I have moved my blog to www.121wellness.blogspot.com. I would very much appreciate you continuing to follow my writing there.
Thanks,
Nick
Saturday, March 14, 2009
Wednesday, October 29, 2008
Why it matters...at least to me
Two weeks ago, I had the pleasure of travelling to the beautiful city of Vancouver to meet and learn from Diane Jacobs. Diane is a physiotherapist whose tireless investigation of neuroscience and pain has been generously shared online for several years. I first bumped into her in cyberspace several years ago and have followed the development of her thinking and practice on SomaSimple ever since. I think it is safe to say that few have done more studying and reflecting than Diane in order to build a scientific foundation under manual therapy for pain.
So why is a scientific foundation so important? For far too long, physiotherapists have settled for "whatever works" in treating pain. Understandably, whatever works is often acceptable for someone who is seeking relief from their suffering. But we can do better. Our understanding of the brain and the rest of the nervous system is growing every day and it is information desperately needed to update our professional body on knowledge. Medicine and therapy, in attempts to emerge from empircism and tradition, have taken up the mantle of Evidence-Based Medicine. While helpful in many ways, this editorial highlights the futility of lobbing outcomes studies at one another like grenades. Rothstein points to the importance of theory to guide our thinking and practice.
I have questioned outdated models of human function on this blog before. Critiquing theory does not necessarily mean I think these models offer nothing of use. Reading outcome studies that show questionable theories are effective in practice does not convince me that the theory is correct. Although much remains to be figured out, there are some concepts that do not meet the criteria of plausibility and do not warrant further consideration. Some explanations offered are little more than perceptual fantasy. If these are not informed with what science tells us, they become nothing more than belief systems and cults of personality.
Throughout her long career, Diane has both studied and subsequently deconstructed many such systems of treatment. She has worked hard to understand - in the light of neuroscience - what she feels under her hands and the changes induced in people's bodies. She understands the role of therapist as catalyst to help a person's nervous system do the necessary work of down-regulating persistent pain and she performs her task with the light hands of an experienced guide that knows the landscape well. All of this and she is still seeking better maps. Here's why it matters: science - the effort to discover and the method of perpetual inquiry - is our best hope of deepening our understanding. It requires informed theory and good research. It requires clinicians to bring it to the care of their patients.
So why is a scientific foundation so important? For far too long, physiotherapists have settled for "whatever works" in treating pain. Understandably, whatever works is often acceptable for someone who is seeking relief from their suffering. But we can do better. Our understanding of the brain and the rest of the nervous system is growing every day and it is information desperately needed to update our professional body on knowledge. Medicine and therapy, in attempts to emerge from empircism and tradition, have taken up the mantle of Evidence-Based Medicine. While helpful in many ways, this editorial highlights the futility of lobbing outcomes studies at one another like grenades. Rothstein points to the importance of theory to guide our thinking and practice.
I have questioned outdated models of human function on this blog before. Critiquing theory does not necessarily mean I think these models offer nothing of use. Reading outcome studies that show questionable theories are effective in practice does not convince me that the theory is correct. Although much remains to be figured out, there are some concepts that do not meet the criteria of plausibility and do not warrant further consideration. Some explanations offered are little more than perceptual fantasy. If these are not informed with what science tells us, they become nothing more than belief systems and cults of personality.
Throughout her long career, Diane has both studied and subsequently deconstructed many such systems of treatment. She has worked hard to understand - in the light of neuroscience - what she feels under her hands and the changes induced in people's bodies. She understands the role of therapist as catalyst to help a person's nervous system do the necessary work of down-regulating persistent pain and she performs her task with the light hands of an experienced guide that knows the landscape well. All of this and she is still seeking better maps. Here's why it matters: science - the effort to discover and the method of perpetual inquiry - is our best hope of deepening our understanding. It requires informed theory and good research. It requires clinicians to bring it to the care of their patients.
Sunday, September 28, 2008
Pain is Like Thirst
A client asked me the other day why she recently began having pain in her legs again after several months of being painfree. In spite of my efforts at education, pain remained for her a signal that something was "broken" and being painfree meant it had been fixed. Now, apparently, something had gone wrong and she wondered why the "fix" had not held. After all, nothing had really happened that would have caused this injury. So why the pain?
As uncomfortable as it may be, it is important to realize that pain is a normal biological experience. It is one way our nervous system communicates information about the outside world or our inner happenings. It often begins as a low rumble and, when ignored, builds to a deafening roar. Even if not ignored, responses are frequently unhelpful and generally end up making the problem worse. We need to learn the language that is being spoken.
When my four year old son says he's "starving" or that he's "dying of thirst" I know (even if he does not) that he's demonstrating his flair for the dramatic and that there's actually no threat of him becoming too hungry or in desperate need of a glass of water. We are very fortunate to have our basic needs met with relative ease and rarely become distressed by these normal biological signals. But let's look at how these "sensations" work and what this has to do with pain.
Our brains constantly monitor what is happening in our internal and external environments. For instance, when blood volume decreases beyond a certain point, the brain detects this change and recognizes a need state. In order to drive the system back toward balance, thirst is produced as an output of the brain to motivate us to drink. In this sense, pain is very similar to thirst. When the brain receives increased inputs from certain nerve fibers, it may produce pain as a means of producing a particular response. The helpful response depends on the context of the signalling and the required behavioral change. In most cases, we're looking for a movement.
And so, I asked my client if she ever became thirsty after working out in her garden in the hot sun. She replied affirmatively and I asked if that meant there was something wrong with her or if her body was simply reacting as it should given the circumstances. Again, she agreed that thirst was normal, even helpful, in this context. Likewise with pain. If you are not giving your body the movement it requires when it requires it, pain is the natural result and the right kind of motion will help you resolve it.
As uncomfortable as it may be, it is important to realize that pain is a normal biological experience. It is one way our nervous system communicates information about the outside world or our inner happenings. It often begins as a low rumble and, when ignored, builds to a deafening roar. Even if not ignored, responses are frequently unhelpful and generally end up making the problem worse. We need to learn the language that is being spoken.
When my four year old son says he's "starving" or that he's "dying of thirst" I know (even if he does not) that he's demonstrating his flair for the dramatic and that there's actually no threat of him becoming too hungry or in desperate need of a glass of water. We are very fortunate to have our basic needs met with relative ease and rarely become distressed by these normal biological signals. But let's look at how these "sensations" work and what this has to do with pain.
Our brains constantly monitor what is happening in our internal and external environments. For instance, when blood volume decreases beyond a certain point, the brain detects this change and recognizes a need state. In order to drive the system back toward balance, thirst is produced as an output of the brain to motivate us to drink. In this sense, pain is very similar to thirst. When the brain receives increased inputs from certain nerve fibers, it may produce pain as a means of producing a particular response. The helpful response depends on the context of the signalling and the required behavioral change. In most cases, we're looking for a movement.
And so, I asked my client if she ever became thirsty after working out in her garden in the hot sun. She replied affirmatively and I asked if that meant there was something wrong with her or if her body was simply reacting as it should given the circumstances. Again, she agreed that thirst was normal, even helpful, in this context. Likewise with pain. If you are not giving your body the movement it requires when it requires it, pain is the natural result and the right kind of motion will help you resolve it.
Friday, August 29, 2008
A Theory of Practice
"In theory there is no difference between theory and practice. In practice there is."
Yogi Berra
People frequently ask me why I practice differently from other therapists they have experienced. Most seem appreciative of the approach. Others struggle to go where they think I want them to go. Expecting someone to tell them everything that is wrong with them and set about fixing it, they are taken aback when I begin with acceptance and follow their lead toward correction. The truth is, they know more about finding their way out of pain than I do. I just need to help them find that path. I decided long ago that since I rarely met anyone's expectations of therapy that I would have to try instead to exceed them. That is easier said than done.
In this thread on SomaSimple, a fellow moderator had this to say about our profession:
"Perhaps as a profession, we've been following the wrong directions so long that we've had to convince ourselves that where we ended up is where we wanted to go. I imagine it would be hard to convince someone that all the hard work used to get somewhere may have been wasted (or at least not used efficiently)."
I think he is exactly right. When one finds oneself somewhere they don't really want to be, they should change course. So, I guess my simplest answer to the question of why my practice is different is that I have corrected course many times.
A few years ago James Willis, MD, gave an address on the importance of science in medicine that I think everyone should read. In The Sea Monster and the Whirlpool, he discusses the difficulty and imperative of steering a course between pseudoscience (see my last post) and scientific fundamentalism. In physiotherapy these days, these two extremes are exemplified by the enthusiasm for alternative methods and the excitement about clinical prediction rules for manipulation. This is not all bad, of course, and one must carefully separate the wheat from the chaff. The main imperative for many, however, seems protection of traditional methods of practice. This makes no sense when the science is leading us in a different direction.
I spend every day encountering patients in pain, trying to figure out how to help them find greater comfort and how to function better in their every day lives. Thankfully, there has been a tremendous amount of work in neuroscience that has revolutionized our understanding of pain. It has charted a course for my profession that we simply must follow if we hope to help those in need of our care. It is time for new theories. And from new theories, new practice.
That is why I practice differently.
Yogi Berra
People frequently ask me why I practice differently from other therapists they have experienced. Most seem appreciative of the approach. Others struggle to go where they think I want them to go. Expecting someone to tell them everything that is wrong with them and set about fixing it, they are taken aback when I begin with acceptance and follow their lead toward correction. The truth is, they know more about finding their way out of pain than I do. I just need to help them find that path. I decided long ago that since I rarely met anyone's expectations of therapy that I would have to try instead to exceed them. That is easier said than done.
In this thread on SomaSimple, a fellow moderator had this to say about our profession:
"Perhaps as a profession, we've been following the wrong directions so long that we've had to convince ourselves that where we ended up is where we wanted to go. I imagine it would be hard to convince someone that all the hard work used to get somewhere may have been wasted (or at least not used efficiently)."
I think he is exactly right. When one finds oneself somewhere they don't really want to be, they should change course. So, I guess my simplest answer to the question of why my practice is different is that I have corrected course many times.
A few years ago James Willis, MD, gave an address on the importance of science in medicine that I think everyone should read. In The Sea Monster and the Whirlpool, he discusses the difficulty and imperative of steering a course between pseudoscience (see my last post) and scientific fundamentalism. In physiotherapy these days, these two extremes are exemplified by the enthusiasm for alternative methods and the excitement about clinical prediction rules for manipulation. This is not all bad, of course, and one must carefully separate the wheat from the chaff. The main imperative for many, however, seems protection of traditional methods of practice. This makes no sense when the science is leading us in a different direction.
I spend every day encountering patients in pain, trying to figure out how to help them find greater comfort and how to function better in their every day lives. Thankfully, there has been a tremendous amount of work in neuroscience that has revolutionized our understanding of pain. It has charted a course for my profession that we simply must follow if we hope to help those in need of our care. It is time for new theories. And from new theories, new practice.
That is why I practice differently.
Thursday, July 24, 2008
Where's My Qi Gone???
The ancient art of Qi Gong has become all the rage in Halifax. It comes complete with extraordinary claims and even a modicum of evidence. I want to be very clear that I think it is a wonderful form of movement therapy and can benefit many. Its focus on movement and breathing addresses two of the fundamental issues so important for people experiencing persistent pain. And it is here that the ancient art intersects with modern science.
There is a growing body of research literature that demonstrates the efficacy of acupuncture and other related modalities - at least in some circumstances. However, one must be careful not to leap to an acceptance of the theories behind these methods. Traditional approaches claim that energy or qi (chi) flows along channels called meridians and that blockages can cause illness or dysfunction of various sorts. In spite of claims to effectiveness, there is no support for this theoretical model. Meridians have never been identified by scientific method and far more plausible mechanisms, such as endorphin release and neuromodulation, are offered by neurophysiological investigations. One need not depend on outdated theory and magical thinking to understand empirical observations.
Dr. Harriet Hall helps shed light on such matters in discussing what she calls Tooth Fairy Science:
"You could measure how much money the Tooth Fairy leaves under the pillow, whether she leaves more cash for the first or last tooth, whether the payoff is greater if you leave the tooth in a plastic baggie versus wrapped in Kleenex. You can get all kinds of good data that is reproducible and statistically significant. Yes, you have learned something. But you haven’t learned what you think you’ve learned, because you haven’t bothered to establish whether the Tooth Fairy really exists."
For instance, Qi Gong or acupuncture or many other similar treatments may produce measurable outcomes (even good ones), but that does not establish the existence of some vital energy that can be manipulated by a practitioner claiming to have special powers. No one has bothered to establish whether qi and meridians even exist.
Here is the protocol for treatment outlined in a pilot study for Qi Gong for people with fibromyalgia (THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 12, Number 9, 2006, pp. 851–856)
"EQT treatment by this specific healer consisted of administering acupressure, qi emission, qi balancing, and magnetic cupping on each individual. The following is a briefdescription of the main steps in the specific EQT of this healer, and the presumed functions of these various steps in the treatment process:
(a) The fully clothed patient lies down on her back on the examination table; the healer lightly touches the abdominal area to sense the blockage of qi flow in the major organs, allegedly moving the qi around, and driving the stagnant qi out via the bottom of the patient’s feet.
(b) The healer examines the key acupoints (not necessarily the tender points) to sense the extent of the blockages at each point and in the internal organs. He uses his palm(s) movements to generate the flow of qi in each blocked area, driving the stagnant qi out through the patient’s feet (Yongchuan acupoint).
(c) The patient turns around facing down on the examination bed and raises the back of her shirt;
(d) The healer examines major organs from the patient’s back with his palm to locate any deficiency in function and qi balance.
(e) The healer moves his own qi to the organs and verifies that the organ is functioning normally with balanced energy. He drives the stagnant qi out, and supplies healthy qi energy to the major organs.
(f) After the qi adjustment, small magnetic cupping is often used to directly take the excessive stagnant qi out from a specific organ (through acupoints)."
I'm leaving it to you readers to spot the Tooth Fairy here. Let me know if you see her. I'll be back with more later.
There is a growing body of research literature that demonstrates the efficacy of acupuncture and other related modalities - at least in some circumstances. However, one must be careful not to leap to an acceptance of the theories behind these methods. Traditional approaches claim that energy or qi (chi) flows along channels called meridians and that blockages can cause illness or dysfunction of various sorts. In spite of claims to effectiveness, there is no support for this theoretical model. Meridians have never been identified by scientific method and far more plausible mechanisms, such as endorphin release and neuromodulation, are offered by neurophysiological investigations. One need not depend on outdated theory and magical thinking to understand empirical observations.
Dr. Harriet Hall helps shed light on such matters in discussing what she calls Tooth Fairy Science:
"You could measure how much money the Tooth Fairy leaves under the pillow, whether she leaves more cash for the first or last tooth, whether the payoff is greater if you leave the tooth in a plastic baggie versus wrapped in Kleenex. You can get all kinds of good data that is reproducible and statistically significant. Yes, you have learned something. But you haven’t learned what you think you’ve learned, because you haven’t bothered to establish whether the Tooth Fairy really exists."
For instance, Qi Gong or acupuncture or many other similar treatments may produce measurable outcomes (even good ones), but that does not establish the existence of some vital energy that can be manipulated by a practitioner claiming to have special powers. No one has bothered to establish whether qi and meridians even exist.
Here is the protocol for treatment outlined in a pilot study for Qi Gong for people with fibromyalgia (THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 12, Number 9, 2006, pp. 851–856)
"EQT treatment by this specific healer consisted of administering acupressure, qi emission, qi balancing, and magnetic cupping on each individual. The following is a briefdescription of the main steps in the specific EQT of this healer, and the presumed functions of these various steps in the treatment process:
(a) The fully clothed patient lies down on her back on the examination table; the healer lightly touches the abdominal area to sense the blockage of qi flow in the major organs, allegedly moving the qi around, and driving the stagnant qi out via the bottom of the patient’s feet.
(b) The healer examines the key acupoints (not necessarily the tender points) to sense the extent of the blockages at each point and in the internal organs. He uses his palm(s) movements to generate the flow of qi in each blocked area, driving the stagnant qi out through the patient’s feet (Yongchuan acupoint).
(c) The patient turns around facing down on the examination bed and raises the back of her shirt;
(d) The healer examines major organs from the patient’s back with his palm to locate any deficiency in function and qi balance.
(e) The healer moves his own qi to the organs and verifies that the organ is functioning normally with balanced energy. He drives the stagnant qi out, and supplies healthy qi energy to the major organs.
(f) After the qi adjustment, small magnetic cupping is often used to directly take the excessive stagnant qi out from a specific organ (through acupoints)."
I'm leaving it to you readers to spot the Tooth Fairy here. Let me know if you see her. I'll be back with more later.
Saturday, June 28, 2008
Sparked
John Ratey's new book Spark combines a look a two of my greatest interests - exercise and brain science. Ratey promises to "supercharge your mental circuits to brain stress, sharpen your thinking, lift your mood, boost your memory, and much more." How could anyone resist? He presents a compelling case for the positive effects of aerobic exercise on brain chemistry. While I agree with much of what he writes, there are some complicated issues that he does not address. I have written Dr. Ratey about these questions, but have yet to receive his reply. To state my position most clearly, I think he would do well to distinguish more explicitly between exercise and recreational activity. Find more on that in previous posts on Good Medicine.
Basically it comes down to this issue at the heart of his book: Ratey states that "the paradox is our that our wonderful ability to adapt and grow doesn't happen without stress - we can't have the good without the bad." He also offers that everybody's threshold for stress is different and admits that "there is no specific point at which scientists can say stress shifts from building up to tearing down." These are extremely important points and I think they are glossed over too quickly and easily in the final analysis of his recommendations. I agree that people need to move more than they do and that enjoyable activity has tremendous psychological and social benefits driven, at least in part, by the chemical changes in one's brain. However, causing the body to adapt requires hard work balanced with adequate recovery. Ratey gives lip service to resistance training and recovery, but neither is given the attention it deserves and requires. If everyone is unique, then generic admonitions to be more active certainly will not do. Again, like any medicine, exercise must be prescribed in a manner that suits a particular individual and accomodates the desired response. He states the importance of individuality in the book, but the rest of his writing contradicts it.
Here, in my opinion, is the biggest mistake in the book: "The process of getting fit is all about building up your aerobic base." This statement simply is not true. Sure, it is important to get your blood pumping but think about where that blood is going. Ratey, importantly, adds the brain to the list of tissues that benefit from exercise; however, he mostly overlooks the muscles. In personal correspondence, he did acknowledge the importance of resistance training for brain changes and he gives it a brief nod for preventing osteoporosis in the book. He recognizes that "even if you do all the aerobic training in the world, your muscles and bones will still atrophy with age." But he seems to fail to see the implications of this. First, it is the primary reason why people become frail and lose functional ability, including performing all that activity he is so fond of. Second, there is growing evidence, though Ratey seems not to have read this research, of the connection between healthy muscles (ie. ones that are not wasting away) and healthy brains.
Good news: a little activity can do wonders for your brain. Spark could be a great motivator for someone requiring a little extra motivation to get moving and stay strong. Beware, however, the generic recommendations. Injury and pain are real problems that often significantly limit activity tolerance and negatively impact quality of life. In other words, don't just do it; do it right!
You can also listen to Dr. Ratey at Brain Science Podcasts, one of my favorite sites on the net. Check it out.
Basically it comes down to this issue at the heart of his book: Ratey states that "the paradox is our that our wonderful ability to adapt and grow doesn't happen without stress - we can't have the good without the bad." He also offers that everybody's threshold for stress is different and admits that "there is no specific point at which scientists can say stress shifts from building up to tearing down." These are extremely important points and I think they are glossed over too quickly and easily in the final analysis of his recommendations. I agree that people need to move more than they do and that enjoyable activity has tremendous psychological and social benefits driven, at least in part, by the chemical changes in one's brain. However, causing the body to adapt requires hard work balanced with adequate recovery. Ratey gives lip service to resistance training and recovery, but neither is given the attention it deserves and requires. If everyone is unique, then generic admonitions to be more active certainly will not do. Again, like any medicine, exercise must be prescribed in a manner that suits a particular individual and accomodates the desired response. He states the importance of individuality in the book, but the rest of his writing contradicts it.
Here, in my opinion, is the biggest mistake in the book: "The process of getting fit is all about building up your aerobic base." This statement simply is not true. Sure, it is important to get your blood pumping but think about where that blood is going. Ratey, importantly, adds the brain to the list of tissues that benefit from exercise; however, he mostly overlooks the muscles. In personal correspondence, he did acknowledge the importance of resistance training for brain changes and he gives it a brief nod for preventing osteoporosis in the book. He recognizes that "even if you do all the aerobic training in the world, your muscles and bones will still atrophy with age." But he seems to fail to see the implications of this. First, it is the primary reason why people become frail and lose functional ability, including performing all that activity he is so fond of. Second, there is growing evidence, though Ratey seems not to have read this research, of the connection between healthy muscles (ie. ones that are not wasting away) and healthy brains.
Good news: a little activity can do wonders for your brain. Spark could be a great motivator for someone requiring a little extra motivation to get moving and stay strong. Beware, however, the generic recommendations. Injury and pain are real problems that often significantly limit activity tolerance and negatively impact quality of life. In other words, don't just do it; do it right!
You can also listen to Dr. Ratey at Brain Science Podcasts, one of my favorite sites on the net. Check it out.
Wednesday, May 28, 2008
One too many dandelions...
I thought of this when a patient of mine wondered aloud about how many of us on our death beds would wish we had spent more time killing weeds. This was while she was being treated for back pain after spending the weekend making her yard look beautiful. Isn't it amazing how often our culture chooses beauty over comfort?
Then again, maybe I'm just rationalizing the state of my lawn and hoping my neighbors forgive my obvious lack of passion for green carpet.
I’d Kill More Dandelions
Nick Matheson, Age 35
If I had my life to live over,
I'd try to make fewer errors next time.
I would stress out. I would stiffen up.
I would be more sober than I have on this trip.
I would be more orderly. I would be neater.
I would take fewer chances, I would stay home more.
I would climb fewer mountains, swim fewer rivers, and watch fewer sunsets.
I would burn less gasoline. I would eat less ice cream and more broccoli.
I would have fewer actual troubles and more imaginary ones.
You see, I am one of those people who throws caution to the wind and hopes it won’t blow back in my face.
Oh, I have had my moments when I thought I had it all figured out.
Everything seemed just right.
Risk appeared to have its reward
and truth was more certain than reality.
But if I had to do it again, I would forget now and live every day in the far off future, ready for any eventuality.
You see, I got kicked out of Boy Scouts and have never been prepared.
If I had to do it over again, I would stay home and do more yard work.
I'd watch more TV and read fewer books.
I’d spend less time worrying about my kids and more time worrying about the neighbors.
If I had my life to live over, I would start weeding earlier in the spring and keep mowing way later in the fall.
I would make sure the grass was greener on my side of the fence.
I would never miss a day of work. I would make more money and live in a bigger house. I would be fully insured.
I would avoid merry-go-rounds, but would run on treadmills.
I'd kill more dandelions.
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