Manual Care and Dementia

[Barrett Dorko]

Without exception, I am asked by a few students in every class to speak to them about the problems inherent to treating their patients with dementia. Many work in skilled nursing facilities where this is a common problem concurrent with the painful ones they have to somehow deal with. Their disappointment in the realization that I have no extensive experience with such a thing is palpable though five minutes on my web site or a careful reading of the course brochure would have made it clear that I treat an essential diagnosis not necessarily related in any way to the problems they see. Nowhere does it say that handling the patient with dementia will be addressed.

The best that I can offer in the way of an answer are essays written over the years and available on my site: “The Piano Lesson,” “Alzheimer’s Gift,” “The Persistence of Memory” and “Peg’s Piano” among them. All involve my mother’s descent into dementia in the 80s and 90s. I found long ago that can’t actually talk about this to the class, so I write about it instead. Of course, to get anything out of that writing the therapist would actually have to read it. Not a common practice, I’m afraid.

So, this hardly satisfies most who seem to want desperately for me to tell them how to handle and understand these patients when they are complaining of pain. I’ve actually seen therapists leave early and/or just tune me out once they realize I don’t have a protocol of care that they can implement in their clinics – clinics very different from the converted boarding house on Portage Trail where I work.

I would love to hear some ideas about this issue of dementia and pain and its relation to manual care. Some of my former students returning to these patients must know something. How about an opinion?

Believe it or not, I’m all out.

[Diane]

What can we do to improve this when the entire profession and its cultural interface (http://www.somasimple.com/forums/showthread.php?t=2338) is demented?

[Barrett Dorko]

I'd prefer this thread not drop out of sight just yet so I'm posting in it again today.

Anyone who wonders about this issue is welcome, as always. Despite asking those who question me about this to give my method a try amongst their population of patients I've never heard anything subsequently. Of course, I've only been asking for a decade or so. The same goes for those who always ask me about Simple Contact in aquatherapy settings.

Maybe it's the nature of the management in the skilled nursing facility that makes this work so difficult to employ. Below is a link to an archived essay I wrote about my personal experience with this in the summer of '04. I used to read it to my classes but too many students started to cry.

Andrew's Flight (http://www.somasimple.com/forums/showthread.php?t=1748)

[nari]

Barrett

Perhaps not many of us have had experience with dementia patients.

I spent 6 months in a dementia/aged care unit four years ago; although it was interesting, the other PT, the incumbent senior, was a real fire-breathing dragon. Put me off no end.
In hindsight, I think SC would have been very worthwhile trying. Quite a few of the dementia folk were willing to give anything a go but attention span was close to zero, so traditional stuff was difficult. Yet it was tried over and over again by the dragon.
Sometimes I'd go in and talk with them; validate their extraordinary ideas and plans while walking around the very pleasant and private ward area.
I don't think I made any sort of impression, but probably settled them down a bit after the dragon had breathed fire over them.

Nari

[Bas]

Barrett, I have no doubt it would have been of great value to me and my patients in the early 80's in a large, sprawling psych hospital with two whole floors of what used to be an National Defence building dedicated to "Geriatrics".
Lots and lots of Alzheimers, "dementia", Parkinson's etc etc. Many patients were there because there was "nowhere else to put them". Needless to say, their pain complaints were ALWAYS extremely complex and mostly misdiagnosed.
I was by myself, new to Canada, and had to work under the 'guidance" of a howitzer of a psychiatrist, who insisted that the patients needed exercise, stretching and medicine. I was "allowed" to do group exercises with them, but handling them was limited to manual stretching (!). Even if I had the necessary maturity in my profession at that time (which obviously I didn't), I doubt I could have applied my knowledge and skills in the open..... I do believe I would have been able to work with two in their room: petite and sweet, very demented and confused, and very painful - limited to their chair (restrained) for "their protection". they had lost literally everything: their spouses, their families (no-one of their offspring ever visited), their homes, their interaction with the world and now, finally, their freedom to move. Hell, I was doing therapy by just taking them for a walk. In the stone and bleak hallways, each described something : the lovely mustard fields, and Mr. Smith, the baker, and the hawk up there....they smiled. I now know they were getting some relief from their pain - but man, if only....
Stupid, but it breaks me up, when I think of those two. I really, really hope they are at peace now.
And they were only 2 of about 72 there....And there was only me for a whole hospital of 550 patients. OK, enough rambling.
I believe that SC or any gentle and 'free" handling can allow the person to address the needs of their body - especially in this specific population. Dementia-patients are being coerced at every turn - medicinally, physically, emotionally. Our society needs to "manage them" somehow. But that I believe, contributes more to their suffering....

[Jon Newman]

I have a few thoughts I'll add to Sebastian's good points. Care for "dementia" patients is a broad topic considering the spectrum of presentation that dementia represents.
Pain measurement tools for this population rely on non-verbal communication, at least for those patients in which verbal communication has become unreliable or non-existent. Also, the move toward the banning of restraints could be understood to serve the purpose of minimizing suffering in the patient and allowing them the humanity they still have a right to no matter whether they make your day difficult. At our hospital, our more "active" dementia patients receive "one-on-one" care to allow them to move about and converse as they feel compelled. This is remarkably effective in the vast majority of instances.
All of this is consistent with what I learned at the Simple Contact course. I'm not sure whether that helps what your students are looking for.

[Barrett Dorko]

Jon,

Until one of those many, many therapists who've asked me for help here bothers to take the time to openly join us we'll never know. I'm not holding my breath, and if my frustration with their unwillingness to speak is evident that is because it is very real.

Several times this past week I was told by female therapists that they hadn't read anything "because I have children." I've heard that one before. Sometimes they add, "Do you?" The implication is that I could only know so much if I completely ignored my family. This makes me furious.

Bas,

What you wrote went right through me. And I mean that as a compliment.

[stregapez]

My father, an intellectual who ran his own marketing research firm, taught at the college level for decades, and had a book published just after his death, died in an adult care facility a few years ago. He was pretty much all there mentally until the last six months to a year of his life, slowly forgetting certain things, but not so as to make him unintelligent or unintelligable. But in the last few months before passing he was both in a lot of pain and unable to communicate what was going on inside him, what hurt, etc. He seemed mentally confused as well, but it was impossible to distinguish between mental confusion and inabilty to talk much or to speak his feelings clearly.

My father was fifty when i was born, my parents divorced when I was 12, i have no other siblings, and my dad and i always had a very stressed relationship (he was a demanding and often very cantankerous fellow) Luckily he made a special female friend in his later years who helped him out alot (a second daughter of sorts) , and he had a faculty friends as well who would come to visit him and occasionally take him out ot to their homes for Bridge meetings. He kept himself busy reading and writing, and i'd like to at least believe his final years weren't so bad.

His final months he seemed to be suffering a lot. His body just kind of shut down, and so did his mind. He had old injuries from riding horses that gave him a lot of pain. I wasn't sure if the pain he seemed to be experiencing wehn i saw him in the last week of his life came from those injuries or other things, and it didn't seem like the nurses really did either.

It seemed like his skin was very hyper-sensitive, or maybe he just felt warm. In any case he REALLY didn't want any clothing on, and he didn't except for a diaper of sorts. But the attending nurses and nurses aid (a nurses aid hired especially to attend to him) wanted the sheet kept over him, for modesty's sake, at all times. He HATED the sheet and spent at least half his energy (probably more) in the final week of his life fighting to keep the sheet off of him ~ to no avail, as he was constantly admonished to keep himself covered. Someone was always with him, so the door was kept shut. Why couldn't they have let him be (relatively) comfortable and find his own dignity without the battle over the sheet? It was painful to watch, and i wish i could have been more assertive about letting him be uncovered. I can't even remember exactly what i said or didn't say about it. I did say something a few times. He gave the nurse's aid a run for her money, and i sympathized with her a somewhat, and didn't feel i could tell her what to do i guess. At the same time, if she'd let him move or rest sans sheet, as he wanted to, maybe they'd not have had such a battle. ( i hadn't seen him in a long time so i only know about the final week, no idea how long this actually went on)

I remember once or twice he touched his genital area, and was admonished for that too. I remember him angrilly heckling the nurse's aid after she admonished him, saying "i'm a dirty old man" Seems like you should be able to touch your on genitals all you want when you are in a ot of pain and about to die...

He did appearently enjoy massages and one of the other nurse's aids did that for him (not sure what type as i wasn't there when that happened)

Dana

[nari]

Dana

I have come across this a number of times - the apparent need to be rid of clothes even in cool weather. In some ways, the dementia state seems to throw off the shackels and chains of culture, clothing restraints included; unfortunately that nurse's aid was too restrained by her own culture to understand what was going on.

I don't think we really appreciate how restrained we are in our apparently normal brains. This thread reminded me again of TS Eliot - where Alfred J Prufrock desperately wants to "eat a peach" (and presumably dribble it all over himself) and "walk upon the beach" with his trousers rolled up. Yet he feels a guilt about doing this.....that's scary.

There are 'happy' dementias and miserable dementias - Iris Murdoch was the latter. Definitely, if there was a choice, a happy dementia is the way to go.

Nari

[stregapez]

I was hoping what i posted wasn't too graphic or personal. I know it doesn't have anything to do directly with manual therapy, but it's related to the whole concept of allowing people to find ther own comfort.

Thinking about it, I'm supposing there is likely something in the nursing code of ethics or standards of practice (or whatever they are called in nursing) that states patients should have their genital area covered, and maybe breast area for women (i'm just guessing based on massage therapist guidlines) There are some good reasons for those standards. Actually my dad probably had just a pad under him and not a diaper much of the time (and i have some vague recollection of being told he pulled them off), so that's probably why she insisted on having him covered. In any case, the sheet was causing him significant frustration and discomfort, if not actual pain (and it may have been), whether physical or mental in origin. I don't know, maybe i'm missing something, but it seems like if it's a matter of nursing standards of practice some kind of exception might be made in the codes for dying patients and /or patients with dementia, especially when they are in their own rooms isolated from other people

[Diane]

Dana, your dad's discomfort with contact of clothing or sheet, etc., could have been from allodynia or pain hypersensitivity... Kevin McHenry on the painonline.com blog talks about that frequently.

Surely there could have been some sort of airy cage rigged up over him that could have held the bedclothes up off his body while still preserving everyones' modesty/sense of decorum/his dignity and comfort both.

[Bas]

Dana, I think your post is addresses a core issue for the group of patients with "dementia" - lack of dignity in a time when communication and cerebral functions are not that clear from a social point of view. No "proper" speech or "acceptable" behaviour (a social construct) at times, yet the person is still a person with a lot of functions fully intact. His disregulated brain may have 'opened" the painful memories of his horse riding injuries - his lack of free movement would not have helped his pain experience, his verbal communication makes him a "hard" patient to deal with etc etc...
Thank you for your story.

I really like Diane's simple but elegant idea for the sake of standards; I would like to think that we could indeed move forward in our society to let the patient be naked in a private room....

And Barrett - thanks. These two ladies still occasionally pop up in my head at the most surprising times. They too are part of my growing up.

[Barrett Dorko]

I wanted to revive this thread for the therapists I will meet in the Carolinas as I travel this week. We'll see if any follow up on my suggestion that they read this and contribute here.

I came across something I wrote in '97 for a now defunct weekly. I was recounting my experience watching Berta Bobath treat patients at a workshop. I'd subsequently read of the science of ethology (http://en.wikipedia.org/wiki/Ethology), a term used primarily in Europe to describe the study and interpretation of animal behavior.

I wrote: "This kind of investigation is highly dependent upon the researcher's perceptions, and runs the risk of being criticized for that very reason...Ethologists are aware that, even with years of training, they cannot trust what they seem to observe explicitly. They know that the behavior of animals (including humans) is often quirky and unexpected. This is especially true when neurologic disability is present."

What I'm suggesting is this: It might help our understanding and management of painful problems concurrent with dementia if we shift our observational skills toward those used in ethology. My old essay goes on:

"This sort of observational skill and reasoning describes much of the work of Einstein, Piaget, F.M. Alexander and Feldenkrais."

Perhaps therapists working with these patients should aspire to work as these scientists and clinicians did.

After all, it was good enough for Berta Bobath.

[Barrett Dorko]

In the absence of speech, or at least speech we can trust, our job as caregivers is transformed. If we hope to do it well we have to transform ourselves.

I remember being charmed completely by James Herriot’s All Creatures Great and Small series a few decades ago. These are the stories of a country veterinarian, originally titled; “If Only They Could Speak” and they are full of his ability to sense the animals in ways that don’t include speech, of course. He often notices that they respond to his care in unexpected ways. I’ve heard that every new grad studying animals in the wild soon finds that “they obviously hadn’t been reading the same books we had.” In fact, I believe Herriot’s first line is, “They didn’t say anything about this in the books…”

My point is this: Absent normal communication, we have to depend upon skills aside from speech and hearing to learn from and teach our patients what we can. It would seem that palpatory skills would be the logical choice. For me, those that form the basis for Simple Contact would be a good place to start.

Anybody out there?

[Barrett Dorko]

Student: What do you do when your patient complains that your touch is irritating?

Me: That’s not something I ever hear.

S: I mean, what if they tell you that they prefer firm pressure rather than this stuff.

M: I’m not massaging them – Is that what you’re talking about?

S: No. I mean this stuff you’re teaching us to do.

M: I simply don’t get such complaints.

S: But a lot of people will tell you that when you touch them they don’t like it.

M: As I said, I don’t hear that from my patients.

S: (Looking doubtful) Have you ever treated many paranoid schizophrenics?

M: Again, as I said, I work alone in the dining room of a converted boarding house. I see “garden variety” spinal and limb pain. These sorts of patients aren’t part of my day.

S: Well, I work for the mental health department and if I don’t prepare my patients for my touch they’ll hit me. I know because I’ve been clocked several times. If you had a patient like that, how would you approach them?

M: I honestly don’t know. I’m not even sure that’s a solvable problem – and, as I’ve said, I don’t encounter this. But there’s a thread on Soma Simple about manual care and dementia. Maybe you could ask your question there.

S: (Looking disappointed) Dementia and paranoid schizophrenia aren’t the same thing.

M: Really? I thought they were. (Okay, I only thought to say that sarcastically, but I didn’t let it out) This is what I actually said: I know that, but both leave us with distinct problems of verbal communication that must be addressed. I think your question fits there. Please ask it.

Anyone? Anyone? Bueller?

[bernard]

Psychiatry Res. (http://javascript%3Cb%3E%3C/b%3E:AL_get%28this,%20%27jour%27,%20%27Psychiatry%20Res.%27%29;) 2001 Apr 15;101(3):289-301. Related Articles, (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Display&dopt=pubmed_pubmed&from_uid=11311932) Links (http://javascript%3Cb%3E%3C/b%3E:PopUpMenu2_Set%28Menu11311932%29;) http://www.ncbi.nlm.nih.gov/entrez/query/egifs/http:--linkinghub.elsevier.com-ihub-images-PubMedLink.gif (http://www.ncbi.nlm.nih.gov/entrez/utils/lofref.fcgi?PrId=3048&uid=11311932&db=pubmed&url=http://linkinghub.elsevier.com/retrieve/pii/S0165178101002141)
Specific body image pathology in acute schizophrenia.

Priebe S (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Priebe+S%22%5BAuthor%5D), Rohricht F (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Rohricht+F%22%5BAuthor%5D).

Unit for Social and Community Psychiatry, St. Bartholomew's and the Royal London School of Medicine and Dentistry, Queen Mary & Westfield College, East Ham Memorial Hospital, University of London, E7 8QR, London, UK. s.priebe@qmw.ac.uk

Despite a wide phenomenological interest in body image pathology in schizophrenia, there has been little systematic empirical research. This study aimed at establishing the specificity of body image pathology in patients with schizophrenia, its changes during acute treatment, and its association with other symptom factors. Cognitive (thoughts/beliefs regarding the body--body concept), affective (body satisfaction--body cathexis) and perceptual (body size estimation--body schema) facets of body image and psychopathology were assessed in in-patients with paranoid schizophrenia (N = 60), schizoaffective disorder (N = 19), depressive disorder (N = 40) and anxiety disorder (N = 28) at admission, and after 2 and 4 weeks of treatment. Body size perception was also assessed in a sample of healthy subjects (N = 44). Patients with paranoid schizophrenia/schizoaffective disorder showed under-estimation of lower extremities at each time point. They expressed a higher degree of body concept disturbances at admission, but not at later stages. In a factor analysis, body perception and body concept loaded on distinct factors, which were separate from positive symptoms, negative symptoms, and anxiety. Patients with acute paranoid schizophrenia and schizoaffective disorder seem to have a specific and consistent disturbance of body size perception, which might indicate a dysfunction of sensory information processing.

PMID: 11311932 [PubMed - indexed for MEDLINE] Barrett,

Many "mental" disorders create a body distortion image and the student is quite right. These patients feel that you're invading their body when you approach/touch them. It is not unpleasant but simply terrific for them. They have strong and often agressive reactions with external touch.

[Barrett Dorko]

Bernard,

Thank you for this. I actually knew of this issue and I suppose the student did as well.

Again, I don't know that this problem can be solved. It was interesting to me that I found this student clearly unwilling to be touched as well. I would guess that her work experience has altered her in this way.

[ian s]

Again, I don't know that this problem can be solved. It was interesting to me that I found this student clearly unwilling to be touched as well. I would guess that her work experience has altered her in this way.


Barrett I think this issue is important . I went on a body awareness course a few years ago with a terrrific Scandanavian lecturer and some of the physiotherapists ( in mental health) would not lie down , participate or said they had intracable pain issues . I am not denying anyones experience but I think interaction with people especially vulnerable people does or can affect care givers . I think the mirror neuron education would help here ?
People who do therapy like Gestalt Psychotherapy are possibly doing similar things with awarness of their own body but supervision and self awareness is an important part of their training . I think this should be part of education for Physiotherpists who inteact with ongoing pain ?

[Barrett Dorko]

Ian,

I certainly agree. Again the mirror neurons explain so much that we think of as mysterious.

The image of Frederick Douglass comes to mind. A slave houseboy in Baltimore in 1829, he was denied reading lessons because his master had discovered that the woman of the house was instructing him. His owner was clearly terrified that he would become less easy to control if his knowledge grew in this way - and he was right, of course. Douglass wrote that he realized that the chains and the law weren't what kept him enslaved. It was his own ignorance.

I just had another fractious exchange with a follower of Barnes who rather loudly called me "rude" because I felt that it was important to actually understand what we are doing when we treat people. I simply wouldn't agree that not knowing was okay as long as people "got better." Nothing new.

What struck me (and led to the image of Douglass) was her disdain for the reading I suggested she do. I mean, the more I spoke of science and medical literature the angrier she became. It was as if some "internal master" possessed her and continually warned her of the price we pay for our acquisition of knowledge - how the subsequent freedom is a burden, never allowing us to look at the world so simply ever again. Maybe this accounts for the willful ignorance of the Barnes crowd.

Is knowledge a burden? Absolutely.

If the therapist who questioned me so sharply yesterday aout her psychiatric patients doesn't contribute here, I can only explain this resistance to learning in the same way.

Of course, I might be wrong. Tell me how.

[Diane]

About mirror neurons, about "taking on" aspects of those with whom we come into contact in daily life, about memes of behavior, about all that and more besides, probably.. I used to say persistent pain was a crooked hall of mirrors, and that to progress and exit the maze, the mirrors needed to be draped deliberately one by one by one so there would be less confusion overall. I still think persistent pain is a crooked hall of mirrors bending around and back on itself, but the metaphor is only really mirroring life itself, isn't it?

The thing with mirrors is to always check one's own body, sans mirror, to re-member that oneself is not the image in the mirror, or the other person in front of one, so that one's own inner image does not become dis-membered.

I think Barrett is saying in his classes, "Know mirrors." Know everything you can find out so you don't end up trapped inside one. Know how to polish up the one that came with you for free. Know what is mirror and what is not mirror. Learn how to have them work for you, not you for them.

Maybe the only difference between "normal" and "demented" is that the "normal" nervous system is still self-correcting (self image can still be ascertained as separate from cultural mirrors and other kinds), it still has a rudder and a gyroscope, while a "demented" one no longer does. Just a thought.

Old joke: What did one mirror say to the other mirror?
Answer: It's all done with people.

[stregapez]

Barrett,

(hopefully not off-topic)

I don't understand the passionate aversion to undertsanding why things work or don't work either. On the other hand, I can relate to "if this works i'm not going to stop doing it just because i don't have complete understading of how it works" I like the balance where 1) one doesn't fool oneself into thinking something works because one wants to believe it does (for either monetary, social belonging or other psychological reasons for example) 2) If one really does have experience with something working well but doesn't understand why (either partially or at all) one doesn't stop doing what they are doing, but one does take some time here and there to try to understand the "science" behind it.

Thanks to post on SomaSismple (and Wikipedia) i now know something about what mirror neurons are!

Here's a thought ~ You seem to be a very intellectual person and you probably have excellent reading and comprehension skills for scientific topics. , and plenty of mental and /or intellectual energy. Some (many?) people don't (I may be somewhere in between, with practice reading anything science-oriented being very new to me) I don't know you, so I don't know if you do this already or not, but trying to meet people half way is sometimes helpful ("I'm glad to hear your getting such wonderful results with such and such...Don't you think it might be really helpful too if you know why and how that works?!" etc) I'm not very good at that myself half the time. Of course in an instance where you don't even believe the results are good (and/or the means are ethical) there's little value in pretending

I have questions with the Barnes folks that go beyond many of them disliking, mistrusting, fearing and denegrating science - like major scope of practice concerns, but that's a different issue.

Not sure if this is on-topic but there are some videos on working with/massaging people who have Alzheimers here (as well as seniors in general) scroll down http://massagereview.com/Merchant2/merchant.mvc?Screen=CTGY&Category_Code=9

I'm interested in anyone's knowledge and/or experience working with folks with Alzheimers or dementia too, as I hope to do some massage (probably volunteer) at a nursing home sometime in the near future and/or just visit . I just got a call from a 73 year old guy who saw my business card and wants me to run an add in his local senior's zine, and frankly it makes me a litle nervous , as I have no experience massaging eldery folks. I intend to take a course via Daybreak Geriatric Massage Institute, probaby in the fall. http://www.daybreak-massage.com/

Dana

[Barrett Dorko]

Dana,

If it makes you feel any better, I think your post was perfectly appropriate and the link is exactly what we're looking for here.

I know that over the years I've lost any semblance of patience with those who portray themselves as "experts" because they use the title of therapist and then never do a single bit of work to underwrite their expertise with study and attention to advances in our general knowledge. They say, "I help people" and, "I'm a healer" and expect a free pass. My student today proclaimed both of these things and then said I was "rude" because I said that this wasn't enough.

But it's true that it isn't enough. If I don't say it - who will?

[stregapez]

Dana,

If I don't say it - who will?

Probably me :)

[nari]

It isn't enough.

Barrett, I am continually surprised by the resistance put up so strongly by a certain proportion of students in classes. As you have said many times, some simply turn up expecting to be told what to do so they can go off and try it.
That's not unusual amongst PTs - what surprises me is the antagonism and aggression....

Not many Chinese and Spanish explorers amongst PTs - simply setting off in order to discover new things despite rumours of a "known" flat world with definite edges leading to an abyss. It seems to be the difference between those falling into an abyss, and those who parachute or abseil down.

However my thoughts are biased this morning as I spent an evening with 7 other PTs, all of whom I know well, but who have locked themselves in the flat world and are not at all keen on straying....

Nari

[Barrett Dorko]

Nari,

The aggression is palpable and overt. Somebody who listened to this exchange today in Charlotte might chime in though I'm not holding my breath. After all, while it took place I was pretty much left to my own devices despite the fact that it was obvious several listening were astounded at a number of things said by this student. I learned long ago not to wait for the class to pipe up even when their own opinions are being trashed loudly. That's why it's so easy to do - nobody (aside from me) says a thing.

I couldn't say it at the time because I was trying to keep this disagreement as civil as I could, but a question I might have asked at the beginning that would have short-circuited the whole thing was in the back of my mind and next time I'm pushed I might very well use this.

The question: Given your attitude toward science in general and neuroscience in particular, how exactly am I to distinguish you from a primitive witch doctor?

[nari]

Barrett

You could probably write a ton of stuff out of the responses elicited from asking such a question. One hope is that you may have backup from those who are prone to look at things neurologically.

On the other hand, you could end up being hanged, drawn and quartered for being a traitor to the glorification of the mesoderm.

Hard to say....

Nari

[christophb]

Barrett, this could just be a symptom of a society that is too

over- stimulated/anxious/worked/pressured/insert your own here-

Hey, working with people in pain is hard enough, let alone trying to make sense of why they are in pain (which could be a number of reasons). To have the pressure to produce results takes up so much energy, how could somebody sit down and study what you are proposing without a bit of their own pain.

If you find a way that works and you don't have to think, well super. And if you find a technique that makes you think you have control over the situation, even better. There are day's when I wonder why I even bother with the profession, and other's when I can't think of anything I would rather be doing (fortunately there are more of the later).

I think there is more operating underneath the resistant students than you can fathom (and I'm sure you know this ) and it's symptomatic of a society that favors consumption and acquisition of things. By understanding an abnormal neurodynamic what do you own? I think you are scratching at some sensitive issues (in patients and therapists) when you show them that the answer to their problem lies somewhere in their own brain and not some marvelous technique you own. What type of worth does that show?

Anyway, I got sidetracked... I wanted to post about a kid with CP (who was non-verbal) I saw a year ago. Now, I know nothing about peds or CP, but I was last ditch effort cause all the other PT's were busy and the former didn't get along with the kid. He was there for ROM maintenance only, so I approached him and basically let him guide me into a position/stretch that was non-threatening. He achieved wonderful ROM and didn't have to tell me verbally cause I listened to him tactily. Things progressed well and the mother learned how to do it herself (actually she was already doing it but thought you had to have a 6 year degree to cause a painful stretch in a child).

Chris

[nari]

Chris

Your last paragraph says (or should say) an awful lot to those therapists out there who believe in forcing tissue in order to achieve an apparent goal set by themselves because of what they see. Their memory map tells them that ROM must be maintained or increased, and this can be painful. Perhaps it comes as a result of following a prescribed map and not observing a territory with a modicum of logic along with a large dollop of environmental awareness.

I am reading a great book at present just on this topic - will post some details on another thread.

Nari

[Jason Silvernail]

...the PT culture, I mean.

I'm not sure I have experienced the overt aggression that Barrett has involving PTs who seem to have gained no new knowledge since they graduated from school. As someone once said, these people don't have a number of years of experience, they have the same first year over and over again.

Being a somewhat opinionated guy, I can usually intimidate into silence those who haven't done the requisite reading required to participate in a given discussion. Those who press me on an issue either:
1. Help me learn something new, because they know something I don't
2. Come up with a slightly less aggressive way to demonstrate why it's OK that they've failed to absorb important therapy concepts - my personal favorite is "BUT I HAVE CHILDREN!" - which, not having children myself, doesn't anger me so much. It makes me think George Carlin is right about people and their kids though...

I have thought for a long time that a reason why many people get into PT is that it seems like half a career. They can get a degree and be respected, but not work too hard or think too much, and they can get out when they want. While I don't deny that it's good to have flexibility, I think that there is a real intellectual laziness in many of our brethren in PT. For the record, it has been my experience that the DPT students I have worked with here in the USA just have a totally different, more dedicated focus, and much more savvy when it comes to absorbing and using knowledge. Perhaps that's just the few schools that I work with here, but I doubt it. Whether we agree with the DPT thing in the USA or not (I'm a reluctant supporter and now a student), it sure seems to have raised the intellectual thirst level in the students I've seen. Though, to be sure those in commonwealth countries like Canada, UK, and Aus - where degree inflation evidently isn't required- have been outperforming us clinically I believe for some time.
I'm hoping this is a trend, and I think the profession's recent momentum in research and scientific underpinnings will continue, all over the world.

I know that's not much about dementia, but it does address that student's "behavior" in a class like that...

J

[stregapez]

I don't want to take the thread way off the dementia topic either. I gotta say though, that one thing that keeps popping into my head every time i read the references to students reminding teachers they have kids, is that there's still a gender gap, even in this country , as to who does the most child care, home care, elder care etc (doesn't really apply to me, since my son has mostly been raised by his dad, but it's not atypically the case) http://www.msnbc.msn.com/id/6011245/ (not an especially scholarly article but a reminder)

Dana

[Jon Newman]

I was discussing non-participation with some co-workers today. We discussed readers versus posters and moved on to tangential topics such as knowing who is running for office and actually voting for someone running for office. We also contemplated whether more people have voted for an American Idol than an American president. I'm unclear what accounts for the apparent apathy that seems to exist for anything beyond a "technique" laden course or the siren song of a certification.

I felt a bit better (in a way) after reading the following perspective found in the May 11 New England Journal of Medicine. (http://content.nejm.org/cgi/content/full/354/19/1982) It once again increased my gratitude that places like Somasimple exist.

[nari]

I reread Chris's post and had some more ideas.

Most courses offer techniques to be practised and applied, along with some background 'whys'. If an experienced and much-touted person is teaching these techniques, so much the better; it positively validates them. ("If he's using this, then it must be right"). Check up a few hits on the subject in PubMed - yes, looks OK - and the stage is set. The techniques work very well and there is that feeling of "wow, I'm so glad I did that course; it was worth the $1000." Then, down the track, it seems they do not work as well....
So, the thought occurs: I spent a lot of money on that new equipment/knowledge/heating system/car/plasma TV, and it doesn't seem to be what I expected. What is missing?
Some people may think that aquiring information in a passive manner from an authoritative source is good. Brain soaks it up, stores it temporarily and cognitive processes extrapolate it from there. Or that is the theory. But gaining new knowledge/info must involve effort, asking whys and why nots, being a bit cynical; bouncing off others; looking to disprove, in a way.

If this isn't done fairly soon (and it takes time and effort) then that newly-gained knowledge becomes a sort of mantra. If a PT technique is wearing off and results aren't as good..then it needs more infill, more practice, more confirmation that it must be right. Forget about the disproving, the thought that it wasn't right to begin with.
I think this will be happening with the core stability mantra; I have muttered for some time that isolating one or two groups of muscle for targeting seems quite silly, and probably impossible. Same with McKenzie - but enough of that, I will not stick my neck out further....:)

Learning about 'techniques' with so-called normal brains of patients takes effort - dealing with a demented brain is peering into abysses. The pat answers don't exist. I think this is what scares off students; if there isn't a pat answer and one has to think about grass roots stuff.....then it isn't worthwhile bothering about.

Enough ranting.


Nari

[stregapez]

I hope my comment about gender and childcare didn’t across as snide and insensitive. The thing I was really trying to say is if the circumstance is not yours you really shouldn’t assume you understand it. People who don’t have kids can’t really even imagine the responsibility, time, and energy it entails (and if/when the labor and attention isn’t shared equally then women often have more of it).

But I don’t see why anyone should be presenting you with that, Barrett , in the context of a weekend seminar. Also, though it’s close to impossible for me to imagine the context of what you were talking about above, I don’t see why anyone should get hostile or call you rude because you express and promote your opinions in your own class, or recommend reading something(s). They can take it or leave it, right? And if someone’s taking an ongoing class or classes they should know ahead of time what it entails, basically, and whether they have time for it.

Dana

[Jon Newman]

In my opinion, people with children have a more compelling reason to learn about life and human nature than those without. Reading seems to be the most time efficient method. Read about things that interest you but you know little about, start and stop as you need and it usually costs less than 30$ for a lesson.

[nari]

jon, you are probably right.

The catch is, people with children up to about 18 years of age, find it hard to consistently read with attention to context. There is always a drama happening somewhere in one's vicinity and it is rarely a simple drama.

Nari

[Diane]

OK, sorry for butting in as I have never had children.. just a comment on this as it pertains to the profession of PT. I wanted to mention a TV science program I saw lately called Battle of the Sexes or War of the Sexes or something to that effect.. as you can likely imagine, different varied scenarios are set up and testing done so that conclusions can be suggested re: Vive la difference.

In one episode (to do with this little side track) participants male and female were set up with mikes in their ears, through which a voice prompt came through. The participants had to, in real time, interview another person about a set topic, while continually adjusting their behavior according to the voice coming through their earphone. The voice would give them new questions to ask, suggest they cross their legs, suggest they smile, all sorts of things.

As it turned out, the women were better multitaskers, able to maintain contact with their interview subject while seamlessly adjusting their behaviors to the prompts. The guys tended to stop, lose track, look confused, completely ignore their interviewee while going into their own mind for a moment to figure out what to do. It was suggested that female brains differed enough to permit this multitasking due to evolution requiring constantly divided attention during child rearing.

Just a story to suggest that its likely thanks to the women in the profession that it has gotten as far as it has for so long (even though plenty of children were no doubt raised in the process), coping with series of crises and relying on recipies for treatment (finding just enough time to write them down/pass them on), even though it hasn't gotten as far as many male researchers think it should have, and even though they think they can come up with sounder (more science based) recipies for treatment...

Barrett says, just cook with whatever is in the fridge. :D

Sorry for all the mixed metaphors here.