A compilation of info, as we know it, about this virus. Sources listed below.
R0 = 2-3
The “R-naught” is description of how spreadable a disease is; how virulent. For example, typical influenza has an R0 of just over 1, meaning that the disease spreads at a one-to-one rate. COVID 19’s R0 is between 2-3. This means that one person can spread to 2-3 people; who then can spread to 2-3 — effectively resulting in 9 people infected. This is the ‘exponential’ aspect of COVID that’s so different from other viruses.
We’re all aware that’s the distance we need to stand to create ‘social distancing.’ That’s because we distribute aerosols by breathing/speaking normally. There’s still clarity needed about how much viral load typical aerosols carry (and therefore the risk of exposure). We do know that droplets carry enough viral load to be a risk. Droplets exist the lungs with more vigorous breathing, such as singing, shouting, panting during heavy exercise, and certainly with coughing and sneezing. Covering our mouths becomes a simple strategy.
The estimate of how long droplets stay in the air before landing on a surface. This measurement assumes still air flow and enclosed spaces. We don’t have clarity about how those factors may reduce the time line.
General agreement of how long this relatively fragile virus can remain on surfaces (between hosts). By comparison, the super-hearty tuberculosis virus can last up to 6 months on surfaces as long as it’s not exposed to sunlight. (That’s why in early days of TB, people were gathered in treatment centers called ‘solariums.’)
2+ / 5 / 11.5 / 14 days
Incubation period between exposure and infection — realizing that some people show few or now symptoms. Two-plus days is a figure from very recent studies in China. Five days is the more agreed upon figure of median incubation period, meaning how long it takes for most people who get the disease. By eleven and a half days after exposure, most people show symptoms (99+%). Fourteen days is the conservative, public health margin for all of us to keep to in case of exposure.
Day 1 = onset of symptoms
With the onset of symptoms, another clock begins. This one is important, because we’re learning that people are most infectious at the beginning of symptoms. While some pre-symptomatic contagion has been shown, later studies have shown that this pre-sypmtomatic window is less risky than first thought. What remains is that some people can be ‘silent spreaders’ — spreading the disease unknowingly — because their own symptoms are so mild. Why social distancing is a dance for all of us!
General span of time from infection to ‘shedding’ the virus — to being through the tunnel. People are developing antibodies — hooray! This is important for three reasons:
• There’s a high likelihood that people will have extended immunity, and so can come back into the work force, potentially in higher risk situations (volunteering, drivers, check out clerks, etc.), and
• Scientists are hot on the trail of vaccines, since this virus appears to be one that mutates slowly. We can be better prepared and protected the next time it comes around, and
• More immediately, clinicians are using antibodies donated from those who have shed the virus as a treatment: injecting antibody rich plasma into severely ill patients giving their immune systems a boost.
This situation keeps unfolding. Do want you need to do to take care of yourself, including the simple precautions of hand washing, social distancing, don’t touch your face. And all the things you know to do to take positive care: sleep, nutrition, exercise, heart connections with beauty and nature.
With the current spaciousness in my schedule, I decided to do something I’ve been wanting to do for years: learn more about the carpal bones! For years, knowing the tarsals has helped my work be more precise and effective. I’m excited to see where this takes me with clients.
How I learned:
Richard has been an obliging client, who conveniently (for me!) has a minor wrist injury from more gardening than usual. Slow, methodical palpation while looking at our plastic forearm model was super helpful. Usually, with clients I feel obliged to stay focused on their treatment. Knowing I could take my time palpating and noodling around was such a treat. I had time to allow my fingers and my mental anatomy atlas meet each other. Then there’s the coloring, mnemonics and some youtube viewing — see links below. Here are some details and insights from my study.
Most mammals have the same number of bones in their appendages, and the upper and lower appendages mirror each other. Distal to the ball-and-socket joint at the girdle, each appendage has:
• one long bone (humerus/femur), followed by a
• two slender bones (radius-ulna/tibia-fibula), followed by
• a cluster of small, rounded bones (carpals/tarsals), then
• five shorter ‘long’ bones (metacarpals/metatarsals – “meta” means after or beyond), and lastly,
• a series of phalanges (fingers/toes).
Like the tarsals, the carpal bones arrange themselves in 2 ways: horizontally across the wrist in two rows, and vertically (roughly) in 2 clusters, relating to either the radius or ulna. In the foot, those separations coordinate with the medial and lateral arches; they relate to the thenar and hypo thenar pads in the hand.
There are 8 carpal bones, here listed in their horizontal row (with the forearm bone or metacarpal noted):
• lunate (ulna); beyond that the triquetrum, pisiform (5th MC), hamate (4th MC)
• scaphoid (radius); beyond that the capitate (3rd MC), trapezoid (2nd MC), trapezium (1st MC)
The joints include elliptical joints between the forearm and first row of carpals (wrist flexion/extension), and sliding joints (among each each and with the metacarpals). Our one and only, world famous saddle joint of the thumb — between the trapezium and the 1st metacarpal — is the one that makes human hand capacity so unique!
Starting from the ulnar side, when I palpate my own wrist on the anterior side I notice:
• A little gap between the end of the ulna and the lunate holds a disc to cushion strong impacts.
• Just distal to that gap, is the prominent pisiform, at the ‘heel’ of the hand.
• Rounding around the pisiform toward the midline of the wrist, you’ll feel another clear edge. That’s the “hook” of the hamate — really that’s its name. Ligaments that create the carpal tunnel attach to this hook.
• The capitate and trapezoid are easiest to feel posteriorly, same with scaphoid.
• Once you’re on the radial side, the trapezium has a projection, but it’s called a ‘tubercle’ — a distinct edge when you roll toward midline.
• The scaphoid also has a small tubercle. The two tubercles are the attachment sites for the other end of the ligaments that form the carpal tunnel.
Palpation = Treatment
Gliding these bones between themselves feels really good!
With the client’s palm facing me, I take my thumb on one side, and index and middle fingers on the back of the wrist. I locate a single carpal bone — for example, one on the hamate, one on the capitate. Using an anatomy image is helpful with this level of detail.
Then glide them gently in opposite directions. When you feel a motion barrier, gently meet it and then sustain your engagement. Give the joint time to respond and release. Remember that the overall range of most of these joints is quite small. Don’t look for large movements, just little bits of sliding past each other.
Anchoring the information — whatever helps!
Youtube links that might be fun:
• Ninja Nerd Science: short discussion of hand anatomy; this guy’s great!
• Armando Hasudungan: cartoon drawn discussion of wrist and hand
• Physiotherapy is Rehabulous: online lecture with charts and diagrams
Mnemonics — with the capital letter of each word/bone matching.
• Some Lovers Try Positions That They Can’t Handle
Scaphoid — Lunate — Triquetrum — Pisiform — Trapezium — Trapezoid — Capitate — Hamate
• Never Lower Tilly’s Pants, Grandmother Might Come Home
Navicular (old name for scaphoid) — Lunate — Triquetrum — Pisiform, — Greater multiform (old name trapezium) — Multiform (old name trapezoid) — Capitate — Hamate
From the Anatomy Coloring Book and Netter’s Anatomy Coloring Book. (If you’d like some pdf’s of these pages, let me know.)
Likely you’ve come across this story. These days, it’s been on my mind as I meet the unknowns of the disruption of COVID-19.
The Two Wolves
An old Cherokee was teaching his grandchildren about life. He said, “A battle is raging inside me…it is a terrible fight between two wolves. One wolf represents fear, anger, envy, sorrow, regret, greed, arrogance, self-pity, guilt, resentment, inferiority, lies, false pride, superiority and ego. The other stands for joy, peace, love, hope, sharing, serenity, humility, kindness, benevolence, friendship, empathy, generosity, truth, compassion and faith.
The old man looked at the children with a firm stare. “This same fight is going on inside every other person, too.”
They thought about it for a minute, and then one child asked his grandfather, “Which wolf will win?”
The old Cherokee replied, “The one you feed.” — from “Transforming Lives Through Resilience Education”
As the waves of fear, worry, confusion or denial have risen in me, I’ve relied on my connection with my body and with spirit to breathe through those moments. Walking, breathing, feeling my body’s strength, sleeping when tired, eating when hungry. The unstructured time has allowed me to reconnect with my body in a deep way, resourcing myself. As Mary Oliver writes, “You only have to let the soft animal of your body love what it loves.”
I’m so grateful for my years as a manual therapist. I’ve learned how this wonderful body coordinates health, how to ground into my immediate physical experience, how to understand stress signals as signs of a body getting ready to meet the challenge — a body attuned to health. All of this helps me meet the various unknowns of this pandemic. Most of the time.
At other times, my fear rises so quickly that it’s like running after a wagon broken free. My sense of self is just behind my body, heart and mouth — panicked– careening down a steep bumpy hill. All spikey adrenaline and grasping. These moments call for a different kind of center, an ‘after the fact’ kind of center. Can I embrace myself and acknowledge that I’m doing my best, even as I flail about – even hurting those nearby? It’s times like these that I sense the deeper wisdom in this story: yes, we grow the parts of us we feed. And sometimes, we need to feed fiercely.
That’s why I love this picture — the fierceness reminds me that the fight is worth it, I’m worth it. Together, we can protect what is most important to us. We can orient our choices and commitments to deepen a sense of connection, health and justice. This is a terrible time, a trying time — and perhaps one where we can come out the other side more connected, more centered. We’re all in it together.
Thanks to Bonnie Wong, DO who sent out this simple graph. I’ve referred to it more than once in the last month, much to my relief. It’s also helped with clients who aren’t sure what’s happening for them. While we’re not doctors (nor can we diagnose — especially these days), we can help people clarify what they are experiencing and what to do next.
What to do next
The first step: if you’re not feeling well, stay home! Rest, recuperate and keep potential germs localized by washing hands, not touching your face…You know the drill.
Next step: if your symptoms worsen (or your anxiety spikes), contact your primary care provider. Review your symptoms with them. If you don’t have an established PCP, contact your insurance carrier. The number is on the back of your card. By this point, most carriers have established tele-health options, so they will connect you with a nurse or doctor who can screen your condition.
Next step: Along with any instructions they give you, remember to take care of yourself. Sleep, diet, movement, and tending your heart and mind. All of these can support your body as it meets whatever condition you have.
Do the Five
The World Health Organization has a simple campaign to help stop the spread of COVID-19 (and many other diseases): Do the Five! I imagine you’ve seen the PSA icon on Google:
1 Hands — wash them often
2 Elbow — cough into it
3 Face — don’t touch it
4 Space — keep safe distance
5 Home — stay if you can
I love the simplicity.
Practicing the Five
Here’s what I’m learning as I practice these 5 steps.
• Changing habits is as difficult as ever, and once I’ve washed my hands multiple times a day, I absolutely need to put lotion on them! Protecting the skin envelope feels important just now.
• Since I’m coughing into my elbow, I’m not so keen on elbow bumping as a greeting. Instead, I’ve been toe tapping or hip bumping, even back wiggling–but only with close friends!
• My left brain says I’m probably not touching my face any more than usual, but wow! I had no idea how often I do in fact touch my “T-zone”: eyes, nose, mouth. So, I’m contenting myself to touch under chin, side of my head. For expert inspiration on this, I’ve been re-watching RuPaul’s Drag Race! Learning to vogue in my spare time. ;-p
• Keeping safe distance on the whole hasn’t felt like such a change in some ways. As an introvert, it feels like society has taken a big shift toward my way of being. (Odd though.) My extrovert family and friends are going stir crazy, desperate for activity and interchange. Where I do feel this change keenly: no hugs or touching, no clients. It’s so strange to be someone who touches for a living, and then have that suspended.
• Home stay has been such a gift, not the least because we are lucky to have a home that suits us — a blessing in so many ways! Richard has been tending the garden as spring begins to really present itself; he’s been cleaning and fixing and puttering. I’ve been doing projects too: tidying, purging, spring cleaning comes early!
And Another Five
Steps to help us when anxiety or fear arises:
- Look around you.
- Find five things you can see,
- four things you can touch,
- three things you can hear,
- two things you can smell, and
- one thing you can taste.
Such a simple exercise — but what a wonderful way of coming into the present moment, with all our senses. The only thing I might add is to take a breath for each one of these senses. With this, we’re able to move from a thought-based orientation to a body-based orientation. Staying in the present moment and connected to our environment is a simple first step.
Take good care of yourself — with one 5 and another!
Managing our practice right now is an unfolding process. How do we coordinate our efforts with others in the profession when most of the time we’re working one-on-one with clients? How do we consider the risks and benefits of our actions during this time? For ourselves, our clients, and on behalf of the larger circles we live within, from neighborhood to herd?
To close or not to close?
We’ve employed a mixed ‘strategy’ of having clients cancel as each appointment nears and of canceling sessions ourselves. We’ve been taking it a few days at a time, rather than making a bolder decision to close outright for several weeks to a month. For our circumstance, that’s been workable. I also know of practitioners who have decided to simplify the process by closing for an extended time. Either way works.
It’s most important to understand that this is all of us exercising our boundaries. Our work is best offered and received within a mutually safe relationship. In this we’re a bit different from some HCPs; we have an unusual degree on interface — physical, temporal and emotional — with our clients. So it has to feel right for all involved.
Opening up again: when and how?
I think this will be an interesting and possibly more complex set of decisions. Here’s how I’m thinking about it at this point:
• Making myself available to those whose need is great
Next week, I’m going to see people who are in high need. As alternative health care providers, we can remain open. Whether people’s concerns are long standing or reflect their experience during C-19 time, our work can help: decreasing aches/pains, increasing relaxation and sense of well being, and supporting the immune and autonomic nervous systems. Offering our clients a sense of well being while supporting their health through touch is the heart of what we do.
• Being more vigilant about the practice space
Wiping down surfaces, washing sheets with hottest water, wearing masks if we have any concerns about our health or theirs. (Given the shortage of surgical masks, this week, the CDC has expanded its recommendation to include cloth/homemade masks.)
• I’m getting better at not touching my face
But that has been a hard one for me! So I continue to adjust my habits. I’m sitting on my hands while listening, instead of putting my hand under my chin or touching my closed mouth.
• I’m getting clearer with clients about my needs (though by this point, most people are on board): “If you’re sick, at all, please stay home. Let’s reschedule.”
• Seeing fewer clients in a day than I was before
Touching people in distress, anxiety and fear takes a toll on us. During this time when anxiety is raised, it’s especially important for us to take care of ourselves — even more than usual. Walks, breaks, play, time off, nutrition, sleep, whatever helps you stay balanced and healthy: please do it, and do it some more!
That’s it for now. In a few weeks, we’ll all know more. Take care til then!
Here we are in the land of COVID-19 — such an unusual time! As the onset of social distancing settled, I began taking notes about any number of topics. My aim to begin blogging again, to help clarify my thinking, to share discoveries and insights and to give myself another creative outlet while my usual ones (practice and teaching) are on hold.
Early on, I realized how often in the past several years I’ve complained of not having enough time, spacious time, for all sorts of projects and play time. And here, now I have the time. One such project: a stack of National Geographic, gathered over 8 years time — kept for collaging and such a fun source of wonder and world events. Here’s a fun image that made me chuckle.
What to do with mouth and nose covered? We’ve got eyes and ears!
I love the waiting in this image, the bulk of the hippo under the still, clear surface. It reminds me of times taking baths as a child, submerged and warm, staying in the water til my fingertips wrinkled. As a child, the bath was one of the quiet places, private places that I enjoyed separate from my siblings. And now, I’m doing this work with the body that is so oriented to water imagery, the fluid body and its patterns. Taking baths is one way that I’m staying connected to body, to the fluids and to stillness — as well as the child-like freshness of discovery that comes with healing.
We’re getting ready to travel to Breitenbush Hotsprings for the Pacific Northwest Massage Practitioner’s Retreat on July 13-16, 2018 in Detroit, OR. We’ll be presenting gentle and effective ways to balance the “lozenge” in our torso (a.k.a. the ‘core’) using Myofascial Balancing assessment and manual techniques. The retreat is superbly organized and hosted by Brian Utting’s Pacific Northwest School: http://pnwschool.com/BreitenbushRetreat
Then later in July, we fly east to Walpole, ME to participate in Tom Myers’ Summer Advanced Training series. We’ll be offering Balancing the Face for Structural Integration on July 28-30. This 3-day class focuses on bringing freedom of movement and alignment to the facial bones (including intranasal work), tongue, deep layers of the neck and cranial base and membranes. We’re already seeing registration from the U.S. and several other countries, with many different modalities represented — it’s sure to be a great conversation. Here’s more information:
Hope to see you in either locale!
This spring, I decided to take a series of craniosacral classes taught by my favorite teacher, Lauren Christman. It’s her first time around running a program like this—but, of course, she’s highly experienced in this modality, in teaching, and in curriculum design. I’ve already learned a lot…
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