I wrote the first version of this over 3 years ago and I still get contacted by health professionals who want to discuss their similar rollercoaster journeys. Here’s an update on my ever-evolving roller coaster.
The first wave
When I emerged proudly with my degree in the late 70s, all packed with Maitland style manual therapy, I was convinced I could fix all and sundry and I often opened a clinical conversation with “what can I fix today?” (I feel ill saying it now!) Anyway, it all worked well for a few years but then I noticed that “it” was not delivering the goods so well. Unbelievably some patients dared not get better. Things were feeling professionally grim, career changes were pondered, but then, proud and erect, fresh from New Zealand, Robin McKenzie rode into town, maybe even on a white horse!
The second wave
Wow – this was it! How silly was I to miss the disc and the novel notion of actually getting people to treat themselves and to give your thumbs a good rest. People started getting better again, my practice was full of lumbar rolls, the “Treat your Own” books and models of discs and I was on a roll too. This McKenzie approach worked wonders for a few years, but then the outcomes began to taper off, some patients wouldn’t improve, some wanted the old fashioned hands on that I had almost given away and a now familiar professional grimness emerged again. What next?
The third wave
I heard about a year-long Maitland post graduate course in South Australia and I reasoned that there must be more to it than I’d first thought, so I signed up for the year. I made it through a bit wounded, but the old “I can fix anything” returned and I went into the outer suburbs of Adelaide to ply my trade, wriggling and cracking joints and doing the new teasing nerves stuff. People got better and complex problems seemed to dissolve. But would you believe it – it happened again – the clinical outcomes tailed off with what I now recognise as centrally sensitised states, overuse syndrome and complex regional pain syndrome. I pondered a career change. Perhaps professional surfing?
The fourth wave
By now (late 80s, early 90s) I was becoming a bit older and wiser and trying to think more deeply about things – so I thought –“stuff the others – I’ll try and work it out myself”. And so I went off on the “neural tension” bandwagon – the idea of the physical health of the nervous system and mobilising nerves. I did some reading, had a few thoughts, stood on the shoulders of a few others and even wrote a couple of books. This was it I thought! Life will be easy from now on as we wriggled and glided and teased nerves from head to toe. Patients flocked in … but the old diminishing outcomes emerged again, even for something I had helped to invent. Grim days – coffee was coming into fashion I pondered becoming a barista and investigated what it would take to become a marriage celebrant.
The fifth mini-wave
I was getting very wary now – the early work of Vladamir Janda was being updated and researched, particularly at the University of Queensland and once obscure bits of anatomy such as transversus abdominis, obturator internus and short neck flexors were now the new targets and the “with it” practitioners had ultrasound machine to view muscles. I went to the courses and gave it a go but my heart wasn’t in it. Waves can be exhausting, and the outcomes were eluding me again, just like my transversus abdominis. I tried the taping stuff too, but like a focus on a single muscle, it just didn’t make enough sense.
I drifted off into the world of pain and neuroscience and am still happily here. No magic, just a lot of hard work using neuroscience to fuel educational and imagery therapy and the good parts of the historic waves I’ve ridden. I thought I may have reached nirvana with the brain, but now I realise that neurones are only 10% of the brain and as the rest is immune cells, so there is long way to go.
I am still on this fifth mini-wave – trying to keep up with the world of brain plasticity, neuroimmunological balances and recent research and concepts of DAMPS (danger associated molecular patterns) and BAMPS (behaviour associated molecular patterns) and even CAMPS (cognitive associate molecular patterns) among others, all identified by Toll Like Receptors which can ratchet up their behaviour and keep enhances immune responses bubbling. It’s infectious science. But …
Uh oh – a sixth mini-wave beckons
I never thought this would happen, but I peering back at the tissues where I started all those years ago. The brain is so trendy that the scientific and some of the clinical world seemed to forget the rest of the body. I have been trimming my nails in anticipation of a return to the flesh! Not giving up the neuroimmunology of course but things like how can we dance with the different receptors in tissues, deal with the immunocompetence of the meninges, or indeed most tissues, and the simple and undervalued licence to touch is sacrosanct – even if just touching a hand while sharing knowledge. I notice and try and understand the trend towards predictive processing and Bayesian thinking, and find it fascinating but I am a wary old bugger. After all – all the talk was about phenomenology a year or so back but it seems to have gone out of favour. Are some of our colleagues onto their next mini waves
Three thoughts
1. I look around now at the course advertisements in the back of the journals and it seems the new roller coaster is still driven by dry needling, loading joints and lifting weights, someone called Pilates, and now mindfulness has become trendy – even yoga is on the up. No doubt some people are flying with it, and good on them, but not me – I am too war weary to get on the roller coaster again but I am sure there is something in it like there is in everything and if your professional paradigms are wide enough and trending towards biopsychosocial then there is a rational place for everything. The waves are not a loss if you can absorb them.
2. What bugs me is that it took so long to realise that it was I myself who was probably the main variable in outcomes – not the techniques. I am not saying that massaging patients with a wet salmon will help. However the interactional power needs better analysis and understanding and as Pat Wall would say “in the end, if the majority of the outcomes are based on placebo, do not fear, but work out what it was in the placebo which gave the outcome”.
3. But what saddens me is that I now see a rapid and enforced rollercoaster in young therapists just out of college – youngsters with that precious, must be captured mindset of wanting to change the world. Yet increasingly employment is all about the dollar, the speed, the getting patients back and thus treatment processes inevitably based on singular biomedial paradigms. There is no time to work out for themselves what this professional rollercoaster of life is all about. We all need to work it out ourselves in some way. If not – we face professional burnout. I am looking forward to wave 7 soon!
– David Butler
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Hi David,
Thanks for this update. Your writings over the years have inspired me to follow a similar path. Did the courses, had the same experiences (although I didn’t write my own books or helped develop a concept in PT) and now I am trying to understand the same things mentioned in wave 5, 6 and 7.
I have another wave though which takes up a lot of my time to get my head around and would benefit health practitioners immensely were they to understand it.
It’s the study of complexity science:
http://www.art-sciencefactory.com/complexity-map_feb09.html.
This will keep you occupied for a while! Insights from the complexity sciences could even help you explain why the physiotherapy/manual therapy/etc. community hasn’t really changed it’s paradigm (see thought 3) when it comes to treating patients with pain.
Keep up the writing! I look forward to the new book.
Greetings from the Netherlands,
Evert Jan Das
Thanks Evert, I have always circled around it, but i will give it a go!
David
Hi David,
I couldn’t find any courses for physiotherapists which address this topic so I did some (free) online courses and read a great deal of books on the topic.
See this links for some (free) online courses:
https://www.complexityexplorer.org
https://www.futurelearn.com/courses/systems-thinking-complexity
http://www.thegreatcourses.com/courses/understanding-complexity.html
http://www.thegreatcourses.com/courses/chaos.html
http://think-academy.io
We will start our own course on “complexity in chronic pain” in 2017 in the Netherlands (for the Dutch readers: http://www.fysioveghel.nl/cursus-complexiteit-bij-chronische-pijn/).
I think we are the first who will run a course on chronic pain viewed from a complex systems perspective (i.e. clinical reasoning, diagnostics and management according to principles from complexity science), at least in the Netherlands. It would be great if noi would integrate knowledge from this field in their courses.
Greetings,
Evert Jan
I see your practice offers Dry Needling and also pain education (to name 2) and your planning to run a course on chronic pain viewed from a complex systems perspective. Seen from the perspective highlighted in the publications by J.Quintner (http://www.bodyinmind.org/trigger-point-evaluation/) could it be that you may have overlooked an important bias?
Marcel
Hi Marcel,
I can understand where you question is coming from…
My view is that by providing dry needling as a treatment option you don’t automatically subscribe to the explanatory models concerning what “myofascial trigger points” are or are not.
What a trigger point turns out to be ( e.g. a clinical expression of central sensitization or a local muscular dysfunction) remains to be seen…
(see short discussion here: http://www.paininmotion.be/blog/detail/myofascial-trigger-points-fact-or-myth-let-battle-continue).
I like the term “muscle contributions to a pain experience” which I heard David Butler say one time.
Now back to a complex systems perspective…
If pain is an emergent property of the human (i.e. the system) and the simple rules by which the system produces its emergent property (pain) are:
“any credible evidence for danger to the body compared to safety” + “the need to protect”
…than I can understand that in some patients dry needling provides a benefit (in terms of influencing the dynamics of the system and thereby it’s outputs) just like…e.g. mobilization/manipulation/massage/hot-pack/cool-pack/pain education/GMI/surgery…etc. This certainly fits with my clinical experience.
By the way…see nice example concerning surgery:
https://www.youtube.com/watch?v=HqGSeFOUsLI
The trick is to find out how to influence the system (human) and use systems principles like e.g. : 1) complexity emerges from simple rules (the protectometer is a great example of the simple rules by which pain emerges from the human!!!), 2) self-organization and 3) adaptation, always realizing that 4) central control is not possible.
To stick with surgery….any idea how this person improved?:
https://noijam.com/2014/02/13/knee-replacements-in-the-brain-the-patients-side/
Greetings,
Evert Jan
Hi Marcel,
Thanks for you’re comment…
I understand where you’re question is coming from…(the ancient discussion about the “issues in the tissues” comes to my mind)
Offering dry needling as a treatment option doesn’t mean I subscribe to the explanatory models concerning what trigger points are or aren’t.
It remains to be seen what trigger points turn out to be (e.g. clinical expression of central sensitization or local muscle dysfunction or something else altogether…).
See for a short discussion:…http://www.paininmotion.be/blog/detail/myofascial-trigger-points-fact-or-myth-let-battle-continue
By the way I like the following description, which I heard David Butler say on a course once…
“muscle contributions to a pain experience”…
With this phrase in mind I approach this trigger point phenomenon (or whatever it should be called). There seems to be something specific to the points where dry needling is performed (local twitch response and often reproduction of the patients pain) which you don’t see if you needle somewhere else in the muscle. I’ll leave the explanations of these findings to someone else…
Concerning complex systems:
I can understand that dry needling works for some patients considering the simple rules from which pain seems to emerge into consioussness:
“any credible evidence for danger to the body compared to credible evidence for safety” + “the need to protect”…
The trick is to find out how you can influence the dynamics of the system (the human) working with these “simple rules” so that it’s output (it’s emergent property i.e. pain) changes (through self-organization, without central control) into a new state (pain free).
Realizing that there is no central control in complex systems: dry needling, mobilization/manipulation, massage, pain education, SURGERY, etc are all possible ways/attempts to influence the system…but by definition should be viewed as only modalities used in a multimodal/multidimensional approach.
I think we all experienced patients having benefit with treatments for which there is no evidence and no benefit with treatments for which there is evidence…
Concerning surgery…have a look at this: https://www.youtube.com/watch?v=HqGSeFOUsLI and read https://www.amazon.com/Surgery-Ultimate-Placebo-Surgeon-Evidence/dp/1742234577
Any idea why this person got better: https://noijam.com/2014/02/13/knee-replacements-in-the-brain-the-patients-side/ ???
Greetings,
Evert Jan Das
Sorry, I posted the comment twice…
After posted the first I didn’t see it appear on the blog. So I tried to write it again and post it…didn’t realize there was a time delay…comment two has some extra thoughts though…
Thanks Evert,
I understand the “desire” to find ways, (or more “tools”) that offer pain relief.
The (new) treatment options we provide should also be safe.
http://aim.bmj.com/content/22/3/122
Interesting reads “Topical issues in Pain”
https://books.google.nl/books?hl=nl&lr=&id=GanZAAAAQBAJ&oi=fnd&pg=PP1&dq=Topical+Issues+in+Pain&ots=Fe0LmBkLVs&sig=ZCrVCA7t8-OxQ9rgL9FQDT0ZS-k#v=onepage&q=dry%20needling&f=false
Regards
Marcel
Hi David,
Thanks for sharing.
An interesting very recent anecdote on the power of touch in a predictive processing context;
I have been working recently with a branch of the military known for their pranks. I try and stay out of trouble but yesterday was caught in some ‘crossfire’ and was frightened when I saw a plastic skeleton hand (hand only, rest of skeleton not attached) sitting on my shoulder while sitting at my desk! The interesting thing was once I realised it was a ‘hand’ it actually started to feel slightly warm and heavy! Just to make sure I wasn’t hallucinating I asked my colleague to try the same thing, with a similar result!?
Max
Hi Max,
Do you think it would been warmer and heavier if the hand was on your crotch!
David
Hey David,
I think it may be warmer but not heavier in the crotch area!
Where I work it wouldn’t be an issue to test the hypothesis tomorrow and report back if something unexpected occurs!
Cheers,
Max
David, apropos your third thought. Do you think “professional oblivion” might be more appropriate than “professional burnout”? Sorry to be so pessimistic but despite our best efforts, I would hazard a guess that the biomedically-oriented health care system in which we are forced to work will always triumph over attempts to implement biopsychosocial approaches to people in pain. I never thought I would say this!
Yes – kind of sad that you are saying that John, but you may be right. There are too many groups, some very powerful, feeding the lie that pain is a measure of tissue damage and not the perceived need to protect. And I am beginning to realise more and more from world events that people somehow don’t mind lies, in fact they survive on them.
David
Don’t tell me the truth otherwise I won’t function properly….!!!
Hello David,
You may be interested in this:
“he search for true numbers of neurons and glial cells in the human brain: A review of 150 years of cell counting.
von Bartheld CS, Bahney J, Herculano-Houzel S.
J Comp Neurol. 2016 Dec 15;524(18):3865-3895. doi: 10.1002/cne.24040. Epub 2016 Jun 16.
Abstract
For half a century, the human brain was believed to contain about 100 billion neurons and one trillion glial cells, with a glia:neuron ratio of 10:1. A new counting method, the isotropic fractionator, has challenged the notion that glia outnumber neurons and revived a question that was widely thought to have been resolved. The recently validated isotropic fractionator demonstrates a glia:neuron ratio of less than 1:1 and a total number of less than 100 billion glial cells in the human brain. A survey of original evidence shows that histological data always supported a 1:1 ratio of glia to neurons in the entire human brain, and a range of 40-130 billion glial cells. We review how the claim of one trillion glial cells originated, was perpetuated, and eventually refuted. We compile how numbers of neurons and glial cells in the adult human brain were reported and we examine the reasons for an erroneous consensus about the relative abundance of glial cells in human brains that persisted for half a century. Our review includes a brief history of cell counting in human brains, types of counting methods that were and are employed, ranges of previous estimates, and the current status of knowledge about the number of cells. We also discuss implications and consequences of the new insights into true numbers of glial cells in the human brain, and the promise and potential impact of the newly validated isotropic fractionator for reliable quantification of glia and neurons in neurological and psychiatric diseases.”
https://www.ncbi.nlm.nih.gov/pubmed/27187682
Cheers Marcel
Ps the title must be “The search for true numbers of neurons and glial cells in the human brain”
Hi Marcel,
Many thanks for that. A good discussion on the numbers is at:
https://blogs.scientificamerican.com/brainwaves/know-your-neurons-what-is-the-ratio-of-glia-to-neurons-in-the-brain/
Best wishes
David