to see if I could lend any help; I and the guest retreat into the house to a bedroom, where I do my very best, and after a half hour at least she can walk a little easier.
Live and learn.
If I had enough lifespan left I would want all therapists to feel competent to help with pain problems or weakness problems stemming from nerve problems in any situation anywhere. Without being overly concerned with conventional North American social boundaries.