I have for some years now, been reading articles by physiotherapists Diane Jacobs. Some of these quotes are from articles and others are from social media debates. Diane Jacobs is one of the lesser known pain experts, but in my opinion she deserves a lot more attention, for the great work that she does, and continue to do.

Diane Jacobs has been a physiotherapist for over 40 years and a manual therapist for over 30 years.  She graduated with diploma in physiotherapy from the University of Saskatchewan, in 1971. In the 70’s she worked in hospitals, while she continued attending university. She has a very popular blog called HumanAntiGravitySuit.

She is also a Moderator at SomaSimple. The SomaSimple forums are one of the best resources and debate groups (if not the best) for health professional who works with chronic pain clients. SomaSimple is a group of internet forums for science-minded physical therapists, osteopaths, chiropractors, massage therapists, personal trainers and manual therapists.

In 2005, she helped form a special interest group in Canada, for physiotherapists interested in pain science. Eventually the Canadian Physiotherapy Association formally recognized our group as the Pain Science Division, in 2008. She served as its communications liaison until 2014, and still volunteer on a committee.

In 2005 she also began to teach her method of manual therapy called DermoNeuroModulation (DNM). DermoNeuroModulation is a structured, interactive approach to manual therapy that considers the nervous system of the patient from skin cell to sense of self.

Without further ado, here are 40 quotes from physiotherapists Diane Jacobs:

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

“Placebo isn’t a “thing” – it isn’t anything we do, or provide, or sell. Placebo is something a patient’s brain makes by itself, as long as you can avoid presenting them with nocebo. (Nocebo stimulates formation of cholecystokinin, which negates endogenous opioid production.) Diane Jacobs

“I’d say, let’s be less physical, more therapist.” Diane Jacobs

“Manual therapy has been with us from antiquity; before that, it evolved biologically as social grooming in primates/ pre-language humans. All the neurologic pathways for appreciating touch and handling from another are still all there in humans, free just for being vertebrates.” Diane Jacobs

“There is the internal regulation system/critter brain being phylogenetically a lot older and fairly independent of cortex (other than perhaps as an annoying stressor to it, much of the time..), so already we know the brain isn’t monolithic, but this is a new way of seeing how function slices up into different levels of processing and awareness, and maybe some day, clever treatment.” Diane Jacobs

“Pathokinesiology: Faulty movement patterns result from some process or problem going on within the organism, perhaps within its nervous system. Find out what the problem is, address the problem (which is usually only pain, but could be something else actually pathological), then watch to see if the faulty movement pattern disappears. Use movement output as a clue, a symptom only. Always see deeper than the surface.” Diane Jacobs

“Kinesiopathology: The movement patterns themselves are the bad guys, to be corrected. If you move badly for long enough, you’ll end up in pain, because.. muscle. Sarcomeres. Or something. Something to do with tissue. You the patient are the bad guy because of moving badly. You’re ruining your body. Your pain is your own fault. Move differently and it will go away. Plus you won’t destroy your body. Plus I can bill for treating a condition (a noun) instead of for interacting with a patient (a verb).” Diane Jacobs

“I’ve heard the best posture is the next posture – motion being lotion, etc…  I think rounded shoulders, etc. DO cause pain, but only in the mirror neurons of therapists, probably, whose belief systems were torqued into believing such a story by their “education” (yeah, that included me too until I learned better stuff and was able to deploy extinction learning).  Can you spell “heuristic”?” Diane Jacobs

“Most of manual therapy defines itself, indeed many of the manual therapy professions define themselves, by the nouns/names stemming from pareidolically perceived patterns. “ Diane Jacobs

“The days of “motor control” are over – it was a useless pursuit – finally evidence emerged showing that bottom-up approaches to changing movement, hoping that changing movement would fix things like “pain” didn’t work. Along with the evidence came the realization that the biomechanical/structural/postural model of everything PT had no validity. (Of course, a lot of people in the profession put their fingers in their ears and hands over their eyes, in response.. )

To me, this is just more bottom-up nonsense. I’m plenty tired of our profession trying so hard to continually emphasize “Physical” (by which it means everything mesodermally derived), and refusing to grasp the meaning of the word “Therapy” or do anything to develop itself/its members toward becoming better at fathoming relationships between nervous system, pain, outputs by brain, physiology, state of mind.” Diane Jacobs

“Let’s face it. Moseley is a PT rockstar. He has done more to move PT along toward taking on and dealing directly with pain science than any other PT in our profession’s history. I mean, there are many distinguished PTs in pain research, but somehow this goofy self-deprecating Aussie with a lopsided grin, many droll stories about pain, knack for telling them, and a canny way of inserting them into presentations to serve as teaching tools, has charmed the profession out of the mesodermal coma it was born into – at least it looks like he might have.” Diane Jacobs

“Here is the thing: a therapist with no awareness of/ interest in/or desire to learn about all things brain and nervous system, has only one eye that has to see two things, at the same time, at different focal lengths; 1. a patient, and 2. the body attached to them, full of all sorts of lurking orthopaedic ailments. Now, *that’s* dualism, right there.. You can treat people that way, but it’s really clunky. Really. Clunky. And often very noceboic.

After one has developed a working knowledge of the afferent nervous system (not just the motor output system), and what the brain does with afferent input, it’s like suddenly you have gained TWO eyes, binocular vision, stereoscopic vision. The best part is, you no longer have to drag fresh patients through that ghastly noceboic morass of all All Things Ortho That Are Wrong With Them, Completely Speculative, Based Entirely On Pain Presentation or Provocation Testing, Bad-looking Biomechanics, etc. Instead, you can explain pain to them, treat them kindly, wait and see.” Diane Jacobs

“Dear Biomedical Model of Pain, We’ve had a long marriage, you and I, about a hundred years… I should “never” have waited this long to broach the topic, but here’s the thing: I want a divorce.  I’ve fallen in love with somebody else who is way more compatible with what I am, and what I do – the BioPsychoSocial model of pain, who I want to be completely devoted to from now on. Can we please get on with our separation, so that I can be free? Thank you for whatever we managed to accomplish together, but now that’s all in the past. I hope we can remain friends,” Diane Jacobs

“There is nothing a cold slimy prickling ultrasound wand can do that a pair of warm hands can’t do way better.” Diane Jacobs

“Seems to me not much exists in treatment-land about what is what or which is which. Blurry. Seems to me everything we do is pretty much based on somebody’s ‘model’ (i.e. ‘opinion’) as opposed to good theories. Can a model, even a good model, ever supplant a good theory? Or will it default to becoming Cartesian yet again?” Diane Jacobs

“Most treatment models are incomplete, focus on one system or a few at the expense of all the others, or give one system (or a few) clear precedence as being causal. But of what?

Example: Orthopaedic thinking, chiropractic thinking: Same in that they view bone/joint position as central to the model of dysfunction. The treatment models involve trying to push bones and joints around. Example: Rolfer thinking, Myofascial Release thinking: Same in that the focus is on connective tissue. The treatment models involve trying to push the fascia around. Example: Massage thinking, Neuromuscular thinking: Same in that the focus is on muscle and its output function. Treatment models consist of trying to stretch/strengthen/alter muscle function and/or posture somehow.

I submit that all these approaches are Cartesian. To be fair, they helped us all get through the twentieth century before much was being learned about the brain, I’ll give them that .. but are they past their due date? ALL of these approaches have to be applied through skin, if hands-on, and/or through the sensory system/cognitive system somehow if they are strictly educative. Therefore I submit that the sensory nervous system must be understood and placed into context first, prior to use of any “model”, as a tool with which to understand and account for “theory”, in this case “neuromatrix theory.”

Further I submit that any claims of efficacy of said models that flow from the assumption that actual tissue has been changed somehow, with no accounting for the simple fact that it is likely the brain that instead has decided to change its outflow, is to not be very adept at using Occam’s razor yet. Using Occam’s razor, in fact, is something the treatment community knows next to nothing about. I can say this because I am a member of it.” Diane Jacobs

“After a brief nervous system explanation, it’s a lot easier to explain effects that are “placeboic” in a way such that people will be more inclined to think of “placebo” in a positive light rather than negative – at least they catch a glimpse that it will be good for pain, that you don’t think it’s undesirable, that you want to help them make their very own, and begin to see achieving it as a victory not a defeat. It must be reframed/ redefined as a treatment effect that is desirable and unique to them, something that is produced naturally as a consequence when a “team” (comprised of patient and therapist) develops a temporary third entity (the interaction of nervous systems) to help a fourth entity (the patient’s own nervous system) wrestle with and overcome a fifth, the “foe” (pain output).” Diane Jacobs

“Both dry needling and acupuncture involve turning people into pin cushions, as far as I know..” Diane Jacobs

“Most human commerce involves a contract agreement to solve a problem. A problem can be an actual object, or it can be an objectification* of a situation. Hairdressers cut hair. Dentists work on teeth. Real estate agents help somebody sell a home or buy one. Surgeons remove diseased appendices. Pedicurists trim and remove toenails. Lawyers argue cases. Some actual object, or objectification of more nebulous subjective situations, plus the objective of resolving a defined problem, are involved. The definition of the object or objectification is made clear, and parties who have contracted to solve the problem, work together to solve it. In manual therapy the objective usually involves helping a fellow human with a pain problem, but pain is a nebulous entity, therefore the actual object in the contract is not and never has been crystal clear.

Pain, although ubiquitous, is a subjective state and has never been precisely defined. Great strides have been made in the last few decades, however: once thought to be a specific sense or input to the brain from the body, pain is now regarded as an output from the brain to its own conscious awareness in response to a perceived threat.*** It is important to bear in mind that manual therapies evolved under the influence of the now-eclipsed former model of pain, and its models are still burdened by this limited understanding.

Manual therapy resorted to objectification and reification of treatment ideas the whole way along. Our fore bearers spotted patterns of behaviour or dysfunction in patients and assigned names to them. Patterns that appear and seem real enough to be given a name (objectified, reified) are termed “pariedolia”.” Diane Jacobs 

“Besides, people live with all sorts of tissue stuff they never ever knew they had. When it comes to pain, correlation definitely does NOT equal causation. So let’s not focus on tissue so much. It’s like developing (cognitive) depth perception, finally, later in life, seeing depth and space in the world; it turns one’s professional role from moving flat cardboard cutout images around, into real interaction, real therapy. Dualism is replaced by (cognitive) binocular vision. Two cognitive “eyes” working together from two slightly different perspectives, does NOT equal “dualism”. It equals depth perception. When you teach binocular vision, this way of appreciating their brain, to patients, stress goes down and they stop being so bothered, worrying that they are going to fall apart.”  Diane Jacobs

“A long time ago, shortly after I moved online and joined discussion groups (way back in 2001), I encountered Barrett Dorko, who was the first PT I had ever met who differentiated between what he called deep models of manual therapy versus shallow models. It made sense to me. Deep models seem to line up well with knowledge of science in general, understanding of neuroscience in particular, and logical deconstruction of the pretence that we, manual therapists, can actually have any direct physical impact on somebody else’s (i.e., a patient’s) tissues that would result in a therapeutic outcome.

I could relate. In my mind, deep models equate with what I call “ectodermal” models – “interactor” models. It’s where I’ve always wanted to see PT go – more emphasis on “therapy” – less on “physical”. Shallow models line up with everything I detested (and still detest) about manual therapy – a tissue is chosen as a target, then an entire world-view built around it, including a whole set of ritual interventions directed toward said tissue target.” Diane Jacobs

“It seems most everyone in the orthopaedic branch of my profession is overly focused on mesoderm of one kind or another as if it had control of its own behavior, ignoring the nervous system as simple background noise. I thought this attitude was chiro driven, a memeplex to which PT had fallen prey, but I don’t think so anymore – I think it’s just naivité/simplistic thinking all round, like drawings of five year old children conforming to a predictable style. Ortho PT bases itself on what it has learned from its roots, the century-ago thinking of army gym trainers, masseuses, and orthopaedic doctors. (Who knows where chiro got its memes from?)

When the nervous system is considered at all in orthopaedic thinking, it seems to me it’s only ever in terms of its output, and then only into muscles, that which can be “controlled” through acts of strengthening or will, i.e., “neuromuscular.” There is rarely any work done or books written about the other side of the coin, sensory input, or what can happen to actual sensory fibres of nerves, physically, except for Shacklock and Butler. No one ever considers skin, how innervated it is, how sympathetically driven it is, how kinesthetically sensitive all the various levels of brain function are, how completely obedient the various levels of output (including pain output, motor output) are to miniscule amounts of sensory input, how the brain immediately engages with it, interprets it, expresses new output as a result. An understanding of sensory input into an intact NS from another nervous system could make our lives as PTs/professional human primate social groomers way easier and less cumbersome, and abolish a whole lot of excessive trappings/techniques/treatments. Something huge is missing!” Diane Jacobs

“In my opinion, the problem stems back to language, and particularly to the human brain’s difficulty with recognizing that as soon as nouns are applied to treatment, the life gets sucked out of treatment as encounter between two human beings. Life is sucked out of the verb of the encounter, out of the encounter as verb. As process. As something that has a beginning, and a middle, and an end. Like a story. Like a story built by two people, interacting, not by one person who thinks they know everything about everything and treats the other like an object.” Diane Jacobs

“The social end is where all manual therapy starts. It’s interactive, not operational, no matter HOW resistant manual therapists might be to that idea. We are not treating stretchy corpses, we are not treating tissues, we are treating people who have pain. We are treating brains in pain. We are treating nervous systems in pain, nervous systems that span the entire distance, both physically and conceptually, between skin cell and sense of self.” Diane Jacobs

“Skin (dermis and hypodermis layers, not epi) has plenty of sensitive interoception. Given that the blubber layer is plenty thick already, and its interoception can pick up on external forces applied from the outside, and decode them just fine, I see no great value in trying to dig through it. Nerves can be moved just fine without heavyhandedness, in most cases. And I should think it’s important to not (adversely) affect vasculature, i.e., veterbral arteries, etc. I’m sticking with the skin layer for most of my patients” Diane Jacobs

“A neurotag is a “pattern of neuron activation which creates a certain output of the brain, such as a perception, thought, movement or immune system response.”” Diane Jacobs

“Construction of a neurotag is perfectly normal brain behaviour. It’s not about your brain being defiant or evil or mean to you. It’s how brains remember what they have learned – they build associations. Synapses are involved. Enhanced signalling is involved. Glia are involved, along with 250,000,000 synaptic proteins that turn over every few days (4). Imagine that. When I think of a pain neurotag, I think of a cobweb gathering dust.” Diane Jacobs

“The thing is, the issue is WAY bigger than just digging a new trench for a particular profession (my own) to inhabit. It’s about making choices that help the human condition itself. It’s about helping each other learn and understand and overcome dualistic thinking rather than comfortably engaging and reinforcing it in ourselves and others. We’re in a position to be able to educate. Why don’t we get busy doing exactly that? I think this whole pathokinesiology business is utterly retrograde, and will help keep us all ignorant. And worse, our patients. Unconscionable actually.” Diane Jacobs

“Whether you think you are or not, if you are applying manual therapy, you are touching skin long before you are pushing into a joint. I don’t know how you could eliminate this as a confound.” Diane Jacobs

“the outside of the body has the densest array of communicatory neurons in the entire body, why not stay outside? The interoceptive neurons? a lot of them are classified as silent “nociceptors”. If that is what they are, I don’t really WANT to bother any of them.”  Diane Jacobs

“Mostly though, I like accessing peoples’ brains through their skin. I like remembering that somatosensory fibres are so long, and so accessible, all the way out to skin, that there are only six cells between my brain and the consciously aware brain of somebody I’m treating. Three on their side and three on mine.” Diane Jacobs

“Pain is an output, just like movement is an output. Brains practice and practice until their predictive ability matches what they produce as output. This occurs once surrounding inhibition produces accuracy, precision. After that, the brain has “got it.” It has a sturdy neurotag built. Norman Doidge called pain “the dark side of neuroplasticity.” Diane Jacobs

“If all goes well you will grow up into an adult with a nervous system in good shape, able to do what it needs to do from a bank of successfully mounted resolutions to physically and emotionally generated experiences and challenges.

As long as you have genes that can make all the necessary proteins, your nervous system should be able to get itself out of pain. Sometimes it might need a bit of help, from the culture, just to get it started, but after that, it should be good to go.

Philosophically speaking, it will never be able to be “the way it was before the thing happened”, but it should be able to get back to coping easily with struggles and strains without hurting you in the process.” Diane Jacobs

“I count myself among this slowly growing cadre of PTs who are laying aside our old tissue-based belief system based on 3 or 400 years of ignorance about pain, in favor of instead understanding the science that has developed around pain. Patrick Wall said (paraphrased), “Placebo is not something administered TO a patient, it is something to be elicited FROM a patient.” He went on to describe the perfection of a placebo response. It was something the patient’s brain made by itself, a chemical substance, antidote, precise in dosage and specific to the problem, which went straight to the receptors in need of it. It was allowed to exist in the brain for only as long as necessary, whereupon the brain would dismantle it by itself. In other words, one sort of nature (placebo response) taking care of another kind of nature (pain response).” Diane Jacobs

“Let me be clear – manual therapy is optional. The aspects of treatment before and after manual “treatment” will work by themselves, a lot of the time. But manual therapy sandwiched in there can be optimal, in my opinion. Whether it is optimal will depend entirely on how we explain what it’s “for” – we need to improve the language around manual therapy!” Diane Jacobs

“Stress is involved in “learning” – the right amount of glucocorticoids will facilitate learning. Too much will be harmful. “Pain” is “learned” at a synaptic level. “Pain” is reinforced through social stress, be it real or just perceived. (Which means, for us independent human primate social groomers, we can give ourselves some leeway – there are some pain mountains out there that we just aren’t going to be able to climb. We can’t fix some of our patients’ broken lives. Furthermore, some people’s pain, even though it may be biopsychosocial, may have abnormal “bio.”)” Diane Jacobs

“First of all, PT “science” should align itself with and adhere to basic science 101 tenets. It shouldn’t make up things for the sake of convenience, such as correlation in any way equaling causal relation. Yet in a PT textbook, apparently, there is being taught some mechanism for doing this very thing. Very pseudo-scientific” Diane Jacobs

“Second, it should assume nothing, and operate according to the essential scientific principle that all hypotheses are there to be knocked over. (I.e., no one should take issue with others if their much beloved “hypothesis” and treatment construct curves around and smacks them in the back of their own head one day.)

Third, in the clinic we can literally BE scientific. E.g, an hypothesis exists that “pain comes from joints”. No one seems to have tried to take that one down yet. Well, except for me and a handful of others perhaps. An easy way to take that one down, to disprove it, to thereby either improve or even disprove the “construct validity” of the “hypothesis”, and by extension all treatments based on that hypothesis, would be to design a system that does not involve treating joints in any way. (One like mine, just as an example.)” Diane Jacobs

“To me, as a clinical scientist, this suggests that I managed, and am still managing, to disprove the hypothesis that “pain comes from joints”, n=1, one at a time, one after another on through time. Not only that, but when pain truly does come from a joint, as in the case of a woman I treated who had a stress fracture of the hip, it is easy to know that in fact the hip joint is involved when the parameters of the method are followed, and the patient responds outside the normal cluster of responses, i.e., does not respond, period, i.e., still can’t weight bear without crutches.

After three attempts, time to send her back to the MD, even though the first x-ray prior to her ever seeing me was negative (i.e., they missed the fracture first time round). She in fact needed a pin. She came once more post op to mop up more pain she had from the whole traumatic process of the hip pinning. Once. Fine after that. I think this process is what is involved in being a good responsible clinician with a grasp of basic science principles and a desire to get past all the clutter our profession saddles us with. Occam’s chainsaw. Everyone can learn to use it.” Diane Jacobs

“In a pain state, it’s just as if someone took ordinary life and turned it upward at a steep angle, with less oxygen available. Thank you for the great analogy Kevin McHenry – good example of something called “graded exposure” – going along toward a goal, but in slow enough and small enough stages that there is no overshoot, no physiological payback, no fall into defeat.

By climbing that mountain slowly, Viesters’ physiology was able to adapt. He was able to build hemoglobin levels that could cope with the altitude and decreased air pressure. His heart had time to “try out” and “learn” new strategies to maintain his blood pressure within normal range. In short, he gave himself time to adapt. He gave his physiology time to learn how to maintain homeostasis in the face of increased allostatic load from the environment.

Graded exposure is a cognitive behavioral therapy tool used by psychologists to help people overcome phobias. For example, let’s consider people afraid of spiders, to the point where ordinary life becomes absolutely narrowed and imprisoned by fear. A patient wants to overcome the fear, which is step one. It has to be, obviously. The patient is so uncomfortable and trapped by this fear that they don’t have much of a life. “ Diane Jacobs

“My attempt to help my friend reminded me of why I was so interested a few years ago in helping set up a pain physiotherapy special interest group/CPA division in Canada. At the time I thought being able to present a new official category would gradually replace the one listed as “complementary”, odious to many because it can mean non-orthopaedic hands-on techniques that include all sorts of anti- and pseudo-scientific hands-on theoretical constructs.

Aha, I thought at the time. All these practitioners really need is access to updated pain science and neuroscience, and all will be well in PT land. The practitioners needn’t necessarily change what they physically do with their hands, or how well they relate to their patients, but their thinking and understanding will take a big leap forward, and the sort of conversations they have and meanings they convey to their patients will become congruent with all that has been learned in the last decade or two. Eventually PT would be able to drop that compromising, dubious and embarrassing, even, “complementary” category in favor of the much preferable (to my mind, anyway..)”pain sciences” category. “  Diane Jacobs