ideomotion inhibitied??

[Tracy]

Barrett (and all others) -

I have been thinking...I evaled a 13 y.o. girl this week - came in for back pain. During the subjective, she indicated chronic neck and back pain for at least 2 years (related this back to an incident when she was "trampled by a horse"). Also revealed she has "ADHD" and has been taking medication for this. During eval, she demonstrated incredible hypersensitivity over a global area of the lumbar paraspinals and lower thoracic paraspinals, with LE strength/Lumbar ROM WNL and negative neurological testing. After starting some treatment and doing some patient education, I asked her if she had any other concerns or questions...she asked her mom (who was present) - "should I tell her about getting pushed in the locker room?", to which her mom replied, rather whimsically, "yeah, she gets pushed around a lot". Apparently, kids at school have been harassing her.


I suspect there are a lot of factors involved here, including some psychosocial components. But primarily, what this young woman got me thinking about, is this: With so many kids being diagnosed with "ADHD" and "ADD", etc., and being medicated as a result, are these medications contributing to the suppression of ideomotor movement? I also just read in our local newspaper that a record number of children are now being prescribed antidepressants, and am wondering if this too would contribute to suppressing ideomotor movement.

AND, if these are indeed suppressing ideomotion, in a group of young people who are already selectively suppressing so many other expressions (teenagers wanting to "fit in" and not look "weird"), are our medical professionals who are prescribing these medications contributing to a generation of children who will more than likely develop chronic pain as a result??

Ideas or comments, anyone??

Thanks - Tracy

[gary s]

Tracy,
What you are saying sounds right to me. A few years back I was THE P.T. for an outpt pain management clinic of a well known Long Island hospital. This was the major leagues! Oxycontin, subdurals, indwelling morphine pumps! With all of this narcotization I would think that ideomotion was not actually inhibited. Perhaps the ability to move in this corrective manner was lost. The over use of meds might remove the stimulus for this movement to occur. Don't know if you could call this a skill, allbeit unconcious--but if you don't use it --you lose it.

[Barrett Dorko]

Tracy,

I've had a couple of hundred therapists recount a similar scenario as they wonder aloud about the connection between ideomotion and the things we see in ADHD. I always say, "I never see these children, but if you do you might investigate the connection further and do enough clinical work to form some sort of opinion."

I've yet to hear anything from anybody. That's a hint.

Occasionally I refer to Gary as my "consigliore," mainly because he's known me for so long and also because my ideas have gotten him into so much trouble. Now we're bound to each other on a level not commonly seen among therapists.

I say all of this because of the new quote I find beneath his signature here. Younger therapists might not recognize it but if you're of a certain age you can still hear the actor - a scary-looking man - practicing this speech in the wedding scene.

Talk about a powerful meme...this is a wonderful example.

One more thing. Luca Brasi wasn't actually Don Corleone's consigliore. He did other things.

[Tracy]

Well, I just finshed a treatment session with the young lady mentioned above. We primarily performed simple contact in standing and supine. She initially, in supine, demonstrated increased neural tension at the L LE (some internal rotation), but had completely relaxed into external rotation by the end of the treatment. She moved quite easily, with only a little verbal education and encouragement...much "better" than a lot of the patients I've tried this with so far (have only been using SC for a few months). We talked a lot about how she feels when she is on her medication (the ADHD medication) vs. when she is off it. Although she had some trouble articulating how she feels different, the resounding difference was "I feel inhibited when I am on the medication"...and admits to "forgetting" her medication on purpose at times because she "feels better without it", although it sounds like she isn't particularly productive when she isn't on the medication.

I always say, "I never see these children, but if you do you might investigate the connection further and do enough clinical work to form some sort of opinion."

Barrett - any particular suggestions on what to do or look for here, other than just what I am doing now? Sort of a case study of sorts??

Thanks - Tracy

[Barrett Dorko]

Tracy,

Were the characteristics of correction concurrent with ideomotion?

Did you follow up with some Feldenkrais? Did this young lady demonstrate the ability to continue moving on her own from standing? Did you do any simple provocative tests prior to and after her moving? By this I mean something like adducting the hips in standing.

[Tracy]

I have not had any formal training in Fledenkrais - just "dabbling" with information/help from other therapists - any suggestion? As for other follow-up, started some of the activities provided in your SC course - rotation and warming for now.

Yes - she was able to demonstrate the ability to continue moving on her own from standing, although not as well as when my hands were on her. Part of her homework was to go home and try to cont. some of this movement on her own.

Simple provacative tests prior to moving: in standing - her preferred posture was adduction of the bilateral LE (so much so that feet/knees were touching), then had her stand in adbduction of the B LE and asked her what she felt - she reported "the back of my knees and my back feel a little "wobbly". I then asked her if it changed the tension she felt, better, worse, or about the same (so as not to lead her into an answer), and she indicated "maybe a little less". Didn't think to do it again after the supine work. Her preferred posture in supine was also adduction of the hips, although not as much as in standing.

Were the characteristics of correction concurrent with ideomotion?


The correction that occured - increased ER at the L LE - began to improve after using SC with the L LE in supine, then was "normal" after some additional time spent with SC at the R LE and L UE in supine.

Tracy

[Barrett Dorko]

Tracy,

Aside from adduction in supine did she also "prefer" internal rotation? Preferred or not, this requires work and is simply irritating to the nerves. What's her breathing pattern like? Her autonomic state? Remember the vitals of pain?

Remember the characteristics of correction do not include the direction people move.

[Tracy]

Aside from adduction in supine did she also "prefer" internal rotation?

I want to be clear...when I say her preferred position, I guess maybe I should say her chosen position. I always assumed if it was their chosen position, it is also then their preferred postion. Her bilateral LE's were adducted relative to what I would expect if there was little to no tension in the LE, that is to say, they were close together, or in a neutral abd/add pattern at the hip, with the L LE not truely internally rotated, but more internally rotated relative to the right LE. The right LE was pointed out into hip ER, relaxed, without apparent tension. The L LE was at about a 30 degree angle into ER, not with the foot/knee pointed straight up or into true internal rotation. Sorry if that was confusing.

Will look more closely at her breathing pattern next time - thanks for a reminder. Her autonomic state seems to be a bit heightened, she has some nervous habits and ways of talking...uses a lot of gestures with talking, nervous figiting, and once she gets talking, talks rather quickly and is a bit scattered. It is hard to tell how much of this is medication, true personality, or ADHD behavior.

Remember the characteristics of correction do not include the direction people move.

O.K...help me out here a little. Are you saying that just because she moved more into ER at the L LE after a treatment with SC, that this is not a characteristic of correction?? If so, I have misunderstood. I was under the impression that if the patient is in supine, with the feet pointed more or less upward, this is a sign of neural tension, and if, after treatment, demonstrates a more externally rotated position, then the neural tension has decreased, thereby indicating some correction has occurred. Could you clear this up for me please?

Thanks for your patience and help Barrett...I would like to learn as much as I can, beyond what was in your course, or as much as your patience allows in this forum! Your assistance in "real life" cases is much more instructive than when working in the lab with fellow therapists, messed up as they may be!


Tracy

[Barrett Dorko]

Tracy,

Increased autonomics in which direction? Is she cold or not? Some people choose adduction and internal rotation and some are stuck there. Some display a combination of these things. You can figure this out.

Read http://www.barrettdorko.com/articles/characte.htm

I still think your fellow therapists are no different whatsoever than the patients we see.

[Diane]

Characteristics of correction:
WESS; warmth, effortlessness, softening, surprise

(Don't worry Tracy, it's hard to get all the details in just one go. :))

[Tracy]

Ah, yes, it's all coming back to me!! Please forgive my poor, feable, biomechanically trained mind!! Don't give up on me, I think there's hope for me yet!

Thanks for your help - I'll see her again tomorrow...may have some more questions or observations then.

Tracy

[Tracy]

Saw this young woman again today - interestingly, she was not on her meds today for the ADHD. Marked difference in her affect and behavior.

We used SC again in standing/supine. Provacative tests: standing add. vs. abd. and supine "bridge" before/after using SC. She indicates she feels "different" in each postion, and different compared to before/after using SC for ideomotion, but cannot articulate what it is that she feels...not necessarily better or worse, just different. Chosen position in stand remains adducted LE's, but easily moves out into abd., again, doesn't necessarily prefer it though. In supine, initial chosen postition today is into abd. of the hips with full ER of the LE (much different than last visit) - related to not being on meds today, or related to treatment last visit?? All characteristics of correction are present today during the ideomotor movement. Breathing pattern is shallow, with poor diaphragmatic movement - time spent in education here, and she is to practice the breathing on her own.

Autonomic system: She reports "getting cold easy", but then also indicates she gets hot easy as well. Denies any specific regions that are sensed as being consistently cold.

Barrett - on a side note - the local paper ran an article on a physician in Minnesota doing some research in the classroom. The classroom is set up non-traditional - no chairs, with multiple level "desks". Exercise balls are available for sitting, otherwise, children are expected to stand, move, squat, kneel, etc. and are encouraged to move throughout the class period. Mainly, they are doing computer work at each station, although I think an Ipod was mentioned?? The physician is primarily doing this as a trial to see if this affects the children weight, tracking calories spent, and movement (it talked about sensors on the children's legs, but was not specific). I don't know for sure if they are tracking the children's ability to learn, concentrate, etc. in this environment, but it would be interesting to see if they did. Again, my thoughts come around to the ideomotor movement and freer expression of movement, and am wondering if this environment will be more conducive to learning, vs. the traditional environment of "sit down, shut up, and learn this stuff".

Tracy

[Barrett Dorko]

Tracy,

Sounds like you're doing fine. I'd probably be working to pin the patient down on some more precise description of the original complaint of pain and how that's changed. In fact, I'd probably do this more forcefully than most and end up alienating the young woman. I consider this my "style" and try not to actually teach it, figuring just about every student is better at talking to patients than I am.

My daughter Jennie teaches language arts to sixth graders and gives them all sorts of freedom to move, create, imagine, express and find what they want to do with words in their own eccentric ways. She has been enormously successful and popular and will always be, I'm sure. She started teaching me how to be better at such things when she was a toddler - and that's what I have to say about the classroom you describe.

[Rolf-Inge]

Hi Barrett!
Do you o rthe SC approach, pay any interest in the patients way of thinking as an understanding to their pain and/or decreased locomotor function?
If so,. in what way?

Rolf-Inge:angel: :angel: :angel:

[Barrett Dorko]

I really have no clear idea of what it is you're asking me.

[Diane]

Barrett, Rolf is asking you if you attend to patients' emotions when you treat, or think they have anything to do with their pain. Am I right Rolf?

[Barrett Dorko]

Okay, if this is what he's asking the answer is "No, not really."

I'm both unqualified to assess such a thing professionally and, in all honesty, pretty much disinterested on a personal level. Our individual capacity for such a thing varies, of course. From what I read of Rolf's interest in the past I think it's safe to say that we are at opposite ends of the spectrum.

I gather that he feels strongly that emotion, movement and pain are very closely aligned. I don't agree. I also think that the therapist's obvious interest in the personal feelings of the patient magnifies the effect of such things and thus the patient's conviction that this must be dealt with in the physical therapist's office.

My obvious disinterest in emotive responses has a similar effect - only in the opposite direction.

[Rolf-Inge]

Hi !
Thanks Diane !Your quite right !
To me its impossible not to be intersted in a patients cognition(the person behind the pain),due to the inseparable body/mind connection!

just finished "The balance within"
The sience connecting Health and Emotion.
Recommended!


"I gather that he feels strongly that emotion, movement and pain are very closely aligned. I don't agree."

We dont have to agree, but it just puzzles me that you dont find or havent experinced any connection between emotion and pain.Anyway thanks for your replay Barrett!

Then i know it woundt be nessecary to join a SC course!

Nari!Thanks!It will be interesting reading!

RIN:angel: :shade: :angel:

[Diane]

Rolf, I think Barrett's reluctance to consider these aspects of being human, has to do with the role culture plays in blurring the ideas surrounding them, from culture to culture. Also the concepts the patient may themselves hold about their own emotions. I assure you, he pays close attention to autonomic function, which are interactive with emotions and with pain.

[Rolf-Inge]

Hi!
Had a patient yesterday ,women 38,unmarried no children beeen working for a 20 year , physical active ,no red flags,no ealier problems regarding ongoing pain as she no experienced,that since a week ago had got increasing neckpain and headache right side..No physical trauma.

Yellow flags:Her mother resently got sick and was in hospital waiting for an stomach operation.
Pain med. did give some reduction on her pain .
She wanted to know what could be the reason for her pain, and what she could do to decrease it.
I always ask my patients what they do belive is the"reason" for their pain!
She told me that she had felt an increasing generel tension,increasing the last weeks ,and she was very worried about her mothers health,problem sleeping the last week.

Decreased neck movement espesially rotation right side and side bending left.Do to pain in the m.trap area.
Im.levator scapulae, and m scalenii right side.ncreased tension in the m.trapezius,
Decreased cervical segmentat rot. espesially c4 -c7 left side.
Pos. n medianus gliding right side.and PBPT same side.
Reflexes,strenght and sensation tests normal!

Any comments?

What do you recommend has to be done ?
Nari,Barrett ,Diane others out there join in!

RIN:angel: :angel: :angel:

[nari]

RIN

Don't be put off by the fact that Barrett does not go into emotional issues. As Diane says, he pays close attention to the autonomic reponses; but not the verbal expression of emotional issues. As I understand it, he feels it is not our job to look at these issues - which is true, as we are not psychologists.

Your patient, I am sure, would respond very well to SC. Think of SC as a simple means of enabling the patient to experience ideomotion, or the nonconscious brain's expression of a corrective movement. When you think about it, the nonconscious part of the patient's brain knows better than we do, as therapists, the 'method' or the means to correct a problem. It is usually submerged by heaps of conscious thoughts and actions on the part of the therapist and the patient.
However, in the meantime, you could try a simple touch, somewhere on the neck or shoulder and ask her where she would like to move. If she begins to move, don't say anything or assist in any way...just keep very light contact for a few moments. Without attending the course, it is very hard to 'know' what to do...it just seems so simple, to our complicated reasoning processes.

Or, in your way, just discuss her story (subjective) and do what you feel OK with. Mobilising the neck/thoracic spine will help, but may resolve the real problem only temporarily.

I think the SC course would confirm the role of emotions in the pain experience from your viewpoint; despite the fact Barrett does not agree. I think that you would be most interested in the 'role' of the nonconscious brain.

Nari

[Rolf-Inge]

hiNari!
I have seen this patient and given her my point of view why she is pain.Without trying to be a psychologist. ,just a manuell therapist interesting in the body/mind connection, ive just informed her of the possibillity that her pain might be a "normal" "fight and flight repons ",increased sympathicus,increased amygdala reaction,due to her anxiethy about her mothers health/op.

The op .went well ,and her mothers is back home!
Saw the patient yesterday,no pain anymore,sleeping well not worrying at all any more.
No physical problems at all!!

Didnt have to use triggerpoint deactivation ,SC, etc,just "commen sens",in my point of view!
Sometimes its just as easy as this ,but........... its hard!

RIN:angel: :angel: :angel:

[nari]

Rin, that's fine!!! Education can fix all sorts of issues, just by itself. It does not need a degree in psychology; it is something any of us can do. But many PTs feel it is not their field. That's fine, too. We do what we feel comfortable with.
Also, her mother's problems were resolved, and as a result hers did too.

It is a tricky area; but I believe you are on the right track with your thoughts re emotions.

Nari

[Barrett Dorko]

Rolf,

Your approach, while common to many therapists, includes a trust in the patient's story that is unwarranted. Though many assume that in response to the question, "What's going on in your life?" the patient's answer will be truthful and relevant - it isn't. Typically the patient doesn't know this either. Any counselor would agree. And I don't mean that people willfully lie. It's far more complicated than that.

And it's not that I don't see any connection between emotion and pain but rather that I trust the expression of the deeper levels of the brain and seriously consider the "mind" itself a questionable concept. Now, a brianbody connection makes sense to me.

I trust motion, not emotion because in the latter there's just too much cortex involved.

[Rolf-Inge]

Hi!
Nari:"Education can fix all sorts of issues, just by itself."
In this case i didnt fiw anything,in my point of view,,the amygdala just calmed down when all went well with her mother!
Her way of thinking(emotions)"normalized" when her mother was back home.

If this "daughter"hadent got well,(mother still in hospitale) i would have been interesting in her way of thinking,cognition ,used CT beside trying out some MT modalities.


Barrett:I belive in both ,motion and emotion,to me they cant be separated..The body/mind connection.

RIN:angel: :angel: :angel:

[nari]

RIN

You are probably right about her pain resolving when her mother was OK. but I wouldn't mind betting that you assisted that process to begin with.

I wonder if that neck/shoulder area pain would return if she faces another emotional situation - I would expect it might.....

I personally think you would gain a great deal out of an SC course, but you would need to travel to North America. The experience of ideomotion is quite startling - almost hard to believe; but there it is, and it is supported by modern neurophysiology. The nonconscious mind is a crucial aspect of everyday life..much more interesting than the conscious mind.

Nari

[Rolf-Inge]

hiNari!
Thanks for useing your time giving me intersting/pos feedback/information.

IF you had seen this patient,without knowing her psychososial background,could you have used SC as an treatment approach and if so in which way?

RIN

[nari]

Hi RIN

SC would have been my first choice; if that was unsuccessful for whatever reason, then education and neurodynamics. All very hypothetical, though, because I am not experienced in SC - have only used it on myself and friends as I am not at work at present.

But I would also listen to her story, as I think that ties in with pain education.

(Can't help it, Barrett... I am a frustrated psych, I'm sure, and have done counselling in the past)...:)
I feel it is important to 'hear' what they are saying, even if it is not accurate.

Nari

[Barrett Dorko]

Rolf,

It's been well established that "knowing" the relevant psychosocial background of another person is a difficult and prolonged process. In fact, many parents don't "know" their children that well. You continue to think that a couple of questions and a little conversation that (I suppose) includes a little empathic listening from you is adequate. It isn't. That's why good counseling from highly qualified individuals takes time.

I don't "believe" (as you say) in anything - I seek to understand. And your repetition of the phrase "body/mind" seems to be used to justify a way of delving into the patient's life in a way I find inappropriate. I'll be blunt; most of the information you feel is essential to have before proceeding with care I don't feel is any of my business.

[Rolf-Inge]

Hi!
Nari:"The mind is like a muscle: it swells with exercise. Gould’s and Kozorovitskiy’s work reminds us not only how easy it is to hurt a brain, but how little it takes for that brain to heal. Give a primate just a few extra playthings, and its neurons are capable of escaping the downward cycle of stress."

Thanks Nari ,found the article!
Neurogenesis,just the word have created some new nerve connections in my hippocampus,thanks to you!

Barrett:
"You continue to think that a couple of questions and a little conversation that (I suppose) includes a little empathic listening from you is adequate. It isn't. That's why good counseling from highly qualified individuals takes time."

How are you able to critzice my way of interacting with patients without
1. beliving in the body/mind connection as i do!?
2.Never seen or heard me with my patients!?

Good counsling=higly qualified idividuals???
I have seen lots of "higly qualified individuals" doing extreamly bad counsling due to lack of social and emotional intelligens,something which lies within you or not,in my point of view.

Even though you have problems not beliving in the body -mind connection,please respect that others do , as i respect your way of thinking without understanding it or at the moment willing to learn more about it.(SC),espessially after your last comment!

RIN:angel: :angel: :angel:

[Barrett Dorko]

Rolf,

I think you're confusing disagreement with disrespect. I don't feel that you are correct in your presumptions about what a little information always means but my respect for your passion remains undiminished. And I fail to see how the mistakes a highly trained counselor may make gives anyone else license to make other mistakes. No, I haven't seen you talk to patients and I can only assume that your own description is as I read it. A brief and superficial interaction is what I have actually seen in my experience too many times to ignore, and I am troubled by what some assume it reveals. Ironically, my respect for good counseling seems to be what separates us.

I also think that you've mistaken my opinion of what you conclude on the basis of your interaction and the results you report as a criticism of your way of being in the world or the way you practice. These are simply not the same thing. I don't tell others how to practice, I just provide information about what science has taught us. What they end up doing is their own business, not mine.

Again, I don't believe in "mind/body" stuff, but I understand as best I can "brain/body" stuff. I hope you can see this distinction as well.

Please also know that I appreciate your impassioned participation here. It's a rare and welcomed event.

[Rolf-Inge]

Hi!
Thanks for your replay,Barrett!

It might be i missunderstand you due to my lack of communicating in good english!
But i still find it rewarding discussing these topics!

RIN:angel: :angel: :angel:

[Diane]

Nari, I feel it is important to 'hear' what they are saying, even if it is not accurate. I think you're right. Even if we might not know what to "do" with such information (by way of our training being focused on other matters) I agree with you that it's important that the patient be allowed to express themselves/debrief to a calm therapist who can manage to at least nod wisely or otherwise indicate that the material has landed somewhere/somehow into their flight path, so the patient can move off the square they were stuck on.

The nonconscious mind of such a patient will then be able to focus better on what else may go on that day in terms of other motor outflow, once the branchial/throat area/efferents are softened/ideomotorically expressed. I'm pretty sure Barrett and Rolf would both see this as important. Rolf might want to think about it as more consequential/influential than Barrett does, but to me it sounds like both are interested in the patient's well-being and helping their autonomics turn around into something more aligned with correction/normalcy. It also sounds to me like Rolf doesn't spend a huge amount of time unravelling or trying to unravel patients' emotions anymore than the rest of us do, just that he wants everyone to know that it is important. Yes, I would agree it is, by and large.

[nari]

I also think that if a patient 'unloads' to me what is important to them, it is part of the therapeutic process - call it placebo or whatever.
If I have established a rapport with the person in front of me and have provided a means for them to talk, if they want to, then even if I have not resolved their pain, I might have eased their suffering so they can deal with the pain better. I have seen this many times, particularly in the case of intractable pain.
Delving into a patient's social history is not a good idea, and any active coercion for them to 'reveal' issues is asking for trouble. BUT, it so happens that they are mostly quite willing to initiate such information, without any sort of prompt from me. Given that, I would not do anything more than reflect with them; and perhaps relate it, judiciously, to their current biological issues.
We are often the only practitioners who may do this in their medical history.
Some GPs make a special effort to listen; but they are so hamstrung by time.

Rin, glad you liked the article. It is inspiring.

Nari

[Diane]

Nari, can you put a link here to the article?

[nari]

ian writes:

http://www.english.ufl.edu/pnm/griffin.html


I used to believe that neuroscience and physiology could explain everything. At one abstract level yes they probably can, i am now no longer sure at all.
I don't think an aware clinician would deliberately 'delve' into someone else's business.
If you operate 'scientifically' its possible to remove yourself in a way from the clinical encounter and explain things in a totally abstract way. I think patients with ongoing pain will inevitable tell you stories that simply do not fit the narratives we are trained in.
Empathy itself is often transformative in these situations. Most GPs I know are not trained counsellors but there are very few patients that get referred to this form of assistance.
I agree with much of the above essay. As you work clinically it is often a two way street. If anyone differs from this opinion i would be interested to hear why.
Being aware of psychosocial stories is one thing and it is an important and neglected area as most people in chronic pain have stroies to tell or issues that are not biomechanical -delving and digging is another.

Rolf I think you will like this:

How Physical Pain may interact with psychological pain: Evidence for a mutual neurobiological basis for emotions and pain - Gundel H and Tolle T ch 7 Narrative pain and Suffering...IASP publications 2005. (Not available online)

ian

[BB]

I'm curious on everyone's thoughts on the appropriateness of cognitive approaches. Is it in our realm if it is related to movement? Is that the distinction? For example, we are addressing fear of movement almost constantly with our interventions, which I think is appropriate, but wouldn't congnitive-behavioral treatment take this to the next level and attempt to alter the processes of fear itself in a more broad context? My take has always been that, as long as I am putting it in the context of the movement dysfunction that is being addressed then I am on solid ground, scope-wise. What about catastrophizing? Learned helplessness? All of these things are seen every day in our clinics, and are also a bit in psych-town. Where does the distinction lie is my question.

Hope I'm making sense.

Cory

[nari]

Diane

Sorry, but I haven't set aside time to work out how the hell to do that. Perhaps it can be transferred from one forum to the other within SS easily, but haven't worked out that either. I know you gave instructions, but I am terrible at following instructions...:embarasse

Cory

I worked in a pain clinic for two years where there were two psychologists; they delved into psycho-social issues and diagnoses, but I still addressed fear and learned helplessness. Catastrophising, no, but I feel very strongly that PTs should address these issues. They all relate to movement, and when one does not have a psych in the room at the time of the consultation...I think we can't educate on pain without mentioning these cognitive issues and thier significant impact on what we as PTs are trying to achieve with chronic pain patients.
In Australia, some psychs attend Butler's courses; and our Association runs CBT courses for physios. The more we attend to cognitive issues, the more complete our management of pain patients will be.

Nari

[Diane]

Cory, I went and dug up this old thread that I started on RE ages ago, on CBT for pain. (http://www.somasimple.com/forums/showthread.php?t=1310) (Good thing they're here!)

If you read through it you'll see that what we offer isn't really all that different from what CBT actually IS! We just called it "physiotherapy" and got on with it. The psychs called it "CBT" and made it special.

Nari, I found the Seed article on neurogenesis. (http://www.seedmagazine.com/news/2006/02/the_reinvention_of_the_self.php)
That's the one, right?

[nari]

That's the one, thanks Diane.

I reread the old RE thread; interesting to see how the standard of posts have changed in a year.

Nari

[BB]

Hi Nari and Diane,

Thanks, Diane, for posting the link. I remember reading it originally, I think it sent me into one of my frenzies of reading I have had a habit of getting into since I started hanging around this site.

I agree with you both, of course. I just think that our place in addressing the cognitive issues is more appropriate in the context of task instead of addressing the cognitive issue itself, broadly. If the treatment of a broad cognitive overlay is needed, this is a good point to bring in the psychologist.

cory

[nari]

Cory, I think you have raised a valuable point or two.

As an example, if someone, without known pathology such as a chronic pain person, said: "I couldn't possibly lie down on my back, I know it will hurt like crazy" and you notice that she (for argument's sake) had stated that she mostly sleeps for a few hours at a time in any position - what would your thoughts be?
(I had someone say that to me - a female with 3 years of LBP and headache)

False narrative? Fear of what you are going to do?
Fear of a PT causing more pain (which is very common)?

How would you approach this fear expression?

Nari

[BB]

Nari,

Based on what you have said about the person so far:
I would respect her statement by not asking her to lay on her back. After developing some trust, that I'm not going to crank on her back or make her do power squats, and having gone through some less threatening positions, I may offer an transition position, such as reclined.

So, I would approach her in a way that hopefully doesn't fulfill any previous nocebo she may have regarding PT.
I would approach her fear of movement by gradually moving through some non-threatening ones.
The false narrative "I can NEVER lay on my back" is to me catastrophizing. So, making small strides or experiments (in the patients mind) towards laying on her back albeit reclined, and offer that never is maybe a bit too permanent of a word in this situation.

I may never even get close to reclined though. If I think that is too ambitious to start, I may just make a comment like, this movement very similar to this other movement in laying down, just to make her think about it.

[bernard]

Nari,

I'm often provocative with such patients.
I ask: "Since you're exactly knowing your future, please give me the numbers that will fall in the next lottery?"
They are replying ever: "But, I can't!"
And I follow: "It's the same with your next move."

[nari]

Cory

It sounds like you would be negotiating with her, which is a cognitive approach; and a compromise may well make her think about things a little more, as to the inconsistencies of what she is saying about lying on her back.
She would not recognise such inconsistencies herself.

Bernard

Quite a different approach! What if she yelled at you that it was agonising and thumped you? ;)

This woman had highly variable pain levels; when she didn't have to follow requests or orders of any sort; she managed. When it was up to her entirely, as an active decision-making process (given that there is no free will, a nonconscious decision?) she managed much better. Her pain "allowed" her to do things. I worked this out after a while; after she had stated she couldn't possibly lie down on her back, I said: 'Well, it doesn't matter. Any postion will do just as well'.

She lay down on her back.

I didn't really understand this until much later, after the SC course. I had presumed she was just rather pernickety and wanted to hang onto what control she had over the pain experience. It is more complex than that...

Nari

[bernard]

Quite a different approach! What if she yelled at you that it was agonising and thumped you? ;)

Several times, the patient stops shouting. My answer disturbs them, a bit.
It is easier then, to "bring" them to a new approach of their pain and defence.
They are quite all the time saying that they are afraid to move but do not know if the movement is really hurting.

[Diane]

I'd probably use soft sell, like BB. I'd ask her to try it with a bolster (I use a bolster all the time to de-stress the NS), just to see if she could tolerate it for a few minutes while we try this or that. I would ask her to tell me when she needed to move and that we would re-organize, before the moment it became un-put-up-withable (graded exposure).

[bernard]

I must add that only the words are "provocative". I never "enforce" patients to make hurting movements.

In the Nari's case, I'll certainly try some soft moves in sitting position.