At Last a Breakthrough!!

[Jason Silvernail]

Well, I just had my first patient where I got her to access ideomotor motion and was improved during the treatment. I thought everyone here should know.

Case:
44 y.o female office worker with recurrent neck and trapezius area pain x3-4 years. Several MVCs in the past as well. No radiation or N&T, rare occipital HA. PMHx for glaucoma only. Not helped by NSAIDs and rest. Had 4 visits of chiropractic with manipulation and modalities without relief. Concerned about some "bone spurs my doctor says may have to get scraped out."
Imaging: moderate global cervical spondylosis with some DDD at C5/6. Also has calcification of the ALL at C5/6.

Exam:
Fwd shoulders Bilat, no significant forward head
AROM limited by pain, ROM 35 Flex, 40 Ext, 30 B sidebend, 60 RRot, 55 LRot
Neg Distraction, Neg compression, NL ULNT Median 1 Bilat without symptoms
BUE MMT 5/5; very poor deep neck flexor activation, very shallow breathing
manual exam: TTP without active TrPs in periscapular area, Tx hypomobility with pain, Cx hypomobility globally.

Treatment:
Tried my standard: Cx mobilizations, some MET, DNF activation exercises, pain education and relaxation techniques.
No change in ROM or pain levels. Does not tolerate positioning or setup for thoracic manipulation, so skipped that.
We talked about relaxation, practiced deep breathing, and talked about ideomotor movement for pain relief.
I also de-mystified her imaging findings (ignore them, they're unrelated to pain) as I spend all day doing with most spine patients.
All this is pretty standard for me when treating a patient who presents this way.

While talking, I realized my next patient had no-showed, and I had some extra time. I stood behind while she was seated, lightly palpated her temples and spoke about characteristics of correction. Almost immediately, her head began to rotate toward the left, and I followed. She did several repetitions of flexion and roation on her own, and I just followed. After a few minutes, her flexion had improved to 50 degrees, L rotation 60, and R rotation 85!
Left with a smile and much better motion.

Based on previous data about manual therapy, I can expect a good between-session improvement if there has been an intrasession improvement (Tuttle 2005). I look forward to seeing her again in a few weeks (her travel requirements).

I don't want to get too excited, but I'm happy it finally has happened, at least only once. I completely see also what Barrett means about "doing nothing".
Feedback... ???

J

[ian s]

Jason ,

I think you set the 'scene ' for success and had time to facilitate change?
Her arousal level was significantly reduced maybe by the cognitive info( I agree totally that demistifying biomedical information should be mandatory!),maybe by your interaction and maybe by a shift via the breathing ...usually it takes this varied package ?
I don't think it is likely that that this kind of work can be done routinely in the standard orthopaedically dominated environment ?
Hopefully this 'success' will cause a domino cns cascade as the threat value to her pain will have reduced significantly . Sometimes this motor pattern may carry on outside the clinic in times of quiet or times just before sleep .This is my own experience having received this kind of treatment myself .
ian

[Barrett Dorko]

Jason,

Welcome back. This sounds like a familiar response though I'm not sure what it means. As always, I proceed with this sort of handling because it offers so much in the way of sense and safety. I don't know whether or not it "works," but it should. Oh yes, if it doesn't, I don't know what else to do.

Now that you've sensed this movement I think you'll find it very easy to continue handling people in this way. In fact, you may be done doing anything at all for the rest of your life. Before you know it you'll be a General. Rim shot!

Did you get a chance to have the patient lie supine? I'm wondering about the resting posture of her hips as reflected in the feet.

[EricM]

Congrats Jason

applause (http://www.sound-effect.com/sounds/human/applause/crowdapplause1.wav)

Eric
:thumbs_up :teeth:

[Jason Silvernail]

Thanks everyone.

Barrett- I actually did not look at that, though you talk about it so often, I feel like a complete fool for not doing so.

I agree with Ian in that typical orthopedic therapy setting (like mine) may not be conducive to this sort of thing, but setting aside time for different patients with different needs is something we already are familiar with, so not sure why this would be different. I do have separate appointments for manual exam and treatment of existing patients, and this may be a way to accomplish some of this.
Once she started moving, I asked myself "how long should I let it go on?".
She appeared to be repeating the same movements, with more motion each time, so I just hung out for a few minutes and let her unwind. JUST KIDDING!

I mean I let her move to reduce her mechanical deformation and improve ease of movement. She was pretty happy afterward, though I'm not sure if it was the relaxation and physiologic quieting, the ideomotor motion, the education, etc, etc. But in any case it seemed to work. :)

J

[Diane]

Congratulations Jason! Careful or you'll end up a neuronut defector. :)

[nari]

Jason,

Welcome to neuronutopathy.

It's a good feeling to "do nothing", and have a measurable outcome, be it subjective or objective or both.

Makes the 'toolbox' theory of practice look rather unnecessary, doesn't it?

The end of Evaluation? Maybe....:)


Nari

[Luke Rickards]

Nice one Jason. It is surprising isn't it?
I'm not sure if it was the relaxation and physiologic quieting, the ideomotor motion, the education, etc, etc.My bet is that is was the ideomotion. I see patients like this everday and without any explanation or education (that comes during or later) they effortlessly, and sometimes instantly, move though the painful range, grow warm, and soften. And I am still amazed every time. I have even found that the breathing pattern usually changes by itself and all I have to do is point out how they are breathing now and to keep it like that.

Luke

[nari]

Luke

I still reckon you have a bit of a knack for eliciting ideomotion - from my personal experience in the Nanaimo class!

Nari

[Diane]

I still reckon you have a bit of a knack for eliciting ideomotion - from my personal experience in the Nanaimo class! Ditto that Nari. Duck to water. Some of the rest of us choke a bit before we learn how to swim. Effortlessness in holding a benign boundary is how I would summarize the attitude required for the event. As a bit of a "fixer" type, myself, I can do it (by doing nothing), but it's quite an internal exercise in restraint.

[mike]

Hi all!
When I read about the movement response that you got during Simple Contact I started to think about the cartoon picture Diane had (the Scientist that seemed to find a simpler explanation (1 +1 = 2)

Can you see a correlation with reflex locomotion?
I have studied this and find it a bit complicated in practise i.e to get the locomotion response. Reflex locomotion is something that has been further developed from prof Vojtas work.
In reflex locomotion you position the pt in different positions (attitudes) and then stimulate different support zones to activate for example the deep stabilization system (transverses abdominis, serratus anterius, diaphragm etc)
For instance one position is in supine (reflex turning, phase 1): head in slight rotation (30 degrees), arms and legs fully relaxed. If the head is rotated to the left, turning towards the right side is activated. Here you can stimulate the nucheal line, mastoid process on the right side (vectors: traction, pressure towards the CC junction), and at the same time stimulate the 5/6/7 intercostals space on the left (vector towards the opposite ASIS). The stimulated zones are so called support zones and are zones that the child use for support to activate different muscle groups. The reaction from this stimulation is turning to the right ( as a baby turning from supine to the side and further to prone). This is automatic, no voluntary control (subconscious) and involve the basic patterns of physiological motor behaviour that is specific to humans.
I have seen the reaction many times during my time studying in Prague. Sometimes the pt is really turning and sometimes you only see the muscle contract (kind of twitching response).

So to my very rash conclusion: could it be that Simple Contact is the scientists 1+1=2?

If you want to read more:

"Importance of Developmental Kinesiology for Manual Medicine


Pavel Kolář, 1996

Dpt. of Rehabilitation, University Hospital Motol, Prague, Czech Republic

(Czech Journal of Rehabilitation and Physical Therapy)



Summary
Developmental kinesiology forms the basis for treatment for children suffering from neurological lesions. The genetically determined constant sensory-motor relations which neurophysiology has not yet clarified come into play during postural ontogenesis. Developmental kinesiology offers a new neurophysiological explanation of postural functions. Understanding the genetically determined functional synergies allows us to apply a new diagnostic and therapeutic approach via acting on peripheral structures to achieve reflex effect.



Key words: developmental kinesiology, postural function, reflex locomotion





Developmental kinesiology is an essential part of physiotherapy for children suffering from any neurological lesion. Most of the neurophysiological techniques used in physiotherapy do not make use of the genetically determined constant sensory-motor relations which come into play during postural ontogenesis.

In physiotherapy motor patterns organized at the spinal or brain stem level are used quite frequently (the deep neck tonic reflexes, vestibular reflexes etc.). These sensory-motor relations are well defined as afferent inputs followed by well known efferent reactions. E.g. it is common knowledge that afferent stimuli at the region of C1-C3 (head rotation) are processed as afferent information at the brain stem level, then evoke the following reactions: on the arm on the side to which the jaw is turned, internal rotation + adduction and protraction at the shoulder, elbow extension + pronation, palmar and ulnar flexion of the hand. Similarly a very well defined reaction can be observed on the arm at the side to which the occiput is turned , on the legs and trunk muscles. Reflexes at the spinal and brain stem level have been well described and made use of both in the diagnosis and therapy. The brain stem is the highest level of reflex organization with experimentally estabilished kinesiological reactions to afferent stimuli.

However it is important for diagnosis and therapy that there are higher levels of the CNS which store motor programs ensuring body posture. These programs are evolved during postural ontogenesis. In these genetically inherited motor programs there is a very well defined relationship between afferent stimuli and efferent reactions, as in programs processed on the spinal and brain stem level. The kinesiological course of their efferent reactions is not yet known or used in diagnosis and therapy. For example chiropractic and osteopathic methods make use of such reflex reactions without knowing their significance.





Postural functions from the sensory-motor point of view


In neurophysiology the kinesiological aspect of postural functions is attributed to unconditioned reflex mechanisms at spinal and brain stem levels. In kinesiology postural functions are usually those of a subject standing erect, and referred to as reflex postural reactions. The reflexes ensuring erect posture are then explained as controlling:

Muscle tonus: (again at spinal and brain stem level of control)
Local static reactions: „Standing reactions“ controlled at spinal level: tactile and the proprioceptive (in interosseal muscles) receptors are stimulated as the foot touches the floor. The reflex reaction is increased tonus in the muscles of that foot, which is then a point of support.
Segmental static reactions: Co-ordinate the activity of the two legs: A typical example is the crossed extension reflex.
Allover (“global”) static reactions:
a: tonic neck reflexes

b: tonic labyrinth reflexes

c: phasic labyrinth reflexes



It follows from the kinesiological course of postural development we must broaden our point of view to include the special sensory-motor relations which come into play when the baby straightens up. As soon as this starts (between the 4th and 6th week of life) the CNS centers responsible for maintaining posture against gravity become activated. It is clear that the highest levels of the CNS control body posture. Analyzing the kinesiological course of postural functions it is obvious that the CNS center controlling body posture cannot be at the spinal or brain stem level.





Automatic body posture control from the neurophysiological point of view



1. Inherited genetically determined CNS programs are crucial.

As the CNS matures those programs become activated. Postural activity and postural re-activity show the kinesiological course of the programs in details.

If the position of the baby’s body is changed passively, the whole locomotor system treacts. This reaction is not haphazard but follows certain rules and depends on afferent stimuli resulting from the position of the body and the support zones.

The way the body reacts to passive change of position (postural re-activity) - its kinesiological course depends on the developmental stage of postural activity. Motor reaction to passive change of body position tells us exactly what level of balance, posture, and phasic functions the baby has reached. These functions develop during postural ontogenesis depending on the maturation of orientation mechanisms (visual, audial, tactile..) As the child orients itself in space it triggers CNS mechanisms which automatically control body posture and movements (locomotion). At the age of 6 weeks when orientation first starts, the whole body posture changes. In this way during postural development motor programs become activated, resulting in global motor patterns. It can be said that global motor patterns are stored in the brain as „a finished matrix”. Very well defined muscular functions follow from such programs. The process of functional muscular differentiation in the course of postural ontogenesis can be illustrated on the pectoralis major muscle.



Example of functional muscle differentiation

There is no support function at the neonatal stage, the baby holds his arms in protraction and internal rotation. For the first straightening maneuver when the child wants to take its bearings, retraction of the arms is necessary. This is effected by the long head of the triceps brachii . Activation of the outward rotators goes hand in hand with relaxation of the pectoralis major. From the 6th week the baby automatically starts to move his arms into the sagittal plane and the first support on the elbows is established. If the body is supported on the elbows the pull of the pectoralis major must be directed distally. During locomotion, if this muscle is activated on the support side, it works against gravity, moving the trunk towards the fixed point (“punctum fixum”) in a ventral, dorsal or lateral direction. The pectoralis major thus works against gravity and at the same time ensures stable posture during movement, in cooperation with its antagonists. This function ensures good balance in the course of movement. The preprogrammed function against gravity of the pectoralis major comes into play when the shoulder angle is between 120 and 135 degrees. This can be observed in partial movement patterns all through ontogenesis.

We know that the child who cannot flex his arm at the shoulder to more than 120 degrees when sitting (or at the knees) cannot stand because the function of the pectoralis major against gravity has not yet matured.

Supine at the end of the first trimenon and prone in the second half of the second trimenon the preprogrammed phasic function of the pectoralis major emerges. It is important for the grasping function of the arm when the fixed point (“punctum fixum”) is located proximally and the moving point (“punctum mobile”) distally.

The differentiated muscular function described above matures in the course of postural ontogenesis in other muscles as well. Activation of one muscle during preprogrammed functions is always coordinated with the activity of other muscles. In this way exact coordination between individual muscles within the whole movement pattern can be defined.



2. Automatic control of body posture depends on integration of many afferent stimuli :

Proprioception, interoception, exteroception (tactile and telereception). The spinal level of integration, asymmetrical tonic neck reflexes (ATNR), symmetrical tonic neck reflexes (STNR) and vestibular reflexes are are only some of the afferent stimuli influencing automatic control of body posture. ATNR, STNR, vestibular reflexes and the spinal level of control are usually given as the most important for body posture control,but all proprio- intero- and exteroceptive stimuli resulting from momentary body posture must be followed by a kinesiologically very well defined motor response, as are the reflexes processed at spinal or brain stem level.

It is important to understand that every mechanical or nociceptive stimulus is processed at the highest levels of the CNS and followed by a motor and postural response. I.e. any afferent input influences the total motor pattern. If e.g. we tap the lig. patellae to evoke the patellar reflex, we activate muscle spindles resulting in contraction of the quadriceps femoris and knee extension is the response. At the same time, however, higher levels of the CNS are informed and as a result a change in posture can be observed. This postural reaction follows exact rules as does the segmental reaction of the patellar reflex. Overall postural reaction results from any afferent stimuli based on the initial position and region of support. Tapping the lig. patellae is of course too short an afferent stimulus for total motor response. If afferent stimulation is performed for a longer period of time, however, noticeable motor response is evoked throughout the whole locomotor system, as can be seen in reflex locomotion according to Vojta. E.g. afferent stimulation at the nucheal line and medial epicondyle after a certain latency period of time produces a reaction in the whole locomotor system. All the muscles are activated automatically, the support zones become weight bearing zones . These specific zones of the body are essential for the postural and straightening mechanisms from which all locomotion follows. If we stimulate zones in a prone or supine position, a different but predetermined motor response is evoked. Afferent inputs resulting from the actual position and support are thus crucial for muscular function within postural reactivity. Knowing the exact kinesiological course of motor patterns it is possible to predict the motor response to afferent stimuli from the position of the body and the regions of support.



Relationship between postural development and reflex locomotion



Kinesiological analysis of functional maturation of the muscles during postural ontogenesis shows that all such functions can be observed in the course of reflex locomotion described by Vojta. These are models of motor patterns involving all the partial motor patterns normally seen during postural development.

For example partial patterns of reflex turning can be observed in motor development as followis: lifting the legs above the table in the supine position at the age of 4 months, grasping over the mid line at 4,5 months, turning to the side at 5 months, turning from supine to prone position at 6 months, support on the elbow while lying on the side at 7 months, oblique sitting position at 8 months, in crawling at 10 months and the first steps walking sideways at the age of 12 months.

These patterns reveal genetically determined muscular interplay in the whole locomotor system, which works as one unit. The exactly defined phasic function against gravity of the muscles ensuring posture and balance is evident throughout each movement. Postural control is part of all phases of the movement and matures as do partial patterns of motor development.

It is now clear that e.g. the pectoralis major cooperates within locomotor patterns cooperates with other muscles with antigravity function (subscapularis, short head of the biceps brachii, coracobrachialis), with the back muscles, and also with the muscles ensuring both the stepping forward and the support function of the legs.

In movement posture is not ensured by the activity of the whole muscle or muscle group but only by specific parts of the muscles which are functionally connected each stage of the movement and which work as one functional unit. E.g. at the initial stage of stepping forward which is coupled with flexion, external rotation and abduction, the following parts of the muscles are activated simultaneously: the pectineus, the gluteus medius and minimus – its posterior part, the lower part of the gluteus maximus and the quadratus femoris. They act as one functional unit. During stepping forward the position at the hip joint changes and more muscles are activated to ensure stabilization according to the anatomical shape of adductors abductors and external rotators. The differentiated postural function of the muscles is activated during all the phases of overall patterns. Just as at the leg the function of the muscles of the homolateral arm is differentiated, ensuring both posture and phasic movement. Every stage of the complete pattern is connected with a particular functional unit which ensures the antigravity function, i.e. stabilization (posture).

As the automatic control of posture matures during postural ontogenesis, differentiated functions of the muscles appear to serve specific functions. This differentiated function of the muscle goes hand in hand with a certain position in the corresponding joint. In this way differentiated function not only within one muscle but also within the functional muscle group is defined in the course of entire range of movement in the corresponding segment.

If we want to understand reflex symptoms which occur under pathological conditions we have to know kinesiological consequences mentioned above. This is the way how to explain sensory-motor responses resulting from nociceptive inputs



Abnormal postural activity and re-actions



The kinesiological course of postural activity and re-actions depends on:

1. The momentary condition of the CNS : If the CNS does not function normally, the postural program is changed. Kinesiological analysis of postural activity and re-actions can be used to evaluate the CNS, allowing us to determine the stage of maturation or pathological development of the CNS even as early as in the newborn.

2. The type of afferent inputs : Under local pathological conditions “adaptation” takes place as a part of the pre-programmed process of self-regulation, to inhibit nociception and allow to recover by itself. As a result we often find reflex changes in muscular function, either hyper- or hypotonus.

It is important to understand that reflex changes do not affect a muscle or muscle group as whole, but are usually found only in one muscle of the group or even only in a certain part of the muscle. These reflex changes in function are called trigger points.

Afferent nociceptive stimuli also influence the pre-programmed postural functions, activating processes of adaptation which never affect only one segment. The entire posture automatically changes.

The functional muscular interplay ensuring posture is thus changed. It is really a protective reaction which protects the segment against the pull of gravity through a purposeful changed postural program.

As there is a close relationship between muscles and joints, any reflex changes also affect joints as well as other tissues. In a reflex way all types of afferent stimuli from all the structures of a certain (lesioned) segment are changed, affecting the whole postural program. This is the protective postural pattern. Affecting any structure of the segment (e.g. by treatment) we affect all other structures in the segment in a reflex way.

Protective postural adaptation resulting from abnormal afferent input can be observed even during postural ontogenesis.

The whole principle can be illustrated by the following examples:

· If the baby has a pathological condition in one CC segment its body posture is changed. The reactions of the whole locomotor system to postural change are also disturbed. Not only the head reacts differently but the spine, trunk and extremities as well. These changed re-actions, i.e. the response to passive change in the baby’s posture,ares not part of the tonic neck reflexes (different postural model) but follow from higher levels of integration.

· Another frequent problem is that coordination between the two hands is delayed if there is any disturbance at the hip joint. Normally hand to hand coordination appears at the age of 8 weeks. If, however, there is abnormal posture at the hip joint, development of supination at the arms is also retarded. Supination is necessary for hand to hand coordination.

· Similarly a disturbed relationship between abnormal afferent inputs and postural re-actions can be observed in newborn babies There are abnormal proprioceptive inputs from the area of the pelvic girdle changing the postural re-actions E.g. the traction test in the first days of life will show different reaction of the legs (extension) than that of normal newborn child (flexion and slight abduction). The same holds for the test suspending the baby by the ankles.This abnormal reaction is not due to pathological development of the CNS but to changed proprioception.

· Chronic respiratory disturbance is another illustration. Due to disturbed interoception characteristic changes in posture and postural re-actions can be observed as well as e.g. disturbed grasping by the hand.





Conclusions



Developmental kinesiology offers a new neurophysiological explanation of postural reactions. This neurophysiological concept allows us to understand local reflex changes as part of the whole system. This postural principle also explains local lesions as kinesiologically defined consequences of the problem, and not its cause.

Understanding such genetically determined functional synergies opens up a new diagnostical and therapeutical approach, a new way of applying techniques which act on peripheral structures (manipulations, fascial, skin techniques etc..)"

Regards
Mike

[mike]

It was Barrett that posted the cartoon picture in the thread Cross country 44...sorry.
I have just some theory knowledge and no practical knowledge regarding Simple Contact so bear with me.:o

Mike

[Barrett Dorko]

Mike,

I don't see the correlation myself. I don't position patients passively and I'm looking for correction, not locomotion.

Who are you?

[nari]

Mike

That theory of reflex locomotion seems unnecessarily complicated.

Cannot quite see the point of it all. However, that's my take on it. Perhaps it is trying to explain how manips and joint techniques in general 'work', but no-one actually know for sure.

Passively positioning someone and causing muscles to contract seems an unusual method. I am not sure why one would want to facilitate muscle action in a passive sense.

I don't see that there is any correlation between ideomotion and reflexes....


Nari

[mike]

Barrett,
I just thought that maybe the neck treatment Jason described enhanced correction by some kind of locomotion. That was my correlation thoughts.


Almost immediately, her head began to rotate toward the left, and I followed. She did several repetitions of flexion and roation on her own, and I just followed.

As Nari says

That theory of reflex locomotion seems unnecessarily complicated.

This is something I been thinking about and that’s also my point.


Passively positioning someone and causing muscles to contract seems an unusual method. I am not sure why one would want to facilitate muscle action in a passive sense.


The reason they want to facilitate muscle activity is when the pt can’t activate the muscle. For instance you may want the pt to activate serratus ant but if the pt do not know how to activate it you can use these techniques to make the serratus part of the whole “motor system” since it work in a functional unit with any movement.
There is a lot of talk today of stabilization training (transverses abd, bracing etc) the problem might be when the pt can’t “find the muscle” and therefore needs help. That’s my understanding of the described method.


I don't see that there is any correlation between ideomotion and reflexes....

They think that these locomotion reflexes are above brainstem.

They haven’t completed the studies on these techniques yet, but they use it on daily basis in the Dpt. of Rehabilitation, University Hospital Motol, Prague, Czech Republic.

Mike

[Barrett Dorko]

Mike,

What you've said here is interesting and I agree that stabilization when the problem is coordination makes no sense.

Again - Who are you?