Friday, September 15, 2017

Three pictures that sum up manual therapy






You cannot be sure that what you think you "feel" in another's body (palpate physically) is really what you feel there. Furthermore, you cannot (objectively) feel another person's pain.
The best you can do is interact empathically with whatever they feel (and are willing to share), and with whatever you feel. With your hands. Without making too many assumptions.
With any luck, whatever they feel will change in the course of a session. For the better. 

Being a manual therapist is not for sissies.

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

We all have to do this, every day, with every new patient: carefully cross a chasm of understanding, on a rickety footbridge, through fog.
Not knowing how long the bridge is, or how deep the gorge below.
Just putting one foot in front of the other, carefully.
Because people are not objects, like cars. And we must not treat them, or any part of their bodies, as though they were.
Being a manual therapist is not for sissies. 





A "profession" (like PT) starts out as a group of idealistic individuals, who probably imagine that "certainty" is a real thing and that they can count on it to support their adventure through life. However, they can turn the profession into an "industry" over time.
People starting out in a profession feel more comfortable acquiring and using "tools."
Being part of a group that sees itself as an industry can turn the individuals within it into thinking they are car mechanics, if we aren't careful. 
Being a manual therapist with the goal of having good ethics is not for sissies.
Being part of a profession that is madly trying to turn itself into an industry is a bit of a downer, to say the least. 



Thursday, August 10, 2017

The conscious mind/self/conscious awareness

I saw a post today on Facebook that seems a good summary of the conscious mind: 

"Our conscious minds are but one part of our nervous system, and they are not dictators." ~Andrew Jurdan

I reposted it, and added a few more thoughts.

I've always viewed the conscious mind as something that finds itself occupying the top floor of City Hall, as mayor, no clue as to how it got there or what it's there for, supposedly in charge of a city it knows nothing about, has never toured, and doesn't understand the workings of all the other floors or even any names of any other people on those floors.
It prefers to hang out with other mayors and play games.
Yet, it is ultimately the mayor's responsibility if anything in the city goes haywire.
 Here is something I wrote about conscious awareness or self as mayor of a city ages ago, at least 12-13 years ago. 

Saturday, June 10, 2017

Catching up to TV culture

.

My personal life lately has included binge-watching of TV shows I had heard of but never watched before, like Mr. Robot, Breaking Bad, and Walking Dead.

All of them are bleak, dystopian. The last two were saturated with violence.

I'm currently watching episodes of Handmaid's tale and Vikings.

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

By far the most disturbing is Walking Dead, on so many levels. And it also seems to be the longest lasting with season 8 coming up. (Maybe this show is a zombie itself.)
Each episode is a waking nightmare of zombies, gore, betrayal, existential crisis, prisoner's dilemma, trolley dilemma.
The protagonist group can't go anywhere or do anything without having to expend energy fighting off/slaying "walkers." Other humans are constantly stealing from them or threatening their existence in multiple ways. They constantly steal and threaten too. Whether they decide to trust others or not seems to depend a lot on whim. As the episodes and seasons have rolled by (99 episodes total so far) the outer threats have become much more about humans in groups than the walkers. The walkers are fairly slow and thoroughly stupid, easily dispatched with a bit of physical force. Killing them requires a stab in the head, through a ridiculously soft skull filled with dilute ketchup. The ketchup budget must be huge in that show.

Here is a short list of things I like:
1. The exploration of ethics and values and how humans behave in groups, how groups treat each other.
2. Women have strong roles, gays are included, racism (apart from the first episode) is a total non-thing. Diversity is valued.
3. It reflects US culture wars.

Here is a short list of things I don't like:
1. Zombies. The premise is stupid, literally. Slightly more plausible metaphorically, perhaps (people who are zombie-like throughout life, mere system-wonks working for/supporting institutions, religions, and political parties that are like un-thinking zombies).
2. The premise of increased environmental stress leading to more egalitarianism, not less, is quite stupid. Humans, especially white male humans still imbued with the value system they have designed and deployed down through generations, do not go from being racist, sexist and gay-phobic to not being any of those things, so instantly, without considerable effort. Especially under the sorts of increased environmental stress posed by having no food/clothing/shelter security, constant vigilance/dependence on others to watch out for all these blood-thirsty mobile walkers, poor nutrition, little sleep, outdoors in the rough, dirty/filthy/no toothpaste, never being able to ever go off to eliminate by yourself (because walkers), and even if you do get hands on some stuff to help you survive, other people will be right there to take it away from you by force.
3. That CGI tiger. 

.........

So, why do I watch these implausible TV shows?
They are immensely popular. I think they are morality plays, disguised, dripping in blood.
I want to catch up to wherever the TV watching culture thinks it is at.
Also, I remind myself that for long long long stretches of time in human evolution and history, life kind of was kind of like that, living rough, minus the zombies of course. Which reminds me to appreciate that I have lived and still live in an era where people like me can lead a comfortable safe private reflective life separated from societal expectations without having to join a monastery. And also that I don't live in the US, although I appreciate how hard its regular people have worked and still work to make it into something, in spite of the current president and his Neganesque amorality, which he seems to be trying to institutionalize.

Vikings is set in the 8th century AD; life is rough, violent, bloodthirsty. Wars are common and mainly fought up close with sharp blades. The premise is valid.

The Handmaid's tale is based on the notion that when push comes to shove, women lose to male-supported institutions. Their default value seems to always end up that they are mere uteruses with arms and legs. The premise is valid.


..........


Addendum:
I have come back in this post to add this: I am also reading these days. Not much in a row, but a few pages or chapters at a time. I've finished Sapiens, by Yuval Noah Harari, and am in early pages of his latest book, Homo Deus. I'm concurrently reading Behave, by Robert Sapolsky.  Here is a nice interview with Sapolsky, You Have No Free Will.

Here is an excerpt of the interview with Robert Sapolsky about the book, and for me, a reflection on The Walking Dead, given that it takes place in the rural US south:


(Q) "What if you're from the rural South?" 
(A) "There's a famous study where student volunteers thought they were involved in a study surrounding their math abilities, but the experiment actually occurred outside in the hallway. Some beefy guy walking the opposite way bumps into a student as he walks past, then says, "Watch it, asshole," before marching away. When the student comes in to take the math test, the researchers take their blood pressure, check their hormones. And if you're from the American South, your blood pressure will be higher, and you'll be more stressed out. This impacts your judgement and how you respond to a given situation.
"This is because, by best evidence, the American South was settled by herders and pastoralists from northern England and Scotland, who had a culture of honor. Centuries later, there's still a residue of that. So this makes culture not such an intangible factor of brain development and behavior. Within minutes of birth, this kind of training starts."








Saturday, June 03, 2017

Ownership and agency in a predictive brain, implications for manual therapy

.


Recently I stumbled upon a lovely article in The Scientist, Understanding Body Ownership and Agency

It suggests there are several "selves" within each of us that integrate into a singular seamless "self". 
It's easy enough to manipulate the sense of ownership in several ways - research on kinaesthetic body illusions such as mirror therapy, rubber hand, are discussed. Brain interface prosthetics for amputees are mentioned. 

A slide I made using definitions from the article



The article proposes that agency and ownership, while slightly different, are integrated into one another, and are interdependent. 



"...recent research has sought to understand how body ownership might have developed through the sum of agency experiences that we accrue throughout our life. What we perceive as our body is not only what looks like our body, but what we typically have conscious control over. This control is asserted by learned associations between our muscular movements and the sensory feedback we perceive when performing an action—the so-called “action effects.” 


So, agency precedes ownership, sounds like... we learn our arm is part of "us" i.e., "self", by realizing we can control its movement. Bring food to mouth. Etcetera.

The two are slightly separable concepts though: Ehrsson's virtual body part research is mentioned.

In 2012, Ehrsson, along with his then graduate student Andreas Kalckert, designed a rubber-gloved wooden model hand to make finger movements that were either linked by a wooden rod to (and thus synchronous with) movements of the participant’s own hidden hand, or detached and controlled independently by the experimenter.16 Initiation of synchronous movements by the participant elicited a strong sense of ownership and agency over the model hand; linked, synchronous movements initiated by the experimenter (passive movements) abolished the sense of agency, while the sense of ownership remained intact. Conversely, when the experimenters rotated the robotic hand by 180 degrees—putting it in an anatomically implausible position, with the fingers facing toward the body—participants maintained a sense of agency, but not of ownership.

(I'll never forget the drama involved in Ehrsson's set up, where he induced the illusion of ownership of a rubber hand, then attacks the rubber hand with a hammer, or a knife or something, and measured all the autonomic reaction in the subject.)

The paper brings up some definitions:


"Based on theoretical ideas of 19th century physician and physicist Hermann von Helmholtz, German scientists Erich von Holst and Horst Mittelstaedt demonstrated the reafference principle in 1950 to distinguish between self-generated movements and external perturbations. Any time we move, we generate a motor command (efference) to control the muscles. At the same time, we also generate a prediction—based on prior experience of the sensation resulting from the movement—termed the efference copy. The actual movement-related sensory input, which comes from receptors in the muscle and skin, is referred to as reafference. Any difference between the two signals (reafference and efference copy) is the result of environmental input, which is termed exafference. Understanding errors that may occur within this system is probably central to understanding problems in agency and ownership perception."


Hurray! Words!
I wondered how manual therapy might be involved. 



.... And I speculate: 








 May 1, Understanding Body Ownership and Agency,  2017, The Scientist

Friday, April 07, 2017

Spinal cord vs. brain, brain vs. spinal cord - endless struggle for control of the body




I made this meme, but I have people to thank:

Acknowledgements for this meme:

1. Lars Avemarie who posted his thoughts on pain a couple days ago. https://www.facebook.com/lars.avemariepersonligtranare/posts/10155196612254025
I replied to his post with some thoughts on nociception/spinal cord, and pain/brain. I included the dead fish moving video (see below).


2. Nick Ng copied my post, and

3. Lee commented. She still seems to think pain is not a brain thing. It made me think, how can I answer this? I replied. https://www.facebook.com/nick.ng.96995/posts/10154481435190893?pnref=story


4. I wrote a longer post this morning, an expansion of my reply to Lee, and included the dead fish moving video again. https://www.facebook.com/diane.jacobs3/posts/10155203629414176?pnref=story

5. I tried hard to come up with an image/metaphor that captured the constant struggle going on that has to do with descending modulation. I think shoreline and sea metaphor does it - it shows ceaseless movement. When brain fails to raise the shoreline it can become flooded by input from spinal cord. Then it has a mess to clean up.


The dead fish moving video:




Wednesday, April 05, 2017

Convergence zone

.


Every day I get up around 6:30, grab some coffee, and sit down to read whatever is on Facebook or in my email or on Feedly.. hoping to be inspired. 

It's always SUCH a pleasure when a mini convergence occurs, when two or three or four things from totally different sources all pile up and make my brain go Whoopee!, this is exciting! 


Here is what has stood out for me in the last few days:

Lisa Feldman Barrett

I first noticed her post to Edge.org a year ago. She was one of a couple hundred people who answered the Edge question that year, which was "What do you consider the most interesting recent [scientific] news? What makes it important?", and she replied,  "Your brain is predictive, not reactive." It made enough of an impression that I referenced it in my book.
In the last few days her name came up again! I found this paper she co-authored, published in October, 
An active inference theory of allostasis and interoception in depression. Wonderfully juicy. The core part of "self" - and all tied in with brainstem necessities and thermodynamic exigencies. 
If that is too dense to absorb all in one sitting, no worries, here is a video of her, explaining what she means.: Just yesterday I saw this piece from Nautilus magazine, Ingenious: Lisa Feldman Barrett. 
Inside a new theory of emotions that spotlights how the brain works. 
Here is a quick excerpt:

"The way that I like to explain it is, if you think about it from your brain’s perspective, your brain is in a dark, silent box called your skull and it can’t get out and experience the world directly. It can only know the world through the sensory inputs that come through your sensory systems—your ears, your eyes, and so on. It only has effects. It only has wavelengths of light, or changes in air pressure, or concentrations of chemicals and it has to figure out what caused those in those wavelengths of light, or changes in concentration, or air pressure, and so on, so that it knows what to do next. So how does it do that? When there’s a flash of light, how does it figure out what that flash of light means? All it has at its disposal is your past experience, the past experience that it has wired into itself, basically."

Reading her carefully it seems to me that "self" sand "mind" are a bit different from each other. I think self is inherent and mind is changeable. I think self uses mind, directs it around to gather info, but isn't fully overlapped with it. If mind is the movie we see of self, or a mental screen on which we see our life as a cognition of self, self is the projector itself, and also the projector operator, running itself from only the new little bits it lets into itself as fuel, as inspiration, as bits of stress it can also auto-manage.

So, my self sees a lot of new stuff in the course of a morning, sitting, drinking coffee, looking at my computer screen, surveying all the world has to offer up. My self screens out most of it as irrelevant. However it latched onto Lisa, because it found her quite salient. It said "See?? This is important. This links Everything Together." What does it link together? Mind, body, biology, existence, thermodynamics. All that stuff.


Camus

I'm not a philosophy geek but I can truly truly appreciate life as an absurdity, so much so since childhood that sometime around age 10, I chose to remove myself from the pool of females who would live to reproduce more humans. This morning this piece by Ralph Ammer, in his blog Personal Growth, linked to by a facebook friend who is very much into personal growth, jumped out at me: Is it worth the trouble? I found it absurdly uplifting. And the gifs are great! We can't deny the unreasonable world. We can't abandon reason. He declares, "One must imagine Sisyphus happy." Imagine!! (This is why the gifs are so great.) He advises:
"1. Permanent revolution: We should constantly revolt against the circumstances of our existence and thus keep the absurd alive. We should never accept defeat, not even death, even though we know it can’t be avoided in the long run. Permanent rebellion is the only way to be present in the world. 
2. Reject eternal freedom: Instead of enslaving ourselves to eternal models we should hold on to reason, but be aware of its limitations and apply it flexibly to the situation at hand — or put simply: we should find freedom here and now, not in eternity.
3. Passion: Most importantly we should always have a passion for life, love everything in it and try not to live as good as possible but as much as possible."

All that is pretty much congruent with my own set of values, and also the ones I learned in PT school. Yup, life can suck bilgewater, but keep at it and keep moving. There is nothing better to do. Be in the "now" and keep going until the end. Try to be a decent person while you're at it.


Mini-brains
Finally. It looks as though attention is being paid to peripheral ganglia and their own computational capacities. They do run a bit of stuff that gets sent back and forth. The headline implies that ganglia have just been discovered, but really, they have been there all along, and in fact were there long before brains or central nervous systems even evolved.  

Discovery of 'mini-brains' could change understanding of pain medication


Pretty sure they are what can help make good results from manual therapy good results. In manual therapeutically naive people anyway.  If the therapists know what they're doing. After all there are opioid receptors in peripheral nerves too. And yes, descending modulation and non-specific FX are still the main effectors of a successful intervention no matter what happens peripherally. Never said they weren't.  

Personal convergence
I feel my existence completely supported by these finds.
1. I already knew life was absurd and in retrospect have continued pushing the boulder up the hill anyway, in life as a manual therapist.
2. Lisa Feldman Barrett makes sense, and she's a female who makes sense, so in a man's world this becomes strategically important to me, who is also female. It's confirmation that females are incredibly brainy, inclusive, and that this one has taken everything into account. I absolutely love her wide angle, panoramic even, point of view. I want to be like her when I grow up.
3. It's a fine way to make a living, moving skin around and affecting nervous systems for the better. There is even a lit path that may have to do with stuff going on in peripheral ganglia, before some of that info even reaches the spinal cord.
...................

1. Barrett LF, Quigley KS, Hamilton P. 2016 An active inference theoryof allostasis and interoception in depression. Phil. Trans. R. Soc. B 371.
2. Ralph Ammer, 2017, Is it worth the trouble? Personal Growth blog, Mar 23.
4. Xiaona Du et al, Local GABAergic signaling within sensory ganglia controls peripheral nociceptive transmission, Journal of Clinical Investigation (2017)









Tuesday, March 28, 2017

Enminded body

I was recently entranced by Peter O'Sullivan's deft demonstrations of cognitive functional therapy at this year's San Diego Pain Summit. I wrote about him, here. I also went through his keynote presentation carefully and took screenshots of his slides, adding his comments, posted those to facebook and twitter. One of these days I will gather them all up and make another blogpost.
There were WAY more presenters and speakers than Peter though, and in case you were wondering, I have not stopped examining all the wonderful material from that summit; I'm simply sidetracked by life itself these days, getting ready for the classes coming up in Europe in a few weeks. 

..... 

This post is an interlude, a slight diversion about something else:
I see a lot of books and papers to do with embodied mind, and I want to turn it around for those of us who treat people in pain because I think it makes more sense that way. 


Therefore, let's consider the enminded body. 

Here was the impetus:

The host for the class in Rio at the end of June, sent me this today, an open access paper: Reflections on osteopathic fascia treatment in the peripheral nervous system. It is the epitome of a tissue-based reflection on manual treatment that stopped me in my tracks because right inside the paper it refers to clinical practitioners as "operators". 

Which, by inference, means the patient is being regarded as no more than a stretchy, still-warm corpse.
I mean, isn't that what you will have to turn into (hopefully with the help of a good anesthesiologist) if you submit to having an "operation"? On your tissue?
Which is fine if someone has to cut into you to save your life or limb..
But that is not what happens, not what should happen, in therapy settings.


Seeing people as fascia that happens to be animated does them no great service. 

Fascia isn't even alive - it's comprised of materials, strings of extracellular material, that were extruded from living cells.
If living body cells are the smallest units of human life, fascia doesn't even rise to THAT bar. If it's extracellular, by definition it's not really "alive."
What IS alive are neurons, embedded in it..

Anyway, I digress. It was a shock to see something this much against the grain. So physical, not therapist. SO FAR away from what Peter is all about, which is interactivity, intersubjectivity.

Just for convenience sake, here is the published letter that Jason Silvernail and I submitted a few years ago, Therapist as operator or interactor? Moving beyond the technique.
You may remember Jason as the guy associated with the phrase "Crossing the Chasm". 


Here is something I whipped up about that.

A new slide for 2017 presentations



Here is the original I had written earlier: 
What is the operator model? What is the interactor model?


I think a conscious aware person in pain is going to come in to see people like us because they want therapy, perhaps therapy that's a bit physical. 
They will not be anesthetized. 
Our attitude should have evolved by now into not viewing them as some sort of mere assemblage of collagen.

Quite possibly clinicians are trying hard to be completely objective, and think being strictly anatomical in their externalized views will make them appear that way, but c'mon... seriously: there is nothing more variable (probably) than individual anatomy, and as clinicians we have NO way of knowing any individual's anatomy when they come in to see us. 


All we can do is try to help them move toward having less pain and better movement. That's it.
They are enminded bodies, and they are not so happy about it when pain is what has become enminded in their bodies. And they don't know it. They think their bodies are still broken or fragile or deranged somehow, structurally, thanks to well-meaning but misguided and mis-guiding treatment models based on anatomical dissections and imaging studies that show in glaring detail every little bit of frayed whatever going on it there and blaming it for "pain".

I think that the tissue-based biomedical attitudes so well reflected in the osteopathic treatment paper, and so ubiquitous, are likely a cover-up for deep seated insecurities of the operators who are disinclined to treat their patients as fellow humans with pain problems (enminded bodies): instead they prefer to see them as chunks of walking anatomy and tissue (embodied minds?). Feels less messy or threatening to their own sense of self, perhaps. Creates a more comfortable distance between I and thou.

So, it's a subtle thing in terms of manual therapy. 

Do we treat people as embodied minds? 
Or do we treat them as enminded bodies?

I like the latter better than the former. 


If I'm thinking of my patient as an embodied mind I would likely expect them to take care of handling any discomfort my treatment might inflict, either inadvertently or deliberately.

If I take the position that my patient's mind extends all the way to the ends of the neurons in their skin surface (patient as an enminded body, especially someone in pain with a sensitized peripheral nervous system), I'll be more apt to be careful and conscientious in my application of physical forces, more inclined to slow down and be interactive with their nervous system, more open to feel it as it fixes itself, takes down its own unnecessary positive feedback loops, changes its own physiology, permits softening, warming, effortlessness of movement once again. 




Saturday, February 18, 2017

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



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

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


You can obtain videos from the summit, here



COGNITIVE FUNCTIONAL THERAPY

DISCONFIRM

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







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





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


DISCONFIRMING FEARS AND BELIEFS OF THERAPISTS


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


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

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





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

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

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

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

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


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

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


DISCONFIRMING FEARS AND BELIEFS OF PATIENTS: JOLETTA


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


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


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

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

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


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


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


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


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


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


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

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


He pulled through. 

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


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


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


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


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


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


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


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


SUMMARIZING THE HOMEWORK

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


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



Peter's summary for one of the workshop patients

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

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


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

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


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

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


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


REFERENCES:

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

  1. O’Sullivan P (2012) It’s time for change in the management of non-specific chronic low back pain, British Journal of Sports Medicine, 46:224-227.
  2. Fersum K, O'Sullivan P, Skouen JS, Smith A, Kv√•le A. (2012), Efficacy of classification based 'cognitive functional therapy' in patients with Non Specific Chronic Low Back Pain -  A randomized controlled trial, European Pain Journal. 17 (6) 916-928. (FULL TEXT)
  3.  O’Keefe, M, Cullinane P, O’Sullivan K, Hurley J, O’Sullivan P, Bunzli S, (2015) What Influences Patient-Therapist Interactions in Musculoskeletal Physiotherapy? A Qualitative Systematic Review and Meta-Synthesis, Physical Therapy Journal, Oct 1. [Epub ahead of print] PMID:26427530
  4.  Paananen M, O'Sullivan P, Straker L, Beales D, Karpinnen J, Pennell C, Smith A, (2015) A low cortisol response to stress is associated with musculoskeletal pain combined with increased pain sensitivity in young adults: a longitudinal cohort study, Arthritis Res Ther. 17: 355. (FULL TEXT)
  5.  Bunzli S, Smith A, Shutze R, O’Sullivan P. (2015) Beliefs underlying pain-related fear and how they evolve: a qualitative investigation in people with chronic back pain and high pain-related fear, BMJ open, 5:e008847. (FULL TEXT)
  6.  O’Sullivan P, Dankaerts W, O’Sullivan K, Fersum K (2015) Multidimensional approach for targeted management of low back pain. Modern Manual Therapy, Elsevier. (NOT FOUND)
  7.  Rabey M, Smith A Slater, S; Beales, D, O'Sullivan, P (2016)  Differing psychologically-derived clusters in people with chronic low back pain are associated with different multidimensional profiles, Clin J Pain, accepted 22.1.16.
  8.  Bunzli S, McEvoy S, Dankaerts W, O’Sullivan P, O’Sullivan K, Patient perspectives on participation in Cognitive Functional Therapy for Chronic Low Back Pain: A qualitative study, Physical Therapy Journal, in press 3.2016
  9. Coenen, P; Smith, A; Paananen, M; O'Sullivan, P; Beales, D; Straker, L. (2016) Trajectories of low-back pain from adolescence to young adulthood, Arthritis Care & Research in press 1.6.16.
  10.  O’Sullivan P, Caniero JP, O’Keefe M, O’Sullivan K, (2016) Unravelling the complexity of low back pain, JOSPT, in press
  11. O'Sullivan K, Dankaerts W, O'Sullivan L, O'Sullivan PB; Cognitive Functional Therapy for Disabling Nonspecific Chronic Low Back Pain: Multiple Case-Cohort Study. Phys Ther. 2015 Nov;95(11):1478-88 (FULL TEXT)

PETER O'SULLIVAN VIDEOS ON YOUTUBE

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


Making Sense of Low Back Pain 1:24:45


Prof Peter O'Sullivan and Core Stability - April 2012







......... 

Thursday, January 05, 2017

Remembering Gayle

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


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


We had many adventures together.


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


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


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


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


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


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


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


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


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

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


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


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


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


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

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

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




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



White Owl Flies Into and Out of the Field

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


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

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

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

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

Gayle Winnifred Robinson
Jan 18 1948 – Jan 3 2017

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

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